Listening to Caregivers: Narratives of Health Seeking for Children Under Five with Pneumonia and Diarrhea: Insights from the NIGRAAN Trial in Pakistan.

Background: Understanding health-seeking behaviors of caregivers is important to reduce child mortality. Several factors influence decision-making related to childhood illnesses. Objective: The objective of this study was to gather caretaker narratives to develop a comprehensive understanding of the context and process of caregiving at household level during all stages of an episode of diarrhea and pneumonia in children <5. Methods: Using a narrative interview approach, stories from caregivers of children <5 were collected from a rural district in Sindh Pakistan. Eleven households with children <5 were randomly selected and purposive sampling was done to interview 20 caregivers. All data collection was conducted privately in participants' homes and informed consent taken. Manual content analysis was carried out by three independent researchers and emerging themes drawn. Results: The role of joint family system is integral in making decisions and the child's paternal grandmother, is an important and trusted source of information regarding child sickness in the household. They often promote home remedies with considerable authority prior to formal consultation with the health care system. Caregivers were generally dissatisfied with doctors in the public sector who were perceived to be providing free consultation with a poor quality of care and long waiting time as compared to private doctors. Financial considerations and child support were favorably addressed in households with a joint family system. Conclusion: The joint family system provides a strong support system, but also tends to reduce parental autonomy in decision-making and delay first contact with formal health providers. Prevalent home remedies, and authority of elders in the family influence management practices. Interventions for reducing improving child mortality should be cognizant of the context of decision-making and social influences at the household level.

Beyond survival: unraveling the adaptive mechanisms of cucurbit weeds to salt and heavy metal stress through biochemical and physiological analyses.

Salt stress and heavy metal are instigating hazard to crops, menace to agricultural practices. Single and combined stresses affecting adversely to the growth and metabolism of plants. To explore salt and heavy metal resistant plant lines as phytoremediants is a need of time. Physiological responses are main adaptive responses of the plants towards stresses. This response varies with species and ecotype as well as type and level of stress. Two cucurbit weeds from two ecotypes were selected to evaluate their physiological adaptations against independent and combined stresses of various levels of salt (NaCl) and heavy metal (NiCl2). Various physiological parameters like water potential, osmotic potential, pressure potential, CO2 assimilation rate, stomatal conductance, chlorophyll a and b, carotenoids, and production of adaptive chemicals like SOD, CAT, proteins, sugars and proline were studied. Citrullus colocynthis showed more adaptive response than Cucumis melo agrestis and desert ecotype was more successful than agricultural ecotype against stresses.

Study of digestive enzymes in marine fish, Terapon jarbua, from Pakistan.

Current analysis were performed to investigate the activity of various digestive enzymes, such as lipases, proteases and amylases in gut and their relationship to the other morphometric variables in a wild marine fish, Terapon jarbua. The descriptive data of the studied traits included fish weight, fish total length, gut weight, gut length, relative gut length, relative gut mass, Fulton's condition factor, standard length and Zihler's index. Gut length showed positive correlation with fish total length and gut weight, relative gut length (RGL) showed positive correlation with gut length. Relative gut mass (RGM) also showed positive correlation with total length (TL), gut weight (GW) and gut length (GL). Fulton's condition factor showed positive correlation with fish weight, while negative correlation with fish total length and relative gut mass. Standard length displayed positive correlation with gut weight and gut length while, it showed negative correlation with Fulton's factor. Zihler's Index displayed positive correlation with gut length, RGL and Zihler's RGM while, while showed negative correlation with Fulton's factor and fish weight. Lipase showed negative correlation with gut weight. Amylase and protease activity have no correlation with other studied traits. Lipase activity displayed negative significant correlation with gut weight. Lipase activity showed significantly negative effect on gut-weight. Amylase activity on y-axis (PC2) contributed 13% in variation but not significantly correlated with first two principal components. It showed non-significant negative correlation with fish weight, fish length and Fulton's factor while positive but not-significant correlation with other traits. Protease has positive and non-significant correlation with fish weight, RGL, Fulton's factor, lipase and amylase while non-significant negative correlation with all other traits.

Orofacial Mycoses in Coronavirus Disease-2019 (COVID-19): A Systematic Review.

OBJECTIVES: Studies reviewing orofacial mycoses in coronavirus disease-2019 (COVID-19) caused by severe acute respiratory syndrome 2 (SARS-CoV-2) infection are sparse. Here we review the major oral and maxillofacial mycoses of COVID-19, the associated comorbidities, and the probable precipitating factors. METHODS: English-language manuscripts published between March 2020 and October 2021 were searched using PubMed, OVID, SCOPUS, and Web of Science databases, using appropriate keywords. RESULTS: We identified 30 articles across 14 countries, which met the inclusion criteria of PRISMA guidelines. These yielded a total of 292 patients with laboratory-confirmed COVID-19, 51.4% (n = 150) of whom presented with oral and maxillofacial fungal infections, mainly comprising candidosis, mucormycosis, and aspergillosis. Candida infections were the most prevalent, present in 64% (n = 96), followed by mucormycosis, and only a single case of aspergillosis was noted. Oral and maxillofacial mycoses were predominantly seen in those with comorbidities, especially in those with diabetes (52.4%). Oral mucormycosis was noted in 8.6% (n = 13) and mainly manifested on the hard palate. An overall event rate of oral/maxillofacial mucormycosis manifestation in patients with COVID-19 with diabetes mellitus type 1/2 was about 94% (49/52; 95% confidence interval, 0.73%-0.89%), implying a very high association between diabetes mellitus and the latter condition. All fungal infections appeared either concurrently with COVID-19 symptoms or during the immediate recovery period. CONCLUSIONS: SARS-CoV-2 infection-related immunosuppression, steroid therapy, as well as comorbidities such as diabetic hyperglycemia appear to be the major predisposing factors for the onset of oral and maxillofacial mycoses in patients with COVID-19 across all age groups.

Comparative Analysis of the Efficacies of the GeneXpert and Solid Culture Media Techniques in the Diagnosis of Mycobacterium Tuberculosis.

Tuberculosis is one of the predominant infectious diseases causing significant deaths worldwide. Detection of Mycobacterium tuberculosis bacilli (MTB) using culture media was officially recognized by World Health Organization. However, there is a significant limitation in the authenticity of evaluation for its effectiveness on clinically important attributes. GeneXpert detects the presence of Mycobacterium tuberculosis (M. tuberculosis) based on the detection of nucleic acid and is able to identify the resistance of both isoniazid (INH) and Rifampicin (RIF) drugs. In this technique, DNA amplification is done using the GeneXpert instrument in the suspected sample with a specific reagent cartridge. Although GeneXpert is a rapid technique compared to other diagnostic tools for MTB identification due to false-negative results, the culture media technique is still considered the gold standard in detecting M. tuberculosis. The current study was designed to evaluate the comparative efficacies of GeneXpert and the solid culture media technique in identifying MTB. Sputum samples of 250 (n=250) suspected tuberculosis (TB) patients were investigated using both diagnostic techniques. The results revealed that out of the 250 suspected patients, 30 (12%) samples were positive with the culture media technique, while only 17 (6.8%) samples showed positive results with GeneXpert. Culture tests and GeneXpert are not equally efficient in detecting M. tuberculosis. The current study's findings showed that the culture-based detection method for M. tuberculosis is more efficient and reliable than GeneXpert.

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) viral positivity and their burden in saliva of asymptomatic carriers - a systematic review and meta-analysis.

AIMS: The coronavirus disease 2019 (COVID-19) due to the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) can present either as an asymptomatic carrier state or an acute respiratory disease, with or without severe pneumonia. The asymptomatic carriers are a challenge for the dental profession as the infection could be transmitted via virus-laden, and saliva in dental settings through aerosol-generating procedures (AGPSs). The aim of this review was to perform a systematic review of SARS-CoV-2 in the saliva of asymptomatic individuals. MATERIALS AND METHODS: PubMed, Google scholar, and MedRxiv databases were searched between and a systematic review and meta-analysis of the available data were performed to assess the viral burden in the saliva of asymptomatic carriers of SARS-CoV-2. All investigators of the included studies used qRT-PCR to detect SARS-CoV-2 and yield quantitative data (the Ct values) appertaining to the viral load. RESULTS: A total of 322 records in the English literature were identified, and eight studies with 2642 SARS-CoV-2-positive and asymptomatic individuals were included in the final analysis. Of these, 16.7% (95% CI: 11-23%) yielded SARS-CoV-2-positive saliva samples in comparison to 13.1% (95% CI: 12-17%) of the respiratory specimens (nasopharyngeal or nose-throat swabs). CONCLUSION: As approximately 1 in 5 to 1 in 10 asymptomatic individuals harbour SARS-CoV-2 in either saliva or respiratory secretions, our results highlight the need for continued vigilance and the critical importance of maintaining strict, additional infection control regimens for the foreseeable future to mitigate the potential risks of COVID-19 transmission in dentistry.

Bioaccumulation of heavy metals in the tissues of Schizothorax plagiostomus at River Swat / Bioacumulação de metais pesados nos tecidos de Plagiostomo esquizotórax em River Swat

Snow trout (Schizothorax plagiostomus) is an economically important freshwater fish, mostly found in northern areas of water reservoirs of Pakistan. The current study was conducted in River Swat to analyze the bioaccumulation of heavy metals (Pb, Cr, Ni, and Zn) in tissues of Schizothorax plagiostomus. Tissues were extracted and dissolved in perchloric acid (HClO4) and nitric acid (HNO3) along with hotplate. The heavy metals, zinc (Zn), lead (Pb), chromium (Cr), and Nickel (Ni) were determined using Perkin Elmer 2380 atomic absorption spectrophotometer. Results shows great variation in the content of the metal related to tissue type and sampling sites. A high concentration of bioaccumulation was reported at Charbagh, whereas lowest at Odigram: Charbagh>Landakai>Odigram. In the same way, Cr was the most accumulated heavy metal followed by lead, nickel, and Zinc.

A truta das neves (Schizothorax plagiostomus) é um peixe de água doce economicamente importante, encontrado principalmente nas áreas ao norte de reservatórios de água do Paquistão. O presente estudo foi realizado em River Swat para analisar a bioacumulação de metais pesados (Pb, Cr, Ni e Zn) em tecidos de Schizothorax plagiostomus. Os tecidos foram extraídos e dissolvidos em ácido perclórico (HClO4) e ácido nítrico (HNO3) com placa de aquecimento. Os metais pesados zinco (Zn), chumbo (Pb), cromo (Cr) e níquel (Ni) foram determinados usando espectrofotômetro de absorção atômica Perkin Elmer 2380. Os resultados mostram grande variação no conteúdo do metal relacionado ao tipo de tecido e locais de amostragem. Uma alta concentração de bioacumulação foi relatada em Charbagh, enquanto a mais baixa, em Odigram: Charbagh > Landakai > Odigram. Da mesma forma, Cr foi o metal pesado mais acumulado, seguido por Pb, Ni e Zn.

Bioaccumulation of heavy metals in the tissues of Schizothorax plagiostomus at River Swat

Abstract Snow trout (Schizothorax plagiostomus) is an economically important freshwater fish, mostly found in northern areas of water reservoirs of Pakistan. The current study was conducted in River Swat to analyze the bioaccumulation of heavy metals (Pb, Cr, Ni, and Zn) in tissues of Schizothorax plagiostomus. Tissues were extracted and dissolved in perchloric acid (HClO4) and nitric acid (HNO3) along with hotplate. The heavy metals, zinc (Zn), lead (Pb), chromium (Cr), and Nickel (Ni) were determined using Perkin Elmer 2380 atomic absorption spectrophotometer. Results shows great variation in the content of the metal related to tissue type and sampling sites. A high concentration of bioaccumulation was reported at Charbagh, whereas lowest at Odigram: Charbagh>Landakai>Odigram. In the same way, Cr was the most accumulated heavy metal followed by lead, nickel, and Zinc:

Resumo A truta das neves (Schizothorax plagiostomus) é um peixe de água doce economicamente importante, encontrado principalmente nas áreas ao norte de reservatórios de água do Paquistão. O presente estudo foi realizado em River Swat para analisar a bioacumulação de metais pesados (Pb, Cr, Ni e Zn) em tecidos de Schizothorax plagiostomus. Os tecidos foram extraídos e dissolvidos em ácido perclórico (HClO4) e ácido nítrico (HNO3) com placa de aquecimento. Os metais pesados zinco (Zn), chumbo (Pb), cromo (Cr) e níquel (Ni) foram determinados usando espectrofotômetro de absorção atômica Perkin Elmer 2380. Os resultados mostram grande variação no conteúdo do metal relacionado ao tipo de tecido e locais de amostragem. Uma alta concentração de bioacumulação foi relatada em Charbagh, enquanto a mais baixa, em Odigram: Charbagh > Landakai > Odigram. Da mesma forma, Cr foi o metal pesado mais acumulado, seguido por Pb, Ni e Zn.

Bioaccumulation of heavy metals in the tissues of Schizothorax plagiostomus at River Swat / Bioacumulação de metais pesados nos tecidos de Plagiostomo esquizotórax em River Swat

Root deformation (RD) caused by errors in the pricking out process are irreversible and very difficult to detect in container-grown seedlings at the time of planting in the field. The objective of this study was to evaluate the effects of RD on leaf gas exchange, growth, biomass allocation and mineral nutrition of G. americana seedlings during the recovery phase after soil flooding. Four-months-old seedlings, with and without RD, were flooded for 42 days and their recovery was evaluated 28 days after soil drainage. There were no significant interactions between RD and soil flooding for all leaf gas exchange, growth and mineral nutrition after soil drainage, with the exception of leaf P concentrations. In plants with no RD, the P concentration in leaves of non-flooded plants was significantly higher than that of plants with RD. Soil flooding and RD did not influence leaf or root N concentrations or whole-plant N content. RD increased the K concentration in the roots, but not in the leaves. Changes in the nutrient concentrations in leaves and roots indicate that RD may affect physiological performance of seedlings after planting in the field.

A deformação da raiz (RD) causada por erros no processo de repicagem é irreversível e difícil de detectar em mudas produzidas em embalagens no momento do plantio no campo. O objetivo deste estudo foi avaliar os efeitos do RD nas trocas gasosas foliares, crescimento, alocação de biomassa e nutrição mineral de mudas de G. americana na fase de recuperação após o alagamento do solo. Mudas com quatro meses de idade, com e sem RD, foram alagadas por 42 dias e a sua recuperação foi avaliada 28 dias após a drenagem do solo. Não houve interação significativa entre RD e alagamento do solo nas trocas gasosas foliares, crescimento e nutrição mineral após a drenagem, com exceção das concentrações de P foliar. Em plantas sem RD, a concentração de P nas folhas de plantas não alagadas foi significativamente maior que a das plantas com RD. O alagamento do solo e a RD não influenciaram as concentrações de N nas folhas e raízes, e no conteúdo de N na planta inteira. A RD aumentou a concentração de K nas raízes, mas não nas folhas. Alterações nas concentrações de nutrientes nas folhas e raízes indicam que a RD pode afetar o desempenho fisiológico das mudas após o plantio no campo.

Sero-epidemiology and risk factor analysis of human brucellosis in Punjab, Pakistan: a cross sectional study.

Human brucellosis is a neglected zoonotic problem worldwide with a high degree of morbidity in humans and is mostly overlooked due to other febrile conditions. The aim of this study was to evaluate the sero-prevalence and risk factors of human brucellosis among subjects living in Punjab, Pakistan. In this cross-sectional study, human blood samples were collected from seven districts of Punjab, Pakistan. Information regarding personal data, demographic data and potential risk factors was collected through a structured questionnaire. Detection of anti-Brucella antibodies was done through Rose Bengal Plate Test (RBPT) and Enzyme Linked Immunosorbent Assay (ELISA). Descriptive analysis, Chi square test and Odds ratio was applied using STATA software version 12. The sero-prevalence of human brucellosis was 13.13% with significantly higher percentage in males 17.23% and age group 25-40 years 16.50% (P=< 0.001). The demographic factors positively associated with human brucellosis were lack of education (P = 0.003; OR = 1.85) and farming as an occupation (P =<0.001; OR = 2.50) Similarly, among the risk factors studied, keeping animals at home (P =<0.001; OR = 2.03), slaughtering of animals (P =<0.001; OR = 15.87) and consuming raw milk (P =<0.001; OR = 5.42) were the factors strongly connected with human brucellosis. A massive awareness should be given to livestock farmers and individuals directly linked to animals regarding risk factors and transmission of brucellosis. Consumption of unpasteurized milk and its products should be condemned to curtail this neglected disease.

Bioaccumulation of heavy metals in the tissues of Schizothorax plagiostomus at River Swat.

Snow trout (Schizothorax plagiostomus) is an economically important freshwater fish, mostly found in northern areas of water reservoirs of Pakistan. The current study was conducted in River Swat to analyze the bioaccumulation of heavy metals (Pb, Cr, Ni, and Zn) in tissues of Schizothorax plagiostomus. Tissues were extracted and dissolved in perchloric acid (HClO4) and nitric acid (HNO3) along with hotplate. The heavy metals, zinc (Zn), lead (Pb), chromium (Cr), and Nickel (Ni) were determined using Perkin Elmer 2380 atomic absorption spectrophotometer. Results shows great variation in the content of the metal related to tissue type and sampling sites. A high concentration of bioaccumulation was reported at Charbagh, whereas lowest at Odigram: Charbagh>Landakai>Odigram. In the same way, Cr was the most accumulated heavy metal followed by lead, nickel, and Zinc.

Sero-epidemiology and risk factor analysis of human brucellosis in Punjab, Pakistan: a cross sectional study

@#Human brucellosis is a neglected zoonotic problem worldwide with a high degree of morbidity in humans and is mostly overlooked due to other febrile conditions. The aim of this study was to evaluate the sero-prevalence and risk factors of human brucellosis among subjects living in Punjab, Pakistan. In this cross-sectional study, human blood samples were collected from seven districts of Punjab, Pakistan. Information regarding personal data, demographic data and potential risk factors was collected through a structured questionnaire. Detection of anti-Brucella antibodies was done through Rose Bengal Plate Test (RBPT) and Enzyme Linked Immunosorbent Assay (ELISA). Descriptive analysis, Chi square test and Odds ratio was applied using STATA software version 12. The sero-prevalence of human brucellosis was 13.13% with significantly higher percentage in males 17.23% and age group 25-40 years 16.50% (P=< 0.001). The demographic factors positively associated with human brucellosis were lack of education (P = 0.003; OR = 1.85) and farming as an occupation (P =<0.001; OR = 2.50) Similarly, among the risk factors studied, keeping animals at home (P =<0.001; OR = 2.03), slaughtering of animals (P =<0.001; OR = 15.87) and consuming raw milk (P =<0.001; OR = 5.42) were the factors strongly connected with human brucellosis. A massive awareness should be given to livestock farmers and individuals directly linked to animals regarding risk factors and transmission of brucellosis. Consumption of unpasteurized milk and its products should be condemned to curtail this neglected disease.

Exploring women and traditional birth attendants' perceptions and experiences of stillbirths in district Thatta, Sindh, Pakistan: a qualitative study.

BACKGROUND: Pakistan reports the highest stillbirth rate in the world at 43 per thousand births with more than three-quarters occurring in rural areas. The Global Network for Women's and Children's Health maintains a Maternal and Newborn Health Registry (MNHR) in 14 study clusters of district Thatta, Sindh Pakistan. For the last 10 years, the MNHR has recorded a high stillbirths rate with a slow decline. This exploratory study was designed to understand the perspectives of women and traditional birth attendants regarding the high occurrence of stillbirth in Thatta district. METHODS: We used an exploratory qualitative study design by conducting in-depth interviews (IDIs) and focus group discussions (FGDs) using semi-structured interview guide with rural women (FGDs = 4; n = 29) and traditional birth attendants (FGDs = 4; n = 14) who were permanent residents of Thatta. In addition, in-depth interviews were conducted with women who had experienced a stillbirth (IDIs = 4). This study presents perceptions and experiences of women and TBAs regarding high rate of stillbirth in Thatta district, Karachi. RESULTS: Women showed reluctance to receive skilled/ standard care when in need due to apprehensions towards operative delivery, poor attitude of skilled health care providers, and poor quality of care as service delivery factors. High cost of care, far distance to facility, lack of transport and need of an escort from the family or village to visit a health facility were additional important factors for not seeking care resulting in stillbirth. The easy availability of unskilled provider in the form of traditional birth attendant is then preferred over a skilled health care provider. TBAs shared their husband or family members restrict them to visit or consult a doctor during pregnancy. According to TBAs after delivering a macerated fetus, women are given herbs to remove infection from woman's body and uterus. Further women are advised to conceive soon so that they get rid of infections. CONCLUSION: Women of this rural community carry lots of apprehension against skilled medical care and as a result follow traditional practices. Conscious efforts are required to increase the awareness of women to develop positive health seeking behavior during pregnancy, delivery and the post-partum period. Alongside, provision of respectful maternity care needs to be emphasized especially at public health facilities.

Therapeutic potential of natural products in glioblastoma treatment: targeting key glioblastoma signaling pathways and epigenetic alterations.

Glioma is the most common primary tumor of the nervous system, and approximately 50% of patients exhibit the most aggressive form of the cancer, glioblastoma. Currently, considerable research in glioblastoma therapeutics is aimed at developing vaccines or drugs to target key molecules for combating this disease. Studies on plant natural products from spices, vegetables, fruits, teas, and traditional medicinal herbs display that these plant-derived natural products can act as effective antioxidant and anti-tumor agents. The advancements in metabolomics and in genomics have enabled researchers to better evaluate the potential use of immunomodulatory natural plant products for treatment of different cancerous diseases. The glioblastoma protective activities of the different natural plant products lie in their effects on cellular defenses such as antioxidant enzyme systems, detoxification and the stimulation of anti-inflammatory, anti-metastasis responses and by modifying epigenetic alterations, often through targeting specific key transcription factors such as activator protein, nuclear factor kappa B, signal transducers and activators of transcription and so on. Here, we review recent knowledge on the molecular mechanisms by which different inflammatory activities are linked to progression of glioblastoma and the particular immunomodulatory plant products that may reduce inflammation and the associated progression and metastasis of glioblastoma both in vitro and in vivo. Furthermore, their impact on the epigenetic alterations will also be discussed.

Molecular cloning, expression, and characterization of E2F transcription factor 4 from Antheraea pernyi.

The E2F transcription factor family is distributed widely in eukaryotes and has been well studied among mammals. In the present study, the E2F transcription factor 4 (E2F4) gene was isolated from fat bodies of Antheraea pernyi and sequenced. E2F4 comprised a 795 bp open reading frame encoding a deduced amino acid sequence of 264 amino acid residues. The recombinant protein was expressed in Escherichia coli (Transetta DE3), and anti-E2F4 antibodies were prepared. The deduced amino acid sequence displayed significant homology to an E2F4-like protein from Bombyx mori L. Quantitative real-time polymerase chain reaction analysis revealed that E2F4 expression was highest in the integument, followed by the fat body, silk glands, and haemocytes. The expression of E2F4 was upregulated in larvae challenged by bacterial (Escherichia coli, Micrococcus luteus), viral (nuclear polyhedrosis virus), and fungal (Beauveria bassiana) pathogens. These observations indicated that E2F4 is an inducible protein in the immune response of A. pernyi and probably in other insects.

Stretching the boundaries of medical education A case of medical college embracing humanities and social sciences in medical education.

OBJECTIVE: Aga Khan University, a private medical college, had a vision of producing physicians who are not only scientifically competent, but also socially sensitive, the latter by exposure of medical students to a broad-based curriculum. The objective of this study was to identify the genesis of broad-based education and its integration into the undergraduate medical education program as the Humanities and Social Sciences (HASS) course. METHODS: A qualitative methodology was used for this study. Sources of data included document review and in-depth key informant interviews. Nvivo software was utilized to extract themes. RESULTS: The study revealed the process of operationalization of the institutional vision to produce competent and culturally sensitive physicians. The delay in the establishment of the Faculty of Arts and Sciences, which was expected to take a lead role in the delivery of a broad-based education, led to the development of an innovative HASS course in the medical curriculum. The study also identified availability of faculty and resistance from students as challenges faced in the implementation and evolution of HASS. CONCLUSIONS: The description of the journey and viability of integration of HASS into the medical curriculum offers a model to medical colleges seeking ways to produce socially sensitive physicians.

How we developed a bioethics theme in an undergraduate medical curriculum.

The 5-year undergraduate medical curriculum at Aga Khan University integrates basic sciences with clinical and community health sciences. Multimodal strategies of teaching and learning, with an emphasis on problem-based learning, are utilized to equip students with knowledge, skills, behaviours, attitudes and values necessary for a high-calibre medical graduate. Bioethics teaching was introduced in the medical curriculum in 1988 and has since undergone several changes. In 2009, a multidisciplinary voluntary group began review of undergraduate bioethics teaching and invested over 350 man-hours in curricular revision. This involved formulating terminal objectives, delineating specific objectives and identifying instructional methodologies and assessment strategies appropriate for the contents of each objective. Innovative strategies were specially devised to work within the time constraints of the existing medical curriculum and importantly, to increase student interest and engagement. The new bioethics curriculum is designed to be comprehensive and robust, and strives to develop graduates who, in addition to being technically skilled and competent, are well-versed in the history and philosophy of ethics and bioethics and are ethical in their thinking and practice, especially in the context of a developing country like Pakistan where health indicators are among the worst in the region, and clinical practices are not effectively regulated to ensure quality of care.

Tawana project-school nutrition program in Pakistan--its success, bottlenecks and lessons learned.

Tawana Pakistan Project, a multifaceted pilot project (Sept. 2002 to June 2005) was funded by the Government of Pakistan to address poor nutritional status and school enrollment of primary school age girls. The core strategy was to create safe environment empowering village women to take collective decisions. Through reflective learning process women learnt to plan balanced menus, purchase food, prepare and serve a noon meal at school from locally available foods at nominal costs (USD 0.12/child). Aga Khan University partnered the government for the design, management, monitoring and evaluation of the project, 11 NGO's facilitated implementation in 4035 rural government girls' schools. Training was provided to 663 field workers, 4383 community organizers, 4336 school teachers and around 95 thousand rural women. Height and weight were recorded at baseline and every 6 months thereafter. Wasting, underweight and stunting decreased by 45%, 22% and 6% respectively. Enrollment increased by 40%. Women's' ability to plan balanced meals improved and >76% of all meals provided the basic three food groups by end of project. Government bureaucracy issues, especially at the district level proved to be the most challenging bottlenecks. Success can be attributed to synergies gained by dealing with nutrition, education and empowerment issues simultaneously.

Medical education and training: responding to community needs.

At its inception in 1987, the Aga Khan University introduced the idea of community-based medical education in Pakistan, at a time when this model was being introduced and adapted internationally. Human resource development has been a major objective in the Department of Community Health Sciences (CHS). CHS has contributed to developing a medical curriculum that addresses the health needs of the community at large. This paper narrates the department's experience in working directly with under-served communities, leading to the development of specialized courses and degree programs. CHS emphasizes operational research and development of managerial skills among front-line public health professionals, in both the public and private sectors. Training is provided by people from diverse backgrounds, such as public health, community development, social sciences, law, epidemiology, economy, biostatistics, demography, theater, and film. The lessons we have learned show that the mode of training depends on the overall objectives of the program, the clients and the setting. However, in the spirit of the participatory approach, the recipients of the training must be involved during all stages so as to ensure the sustainability of the training program. Training must focus on the communities at the grass roots level or community based organizations, where the communities identify their own capacity and needs. Wide dissemination of training materials, courses and manuals is also useful to replicate successful experience.

Outcome of singleton breech deliveries beyond 28 weeks gestation: the experience at MCH Centre, PIMS. Mother and Child Health. Pakistan Institute of Medical Sciences.

OBJECTIVE: To conduct an audit of breech deliveries at or beyond 28 weeks gestation to determine the neonatal outcome at different gestations in relation to the mode of delivery. SETTING: MCH Centre, PIMS, Islamabad. SUBJECTS AND METHODS: Records of 171 consecutive singleton breech deliveries > or = 28 weeks gestation were retrieved and stratified into 3 groups by gestational age, 28-33 completed weeks, 34-36 completed weeks and beyond 37 weeks. The main outcome measures were the incidence of perinatal morbidity and mortality of the three gestation groups in relation to the mode of delivery. RESULTS: Of 171 cases, 20 women (11.7%) delivered at 28 to 33 weeks, 17 of whom were delivered vaginally. The main birth weight (MBW) was 1.4 kg. Perinatal deaths occurred in 15 cases, these included 4 intrauterine deaths (IUDs) and 6 infants with congenital anomalies. Thirty three women (19.3%) delivered at 34 to 36 weeks gestation, of whom 17 (51.5%) delivered vaginally. The MBW was 2 kg with 6 perinatal deaths (one with cephalhaematoma and 4 IUD and 2 congenital anomalies). Sixteen women (48.5%) had caesarean sections. The MBW was 2.2 kg with only 2 perinatal deaths due to IUD and congenital pneumonia. One hundred and eighteen (69%) women delivered at term. The MBW of the 45 (38.1%) vaginally delivered infants was 2.2 kg with 9 perinatal deaths (1 IUD and 7 congenital anomalies). Seventy three (61.9%) had caesarean sections, 41 emergency and 32 elective. The MBW was 2.9 kg with 4 perinatal deaths (1 IUD, 2 congenital anomalies and 1 sepsis). CONCLUSION: There was significant association of breech presentation with congenital anomalies. After the exclusion of congenital anomalies, greater recourse to caesarean section beyond 34 weeks seems to confer a survival advantage to the new born infant.