Effective strategies for increasing the uptake of modern methods of family planning in South Asia: a systematic review and meta-analysis.

BACKGROUND: Family planning (FP) interventions have improved the use of modern contraceptives, yet a high unmet need for contraception still exists in South Asia. This systematic review of existing research was conducted to identify effective FP interventions that led to an increase in the uptake of modern methods of contraception in South Asia. METHODS: Five electronic databases were searched for relevant studies published between January 1st, 2000 and May 4, 2023. Experimental studies that reported data on the impact of FP interventions on modern contraceptive use among women of reproductive age (15-49 years) in the South Asian region were included. A random-effects Inverse Variance weighted model was employed to pool the adjusted odds ratio (OR) on modern contraceptive use and unmet need for contraception. In addition, we computed subgroup meta-estimates based on intervention type and the urban-rural divide. RESULTS: Among 643 studies identified, 21 met the inclusion criteria. The overall pooled odds ratio for modern contraceptive use was significantly higher (OR 1.51; 95% CI 1.35-1.70; heterogeneity; I2 = 81%) for FP interventions with a significant reduction in unmet need for contraception (OR 0.86; 95% CI 0.78-0.94, I2 = 50%). The subgroup analysis revealed demand-generation (OR 1.61; 95% CI 1.32-1.96), health system integrated (OR 1.53; 95% CI 1.07-2.20), and franchised FP clinic interventions (OR 1.32; 95% CI 1.21-1.44) had promoted the modern contraceptive uptake. Further, FP interventions implemented in urban settings showed a higher increase in modern contraceptive use (OR 1.73; 95% CI 1.44-2.07) compared to rural settings (OR 1.46; 95% CI 1.28-1.66). Given the considerable heterogeneity observed across studies and the low degree of certainty indicated by the GRADE summary for the primary outcome, caution is advised when interpreting the results. CONCLUSION: The review collated experimentally evaluated FP interventions that increased modern contraception use and reduced the unmet need in South Asia. The demand generation interventions were the most effective in increasing the uptake of modern contraceptive methods. Furthermore, the urban environment provides a conducive environment for interventions to improve contraceptive usage. However, further studies should assess which aspects were most effective on attitudes towards contraception, selection of more effective methods, and contraceptive behaviors.

Normal preoperative levels of gamma-glutamyltransferase predict the absence of common bile duct stones in patients scheduled for laparoscopic cholecystectomy: a retrospective cohort study.

Laparoscopic cholecystectomy, nowadays, is considered the gold standard option for management in patients diagnosed with symptomatic cholelithiasis. Nevertheless, some patients may have coexisting choledocholithiasis, which manifests later in life with grave complications such as cholangitis and pancreatitis. The objective of this study is to evaluate the role of preoperative gamma-glutamyltransferase (GGT) in predicting choledocholithiasis in patients undergoing laparoscopic cholecystectomy. Method: A total of 360 patients with symptomatic cholelithiasis based on diagnosis aided with abdominal ultrasound were included in the study. The study design was a retrospective cohort. Patients were evaluated based on a comparison between findings of per-operative cholangiogram and laboratory measure of GGT. Result: The mean age of study participants was 47.22 (±28.41) years. Mean GGT levels were 121.54 (±87.91) U/l. One hundred (27.7%) participants had raised GGT. But only 19.4% had been diagnosed with filling defect positive on cholangiogram. The predictability of GGT for positive cholangiogram is statistically significant at less than 0.001 with an area under the curve of 0.922 (0.887-0.957), sensitivity of 95.7%, specificity of 88.6%, and accuracy of 90%. The standard error reported (0.018) was found to be relatively low. Conclusion: Based on the provided information, it is concluded that GGT plays an important role in predicting the coexistence of choledocholithiasis in symptomatic cholelithiasis and can be used in the setting where the facility of per-operative cholangiogram is not available.

Clinicopathological correlation of aspartate aminotransferase-to-platelet ratio (APRI) and aspartate aminotransferase-to-alanine aminotransferase ratio (AAR) with survival in esophageal carcinoma patients: a retrospective cohort analysis of 951 patients.

Esophageal cancer is the eighth most prevalent cancer globally. Previously, several biomarkers have been used to predict the prognosis, although with variable reliability. Interestingly, it is noted that changes in liver function tests levels before and after neoadjuvant treatment are predictive in terms of cancer recurrence. Objectives: The objectives of the current study were to associate novel markers, including aspartate aminotransferase-to-platelet ratio (APRI) and aspartate aminotransferase-to-alanine aminotransferase ratio (AAR) with survival in esophageal malignancy. Materials and Methods: A retrospective study in a tertiary care hospital (single-center) included 951 patients having diagnosed esophageal carcinoma of any age group. Results: The median (interquartile range) age of study participants were 50 (38-60) years, including 43% males and 57% female patients, while the median (interquartile range) levels of AAR and APRI were 0.97 (0.81-1.25) and 0.19 (0.13-0.29), respectively. AAR was found to be higher in dysphagia for solids only and dysphagia for both liquids and solids rather than liquids only (P=0.002), while other associations included well-differentiated tumor grade (P=0.011), finding of esophageal stricture on esophagogastroduodenoscopy (P=0.015), and characteristic of mass on computerized tomography scan being both circumferential and mural (P=0.005). APRI was found to be higher in adenocarcinoma (P=0.038), and finding of circumferential±ulcerated mass on esophagogastroduodenoscopy (P<0.001). On survival analysis, adenocarcinoma (P<0.001), luminal narrowing (P=0.002), AAR greater than 1.0 (P=0.006), and APRI greater than 0.2 (P=0.007) were found to be poor survival predictors. On Cox proportional hazards regression, APRI was found to be more associated with poor survival than AAR (Hazard ratio: 1.682, 1.208-2.340, P=0.002). Conclusion: This study correlated clinical and pathological features of esophageal malignancy with noninvasive markers of hepatic function.

Community and Health Care Provider Perspectives on Barriers to and Enablers of Family Planning Use in Rural Sindh, Pakistan: Qualitative Exploratory Study.

BACKGROUND: Unmet need for family planning in Pakistan is high, with 17% of all married women wanting to avoid or delay pregnancy. However, they cannot owing to a lack of access to modern contraception and sociocultural hindrances. With the modern contraceptive prevalence rate stagnant at approximately 25% over the last 5 years, it is important to explore barriers and enablers to modern contraception uptake to reduce maternal and child mortality and improve reproductive health outcomes for young girls and women. OBJECTIVE: A formative research approach was taken to explore community member and health care provider perspectives on access to and use of family planning methods in 2 rural districts of Sindh, Pakistan. The broader goal of this study was to provide evidence to design and implement a socioculturally appropriate family planning intervention within the existing service delivery platforms to increase modern contraceptive uptake in the context of rural Sindh. METHODS: A qualitative exploratory design was used. Between October 2020 and December 2020, 11 focus group discussions and 11 in-depth interviews were conducted. Focus group discussions were held with men and women from the community, including adolescents, to build an understanding of community beliefs and concepts regarding modern contraceptive methods. In-depth interviews were conducted with health care workers and explored intersections between family planning and reproductive health service delivery at the facility and outreach levels. RESULTS: The findings revealed that limited financial autonomy, restricted women's mobility, discriminatory gender norms, and cultural practices left women with little opportunity for independent decision-making on the use of modern contraceptive methods. Furthermore, facility-level and supply-side barriers, including frequent stock-outs of modern contraceptives combined with a lack of capacity of health workers to provide quality family planning services and counseling, played an important role in demotivating women from seeking services. In addition, a lack of integration of family planning with maternal and child health service delivery at the health system level was emphasized as a major missed opportunity for contraceptive uptake. Several demand-side barriers to family planning uptake were also highlighted. These included husbands' or in-laws' disapproval, social stigma, and perceived fear of side effects regarding modern family planning method use. More importantly, a lack of adolescent-friendly reproductive health services and spaces for counseling was identified as a critical intervention area. CONCLUSIONS: This study provides qualitative evidence on issues related to the effectiveness of family planning interventions, specifically in the context of rural Sindh. The findings emphasize the need to design socioculturally appropriate and health system-relevant family planning interventions-the effectiveness of which can be improved through their integration with maternal and child health service delivery mechanisms, consistent service provision, and opportunities for the capacity building of the health care workforce. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/35291.

Effects of Integrating Family Planning With Maternal, Newborn, and Child Health Services on Uptake of Voluntary Modern Contraceptive Methods in Rural Pakistan: Protocol for a Quasi-experimental Study.

BACKGROUND: The uptake of modern contraceptive methods (MCMs) remains low, with 25% of women reporting their use in Pakistan. The overarching interventions covering service delivery platforms at facility and community levels necessitate the integration of family planning (FP) with maternal, newborn, and child health (MNCH) services. OBJECTIVE: The main aim of this study is to evaluate the impact of an integrated FP-MNCH service delivery model to increase coverage of MCMs in rural Pakistan. Moreover, we aim to measure the level of effectiveness of interventions regarding the uptake of MCMs. METHODS: A quasi-experimental, sequential, mixed methods study design with pre- and postevaluation will be adopted to evaluate the impact of integration of FP with MNCH services. The interventions include the following: (1) capacity strengthening of health care providers, including technical trainings; training in counseling of women who attend immunization centers, antenatal care (ANC) clinics, and postnatal care (PNC) clinics; and provision of job aids; (2) counseling of women and girls attending ANC, PNC, and pediatric clinics; (3) ensuring sustained provision of supplies and commodities; (4) community engagement, including establishing adolescent-friendly spaces; and (5) use of District Health Information System data in decision-making. Descriptive statistics will be used to estimate prevalence (ie, proportions) and frequencies of outcome indicators. A univariate difference-in-difference analytical approach will be used to estimate the effect of the interventions. In addition, a Blinder-Oaxaca decomposition analysis will be conducted to identify and quantify determinants of the modern contraceptive prevalence rate. RESULTS: The intervention phase began in July 2021 and will run until June 2022. The impact assessment will be conducted from July to September 2022. CONCLUSIONS: This project will evaluate the impact of integrating FP with MNCH services. Furthermore, this study will identify the drivers and barriers in uptake of MCMs and will simultaneously help in modifying the interventional strategies that can be scaled up through existing service delivery platforms within the public and private sectors, according to the local sociocultural and health system context. TRIAL REGISTRATION: ClinicalTrials.gov NCT05045599; https://clinicaltrials.gov/ct2/show/NCT05045599. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/35291.

Impact of pulse oximetry on hospital referral acceptance in children under 5 with severe pneumonia in rural Pakistan (district Jamshoro): protocol for a cluster randomised trial.

BACKGROUND: Pneumonia is a leading cause of death among children under 5 specifically in South Asia and sub-Saharan Africa. Hypoxaemia is a life-threatening complication among children under 5 with pneumonia. Hypoxaemia increases risk of mortality by 4.3 times in children with pneumonia than those without hypoxaemia. Prevalence of hypoxaemia varies with geography, altitude and severity (9%-39% Asia, 3%-10% African countries). In this protocol paper, we describe research methods for assessing impact of Lady Health Workers (LHWs) identifying hypoxaemia in children with signs of pneumonia during household visits on acceptance of hospital referral in district Jamshoro, Sindh. METHODS AND ANALYSIS: A cluster randomised controlled trial using pulse oximetry as intervention for children with severe pneumonia will be conducted in community settings. Children aged 0-59 months with signs of severe pneumonia will be recruited by LHWs during routine visits in both intervention and control arms after consent. Severe pneumonia will be defined as fast breathing and/or chest in-drawing, and, one or more danger sign and/or hypoxaemia (Sa02 <92%) in PO (intervention) group and fast breathing and/or chest in-drawing and one or more danger sign in clinical signs (control) group. Recruits in both groups will receive a stat dose of oral amoxicillin and referral to designated tertiary health facility. Analysis of variance will be used to compare baseline referral acceptance in both groups with that at end of study. ETHICS AND DISSEMINATION: Ethical approval was granted by the Ethics Review Committee of the Aga Khan University (4722-Ped-ERC-17), Karachi. Study results will be shared with relevant government and non-governmental organisations, presented at national and international research conferences and published in international peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER: NCT03588377.

Effect and feasibility of district level scale up of maternal, newborn and child health interventions in Pakistan: a quasi-experimental study.

INTRODUCTION: Pakistan has a high burden of maternal, newborn and child morbidity and mortality. Several factors including weak scale-up of evidence-based interventions within the existing health system; lack of community awareness regarding health conditions; and poverty contribute to poor outcomes. Deaths and morbidity are largely preventable if a combination of community and facility-based interventions are rolled out at scale. METHODS AND ANALYSIS: Umeed-e-Nau (UeN) (New Hope) project aims is to improve maternal, newborn and child health (MNCH) in eight high-burden districts of Pakistan by scaling up of evidence-based interventions. The project will assess interventions focused on, first, improving the quality of MNCH care at primary level and secondary level. Second, interventions targeting demand generation such as community mobilisation, creating awareness of healthy practices and expanding coverage of outreach services will be evaluated. Third, we will also evaluate interventions targeting the improvement in quality of routine health information and promotion of use of the data for decision-making. Hypothesis of the project is that roll out of evidence-based interventions at scale will lead to at least 20% reduction in perinatal mortality and 30% decrease in diarrhoea and pneumonia case fatality in the target districts whereas two intervention groups will serve as internal controls. Monitoring and evaluation of the programme will be undertaken through conducting periodical population level surveys and quality of care assessments. Descriptive and multivariate analytical methods will be used for assessing the association between different factors, and difference in difference estimates will be used to assess the impact of the intervention on outcomes. ETHICS AND DISSEMINATION: The ethics approval was obtained from the Aga Khan University Ethics Review Committee. The findings of the project will be shared with relevant stakeholders and disseminated through open access peer-reviewed journal articles. TRIAL REGISTRATION NUMBER: NCT04184544; Pre-results.

Knowledge, attitude and practice of medical students towards HIV patients in their pre-clinical and post-clinical years in Karachi, Pakistan: a dual-center cross-sectional study.

The human immunodeficiency virus (HIV) is currently a global threat with an estimated 38.6 million people affected with HIV worldwide. According to the Joint United Nations Program on HIV/AIDS (UNAIDS), since 2004 the total number of cases of HIV in Pakistan has risen from 2700 to 130,000. In light of the rising burden of HIV/AIDS across the country, it is essential that medical students possess appropriate knowledge regarding the subject. Therefore, we aimed to assess the knowledge, attitude and practice of medical students towards HIV patients in their pre-clinical and post-clinical years in Karachi, Pakistan. A cross-sectional study was conducted among 518 pre-clinical (year 1 and 2) and post-clinical (year 3, 4, and 5) medical students from two medical schools in Karachi during the months of October - December 2019. Similar numbers of participants were taken from each year. Data were analyzed using SPSS. Descriptive statistics were used to report frequencies and proportions for categorical responses. Chi-square and Kruskal-Wallis tests were used as the primary statistical tests. About 55% of participants were female, and most belonged to the Islamic faith. More than half of the participants learned about HIV from books (315/518), followed by medical personnel (287/518). A quarter (134/518) of the participants believed HIV could be transmitted by sharing saliva, more than half of whom consisted of pre-clinical year students. Over half the participants (60.4%) knew that there was a difference between HIV and AIDs, most of whom belonged to the 5th year group. When detecting HIV, only about 30% of participants knew about indirect fluorescent antibody. Regarding attitudes, one-third would not be friends with a person diagnosed with HIV/AIDS. As a medical officer, a large majority (76.6%; n=397/518) of the participants would be anxious or somewhat anxious. Two-thirds believed that treating an HIV patient can make them contract HIV, and a majority of participants (333/518) did not feel adequately prepared to deal with the psycho-social problems of an HIV/AIDS patient. Finally, regarding practice, only one-third of the participants were willing to treat an HIV/AIDS patient, most of whom belonged to the pre-clinical 2nd year group and fewer to the post-clinical 3rd year group. Knowledge amongst medical students regarding HIV/AIDS was generally high, although there are some knowledge inadequacies which require more emphasis in the medical school curriculum. However, contrasting with the level of knowledge, in terms of attitude the majority were anxious or somewhat anxious when treating an HIV patient, and only one-third were willing to treat a patient with HIV.

Compliance and Knowledge of Healthcare Workers Regarding Hand Hygiene and Use of Disinfectants: A Study Based in Karachi.

Background Hand hygiene is the cardinal step in combating various healthcare-associated infections. These infections are a cause of 37,000 deaths in Europe and 100,000 deaths in the United States annually. Thus, prevention of their spread is of utmost importance today. A study conducted in a tertiary care center in Karachi found that 17% of the medical professionals were aware of the World Health Organization (WHO) guidelines on hand hygiene while only 4.9% followed these hand-washing techniques. Lack of hand hygiene practice and awareness has raised a need to reassess infection control in hospitals. There is currently undisputed proof that adherence to hand cleanliness diminishes the danger of transmission of various infections. Methods A questionnaire-based cross-sectional study was conducted at Dr. Ruth K.M. Pfau Civil Hospital, Karachi in January 2019. Data from 212 participants who met the inclusion criteria were analyzed. A three-part questionnaire was used for the hospital staff who had been present at the hospital for at least six hours and had attended to the patients during the last three continuous working days. Staff members who visited the hospital but did not attend to any patients or those who had been present at the hospital for less than six hours were excluded. Collected data were analyzed using Statistical Package for Social Science (SPSS) version 23.0 (IBM, Armonk, NY). Results A total of 212 individuals (74 doctors, 66 nurses, 52 technicians, and 20 ward assistants) agreed to participate in our study, of which 124 were females. The compliance with hand disinfectant use before and after every patient contact was found to be 12.3%. The use of disinfectant was found to be more among males than females (mean 7.88 times for males vs. 6.20 for females) and the younger individuals were more compliant with hand hygiene practices; 62.73% of participants were aware of the WHO guidelines regarding hand hygiene and 65.56% were aware of hospital-acquired infections. However, nearly half of the participants (45.75%) had never attended a formal lecture on the subject and more than half (62.26%) of the participants were unenlightened about the complications of hospital-acquired infections. Conclusions Hand hygiene is a basic requirement for every medic and paramedic in a hospital setting today. Keeping in mind the drastic consequences of the spread of hospital-associated infections, it is evident that hand hygiene should be stressed upon. The rising incidence of nosocomial infections and their complications can be prevented by raising awareness about hand hygiene practices. There is a need to further investigate the application of and adherence to the basic guidelines on hand hygiene. Our results indicate that this issue should be tackled through a multidimensional approach.

Relationship between Night Eating Syndrome and Self-esteem: A Cross-sectional Population-based Study in Karachi, Pakistan.

Background The amount of literature shedding light upon eating disorders in developing countries, such as Pakistan, is scarce. This is partially because talking about such matters is considered taboo in the general population. Night Eating Syndrome's (NES) link with depression and obesity has been established; however, presently, no study has been conducted which solely focuses on NES's correlation with self-esteem. Therefore, to bridge this knowledge gap, we conducted this study to assess the prevalence of NES in Karachi and its association with self-esteem. Methods We conducted a cross-sectional study in August 2018 using convenience sampling in 395 individuals, out of which 197 belonged to the age group 18-24 and 198 to 25-30. The participants were interviewed for their gender, body mass index (BMI), and their level of education. The participants were asked to complete a structured, standardized questionnaire assessment, which comprised of questions from the Night Eating Questionnaire (NEQ) and Rosenberg Self-Esteem scale (RSE). The eating habits of the participants and the level of self-esteem were assessed using four- and five-point Likert scales. Kruskal-Wallis and chi-square tests were used as the primary statistical tests. Results Out of the 395 respondents, more than half of the respondents were females (n = 235/395, 59.5%). About one-fourth (n = 92/395, 23.3%) of the participants had a BMI of greater than 25.0 kg/m2. More than one-third of the underweight (n = 20/55, 36.4%) and overweight population (n = 33/92, 35.9%) had low self-esteem, while more than one-fourth (n = 25/92, 27.2%) of the overweight participants fulfilled the criteria of NES. The final outcomes showed that 14.4% of the participants had NES, and 4.6% of the participants had low self-esteem. Conclusion Our results pointed out to a significant relationship between NES and self-esteem. Furthermore, NES and self-esteem also had a significant association with age, gender, and BMI. Additionally, awareness regarding eating and mental disorders should be done in countries like Pakistan, where talking in regard to such matters is considered taboo. Given the various factors that further strengthen the positive relationship between NES and low self-esteem, these factors can be the targets on which the treatment can be focused.

Recognition of Antibiotic Resistance in Spontaneous Bacterial Peritonitis Caused by Escherichia coli in Liver Cirrhotic Patients in Civil Hospital Karachi.

Introduction Spontaneous bacterial peritonitis (SBP) is the most common life-threatening infection in patients with ascites due to liver cirrhosis. The infection is most commonly caused by the bacterium Escherichia coli, commonly referred to as E. coli. Over the past few years, the incidence of antimicrobial resistance against E. coli has risen drastically, leading to increased morbidity and mortality. Methods This cross-sectional study was conducted to determine the pattern of resistance using variations of antibiotics against E. coli, to prevent its empirical usage and initiate an appropriate target antibiotic therapy. The data were collected from May 2017 to October 2017 and included a total of 184 patients. The patients had previously been diagnosed with chronic liver disease and had presented with E. coli-induced SBP in the medicine wards at Civil Hospital, Karachi, which is the largest tertiary care hospital in the city. All participants underwent diagnostic paracentesis, and the ascitic fluid samples were sent to labs for culture and sensitivity to antibiotics. Results The sample population consisted of 184 participants, of which two-thirds (63.6%; n=117/184) of the population consisted of males. The mean age of the participants was 47.6±10.7 years. More than half of the patients had hepatitis C (54.9%; n=101/184) while the remaining were diagnosed with hepatitis B (45.1%; n=83/184). The ascitic fluid showed varying percentages of resistance for drugs, with no resistance to imipenem and meropenem while ciprofloxacin showed the highest resistance in eradicating the bacterium, E. coli. Additionally, a statistical correlation was tested between drug resistance and factors like age, gender, duration of liver disease, and duration of ascites. Ciprofloxacin and tetracycline showed a positive correlation between the resistance of these drugs and the age, gender, and duration of chronic liver disease in the participants while trimethoprim/sulfamethoxazole, amoxicillin/clavulanic acid, and piperacillin/tazobactam showed a positive association with the duration of ascites. Conclusion A rapid diligent intervention of cirrhotic patients with complicated ascites is crucial to alleviate patient mortality. Due to the rising bacterial resistance, primarily, epidemiological patterns should be assessed and analyzed in our regional hospitals, and then, antibiotics should be prescribed meticulously.

Assessment of Clinicians' Satisfaction With Laboratories at a Public Sector Hospital in Karachi, Pakistan.

Objective The goal of this study was to assess the level of satisfaction of clinicians regarding the provision of information, accessibility, and services by clinical laboratories at a public sector hospital in Karachi, Pakistan. Methods We conducted a cross-sectional survey of 151 participants from a public sector hospital in Karachi to assess their satisfaction regarding the associated laboratories. A five-point Likert scale questionnaire, consisting of 18 study items total, was used. Apart from the sociodemographics, the questionnaire was divided into three main sections: Services, Accessibility, and Provision of Information. The study lasted six months from October 2018 to March 2019. Results Most study participants were women. Less than one-third of the participants were consultants (21.9%). The overall satisfaction score was 62/90, indicating that the respondents were satisfied with most of the items on the scale. Factors such as notification about abnormal test results and courier services provided by the laboratories had the lowest satisfaction score. Conclusion Laboratory services are lacking in certain areas, specifically notifications and courier services, that need development and improvement, both of which can be achieved through seminars and clear communication between the laboratory staff and the associated clinicians.

Rare Case of Peritonitis due to Ileal Perforation Secondary to Richter's Type of Obturator Hernia.

Obturator hernia is an extremely rare condition accounting for almost 0.07%-1% of all abdominal wall hernias, usually occurring in the elderly and emaciated females with a history of previous abdominal surgery. The symptoms of this particular hernia are non-specific; therefore, a high index of clinical suspicion should always be made. This rare condition may lead to acute small intestinal obstruction. The pre-operative diagnosis is challenging and often misleading on occasions, especially in co-morbid cases. This leads to delayed diagnosis and surgical intervention, hence causing an increased morbidity and mortality rate. The computed tomography (CT) scan of the abdomen and pelvis is the gold standard for diagnosis. We present a case of an 80-year-old female, with known comorbid of hypertension, initially diagnosed as peritonitis and on further examination revealed strangulated obturator hernia with proximal perforation, that underwent lower midline laparotomy with resection of necrotic bowel, an end-to-end anastomosis, and repair of the defect by vicryl suture.

Superior mesenteric artery syndrome in an 18-year old female: Case report.

We report an unusual case of an 18-year old woman, who presented to Civil Hospital Karachi in May 2016 with complaints of vomiting, abdominal pain, dysphagia, altered bowel habits, loss of appetite and chronic weight loss. On examination, abdomen was found to be soft and non-tender with discomfort on breathing. CT angiogram revealed reduction of aortomesenteric angle and aortomesenteric distance which were both consistent with superior mesenteric artery syndrome. Reduction in angle was thought to be because of weight loss and adipose tissue depletion so patient was started on enteral and parenteral nutritional supplements. Upon seeing little to no improvement, duodenojejunostomy was performed and patient was kept under observation. Nutritional supplements were continued. The after procedure course was uneventful.

An observational study on the association of nonalcoholic fatty liver disease and metabolic syndrome with gall stone disease requiring cholecystectomy.

OBJECTIVE: Recognition of Non alcoholic fatty liver disease (NAFLD) and metabolic syndrome in patients with gallstones undergoing laparoscopic or open cholecystectomy, along with it we will also study the life style of patients with gall stones. BACKGROUND: Patients with gallstones have associated NAFLD, with concurrent metabolic syndrome and these ailments share similar factors for example obesity, hypertriglyceridemia and diabetes mellitus. Factors like body mass index, gender, raised lipid levels, use of contraceptives and alcohol and having diabetes, physical inactiveness, multiparous women, water with excessive iron content, metabolic syndrome, and NAFLD are accountable factors for gallstones formation. METHODOLOGY: This was a case series done at Surgical Unit 1 of Civil Hospital Karachi. Selective samples of 88 patients were included. Duration was 3 months. We included both sexes with ultrasound proof of gall stone irrespective of cholecystitis. Excluded patients with history of seropositive viral hepatitis, autoimmune and wilson's disease. As these conditions can act as a confounder to our variables. RESULTS: Nafld was present in 62.5%(n = 55) while 28.4% (n = 25) had metabolic syndrome. 26.94% had BMI less than 18, 32.12 had BMI between 18 and 25 and majority had BMI greater than 25 i.e in 40.93%. Of all 46.6% had a family history of cholelithiasis. Gallstone patients with NAFLD reported about their first degree relative being suffering from cholelithiasis at a significant p-value of 0.034 while this was not significant in cases of metabolic syndrome and the p -value was 0.190. CONCLUSION: We found association of metabolic syndrome with gallstones and NAFLD. Non alcoholic fatty liver was highly prevalent in our study subjects. Huge percentage of first degree relatives of gall stone patients had gallstones and this relation was more pronounced patients who had associated NAFLD.

Clinical Presentation and Frequency of Risk Factors in Patients with Breast Carcinoma in Pakistan.

BACKGROUND: Breast cancer is known to be one of the most prevalent cancers among women in both developing and developed countries .The incidence of breast cancer in Pakistan has increased dramatically within the last few years and is the second country after Israel in Asia to have highest proportional cases of breast cancer. However, there are limited data for breast cancer available in the literature from Pakistan. OBJECTIVES: The study was conducted to bring to light the common clinical presentation of breast cancer and to evaluate the frequency of established risk factors in breast carcinoma patients and furthermore to compare the findings between premenopausal and postmenopausal women in Pakistan. MATERIALS AND METHODS: A 6 months (from July 2012 to Dec 2012) cross sectional survey was conducted in Surgical and Oncology Units of Civil Hospital, Karachi. Data were collected though a well developed questionnaire from 105 female patients diagnosed with carcinoma of breast and analyzed using SPSS version 17. Institutional ethical approval was obtained prior to data collection. RESULTS: Out of 105 patients, 43 were premenopausal and 62 were postmenopausal, 99 being married. Mean age at diagnosis was 47.8 ± 12.4 years. A painless lump was the most frequent symptom, notived by 77.1%(n=81). Some 55.2% (n=58) patients had a lump in the right breast and 44.8%(n=47) in the left breast. In the majority of cases, the lump was present in upper outer quadrant 41.9% (n=44). Mean period of delay from appearance of symptoms to consulting a doctor was 5.13 ± 4.8 months, from the shortest 1 month to the longest 36 months. Long delay (> 3 months) was the most frequent figure 41.9%. Considering overall risk factors most frequent were first pregnancy after 20 years of age (41%), physical breast trauma (28.6%), lack of breast feeding(21.9%), and early menarche <11 years (19%), followed by null parity (16.2%), consumption of high fat diet (15.2%), family history of breast cancer or any other cancer in first degree relatives (9.5% and 13.3%, respectively). Some of the less common factors were late menopause >54 years (8.6%), use of oral contraceptive pills (10.5%), use of hormone replacement therapy (4.7%),smoking (4.7%) and radiation (0.96%). Significant differences (p<0.005) were observed between pre and post menopausal women regarding history of physical breast trauma, practice of breast feeding and parity. CONCLUSIONS: A painless lump was the most frequent clinical presentation noted. Overall age at first child > 20 years, physical breast trauma, lack of breast feeding ,early menarche <11 were the most frequent risk factors. Physical breast trauma, lower parity, a trend for less breast feeding had more significant associations with pre-menopausal than post-menopausal onset. Increase opportunity of disease prevention can be obtained through better understanding of clinical presentation and risk factors important in the etiology of breast cancer.

Risk of Breast Cancer among Young Women and Importance of Early Screening.

BACKGROUND: Breast cancer is the most common type of cancer in women throughout the world. However, in comparison with Western women, it presents relatively early in women of Asian ethnicity. Early menarche, late menopause, use of OCP's, family history of benign or malignant breast disease, exposure to radiation and BMI in the under-weight range are well known risk factors for the development of breast cancer in premenopausal women. Early detection with the use of breast self-examination (BSE) and breast cancer screening programs can lead to a reduction in the mortality rates due to breast cancer. The aim of our study was to assess the risk factors for breast cancer among young women and to emphasize the importance of early screening among them. MATERIALS AND METHODS: We conducted a cross-sectional study among women aged 18 to 25 using a self- administered questionnaire. Data was collected over a period of 6 months from June to December, 2014. A total of 300 young women selected randomly from Dow Medical College and various departments of Karachi University successfully completed the survey. RESULTS: Respondents were 18-25 years of age (mean age=21.5). Out of the 300 young females, 90 (30%) had at least one risk factor, 90 (30%) had two, 40 (13%) had three, 8 (2.7%) had four, 2 (0.7%) had five while one female was found to have six positive risk factors for breast cancer. Some 66 women (22%) experienced symptoms of breast cancer such as non-cyclical pain and lumps. While 222 women (74%) had never performed breast self-examination, 22 (7.3%) had had a breast examination done by a health professional while 32 (10.7%) had participated in breast screening programs. A total of 223 (74.3%) women considered breast cancer screening important for young women. CONCLUSIONS: The percentage of young women with risk factors for breast cancer was found to be alarmingly high. Therefore, screening for breast cancer should start at an early age especially in high risk groups. Awareness about breast self-examination should be emphasized. Moreover, screening programs should be started to ensure early detection and reduction of mortality rates caused by breast cancer also in young Pakistani females.

Coverage and quality of antenatal care provided at primary health care facilities in the 'Punjab' province of 'Pakistan'.

BACKGROUND: Antenatal care is a very important component of maternal health services. It provides the opportunity to learn about risks associated with pregnancy and guides to plan the place of deliveries thereby preventing maternal and infant morbidity and mortality. In 'Pakistan' antenatal services to rural population are being provided through a network of primary health care facilities designated as 'Basic Health Units and Rural Health Centers. Pakistan is a developing country, consisting of four provinces and federally administered areas. Each province is administratively subdivided in to 'Divisions' and 'Districts'. By population 'Punjab' is the largest province of Pakistan having 36 districts. This study was conducted to assess the coverage and quality antenatal care in the primary health care facilities in 'Punjab' province of 'Pakistan'. METHODS: Quantitative and Qualitative methods were used to collect data. Using multistage sampling technique nine out of thirty six districts were selected and 19 primary health care facilities of public sector (seventeen Basic Health Units and two Rural Health Centers were randomly selected from each district. Focus group discussions and in-depth interviews were conducted with clients, providers and health managers. RESULTS: The overall enrollment for antenatal checkup was 55.9% and drop out was 32.9% in subsequent visits. The quality of services regarding assessment, treatment and counseling was extremely poor. The reasons for low coverage and quality were the distant location of facilities, deficiency of facility resources, indifferent attitude and non availability of the staff. Moreover, lack of client awareness about importance of antenatal care and self empowerment for decision making to seek care were also responsible for low coverage. CONCLUSION: The coverage and quality of the antenatal care services in 'Punjab' are extremely compromised. Only half of the expected pregnancies are enrolled and out of those 1/3 drop out in follow-up visits.

Acute appendicitis: diagnostic accuracy of Alvarado scoring system.

OBJECTIVE: To evaluate the usefulness of the Alvarado scoring system in reducing the percentage of negative appendectomy in our unit. MATERIALS AND METHODS: A cross-sectional study was conducted, comprising 110 patients, admitted to Surgical Unit I, Civil Hospital, Karachi, in 2011 with a preliminary diagnosis of acute appendicitis. Patients of both sexes and all age groups except younger than 10 years were included in the study and their Alvarado scores calculated, on the basis of which patients were divided into two groups: Group A (Alvarado score <6) and Group B (Alvarado score ≥6). The signs, symptoms, laboratory values, surgical interventions, and pathology reports of each patient were evaluated. Diagnosis was confirmed by histopathological examination. Sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS: Out of 110 cases (79 males, 31 females), 31 belonged to Group A (28.2%) and 79 belonged to Group B (71.8%). Surgical procedures were performed in 98.2% of cases, along with conservative treatment. Final diagnosis by histopathology was confirmed in 77 cases (71.3%). The overall negative appendectomy rate was 28.7% (males: 28.2%, females: 30%). Sensitivity and specificity of the Alvarado scoring system were found to be 93.5% and 80.6% respectively. Positive and negative predictive values were 92.3% and 83.3%, respectively, and accuracy was 89.8%. CONCLUSION: Alvarado score can be used effectively in our setup to reduce the incidence of negative appendectomies. However, its role in females was not satisfactory and needs to be supplemented by other means.

Accessibility of antenatal services at primary healthcare facilities in Punjab, Pakistan.

INTRODUCTION: Almost one-fifth of the world's population constitutes women of reproductive age who are repeatedly exposed to pregnancy and childbearing. Many are often at high risk of illness and mortality during pregnancy and require maternal healthcare services for early detection of complications. More than 0.5 million women die every year worldwide due to pregnancy-related complications. Almost 0.03 million of them are in Pakistan. Maternal healthcare in Pakistan is poor and results in high rates of morbidity and mortality. This paper evaluates the accessibility of antenatal care (ANC) services in primary healthcare settings in the Punjab province of Pakistan during the period June 2010- August 2011. METHODS: The paper uses a cross-sectional study including mix methods (qualitative and quantitative). Nine districts were included in the project; one from each administrative tier or division. Nineteen health facilities, including two rural health centres (RHCs) and 17 basic health units (BHUs) were randomly selected from each district. The total sample was 171 health facilities. The qualitative assessment was carried out through focus-group discussions (FGDs) and indepth interviews with clients, providers, and health managers. RESULTS: The reasons for the gaps in service accessibility were the distant location of facilities, a lack of transport, and inconvenient facility working hours. The issues of service accessibility were further exacerbated by sociocultural factors such as low levels of client awareness, a lack of decision-making by clients, and the influence of spiritual healers and quacks. Health managers further pointed out weak co-ordination between vertical programmes and routine integrated health services, and a lack of human resources in distantly located facilities. CONCLUSION: In order to increase the accessibility of ANC services, facility working hours must be extended and adjusted according to the convenience of clients in primary healthcare (PHC) facilities. The utilisation of ANC services can also be increased through client awareness and gender empowerment for ANC decisionmaking.