Integrated Information Rich Engineering Course Design.

This study applies several high impact practices in an integrated fourth-year biomedical engineering course. The engineering design project is mapped to six deliverables using an adaptation of the Information Rich Engineering Design (IRED) model. This pedagogy facilitates regular student interactions with the instructor, the teaching assistant, the librarian and peers. Periodic information audits provide students with opportunities to reflect, integrate their learning, and share diverse experiences with the instructor. The term project is a real-world application which allows students to discover the relevance of theoretically learned concepts to hands-on problem solving. Students demonstrate competence in skills related to information seeking, writing and critical thinking through the completion of an IEEEstyle conference paper.

Higher Impulsivity and HIV-Risk Taking Behaviour in Males with Alcohol Dependence Compared to Bipolar Mania: A Pilot Study.

To study the association of impulsivity, high-risk behaviours and incidence of HIV infection in patients with alcohol dependence and bipolar mania. This was a cross-sectional hospital-based pilot study and the sample consisted of male patients divided into three groups: 25 patients with alcohol dependence and 25 with bipolar mania as per ICD-10 Diagnostic Criteria for Research and 25 normal controls. Severity of Alcohol Dependence Questionnaire (SADQ) and Young Mania Rating Scale (YMRS) were administered on alcohol dependent and bipolar patients, respectively. All three groups were rated on Barrett's Impulsivity Scale (BIS) and HIV Risk-taking Behaviour Scale (HRBS). None of the patients tested positive for either HIV 1 or 2. BIS motor impulsivity, BIS total score and HRBS total score were significantly higher in alcohol dependent patients as compared to bipolar mania patients. In the Alcohol dependent group, BIS score significantly correlated with education years, age of onset of alcohol use and SADQ, whereas, HRBS total score significantly correlated with SADQ scores. In the bipolar mania group, BIS significantly correlated with YMRS, and total number of episodes, whereas, there was no significant correlation of HRBS total score with any clinical variable. The findings of this pilot study underscore the link between alcohol use disorder and the impulsive behaviours that can lead to HIV infection, and highlight that those risks are higher for individuals with alcohol dependency than for individuals with bipolar disorder.

The emerging threat of schistosomiasis spread in Pakistan.

Schistosomiasis is among the thirteen neglected tropical diseases of the world. While prevalent in a number of countries, it has only rarely been reported in Pakistan. Here we report a 25 year old male who acquired the infection during travel to Malawi and presented with haematuria and dysuria. He was successfully treated with praziquantel. The possibility of schistosomiasis becoming endemic in the country is discussed. A number of risk factors are present including dams, irrigation, increased travel and geographical proximity to endemic countries. The local presence of at least one snail species of potential hosts for Schistosoma mansoni is confirmed. We see that schistosomiasis endemicity is a possible threat in Pakistan. Solutions to prevent this include reducing travel to endemic areas, prompt recognition and treatment of cases, and health education.

Physiologic load-bearing characteristics of autografts, allografts, and polymer-based scaffolds in a critical sized segmental defect of long bone: an experimental study.

BACKGROUND: To address the challenge of treating critical sized intercalary defects, we hypothesized that under physiologic cyclic loading, autografts, allografts, and scaffolds loaded with and without human mesenchymal stem cells (hMSCs) would have different biomechanical characteristics. METHODS: Using a rat femoral defect model, 46 rats were assigned to four groups, ie, autograft (n = 12), allograft (n = 10), scaffold (n = 13), and scaffold with hMSCs (n = 11). The scaffold groups used a 5 mm segment of scaffold composed of 80% poly-ε-caprolactone and 20% hydroxyapatite. Rats were sacrificed 4 months postoperatively, and the repairs were assessed radiographically and biomechanically. RESULTS: Autograft and allograft groups exhibited the most bridging callus, while the scaffold/hMSCs group had more callus than the scaffold repairs. Although signs of radiographic healing did not accurately reflect restoration of mechanical properties, addition of hMSCs on the scaffold enhanced bone formation. The scaffold alone group had significantly lower elastic and viscous stiffness and higher phase angles than other repairs and the contralateral controls. Addition of hMSCs increased the elastic and viscous stiffness of the repair, while decreasing the phase angle. CONCLUSION: Further comparative analysis is needed to optimize clinical use of scaffolds and hMSCs for critical sized defect repairs. However, our results suggest that addition of hMSCs to scaffolds enhances mechanical simulation of native host bone.

Seroprevalence of hepatitis E and Helicobacter pylori in a low socioeconomic area of a metropolitan city in a developing country.

This study aims to determine the prevalence of coinfection of H. pylori and hepatitis E virus (HEV) in the paediatric age group in an urban slum area of Karachi and identify risk factors associated with co-infection. Five hundred and forty children aged one to 15 years were investigated. Blood samples were collected and questionnaires completed on socio-demographic characteristics. Anti-H. pylori, HEV IgG and IgM antibodies were analysed by enzyme immunoassays (EIAs). The seroprevalence of H. pylori antibody was 47.2%, while that of HEV IgG and IgM was 14.4% and 2.4%, respectively. 12.4% exhibited seroprevalence for both H. pylori and HEV (IgG). In 67 (26%) cases positive for H. pylori IgG, HEV IgG positivity was also seen (P < 0.001). Only 13 (5%) positive for H. pylori were also positive for HEV IgM (P < 0.001). Only 11 (4%) HEV IgG-positive cases were H. pylori antibody-negative (P < 0.001). Hepatitis E virus was common in children who had access to municipal piped water (P = 0.025). H. pylori was common in children who used a non-flush toilet system (P < 0.001). Children exposed to H. pylori infection were also exposed to the risk of HEV.

Epidemiology, clinical presentation, and patterns of drug resistance of Salmonella Typhi in Karachi, Pakistan.

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.

Effectiveness of Vi capsular polysaccharide typhoid vaccine among children: a cluster randomized trial in Karachi, Pakistan.

BACKGROUND: Typhoid fever is endemic in Karachi, with an incidence among children ranging from 170 to 450 per 100,000 child-years. Vaccination strategies are important for prevention, and the Vi capsular polysaccharide (ViCPS) vaccine has been shown to be effective in reducing the burden of typhoid fever. METHODS: A cluster randomized trial was conducted in three low socioeconomic urban squatter settlements in Karachi, Pakistan between 2002 and 2007. Subsamples were followed up for assessment of immune response and adverse events after vaccination. RESULTS: The study participants were similar in a wide variety of socio-demographic and economic characteristics at baseline. A total of 27,231 individuals of the total target population of 51,965 in 120 clusters either received a ViCPS vaccine (13,238 [52% coverage]) or the control Hepatitis A vaccine (13,993 [53%]). Typhoid fever was diagnosed in 30 ViCPS vaccine recipients and 49 Hepatitis A vaccine recipients with an adjusted total protective effectiveness of 31% (95%CI: -28%, 63%). The adjusted total vaccine protective effectiveness was -38% (95%CI: -192%, 35%) for children aged 2-5 years and 57% (95%CI: 6%, 81%) for children 5-16 years old. CONCLUSION: The ViCPS vaccine did not confer statistically significant protection to children in the study areas, and there was a decline in antibody response 2 years post-vaccination. However, the ViCPS vaccine showed significant total protection in children 5-16 years of age, which is consistent with other studies of ViCPS vaccine conducted in India, Nepal, China and South Africa. These findings suggest that ViCPS vaccination of school-aged children will protect the children of urban, typhoid endemic areas against typhoid fever.

Risk factors associated with typhoid fever in children aged 2-16 years in Karachi, Pakistan.

We analysed the data from the control group in a typhoid vaccine trial in Karachi to assess the differences in individual-, household- and cluster-level characteristics for developing typhoid fever. The annual incidence of typhoid in children aged 2-16 years in the control arm of the vaccine trial was 151/100 000 population. After adjustment, the risk of typhoid was lower with increasing age [risk ratio (RR) 0·89, 95% confidence interval (CI) 0·83-0·95], was higher with an increase in population density (RR 1·13, 95% CI 1·05-1·21) and was lower in the households using a safe drinking-water source (RR 0·63, 95% CI 0·41-0·99). Typhoid fever affects younger children living in areas of high population density and lack of access to safe water in Pakistan. A combination of environmental and biological interventions is required to prevent the continued epidemiological and economic impact of typhoid fever in high-risk areas of Pakistan.

Graphic tobacco health warnings: which genre to choose?

BACKGROUND: Tobacco prevention studies show that graphic health warnings are more effective than text warnings, but there are no data on the effectiveness of different types of graphic health warnings in a Pakistani population. Even marginal differences in the effectiveness of genres can be of potential significance for public health. OBJECTIVE: To study the effectiveness of different types of graphic tobacco warnings in a Pakistani population. STUDY DESIGN: We presented ten anti-smoking warnings to randomly selected volunteers (n = 170) and recorded their opinion on the effectiveness of each warning. The warnings were based on a range of images aimed at the diverse population interviewed. A grading scale based on appeal, application, educational potential and motivation towards cessation was used to produce a composite grade of perceived effectiveness of the warning. RESULTS: Our results indicate that graphic warnings reach a greater proportion of the population than text warnings. Those appealing to logic, and those inculcating a sense of fear by showing a deleterious outcome of smoking, were judged likely to be most effective in motivating smokers to quit and preventing experimental smokers from forming a habit.

Helicobacter pylori infection in children: population-based age-specific prevalence and risk factors in a developing country.

AIM: We estimated the prevalence, age of acquisition and risk factors for Helicobacter pylori (H. pylori) seroprevalence in children aged 1-15 years. METHODS: Exposure was assessed using ELISA. Parents responded to a questionnaire regarding number of individuals sharing house, rooms, water source, latrines, housing and assessment of socioeconomic status (SES) by Hollingshead Index. RESULTS: Serum of 1976 children was tested. Helicobacter pylori seropositivity in children aged 11-15 years was 53.5% (OR: 2.0, 95% CI: 1.58-2.5). It increased with moderate crowding index (CRI) of 2-4 to 45.9% (OR: 1.23, 95% CI: 0.92-1.63) and to 51.2% with CRI >4 (OR: 1.52, 95% CI: 1.12-2.06). In middle SES, seropositivity was 50.5% (331/655) (OR: 1.7, 95% CI: 1.29-2.35), whereas in lower SES, it was 47.1% (500/1062) (OR: 1.5, 95% CI: 1.1-2.0). Multivariate analysis showed that Helicobacter pylori seroprevalence was high in children aged 6-10 and 11-15 years (OR: 1.5, 95% CI: 1.2-1.9 and OR: 1.9, 95% CI: 1.56-2.47 respectively), in lower-middle SES (OR: 1.6, 95% CI: 1.2-2.1 and OR: 1.5, 95% CI: 1.10-2.0 respectively) and in uneducated fathers (OR: 1.58, 95% CI: 1.27-1.95). CONCLUSION: Helicobacter pylori seropositivity increases with age, in low-middle SES and is related to father's educational status. Reducing H. pylori seroprevalence will require improvement in sanitary conditions and educational status of the population.

Enhanced detection rate of typhoid fever in children in a periurban slum in Karachi, Pakistan using polymerase chain reaction technology.

OBJECTIVE: Yield of blood culture in clinically suspected cases of typhoid fever is low, whereas indirect serological diagnostic tests are unreliable. Hence, polymerase chain reaction (PCR)-based detection of Salmonella enterica Serovar typhi was used as an aid for diagnosis of typhoid fever in addition to other diagnostic tests. Two periurban communities in Karachi were selected for an epidemiological study of typhoid fever. The aim of the study was to assess whether PCR increased the detection rate of typhoid fever in children in the community. MATERIAL AND METHODS: Children aged 2 to 14 years presenting with fever lasting for three or more days were selected. PCR using Hashimoto's protocol based on ViaB gene sequence was used in addition to blood culture and other serological tests. RESULTS: Of the 214 children included in the study, blood culture was found positive for S. enterica S. typhi in 26 (12.4%) cases, whereas 24 children (11.7%) were diagnosed as suffering from typhoid fever when the PCR-based method was used. Both tests were positive in only 10 (4.9%) children. The number of children found positive for either test was 40. PCR increased the rate of detection of typhoid fever by 51%. CONCLUSION: The sensitivity, specificity, +ve and -ve predictive values of PCR in this study were 40%, 93%, 45% and 92%, respectively.

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

OBJECTIVE: 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. DESIGN: A cross-sectional survey. PLACE AND DURATION OF STUDY: Four slums in and around Karachi during October and November, 2001. PATIENTS AND METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Status epilepticus in children: a five-year experience at Aga Khan University Hospital.

OBJECTIVE: Status epilepticus is an under diagnosed entity in Pakistan. It is a potentially reversible condition but has a high mortality, if it is not recognized and managed on time. The purpose of this study was to determine the clinical profile and the relationship of mortality of status epilepticus with its known risk factors. METHODS: This was a retrospective study. Medical records of all the patients admitted in the last five years (1998-2002) with a diagnosis of status epilepticus (ICDcode 345.30, 345.31) were reviewed. Data was recorded on a Performa and analyzed by using the statistical programme SPSS, chi square and Fischer exact test. RESULTS: The total number of patients were twenty-four. Sixteen patients were males (66.7%). Mean age was fifty-eight months and mean duration of hospital stay 5.5 days (range 2 to 22days). Eight patients were diagnosed to have epilepsy. Four (16.7%) had a previous history of status epilepticus. Three patients presented with status epilepticus for the first time without any previous history of seizures. Ten patients required midazolam infusion (41.7%) and out of these 3 (12.5%) were also given thiopentone infusion to control the seizures. Nine patients were shifted to the ICU for ventilation and control of seizures. Mortality in our study was 25%. Risk factors for mortality included age less than or equal to one year, abnormal MRI, type of the status epilepticus and the total duration of status epilepticus. No significant relationship was found with any of the known risk factors CONCLUSION: Status epilepticus is a neurological emergency. A very high mortality was seen in our study. No risk factors were identified for this high mortality.

Synthesis and antimicrobial activities of 1, 2-di (6-methylquinolyl-2) 1, 2-ethanedion.

The 1,2-di(6-methylquinolyl-2)-1,2-ethanedion is obtained when 1,2-di(6-methylquinolyl-2)-1,2-ethenediol was oxidized using air as an oxidizing agent whereas the starting material itself was synthesized when 6-methyl quinoline-2-carboxaldehyde was subjected to condensation reaction in the presence of potassium cyanide. The biological screening of the resulting substituted 1,2-diketone revealed its significant antimicrobial activities.

Insulin-like growth factor I response during nutritional rehabilitation of persistent diarrhoea.

OBJECTIVE: Evaluation of nutritional recovery, intestinal permeability, and insulin-like growth factor I (IGF-I) response in malnourished children with persistent diarrhoea and their relation to concomitant systemic infection(s). STUDY DESIGN: Open study of severely malnourished children (aged 6-36 months) with persistent diarrhoea (>/= 14 days) admitted for nutritional rehabilitation with a standardised rice-lentil and yogurt diet. Successful recovery was defined prospectively as overall weight gain (> 5 g/kg/day) with a reduction in stool output by day 7 of treatment. Data on coexisting infections and serum C reactive protein (CRP) were collected at admission. RESULTS: Of 63 children, 48 (group A) recovered within seven days of dietary treatment. These children had a significant increase in serum IGF-I (DeltaIGF-I%) and, in contrast to serum prealbumin and retinol binding protein, DeltaIGF-I% correlated with weight gain (r = 0.41). There was no correlation between the IGF-I response and intestinal permeability as assessed by urinary lactulose/rhamnose excretion. Treatment failures (group B) included more children with clinical (relative risk, 4.8; 95% confidence interval, 1.2 to 19.7) and culture proven sepsis at admission and higher concentrations of serum CRP (median (range), 36 (0-182) v 10 (0-240) mg/l) at admission. There was a negative correlation between admission CRP concentration and DeltaIGF-I% (r = -0.45). CONCLUSIONS: In comparison with serum albumin, prealbumin, and retinol binding protein, serum IGF-I increment is a better marker of nutritional recovery in malnourished children with persistent diarrhoea. The possible association of systemic infections, serum IGF-I response, and mucosal recovery needs evaluation in future studies.

Zinc supplementation in malnourished children with persistent diarrhea in Pakistan.

OBJECTIVE: To evaluate the potential benefit of dietary supplementation of a rice-lentil (Khitchri) and yogurt diet with 3 mg/kg/d of elemental zinc (as zinc sulfate) in hospitalized malnourished children (age 6-36 months) with persistent diarrhea for 14 days. METHODOLOGY: Randomized, double-blind placebo-controlled trial. SETTING: Nutrition Research Ward at the National Institute of Child Health, Karachi, Pakistan, where children were admitted for 14 days of inpatient supervised rehabilitation. PRIMARY OUTCOME: overall weight gain by day 14. SECONDARY OUTCOMES: overall energy intake, stool output, time to diarrheal recovery and weight gain (>/=3 days), plasma zinc, copper, prealbumin, and insulin-like growth factor-1. RESULTS: Of 87 children randomized for supplementation with either zinc or placebo, the two groups were comparable at admission in terms of severity and duration of diarrhea, as well as nutritional and anthropometric parameters. The overall weight gain, stool volume, stool frequency, as well as the time taken for diarrheal recovery or steady weight gain, were comparable for both supplemented children and controls. Supplemented children had a significant improvement in plasma zinc levels and serum alkaline phosphatase by day 14 of therapy in comparison with controls. Plasma copper levels were low in both groups at admission and although an increase was seen in control children, levels decreased further after zinc supplementation. There was no significant difference between the two groups for hemoglobin, serum albumin, prealbumin, and plasma insulin-like growth factor-1 increments during the course of therapy. Evaluation of primary and secondary outcome criteria among the subset of children with plasma zinc levels <60 microg/d at admission did not reveal any significant differences. CONCLUSIONS: Although there was satisfactory recovery in malnourished children with persistent diarrhea receiving the Khitchri-yogurt diet, there was no evidence of improved weight gain or acceleration of recovery from diarrhea with zinc supplementation. In contrast, the reduction in plasma copper levels in zinc-supplemented malnourished children suggests that caution should be exercised in supplementing severely malnourished children with zinc alone.

Self-reported feeding advice by physicians for common childhood illnesses.

BACKGROUND: 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. OBJECTIVES: To look at the food-advising behaviour of physicians during illnesses and to know the maternal concepts about various foods being hot or cold. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Maternal vitamin-D deficiency in Pakistan.

OBJECTIVE OF THE STUDY: This study was performed to assess the vitamin D status of healthy Pakistani nursing mothers and their breastfed infants. METHODS: Seventy-one nursing mothers and their breastfed infants belonging to upper and lower socio-economic class were examined 6 weeks to 11 months after delivery. Serum 25-hydroxy vitamin D [25(OH)D], serum calcium, phosphorus and alkaline phosphatase were measured. RESULTS: The mean serum 25(OH)D in mothers was 36.7+/-32.4 nmol/L and 41.25+/-35.4 nmol/ L in infants. Thirty-four (48%) mothers and 37 (52%) infants had levels less than 25 nmol/ L. Significantly higher levels were found in uneducated mothers (p=0.01), mothers of lower socio-economic class (p<0.001) and in those living in mud houses (p<0.001). A significant correlation was found between serum 25(OH)D levels of infants under three months of age and their mothers (p<0.01). CONCLUSIONS: High prevalence of vitamin D deficiency was found in nursing mothers and their infants predominantly in the upper socioeconomic class.