Disparities with global standards about growth references of mid-upper arm circumference-for-age for Pakistani children aged 6-60 months.

AIM: Growth reference values about mid-upper arm circumference (MUAC) are vital for assessing children's nutritional status. However, Pakistan lacks these reference values and growth charts. This study aims to develop these for children aged 6-60 months and compare them with global standards. METHODS: The data were acquired from the 2018 National Nutrition Survey of Pakistan, which was conducted by the United Nations Children's Fund (UNICEF) during 2018-2019. The final study cohort comprised 57 285 children, with 51% being boys. Percentile values and charts for MUAC-for-age were developed using generalised additive models for location, scale and shape with the Box-Cox power exponential distribution. RESULTS: The mean MUAC was 14.21 cm (±2.07 cm) and 14.13 cm (±2.12 cm) for the boys and girls, respectively. At 60 months of age, the P3 and P97 percentiles for girls were slightly higher than those for boys. The median percentiles of Pakistani children were smaller than the World Health Organisation 2007 standards and with international references. CONCLUSION: We observed disparities in MUAC-for-age growth references among Pakistani children compared to global standards, highlighting regional, age and gender variations. This underscores the need for developing countries like Pakistan to establish their growth references.

Developing neck circumference growth reference charts for Pakistani children and adolescents using the lambda-mu-sigma and quantile regression method.

OBJECTIVE: Neck circumference (NC) is currently used as an embryonic marker of obesity and its associated risks. But its use in clinical evaluations and other epidemiological purposes requires sex and age-specific standardised cut-offs which are still scarce for the Pakistani paediatric population. We therefore developed sex and age-specific growth reference charts for NC for Pakistani children and adolescents aged 2-18 years. DESIGN: Cross-sectional multi-ethnic anthropometric survey (MEAS) study. SETTING: Multan, Lahore, Rawalpindi and Islamabad. PARTICIPANTS: The dataset of 10 668 healthy Pakistani children and adolescents aged 2-18 years collected in MEAS were used. Information related to age, sex and NC were taken as study variables. The lambda-mu-sigma (LMS) and quantile regression (QR) methods were applied to develop growth reference charts for NC. RESULTS: The 5th, 10th, 25th, 50th, 75th, 90th and 95th smoothed percentile values of NC were presented. The centile values showed that neck size increased with age in both boys and girls. During 8 and 14 years of age, girls were found to have larger NC than boys. A comparison of NC median (50th) percentile values with references from Iranian and Turkish populations reveals substantially lower NC percentiles in Pakistani children and adolescents compared to their peers in the reference population. CONCLUSION: The comparative results suggest that the uses of NC references of developed countries are inadequate for Pakistani children. A small variability between empirical centiles and centiles obtained by QR procedure recommends that growth charts should be constructed by QR as an alternative method.

Radiation absorbed dose for cobalt-60 gamma source in phantoms for different materials.

Current practices in radiation therapy required high doses of radiation to be delivered with increased accuracy. Treatment planning task is exercised till an optimum dose distribution is achieved. The present reported work was performed to compare the various aspects of the cobalt-60 radiation beam therapy with fixed source-surface distance 70cm incident normally. This study was conducted in May 2012 at the Department of Radiation Physics of MD Anderson Cancer Centre, University of Texas, Houston, United States. Radiation doses were calculated in a solid phantom as well as in water phantom at different square field sizes and depths. It was noted that the rate of absorbed dose increased with the increase in the field size and decreased with the increase in depths. The rate of absorbed dose was found to be directly proportional to the increase in the square field size and inversely proportional to the increase in depth. Moreover, the solid phantom demonstrated more absorbed doses as compared to the water phantom.

Predictors of pulmonary function test values for Pakistani children, aged 5-14 years.

OBJECTIVE: To predict pulmonary function test values in children. METHODS: This cross-sectional study was carried out at Nishtar Medical College, Multan, Pakistan, from August 2014 to March 2015, and comprised school-going children aged 5-14 years. After noting their gender, age, height and weight, the pulmonary function test measures, force vital capacity, forced expiratory volume in 1 second and peak expiratory flow rate were taken. Simple and multiple regression models were used for the prediction of pulmonary function test values. SPSS 19 was used for statistical analysis. RESULTS: Of the 3,275 participants, 1,809(55.2%) were boys and 1,466 (44.8%) were girls. The overall mean age was 10.27±2.41 years. The means height, weight, forced expiratory volume in 1 second, force vital capacity and peak expiratory flow rate were 137.37±13.41cm, 30.44±8.56kg, 1.56±0.58, 1.72±0.50 and 3.66±1.10, respectively. Generally, no significant difference between the mean pulmonary function test values was noted for boys and girls (p>0.05), except that the boys of age 13 and 14 had higher mean values (p<0.05). All the three variables - age, height and weight - had significant linear relationship with the pulmonary function test values (p<0.05). CONCLUSIONS: The pulmonary function test values tended to increase with increase in age, height and weight.

Forecasting Health Indicators Of Pakistan.

BACKGROUND: Forecasting of health indicators is of great importance for health policy makers. This study is aimed to forecast some important health indicators like crude death rate (CDR), crude birth rate (CBR), and infant mortality rate (IMR) and total fertility rate (TFR) of Pakistan. METHODS: In this retrolective study, annual data of these indicators for years 1984-2010 have been used. The simple linear regression model with time as independent variable has been used to forecast these health indicators. RESULTS: The within-sample forecast results are close enough to the actual values. All the forecast values of the stated indicators tend to decrease with time. The forecast values of CDR, CBR, IMR and TFR for year 2020 are 12.85, 5.61, 43.61 and 0.93, respectively. CONCLUSIONS: Although the forecast values show an improvement in health indicators of Pakistan but the IMR is expected to remain high even in 2020, a concern for the health policy makers.

Quality assurance for cancer patient safety: Clinical assessment for precise angles in linac during radiation therapy.

PURPOSE: Quality assurance for stereotactic body radiation treatment requires that isocentric verification be ensured during gantry rotation at various angles. This study examined statistical parameters on Winston-Lutz tests to distinguish the deviation of angles from isocenter during gantry rotation using machine learning. METHOD: The Varian TrueBeam linac was aligned with the marked lines on the Ruby phantom. Eight images were captured while the gantry was rotating at a 45° shift. The statistical features were derived from IsoCheck EPID software. The decision tree model was applied to these Winston-Lutz tests to cluster data into two groups: precise and error angles. RESULTS: At 90° and 270° angles, the gantry exhibits isocentric stability compared to other angles. In these angles, the most statistical features were inside the range. Most variations were observed at 0° and 180° angles. In most tests, the angles 45°, 135°, 225°, and 315° showed reasonable performance and with less variation. CONCLUSION: The comprehensive statistical analyses for gantry rotation of angles assists expert radiotherapists in determining the contribution of each feature that highly affects gantry movement at specific angles. Misalignment between radiation isocenter and imaging isocenter, tuning of the beam at each angle, or a slight change in the position of the Ruby phantom can further improve the inaccuracy that causes the most variations. Better precision can effectively increase patient safety and quality during cancer treatment.

Establishing Body Mass Index growth charts for Pakistani children and adolescents using the lambda-mu-sigma (LMS) and quantile regression method.

BACKGROUND: Assessment of growth and nutritional status is an essential part of clinical evaluation and care in pediatrics. Therefore, we aimed to establish age and gender specific smoothed BMI growth reference charts of Pakistani children and adolescents aged 2-18 years and to compare our LMS median percentile values with WHO 2007 international references and with references from other foreign studies. METHODS: A representative cross-sectional sample of 10,668 healthy Pakistani subjects aged 2 to 18 years was studied. For calculation of BMI (kg/m2), height (cm) and weight (kg) were measured using standard procedures. Age and gender specific smoothed BMI growth reference values and associated charts were obtained using lambda-mu-sigma (LMS) as well as quantile regression (QR) statistical methods. RESULTS: In the sample studied, the mean (±SD) BMI of all subjects was 16.50 (±2.83 kg/m2). Smoothed BMI percentile curves (5th, 10th, 25th, 50th, 75th, 90th and 95th) obtained by using LMS and QR methods, showed that BMI increased with age in both sexes. During pubertal age, girls had larger percentiles than boys. Centile values estimated by the LMS and QR procedure had small variability from the empirical centiles. Comparison of LMS BMI 50th percentile with references from WHO 2007 and data from other countries demonstrated that Pakistani children had substantially lower BMI percentiles than their counterparts in the reference population. CONCLUSIONS: This comprehensive study suggests that WHO 2007 references are not suitable for Pakistani children. The QR method should be considered as an alternative method to develop growth charts.

A dataset about anthropometric measurements of the Pakistani children and adolescents using a cross-sectional multi-ethnic anthropometric survey.

Evaluation of nutritional status is necessary during childhood and the juvenile years when the level of hydration and the adipose tissues experience significant changes. Anthropometric measurements and their derived indices are valid proxies to predict body fat, obesity (general or central) and their associated cardiovascular risks. The dataset under consideration also provides the socio-demographic related information and anthropometric measurement values related to height, weight, body mass index (BMI), waist circumference (WC), hip circumference (HpC), waist-to-hip ratio (WHpR), waist-to-height ratio (WHtR), mid-upper arm circumference (MUAC), neck circumference (NC), and wrist circumference (WrC). Standard procedure was adopted for quantifying the body measurements. The data were consisting of 10,782 children and adolescents aged 2-19 years, belonging four major cities of Pakistan viz. Multan, Lahore, Rawalpindi and Islamabad. This dataset is beneficial to develop anthropometric growth charts which will provide the essential knowledge of growth and nutritional disorders (e.g., stunted, overweight and obesity) of Pakistani children and adolescents. The dataset can also be used by researchers to calculate body surface area (BSA), body frame size (BFS), body shape index (BSI), and tri-ponderal mass index (TMI) of children and adolescents that are also some other reliable indicators of obesity and insulin resistance as well as cardiometabolic risk in children and adults.

Developing waist circumference, waist-to-height ratio percentile curves for Pakistani children and adolescents aged 2-18 years using Lambda-Mu-Sigma (LMS) method.

Objectives Children from different countries and with different ethnic backgrounds have a distinct pattern of central fat deposition. Therefore, it is essential to develop population-specific percentiles of waist circumference (WC), waist-to-height ratio (WHtR) and waist-to-height ratio exponent (WHtR (exp)) for the evaluation of central obesity. The objective of this study was to develop age-and-gender-specific smoothed WC and WHtR percentile curves for the Pakistani children and adolescents aged 2-18 years. Methods A cross-sectional data-set from a multi-ethnic anthropometric survey was considered. A sample of 10,668 healthy subjects (boys = 51.92%; and girls = 48.08%), aged 2-18 years was studied. Height (cm) and WC (cm) of each subject was measured under standard procedure and WHtR & WHtR (exp) were calculated. Age-and-gender-specific smoothed curves were obtained using the lambda-mu-sigma (LMS) method and compared with percentile curves obtained from different countries. Results Except few early ages, the WC values increased with age in both sexes. Both boys and girls had approximately similar WC during 6-11 years of age and after age of 11, the boys had larger WC than the girls had. For WHtR, the centile curves showed a continuous decrease by 16 years of age and then increased gradually. WHtR of the girls in various ages were having similar or higher than those of the boys. In comparison of WC 50th and 90th percentiles with other countries, it was found that except few ages, the Pakistani children had larger WC than the other reference populations and the results of WHtR were also comparable to the other nations. Conclusions We present new reference data of WC, WHtR and WHtR (exp) using a representative sample of the Pakistani children aged 2-18 years. These reference values can be used provisionally for early detection of central obesity and its associated risks in the Pakistani children.

Diagnostic Performance of Neck Circumference and Cut-off Values for Identifying Overweight and Obese Pakistani Children: A Receiver Operating Characteristic Analysis

Objective: Neck circumference (NC) is considered to be an alternative screening method for obesity. The aims were: (1) to examine the correlation between body mass index (BMI) and NC; and (2) to determine diagnostic performance including the best cut-off values of NC for identification of overweight and obese Pakistani children. Methods: The study sample was 7,921 children, aged 5-14 years, by cross-sectional survey carried-out in four major cities of Pakistan. Receiver operating characteristic analysis was used to investigate the diagnostics performance of NC and to determine the optimal cut-off points for identifying children with overweight and obesity. Results: The mean of each anthropometric variable (i.e., height, weight, BMI and NC) increased with age in both sexes. In the whole sample, NC had a strong positive correlation (r=0.61, p<0.01) with BMI. NC optimal cut-off points for identifying overweight and obesity in Pakistani boys ranged between 25.00 to 30.35 cm and the corresponding values for the girls were 24.00 to 31.62 cm. In the prepubertal period, NC cut-off points indicative overweight, in both boys and girls were 26.36 cm and 25.27 cm, respectively; the corresponding values for obesity were 26.78 cm and 25.02 cm. During puberty, the cut-off values for overweight and obesity respectively were 28.32 cm and 28.57 cm in boys and 28.70 cm and 28.82 cm in girls. Conclusion: NC may be used as a simple and widely applicable measure for identification of overweight and obesity with reasonable accuracy in Pakistani children.

Prevalence and Sociodemographic Factors of Overweight and Obesity among Pakistani Adults.

BACKGROUND: Obesity is a serious public health problem that is growing alarmingly worldwide. The main objective of this study is to examine the current prevalence of overweight and obesity among Pakistani adults and to identify the sociodemographic factors that are associated with overweight and obesity. METHODS: Secondary data from a population-based household survey (the Pakistan Panel Household Survey) were used for this study. A total of 10,063 participants (3,916 men and 6,147 women) were included. Overweight and obese individuals were identified using the World Health Organization-recommended cutoffs for body mass index (kg/m2). Along with descriptive statistics, the Pearson chi-square test was used to investigate the association among categorical variables. Odds ratios (ORs) along with 95% confidence intervals (CIs) were estimated using univariate logistic regression analysis to evaluate the most significantly associated risk factors for overweight/obesity. RESULTS: The mean age and body mass index of the participants were 38.2 years and 22.9 kg/m2, respectively. Overall, 22.8% of the participants (23.9% of the women and 21.1% of the men) were overweight, and 5.1% (6.3% of the women and 3.2% of the men) were obese. Sociodemographic factors, such as sex, marital status, and residential area, were significantly associated with body mass index categories. Women (OR, 1.34; 95% CI, 1.23-1.47; P<0.01), ever-married individuals (OR, 1.92; 95% CI, 1.70-2.16; P<0.01), and individuals living in urban areas (OR, 1.23; 95% CI, 1.12-1.35; P<0.01) were more likely to become overweight/obese than their counterparts. CONCLUSION: We have found the excess weight problem to be quite high in the Pakistani adult population. The government and other health agencies should take initiatives in launching programs about nutritional awareness for adults to prevent obesity.

Mid-upper-arm circumference as a screening measure for identifying children with elevated body mass index: a study for Pakistan.

PURPOSE: Mid-upper-arm circumference (MUAC) is considered an alternative screening method for obesity. The aims of this investigation were to examine the ability of MUAC to correctly identify children with elevated body mass index (BMI) and to determine the best MUAC cutoff point for identification of children with high BMI. METHODS: Anthropometric measurements (height, weight, and MUAC) from a cross-sectional sample of 7,921 Pakistani children aged 5-14 years were analyzed. Pearson correlation coefficients between MUAC and other anthropometric measurements were calculated. Receiver operating characteristic curve analysis was used to determine the optimal MUAC cutoff point for identifying children with high BMI. RESULTS: Among 7,921 children, the mean (±standard deviation) age, BMI, and MUAC were 10.00 (±2.86 years), 16.16 (±2.66 kg/m2), and 17.73 (±2.59 cm), respectively. The MUAC had a strong positive correlation with BMI. The optimal MUAC cutoff points indicating elevated BMI in boys ranged from 16.76 to 22.73, while the corresponding values in girls ranged from 16.38 to 20.57. CONCLUSION: MUAC may be used as a simple indicator of overweight/obesity in children, with reasonable accuracy in clinical settings.

Evaluation of anthropometric parameters of central obesity in Pakistani children aged 5-12 years, using receiver operating characteristic (ROC) analysis.

Background Different anthropometric parameters have been proposed for assessing central obesity in children, but the ability of these anthropometric parameters to correctly measure central obesity in Pakistani children is questionable and needs to be assessed. The aims of this investigation were to examine the diagnostic performance of anthropometric parameters as indicators of central obesity in Pakistani children as measured by waist circumference (WC) and to determine the sex-specific best cut-off values for these parameters that would identify obese children. Methods Anthropometric measurements - height, weight, WC, waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), conicity index (CI) and neck circumference (NC) - from a cross-sectional sample of 5964 Pakistani children aged 5-12 years were analyzed. Receiver operating characteristics (ROC) analysis was used to examine the diagnostic performance and to determine the optimal cut-off point of each anthropometric parameter for identifying centrally obese children. Results It was found that WC had a significantly positive correlation with all studied anthropometric parameters. The ROC curve analysis indicated that all the parameters analyzed had good performance but WHtR had the highest value of the area under the curve (AUC). Optimal cut-off points associated with central obesity for boys and girls were, respectively, 0.47 and 0.48 for WHtR, 1.20 and 1.23 for CI, 0.96 and 0.96 for WHR and 26.36 and 26.54 cm for NC. Conclusions The sex-specific cut-off points for WHtR, CI, WHR and NC can be used to detect central obesity in Pakistani children.

A comparative study of RapidArc and intensity-modulated radiotherapy plan quality for cervical cancer treatment.

BACKGROUND: RapidArc therapy, a complex form of intensity-modulated radiotherapy (IMRT), is now widely used to treat cancer patients. AIMS: This study aimed to investigate and compare the plan quality of IMRT and RapidArc techniques using various dosimetric indices to find the better treatment modality for treating patients with cervix cancer. MATERIALS AND METHODS: Thirteen cervical cancer patients treated with IMRT were selected for analysis and original plans were subsequently re-optimized using the RapidArc technique. Plans were generated such that dose of 5000 cGy was delivered in 25 equal fractions. Inverse planning was done by Eclipse (Varian Medical Systems, Palo Alto, CA) treatment planning system for 15 MV photon beams from computed tomographic data. Double arcs were used for RapidArc plans. Quality of treatment plans was evaluated by calculating conformity index (CI), homogeneity index (HI), gradient index (GI), coverage, and unified dosimetry index (UDI) for each plan. RESULTS AND CONCLUSION: RapidArc resulted in better planning target volume (PTV) coverage as is evident from its superior conformation number, coverage, CI, HI, GI, and UDI. Regarding organs at risk (OARs), RapidArc plans exhibit superior organ sparing as is evident from integral dose comparison. Difference between both techniques was determined by statistical analysis. For all cases under study, modest differences between IMRT and RapidArc treatment were observed. RapidArc-based treatment planning is safer with similar planning goals compared to the standard fixed IMRT technique. This study clearly demonstrated that favorable dose distribution in PTV and OARs was achieved using RapidArc technique, and hence, the risk of damage to normal tissues is reduced.