Lower opportunity ZIP code is associated with worse outcomes after listing in pediatric heart transplantation.

BACKGROUND: The Child Opportunity Index (COI) comprehensively measures children's social determinants of health. We describe association between COI and outcomes after listing for heart transplantation. METHODS: We conducted a retrospective review of the United Network for Organ Sharing (UNOS) database for U.S. children listed for heart transplant between 2012 and 2020. ZIP codes were utilized to assign COI. Primary outcome was survival from time of listing. Secondary outcomes included waitlist survival, 1-year post-transplant survival, and conditional 1-year post-transplant survival. Cox regression was performed adjusting for payor, age, race, diagnosis, and support at listing for all outcomes except waitlist survival, for which Fine-Gray competing risk analysis was performed. RESULTS: Of 5,723 children listed, 109 were excluded due to missing ZIP codes. Race/ethnicity and payor were associated with COI (p < 0.001). Patients living in very low COI ZIP codes compared to all others had increased mortality from time of listing (HR 1.16, CI 1.03-1.32, p = 0.02) with 1-, 5-, and 9-year survival of 79.3% vs 82.2%, 66.5% vs 73.0%, and 53.6% vs 64.7% respectively, were more likely to be removed from the waitlist due to death or being too sick (subdistribution HR 1.26, 95% CI 1.10-1.42), and had increased mortality conditional on one-year post-transplant survival (HR 1.38, 1.09-1.74, p = 0.008) with 1-, 3-, and 5- year survival of 94.7% vs 97.3%, 87.0% vs 93.1%, and 78.6% vs 86.9%. CONCLUSIONS: Children living in lower opportunity ZIP codes had poorer survival from time of listing, poorer waitlist survival, and poorer conditional one-year post-transplant survival.

Informal E -waste recycling in nine cities of Pakistan reveals significant impacts on local air and soil quality and associated health risks.

The global increase in electronic waste (e-waste) has led to a rise in informal recycling, emitting hazardous heavy metals (HMs) that threaten human health and ecosystems. This study presents the first comprehensive assessment of HM levels in dry deposition and soils at proximity of forty (40) informal e-waste recycling sites across Pakistan, between September 2020 to December 2021. Findings reveal that Zn (1410), Pb (410) and Mn (231) exhibited the higher mean deposition fluxes (µg/m2.day), derived from air samples, particularly in Karachi. Similarly, soils showed higher mean concentrations (µg/g dw) of Mn (477), Cu (514) and Pb (172) in Faisalabad, Lahore, and Karachi, respectively. HMs concentrations were found higher in winter or autumn and lower in summer. In addition, HM levels were significantly (p = 0.05) higher at recycling sites compared to background sites year-round, highlighting the e-waste recycling operations as the major source of their emissions. The Igeo index indicated moderate to extremely contaminated levels of Cu, Pb, Cd, and Ni in Karachi, Lahore and Gujranwala. Ingestion was found as a leading human exposure route, followed by dermal and inhalation exposure, with Pb posing the greatest health risk. The Cumulative Incremental Lifetime Cancer Risk (ILCR) model suggested moderate to low cancer risks for workers. Strategic interventions recommend mitigating health and environmental risks, prioritizing human health and ecosystem integrity in Pakistan's e-waste management.

Intravenous prostacyclins for right ventricular failure following left ventricular assist device in paediatric heart failure.

Right ventricular failure after placement of left ventricular assist device in paediatric heart failure is associated with increased mortality. We report successful use of intravenous prostacyclin for right ventricular support and pulmonary hypertension after initiation of left ventricular assist device support. This suggests that intravenous prostacyclins may be an important therapy in right ventricular failure following ventricular assist device implantation.

Knowledge and Attitude of Cervical Cancer Screening and Vaccination in Patients Attending Gynecology Outpatient Clinic at a Tertiary Care Hospital in Pakistan.

Shamaila ShamaunBackground Cervical cancer is the third most prevalent female cancer in Pakistan; nearly 70% present at a very advanced stage of malignancy due to lack of awareness, proper screening, and vaccination. Therefore, we aimed to assess the knowledge and attitude toward screening, vaccination, and risk factors of cervical cancer in sexually active women of Pakistan. Methods This cross-sectional study was conducted at the gynecology outpatient clinic of a public sector hospital in Karachi, Pakistan, from December 2021 to March 2022. We included sexually active women with exception of diagnosed cases of cervical cancer, pregnancy, vaginal bleeding, and psychological disorder. Collected data were regarding demographic characteristics, awareness regarding cervical cancer, screening, human papillomavirus (HPV) vaccine, and risk factors, history of cervical screening, and wiliness to opt-in for cervical screening. Results We included 226 women with a mean age of 41.25 ± 10.54 years. The mean parity level was observed to be 3.8 ± 1.95. A majority of women were housewives by profession (88.9%) and uneducated (61.9%). Only 41.2% (93) of women were aware of cervical cancer, 33.6% (76) were aware of cervical screening, and only 15.9% (36) had a history of cervical screening. Only four women (1.8%) were aware of the HPV vaccine and 31% (70) showed intention to opt-in for cervical screening. A vast majority of women (96.9%) were not aware of the risk factors of cervical cancer. Conclusion(s) We have observed poor awareness regarding cervical cancer, HPV vaccination, and cervical screening among women in our population. Lack of awareness was not restricted to a certain segment but it prevails all across the demographic in our population.

Machine Learning for Pediatric Echocardiographic Mitral Regurgitation Detection.

BACKGROUND: Echocardiography-based screening for valvular disease in at-risk asymptomatic children can result in early diagnosis. These screening programs, however, are resource intensive and may not be feasible in many resource-limited settings. Automated echocardiographic diagnosis may enable more widespread echocardiographic screening, early diagnosis, and improved outcomes. In this feasibility study, the authors sought to build a machine learning model capable of identifying mitral regurgitation (MR) on echocardiography. METHODS: Echocardiograms were labeled by clip for view and by frame for the presence of MR. The labeled data were used to build two convolutional neural networks to perform the stepwise tasks of classifying the clips (1) by view and (2) by the presence of any MR, including physiologic, in parasternal long-axis color Doppler views. The view classification model was developed using 66,330 frames, and model performance was evaluated using a hold-out testing data set with 45 echocardiograms (11,730 frames). The MR detection model was developed using 938 frames, and model performance was evaluated using a hold-out testing data set with 42 echocardiograms (182 frames). Metrics to evaluate model performance included accuracy, precision, recall, F1 score (average of precision and recall, ranging from 0 to 1, with 1 suggesting perfect precision and recall), and receiver operating characteristic analysis. RESULTS: For the parasternal long-axis view with color Doppler, the view classification convolutional neural network achieved an F1 score of 0.97. The MR detection convolutional neural network achieved testing accuracy of 0.86 and an area under the receiver operating characteristic curve of 0.91. CONCLUSIONS: A machine learning model is capable of discerning MR on transthoracic echocardiography. This is an encouraging step toward machine learning-based diagnosis of valvular heart disease on pediatric echocardiography.

Evaluation of Seizure Risk in Infants After Cardiopulmonary Bypass in the Absence of Deep Hypothermic Cardiac Arrest.

BACKGROUND: Guidelines recommend evaluation for electrographic seizures in neonates and children at risk, including after cardiopulmonary bypass (CPB). Although initial research using screening electroencephalograms (EEGs) in infants after CPB found a 21% seizure incidence, more recent work reports seizure incidences ranging 3-12%. Deep hypothermic cardiac arrest was associated with increased seizure risk in prior reports but is uncommon at our institution and less widely used in contemporary practice. This study seeks to establish the incidence of seizures among infants following CPB in the absence of deep hypothermic cardiac arrest and to identify additional risk factors for seizures via a prediction model. METHODS: A retrospective chart review was completed of all consecutive infants ≤ 3 months who received screening EEG following CPB at a single center within a 2-year period during 2017-2019. Clinical and laboratory data were collected from the perioperative period. A prediction model for seizure risk was fit using a random forest algorithm, and receiver operator characteristics were assessed to classify predictions. Fisher's exact test and the logrank test were used to evaluate associations between clinical outcomes and EEG seizures. RESULTS: A total of 112 infants were included. Seizure incidence was 10.7%. Median time to first seizure was 28.1 h (interquartile range 18.9-32.2 h). The most important factors in predicting seizure risk from the random forest analysis included postoperative neuromuscular blockade, prematurity, delayed sternal closure, bypass time, and critical illness preoperatively. When variables captured during the EEG recording were included, abnormal postoperative neuroimaging and peak lactate were also highly predictive. Overall model accuracy was 90.2%; accounting for class imbalance, the model had excellent sensitivity and specificity (1.00 and 0.89, respectively). CONCLUSIONS: Seizure incidence was similar to recent estimates even in the absence of deep hypothermic cardiac arrest. By employing random forest analysis, we were able to identify novel risk factors for postoperative seizure in this population and generate a robust model of seizure risk. Further work to validate our model in an external population is needed.

Legacy and emerging flame retardants (FRs) in the urban atmosphere of Pakistan: Diurnal variations, gas-particle partitioning and human health exposure.

Atmospheric concentration of legacy (LFRs) and emerging flame retardants (EFRs) including 8 polybrominated diphenyl ethers (PBDEs), 6 novel brominated flame retardants (NBFRs), 2 dechlorane plus isomers (DP), and 8 chlorinated organophosphate flame retardants (OPFRs) were consecutively measured in eight major cities across Pakistan. A total of 96 samples (48 PM2.5 & 48 PUFs) were analyzed and the concentrations of ∑8PBDEs (gaseous+particulate) ranged between 40.8 and 288 pg/m3 with an average value of 172 pg/m3. ∑6NBFRs ranged between 12.0 and 35.0 pg/m3 with an average value of 22.5 pg/m3 while ∑8OPFRs ranged between 12,900-40,800 pg/m3 with an average of 24,700 pg/m3. Among the studied sites, Faisalabad city exhibited the higher concentrations of FRs among all cities which might be a consequence of textile mills and garment manufacturing industries. While analyzing the diurnal patterns, OPFRs depicted higher concentrations during night-time. The estimated risks of all groups of FRs from inhalation of ambient air were negligible for all the cities, according to USEPA guidelines. Nonetheless, our study is the first to report gaseous and particulate concentrations of FRs in air on a diurnal basis across major cities in Pakistan, offering insights into the atmospheric fate of these substances in urban areas in a sub-tropical region.

Assessing the generation, recycling and disposal practices of electronic/electrical-waste (E-Waste) from major cities in Pakistan.

Rapid increase in the quantity of electronic/electrical-waste (e-waste) has become an emerging issue throughout the world. To avoid higher expenditures on safe disposal and recycling, large quantities of e-waste are being exported from developed to developing countries like Pakistan. Emerging issue of e-waste in Pakistan demands its effective management strategy for the country. However, it cannot be achieved until assessment of e-waste quantification and disposal is carried out. The main objective of this study was to quantify the e-waste inventory and it's processing from major cities of Pakistan to evaluate its generation (domestic/import) and recycling practices. This study comprises the information of only those e-waste items (desktop computers, laptops/notebooks, computer monitors and liquid-crystal display units) which form the major portion of e-waste imported to Pakistan. Survey based data collected from three major cities/areas have been extrapolated to develop an e-waste generation inventory for the country. The study reveals that approximately 50 kt of e-waste is being imported as scrap in addition to its local generation of about 38 kt per year. During field visits and data collection surveys, it has been observed that the processing of e-waste in the country is being carried out in crude manner without safety gears. Findings of our study strongly recommend dire need for urgent and effective monitoring as well as control of informal e-waste management in Pakistan.

E-Waste Driven Pollution in Pakistan: The First Evidence of Environmental and Human Exposure to Flame Retardants (FRs) in Karachi City.

Informal e-waste recycling activities have been shown to be a major emitter of organic flame retardants (FRs), contributing to both environmental and human exposure to laborers at e-waste recycling sites in some West African countries, as well as in China and India. The main objective of this study was to determine the levels of selected organic FRs in both air and soil samples collected from areas with intensive informal e-waste recycling activities in Karachi, Pakistan. Dechlorane Plus (DP) and "novel" brominated flame retardants (NBFRs) were often detected in high concentrations in soils, while phosphorus-based FRs (OPFRs) dominated atmospheric samples. Among individual substances and substance groups, decabromodiphenyl ether (BDE-209) (726 ng/g), decabromodiphenyl ethane (DBDPE) (551 ng/g), 1,2-bis(2,4,6-tribromophenoxy) ethane (BTBPE) (362 ng/g), and triphenyl-phosphate (∑TPP) (296 ng/g) were found to be prevalent in soils, while OPFR congeners (5903-24986 ng/m3) were prevalent in air. The two major e-waste recycling areas (Shershah and Lyari) were highly contaminated with FRs, suggesting informal e-waste recycling activities as a major emission source of FRs in the environment in Karachi City. However, the hazards associated with exposure to PM2.5 appear to exceed those attributed to exposure to selected FRs via inhalation and soil ingestion.

Polycyclic aromatic hydrocarbons (PAHs) in Chinese forest soils: profile composition, spatial variations and source apportionment.

Previous studies reported that forest ecosystems can play a vital role in scavenging anthropogenic polycyclic aromatic hydrocarbons (PAHs) and act as primary reservoirs of these environmental pollutants. The present study aimed to investigate the occurrence, spatial pattern and source apportionment of PAHs across Chinese background forest soils (O- & A-horizons). The 143 soils collected from 30 mountains showed significantly (p < 0.05) higher levels of ∑15PAHs (ng g-1 dw) in O-horizon (222 ± 182) than A-horizon (168 ± 161). A progressive increase in the levels of lighter PAHs was observed along altitudinal gradient, however heavier PAHs did not show any variations. Carbon contents (TOC & BC) of forest soils were found weakly correlated (p < 0.01) with low molecular weight (LMW)-PAHs but showed no relation with high molecular weight (HMW)-PAHs. Source apportionment results using PMF and PCA revealed that PAHs in forest soils mainly come from local biomass burning and/or coal combustion and attributed that forest soils may become a potential sink for PAHs in the region.

Legacy and emerging flame retardants (FRs) in the freshwater ecosystem: A review.

In this review article, we have compiled and reviewed the previously published available literature on environmental distribution, behaviour, fate and regional trends of legacy and emerging flame retardants (FRs) including brominated (BFRs), organo-phosphate (OPFRs), novel brominated flame retardants (NBFRs) and dechlorane plus (DP) in the freshwater ecosystem. Transport and fate is discussed briefly with the evidences of de-bromination, sedimentation and accumulation in biota. De-bromination of BDE-209 is considered of concern because the lower brominated congeners are more toxic and mobile thus posing increased risk to the freshwater ecosystem. The available data on temporal and spatial trends as yet, is too few to show any consistent trends, enabling only general conclusions to be drawn. There is a lack of temporal studies in Asia, while, overall the trends are mixed, with both increasing and decreasing concentrations of BFRs and OPFRs. OPFRs and NBFRs have replaced classical BFRs (polybrominated diphenyl ethers (PBDEs)) in some countries but the amount of PBDEs in the environment is still considerable. Knowledge gaps and recommendations for future research are discussed emphasizing on further monitoring, advanced analytical methodologies, and risk assessment studies to completely understand the science of flame retardants in the freshwater ecosystem.

ASSESSING THE KNOWLEDGE, ATTITUDES AND PRACTICES OF SCHOOL TEACHERS REGARDING DYSLEXIA, ATTENTION-DEFICIT/ HYPERACTIVITY AND AUTISTIC SPECTRUM DISORDERS IN KARACHI, PAKISTAN.

BACKGROUND: Learning impairments in children consist of a spectrum of disorders that are under diagnosed in Pakistan. Most learning disorders have long term consequences for a child and early detection is thus imperative. Teachers may be able to play a key role in such identification. The objective of our study was to survey knowledge, attitudes and practices of school teachers regarding dyslexia, Attention-deficit/hyperactivity disorder (ADHD) and autistic spectrum disorder, and assess their ability to identify learning disabilities. METHODS: A cross-sectional study was conducted with 233 primary school teachers from Karachi using a self-administered questionnaire. RESULTS: Mean scores for the knowledge test and the ability to identify learning- impaired children were 58.8% and 53.3%, respectively. Better qualified teachers scored significantly more on the knowledge and ability to identify learning impairments sections. Most teachers believed that these students should study in mainstream schools with special educators. Majority of the teachers belonged to schools where children with learning disabilities were detected using teachers' judgment. Most teachers manage these children by involving them in discussions, seating them at the front of the class, and giving them extra time. CONCLUSION: Knowledge about learning disabilities is very low amongst school teachers, which may limit their ability to identify learning impairments.

The relative abundance and seasonal distribution correspond with the sources of polycyclic aromatic hydrocarbons (PAHs) in the surface sediments of Chenab River, Pakistan.

Chenab River is one of the most important rivers of Punjab Province (Pakistan) that receives huge input of industrial effluents and municipal sewage from major cities in the Central Punjab, Pakistan. The current study was designed to evaluate the concentration levels and associated ecological risks of USEPA priority polycyclic aromatic hydrocarbons (PAHs) in the surface sediments of Chenab River. Sampling was performed from eight (n = 24) sampling stations of Chenab River and its tributaries. We observed a relatively high abundance of ∑16PAHs during the summer season (i.e. 554 ng g(-1)) versus that in the winter season (i.e. 361 ng g(-1)), with an overall abundance of two-, five- and six-ring PAH congeners. Results also revealed that the nitrate and phosphate contents in the sediments were closely associated with low molecular weight (LMW) and high molecular weight (HMW) PAHs, respectively. Source apportionment results showed that the combustion of fossil fuels appears to be the key source of PAHs in the study area. The risk quotient (RQ) values indicated that seven PAH congeners (i.e. phenanthrene, anthracene, fluoranthene, pyrene, benzo(a)pyrene, chrysene and benzo(a)anthracene) could pose serious threats to the aquatic life of the riverine ecosystem in Pakistan.

Emerging issue of e-waste in Pakistan: A review of status, research needs and data gaps.

This review article focuses on the current situation of e-waste in Pakistan with the emphasis on defining the major e-waste recycling sites, current and future domestic generation of e-waste, hidden flows or import of e-waste and discusses various challenges for e-waste management. Needed policy interventions and possible measures to be taken at governmental level are discussed to avoid the increasing problem of e-waste in the country. Our findings highlight that there is still a general lack of reliable data, inventories and research studies addressing e-waste related issues in the context of environmental and human health in Pakistan. There is therefore a critical need to improve the current knowledge base, which should build upon the research experience from other countries which have experienced similar situations in the past. Further research into these issues in Pakistan is considered vital to help inform future policies/control strategies as already successfully implemented in other countries.

Equitable access to comprehensive surgical care: the potential of indigenous private philanthropy in low-income settings.

INTRODUCTION: Equitable access to surgical care is necessary for improving global health. We report on the performance, financial sustainability, and policy impact of a free-of-cost multispecialty surgical delivery program in Karachi, Pakistan built upon local private philanthropy. MATERIALS AND METHODS: We evaluated trends in surgical service delivery, expenditures, and philanthropic donations from Indus Hospital's first 5 years of operation (2007-2012), projected these over the hospital's current expansion phase, compared these to publicly accessible records of other philanthropic hospitals providing surgical care, and documented the government's evolving policies toward this model. RESULTS: Between 2007 and 2012, Indus Hospital treated 40,012 in-patients free of cost, 33,606 (84 %) of them for surgical procedures. Surgical procedures increased fivefold to 9,478 during 2011-2012 from 1,838 during 2007-2008. Bed occupancy increased to 91 % from 65 % over the same period. External surgical missions accounted for less than 0.5 % of patients served. Ninety-eight percent (98 %) of all philanthropic donations--totaling USD 26.6 million over 2007-2012--were locally generated. Zakat (obligatory annual religious alms in the Islamic faith) constituted 34 % of all donations, followed by unrestricted funds (24 %) and donations-in-kind (24 %), buildings (12 %), grants (5 %), and return on investments (1 %). Overall, donations received between 2007 and 2012 increased sevenfold, with Zakat increasing 12-fold. During 2013-2014, the Government of Pakistan provided land lease and annual operational grants totaling USD 9 million. CONCLUSIONS: Local philanthropy can sustain and grow the provision of free, high-quality surgical care in low-income settings, and encourage the development of hybrid government-philanthropic models of surgical care.