Role of sociocultural perceptions in malnutrition of children under the age of 5 years in a semi-urban community of Pakistan.

OBJECTIVE: To assess the impact of sociocultural perception on the nutritional status of children under five years of age. METHODS: This cross-sectional study using a self-constructed questionnaire was conducted at the Shifa Rotary Clinic, Nurpur Shahan, Pakistan, from February to October 2016, and comprised mothers and children. Mothers age 18-45years having a child less than 5 years old were included. SPSS 21 was used for data analysis. . RESULTS: Of the 564 participants, 526(93.3%) were housewives and 38(6.5%) were working mothers. The overall mean age was 27.49±5.197 years. Mother was the decision-maker for child nutrition in 344(61.0%) cases while the father was the decision-maker for child nutrition in 106(18.8%) cases. About 64(11.3%) wasted colostrums, of which 18(28.1%) acted on their own accord 46(71.9%) on others' advice. Mother as the decision-maker for child nutrition was found to be significantly associated with normal child nutritional status (p<0.05).In our study male child was 2.29 times likely to have a normal nutritional status as compared to a female child (p<0.05). CONCLUSIONS: Sociocultural perceptions were found to have a significant impact on nutritional status of children under the age of 5 years.

Short Variable Regions flaA Gene (SVR-flaA) Diversity and Virulence Profile of Multidrug-Resistant Campylobacter from Poultry and Poultry Meat in India.

Human gastrointestinal infections caused by Campylobacter species is the second most important foodborne illness after salmonellosis worldwide. Poultry represent one of the main sources of Campylobacter organisms. In the present study, the short variable region of flagellin gene (SVR-flaA) typing was carried out to determine the variation among the circulating strains of Campylobacter jejuni and Campylobacter coli. The C. jejuni and C. coli isolated from poultry and poultry meat were screened for the presence of virulence determinants like cadF, flaA, cdtB, and wlaN gene. The screening for wlaN gene is crucial in view of the fact that most patients with Guillian Barre's (GB) syndrome with a preceding history of diarrheal illness have been found to harbor wlaN gene-positive C jejuni strains. Out of the 200 samples comprising poultry meat and cloacal swabs, 21.5% of samples were found to harbor Campylobacter spp. of which 2.5% were Campylobacter jejuni, and 19% were confirmed as Campylobacter coli. The cadF, flaA, cdtB virulence genes were detected in all the Campylobacter spp. isolated in the present study. The presence of the wlaN gene in the Campylobacter jejuni isolated in the present study may pose a public health threat with long-term human health implications. The SVR-flaA typing of twelve Campylobacter isolates obtained in the present study revealed that Campylobacter coli flaA sequence OL471375 is a new strain with a novel allele type 1,675 and peptide sequence 5 which stands deposited in pubMLST database for Campylobacter. The other flaA-SVR gene sequences identified in this study were OL471369, OL471370, OL471371, OL471372, OL471373, and OL471374. Among twelve Campylobacter spp., three distinct DdeI-RFLP patterns were observed, each varying in size from 100 to 1,000 base pairs. Antimicrobial profiling of the Campylobacter spp. isolated in the present study revealed that 50% of the strains were multidrug resistant. All the Campylobacter spp. were resistant to ciprofloxacin (CIP), ampicillin (AMP), penicillin (PEN), and nalidixic acid (NAL) whereas 57.1% of strains were resistant to tetracycline (TET) and erythromycin (ERY) 28% to amoxicillin (AMX) and enrofloxacin (ENO), 85% to amikacin (AMK). The high degree of resistance to fluoroquinolones observed in the present study is crucial in view of fluoroquinolones being drugs of choice for the treatment of human Campylobacter infections.

Methotrexate nephrotoxicity: Novel treatment, new approach.

This is the report of a case of methotrexate nephrotoxicity for which glucarpidase was used. We use the case to review a number of teaching points related to this new treatment option.

Student seminar on smoking: A novel way to introduce different perspectives on smoking to medical students.

BACKGROUND: The respiratory module at Shifa College of Medicine (SCM) is delivered in third year with emphasis on respiratory pathophysiology and respiratory medicine. Smoking as a topic was introduced to emphasize the preventive aspects of respiratory illnesses. An innovative approach to involve students in their learning was developed. To determine whether this innovation would be well received and effective for students' learning about smoking, we carried out this study. MATERIALS AND METHODS: This is a one group post-test quasi-experiment. Two days were assigned for a smoking seminar. The class of 106 students was divided into 10 batches, and each batch was assigned a theme related to smoking. These themes were developed by the faculty, and each theme was related to a different perspective on smoking. A post-test questionnaire was distributed at the end of the seminar for feedback to see what aspects of students' learning were highlighted and what needed to be improved upon. Questions related to the usefulness of the activity were incorporated into the questionnaire and the students were asked to agree or disagree on a five-point Likert scale. RESULTS: Most (68.3%) students agreed that this activity improved their knowledge regarding smoking, and 54.8% agreed that it also helped in application of this knowledge. Improvement in presentation and counseling skills (59.8%), evidence-based medicine (47.6%), and softer skills, such as teamwork (72%) and creativity (63.4%), were also reported to be enhanced. CONCLUSION: Seminars led by the students have shown to be effective in breaking the monotony and generating an interest of the topic. Such an activity serves as a small step to make our graduates more empathic, humane, competent, and skilful.

The role of family and culture in the disclosure of bad news: A multicentre cross-sectional study in Pakistan.

Objectives: Disclosure of bad news is distressing for patients and family members. Our aim was to assess patients' perceptions and preferences regarding bad news in the health setting. Methods: Cross-sectional, multi-centered study supported by an external grant in 15 Government and Private Hospitals across Pakistan. A sample size of 1673 patients and family members was used. Ethics permission/consent was taken from each participating hospital and participant. Responses were compared across provinces, gender, age, education and income. Results: >80% patients preferred their relatives to know the diagnosis first and they wanted the news to be disclosed to them by doctors. Significant association between education level, income and preference for wanting to know the diagnosis was found. Reasons for wanting to know the diagnosis included treatment, prognosis and prevention options whereas reasons for not wanting to know included fear of emotions and God's will. Conclusion: The majority of Pakistani patients want to be informed and want the family to know first. Preferences for disclosure vary across, age, education and income level. Innovation: First countrywide study on this topic. Identifies need for culturally sensitive guidelines that include the family's role in disclosure of bad news.

Factors predicting erythropoietin resistance among maintenance hemodialysis patients.

BACKGROUND: Erythropoiesis-stimulating agent (ESA) resistance remains incompletely understood among hemodialysis (HD) patients. METHOD: A retrospective, multicenter study was designed to analyze data from 1,934 patients followed for up to two years. The outcome measure was the erythropoietin resistance index (ERI), defined as erythropoietin dosage over a week divided by the post-HD weight and hemoglobin value. RESULTS: Multivariate analysis revealed albumin, Kt/V, transferrin saturation, statin use and male gender to be inversely related to ERI, whereas parathyroid hormone and angiotensin-converting enzyme inhibitors (ACEI)/angiotensin receptor blockers (ARB) use were associated with higher ESA resistance. ERI was statistically lower in patients with higher levels of albumin (p < 0.001) and with higher transferrin saturation levels (p < 0.05). DISCUSSION: The results allow for a better understanding of predictors of erythropoietin resistance among HD patients including not extensively studied factors such as statin and ACEI/ARB use.

Ethical review in Pakistan: the credibility gap.

The concept of mandatory ethical review of research involving human participants is gradually taking root in Pakistani institutions. Based on the opinions of Institutional Review Board (IRB) members from institutions across the country, the process faces several challenges which threaten its integrity. The lack of registration or accreditation for IRBs has resulted in a wide variation in the calibre and working of such Boards. Despite the recent growth in numbers of people with formal bioethics degrees in the country, a majority of membership remains without any formal training for the work expected from them in ethical review. External pressures to influence deliberations, conflict of interest issues within board leadership and inconsistent application of review requirements all contribute in undermining the reliability of the process. Some of the most significant threats to independent and uninfluenced functioning of such boards arise from institutional leadership itself. In the opinions of IRB members, the review process has to be uniform, consistent and trustworthy if it is to gain the respect of researchers, and IRB need to be given the autonomous space to make independent decisions. Otherwise there is a real danger of IRBs being relegated to being no more than rubber stamping committees.

Comparison of Peer-Assisted Learning with Traditional Faculty-led Teaching in Family Medicine Clerkship: An Experimental Study.

OBJECTIVE: To compare the effects of reciprocal peer-assisted learning (PAL) with traditional faculty-led teaching on the academic performance of fourth-year medical students in Family Medicine clerkship. STUDY DESIGN: An experimental study. PLACE AND DURATION OF STUDY: Department of Health Professions Education and Department of Family Medicine, Shifa College of Medicine, Islamabad, Pakistan, from 22nd February 2019 to 25th February 2020. METHODOLOGY: The study was conducted longitudinally in three clerkship rounds of Family Medicine with 77 fourth-year students separated into a control group and an intervention group taught by faculty and peers respectively. All peer tutors were trained prior to their sessions and there were parallel peer-led and faculty-led sessions. Both groups were given a pre-test prior to the intervention and a post-test after the intervention. The data were entered in SPSS version 24 and analysed using chi-square, independent and paired sample t-tests. RESULTS: Participants of both intervention (PAL) and control (non-PAL) groups demonstrated a significant difference in post and pre-test scores with a p-value <0.05. However, the mean difference in the post-and pre-test scores between the two groups was not significant with a p-value >0.05. CONCLUSION: Students taught by peers performed as well as students taught by the faculty in this study, as depicted by their academic scores. Henceforth PAL is comparable to faculty-led teaching in acquisition of knowledge in Family Medicine clerkship. KEY WORDS: Peer-assisted learning, Reciprocal peer-assisted learning, Traditional teaching, Family medicine.

Pregnancy outcome in late maternal age in a high-income developing country.

AIM: This study aimed to compare the pregnancy outcome at maternal age 35 years and above with those aged between 20 and 34 years in a high-income developing country. METHODS: In this prospective study, pregnant women that delivered at Al-Ain Hospital from the 1st April 2009 till 30th September 2009 were included. The obstetrical and perinatal outcome of mothers aged between 20 and 34 years and those aged 35 years old and above was compared. RESULTS: There were a total of 888 patients. 699/888 (78.7%) were aged between 20 and 34 years and 189 (21.3%) were aged 35 years and above. Advanced maternal age was significantly associated with a higher incidence of type II diabetes mellitus (p = 0001), hypothyroidism (p = 0.02), history of miscarriages (p = 0.0001), GDM (p = 0.0001), placenta previa p = 0.04, induction of labor (p = 0.04), and Cesarean section (p = 0.009). CONCLUSION: Pregnant women at 35 years and above have higher incidence of gestational diabetes mellitus, placenta previa, and operative delivery. However, perinatal outcome are comparable to younger mothers.

Availability of expanded programme of immunization services provided to children in a rural Pakistani village.

OBJECTIVES: To evaluate the immunization status of children under 5 years age, living in the Nurpur Shahan area and to identify various factors which influenced the rate of immunization. METHODS: A cross sectional study was conducted in which mothers of children under 5 years of age were questioned about the immunization of their children and the immunization services provided in the area. Systematic random sampling was used and the collected data was analyzed using SPSS v. 10.0. RESULTS: The overall immunization rate in the children of Nurpur Shahan was 77.4%. This study found strong correlations to immunization rates in children. Increased educational status of the mother, greater maternal immunization during pregnancy, and home delivery of vaccines, were all directly linked to higher rates of immunization amongst children. Lack of awareness, followed by inadequate facilities were the most commonly cited reasons for discontinuing the programme or abstaining from it altogether. CONCLUSION: The EPI coverage in Nurpur Shahan is quite well established, but still left room for improvement. Factors that encouraged higher immunization rates were more educated mothers, better awareness and availability of door-to-door services.

Factors affecting the utilization of antenatal care among women of reproductive age in Nurpur Shahan.

Antenatal care is important for the prevention of maternal and foetal mortality and morbidity. The purpose of this study was to determine the frequency of utilization of antenatal care and to identify the factors that affect it. A cross sectional survey was conducted in the community of Nurpur Shahan, Islamabad, Pakistan in January 2010 using a structured questionnaire. Included were 390 women of reproductive age who were questioned about their knowledge of antenatal care and its utilization. The frequency of utilization of antenatal care was (84.4%). Among those who never used the antenatal care, permission to use the facility and ignorahce were the main reasons. Education of both the wife and husband with this regard must be worked upon.

Awareness about organ donation especially kidney donation in Nurpur Shahan, a rural community area in Islamabad, Pakistan.

OBJECTIVE: To assess the level of awareness and ethical issues related to organ donation especially kidney donation and the willingness to donate a kidney among the rural population of Pakistan. METHOD: A cross sectional study was conducted in a sample of 324 subjects residing in Nurpur Shahan by means of a pre tested questionnaire. Data collection was carried out via a face to face interview and the data was analyzed using SPSS 10.0 and associations were tested using the Chi-square test. RESULTS: Knowledge about organ donation was significantly associated with age (p = 0.00) and education (p = 0.024). Allowance of organ donation in religion was an important factor in determining the attitude of individuals towards organ donation and their willingness to donate. Media emerged as a major source of information for the population of Nurpur Shahan; kidney was the organ most known for its donation. Most (69%) respondents did not consider organ vending to be ethically correct but a sizeable proportion (25%) thought it may be considered in times of dire need. CONCLUSION: Awareness of organ donation in our sample was high and more than half of the people were willing to become donors.

Assessment of frequency of diarrhoea in relation to drinking water among residents of Nurpur Shahan, Pakistan.

OBJECTIVES: To determine the source of drinking water and to assess its relationship with the frequency of diarrhoea among households of Nurpur Shahan. METHODS: A cross-sectional descriptive study was carried out in January 2010 with a preformed questionnaire. Systematic random sampling was used to collect data. Participants' consent was obtained and confidentiality was maintained during the survey and during analysis. Households were evaluated for the frequency of diarrhoea in relation to their water source, its purification, and availability of sanitation facilities. All collected data was analyzed using SPSS 10.0. RESULTS: Of the 107 households surveyed, 2.8% used wells, 63% used tap water and 32.7% used hand pumps, whereas only 0.9% consumed store-bought water as their major source of drinking water. The difference in the frequency of diarrhoea between those households who purified their water and those that did not was just 1%. The relationship between the source of drinking water and the frequency of diarrhoea was not statistically significant (p = 0.319). Surprisingly households with no disposal facilities only had a 20% frequency of diarrhoea; this was found to be statistically significant (p = 0.023). CONCLUSIONS: This study contradicts the general conception that water supply is responsible for diarrhoea in the locality of Nurpur Shahan; it was found that the statistical difference between diarrhoea resulting from purified and non purified water was very small (p-value=0.587). Rather, improper sanitation and poor personal hygiene seem largely responsible for diarrhoea in this rural Islamabad community.

Adapting the ethical review process for COVID-19 research: reviewers' perspectives from Pakistan.

BACKGROUND: Research ethics committees (RECs) globally have adapted their responses to provide timely reviews of research proposals in the wake of the COVID-19 pandemic. The REC of the National Bioethics Committee (NBC) of Pakistan has followed suit. AIMS: To explore perceptions of NBC-REC reviewers who reviewed COVID-19 research proposals while describing the newly instituted Rapid Turnaround Review (RTR) system. METHODS: This cross-sectional study used 3 methods of data collection: a demographic questionnaire filled in by permanent members and co-opted reviewers; qualitative in-depth interviews conducted with both groups; and document review related to COVID-19 research proposals. RESULTS: Eight permanent members and 3 co-opted members participated. Under the RTR system, the time for review was established as 72 hours after receipt of the proposal. The Committee reviewed 55 projects over 10 months. Participants described numerous strengths of the new system, including introduction of online discussions via Zoom as well as presence of co-opted members leading to learning opportunities, particularly for junior members. The RTR system also allowed NBC-REC to gain recognition it had not enjoyed previously. Challenges identified by respondents included initial difficulty in initiating the system and tighter deadlines that may have compromised review quality. Poor scientific quality of proposals, compounded by external pressures to provide rapid approval, added to reviewers' frustrations. While fruitful, the RTR system was considered unsustainable beyond a public health emergency. CONCLUSION: Adaptation of ethical review processes is essential in emergencies, however, existing guidelines have to be modified to suit contextual needs.

Mean Changes in Estimated Glomerular Filtration Rate in Patients Undergoing Percutaneous Nephrolithotomy Having Renal Stone Disease.

Background Urinary stone disease is associated with renal impairment because of obstruction and infection. Comorbidities include hypertension, dyslipidemia, diabetes, and impaired renal function. Furthermore, as recurrences are common in urolithiasis, such patients undergo many treatments throughout their life. Percutaneous nephrolithotomy (PCNL) is an effective treatment for renal stones with a diameter greater than 2 cm. The primary objective of this study was to observe the mean changes in estimated glomerular filtration rate (GFR) in patients undergoing PCNL having renal stone disease. Methodology This cross-sectional study was conducted for six months between June and November 2020 at a tertiary care hospital in Karachi, Pakistan. All male and female patients aged between 15 and 70 years who were diagnosed with renal stones using X-ray of the kidney, ureter, and bladder or using ultrasound of the abdomen and planned for PCNL were selected. Patients with any duration of kidney stone disease were included. Statistical Package for Social Sciences version 20.0 (IBM Corp., Armonk, NY, USA) was used to statistically analyze the data. Results The mean age of the patients was 41.11 ± 14.30 (17-70) years. A total of 61 (38.1%) patients were female and 99 (61.9%) were male. Mean preoperative GFR was 91.22 ± 5.88 mL/min which decreased to 83.64 ± 5.70 mL/min at 48 hours post-PCNL. GFR significantly decreased after surgery (p = 0.0001). Conclusions During early postoperative days, GFR was decreased in patients undergoing PCNL. Factors that may impair renal function should be avoided during the first few days after undergoing PCNL. Further large-scale studies are needed to investigate these changes in GFR in post-PCNL patients.

Family medicine in undergraduate medical curriculum: a cost-effective approach to health care in Pakistan.

BACKGROUND: Shifa College of Medicine introduced a two-week rotation in Family Medicine for their third-year medical students in 2008. The purpose of this study was to determine what impact it made on students and how many would consider becoming Family Physicians in future. METHODS: A questionnaire-based prospective study conducted at Shifa College of Medicine, Islamabad during academic year 2008. RESULTS: A total of 46 students rotated in Family Medicine throughout the academic year-2008. Fifteen students were aware of Family Medicine as a specialty prior to starting their rotation, and only 3 expressed an interest to pursue Family Medicine as a future career. At the start of the rotation only 15 students were able to give correct definition of Family Medicine and on questioning whether it should be a part of the undergraduate curriculum, only 24 answered yes while the rest were unsure. After the rotation, a significant number of students (37%; p < 0.01) considered having a career in Family Practice, and 80% (n = 37) were able to give correct definition of Family Medicine as a humanistic approach of medicine with aim to prevent, treat and rehabilitate. About its utility in the undergraduate curriculum, 44 (96%) students believed it should be a regular feature in their curriculum, while 30 (65%) students agreed that their outlook towards patient care had changed. When asked what they learnt most during the rotation, students quoted empathy and development of communication skills. CONCLUSION: Family medicine rotation as part of undergraduate medical curriculum may help in fostering an interest among medical students in this newly emerging subspecialty which could have a profound effect on delivery of quality health care in this country.

Implication of Prophetic Variables and their Impulsive Interplay in CA Prostate Patients Experiencing Osteo-Metastasis.

AIMS: To identify variables having a critical role in prostate cancer patients experiencing osteometastasis. BACKGROUND: Prostatic carcinoma is a multifactorial complex disorder that exhibits an increased propensity to develop bone metastasis. An interplay of inflammatory and bone remodeling parameters promotes the formation of pre-metastatic niches in bones of patients, which could render them more vulnerable to skeletal disabilities. OBJECTIVE: To evaluate the multi-dynamic inter-relationship of circulating variables in prostate cancer patients experiencing osteo-metastasis. MATERIALS AND METHODS: Fifty-seven (n=57) men with clinically confirmed prostate cancer, fifty-nine (n=59) with skeletal metastases, and one hundred (n=100) healthy subjects i.e., men aging from 53-84 years with no clinical evidence of prostate were recruited from the Jinnah Hospital Lahore, Pakistan. Informed consent was obtained, and a venous blood sample was drawn and stored at -70oC until assayed. Levels of variables were evaluated using appropriate methods. Levels of Matrix Metalloproteinases (MMPs), Osteopontin (OPN), TGH- ß, and sRANKL were estimated by the ELISA method. Each sample was suspended and the given protocol was employed. ELISA readings were obtained for the estimation of all variables. RESULTS: Highly significant (P˂0.05) differential expression of oxidative stress, inflammatory cytokines, and bone remodeling variables were observed in localized and osteo-metastatic CA prostate patients. A strong positive correlation was revealed among OPN, sRANKL, MMP-7, MMP-9, PSA, and TGF-ß (OPN vs. MMP-7, r=0.698* and OPN vs. MMP-9, r=0.765**, OPN vs. RANKL, =0.856*, sRANKL vs. MMP-9, r=0.825**, TGF- ß vs. RANKL, r=0.868* and PSA vs. TGF- ß, r=0.752*); lower levels of OPG were estimated in metastasized patients, showing that both osteolytic and osteoblastic phases of bone remodeling occur simultaneously. CONCLUSION: The altered oxidative and inflammatory responses endorse Matrix Metalloproteinases (MMPs) increased activity, RANKL/OPG imbalance, and enhanced bone matrix proteins turnover, which can foster the process of osteo-metastasis. The perturbed RANKL/OPG drift and enhanced PSA levels are associated with increased TGF-ß activity to aggravate Epithelial Mesenchymal transition (EM) and osteo-tropism of prostate cancer. Thus, designing novel targets of these major variables can minimize the incidence of prostate cancer patients.