Evaluating an immunization carpool service for women in rural areas for facilitating routine childhood immunizations in Pakistan -a feasibility study on acceptability, demand, and implementation.

Introduction: Poor accessibility of immunization services coupled with limited options for transportation and socio-cultural norms that hinder women's mobility are among the key factors contributing to poor immunization coverage in rural areas. We assessed the feasibility and acceptability of establishing a free-of-cost, women-only carpool service for immunization in a rural setting in Pakistan and evaluated its preliminary impact on immunization coverage and timeliness among children. Methods: We conducted a feasibility study in four selected immunization facilities in Shikarpur District, Sindh. A local transport vehicle was hired and branded as an immunization carpool service. Women having un- or under-immunized children aged ≤2 years were invited to visit immunization facilities using carpool vehicles. Information on demographic indicators and service experience was collected. Child immunization details were extracted using the government's provincial electronic immunization registry to estimate immunization coverage and timeliness. Results: Between January and October 2020, six immunization carpool vehicles provided uninterrupted service and transported 2422 women-child pairs, completing 4691 immunization visits. Majority of women reported that the carpool service improved accessibility (99.6%) by offering group travel (82.9%) and reducing their dependency on family members (93.4%). Preliminary estimates reported an increase in immunization coverage and timeliness across antigens among participating children compared to non-participating children, with significant increase in proportion for BCG coverage (38.1%; p < 0.001, CI: 32.8%, 43.4%) and measles-2 timeliness (18%; p < 0.001, CI: 13.3%, 22.4%). Conclusion: A women-only immunization carpool service implemented within a rural setting is feasible and highly acceptable. Key factors contributing to the model's success include increased mobility and independence of women, cost-savings, and a culturally and contextually appropriate mechanism of transport embedded within the local setting. Increased accessibility to health services also contributed to improved immunization coverage and timeliness among children.

Evaluation of a Mobile-Based Immunization Decision Support System for Scheduling Age-Appropriate Vaccine Schedules for Children Younger Than 2 Years in Pakistan and Bangladesh: Lessons From a Multisite, Mixed Methods Study.

BACKGROUND: Missed opportunities for vaccination (MOVs), that is, when children interact with the health system but fail to receive age-eligible vaccines, pose a crucial challenge for equitable and universal immunization coverage. Inaccurate interpretations of complex catch-up schedules by health workers contribute to MOVs. OBJECTIVE: We assessed the feasibility of a mobile-based immunization decision support system (iDSS) to automatically construct age-appropriate vaccination schedules for children and to prevent MOVs. METHODS: A sequential exploratory mixed methods study was conducted at 6 immunization centers in Pakistan and Bangladesh. An android-based iDSS that is packaged in the form of an application programming interface constructed age-appropriate immunization schedules for eligible children. The diagnostic accuracy of the iDSS was measured by comparing the schedules constructed by the iDSS with the gold standard of evaluation (World Health Organization-recommended Expanded Programme on Immunization schedule constructed by a vaccines expert). Preliminary estimates were collected on the number of MOVs among visiting children (caused by inaccurate vaccination scheduling by vaccinators) that could be reduced through iDSS by comparing the manual schedules constructed by vaccinators with the gold standard. Finally, the vaccinators' understanding, perceived usability, and acceptability of the iDSS were determined through interviews with key informants. RESULTS: From July 5, 2019, to April 11, 2020, a total of 6241 immunization visits were recorded from 4613 eligible children. Data were collected for 17,961 immunization doses for all antigens. The iDSS correctly scheduled 99.8% (17,932/17,961) of all age-appropriate immunization doses compared with the gold standard. In comparison, vaccinators correctly scheduled 96.8% (17,378/17,961) of all immunization doses. A total of 3.2% (583/17,961) of all due doses (across antigens) were missed in age-eligible children by the vaccinators across both countries. Vaccinators reported positively on the usefulness of iDSS, as well as the understanding and benefits of the technology. CONCLUSIONS: This study demonstrated the feasibility of a mobile-based iDSS to accurately construct age-appropriate vaccination schedules for children aged 0 to 23 months across multicountry and low- and middle-income country settings, and underscores its potential to increase immunization coverage and timeliness by eliminating MOVs.

Adolescent girls' recommendations for the design of a human papillomavirus vaccination program in Sindh, Pakistan: a qualitative study.

PURPOSE: Vaccination of adolescent girls against human papillomavirus (HPV) significantly reduces the incidence of cervical cancer. HPV vaccines are available in Pakistan but plans to develop HPV vaccination program are at a nascent stage. We conducted a formative study to explore adolescent girls' knowledge and perspectives on HPV and cervical cancer and collect their recommendations for implementing an HPV vaccination program in their community. METHODS: Using qualitative exploratory study design, we conducted four focus group discussions (FGDs) with 12 adolescent girls per group in District West, Karachi. We recruited unmarried girls aged 16-19 years from schools and community settings between May-December 2020. Data analysis was done using NVivo. RESULTS: Overall, participants displayed a positive attitude toward HPV vaccine. However, they were unfamiliar with basic concepts related to female reproductive health. Female relatives were indicated as girls' preferred point of contact for discussions on HPV and cervical cancer, but fathers were portrayed as decision-making authority on vaccination. Participants indicated vaccine hesitancy among parents may affect HPV vaccination uptake. Girls suggested individual household visits and community-based camps as strategies for successful implementation of HPV vaccination program. A solid foundation of trust between girls' families, program managers, and other stakeholders emerged as a key asset for the program's success. CONCLUSION: Adolescent girls' suggestions of informing key decision-makers in the family (particularly fathers) of the benefits of HPV vaccination, establishing trust with vaccine providers, and increasing accessibility of vaccinations should be explored for successful implementation of an HPV vaccination program in Pakistan.

Integrating tuberculosis screening into antenatal visits to improve tuberculosis diagnosis and care: Results from a pilot project in Pakistan.

BACKGROUND: Active tuberculosis (TB) during pregnancy has an adverse effect on maternal and neonatal outcomes. This study analysed the results of a pilot project integrating TB screening into antenatal care (ANC) visits in a high-TB-burden, low-resource setting. METHODS: Data were extracted from the TB screening pilot in obstetrician-gynaecologist clinics of six tertiary care facilities in Karachi, Pakistan from April to December 2017. Data from the verbal symptom screening conducted at each ANC visit for all women and the Xpert MTB/RIF testing for all symptomatic women to investigate TB yield were analysed by assessing the numbers screened, presumptive patients and active TB diagnoses among pregnant women and neonates. RESULTS: Symptom screening was performed on 113,078 pregnant women, 2,965 (2.6%) of whom reported at least one TB symptom. Sputum samples were collected from 2,896 (97.7%) symptomatic women. Of the 27 (0.9%) newly diagnosed bacteriologically positive TB patients, 25 (93%) initiated TB treatment. No case of vertical TB transmission was reported among 26 live births. DISCUSSION: TB screening is feasible and should be implemented during routine ANC visits in high-TB-burden settings. There is a need to explore a multi-faceted approach with inclusion of clinical examination and chest X-rays to diagnose TB in pregnant women.

Unusual cause of persistent dyspnea in a patient with nephrotic syndrome: dapsone-induced methemoglobinemia.

Acquired methemoglobinemia is a rare, but important cause of tissue hypoxemia, which often results from commonly prescribed medications. We report a case of an 83-year-old female with stage III chronic kidney disease, who was started on high-dose prednisone for nephrotic syndrome and dapsone for pneumocystis jirovecii pneumonia prophylaxis. A week after initiation of dapsone, this patient presented with shortness of breath, and an oxygen saturation gap while on supplemental O2 via nasal cannula, with no obvious cardiopulmonary cause. Methemoglobin level was elevated on arterial blood gas. Our patient was treated with IV methylene blue. Dapsone was determined to be the culprit and immediately discontinued. Patient responded with a rapid decrease in methemoglobin levels and resolution of symptoms. This case report highlights the importance of maintaining a high index of suspicion and careful review of medication history for prompt and successful management of methemoglobin poisoning, as not all patients present with classical signs of methemoglobinemia such as cyanosis and/ or dark red blood.

Effect of vaccine reminder and tracker bracelets on routine childhood immunization coverage and timeliness in urban Pakistan (2017-18): a randomized controlled trial.

BACKGROUND: Inability to track children's vaccination history coupled with parents' lack of awareness of vaccination due dates compounds the problem of low immunization coverage and timeliness in developing countries. We evaluated the impact of two types of silicone immunization reminder bracelets for children in improving immunization coverage and timeliness of Pentavalent-3 and the Measles-1 vaccines. METHODS: Children < 3 months were enrolled in either of the 2 intervention groups (Alma Sana Bracelet Group and Star Bracelet Group) or the Control group. Children in the intervention groups were provided the two different bracelets at the time of recruitment. Each time the child visited the immunization center, a hole was perforated in the silicone bracelet to denote vaccine administration. Each child was followed up till administration of Measles-1 vaccine or till 12 months of age (if they did not come to the center for vaccination). Data was analyzed using the intention-to-treat population between groups. The unadjusted and adjusted Risk Ratios (RR) and 95% confidence interval (CI) for Pentavalent-3 and Measles-1 coverage at 12 months of age were estimated through bivariate and multivariate analysis. Time-to-Pentavalent-3 and Measles-1 immunization curves were calculated using the Kaplan-Meier method. RESULTS: A total of 1,445 children were enrolled in the study between July 19, 2017 and October 10, 2017. Baseline characteristics among the three groups were similar. Up-to-date coverage for the Pentavalent-3 /Measles-1 vaccine at 12 months of age was 84.6%/72.0%, 85.4%/70.5% and 83.0%/68.5% in Alma Sana Bracelet group, Star Bracelet group and Control group respectively but the differences were not statistically significant. In the multivariate analysis, neither the Alma Sana bracelet (adjusted RR = 1.01; 95% CI: 0.96-1.06), (adjusted RR: 1.05; 95% CI: 0.97-1.13) nor the Star bracelet (adjusted RR = 1.01; 95% CI: 0.96-1.06) (adjusted RR: 1.03; 95% CI: 0.95-1.11) was significantly associated with Pentavalent-3 vaccination or Measles-1 vaccination. CONCLUSION: Although we did not observe any significant impact of the bracelets on improved immunization coverage and timeliness, our findings add to the existing literature on innovative, low cost reminders for health and make several suggestions for enhancing practical implementation of these tools. TRIAL REGISTRATION: ClinicalTrials.gov NCT03310762 . Retrospectively Registered on October 16, 2017.

Complications in DIEP Flap Breast Reconstruction After Mastectomy for Breast Cancer: A Prospective Cohort Study Comparing Unilateral Versus Bilateral Reconstructions.

BACKGROUND: The demand for bilateral breast reconstructions is rising worldwide. In the UK, approximately 30% of breast cancer patients undergoing mastectomy choose autologous tissue breast reconstruction. Although the deep inferior epigastric perforator (DIEP) flap is gaining popularity, bilateral DIEP flap breast reconstruction remains a complex procedure and reliable outcome data are lacking. In the absence of clinical trials, evidence from cohort studies is needed to better inform clinicians and patients. METHODS: Over a 6-year period, all consecutive patients undergoing DIEP flap breast reconstruction were prospectively included and categorized as unilateral or bilateral reconstruction for comparative analyses of outcomes and complications, with the patient as the unit of analysis. RESULTS: Overall, 565 DIEP flaps were performed on 468 women (371 unilateral and 97 bilateral reconstructions [194 flaps]). Postoperative complications requiring reoperation were twice as likely for bilateral reconstructions (risk ratio [RR] 2.1, 95% CI 1.4-3.4, p = 0.002) and were mainly due to venous congestion (RR 3.1, 95% CI 1.2-7.5, p = 0.011). The risk of total flap loss was six times greater in bilateral reconstruction (RR 6.4, 95% CI 1.6-26, p = 0.011). The rates of revision breast and abdominal surgery were similar between groups. CONCLUSIONS: Both unilateral and bilateral DIEP flap breast reconstructions are safe, with a low risk of complications; however, bilateral reconstruction was associated with a higher risk of complications and total flap loss. This information should be highlighted to patients requesting bilateral breast reconstruction, particularly those requesting risk-reducing mastectomy and reconstruction.

Contralateral breast symmetrisation in unilateral DIEP flap breast reconstruction.

INTRODUCTION: Women undergoing unilateral deep inferior epigastric artery perforator (DIEP) flap breast reconstruction may be offered a contralateral symmetrisation either at the time of reconstruction (simultaneous/immediate) or at a later stage (delayed). Simultaneous contralateral breast symmetrisation may be more beneficial to patients and healthcare institutions by avoiding staged surgery, although there is limited evidence on which to base practice. This deficit formed the rationale for our study. The primary outcome was the overall rate of revision surgery. METHODS: Over a 6-year period, this prospective cohort study recorded the demographics, cancer treatments and operative outcomes of all consecutive unilateral DIEP flap breast reconstructions with or without contralateral symmetrising surgery. Patients were categorised into three groups: (1) simultaneous symmetrisation, 2) delayed symmetrisation and (3) no symmetrisation for comparative analysis. RESULTS: During the study period, 371 women underwent unilateral DIEP flap breast reconstruction 194 (52.3%) were not symmetrised, 155 (41.8%) were simultaneously symmetrised and 22 (5.9%) underwent delayed symmetrisation. Simultaneous symmetrisation of the contralateral breast and unilateral DIEP flap breast reconstruction increased the mean total operative time by 28 min. There were no differences in the rates of peri-operative complications. There were significantly higher rates of all-cause revision surgery (OR 3.97 [1.58, 9.94], p = 0.003) in women undergoing delayed symmetrisation, because of higher rates of revision lipomodelling, scar revision and revision contralateral symmetrisation. CONCLUSION: Simultaneous contralateral breast symmetrisation was associated with a lower risk of all-cause revision surgery. It is safe, beneficial and likely to be more cost-effective for women undergoing unilateral free DIEP flap breast reconstruction.

Safety watch: reducing constant observation through nurse empowerment and accountability.

Safety watch (SW), a nurse-driven surveillance program, provides a framework for the appropriate level of patient observation. It empowers nurses to initiate flexible levels of patient safety observation that can be adjusted based on the patient's need and be discontinued safely at the earliest opportunity. The SW program resulted in dramatic reductions in constant observation and restraint use while sustaining quality of care.

Surgical strategies to salvage the venous compromised deep inferior epigastric perforator flap.

BACKGROUND: Elevation of the deep inferior epigastric perforator (DIEP) flap interrupts its superficial venous system, and if drainage through the deep venous system is inadequate the flap may develop congestion. The purpose of this retrospective study was to determine the fate of the congested DIEP flap and to optimize the strategy for its salvage. METHODS: Thirty-two of 162 patients who underwent unilateral breast reconstruction with a DIEP flap developed venous congestion. For the purpose of outcome analysis, cases were retrospectively allocated to "observation-only" (group A, n = 11), postoperative salvage (group B, n = 7), and intraoperative salvage (group C, n = 14), and complications among the various groups were compared to determine the necessity and optimal timing of salvage intervention. RESULTS: Two flaps (1 in group A, another in group B) failed completely, giving a success rate 98.8%. The complication rate and hospital stay were significantly lower in group C than in group B (P = 0.03, P = 0.02). The rate of venous congestion requiring salvage procedures was 13%, with a salvage rate of 95%. Salvage procedures included venous augmentation with an additional recipient vein in 7 procedures, adding superficial inferior epigastric vein (SIEV) to DIEV in 11 procedures, and substituting with SIEV in 7 procedures. There was no statistical difference in flap salvage rate using the SIEV between "augmentation" and "substitution." CONCLUSIONS: The salvage procedures for venous compromised DIEP flap are better performed intraoperatively rather than postoperatively to prevent further complications. The engorged SIEV could be incorporated by anastomosing to an additional recipient vein or adding to the DIEV-internal mammary vein axis or substituting for DIEV.

Reducing mandibular height to increase mouth opening in unreleasable trismus.

PURPOSE: We submit an alternative treatment for unreleasable trismus to increase the interincisal distance and allow adequate oral nutrition and masticatory function. PATIENT AND METHODS: The patient presented with severe trismus after receiving postoperation radiotherapy for oral carcinoma. We undertook radical release of the left-sided trismus, and covered the resultant soft tissue defect with an anterolateral thigh free flap, but the patient was only able to open his mouth an interincisal distance of 8 mm. The right mandible was accessed and the functionless residual teeth were extracted. Marginal mandibulectomy of the native mandible was performed. RESULTS: Dental implants (POI, Kyocera, Japan) were inserted into the leveled right mandible. A bridge dental prosthesis was inserted and resulted in a final functional interincisal distance of 19 mm. CONCLUSION: We offer that leveling the native mandible to match the reconstructed side is a simple procedure that can be reasonably used as an alternative measure in a selected group of patients.

The versatility of the anterolateral thigh flap.

In the last two decades, the anterolateral thigh flap has emerged as one of the most popular reconstructive options for multiple body sites. Based on a perforator flap harvest concept, the flap encompasses the advantages of versatility, pliability, and potential for composite tissue replacement. Although numerous anatomical variations exist, these are well-described, and flap safety remains uncompromised if certain anatomical boundaries are respected. Careful preoperative planning and identification of perforators remain the cornerstone of successful flap harvest. Once perforators are identified, variations in skin paddle design allow for multiple skin paddle configurations, central or eccentric orientations, and custom-made flaps tailored to fit almost any defect. A suprafascial dissection allows for "ultra-thin" flaps ideal for folding, tubing, or packing purposes. The versatility of the lateral circumflex femoral artery branches can be exploited to include muscle, iliac bone, tendon, fascia, or nerve in extended designs. The anterolateral thigh flap is currently the frontline choice for head and neck reconstruction, including intraoral, mandibular-maxillary, tongue, and facial defects, and is gaining popularity in abdominal and pelvis reconstruction. It can also be used as a pedicled flap in phallus or perineum reconstruction. More recently, the flap has proved to be extremely useful in skin resurfacing and even functional reconstruction in traumatic wounds. This review summarizes the anatomy, planning, flap harvest, donor morbidity, and clinical applications of the anterolateral thigh flap. An algorithm is proposed that facilitates a clear, problem-based approach for the use of this versatile reconstructive option.

Vascularized groin lymph node transfer using the wrist as a recipient site for management of postmastectomy upper extremity lymphedema.

BACKGROUND: Restoring the continuity of lymphatic drainage by lymphaticovenous or lymphaticolymphatic anastomosis was observed in the short term to be patent but eventually occluded because the elevated interstitial pressure will cause obliteration of these tiny, thin-walled, low-pressure lumens. The purpose of this study was to evaluate the outcome of vascularized groin lymph node transfer using the wrist as a recipient site in patients with postmastectomy upper extremity lymphedema. METHODS: Between January of 1997 and June of 2005, 13 consecutive patients with a mean age of 50.69 +/- 11.25 years underwent vascularized groin lymph node transfer for postmastectomy upper extremity lymphedema. A vascularized groin lymph node nourished by the superficial circumflex iliac vessels was harvested and transferred to the dorsal wrist of the lymphedematous limb. The superficial radial artery and the cephalic vein were used as the recipient vessels. Outcome was assessed by upper limb girth, incidence of cellulitis, and lymphoscintigraphy. RESULTS: All flaps survived, and one flap required reexploration, with successful salvage. No donor-site morbidity was encountered. At a mean follow-up of 56.31 +/- 27.12 months, the mean reduction rate (50.55 +/- 19.26 percent) of the lymphedematous limb was statistically significant between the preoperative and postoperative groups (p < 0.01). The incidence of cellulitis was decreased in 11 patients. Postoperative lymphoscintigraphy indicated improved lymph drainage of the affected arm, revealing decreased lymph stasis and rapid lymphatic clearance. A hypothesis was proposed that the vascularized groin lymph node transfer might act as an internal pump and suction pathway for lymphatic clearance of lymphedematous limb. CONCLUSION: Vascularized groin lymph node transfer using the wrist as a recipient site is a novel and reliable procedure that significantly improves postmastectomy upper extremity lymphedema.

The plastic surgeon's role in extracranial-to-intracranial bypass using a reverse great saphenous vein graft.

BACKGROUND: Extracranial-to-intracranial bypass is used for flow replacement and diversion that prevent the serious complications associated with sudden ligation of the middle cerebral artery for treatment of complex tumors or aneurysms. Extracranial-to-intracranial bypass is a demanding procedure that requires experience in advanced microsurgical techniques. In this article, the authors review the first report of an extracranial-to-intracranial bypass performed by a plastic surgeon with emphasis on indications for microsurgical involvement in neurosurgical practice and on description of the surgical technique. METHODS: Between April of 2004 and October of 2006, three extracranial-to-intracranial bypass cases were performed including one for a complex aneurysm rupture and two for resections of cranial base tumors. In every case, the intracranial approach was used by the neurosurgeon. The bypass was performed by interposing a reverse great saphenous vein graft between the superficial temporal artery, in end-to-end anastomosis, and the second segment of the middle cerebral artery, in end-to-side anastomosis. RESULTS: In each case, postoperative cerebral angiography demonstrated complete patency of the extracranial-to-intracranial bypass. Neither of the two surviving patients at a mean follow-up of 13 months had deterioration of neurologic function, postoperative stroke, or surgery-related death. One of the patients was dead before the 6-month follow-up. CONCLUSIONS: The reverse great saphenous vein graft is a good option for extracranial-to-intracranial bypass, with the advantages of high-flow graft, wide lumen, adequate length, easy harvest, and minimal donor-site morbidity. The plastic surgery/neurosurgery alliance allows scope for improved outcomes in complex neurosurgical cases and continues to push the frontiers of reconstructive microsurgery.

Bilateral breast reconstruction using bilateral anterolateral thigh flaps: a case report.

Options for autologous reconstruction have been limited in some patients by previous abdominal surgeries, and by lack of adequate abdominal tissue. The anterolateral thigh (ALT) flap has previously been described as an alternate donor site for autologous breast reconstruction when abdominal tissue is unavailable or unsuitable.We describe our experience with a 41-year-old low body mass index (19.8 kg/m) patient with previous suction-assisted lipectomy underwent bilateral breast reconstruction using bilateral ALT flaps.At a follow-up of 2 years, the patient was delighted with her reconstructed breasts and despite her athletic build was able to fill a B cup bra.ALT flap has the advantages of a long pedicle, adequate soft adipose tissue, and also allowing supine positioning with a 2-team approach. The anterolateral flap is a credible alternative that may be considered for bilateral autologous breast reconstruction in selected patients.

Osteomyocutaneous peroneal artery-based combined flap for reconstruction of composite and en bloc mandibular defects.

BACKGROUND: The osteomyocutaneous peroneal artery-based combined (OPAC) flap is a refinement of fibula osteoseptocutaneous flap, with the inclusion of partial soleus muscle based on an independent myocutaneous perforator. METHODS: Seventeen men underwent composite oromandibular reconstruction using an OPAC flap. Flaps were raised with 1 or 2 skin paddles and 2 to 3 bone segments. In 8 cases, a portion of soleus muscle was included. RESULTS: All flaps survived, but partial failure occurred in 2 cases (11.7%). At a mean follow-up of 25.3 +/- 19.4 months, 6 of 12 patients tolerated a regular diet, 5 a soft diet, and 1 a liquid diet. Speech was normal in 2 patients, intelligible in 4, and slurred in 6. CONCLUSION: Advantages of the OPAC flap include a single donor site, 1 pair of recipient vessels, versatile 3-dimensional inset, adequate soft tissue augmentation, and better aesthetic and functional outcomes.

One-stage immediate breast reconstruction with implant following skin-sparing mastectomy in Asian patients.

The Asian breast reconstruction patient is usually of lower mean age, lower body mass index (BMI), and has relatively small breasts. This study aimed to investigate the outcome of 1-stage immediate breast reconstruction using saline-filled implants in the Asian patients.Between April 2002 and July 2005, 30 patients underwent skin-sparing mastectomy and 1-stage immediate breast reconstruction with a saline-filled implant. Mean age was 42.9 years, with a mean BMI of 21.9 and a mean implant volume of 283 mL. The overall success rate was 96.6%, with 1 case of implant exposure secondary to chest skin necrosis. At mean follow-up of 21.5 months (range 6 to 40 months), 1 patient developed local recurrence (3.33%). Perfusion of the chest skin flap is reliable enough to allow 1-stage breast reconstruction with small saline-filled breast implants. We present this as an additional option for immediate breast reconstruction in thin women with small breasts.