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Understanding the long-term spatiotemporal variability of precipitation at the regional scale is critical for developing flood and drought control strategies and water resource management. This study assessed the spatiotemporal variability of monthly precipitation over the Khyber Pakhtunkhwa province of Pakistan for 1998–2019 using hierarchical cluster analysis to cluster 156 Tropical Rainfall Measuring Mission grids. Statistical properties of clusters were calculated and the relationship of geographical features such as latitude, longitude, and altitude and statistical variables including standard deviation, maximum and minimum precipitation, and coefficient of variation (CV) with average precipitation was assessed. Findings showed that northeast parts received maximum precipitation while north and southern regions received less precipitation. Temporal analysis showed two clusters of rainy months (February, March, April, May, July, and August) and dry months (January, June, September, October, November, and December). The region was divided into two homogeneous precipitation regions. From January to April and November to December, cluster 1 occupied northern parts with maximum average precipitation while cluster 2 southern parts. From June to September, cluster 2 covered the northeast and southern parts with the highest average precipitation. During May, cluster 2 received the highest average precipitation in the northeast and southeast parts, whereas cluster 1 covered the northwest and southwest. In October, cluster 2 received maximum average precipitation covering the northeast. CV suggested higher temporal variability in cluster 2 (67.75–102.36)% than cluster 1 (65.82–99.55)%. Precipitation correlation showed that CV opposed the longitude and averages, whereas latitude and altitude demonstrated minimal correlations. These insights can assist decision-makers in devising suitable strategies to plan and control unexpected volumes of precipitation. [ABSTRACT FROM AUTHOR]

Sindh province of Pakistan has a long history of severe droughts. Several large scale climate drivers (LSCD) are known for their effect on precipitation worldwide but studies in the Sindh region are missing; wide variety of LSCDs and lagged associative information. This study aimed to identify the significant LSCDs in Sindh province of Pakistan and improve the forecast skill of monthly precipitation by employing the principal component analysis (PCA), artificial neural network (ANN), Bayesian regularization neural network (BRNN), and multiple regression analysis (MRA), while considering the 12 months lagged LSCDs such as Nino-1+2, Nino-3, Nino-3.4, Nino-4, Quasi-Biennial Oscillation (QBO) at 30 and 50hPa (QBOI and QBOII), sea surface temperature (SST), 2m air temperature (T2M), 500 hPa and 850 hPa geopotential heights (H500 and H850), surface and 500 hPa zonal velocity (SU and U500), latent and sensible heat fluxes over land (LHFOL and SHFOL), and surface specific humidity (SSH). Global Land Data Assimilation System (GLDAS), Tropical Rainfall Measuring Mission (TRMM), Modern-Era Retrospective Analysis for Research and Application (MERRA-2), NOAA, Freie University Berlin, and Hadley Centre Sea Ice and Sea Surface Temperature (HadISST) datasets were used. Results manifested that significant LSCDs with 99% confidence level were SU, U500, T2M, SST, SHFOL, LHFOL, SSH, and H850. During test period, compared with MR models of 0.39 to 0.64 and principal components of 0.31 to 0.57, the ANN and BRNN models had better predictive skills with correlation coefficients of 0.57 to 0.83 and 0.52 to 0.76, respectively. It can be concluded that the ANN and BRNN models enable us to predict monthly precipitation in Sindh region with lagged LSCDs. [ABSTRACT FROM AUTHOR]

Background: Published research on senior care facilities in Pakistan is scarce and no large-scale study has been conducted to assess factors affecting well-being of older adults in these facilities. This study, therefore, investigated the effects of relocation autonomy, loneliness, and satisfaction with services along with socio-demographic characteristics on physical, psychological, and social well-being of older residents living in senior care facilities of Punjab, Pakistan. Methods: This cross-sectional study collected data from 270 older residents living in 18 senior care facilities across 11 districts of Punjab, Pakistan from November 2019 to February 2020 using multistage random sampling. Existing reliable and valid scales were used to collect information from older adults related to relocation autonomy (Perceived Control Measure Scale), loneliness (de Jong-Gierveld Loneliness Scale), satisfaction with service quality (Service Quality Scale), physical and psychological well-being (General Well-Being Scale), and social well-being (Duke Social Support Index). A psychometric analysis of these scales was carried out followed by three separate multiple regression analyses to predict physical, psychological, and social well-being from socio-demographic variables and key independent variables (relocation autonomy, loneliness, and satisfaction with service quality). Results: The results of multiple regression analyses showed that the models predicting physical (R2 = 0.579), psychological (R2 = 0.654), and social well-being (R2 = 0.615) were statistically significant (p < 0.001). Number of visitors was a significant predictor of physical (b = 0.82, p = 0.01), psychological (b = 0.80, p < 0.001), and social (b = 2.40, p < 0.001) well-being. Loneliness significantly predicted physical (b = -0.14, p = 0.005), psychological (b = -0.19, p < 0.001), and social (b = -0.36, p < 0.001) well-being. Control over relocation process significantly predicted physical (b = 0.56, p < 0.001) and psychological (b = 0.36, p < 0.001) well-being. Satisfaction with services significantly predicted physical (b = 0.07, p < 0.001) and social (b = 0.08, p < 0.001) well-being. Conclusion: Pragmatic, equitable and cost-effective interventions are needed to improve the wellbeing of older residents living in senior care facilities. Friendly behavior of mobilizing staff and adjusted residents to facilitate new residents, therapeutic interventions such as relocation support programs, reminiscence therapy and intergenerational support, and increasing their exposure and connection to the outside world, can raise their physical, psychological, and social well-being. [ABSTRACT FROM AUTHOR]

HEV is the most common cause of acute hepatitis globally. This review summarizes the latest knowledge on the epidemiology, clinical characteristics, testing, and treatment of HEV infection. We also focused on Bangladesh to highlight the distinct challenges and the possible remedies. In low-income settings, the virus is mainly transmitted between people by fecal contamination of drinking water causing large outbreaks, and sporadic cases. The disease is usually mild and self-limiting acute hepatitis. Still, pregnant women and their offspring in low-income countries are at particular risk for severe disease, with up to 20% maternal mortality. Despite the high burden of the disease, HEV remains a relatively neglected virus, with detection hampered by costly tests and a lack of suitable treatments. Molecular PCR diagnostics, together with ELISA antibody tests, remain the preferred methods for diagnosis of HEV; however, rapid bedside diagnostics are available and could offer a practical alternative, especially in low-income countries. One vaccine (HEV 239) is only available in China and Pakistan, as efficacy against the other genotypes remains uncertain. The effectiveness trial conducted in Bangladesh might lead the way in gathering more efficacy data and could, together with improved surveillance and raised awareness, dramatically reduce the global burden of HEV. [ABSTRACT FROM AUTHOR]

Several countries across different continents experienced severe flooding in 2022, including Pakistan. Given the greater frequency and affliction of natural disasters like flooding in an increasing number of countries, we share lessons from the experience of Pakistan in helping the most vulnerable populations through community-based health workers. [ABSTRACT FROM AUTHOR]

The study was an attempt to identify demographic, household, and women empowerment factors that predicted emotional, physical, and sexual violence in ever-married women of reproductive age (15–49 years, n = 3,965) in Pakistan by performing secondary analysis on Pakistan Demographic and Health Survey, 2017–2018. The analysis was done using SPSS (v.22) and binary and multivariate logistic regression techniques were performed for analyses. The analysis found that 30.2% of women experienced emotional, 24.1% reported less severe physical, 6.5% experienced severe physical, and 4.3% experienced sexual violence, respectively. The multivariate analysis found that husband's age, education, wealth, and alcohol consumption were significant predictors of intimate partner violence (IPV). Additionally, womens' age, education, and number of children also significantly predicted IPV. With respect to empowerment variables, ownership of house was a significant predictor of less severe physical violence, ownership of property significantly predicted emotional violence, and autonomy in household purchase decisions was significantly related to severe physical violence. The control on husband's income as a measure of empowerment significantly predicted all four types of IPV. Belief in patriarchy also turned out to be an important factor in determining emotional and less severe physical violence. The study concludes that women empowerment in household context can prevent less serious forms of violence but to hinder serious forms of violence, interventions at family and community level will be required. [ABSTRACT FROM AUTHOR]

The study investigated the role of institutional environment in adjustment of older adults living in old age homes of Punjab, Pakistan. The study was conducted on a sample of 270 residents, living in 18 old age facilities across Punjab. The data was collected through a structured interview questionnaire and was analyzed through SPSS (v. 22). The multiple regression analyses suggested that institutional environment along with number of children and number of visitors was a significant predictor of adjustment of older adults. Interventions such as higher support from staff and residents, autonomy, and engagement can help older adults to adjust better in old age homes. [ABSTRACT FROM AUTHOR]

The purpose of this study is to find out the impact of Terrorism on FDI inflow in Pakistan as well as other variables such as economic growth, market size, trade openness and infrastructure. Using a simple regression model to estimate time series, annual data from 2001 to 2016, the study concludes that market size, economic growth, and trade openness have a significant positive relationship with FDI. At the same time, the result shows that Terrorism and infrastructure has a significant negative relationship with FDI. This empirically builds up the way that Terrorism is a real threat to FDI and economic development of the economies of Pakistan. The empirical outcomes of the study of Terrorism confirmed the way that Terrorism based oppression has harmed the economic prosperity of Pakistan and has debilitated FDI inflows during the sample period. Therefore, Pakistan will take to measures the investment environment in this area. Government strategy makers should consider the situation of Terrorism, instability and lawfulness circumstance to decrease the risk of investors and to ensure their investment ability to host FDI. [ABSTRACT FROM AUTHOR]

Hepatitis C (HCV) and diabetes mellitus are the two main health concerns that cause devastating health and financial worries worldwide. It has been observed in the past that both diseases have a high correlation that might be due to the abnormal conditions of the liver. But the mechanism of the prevalence of diabetes in patients with chronic HCV infection still remains unclear. In our study, we have investigated T2DM in the male and female patients at Lady Reading Hospital (LRH), Peshawar. The blood samples of both in- and outpatients were analysed in the PCR laboratories of LRH from December 2014 to April 2015. Great prevalence of diabetes in hepatitis C infected male and female patients was observed during this study. The data were collected from the patients through a preplanned questionnaire that included name of the patient, HCV, being diabetic, age, gender, location, educational background, family history of the disease, other diseases, and any treatments if taken. The results of our study have found 26.42% prevalence of T2DM in HCV infected patients. So we conclude that HCV infection may be one of the reasons that could lead to T2DM. [ABSTRACT FROM AUTHOR]

Background. We aimed to assess the feasibility of using community-based informants’ networks to identify maternal deaths that were followed up through verbal autopsies (MADE-IN MADE-FOR technique) to estimate maternal mortality in a rural district in Pakistan. Methods. We used 4 community networks to identify deaths in women of reproductive age in the past 2 years in Chakwal district, Pakistan. The deaths recorded by the informants were followed up through verbal autopsies. Results. In total 1,143 Lady Health Workers (government employees who provide primary health care), 1577 religious leaders, 20 female lady councilors (elected representatives), and 130 nikah registrars (persons who register marriages) identified 2001 deaths in women of reproductive age. 1424 deaths were followed up with verbal autopsies conducted with the relatives of the deceased. 169 pregnancy-related deaths were identified from all reported deaths. Through the capture-recapture technique probability of capturing pregnancy-related deaths by LHWs was 0.73 and for religious leaders 0.49. Maternal mortality in Chakwal district was estimated at 309 per 100,000 live births. Conclusion. It is feasible and economical to use community informants to identify recent deaths in women of reproductive age and, if followed up through verbal autopsies, obviate the need for conducting large scale surveys. [ABSTRACT FROM AUTHOR]

The article reports on the occurrence of the Chelonibia testudinaria barnacle species that was found attached on the back of a dead green turtle Chelonia mydas on the Gadani coast in Pakistan. Topics covered include the specimens found attached on carapace of the dead turtle, mesurement of the species' barnacles, and previous occurrences of the species.

Background: According to the Pakistan Demographic and Health Survey from 2006-2007, the maternal mortality ratio in rural areas is 319 per 100,000 live births. Postpartum hemorrhage is the leading cause of maternal deaths in Pakistan. The objectives of the study were to document the feasibility of distribution of misoprostol tablets by community-based providers mainly traditional birth attendants and acceptability and use of misoprostol by women who gave birth at home. Methods: A quasi-experimental design, comprising intervention and comparison areas, was used to document the acceptability of providing misoprostol tablets to pregnant women to prevent postpartum hemorrhage in the rural community setting in Pakistan. Data were collected using structured questionnaires administered to women before and after delivery at home and their birth attendants. Results: Out of 770 women who delivered at home, 678 (88%) ingested misoprostol tablets and 647 (84%) ingested the tablets after the birth of the neonate but prior to the delivery of the placenta. The remaining women took misoprostol tablets after delivery of the placenta. Side effects were experienced by 40% of women and were transitory in nature. Among women who delivered at home, 80% said that they would use misoprostol tablets in the future and 74% were willing to purchase them in the future. Conclusions: Self-administration of misoprostol in the home setting is feasible. Community-based providers, such as traditional birth attendants and community midwives with proper training and counseling, play an important role in reducing postpartum hemorrhage. Proper counseling and information exchange are helpful for introducing new practices in resource-constrained rural communities. Until such a time that skilled birth attendance is made more universally available in the rural setting, alternative strategies, such as training and using the services of traditional birth attendants to provide safe pregnancy care, must be considered. [ABSTRACT FROM AUTHOR]

Kidney biopsy is an investigation for diagnosis and prognosis of a variety of nephritides. It also influences therapeutic options. Immunofluorescence (IMF) greatly adds in identifying the pathologies which may not be obvious on light microscopy (L/M), such as IgM, IgA nephropathy, pauci-immune glomerulonephritis, and anti-glomerular basement membrane disease. We present here data of 170 pediatric kidney biopsies from July 2005 to December 2009 from Department of Nephrology and Hypertension, Lady Reading Hospital, Peshawar, Pakistan. The study was undertaken to see whether IMF would alter the histological pattern of pediatric kidney biopsies and to compare these data with an earlier data from our department of 415 pediatric kidney biopsies done over 7-year period from 1998 to 2005, which were analyzed with L/M alone. Out of 170 kidney biopsies using L/M and IMF, IgM turns out to be most common pattern (20%%), followed by minimal change disease (MCD) (17.05%%), focal and segmental glomerulosclerosis (FSGS) (15.88%%), chronic sclerosing glomerulonephritis (Chr. sclerosing GN) (12.35%%), mesangio proliferative glomerulonephritis (MPGN) (7.65%%), mesangio capillary glomerulonephritis (MCGN) (6.47%%), membranous glomerulonephritis (Mem. GN) (5.29%%), IgA nephropathy (5.29%%), cresentic glomerulonephritis (Cres. GN) (3.53%%), lupus nephritis (2.96%%), and others (3.53%%). Comparing these results of 170 cases with 415 renal biopsies without IMF, IgM dominated the histological pattern in IMF group whereas MCD followed by FSGS and MPGN were prominent in group without IMF. Therefore, variation in the overall histological pattern with IMF technique proved statistically significant ( p < 0.0001). Addition of IMF has altered the frequency of MCD, a change from 24%% (100/415) to 17%% (29/170), FSGS from 18.3%% (76/415) to 15.88%% (27/170), and MPGN from 17.35%% (72/415) to 7.65%% (13/170). [ABSTRACT FROM AUTHOR]

Summary: In July 2002 and June 2003, cholera outbreaks were detected by a diarrhoea surveillance system in a village outside Karachi, Pakistan. Specimens were culture confirmed. The first outbreak was caused by Vibrio cholerae O139 (n =30) and the second outbreak by V. cholerae O1 (n =39). Demographic and clinical features of patients were recorded and case–control studies were conducted following each outbreak. Clinical information was obtained for 29 of the 30 patients in the first outbreak, and 2 of the patients in the second outbreak were either out of the area or lost to follow-up, leaving 29 and 37 cases in the analysis for the first and second outbreak, respectively. Eighteen (49%) of the 37 V. cholerae O1 patients were under 2 years of age compared with 6 (21%) of the 29 V. cholerae O139 patients (P =0.02). Vibrio cholerae O139-infected patients were more likely to be febrile (16/29) than those infected with V. cholerae O1 (2/37; P <0.001). A household contact with cholera was a risk factor in both outbreaks; water source was a risk factor in the first outbreak only. Geographically, cases were clustered during the first outbreak but not during the second. Person-to-person contact and water reservoirs appear to be the main transmission routes for cholera in this setting. [Copyright &y& Elsevier]

The Global Polio Eradication Initiative reports Pakistan as the only country with consistent barriers preventing vaccination and the eradication of the disease. Avoidance of the vaccination by the public because of a lack of awareness is far more dangerous in the eradication of polio than dealing with the smaller fractions involved in anti-polio vaccination propaganda. 2 W Mahmood, Social mobilisers tackle polio vaccine misconceptions in Pakistan, http://www.endpolio.com.pk/polioin-pakistan/107-social-mobilisers-tackle-polio-vaccine-misconceptions-in-pakistan 2014,Mahmood W. Social mobilisers tackle polio vaccine misconceptions in Pakistan. [Extracted from the article]

Introduction: Enteric fever remains a major public health problem in Asia. Planning appropriate preventive measures such as immunization requires a clear understanding of disease burden. We conducted a community-based surveillance for Salmonella Typhi infection in children in Karachi, Pakistan. Methodology: A de jure household census was conducted at baseline in the study setting to enumerate all individuals. A health-care facility- based passive surveillance system was used to capture episodes of fever lasting three or more 3 days in children 2 to 16 years old. Results: A total of 7,401 blood samples were collected for microbiological confirmation, out of which 189 S. Typhi and 32 S. Paratyphi A isolates were identified with estimated annual incidences of 451/100,000 (95% CI: 446 - 457) and 76/100,000 (95% CI: 74 - 78) respectively. At the time of presentation, after adjusting for age, there was an association between the duration of fever and temperature at presentation, and being infected with multidrug-resistant S. Typhi. Of 189 isolates 83 were found to be resistant to first-line antimicrobial therapy. There was no statistically significant difference in clinical presentation of blood culture sensitive and resistant S. Typhi isolates. Conclusion: Incidence of S. Typhi in children is high in urban squatter settlements of Karachi, Pakistan. Findings from this study identified duration of fever and temperature at the time of presentation as important symptoms associated with blood culture-confirmed typhoid fever. Preventive strategies such as immunization and improvements in water and sanitation conditions should be the focus of typhoid control in urban settlements of Pakistan. [ABSTRACT FROM AUTHOR]

Objective: To identify the characteristics of women at risk of death due to eclampsia, and steps to improve maternal outcome., Methods: This study is a part of a retrospective study conducted in 2016 and included Mansehra, Swabi, Haripur, Nowshera, Kohat, and Dera Ismail Khan districts of the Khyber Pakhtunkhwa province of Pakistan, and used information cited by a 2016 study to estimate the maternal mortality rate in the province based on data pertaining to the 2013-14 period. The Maternal Death from Informants / Maternal Death Follow-on Review method was applied to identify the magnitude, causes and circumstances of maternal deaths in the province. SPSS 21 was used for data analysis., Results: Of the 958 cases of maternal death identified, 167(17%) were related to eclampsia. The median age of such women was 28 years (interquartile range: 11 years). Of them, 88 (53%) died undelivered, 48 (29%) had a live birth while 31 (18%) had a stillbirth or abortion. Mothers aged 25 years or above (p<0.01), primiparous (p<0.01) and those with a previous history of stillbirth (p<0.005) carried higher risk, while higher socioeconomic status had a protective effect (p<0.007)., Conclusions: Eclampsia deaths can be prevented through Continuum of Care approach and by ensuring provision of basic health facilities across the board.

Objective: To determine the incidence of tumour lysis syndrome and to identify associated factors and mortality rate in paediatric haematological patients., Methods: The prospective study was conducted from April to September 2016 at Indus Children Cancer Hospital, Karachi, and collected data for all new paediatric oncology patients registered with diagnosis of haematological malignancies. Each patient was monitored for a period of three days before and seven days after the start of the treatment. SPSS 21 was used for data analysis., Results: of the 232 patients, 86(37.1%) developed laboratory tumour lysis syndrome and 35(40.7%) of these patients developed the spontaneous variety. Overall, 24 (10.3%) patients progressed to clinical syndrome with 12(50%) of them developing spontaneous clinical syndrome. Mortality occurred in 17 (7.3%) patients., Conclusions: Despite preventive measures, tumour lysis syndrome remains an oncological emergency in children with haematological malignancies.

Introduction: The main aim of this study was to determine the frequency of Enterobius vermicularis infections and other unique histopathological findings in patients diagnosed with acute appendicitis., Materials: This retrospective study was conducted in a tertiary care hospital of Karachi, Pakistan over a time period of 9 years from 2005 to 2013. The recorded demographic and histopathological data for the 2956 appendectomies performed during this time frame were extracted using a structured template form. Negative and incidental appendectomies were excluded from the study., Results: Out of the 2956 patients diagnosed with acute appendicitis, 84 (2.8%) patients had Enterobius vermicularis infections. Malignancy (n=2, 0.1%) and infection with Ascaris (n=1, 0.1%) was found very rarely among the patients.Eggs in lumen (n=22, 0.7%), mucinous cystadenoma (n=28, 1.0%), mucocele (n=11, 0.4%), lymphoma (n=9, 0.3%), obstruction in lumen (n=17, 0.6%) and purulent exudate (n=37, 1.3%) were also seldom seen in the histopathological reports., Conclusion: Enterobius vermicularis manifestation is a rare overall but a leading parasitic cause of appendicitis. Steps such as early diagnosis and regular de worming may help eradicate the need for surgeries.

The geometric mean concentration (GMC) and the proportion maintaining a protective level (150 enzyme-linked immunosorbent assay (ELISA) units [ELU]/ml) 2 years following a single dose of 25 μg of injectable Vi capsular polysaccharide typhoid vaccine was measured against that of the control hepatitis A vaccine in children 2 to 16 years old in cluster randomized trials in Karachi and Kolkata. The GMC for the Vi group (1,428 ELU/ml) was statistically significantly different from the GMC of the control hepatitis A vaccine group (86 ELU/ml) after 6 weeks. A total of 117 children (95.1%) in the Vi group and 9 (7.5%) in the hepatitis A group showed a 4-fold rise in Vi IgG antibody concentrations at 6 weeks (P < 0.01). Protective antibody levels remained significantly different between the two groups at 2 years (38% in the Vi vaccine groups and 6% in the hepatitis A group [P < 0.01]). A very small proportion of younger children (2 to 5 years old) maintained protective Vi IgG antibody levels at 2 years, a result that was not statistically significantly different compared to that for the hepatitis A group (38.1% versus 10.5%). The GMCs of the Vi IgG antibody after 2 years were 133 ELU/ml for children 2 to <5 years old and 349 ELU/ml for children 5 to 16 years old. In conclusion, Vi capsular polysaccharide typhoid vaccine is immunogenic in children in settings of South Asia where typhoid is highly endemic. The antibody levels in children who received this vaccine remained higher than those in children who received the control vaccine but were significantly reduced at 2 years of follow-up.

Objective: To assess the feasibility and efficacy of a novel, minimally invasive spinal surgery technique for the correction of lumbar spinal stenosis involving unilateral approach for bilateral decompression., Study Design: Cross-sectional observational study., Place and Duration of Study: Neurosurgery Department of PGMI, Lady Reading Hospital, Peshawar, from January to December 2010., Methodology: A total of 60 patients with lumbar stenosis were randomly assigned to undergo either a conventional laminectomy (30 patients, Group A), or a unilateral approach (30 patients, Group B). Clinical outcomes was measured using the scale of Finneson and Cooper. All the data was collected by using a proforma and different parameters were assessed for a minimum follow-up period of three months. Data was analyzed by descriptive statistics using SPSS software version 17., Results: Adequate decompression was achieved in all patients. Compared with patients in the conventional laminectomy group, patients who received the novel procedure (unilateral approach) had a reduced mean duration of hospital stay, a faster recovery rate and majority of the patients (88.33%) had an excellent to fair operative result according to the Finneson and Cooper scale. Five major complications occurred in all patient groups, 2 patients had unintended dural rent and 2 wound dehiscence each and fifth patient had worsening of symptoms. There was no mortality in the series., Conclusion: The ultimate goal of the unilateral approach to treat lumbar spinal stenosis is to achieve adequate decompression of the neural elements. An additional benefit of a minimally invasive approach is adequate preservation of vertebral stability, as it requires only minimal muscle trauma, preservation of supraspinous/intraspinous ligament complex and spinous process, therefore, allows early mobilization. This also shortens the hospital stay, reduces postoperative back pain, and leads to satisfactory outcome.

Background: Obesity is considered a disease and one of the fastest growing global threats. In Pakistan General Physicians (GPs) are approached first in case of any disease thus their knowledge and practices regarding obesity are very important to assess. Our objective was to assess the knowledge and practices of GPs regarding obesity and management., Methods: This was a cross-sectional study conducted among GPs of Karachi. 140 GPs from 17 towns of Karachi were selected by convenience sampling. Data was analyzed using SPSS-16., Results: Total 140 GPs with mean age of 46.1 +/- 11.1 years were included in the study. Among them 90 (64.3%) were males and 40 (28.3%) were females. Awareness was assessed regarding factors related to obesity and knowledge was compared on basis of qualification and knowledge update. Significant difference was found for insufficient physical activity (p = 0.001) and social problems (p = 0.02). On the basis of knowledge update, stress and anxiety (p = 0.013) were found to be significant. Significant difference was found in readings for BMI (p = 0.038) and waist circumference (p = 0.000) to label patient obese. Among several lifestyle modifications advised, significant difference was found for increase fibre in diet (p = 0.006), low fat intake (p = 0.003), low carbohydrate intake (p = 0.02)., Conclusion: Overall awareness regarding obesity was fair among GPs, while certain gaps were found in criteria for labelling patient obese. Significant difference in knowledge of GPs was found among those GPs who update their knowledge and who did not.

Objective: To identify the challenges confronting the Pakistan province of Punjab in delivering maternal and child health services at the district level., Methods: The qualitative assessment was done from May 15 to June 15, 2010, comprising 5 focus group discussions, 5 in-depth interviews with district managers, 49 in-depth interviews with providers, and direct observation of 19 facilities providing comprehensive emergency obstetric care in the districts of Multan, Muzaffargarh, Bahawalpur, Khanewal and Jhelum. Using skilled birth attendance coverage as an indicator, Punjab districts were stratified into three socio-economic strata, and from these the five-districts were selected., Results: Distribution of basic emergency obstetric care facilities by population size was found to be inadequate in all districts. Quality of care was compromised by lack of staff and equipment. No anaesthetist was available in majority of the district hospitals and tehsil facilities. Half of the teshil headquarter hospitals were devoid of staff nurses. Vital medicines used in obstetric care were not available. Partograph was not being used in any of the tehsil-level facilities. Chlorine solution was not present in any of the facilities. Governance issues included multiplicity of command channels, delays in receipt of medicines and political interference., Conclusion: If the province has to achieve the related Millennium Development Goals (MDGs), related to maternal and child health, the existing facilities are not adequate. To achieve progress, proven and innovative approaches will have to be put in place that may influence the continuum of care from the household to the health facility.

Objectives: Adequate knowledge and positive attitudes of health care professionals regarding deceased-donor organ transplants lead to higher donation consent rates. This study assessed the knowledge and attitudes of health care professionals toward this issue in the light of recent organ transplant legislation in Pakistan., Materials and Methods: Health care professionals in critical care areas of 2 hospitals in Karachi were selected (n=243) and asked to complete a questionnaire regarding their knowledge and attitudes toward deceased-donor organ transplants., Results: In all, 58.8% of the participants were physicians and 41.2% were nurses; 91.4% correctly identified brain death; 51.5% expressed support for deceased-donor organ transplants; 56.8% had concerns of religious rulings against deceased organ donation; 67.5% felt that a government body could not run such a system fairly; 56.4% of the respondents would consider receiving a deceased-donor organ if needed, but only 35.3% would donate after their own death. Only 42.7% and 37% were willing to approach patients and families for consent for a deceased-donor organ transplant, respectively. Most of those unwilling felt that the patient could refuse, become upset and aggressive, and lose trust in the health care professionals., Conclusions: Before implementing a deceased-donor organ transplant system in hospitals, health care professionals should attend a training program regarding their concerns. This would increase motivation when approaching patients/patients' families for consent, thus increasing deceased-donor consent rates.

Management of obstetrical acute renal failure remains a challenging task. We present data of 100 cases of obstetrical -related acute renal failure of 3-year duration (2007-2009) from Department of Nephrology & Hypertension, Lady Reading Hospital, Peshawar, Pakistan. The study is aimed to look at overall mortality and relationship of oliguria/anuria at presentation to dialysis dependency and renal cortical necrosis (RCN). Evaluation of comorbidity to dialysis dependency and RCN was also considered. While 91 patients required hemodialysis, 9 were managed conservatively; 57 were dialysis dependent whereas 43 remained dialysis independent on discharge; 47 patients had oliguria, 30 had anuria, and 23 had an output of >800 mL per 24 h on admission. RCN was seen in 30 cases, all biopsy confirmed; among these, 26 cases (86.67%) were associated with oliguria/anuria and dialysis dependency right from the beginning (p < 0.0001). However, four (13.33%) with RCN had output >800 mL per 24 h but remained dialysis dependent. Our data showed that out of 30 patients who presented with anuria, only 10 patients (33.33%) were dialysis independent on discharge, whereas out of 47 oliguric patients, 21 patients (44.6%) were dialysis independent upon discharge. Thus dialysis dependency does not correlate with anuria or oliguria at presentation (p = 0.133). Mortality of 7% was recorded; 23% were discharged with normal renal function. Septicemia, operative interventions, retained product of conception, post-partum hemorrhage, and RCN remained important comorbid conditions with regard to survival and dialysis dependency.

Objectives: To determine the effect of fasting immediately after exercise on blood lactate clearance., Methods: This study was conducted at College of Medicine, Dammam University, KSA. Untrained male volunteers (n = 26) between 18-23 years of age were divided into two equal groups; fasting and non-fasting. After an overnight fasting both groups were made to exercise on a bicycle ergometer starting with 100 watt resistance with 25 watt increment after every 2 minutes until voluntary exhaustion. The fasting group was then asked to continue fasting 30 minutes after exercise, while the non-fasting group was given 600 ml of carbohydrate-rich (about 16g per 100 ml) drink immediately after exercise. We measured the blood lactate level before, immediately after, and 30 minutes after exercise in both the groups., Results: A significant (p < 0.001) increase in mean blood lactate level was observed in both the groups immediately after exercise as compared to the baseline means. Similarly there was a significant (p < 0.001) drop of lactate level in both the groups 30 minutes after exercise as compared with the blood lactate level immediately after exercise. There was a significant (p < 0.001) difference between the number of subjects with a blood lactate drop of more than 50% between the two groups (84.61% of subjects in the fasting group, versus 46.15% in the non-fasting group)., Conclusion: Fasting after exercise accelerates lactate clearance from blood, probably by utilizing gluconeogenesis pathway.

Objective: To describe the prevalence of Herpes Simplex Virus-2 (HSV-2) infection among males in six major cities of Pakistan., Methods: A cross sectional behavioural and biological survey of urban male population aged 16-45 years was conducted in Rawalpindi, Lahore, Karachi, Faisalabad, Peshawar and Quetta to measure the prevalence of five sexually transmitted infections and assess sexual behaviours. Respondents were selected through a multistage sampling technique. In each city 10 blocks demarcated by the Population Census Organization were selected based on probability proportional to socio-economic status. In each block 40 men were selected through systematic sampling with a random start. In total 2400 men were administered a behavioural questionnaire and 2396 provided biological specimens for laboratory testing., Results: This paper discusses the overall and city wise prevalence of HSV-2 infection. The overall prevalence of HSV-2 infection in the six cities was 3.4 percent (95% CI 2.8-4.3). City wise the highest prevalence was reported in Karachi 6 percent (95% CI 4.1-8.8), followed by Lahore and Quetta at 4.3 percent (95% CI 2.7-6.7), and Faisalabad at 2.5 percent (95% CI 1.4-4.5). The lowest prevalence was in Rawalpindi at 1.8 percent (95% CI 0.9-3.6)., Conclusion: Empirical evidence from this study suggests that there is city wise variation in the prevalence of HSV-2 infection across the major cities in Pakistan. Based on possible link between HSV-2 and HIV, future HIV control strategies must also focus on the better management of HSV-2 infections in Pakistan.

Background: Renal cortical necrosis (RCN) carries high morbidity and mortality in South East Asia. The purpose of this study was to look specifically at the incidence of obstetrical related RCN in renal biopsies and to evaluate its precipitating factors. In addition, prognosis, impact of aetiology and outcomes on discharge were also considered., Methods: The study was conducted in the Department of Nephrology, Lady Reading Hospital Peshawar, Pakistan. Renal biopsies of 1,670 patients were analysed during the study period of 1998 to 2008. All the patients with obstetrical related RCN were included. Patient records, demographic data, urine output on admission and preceding history of ante-partum haemorrhage (APH), post-partum haemorrhage (PPH), septicaemia, operative interventions and retained product of conception (ROPC) was noted and need for dialysis was considered., Results: Out of 1670 kidney biopsies analysed, 48 turned out to be RCN. Among them 39 patients (81.3%) had diffuse cortical necrosis, 6 patients (12.5%) had patchy cortical necrosis with ATN while 3 patients (6.3%) had predominant ATN with partial patchy cortical necrosis. Out of 48 patients, 25 (52.1%) were oliguric, 18 (37.5%) were anuric while 5 (10.4%) had urine output > 800 ml 24 hr. Operative interventions were found in 29 patients while 19 patients had normal vaginal delivery (NVD). 16 (55.2%) patients with operative intervention had PPH. Thus the association proved to be significant (p = 0.037)., Conclusion: Overall incidence of RCN was 2.9%. Oliguria/anuria on admission and dialysis dependency are associated with RCN. PPH and history of operative intervention have significant association and are contributing factors to development of RCN.

Introduction: In research projects such as vaccine trials, accurate and complete surveillance of all outcomes of interest is critical. In less developed countries where the private sector is the major health-care provider, the private sector must be included in surveillance systems in order to capture all disease of interest. This, however, poses enormous challenges in practice. The process and outcome of recruiting private practice clinics for surveillance in a vaccine trial are described., Methods: The project started in January 2002 in two urban squatter settlements of Karachi, Pakistan. At the suggestion of private practitioners, a phlebotomy team was formed to provide support for disease surveillance. Children who had a reported history of fever for more than three days were enrolled for a diagnosis., Results: Between May 2003 and April 2004, 5540 children younger than 16 years with fever for three days or more were enrolled in the study. Of the children, 1312 (24%) were seen first by private practitioners; the remainder presented directly to study centres. In total, 5329 blood samples were obtained for microbiology. The annual incidence of Salmonella typhi diagnosed by blood culture was 407 (95% confidence interval (95% CI), 368-448) per 100 000/year and for Salmonella paratyphi A was 198 (95% CI, 171-227) per 100 000/year. Without the contribution of private practitioners, the rates would have been 240 per 100 000/year (95% CI, 211-271) for S. typhi and 114 (95% CI, 94-136) per 100 000/year for S. paratyphi A., Conclusion: The private sector plays a major health-care role in Pakistan. Our experience from a surveillance and burden estimation study in Pakistan indicates that this objective is possible to achieve but requires considerable effort and confidence building. Nonetheless, it is essential to include private health care providers when attempting to accurately estimate the burden of disease in such settings.

Phase-III vaccine efficacy trials typically employ individually randomized designs intended to ensure that measurements of vaccine protective efficacy reflect only direct vaccine effects. As a result, decisions about introducing newly licensed vaccines into public health programmes often fail to consider the substantially greater protection that may occur when a vaccine is deployed in public health programmes, due to the combination of direct plus indirect vaccine protective effects. Vaccine total protection can be better evaluated with cluster randomized trials. Such a design was considered to generate policy relevant data to accelerate the rationale introduction of the licensed typhoid fever Vi polysaccharide (PS) vaccine in Asia by the Diseases of the Most Impoverished (DOMI) typhoid fever programme. The DOMI's programme multi-country study is one of the largest cluster randomized vaccine trials ever mounted in Asia, which includes approximately 200,000 individuals. Its main objective is to determine the effectiveness of a licensed Vi PS vaccine. The rationale and design of this study are discussed. Preliminary results are presented that determined the final planning of the trial before immunization. Important methodological and practical issues regarding vaccine cluster randomized designs are illustrated.