Analgesic and neuropharmacological activities of Berberis lycium Royle collected from district Sherani Balochistan, Pakistan.

Berberis lycium (family Berberidaceae) grows in district Sherani, Balochistan, Pakistan. It is used for the treatment of various disorders by the people of Balochistan. The present work was carried out to explore analgesic and neuropharamcological activities of crude methanolic extracts of B. lyceum. The analgesic activity was carried out by acetic acid induced writhing test and formalin test. Open field test, cage crossing test, rearing test, traction test and forced swimming test were carried out in neuropharmacological activities. The results reveal that crude methanolic extracts of B. lyceum showed significant (P<0.05) analgesic activity in acetic acid induced pain as well as with formalin test. In neuropharmacological activities, crude methanolic extracts of B. lyceum showed significant (P<0.05) central nervous system depressant activity and in forced swimming test it showed anxiolytic effects.

Comparison of 3 Days Amoxicillin Versus 5 Days Co-Trimoxazole for Treatment of Fast-breathing Pneumonia by Community Health Workers in Children Aged 2-59 Months in Pakistan: A Cluster-randomized Trial.

BACKGROUND: Globally, most deaths due to childhood pneumonia occur at the community level. Some countries are still using oral co-trimoxazole, despite a World Health Organization recommendation of oral amoxicillin for the treatment of fast-breathing pneumonia in children at the community level. METHODS: We conducted an unblinded, cluster-randomized, controlled-equivalency trial in Haripur District, Pakistan. Children 2-59 months of age with fast-breathing pneumonia were treated with oral amoxicillin suspension (50 mg/kg/day) for 3 days in 14 intervention clusters and oral co-trimoxazole suspension (8 mg trimethoprim/kg and 40 mg sulfamethoxazole/kg/day) for 5 days in 14 control clusters by lady health workers (LHW). The primary outcome was treatment failure by day 4 for intervention clusters and by day 6 for control clusters. The analysis was per protocol. RESULTS: Out of the 15 749 cases enrolled in the study, 9153 cases in intervention and 6509 cases in control clusters were included in the analysis. Treatment failure rates were 3.6% (326) in intervention clusters and 9.1% (592) in control clusters. After adjusting for clustering, the risk of treatment failure was lower in intervention clusters (risk difference [RD] -5.5%, 95% confidence interval [CI] -7.4--3.7%) than in control clusters. Children with incomplete adherence had a small increase in treatment failure versus those with complete adherence (RD 2.9%, 95% CI 1.6-4.1%). No deaths or serious adverse events occurred. CONCLUSIONS: A 3-day course of oral amoxicillin, administered by LHWs, is an effective and safe treatment for fast-breathing pneumonia in children 2-59 months of age. A shorter course of amoxicillin improves adherence to therapy, is low in cost, and puts less pressure on antimicrobial resistance. CLINICAL TRIALS REGISTRATION: ISRCTN10618300.

Prevalence of diabetic foot syndrome amongst population with type 2 diabetes in Pakistan in primary care settings.

OBJECTIVE: To determine the prevalence of diabetic foot syndrome in type 2 diabetes mellitus patients. METHODS: This cross-sectional study was conducted at 25 centres across eight cities in Pakistan from August 2010 to March 2011, and comprised adult type 2 diabetics. The subjects underwent ankle brachial pressure index evaluation for diabetic foot, and neurological assessment using 10g monofilament for sensation and 128Hz tuning fork to elicit vibration. RESULTS: Of the 230 subjects, 94(40.86%) were males and 136(59.13%) females. The overall mean age was 53.82±9.96 years and mean glycated haemoglobin was 8.81±2.04%. The prevalence of diabetic foot syndrome was 32(13.9%). Based on established diabetic foot risk classification, 37(16.08%) patients were in category-1, 6(2.60%) in category-2, 32(13.91%) in category-3 and 148(64.34%) in category-0. On ankle brachial pressure index assessment, 94(40.86%) patients had impaired values (p<0.9). Sensation was impaired in 50(21.73%) patients, vibrations could not be detected in 37(16.08%), ankle reflexes could not be elicited in 35(15.21%), and foot pulses could not palpated in 28(12.17%) patients. CONCLUSIONS: A high prevalence of diabetic foot syndrome was observed.

Assessing decision of inpatient or outpatient care in community acquired pneumonia: APT care study.

OBJECTIVE: To estimate the proportion of community-acquired pneumonia patients with disagreement between Confusion, Uraemia, Respiratory rate, Blood pressure, age > 65 years recommendation and physician's decision to hospitalise or not. METHODS: This cross-sectional nation-wide, non-interventional, cross-sectional study was carried out across 10 cities of Pakistan from December 2011 to May 2012, and recruited consenting adult patients with confirmatory diagnosis of community-acquired pneumonia on chest X-ray. Confusion, Uraemia, Respiratory rate, Blood pressure, age > 65 years recommendation for each patient was determined at the time of analysis. This recommendation was compared with treatment decision made by the physician. Disagreement was considered when the physician's decision did not match with the recommendation. SPSS 18 was used for data analysis. RESULTS: Of the 352 patients, 201(57.10%) were males. The overall mean age was 50.67±18.45 years. In 140(39.77%) patients there was disagreement between Confusion, Uraemia, Respiratory rate, Blood pressure, age > 65 years recommendation and physician's decision regarding hospitalisation or outpatient care. Of the 352 cases 132(37.50%) were hospitalised despite the recommendation of outpatient treatment. CONCLUSIONS: In almost four out of every 10 patients there was disagreement between Confusion, Uraemia, Respiratory rate, Blood pressure, age > 65 years recommendation and the physician's decision regarding hospitalisation of community-acquired pneumonia patients.

Reproductive, maternal, newborn, and child health in Pakistan: challenges and opportunities.

Globally, Pakistan has the third highest burden of maternal, fetal, and child mortality. It has made slow progress in achieving the Millennium Development Goals (MDGs) 4 and 5 and in addressing common social determinants of health. The country also has huge challenges of political fragility, complex security issues, and natural disasters. We undertook an in-depth analysis of Pakistan's progress towards MDGs 4 and 5 and the principal determinants of health in relation to reproductive, maternal, newborn, and child health and nutrition. We reviewed progress in relation to new and existing public sector programmes and the challenges posed by devolution in Pakistan. Notwithstanding the urgent need to tackle social determinants such as girls' education, empowerment, and nutrition in Pakistan, we assessed the effect of systematically increasing coverage of various evidence-based interventions on populations at risk (by residence or poverty indices). We specifically focused on scaling up interventions using delivery platforms to reach poor and rural populations through community-based strategies. Our model indicates that with successful implementation of these strategies, 58% of an estimated 367,900 deaths (15,900 maternal, 169,000 newborn, 183,000 child deaths) and 49% of an estimated 180,000 stillbirths could be prevented in 2015.

Improvement of perinatal and newborn care in rural Pakistan through community-based strategies: a cluster-randomised effectiveness trial.

BACKGROUND: Newborn deaths account for 57% of deaths in children younger than 5 years in Pakistan. Although a large programme of trained lady health workers (LHWs) exists, the effectiveness of this training on newborn outcomes has not been studied. We aimed to evaluate the effectiveness of a community-based intervention package, principally delivered through LHWs working with traditional birth attendants and community health committees, for reduction of perinatal and neonatal mortality in a rural district of Pakistan. METHODS: We undertook a cluster randomised trial between February, 2006, and March, 2008, in Hala and Matiari subdistricts, Pakistan. Catchment areas of primary care facilities and all affiliated LHWs were used to define clusters, which were allocated to intervention and control groups by restricted, stratified randomisation. The intervention package delivered by LHWs through group sessions consisted of promotion of antenatal care and maternal health education, use of clean delivery kits, facility births, immediate newborn care, identification of danger signs, and promotion of careseeking; control clusters received routine care. Independent data collectors undertook quarterly household surveillance to capture data for births, deaths, and household practices related to maternal and newborn care. Data collectors were masked to cluster allocation; those analysing data were not. The primary outcome was perinatal and all-cause neonatal mortality. Analysis was by intention to treat. This trial is registered, ISRCTN16247511. FINDINGS: 16 clusters were assigned to intervention (23,353 households, 12,391 total births) and control groups (23,768 households, 11,443 total births). LHWs in the intervention clusters were able to undertake 4428 (63%) of 7084 planned group sessions, but were only able to visit 2943 neonates (24%) of a total 12,028 livebirths in their catchment villages. Stillbirths were reduced in intervention clusters (39·1 stillbirths per 1000 total births) compared with control (48·7 per 1000; risk ratio [RR] 0·79, 95% CI 0·68-0·92; p=0·006). The neonatal mortality rate was 43·0 deaths per 1000 livebirths in intervention clusters compared with 49·1 per 1000 in control groups (RR 0·85, 0·76-0·96; p=0·02). INTERPRETATION: Our results support the scale-up of preventive and promotive maternal and newborn interventions through community health workers and emphasise the need for attention to issues of programme management and coverage for such initiatives to achieve maximum potential. FUNDING: WHO; Saving Newborn Lives Program of Save the Children USA, funded by the Bill & Melinda Gates Foundation.

Community case management of severe pneumonia with oral amoxicillin in children aged 2-59 months in Haripur district, Pakistan: a cluster randomised trial.

BACKGROUND: First dose oral co-trimoxazole and referral are recommended for WHO-defined severe pneumonia. Difficulties with referral compliance are reported in many low-resource settings, resulting in low access to appropriate treatment. The objective in this study was to assess whether community case management by lady health workers (LHWs) with oral amoxicillin in children with severe pneumonia was equivalent to current standard of care. METHODS: In Haripur district, Pakistan, 28 clusters were randomly assigned with stratification in a 1:1 ratio to intervention and control clusters by use of a computer-generated randomisation sequence. Children were included in the study if they were aged 2-59 months with WHO-defined severe pneumonia and living in the study area. In the intervention clusters, community-based LHWs provided mothers with oral amoxicillin (80-90 mg/kg per day or 375 mg twice a day for infants aged 2-11 months and 625 mg twice a day for those aged 12-59 months) with specific guidance on its use. In control clusters, LHWs gave the first dose of oral co-trimoxazole (age 2-11 months, sulfamethoxazole 200 mg plus trimethoprim 40 mg; age 12 months to 5 years, sulfamethoxazole 300 mg plus trimethoprim 60 mg) and referred the children to a health facility for standard of care. Participants, carers, and assessors were not masked to treatment assignment. The primary outcome was treatment failure by day 6. Analysis was per protocol with adjustment for clustering within groups by use of generalised estimating equations. This study is registered, number ISRCTN10618300. FINDINGS: We assigned 1995 children to treatment in 14 intervention clusters and 1477 in 14 control clusters, and we analysed 1857 and 1354 children, respectively. Cluster-adjusted treatment failure rates by day 6 were significantly reduced in the intervention clusters (165 [9%] vs 241 [18%], risk difference -8·9%, 95% CI -12·4 to -5·4). Further adjustment for baseline covariates made little difference (-7·3%, -10·1 to -4·5). Two deaths were reported in the control clusters and one in the intervention cluster. Most of the risk reduction was in the occurrence of fever and lower chest indrawing on day 3 (-6·7%, -10·0 to -3·3). Adverse events were diarrhoea (n=4) and skin rash (n=1) in the intervention clusters and diarrhoea (n=3) in the control clusters. INTERPRETATION: Community case management could result in a standardised treatment for children with severe pneumonia, reduce delay in treatment initiation, and reduce the costs for families and health-care systems. FUNDING: United States Agency for International Development (USAID).

Making birthing safe for Pakistan women: a cluster randomized trial.

BACKGROUND: Two out of three neonatal deaths occur in just 10 countries and Pakistan stands third among them. Maternal mortality is also high with most deaths occurring during labor, birth, and first few hours after birth. Enhanced access and utilization of skilled delivery and emergency obstetric care is the demonstrated strategy in reducing maternal and neonatal mortality. This trial aims to compare reduction in neonate mortality and utilization of available safe birthing and Emergency Obstetric and Neonatal Care services among pregnant mothers receiving 'structured birth planning', and/or 'transport facilitation' compared to routine care. METHODS: A pragmatic cluster randomized trial, with qualitative and economic studies, will be conducted in Jhang, Chiniot and Khanewal districts of Punjab, Pakistan, from February 2011 to May 2013. At least 29,295 pregnancies will be registered in the three arms, seven clusters per arm; 1) structured birth planning and travel facilitation, 2) structured birth planning, and 3) control arm. Trial will be conducted through the Lady Health Worker program. Main outcomes are difference in neonatal mortality and service utilization; maternal mortality being the secondary outcome. Cluster level analysis will be done according to intention-to-treat. DISCUSSION: A nationwide network of about 100,000 lady health workers is already involved in antenatal and postnatal care of pregnant women. They also act as "gatekeepers" for the child birthing services. This gate keeping role mainly includes counseling and referral for skill birth attendance and travel arrangements for emergency obstetric care (if required). The review of current arrangements and practices show that the care delivery process needs enhancement to include adequate information provision as well as informed "decision" making and planned "action" by the pregnant women. The proposed three-year research is to develop, through national technical working group process, and then test a set of arrangements for achieving the enhanced utilization of safe birthing services. TRIAL REGISTRATION: Current Controlled Trials ISRCTN86264432.

The importance of human factors in therapeutic dietary errors of a hospital: A mixed-methods study.

An accurate therapeutic diet can help people improve their medical condition. Any discrepancy in this regard could jeopardize a patient's clinical condition. This study was aimed to determine prevalence of dietary errors among in-patients at an international private hospital's food department, and to explore causes of error to suggest strategies to reduce such errors in the future. Thus, a sequential explanatory mixed-methods study was carried out. For the quantitative part, secondary data were collected on a daily basis over one-month. For qualitative data, errors arising during the meal flow process were traced to the source on the same day of error followed by qualitative interviews with person responsible. Quantitative data were analyzed in SPSS v.25 as percentages. Qualitative data were analyzed by deductive-inductive thematic analysis. Out of a total of 7041 diets, we found that only 17 had errors. Of these, almost two-thirds were critical. Majority of these errors took place during diet card preparation (52.94%), by dietitians (70.59%), during weekdays (82.35%), breakfasts (47.06%), and in the cardiac care ward (47.06%). The causes identified through interviews were lack of backup or accessory food staff, and employee's personal and domestic issues. It was concluded that even though the prevalence of dietary errors was low in this study, critical errors formed majority of these errors. Adopting organizational behavior strategies in the hospital may not only reduce dietary errors, but improve patients' well-being, and employee satisfaction in a long run.

Salt Stress in Plants and Mitigation Approaches.

Salinization of soils and freshwater resources by natural processes and/or human activities has become an increasing issue that affects environmental services and socioeconomic relations. In addition, salinization jeopardizes agroecosystems, inducing salt stress in most cultivated plants (nutrient deficiency, pH and oxidative stress, biomass reduction), and directly affects the quality and quantity of food production. Depending on the type of salt/stress (alkaline or pH-neutral), specific approaches and solutions should be applied to ameliorate the situation on-site. Various agro-hydrotechnical (soil and water conservation, reduced tillage, mulching, rainwater harvesting, irrigation and drainage, control of seawater intrusion), biological (agroforestry, multi-cropping, cultivation of salt-resistant species, bacterial inoculation, promotion of mycorrhiza, grafting with salt-resistant rootstocks), chemical (application of organic and mineral amendments, phytohormones), bio-ecological (breeding, desalination, application of nano-based products, seed biopriming), and/or institutional solutions (salinity monitoring, integrated national and regional strategies) are very effective against salinity/salt stress and numerous other constraints. Advances in computer science (artificial intelligence, machine learning) provide rapid predictions of salinization processes from the field to the global scale, under numerous scenarios, including climate change. Thus, these results represent a comprehensive outcome and tool for a multidisciplinary approach to protect and control salinization, minimizing damages caused by salt stress.

Paying health workers for performance in Battagram district, Pakistan.

BACKGROUND: There is a growing interest in using pay-for-performance mechanisms in low and middle-income countries in order to improve the performance of health care providers. However, at present there is a dearth of independent evaluations of such approaches which can guide understanding of their potential and risks in differing contexts. This article presents the results of an evaluation of a project managed by an international non-governmental organisation in one district of Pakistan. It aims to contribute to learning about the design and implementation of pay-for-performance systems and their impact on health worker motivation. METHODS: Quantitative analysis was conducted of health management information system (HMIS) data, financial records, and project documents covering the period 2007-2010. Key informant interviews were carried out with stakeholders at all levels. At facility level, in-depth interviews were held, as were focus group discussions with staff and community members. RESULTS: The wider project in Battagram had contributed to rebuilding district health services at a cost of less than US$4.5 per capita and achieved growth in outputs. Staff, managers and clients were appreciative of the gains in availability and quality of services. However, the role that the performance-based incentive (PBI) component played was less clear--PBI formed a relatively small component of pay, and did not increase in line with outputs. There was little evidence from interviews and data that the conditional element of the PBIs influenced behaviour. They were appreciated as a top-up to pay, but remained low in relative terms, and only slightly and indirectly related to individual performance. Moreover, they were implemented independently of the wider health system and presented a clear challenge for longer term integration and sustainability. CONCLUSIONS: Challenges for performance-based pay approaches include the balance of rewarding individual versus team efforts; reflecting process and outcome indicators; judging the right level of incentives; allowing for very different starting points and situations; designing a system which is simple enough for participants to comprehend; and the tension between independent monitoring and integration in a national system. Further documentation of process and cost-effectiveness, and careful examination of the wider impacts of paying for performance, are still needed.

Immunomodulatory and hepatoprotective role of feed-added Berberis lycium in broiler chicks.

BACKGROUND: A large number of plants and their isolates have been shown to potentiate immunity. Some plants exert anti-inflammatory and anti-stress effects, others hepatoprotective activity. In this study, 320 1-day-old broiler chicks were randomly divided into four major groups A, B, C and D and fed rations supplemented with 0, 15, 20 and 22.5 g Berberis lycium kg⁻¹ ration respectively. Each group was further divided into two subgroups, one vaccinated against Newcastle disease (ND) and infectious bursal disease (IBD), the other non-vaccinated. Antibody titre against IBD and ND, relative weight of lymphoid organs, post-challenge morbidity and mortality, serum hepatic enzymes and total serum protein were observed. RESULTS: Group C had higher anti-IBD and anti-ND antibody titres. Relative bursa weight in groups C and D was higher until day 28, but birds in group C performed better at later stages of examination. Relative spleen weight was highest in group C. During initial stages there was no effect on relative thymus weight, but at later stages the effect was significant. Groups C and D performed similarly in terms of relative thymus weight. The birds were challenged to field IBD through intramuscular injection at a dose rate of 0.5 mL per bird. Post-challenge morbidity was lowest in groups C and D, while treatment significantly (P < 0.001) affected mortality amongst affected (morbid) birds. Levels of serum alanine aminotransferase and alkaline phosphatase were lowest in group C. Serum protein was similar in all groups and in both vaccinated and non-vaccinated broiler chicks. CONCLUSION: Berberis lycium added to feed at 20 g kg⁻¹ is effective in improving immunity against ND and IBD as well as liver function in broiler chicks.

Evaluation of exotic oat (Avena sativa L.) varieties for forage and grain yield in response to different levels of nitrogen and phosphorous.

A field experiment was conducted during the Rabi season 2017-2018 (October-March) at the University of Agriculture, Peshawar research farm to examine the influence of different nitrogen (N) and phosphorus (P) levels on two different oat varieties: Australian and Ukrainian. The treatments included control and three levels of nitrogen and phosphorus at 30, 60, and 90 kg ha-1. The treatments were arranged in randomized complete block design (RCBD) and replicated three times. The findings showed that the oat varieties were significantly different from one another in yield and yield parameters. The Australian variety recorded higher emergence (49 plants m-2), days to emergence (15 days), days to flowering (122 days), days to maturity (145 days), plant height (142.7 cm), number of leaves (6.03 leaves plant-1), number of tillers (92.2 tillers m-1), biological yield (8,179.2 kg ha-1), and grain yield (3,725.6 kg ha-1) than the Ukrainian variety. Similarly, different N and P levels, the maximum days to emergence, days to flowering, and days to maturity were recorded in a control plot. The application of 105 kg N + 90 kg P ha-1 was statistically similar to the application of 105 kg N + 60 kg P ha-1. Maximum emergence (60 plants m-2), number of leaves (7.0 leaves plant-1), plant height (118.6 cm), number of tillers m-1 (102.6), biological yield (9,687.5 kg ha-1), and grain yield (4,416.7 kg ha-1) were determined in Australian variety. Based on the findings of this study, the Australian variety performed better in terms of yield and yield components and the application of N and P fertilizers at the rate of 105 kg N + 60 kg P ha-1 produced the best results in both oat varieties.

Attitude and practice of dental surgeons towards pharmaceutical companies' marketing gifts.

Interaction of pharmaceutical companies (PC) with healthcare services has been a reason for concern. In medicine, awareness of the ethical implications of these interactions have been emphasized upon, while this issue has not been highlighted in dentistry. This study undertook a cross-sectional rapid assessment procedure to gather views of dentists in various institutions towards unethical practices in health care and pharmaceutical industry. The purpose of this study was to assess the need for the formulation and implementation of guidelines for the interaction of dentists with the pharmaceutical and device industry in the best interest of patients. A group of 209 dentists of Lahore including faculty members, demonstrators, private practitioners and fresh graduates responded to a questionnaire to assess their attitudes and practices towards pharmaceutical companies' marketing gifts. The study was conducted during 2011 and provided interesting data that showed the pharmaceutical industry is approaching private practitioners more frequently than academicians and fresh graduates. Private practioners accepted the gifts but mostly recognized them as unethical (over 65%). Both groups considered sponsoring of on-campus lectures as acceptable (over 70%). Respondents are not fully aware of the ethical demands which are imperative for all health care industries, and there is a dire need of strict guidelines and code of ethics for the dentist's interaction with the pharmaceutical and device industry so that patient interest is protected.

Household costs for treatment of severe pneumonia in Pakistan.

Current World Health Organization (WHO) guidelines for severe pneumonia treatment of under-5 children recommend hospital referral. However, high treatment cost is a major barrier for communities. We compared household costs for referred cases with management by lady health workers (LHWs) using oral antibiotics. This study was nested within a cluster randomized trial in Haripur, Pakistan. Data on direct and indirect costs were collected through interviews and record reviews in the 14 intervention and 14 control clusters. The average household cost/case for a LHW managed case was $1.46 compared with $7.60 for referred cases. When the cost of antibiotics provided by the LHW program was excluded from the estimates, the cost/case came to $0.25 and $7.51 for the community managed and referred cases, respectively, a 30-fold difference. Expanding severe pneumonia treatment with oral amoxicillin to community level could significantly reduce household costs and improve access to the underprivileged population, preventing many child deaths.

Newborn survival in Pakistan: a decade of change and future implications.

Pakistan has the world's third highest national number of newborn deaths (194 000 in 2010). Major national challenges over the past decade have affected health and development including several large humanitarian disasters, destabilizing political insurgency, high levels of poverty and an often hard-to-reach predominately rural population with diverse practices. As part of a multi-country analysis, we examined changes for newborn survival between 2000 and 2010 in terms of mortality, coverage and health system indicators as well as national and donor funding. Neonatal mortality declined by only 0.9% per annum between 2000 and 2010; less than the global average (2.1%) and less than national maternal and child mortality declines. Coverage of newborn care interventions increased marginally, with wide socio-economic variations. There was little focus on newborn health until 2000 when considerable policy change occurred, including integration of newborn care into existing community-based maternal and child packages delivered by the Lady Health Worker Programme and national behaviour change communications strategies and programmes. The National Maternal, Newborn and Child Health Programme catalyzed newborn services at both facility and community levels. Civil society and academics have linked with government and several research studies have been highly influential. Since 2005, donor funding mentioning the term 'newborn' has increased more for Pakistan than for other countries. The country faces ongoing challenges in reducing neonatal mortality, and in much of Pakistan, societal norms discourage care-seeking and many women are unable to access care for themselves or their children. The policy advances and existing delivery platforms offer the potential to substantially accelerate progress in reducing neonatal deaths. The recent decision to dismantle the national Ministry of Health and devolve responsibility for health sector management to the provincial level presents both challenges and opportunities for newborn health.

Perception of consent among dental professionals.

BACKGROUND: Informed Consent concept has been recognized in all patient care fields. The contents and wordings of the informed consent are still being debated and experimented. Dental care services have considered the role of informed consent since 1980's, after some legal claims of malpractices. METHODOLOGY: A cross-sectional analytic study was undertaken involving 375 senior dental students and fresh graduates in their house job. A self-administered questionnaire explored their knowledge, attitude and practices regarding the need and importance of informed consent in dental services. The study instrument was designed keeping in view the content of courses in dental education and international standards. The questionnaire was pre-tested on a small group for assessing the suitability and validity of the responses. RESULTS: The data was entered in SPSS version 16 and cross-tabulated through it. Most of the respondents (87%) were aware of the concept of informed consent, 6.9% considered it unnecessary and 21.9% were not practicing it. Invasiveness of dental procedure was found to be directly related to the need of including informed consent. Major justification for presence of informed consent was to protect the dentist from any legal proceedings. CONCLUSION: Dental professionals were aware about the informed consent as a step, but were unaware about its precise significance, content application and practice.

Improvement of perinatal and newborn care in rural Pakistan through community-based strategies: a cluster-randomised effectiveness trial

Newborn deaths account for 57% of deaths in children younger than 5 years in Pakistan. We aimed to evaluate the effectiveness of a community-based intervention package, principally delivered through LHWs working with traditional birth attendants and community health committees, for reduction of perinatal and neonatal mortality in a rural district of Pakistan. We undertook a cluster randomised trial between February, 2006, and March, 2008, in Hala and Matiari subdistricts, Pakistan. Catchment areas of primary care facilities and all affiliated LHWs were used to define clusters, which were allocated to intervention and control groups by restricted, stratified randomisation. The intervention package delivered by LHWs through group sessions consisted of promotion of antenatal care and maternal health education, use of clean delivery kits, facility births, immediate newborn care, identification of danger signs, and promotion of careseeking; control clusters received routine care. Independent data collectors undertook quarterly household surveillance to capture data for births, deaths, and household practices related to maternal and newborn care. The primary outcome was perinatal and all-cause neonatal mortality. Analysis was by intention to treat. Our results support the scale-up of preventive and promotive maternal and newborn interventions through community health workers and emphasise the need for attention to issues of programme management and coverage for such initiatives to achieve maximum potential.