Implementation of a clinical breast exam and referral program in a rural district of Pakistan.

BACKGROUND: The role of clinical breast examination (CBE) for early detection of breast cancer is extremely important in lower-middle-income countries (LMICs) where access to breast imaging is limited. Our study aimed to describe the outcomes of a community outreach breast education, home CBE and referral program for early recognition of breast abnormalities and improvement of breast cancer awareness in a rural district of Pakistan. METHODS: Eight health care workers (HCW) and a gynecologist were educated on basic breast cancer knowledge and trained to create breast cancer awareness and conduct CBE in the community. They were then deployed in the Dadu district of Pakistan where they carried out home visits to perform CBE in the community. Breast cancer awareness was assessed in the community using a standardized questionnaire and standard educational intervention was performed. Clinically detectable breast lesions were identified during home CBE and women were referred to the study gynecologist to confirm the presence of clinical abnormalities. Those confirmed to have clinical abnormalities were referred for imaging. Follow-up home visits were carried out to assess reasons for non-compliance in patients who did not follow-through with the gynecologist appointment or prescribed imaging and re-enforce the need for follow-up. RESULTS: Basic breast cancer knowledge of HCWs and study gynecologist improved post-intervention. HCWs conducted home CBE in 8757 women. Of these, 149 were warranted a CBE by a physician (to avoid missing an abnormality), while 20 were found to have a definitive lump by HCWs, all were referred to the study gynecologist (CBE checkpoint). Only 50% (10/20) of those with a suspected lump complied with the referral to the gynecologist, where 90% concordance was found between their CBEs. Follow-up home visits were conducted in 119/169 non-compliant patients. Major reasons for non-compliance were a lack of understanding of the risks and financial constraints. A significant improvement was observed in the community's breast cancer knowledge at the follow-up visits using the standardized post-test. CONCLUSIONS: Basic and focused education of HCWs can increase their knowledge and dispel myths. Hand-on structured training can enable HCWs to perform CBE. Community awareness is essential for patient compliance and for early-detection, diagnosis, and treatment.

Predictors of voluntary uptake of modern contraceptive methods in rural Sindh, Pakistan.

The use of modern contraceptive methods (MCMs) has been stagnant for the last decade in Pakistan. The second most populous province, Sindh reports 25% of MCMs use. Various factors including demographics and health services utilization are associated with the uptake of family planning services. This research aimed to identify and assess specific predictors of MCMs among women aged 15-49 in two districts of Sindh-Matiari and Badin. A cross-sectional household survey was conducted from October 2020- December 2020. In total, 1684 Married Women of Reproductive Age (MWRA) 15-49 years were interviewed. For the selection of eligible respondents, a two-stage stratified cluster sampling strategy was used. Univariate and multivariable logistic regression was used to determine the predictors for the use of MCM. Use of modern methods of contraceptive was 26.1% (n = 441). Statistically significant socio demographic predictors of MCM included: number of children 4 or more (AOR: 5.23; 95%CI: 2.78-9.84), mother having primary education (AOR: 1.73; 95% CI: 1.26-2.36), and husband having middle education (AOR: 1.69; 95% CI: 1.03-2.76). Maternal health services indicators included: postnatal care of mother (AOR: 1.46; 95% CI: 1.09-2.05); women who were visited by Lady Health Workers in their postnatal period and were counselled on family planning (AOR: 1.83; 95% CI: 1.38-2.42). Since the primary purpose of using modern contraceptive methods is for limiting pregnancies, there is a potential to promote awareness about the benefits of birth spacing as part of implementing a more integrated approach to family planning. The integration of family planning services within maternal and newborn child healthcare services effectively promote the voluntary adoption of modern contraceptive methods. The role of Lady Health Workers in family planning counseling and service provision and uptake is important in the context of Sindh and should be fostered further by opportunities for capacity building and their empowerment.

Applicability of Child-Turcotte-Pugh Score in Anticipating Post-ERCP Adverse Events in Patients With Cirrhosis: A Systematic Review and Meta-analysis.

Limited objective data exist on the comparison of post-endoscopic retrograde cholangiopancreatography (ERCP) complications in patients with cirrhosis based on the severity of the disease. We evaluated the effectiveness of the Child-Turcotte-Pugh (CTP) score system in anticipating the risk of post-ERCP complications in patients with cirrhosis. The PubMed, Scopus, Embase, and Cochrane databases were searched from inception through September 2022 to identify studies comparing post-ERCP complications in patients with cirrhosis based on CTP score. Odds ratios (ORs) and their associated 95% CIs were pooled using a random-effect model to calculate effect size. The reference group for analysis was the CTP class C patient group. Seven studies comprising 821 patients who underwent 1068 ERCP procedures were included. The CTP class C patient population exhibited a higher risk of overall post-ERCP adverse events compared with those with class A or B (OR: 2.87, 95% CI: 1.77-4.65, P = 0.00 and OR: 2.02, 95% CI: 1.17-3.51, P = 0.01, respectively). Moreover, CTP class B patients had a significantly higher complication rate than CTP class A patients (OR: 1.62, 95% CI: 1.04-2.53, P = 0.03). However, no statistically significant differences were found in the occurrence of specific types of complications, including bleeding, pancreatitis, cholangitis, perforation, or mortality across the three CTP groups. We demonstrated that the CTP classification system is a reliable predictor of ERCP complications in patients with cirrhosis. Consequently, caution should be exercised when performing ERCP in patients classified as CTP class C.

Efficacy and Safety of Omarigliptin, a Novel Once-Weekly Dipeptidyl Peptidase-4 Inhibitor, in Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis.

BACKGRUOUND: No recent meta-analysis has holistically analyzed and summarized the efficacy and safety of omarigliptin in type 2 diabetes mellitus (T2DM). We conducted a meta-analysis to address this knowledge gap. METHODS: Electronic databases were searched to identify randomized controlled trials (RCTs) that included patients with T2DM who received omarigliptin in the intervention arm. The control arm consisted of either a placebo (passive control group [PCG]) or an active comparator (active control group [ACG]). The primary outcome assessed was changes in hemoglobin A1c (HbA1c), while secondary outcomes included variations in glucose levels, achievement of glycemic targets, adverse events (AEs), and hypoglycemic events. RESULTS: From 332 initially screened articles, data from 16 RCTs involving 8,804 subjects were analyzed. Omarigliptin demonstrated superiority over placebo in reducing HbA1c levels (mean difference, -0.58%; 95% confidence interval, -0.75 to -0.40; P<0.00001; I2=91%). Additionally, omarigliptin outperformed placebo in lowering fasting plasma glucose, 2-hour postprandial glucose, and in the percentage of participants achieving HbA1c levels below 7.0% and 6.5%. The glycemic efficacy of omarigliptin was similar to that of the ACG across all measures. Although the omarigliptin group experienced a higher incidence of hypoglycemic events compared to the PCG, the overall AEs, serious AEs, hypoglycemia, and severe hypoglycemia were comparable between the omarigliptin and control groups (PCG and ACG). CONCLUSION: Omarigliptin has a favorable glycemic efficacy and safety profile for managing T2DM.

Assessment of Resistance Induction in Mungbean against Alternaria alternata through RNA Interference.

A comprehensive survey of mungbean-growing areas was conducted to observe leaf spot disease caused by Alternaria alternata. Alternaria leaf spot symptoms were observed on the leaves. Diversity of 50 genotypes of mungbean was assessed against A. alternata and data on pathological traits was subjected to cluster analysis. The results showed that genotypes of mungbean were grouped into four clusters based on resistance parameters under the influence of disease. The principal component biplot demonstrated that all the disease-related parameters (% disease incidence, % disease intensity, lesion area, and % of infection) were strongly correlated with each other. Alt a 1 gene that is precisely found in Alternaria species and is responsible for virulence and pathogenicity. Alt a 1 gene was amplified using gene specific primers. The isolated pathogen produced similar symptoms when inoculated on mungbean and tobacco. The sequence analysis of the internal transcribed spacer (ITS) region, a 600 bp fragment amplified using specific primers, ITS1 and ITS2 showed 100% identity with A. alternata. Potato virus X (PVX) -based silencing vector expressing Alt a 1 gene was constructed to control this pathogen through RNA interference in tobacco. Out of 50 inoculated plants, 9 showed delayed onset of disease. Furthermore, to confirm our findings at molecular level semi-quantitative reverse transcriptase polymerase chain reaction was used. Both phenotypic and molecular investigation indicated that RNAi induced through the VIGS vector was efficacious in resisting the pathogen in the model host, Tobacco (Nicotiana tabacum). To the best of our knowledge, this study has been reported for the first time.

Challenges of Management of Subaortic Membrane in a Young Adult Patient: A Case Report.

This article presents a case review and literature review focused on the challenges of managing subaortic membranes (SAMs) in young adult patients with mild aortic regurgitation (AR) or aortic stenosis (AS). The study aims to discuss the diagnosis of SAM, the imaging studies used for assessment, the management strategies in young patients, the risk of valvular damage, and the controversy surrounding prophylactic resection in mild AR. The management of SAM in adults poses challenges due to limited treatment options and potential complications, necessitating further investigation into the progression of AS and AR in asymptomatic SAM patients. The case presentation describes a 40-year-old male with muscular dystrophy who presented with symptoms and was diagnosed with SAM. Various imaging techniques, including CT chest, transthoracic echocardiogram (TTE), and transesophageal echocardiogram (TEE), were used to confirm the presence and severity of SAM. Based on the patient's clinical profile and the absence of surgical indications, medical therapy was initiated, and regular outpatient follow-up was recommended to monitor disease progression. The discussion highlights the challenges in diagnosing SAM, the importance of imaging studies, and the potential complications associated with SAM in young patients. The article also explores the management options for SAM, emphasizing surgical resection as the definitive treatment, while acknowledging the limited success rates of alternative approaches. Close monitoring and prompt intervention for complications are crucial in the management of SAM. The concluding statement emphasizes the need for further research to explore alternative treatments for SAM in young patients.

Status of lipid control in Bangladeshi subjects with type 2 diabetes mellitus on lipid-lowering drugs: a multicenter, facility-based, cross-sectional study.

BACKGROUND: Achievement of lipid targets is crucial in patients with type 2 diabetes mellitus (T2DM) to mitigate the risk of cardiovascular diseases (CVD). Data on lipid-control status among patients with T2DM in Bangladesh are scarce. This study was conducted to determine the lipid-control status among patients with T2DM who were on lipid-lowering drugs in the country. METHODS: This cross-sectional study was conducted in the diabetes outpatient departments of several tertiary hospitals in Bangladesh from January 2022 to December 2022. Adults of both sexes diagnosed with T2DM for at least one year and were on the lipid-lowering drug(s) for a minimum of 3 months were included in the study by consecutive sampling. Patients' data were collected by face-to-face interviews, and blood samples were collected for fasting lipid profile. The lipid target was set at < 200 mg/dL for total cholesterol (TC), < 150 mg/dL for triglyceride (TG), < 100 mg/dL for low-density lipoprotein cholesterol (LDL-C), > 40 mg/dL for high-density lipoprotein cholesterol (HDL-C), and < 160 mg/dL for non-HDL cholesterol (non-HDL-C). RESULT: Three thousand sixty patients (age 44.7 ± 13.3 years, female 57%) with T2DM were evaluated. Overall, almost 81% of the study subjects achieved the LDL-C target. Besides, TC, TG, HDL-C, and non-HDL-C targets were achieved by 40.8, 21.6, 66.3, and 44.1% of patients, respectively. However, all the lipid parameters were under control in only 8.8% of patients. Almost 77.6% of the patients with ischemic heart disease, 81.5% of patients with stroke, and 65% of patients with CKD had LDL levels < 70 mg/dL. Only 10.03% achieved the HbA1c target of < 7%. 7.4% of patients achieved both HbA1c < 7% and LDL < 100 mg/dL and 5% achieved both HbA1c < 7% and LDL < 70 mg/dL. Advanced age (aOR 0.97, 95% CI 0.96, 0.98, p < 0.001), longstanding T2DM (aOR 0.53, 95% CI 0.39, 0.72, p < 0.001), and non-statin therapy (aOR 0.25, 95% CI 0.16, 0.37, p < 0.001) were negatively associated with lipid control (LDL < 100 mg/dL) while using oral hypoglycemic drugs or insulin (aOR 2.01, 95% CI 1.45, 2.77, p < 0.001) and having cardiovascular comorbidity (aOR 3.92, 95% CI 3.00, 5.12, p < 0.001) were positively associated with lipid control. CONCLUSION: Though most patients with T2DM achieved their target LDL level, the prevalence of both glycemic and overall lipid control was low in our study despite lipid-lowering therapy.

Facility-Based Audit System With Integrated Community Engagement to Improve Maternal and Perinatal Health Outcomes in Rural Pakistan: Protocol for a Mixed Methods Implementation Study.

BACKGROUND: Maternal and newborn mortality in Pakistan remains as a major public health challenge. Pakistan faces significant infrastructure challenges and inadequate access to quality health care, exacerbated by sociocultural factors. Facility-based audit systems coupled with community engagement are key elements in achieving improved health system performance. We describe an implementation approach adapted from the World Health Organization audit cycle in real-world settings, with a plan to scale-up through mixed methods evaluation plan. OBJECTIVE: This study aims to implement a locally acceptable and relevant audit system and evaluate its feasibility within the rural health system of Pakistan for scale-up. METHODS: The implementation of the audit system comprises six phases: (1) identify facility and community leadership through consultative meetings with government district health offices, (2) establish the audit committee under the supervision of district health officer, (3) initiate audit with ongoing community engagement, (4) train the audit committee members, (5) launch the World Health Organization audit cycle (monthly meetings), and (6) quarterly review and refresher training. Data from all deliveries, live births, maternal deaths, maternal near misses, stillbirths, and neonatal deaths will be identified and recorded from four sources: (1) secondary-level care rural health facilities, (2) lady health workers' registers, (3) community representatives, and (4) project routine survey team. Concurrent quantitative and qualitative data will be drawn from case assessments, process analysis, and recommendations as components of iterative improvement cycles during the project. Outcomes will be the geographic distribution of mortality to measure the reach, proportion of facilities initiated to implement an audit system for measuring the adoption, proportion of audit committees with community representation, and proportion of audit committee members' sharing feedback regularly to measure acceptability and feasibility. In addition, outcomes of effectiveness will be measured based on data recording and reporting trends, identified modifiable factors for mortality and morbidity as underpinned by the Three Delays framework. Qualitative data will be analyzed based on perceived facilitators, barriers, and lessons learned for policy implications. Results will be summarized in frequencies and percentages and triangulated by the project team. Data will be analyzed using Stata (version 16; StataCorp) and NVivo (Lumivero) software. RESULTS: The study will be implemented for 20 months, followed by an additional 4-month period for follow-up. Initial results will be presented to the district health office and the District Health Program Management Team Meeting in the districts. CONCLUSIONS: This study will generate evidence about the feasibility and potential scale-up of a facility-based mortality audit system with integrated community engagement in rural Pakistan. Audit committees will complete the feedback loop linking health care providers, community representatives, and district health officials (policy makers). This implementation approach will serve decision makers in improving maternal and perinatal health outcomes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/49578.

REPercussions: how geminiviruses recruit host factors for replication.

Circular single-stranded DNA viruses of the family Geminiviridae encode replication-associated protein (Rep), which is a multifunctional protein involved in virus DNA replication, transcription of virus genes, and suppression of host defense responses. Geminivirus genomes are replicated through the interaction between virus Rep and several host proteins. The Rep also interacts with itself and the virus replication enhancer protein (REn), which is another essential component of the geminivirus replicase complex that interacts with host DNA polymerases α and δ. Recent studies revealed the structural and functional complexities of geminivirus Rep, which is believed to have evolved from plasmids containing a signature domain (HUH) for single-stranded DNA binding with nuclease activity. The Rep coding sequence encompasses the entire coding sequence for AC4, which is intricately embedded within it, and performs several overlapping functions like Rep, supporting virus infection. This review investigated the structural and functional diversity of the geminivirus Rep.

Surgeon's Experience May Circumvent Operative Volume in Improving Early Outcomes After Pancreaticoduodenectomy.

Introduction Pancreaticoduodenectomy (PD) is a complex procedure with a significant proportion of postoperative complications and improving but notable mortality. PD was the prototype procedure that initiated the lingering debate about the relationship of better operative outcomes when performed at higher-volume centers. This has not translated into practice. Impediments include the absence of a universally accepted definition of a high-volume center among others. Contrary evidence suggests equivalent outcomes for PD at low-volume centers when performed by experienced hepatobiliary surgeons. We reviewed our perioperative outcomes for PD from an earlier period as a low-volume center with an experienced team. Methods A longitudinal study of all PDs completed in our department between 2012 and 2017 was performed. Results A total of 28 PD were performed during this period. Pylorus-preserving PD was performed in 23 patients and classical PD in the remaining. A separate Roux-en-Y loop was used for high-risk pancreatic anastomosis in six cases. The mean patient age was 49.3±12.4 years. The male-to-female ratio was 1.3:1. Preoperative drainage procedures were carried out in 19 patients. The mean serum total bilirubin level was 3.98(±4.5) mg/dL. There was no 90-day mortality. Postoperative complications included wound infection in 10 (36.7%) and respiratory complications in 10 (36.7%) patients. Postoperative bleeding requiring intervention occurred in one patient, and two patients had an anastomotic leak (one pancreatojejunostomy (PJ) and one gastrojejunostomy (GJ)). Delayed gastric emptying (DGE) was noted in three (10.7%) patients. The mean length of hospital stay was 14±7 days. The median overall survival (OS) was 84 months. Conclusion Comparable early outcomes can be achieved at low-volume centers for patients undergoing PD with an experienced team, optimal patient selection, and the ability to rescue for complications.

Predictors and disparities in neonatal and under 5 mortality in rural Pakistan: cross sectional analysis.

Background: Adopted in 2015, the sustainable development goals (SDGs) have set specific targets (SDG 3.2) for countries to reduce their neonatal mortality rate (NMR) to below 12 deaths per 1000 live births and under 5 mortality rate (U5MR) to below 25 deaths per 1000 live births by 2030. For Pakistan to achieve these targets, there is a need to measure these rates and understand the predictors of child mortality at sub-national level. Launched in 2016, the Umeed-e-Nau (UeN) or New Hope project is based on scaling up proven and effective Maternal and Newborn Child Health (MNCH) interventions in 8 of the highest burden districts of the country, using existing public sector platforms in Pakistan at both the community and facility level. The primary aim of the project is to reduce perinatal mortality in these districts by 20% from baseline. Methods: We report overall neonatal and post neonatal mortality rates for the two years preceding the UeN baseline household survey. Rates were calculated using the synthetic cohort probability method and predictors of neonatal and post neonatal mortality examined using Cox regression. To investigate spatial variations in the mortality rates, we calculated Moran's I at the district level using predicted probabilities of mortality. Finally, we create district level maps of predicted under 5 child mortality using a stochastic partial differentiation approach. Findings: A total of 26,258 children contributed to the analysis of mortality with 838 deaths in the neonatal period and 2236 under-5 deaths during the observation period from March 1, 2015 to March 17, 2017. Overall, we estimated the NMR to be 29.2 per 1000 live births (95% CI: 26.9-31.4) and the U5MR to be 86.1 per 1000 live births (95% CI: 85.5-86.8). We found evidence of within-district geospatial clustering of under 5 mortality (P < 0.0001) and that social factors (poverty, illiteracy, multiparity), poor coverage of community health workers and distance from health facilities were strongly associated with child mortality. Interpretation: Important factors associated with neonatal and post-neonatal mortality in our study population included maternal education, parity, household size and gender. Additionally, antenatal care coverage (at least 4 visits) was specifically associated with neonatal mortality only, whereas, LHW coverage and distance to health facility were strongly associated with post-neonatal mortality. These findings emphasise the need for comprehensive, multisectoral strategies to be implemented for future maternal and child health programs and outreach services in rural areas. Funding: The study was funded by an unrestricted grant from the Bill & Melinda Gates Foundation to the Aga Khan University (Grant OPP 1148892).

The Responsiveness Of Childhood/Adolescent Chronic Myeloid Leukaemia Patients Of Pakistani Origin To Tyrosine Kinase Inhibitor.

Chronic myelogenous leukaemia is a disease in which bone marrow produces too many white blood cells. It is more common in middle age and its incidence is rare in children. Imatinib is the standard first-line treatment in chronic myeloid leukaemia. It improved the prognosis with lesser side effects. Our point of interest is to highlight its role in the paediatric age group. we present case series of a patient with chronic myeloid leukaemia responsive to imatinib. Because of the rare incidence of chronic myeloid leukaemia in this age room limited studies to explore the role of treatment modalities in the paeds group. Our case series highlights imatinib's effectiveness in treatment and improving the prognosis of the disease in this age group.

Genome-Wide Identification, Evolutionary and Mutational Analysis of the Buffalo Sox Gene Family.

The Sox gene family constitutes transcription factors with a conserved high mobility group box (HMG) that regulate a variety of developmental processes, including sex differentiation, neural, cartilage, and early embryonic development. In this study, we systematically analyzed and characterized the 20 Sox genes from the whole buffalo genome, using comparative genomic and evolutionary analyses. All the buffalo Sox genes were divided into nine sub-groups, and each gene had a specific number of exons and introns, which contributed to different gene structures. Molecular phylogeny revealed more sequence similarity of buffalo Sox genes with those of cattle. Furthermore, evolutionary analysis revealed that the HMG domain remained conserved in the all members of the Sox gene family. Similarly, all the genes are under strong purifying selection pressure; seven segmental duplications occurred from 9.65 to 21.41 million years ago (MYA), and four potential recombination breakpoints were also predicted. Mutational analysis revealed twenty non-synonymous mutations with potential effects on physiological functions, including embryonic development and cell differentiation in the buffalo. The present study provides insights into the genetic architecture of the Sox gene family in buffalo, highlights the significance of mutations, and provides their potential utility for marker-assisted selection for targeted genetic improvement in buffalo.

Post Dural Puncture Subdural Hematoma: A Rare Iatrogenic Complication of Neuraxial Anesthesia.

Although post-dural puncture headache is a well-known complication of neuraxial anesthesia, subdural hematoma following epidural injection is a rare but potentially under-recognized complication. The following is the case of a young female patient with no significant past medical history who developed a persistent and severe headache following the introduction of epidural anesthesia for labor induction. Imaging demonstrated multiple small subdural hematomas with findings concerning intracranial hypotension. She eventually underwent a blood patch and reported immediate relief from her headache.

Comparison of fasting and random lipid profiles among subjects with type 2 diabetes mellitus: an outpatient-based cross-sectional study in Bangladesh.

BACKGROUND: Despite the wide acceptability of fasting lipid profiles in practice, emerging evidence suggests that random lipid profiles might be a convenient alternative for lipid measurement. The objective of the present study was to compare the fasting and random lipid profile among subjects with type 2 diabetes mellitus (T2DM). METHODS: The present cross-sectional study included 1543 subjects with T2DM visiting several endocrinology outpatient clinics throughout Bangladesh from January to December 2021. The fasting lipid profile was measured in the morning following 8-10 h of overnight fasting, and the random lipid profile was measured at any time of the day, irrespective of the last meal. The values of fasting and random lipids were compared using the Wilcoxon signed-rank test and Spearman rank correlation coefficients. RESULTS: In this study, a good level of correlation was observed between fasting and random lipid levels [r = 0.793, p < 0.001 for triglyceride (TG); r = 0.873, p < 0.001 for low-density lipoprotein cholesterol (LDL-C); r = 0.609, p < 0.001 for high-density lipoprotein cholesterol (HDL-C); and r = 0.780, p < 0.001 for total cholesterol (TC)]. In addition, TG and TC levels increased by 14% and 0.51%, respectively, in the random state compared to the fasting state (p- <0.05), while LDL-C levels decreased by 0.71% (p-value 0.42). No change was noticed in the HDL-C level. The difference between fasting and random lipid profiles was similar irrespective of patients' age, sex, BMI, glucose-lowering drug(s), and lipid-lowering therapy. CONCLUSIONS: Random lipid profile correlates significantly with fasting lipid profile with little difference. Hence, it might be a reliable alternative for fasting lipid profile in patients with T2DM.

Randomized Trial of Early Detection and Treatment of Postpartum Hemorrhage.

BACKGROUND: Delays in the detection or treatment of postpartum hemorrhage can result in complications or death. A blood-collection drape can help provide objective, accurate, and early diagnosis of postpartum hemorrhage, and delayed or inconsistent use of effective interventions may be able to be addressed by a treatment bundle. METHODS: We conducted an international, cluster-randomized trial to assess a multicomponent clinical intervention for postpartum hemorrhage in patients having vaginal delivery. The intervention included a calibrated blood-collection drape for early detection of postpartum hemorrhage and a bundle of first-response treatments (uterine massage, oxytocic drugs, tranexamic acid, intravenous fluids, examination, and escalation), supported by an implementation strategy (intervention group). Hospitals in the control group provided usual care. The primary outcome was a composite of severe postpartum hemorrhage (blood loss, ≥1000 ml), laparotomy for bleeding, or maternal death from bleeding. Key secondary implementation outcomes were the detection of postpartum hemorrhage and adherence to the treatment bundle. RESULTS: A total of 80 secondary-level hospitals across Kenya, Nigeria, South Africa, and Tanzania, in which 210,132 patients underwent vaginal delivery, were randomly assigned to the intervention group or the usual-care group. Among hospitals and patients with data, a primary-outcome event occurred in 1.6% of the patients in the intervention group, as compared with 4.3% of those in the usual-care group (risk ratio, 0.40; 95% confidence interval [CI], 0.32 to 0.50; P<0.001). Postpartum hemorrhage was detected in 93.1% of the patients in the intervention group and in 51.1% of those in the usual-care group (rate ratio, 1.58; 95% CI, 1.41 to 1.76), and the treatment bundle was used in 91.2% and 19.4%, respectively (rate ratio, 4.94; 95% CI, 3.88 to 6.28). CONCLUSIONS: Early detection of postpartum hemorrhage and use of bundled treatment led to a lower risk of the primary outcome, a composite of severe postpartum hemorrhage, laparotomy for bleeding, or death from bleeding, than usual care among patients having vaginal delivery. (Funded by the Bill and Melinda Gates Foundation; E-MOTIVE ClinicalTrials.gov number, NCT04341662.).

Incidence and Cross-Continents Differences in Endoscopic Retrograde Cholangiopancreatography Outcomes Among Patients With Cirrhosis: A Systematic Review and Meta-Analysis.

Background: There are conflicting data on the frequency and variability of endoscopic retrograde cholangiopancreatography (ERCP) outcomes in patients with cirrhosis. Our aim was to systematically review the literature on the incidence of post-ERCP adverse events in cirrhotic patients and to examine the differences across continents. Methods: We searched PubMed/MEDLINE, EMBASE, Scopus, and Cochrane databases to identify studies reporting adverse events after ERCP in patients with cirrhosis from conception to September 30, 2022. The random effects model was used to calculate odds ratios (ORs), mean differences (MDs), and confidence intervals (CIs). A P value < 0.05 was considered statistically significant. Heterogeneity was assessed using the Cochrane Q-statistic (I2). Results: Twenty-one studies that included 2,576 cirrhotic patients and 3,729 individual ERCPs were analyzed. The pooled overall rate of adverse events after ERCP in patients with cirrhosis was 16.98% (95% CI: 13.06-21.29%, P < 0.001, I2 = 86.55%). ERCPs performed in Asia had the highest ERCP adverse events with an overall complication rate of 19.90%, while the lowest overall adverse events were in North America at 13.04%. The pooled post-ERCP bleeding, pancreatitis, cholangitis and perforation were 5.10% (95% CI: 3.33-7.19%, P < 0.001, I2 = 76.79%), 3.21% (95% CI: 2.20-5.36%, P = 0.03, I2 = 42.25%), 3.02% (95% CI: 1.19-5.52%, P < 0.001, I2 = 87.11%), and 0.12% (95% CI: 0.00 - 0.45, P = 0.26, I2 = 15.76%), respectively. The pooled post-ERCP mortality rate was 0.22% (95% CI: 0.00-0.85%, P = 0.01, I2 = 51.86%). Conclusions: This meta-analysis shows that the overall complication rates after ERCP, bleeding, pancreatitis, and cholangitis are high in patients with cirrhosis. Because cirrhotic patients are more likely to have post-ERCP complications, with significant cross-continent variations, the risks and benefits of ERCP in this patient population should be carefully considered.

Sexual dysfunction in women with type 2 diabetes mellitus: A single-centre cross-sectional study from Bangladesh.

Objective: Sexual dysfunction among women with diabetes is a common but neglected health issue worldwide. The objective of the present study was to investigate the prevalence of sexual dysfunction and its associated factors among women with type 2 diabetes mellitus (T2DM). Subjects and methods: This cross-sectional comparative study comprises 150 women with diabetes and 100 healthy women without diabetes who visited the endocrinology outpatient department of Mymensingh Medical College Hospital (MMCH). The data were collected from July to December 2019. Sexual dysfunction was assessed by the 19-item Female Sexual Function Index (FSFI). Informed consent was obtained before participation. Collected data were analysed by SPSS 26. Results: More women with diabetes than control subjects reported sexual dysfunction (79% vs. 72%; p = 0.864). The global FSFI score was lower among the diabetes patients than among the healthy controls (20.8 ± 7.2 vs. 23.7 ± 4.8; p < 0.001). Patients with T2DM scored significantly lower in the domains of desire (p = 0.04), lubrication (p = 0.01), orgasm (p = 0.01), and satisfaction (p < 0.001), but not the domain of arousal (p = 0.09). A prolonged duration of diabetes was the primary contributor to orgasm problems (adjusted odds ratio, aOR 1.3, 95% CI 1.1-1.7) and painful intercourse (aOR 1.2, 95% CI 1.1- 1.5). Conclusion: Sexual problems are frequent in women with diabetes. Inclusion of sexual health in comprehensive diabetes management is crucial to address this problem as well as to improve the quality of life of female diabetes patients.

Risk stratification using the 2021 IDF-DAR risk calculator and fasting experience of Bangladeshi subjects with type 2 diabetes in Ramadan: The DAR-BAN study.

Aims: To risk-stratify patients with type 2 diabetes mellitus (T2DM) according to the IDF-DAR 2021 guidelines and observe their responsiveness to risk-category-based recommendations and fasting experience. Methods: This prospective study, conducted in the peri-Ramadan period of 2022, evaluated adults with T2DM and categorized them using the IDF-DAR 2021 risk stratification tool. Recommendations for fasting according to the risk categories were made, their intention to fast was recorded, and follow-up data were collected within one month of the end of Ramadan. Results: Among 1328 participants (age 51.1 ± 11.9 years, female 61.1 %), only 29.6 % had pre-Ramadan HbA1c < 7.5 %. According to the IDF-DAR risk category, the frequencies of participants in the low-risk (should be able to fast), moderate-risk (not to fast), and high-risk (should not fast) groups were 44.2 %, 45.7 %, and 10.1 %, respectively. Most (95.5 %) intended to fast, and 71 % fasted the full 30 days of Ramadan. The overall frequencies of hypoglycemia (3.5 %) and hyperglycemia (2.0 %) were low. Hypoglycemia and hyperglycemia risks were 3.74-fold and 3.86-fold higher in the high-risk group than in the low-risk group. Conclusion: The new IDF-DAR risk scoring system seems conservative in the risk categorization of T2DM patients in terms of fasting complications.