Strategies to avert preventable mortality among mothers and children in the Eastern Mediterranean Region: new initiatives, new hope

We conducted an assessment of maternal, newborn and child health and progress towards achieving Millennium Development Goals [MDG] 4 and 5 in the Eastern Mediterranean Region [EMR]. We provide recommendations for scaling up and sustaining gains post-2015. Data were obtained from global data repositories. We constructed time trends from 1990 to 2013 and evaluated inequities across the Region. Under-5, neonatal and maternal mortality rates decreased 46%, 35%, and 50% respectively from 1990 to 2013. Pneumonia and diarrhoea accounted for 50% of all post-neonatal deaths; pregnancy- and delivery-related complications were the leading causes of neonatal and maternal deaths. Coverage of maternal, newborn and child health interventions is suboptimal, and poverty, food insecurity and conflict are pervasive across the Region. The EMR has made progress but is unlikely to attain MDG 4 and 5 targets. To sustain and further accelerate gains, the Region must reduce inequities and scale up implementation of recommendations made by the independent Expert Review Group

comparison of disease caused by Shigella and Campylobacter species: 24 months community based surveillance in 4 slums of Karachi, Pakistan

Despite the efforts of the international community diarrheal diseases still pose a major threat to children in children less than five years of age. Bacterial diarrhea has also emerged as a public health concern due to the proliferation of drug resistant species in many parts of the world. There is a paucity of population-based data about the incidence of shigellosis and Campylobacter infections in Pakistan. We report country specific results for Shigella diarrhea that were derived from a multicenter study conducted in six Asian countries. Disease surveillance was conducted over a 24 month period in urban slums of Karachi, Pakistan, a city with a population of 59,584. Cases were detected through passive detection in study treatment centers. Stool specimens or rectal swabs were collected from all consenting patients. Between January 2002 and December 2003 10,540 enteric infection cases were detected. The incidence rate of treated diarrhea in children under 5 was 488/1000/year. In children, 5 years and older, the diarrhea rate was 22/1000/year. 576 [7%] Campylobacter isolates were detected. The pre-dominant Campylobacter species was C. jenuni with an increase of 29/1000 year in children under 5 years. Shigella species were isolated from 394 of 8032 children under 5 years of age. Shigella flexneri was the dominant species [10/1000/year in children under 5 years] followed by Shigella sonnei [3.9/1000/year], Shigella boydii [2.0/1000/year] and Shigella dysenteriae [1.3/1000/year]. Shigellosis and Campylobacter infection rates peaked during the second year of life. The incidence rate of shigellosis increased in old age but such a trend was not observed in Campylobacter infections. Of 394 shigellosis patients 123 [31%] presented with dysentery in contrast to only 54 [9%] of 576 patients with Campylobacter infections [p < 0.001]. Both Campylobacter infections and shigellosis are common in community settings of Pakistan but shigellosis presented more frequently with abdominal pain and dysentery than Campylobacter infections indicating that shigellosis may be a more severe illness than Campylobacter infections. Due to the increased and disease severity, drug resistant shigella have become a significant health problem; moreover it is a disease of poor and impoverished people who do not have the access to standard water and sanitary conditions, health care services or optimal treatment. In the face of these facts it is empirically important to develop a low cost effective vaccine that can protect these populations for a longer duration

Effect of zinc in tablet and suspension formulations in the treatment of acute diarrhoea among young children in an emergency setting of earthquake affected region of Pakistan

A longitudinal cohort study was conducted at Camp Hospital Batagram in August 2006 to ascertain the effect of Zinc utilization in tablet and suspension formulations on thr frequency and recovery rates of diarrhoea among young children in the emergency settings of earthquake affected region of Pakistan. Two hundred patients were recruited and followed-up, the patients were allocated either of the 2 groups i.e. A [Zinc in tablets form] and B [Zinc in suspension form]. Both groups also received WHO recommended treatment for diarrhoea. Most of the cases recovered from the illness within 3 days after presentation. Significant p-values were established among Zinc use and reduction in frequency of stools on Day 2 and 3, with better outcome in group B. The study supports the notion that Zinc reduces the frequency and improves recovery rates of diarrhoea in any form and has better compliance and outcomes with the use in suspension form

Health care utilization for diarrhea and fever in 4 urban slums in Karachi

To estimate the fraction of fever and diarrhea patients making use of private practitioners, self-treatment, hospital care, drug vendors, community health centers and traditional healers. A cross-sectional survey. Four slums in and around Karachi during October and November, 2001. A sample of 1842 households was selected with probability proportional to size of the slum. The household head or a representative was asked regarding the treatment providers for diarrhea and cases of fever persistent for 3 days or more. Only households with an actual case of fever and/or diarrhea were included in the analysis. The study found that more than half of diarrhea and fever cases are seen by private practitioners. Self medication with medicines available in the home or specifically purchased for the disease episode from a drug vendor combined provides 13% to 18% of health care. Only between 11% and 13% of patients are seen by the public sector, hospitals and community health centers. There was no significant difference between the choice of health care provider for diarrhea and fever cases. In this survey, the majority of fever and diarrhea patients presented first to private practitioners and not to drug vendors or the public sector. Successful passive surveillance of febrile or diarrheal illness in these communities has to integrate private practitioners

Frequency of isolation of Shigella Serogroups/Serotypes and their antimicrobial susceptibility pattern in children from slum areas in Karachi

To assess the frequency of serogroups and serotypes, as well as the antimicrobial susceptibility pattern of Shigella species isolated from known cases of diarrhoea and dysentery from Karachi, Pakistan. A cross-sectional study was conducted between January 2002 and March 2003 at Aga Khan University on stool samples received from children with diarrhoea and dysentery from four low socio-economic areas [Sultanabad, Rehri Goth, Hijrat and Sherpao colony] of Karachi. Stool samples yielding growth of Shigella species, were further identified for serotypes by slide agglutination. Antibiotics susceptibility was performed by Kirby Bauer disk diffusion method. Out of 4688 stool samples received, 193 [4.1%] were positive for Shigella species. Shigella flexneri was the predominant serogroup [58%] followed by Shigella sonnei [16%], Shigella boydii [15%] and Shigella dysentriae being the least common [11%]. A number of serotypes were isolated in each serogroup, 8 serotypes in S. flexneri, 8 serotypes in S. dysenteriae, 9 serotypes in S. boydii, and Phase 1 and 2 were found in S. sonnei. 17% isolates remained non-serotypeable. All isolates were susceptible to Ofloxacin and Ceftriaxone, high rate of resistance was observed in Cotrimoxazole [87.75%] and Ampicillin [55.5%]. Emerging resistance against Nalidixic acid [39%] was observed. Shigella still accounts for a significant proportion of bacillary dysentery in many tropical and subtropical countries. Serotype identification can help in devising strategies such as development of effective vaccine for controlling this problem. Increasing antibiotic resistance against commonly prescribed drugs signify that treatment options have become difficult in cases of severe dysentery [JPMA 55:184;2005]

Port site wound hernias after laproscopic cholecystectomy

This comparative study was conducted on 100 patients coming for follow up after laparoscopic cholecystectomy at Sir Ganga Ram Hospital, Lahore. These patients were divided into two equal groups. In group A we stitched the linea alba and skin with monofilament polypropylene and in group B linea alba was not stitched and skin wound was closed with steri strips. In group A, two patients developed wound complications, one had wound infection and the other had bleeding from wound. In group B, four patients out of fifty in whom we did not stitch linea alba and skin, developed wound infection, and in 3 patients minor bleeding was seen from port site. No patients developed hernia at port site in both groups. Port site hernia is a rare complication after laparoscopic cholecystectomy. This clinical trial was carried out to see the prevalence of port site wound hernias after laparoscopic cholecystectomies

review of Rotavirus Diarrhhea in Pakistan How much do we know?

Rotavirus diarrhea has a worldwide distribution, infecting almost all children by the age of 3-5 years. Epidemiology: A comparable etiological 2-year survey carried out by the W.H.O Diarrheal Disease control [CDD] Program in 1991, in a multicenter study in 5 developing countries including Pakistan revealed that Rotavirus was found to be the most frequently detected pathogen in diarrheal episodes, during the first year of life, with the highest incidence [20%] occurring among 6-11 months old. Two other studies done in Pakistan, in under five children done in Lahore [between 1985 and 1991] and Rawalpindi [between May 1983 and April 1984] showed that Rotavirus was the second most common Diarrhea causing enteric pathogen following E.Coli Transmission: Rotaviruses are shed in high concentrations 2 days before and as many as 10 days after onset of symptoms in immunocompetent hosts, thus being an important source of viral transmission1. Clinical Course: A multicenter study in 5 developing countries including Pakistan conducted by WHO CDD program revealed that only 1.8% of cases presented with severe dehydration and these were mostly due to Rotavirus, V.Cholerae and ETEC13. Diagnostic Tests: A study conducted in local hospitals in Pakistan during the period of October 1985-April 1986 compared the different diagnostic modalities for the detection of rotavirus in the faeces of children with acute diarrhea.2,3 The study all methods detected Rotavirus to varying degrees but ELISA was found to be the most sensitive method with 72.4% stools being positive. Preventive Strategies: A study was conducted in Lahore [Pakistan] among 72 infants 6 weeks old in 1991 to assess safety and efficacy of RRV vaccine. It was found that of all infants given RRV with OPV, 50% had a two to four-fold rise in neutralization titers against rotavirus. RRV was found to be safe and not associated with adverse reactions in the 6 weeks old infants. With regards to Pakistan, there is a great need for defining rotavirus associated disease burden and strain prevalence. We also need to conduct Rotavirus vaccine trials to assess its efficacy and safety in our setting

Cutaneous leishmaniasis in Multan: Species identification

To identify the Leishmania species being responsible for cutaneous leishmaniasis in Multan. Parasites were isolated from clinically and parasitologically confirmed lesions of cutaneous leishmaniasis from 30 patients by fine needle aspiration [FNA]. The bioptical materials were then cultured in Evans Tobie's medium and parasites isolated were identified by isoenzyme electrophoresis technique. Successful Leishmania isolates were obtained from 16 patients. All strains were identified by biochemical techniques as belonging to Leishmania tropica zimodeme MON7 variant PGD. The causative species was identified as Leishmania tropica

Management of closed comminuted femoral shaft fractures in adults: comparison of closed interlocking intramedullary nailing and minimally invasive plate osteosynthesis

All the data was retrieved from hospital records and supplemented by continuing follow up. They were divided into 2 groups on the basis of method of fixation used. Among those, 25 were treated by interlocking intramedullary nailing and 22 with MIPO. A total of 47 patients of closed comminuted femoral shaft fractures were studied. They included 39 males and 8 females - a ratio of 4.87:1. The mean age was 33.6 years [range 16 to 68]. Most of the fractures were in age group of 21 to 40 years [96.6%]. Most common sight was middle 1/3 [24 cases] followed by distal 1/3 [13 cases] and proximal 1/3 [10 cases]. Most common cause was road side accidents [74.4%] followed by motorcycle and auto pedestrian accidents. In these 13 fractures were of type II, 17 of type III and 17 of type IV comminution. The average hospital stay was 12.8 days in nailing and 15 days in MIPO. The mean anaesthesia time for operative procedure in nailing was 116.6 minutes and in MIPO it was 83.4 minutes. At follow up, there were 2 cases of implant failure, one with broken interlocking screw and the other with loosened screw in MIPO. There was deep infection in 3 cases, 1 with nailing and 2 with MIPO. Knee stiffness was noted in 4 cases of MIPO and 2 cases in nailing but <100 degree in one case with MIPO. Delayed union was observed in 2 cases with nailing and 3 with MIPO group, in which we went for bone marrow injection and bone grafting in one case of nailing and MIPO each. Shortening of 2 cm in 1 case of nailing and 2 in MIPO was observed. Implant failure with loosened screws occurred after fall in one case of MIPO which required repeated fracture fixation. The mean fracture healing time in nailing was 16.88 weeks but in MIPO it was 19.82 weeks. According to Nicholas and McCoy score, there were 10 excellent, 9 good and 3 poor results and no failure. In nailing group 15 excellent, 8 good and 2 poor results but no failure. Closed interlocked I/M nailing is an excellent method of treating closed comminuted femoral shaft fractures, with advantages of lower complication rate and early weight bearing. MIPO is an acceptable method of treatment with advantages of being less expensive and short operative time

Assessment of zinc status in populations: some contemporary issues

Intense measures are needed to be undertaken to ensure accurate and precise assessment of zinc status when utilizing plasma/serum as an index. As larger population surveys of micronutrient status are undertaken, close attention to techniques and precautions in sample collection and analysis will ensure that the most accurate information is obtained. This is a review article

Self-reported feeding advice by physicians for common childhood lllnesses

A nutritious diet is important for recovery during illnesses. Dietary advice by physicians and consumption of food by the patients are often based upon their hot and cold concepts and beliefs about various foods rather than on scientific basis. To look at the food-advising behaviour of physicians during illnesses and to know the maternal concepts about various foods being hot or cold. A questionnaire was served to the physicians participating in a continuous medical education session held at the Aga Khan University and Hospital, asking them to write the foods they advise or restrict during different illnesses such as fever, jaundice etc. Mothers of sick children suffering from diarrhea and other illnesses were also interviewed to know their concepts about various foods. Six [10%] out of sixty physicians believed in hot and cold concepts of the food. A variety of common foods were either restricted or strongly recommended by 10% to 50% of these physicians without any scientific basis, 23% physicians restricted fatty foods in jaundice, 17% physicians restricted in cough and cold. Although the interviewed mothers believed in hot-cold concepts of food but 55-63% of them were not sure what is meant by hot or cold food. In spite of that 70-80% of these mothers classified chicken, meat, egg, brinjal, masoor and mangoes are hot foods and rice, yogurt, moong, banana and orange as cold foods. Hot-Cold concept of food exists not only in mothers but also in physicians. Proper education regarding food intake is mandatory for both mothers and physicians to ascertain adequate intake of calories during sickness

Lactose intolerance in persistent diarrhea during childhood: the role of a traditional rice-lentil [khitchri] and yogurt diet in nutritional management

Lactose intolerance is frequently encountered in children with persistent diarrhoea [PD]. Selection of an appropriate milk-based formulation is a major management problem in the developing world. In a consecutive series of studies, we evaluated the role of feeding a traditional rice-lentil [khitchri] diet alone [KY] or in combination with either soy formula [KY-Soy] a dilute buffalo milk [KY-B], in children [age 6 months-3 years] with PD. Serial observations of stool output, caloric intake and weight gain of these children over a 14 day period indicated satisfactory tolerance of the KY diet with adequate weight gain. The weight gain and stool output was however higher in lactose intolerant children, with the worst results seen with K-Y and buffalo milk combination. While lactose intolerant children with PD do have higher. rates of therapeutic failure, our data indicates that a traditional diet and yogurt combination can be used satisfactorily for nutritional rehabilitation in over 80% of such children

Pediatric prescribing in Karachi

To assess amount of drug overuse we studied drug prescribing for common childhood problems by 65 general practitioners [GPs] and 29 paediatricians. A total of 2433 encounters between GPs or paediatricians and children under five years of age were observed. The presenting complaints were fever in 18%, cough in 9%, both fever and cough in 21%, vomiting in 20% and diarrhoea in 41% of encounters. Antibacterials were prescribed in 49% of encounters, analgesics and antipyretics in 29%, antiemetics in 8% and injectables in 15%. Antidiarrhoeals were prescribed in 41% encounters with children reported to have diarrhoea. Ampicillin and cotrimoxazole were the two common antibacterials prescribed by both GPs and paediatricians. Antibacterials were prescribed in significantly larger number of encounters with GPs than in those with paediatricians. Mean encounter time of patients with GPs was 3.4 +/- 2.7 minutes and with paediatricians 9.7 +/- 4.1 minutes