Hepatitis C prevalence and elimination planning in Pakistan, a bottom-up approach accounting for provincial variation.

In Pakistan, substantial changes to hepatitis C virus (HCV) programming and treatment have occurred since the 2008 nationwide serosurvey estimated a 4.8% anti-HCV prevalence. In the absence of an updated national study, this analysis uses provincial data to estimate a national prevalence and the interventions needed to achieve elimination. Using a Delphi process, epidemiologic HCV data for the four provinces of Pakistan (accounting for 97% of the population) were reviewed with 21 subject-matter experts in Pakistan. Province-level estimates were inputted into a mathematical model to estimate the national HCV disease burden in the absence of intervention (Base), and if the World Health Organization (WHO) elimination targets are achieved by 2030 (80% reduction in new infections, 90% diagnosis coverage, 80% treatment coverage, and 65% reduction in mortality: WHO Elimination). An estimated 9,746,000 (7,573,000-10,006,000) Pakistanis were living with viraemic HCV as of January 1, 2021; a viraemic prevalence of 4.3% (3.3-4.4). WHO Elimination would require an annual average of 18.8 million screens, 1.1 million treatments, and 46,700 new infections prevented anually between 2022 and 2030. Elimination would reduce total infections by 7,045,000, save 152,000 lives and prevent 104,000 incident cases of hepatocellular carcinoma from 2015 to 2030. Blood surveys, programmatic data, and expert panel input uncovered more HCV infections and lower treatment numbers in the provinces than estimated using national extrapolations, demonstrating the benefits of a bottom-up approach. Screening and treatment must increase 20 times and 5 times, respectively, to curb the HCV epidemic in Pakistan and achieve elimination by 2030.

Genetic Evaluation for Hereditary Cancer Syndromes Among African Americans: A Critical Review.

While hereditary cancer syndromes have been described and studied for centuries, the completion of the human genome project fueled accelerated progress in precision medicine due to the introduction of genetic testing in the 1990s, creating avenues for tailored treatments and medical management options. However, genetic testing has not benefited everyone equitably, with nearly all of the published work based on individuals of non-Hispanic White/European ancestry. There remains a gap in knowledge regarding the prevalence, penetrance, and manifestations of common hereditary cancer syndromes in the African-American population due to significant disparities in access and uptake of genetic testing. This review summarizes the available literature on genetic testing for breast, colon, and prostate cancers in the African-American population and explores the disparities in access to genetic testing between non-Hispanic White and African-American patients. This article also addresses the barriers to genetic testing and discrepancies in the uptake of recommendations for hereditary cancer syndromes in the African-American population when compared with non-Hispanic Whites. The review offers practice implications for many healthcare providers and demonstrates gaps in the existing knowledge to be addressed in future studies to help eliminate the persisting health disparities faced by the African-American population.

Implementing innovative service delivery models in genetic counseling: a qualitative analysis of facilitators and barriers.

Given the increasing demand for genetic counseling, implementation of innovative service delivery models (SDMs) has been proposed to improve access and increase the efficiency of genetic counseling services. This study investigated the key considerations in genetic counseling practices that impact the decision to implement innovative SDMs, as well as barriers and facilitators to implementation. A cross-sectional, qualitative research design was employed, using focus groups. Genetic counselors (GCs) were recruited from respondents to an online survey about SDMs and by posting an invitation to the National Society of Genetic Counselors (NSGC) listserv. A total of 30 participants participated in either in-person (n = 3) or online (n = 5) focus groups, facilitated by members of the Service Delivery Model subcommittee of the NSGC Access and Service Delivery Committee. Transcribed audio and written notes from the focus groups were coded, utilizing an inductive thematic analysis method. Five overarching themes that impact decisions to implement and use innovative SDMs were identified: (a) Patient volume and efficiency are key motivators in trying innovative SDMs; (b) the decision to change is facilitated by available resources; (c) the implementation of innovative SDMs is multidimensional and complex process; (d) there is concern about the impact on patient-provider relationships with the utilization of innovative SDMs; and (e) measuring outcomes of innovative SDM facilitates acquisition of additional resources and support. Approaches to innovative SDM selection and implementation vary by institution needs, resources, and population as demonstrated by the variety of approaches to similar barriers. Outcomes related to the implementation of innovative SDMs in genetic counseling practice should be measured to demonstrate the value of innovative genetic counseling SDMs, improvement of access to care, and to justify need for additional resources to support implementation of these models.

Summary report of the 2019 Diversity and Inclusion Task Force of the National Society of Genetic Counselors.

The size and reach of the genetic counseling profession have expanded on a global scale since the 1970s. Despite this growth, the profession of genetic counseling has remained demographically homogenous. Promoting a culture of inclusivity that supports visible and invisible diversity and leveraging that culture not only expands perspectives represented in the field, but also helps foster equity in genetic services. This report summarizes the formation, implementation, and outcomes of the 2019 Diversity and Inclusion Task Force (TF) of the National Society of Genetic Counselors (NSGC), including the group's responses to their allotted charges from the NSGC Board of Directors. The recommendations generated by the TF aim to aid in the (1) establishment of infrastructure for ongoing diversity, inclusion, and equity (DEI) work by collaborating with a DEI organizational expert and forming a DEI advisory group within the NSGC, (2) development of specific short-term DEI initiatives, and (3) identification of seven areas of focus areas that must be addressed in order to create meaningful and measurable DEI improvements. The efficacy of these recommendations will depend on the consistency and creativity of implementation, shared responsibility, sufficient resources allocated to DEI initiatives, and measurable outcomes.

Compliance of surgical hand washing before surgery: Role of remote video surveillance.

OBJECTIVE: To evaluate and increase the compliance of surgical hand scrubbing with periodic feedback. METHODS: This study was conducted at the Aga Khan Hospital for Women and Children, Karachi, Pakistan, from April to July 2014. A remote video auditing system consisting of human auditors was used for visualising surgical hand wash compliance of the surgical team. The equipment, which used motion sensor, was installed in the scrub area wall, visualising the scrub sink only. A clock was displayed for the healthcare professionals to aid in ensuring two-minute hand washing. All surgeons, technicians and surgical assistants were included in the study. Surgical scrubbing was measured during a 4-week period by remote video auditing without feedback and a 12-week period with feedback. SPSS 19 was used for data analysis. RESULTS: Of the 534 observations, 150(28%) were made during the pre-feedback period and 384(71.9%) during the post-feedback period. During the first 4 weeks, the overall compliance was 22(14.6%). The rate of compliance increased to 310(80.7%) during the 12-week post-feedback period. CONCLUSIONS: Video surveillance with feedback for hand washing was found to be an effective tool for measuring hand hygiene and improving compliance.

Hepatitis E virus seroprevalence in pregnant women in Pakistan: maternal and fetal outcomes.

Hepatitis E virus (HEV) is endemic in Pakistan. Although otherwise asymptomatic, HEV infection becomes fatal in pregnancy, with considerable maternal and fetal morbidity and mortality. We conducted a descriptive study from April to October 2015 in 10 tertiary care hospitals throughout Pakistan to determine maternal and fetal morbidity and mortality in HEV-positive pregnant women with acute jaundice or raised liver function tests. Twenty-one of 135 women were HEV positive and in 3rd trimester except for 1 in 1st trimester. Overall prevalence of HEV in pregnancy was 0.19%. Ten women were artificially induced, 3 had premature labour, 4 delivered spontaneously (full term), 3 died and there was 1 intrauterine death. One woman had a home abortion before coming to hospital. There were 7 perinatal infant deaths: 4 intrauterine, 3 stillbirths and 1 abortion. Maternal mortality was significantly associated with delivery, as 17 mothers who lived went into labour spontaneously or were artificially induced, whereas 3 women who continued their pregnancy and did not deliver, died. Case fatality rate of HEV infection in pregnancy was 14.2%.

Silver Nanowire-Based Transparent Electrodes for V2O5 Thin Films with Electrochromic Properties.

The development of electrochromic systems, known for the modulation of their optical properties under an applied voltage, depends on the replacement of the state-of-the-art ITO (In2O3:Sn) transparent electrode (TE) as well as the improvement of electrochromic films. This study presents an innovative ITO-free electrochromic film architecture utilizing oxide-coated silver nanowire (AgNW) networks as a TE and V2O5 as an electrochromic oxide layer. The TE was prepared by simple spray deposition of AgNWs that allowed for tuning different densities of the network and hence the resistance and transparency of the film. The conformal oxide coating (SnO2 or ZnO) on AgNWs was deposited by atmospheric-pressure spatial atomic layer deposition, an open-air fast and scalable process yielding a highly stable electrode. V2O5 thin films were then deposited by radio frequency magnetron sputtering on the AgNW-based TE. Independent of the oxide's nature, a 20 nm protective layer thickness was insufficient to prevent the deterioration of the AgNW network during V2O5 deposition. On the contrary, crystalline V2O5 films were grown on 30 nm thick ZnO or SnO2-coated AgNWs, exhibiting a typical orange color. Electrochromic characterization demonstrated that only V2O5 films deposited on 30 nm thick SnO2-coated AgNW showed characteristic oxidation-reduction peaks in the Li+-based liquid electrolyte associated with a reversible orange-to-blue color switch for at least 500 cycles. The electrochromic key properties of AgNW/SnO2 (30 nm)/V2O5 films are discussed in terms of structural and morphological changes due to the AgNW network and the nature and thickness of the two protective oxide coatings.

Rational use of antibiotics--a quality improvement initiative in hospital setting.

OBJECTIVES: To minimise irrational use of antibiotics by implementing guidelines for antibiotic usage in obstetrics and Gynaeocology. METHODS: The observational study was conducted from January to December 2010 at the maternity unit of Aga Khan Hospital for Women and children, Kharadar, a secondary care facility in Karachi, Pakistan. Data was collected from medical records related to the study period. Prophylactic antibiotics were given according to the American College of Obstetricians and Gynaecologists recommendation 2009. Surveillance was done by surgical site infection rates and infectious morbidity. Data was analysed on SPSS 13. RESULTS: Therapeutic antibiotic use was rationalized, reducing the use of therapeutic antibiotics from 97% (n = 160/165) in January 2010 to 8% (n = 10/125) in December 2010. Surgical site infection rates were less than 5%. Cost of antibiotics per patient decreased by 90%. Decrease in the length of stay and workload on nursing staff was also observed. CONCLUSION: Implementing guidelines for antibiotic use in obstetrics and gynaecology and translating it into our protocols was effective in decreasing the irrational antibiotic consumption and increasing the rational use of antibiotics in the hospital.

Simulation of Fixed-Bed Chromatographic Processes Considering the Nonlinear Adsorption Isotherms.

This paper presents the numerical approximation of a nonlinear equilibrium-dispersive (ED) model of multicomponent mixtures for simulating single-column chromatographic processes. Using Danckwerts boundary conditions (DBCs), the ED is studied for both generalized and standard bi-Langmuir adsorption isotherms. Advection-diffusion partial differential equations are used to represent fixed-bed chromatographic processes. As the diffusion term is significantly weaker than the advection term, sophisticated numerical techniques must be applied for solving such model equations. In this study, the model equations are numerically solved by using the Runge-Kutta discontinuous Galerkin (RKDG) finite element method. The technique is designed to handle sudden changes (sharp discontinuities) in solutions and to produce highly accurate results. The method is tested with several case studies considering different parameters, and its results are compared with the high-resolution finite volume scheme. One-, two-, and three-component liquid chromatography elutions on fixed beds are among the case studies being considered. The dynamic model and its accompanying numerical case studies provide the initial step toward continuous monitoring, troubleshooting, and effectively controlling the chromatographic processes.

Cardiac arrest in seronegative idiopathic inflammatory myopathy: a case report.

Background: Idiopathic inflammatory myopathies (IIMs) are autoimmune diseases that are characterized by muscle injury. These disorders can cause cardiomyopathy and heart failure, myocarditis, and arrhythmias. However, only a few cases of cardiac arrest as a result of IIMs have been previously reported. Case summary: A 46-year-old male presented with an out-of-hospital ventricular fibrillation cardiac arrest. A diagnosis of IIM had been made through a muscle biopsy performed 2 years before presentation. The patient had a positive anti-nuclear antibody but negative myositis-specific antibodies. His initial symptoms of IIM were mild and consisted of myalgias. His only cardiac symptoms were minor palpitations that occurred 3 years prior to the cardiac arrest, with a negative Holter monitor test result at that time. His cardiac catheterization was normal. He was suspected to have myocarditis, and a rheumatologist was consulted, following which the patient was initiated on intravenous immunoglobulin (IVIG). Cardiac magnetic resonance imaging demonstrated evidence of chronic myocarditis and an ejection fraction of 44%. He was initiated on goal-directed medical therapy for heart failure. A VVI implantable cardioverter defibrillator was implanted for secondary prevention. He was discharged and prescribed additional immunosuppression including further IVIG infusions, prednisone taper and rituximab infusions. Discussion: Our case demonstrates that cardiac arrest in IIM is not only plausible, but can be the first major cardiac manifestation of the disease. When a diagnosis of IIM is made, patients require a thorough assessment of cardiac symptomatology and a low threshold for additional cardiac investigations.

Considerations for Germline Testing in Melanoma: Updates in Behavioral Change and Pancreatic Surveillance for Carriers of CDKN2A Pathogenic Variants.

The largest proportion of hereditary melanoma cases are due to pathogenic variants (PVs) in the CDKN2A/p16 gene, which account for 20%-40% of familial melanomas and confer up to a 30%-70% lifetime risk for melanoma in individuals with these variants. In addition, PVs in the CDKN2A gene also increase risk for pancreatic cancer (~5-24% lifetime risk). Individuals with PVs in the CDKN2A gene also tend to have an earlier onset of cancer. Despite these known risks, uptake of germline testing has been limited in the past, largely due to perceptions of limited benefit for patients. Prevention recommendations have been developed for individuals with CDKN2A PVs as well the providers who care for them. On the patient level, behavioral modifications regarding melanoma prevention such as wearing sunscreen, limiting prolonged sun exposure and practicing general sun safety can help reduce risks. Germline testing can provide motivation for some individuals to adhere to these lifestyle changes. On the provider level, pancreatic cancer surveillance for individuals with CDKN2A PVs has been increasingly endorsed by expert consensus, although the efficacy of these surveillance methods remains under study. This review summarizes the updated surveillance guidelines for individuals with CDKN2A PVs and explores the impact of genetic counseling and testing in influencing behavioral changes in these individuals.

Optimizing imaging in the pediatric trauma patient, part 2: thoracic and abdominal trauma.

Imaging is a critical tool for the diagnosis and management of thoracic and abdominal injuries in pediatric patients. The location and mechanism of injury, the physical examination, and other clinical findings should guide emergency clinicians in the selection of the most appropriate imaging modality for the pediatric trauma patient. This supplement reviews the evidence for imaging decisions in the setting of pleural space, lung parenchyma, chest wall, cardiac, diaphragm, solid-organ, and hollow-viscus injuries in pediatric patients. Examples demonstrating imaging modalities, interpretations, and specific findings are provided. Considerations for imaging in suspected nonaccidental abdominal trauma are also discussed.

Thermo-Priming Mediated Cellular Networks for Abiotic Stress Management in Plants.

Plants can adapt to different environmental conditions and can survive even under very harsh conditions. They have developed elaborate networks of receptors and signaling components, which modulate their biochemistry and physiology by regulating the genetic information. Plants also have the abilities to transmit information between their different parts to ensure a holistic response to any adverse environmental challenge. One such phenomenon that has received greater attention in recent years is called stress priming. Any milder exposure to stress is used by plants to prime themselves by modifying various cellular and molecular parameters. These changes seem to stay as memory and prepare the plants to better tolerate subsequent exposure to severe stress. In this review, we have discussed the various ways in which plants can be primed and illustrate the biochemical and molecular changes, including chromatin modification leading to stress memory, with major focus on thermo-priming. Alteration in various hormones and their subsequent role during and after priming under various stress conditions imposed by changing climate conditions are also discussed.

Electro-osmotic peristaltic flow and heat transfer in an ionic viscoelastic fluid through a curved micro-channel with viscous dissipation.

Emerging systems in microfluidics are embracing bio-inspired designs in which boundaries are flexible and mimic peristaltic propulsion mechanisms encountered in nature. These devices utilize electro-kinetic body forces to manipulate very precisely ionic biofluids for a range of medical applications including. Motivated by exploring in more detail electro-hemorheological micro-pumping, in the current article, a mathematical model is developed for peristalsis propulsion of a viscoelastic biofluid in a curved microchannel with electro-osmotic effect and thermal transport under static axial electrical field and with viscous heating. The third grade Reiner-Rivlin model is deployed for blood rheology. The novelty of the current work is therefore the simultaneous consideration of electrokinetics, viscoelastic behavior with the third grade Reiner-Rivlin model and coupled flow and heat transport with viscous dissipation in peristaltic pumping in a curved micro-channel. A Poisson-Boltzmann formulation is adopted to simulate the charge number density associated with the electrical potential. Asymmetric zeta potential (25 mV) is prescribed and mobilizes an electric double layer (EDL). The governing conservation equations for mass, energy, momentum and electrical potential with associated boundary conditions are simplified using lubrication approximations and rendered dimensionless via appropriate scaling transformations. Analytical solutions are derived in the form of Bessel functions and numerical evaluations are conducted via the ND solver command in MATHEMATICA symbolic software. The simulations show that with stronger viscoelastic effect, boluses are eliminated and there is relaxation in streamlines in the core and peripheral regions of the micro-channel. Increasing Brinkman number (dissipation parameter) elevates temperatures. An increase in electrical double layer thickness initially produces a contraction in the upper bolus and an expansion (lateral) in the lower bolus in the micro-channel. With modification in zeta potential ratio parameter from positive to negative values, in the lower half of the micro-channel, axial flow deceleration is generated.

Intimate-partner violence and its association with symptoms of depression, perceived health, and quality of life in the Himalayan Mountain Villages of Gilgit Baltistan.

STUDY OBJECTIVES: We aimed to estimate the prevalence of intimate partner violence (IPV) and associated risk factors in married women in rural villages of Gilgit Baltistan in Pakistan. METHODS: A cross-sectional design to assess the magnitude and factors associated with IPV in a random sample of 789 married women aged 18-49 years. A World Health Organization screening instrument was used to assess the presence of IPV in the previous 12 months. A locally validated instrument was adopted to identify self-reported symptoms of major depression according to the DSM IV. Trained nurses obtained socio-demographic and reproductive history through structured interviews. Bivariate and multivariable logistic regression analyses were used to estimate prevalence and identify significant predictors of IPV. RESULTS: The mean age of the participants was 38.3 years (SD: ±12.8). The prevalence of IPV in women was 22.8% (95% Confidence Interval: 20.0-25.9), 18.5% in pregnant women (95% CI: 11.7-27.9) and significantly associated with depression in 55.1% of IPV cases. Husband education level (college/higher) (Adjusted Odds Ratio: 0.40; 95%CI: 0.22-0.70) and high household income (AOR: 0.44; 95% CI: 0.29-0.68) were protective against IPV. Increase in age (AOR;1.02; 95% CI: 1.01-1.02) and poor relationship with mother-in-law increased the risk of IPV (AOR = 2.85; 95% CI: 1.90-4.28). IPV was positively associated with symptoms of depression (AOR = 1.97; 95% CI:1.39-2.77), poor perceived quality of life (AOR = 3.54; 95% CI: 1.90-6.58) and poor health (AOR = 2.74; 95% CI: 1.92-3.92). CONCLUSION: IPV is substantial public health burden significantly associated with depressive symptoms, poor perceived health and the quality of life.

Optimizing imaging in the pediatric trauma patient, part 1: head and neck trauma.

Trauma is the leading cause of death in the pediatric population and is among the most common reasons for ED visits by children. Imaging is an important tool for the diagnosis and management of pediatric trauma, but there are risks associated with exposure to ionizing radiation. In pediatric head and neck injuries, clinical findings and clinical decision tools can help inform selection of the most appropriate imaging modalities for the trauma patient, while also reducing unnecessary radiation exposure. This supplement reviews evidence-based recommendations for imaging decisions and interpretations in skull fractures, traumatic brain injuries, abusive head trauma, cervical spine injuries, and facial bone fractures. Examples demonstrating imaging modalities and specific findings for the types of injuries are also provided.

Leveraging technology and supply chain to improve family planning logistics in Pakistan.

BACKGROUND: Pakistan and USAID have invested in improving the contraceptive supply chain data and commodity security. In 2011, the first digital contraceptive logistics management information system (cLMIS) was launched, enabling supply chain data visibility from the federal level to health facilities. The system has built-in modules on forecasting and supply planning, inventory management, consumption reporting, business intelligence tools, automatic email and SMS alerts. Using these features, policy-makers and health managers annually forecast needs, and procure contraceptives accordingly. AIMS: The objective of this research was to understand the existing technological platforms for family planning (FP) supply chain data visibility and the potential impact on contraceptive commodity security. METHODS: The authors reviewed available published and grey literature papers on contraceptives and supplies in Pakistan. We extracted data from the cLMIS, evaluated indicators including reporting compliance, reported stock-out rates, and contraceptive performance. The analysis was validated by reviewing supply chain and FP indicators, such as average monthly consumption, months of stock, and couple years of protection. RESULTS: The cLMIS has resulted in improved distribution, early warning and accountability at the lowest tiers in the FP supply chain in the public sector. At the facility level, FP commodity availability increased from 40% in 2009 to 84% in 2018. CONCLUSION: Contraceptive supply chain has seen significant growth over the past decade to meet expanding reproductive health evidence to inform strategic decisions; cLMIS is a prime contributor to improvements registered in FP stock availability at public sector facilities.

Priming by High Temperature Stress Induces MicroRNA Regulated Heat Shock Modules Indicating Their Involvement in Thermopriming Response in Rice.

Rice plants often encounter high temperature stress, but the associated coping strategies are poorly understood. It is known that a prior shorter exposure to high temperature, called thermo-priming, generally results in better adaptation of the plants to subsequent exposure to high temperature stress. High throughput sequencing of transcript and small RNA libraries of rice seedlings primed with short exposure to high temperature followed by high temperature stress and from plants exposed to high temperature without priming was performed. This identified a number of transcripts and microRNAs (miRs) that are induced or down regulated. Among them osa-miR531b, osa-miR5149, osa-miR168a-5p, osa-miR1846d-5p, osa-miR5077, osa-miR156b-3p, osa-miR167e-3p and their respective targets, coding for heat shock activators and repressors, showed differential expression between primed and non-primed plants. These findings were further validated by qRT-PCR. The results indicate that the miR-regulated heat shock proteins (HSPs)/heat shock transcription factors (HSFs) may serve as important regulatory nodes which are induced during thermo-priming for plant survival and development under high temperatures.

Prevalence and antibiogram of non-fermenting Gram-negative bacilli in blood stream infections: Study in a tertiary care centre, Western Uttar Pradesh, India.

Non-fermenting Gram-negative bacilli (NFGNB) are emerging as important cause of blood stream infections. We aimed to determine the prevalence and antibiotic susceptibility pattern of NFGNB isolated from blood of patients with sepsis. We found, in 176 patients, the most common to be Pseudomonas aeruginosa (74) and Acinetobacter baumanii complex (39) followed by Stenotrophomonas maltophilia (16), Sphingomonas paucimobilis (6), Burkholderia cepacia (5) and Ochrobactrum anthropic (1). Generally, organisms showed a good sensitivity towards colistin, carbapenems and fluoroquinolones, whereas cephalosporins were ineffective.

Characterization and antiglycation activity of phenolic constituents from Viscum album (European Mistletoe).

4'-O-[beta-D-Apiosyl(1-->2)]-beta-D-glucosyl]-5-hydroxyl-7-O-sinapylflavanone (1), 3-(4-acetoxy-3,5-dimethoxy)-phenyl-2E-propenyl-beta-D-glucopyranoside (2), 3-(4-hydroxy-3,5-dimethoxy)-phenyl-2E-propenyl-beta-D-glucopyranoside (3), 5,7-dimethoxy-4'-O-beta-D-glucopyranoside flavanone (4), 4',5-dimethoxy-7-hydroxy flavanone (5), and 5,7-dimethoxy-4'-hydroxy flavanone (6), were isolated from the organic extracts of Viscum album L. (European Mistletoe). These compounds were studied for their anti-glycation and antioxidant properties. The structures of new compounds 1 and 2 were deduced on the basis of spectroscopic evidence.