Publications by authors named "Shiyam Sunder Tikmani"

23 Publications

  • Page 1 of 1

Frequency and risk factors of non-alcoholic fatty liver disease in -infected dyspeptic patients: A cross-sectional study.

SAGE Open Med 2021 18;9:20503121211025421. Epub 2021 Jun 18.

Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan.

Background: In dyspeptic patients with contributes to non-alcoholic fatty liver disease. However, little evidence available from Pakistan.

Objective: The study aims to determine the frequency and risk factors of non-alcoholic fatty liver disease in dyspeptic patients with .

Methods: This cross-sectional study was conducted between 22 November 2016 and 30 June 2018. Adults of age between 18 and 90 years who attended the out-patient department due to abdominal discomfort, pain, fullness, and bloating who underwent upper gastrointestinal tract endoscopy were enrolled after taking informed consent. Patients with celiac disease, inflammatory bowel disease, taking alcohol, pregnant women and lactating mothers, known cases of hepatitis B and C, and history of recent antibiotic use were excluded. Data on age, gender, smoking, alcohol use, dyslipidemia, hypertension, type 2 diabetes mellitus, and ischemic heart disease were collected. Non-alcoholic fatty liver disease was diagnosed through ultrasonography. infection was detected using a carbon urea breath test.

Results: A total of 698 patients were screened for eligibility, and 399 (57.2%) had infection and were enrolled in the study after consent. The median age was 50.1 (interquartile range = 14.5) years and 209 (52.4%) were males. Frequency of non-alcoholic fatty liver disease in patients with dyspeptic patients was 153 (38.3%). Factors associated with non-alcoholic fatty liver disease in the presence of were dyslipidemia 7.38 (95% confidence interval = 2.4-22.71), type 2 diabetes mellitus 5.96 (95% confidence interval = 1.86-19.07), hypertension 3.0 (95% confidence interval = 1.21-7.45), and moderate gastritis 2.81 (95% confidence interval = 1.2-6.59).

Conclusion: The frequency of non-alcoholic fatty liver disease in dyspeptic patients was 38.3%. Male gender, dyslipidemia, hypertension, ischemic heart disease, and moderate gastritis were associated with non-alcoholic fatty liver disease.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/20503121211025421DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8216349PMC
June 2021

Maternal and Fetal Vascular Lesions of Malperfusion in the Placentas Associated with Fetal and Neonatal Death: Results of a Prospective Observational Study.

Am J Obstet Gynecol 2021 Jun 7. Epub 2021 Jun 7.

Columbia University, New York NY USA.

Background: Fetal death, one of the major adverse pregnancy outcomes, is especially common in low and middle-income countries. Placental lesions may play an important role in the etiology of fetal and possibly neonatal death. Prior research relating placental lesions to fetal death causation was often hindered by the lack of agreement on a placental classification scheme. The Amsterdam Consensus statement, published in 2016, focused attention on malperfusions in the maternal and fetal placental circulations.

Objectives: Our purpose was to investigate the relationships of placental maternal vascular (MVM) and fetal vascular malperfusion (FVM) to fetal and neonatal death with a focus on the most important maternal clinical conditions in the pathway to fetal and neonatal death; maternal hypertension, antepartum haemorrhage and decreased fetal growth.

Study Design: This was a prospective, observational cohort study conducted at two Asian sites. Data collected included clinical history, gross and histologic evaluation of the placenta, and a number of other investigations to determine cause of death. The placenta was evaluated at both sites using the Amsterdam Consensus framework. We estimated the risk of placental MVM and FVM among fetal and neonatal deaths.

Results: Between July 2018 and January 2020 in India and Pakistan, 814 women with a fetal death, 618 with a preterm live birth and subsequent neonatal death, and 201 term live births, all with a placenta available for study, provided consent. The prevalence of MVM was higher in placentas of fetal deaths (58.4%) and preterm neonatal deaths (31.1%) compared to the term live births (15.4%). Adjusting for site, MVM had a RR of 3.88 (95% CI 2.70-5.59) among fetal deaths vs. term live births and a RR of 2.07 (95% CI 1.41-3.02) for preterm neonatal deaths vs. term live births. Infarcts and distal villous hypoplasia were the most common histological components of MVM. FVM was found less frequently in the placentas of fetal deaths (19.0%) than was MVM (58.4%). However, there were higher frequencies of FVM in fetal death placentas (19.0%) than in placentas from neonatal deaths (8.3%) or in the term live birth placentas (5.0%). Adjusting for site, FVM had a RR of 4.09 (95% CI 2.15-7.75) among fetal deaths vs. term live births and RR 1.77 (95% CI 0.90-3.49) for preterm neonatal deaths vs. term live births. There was a higher incidence of MVM in cases of maternal hypertension (71.4%), SGA (69.9%) and antepartum hemorrhage (59.1%) compared to the incidence of MVM in fetal deaths with none of these conditions (43.3%). There were no significant differences in the occurrence of FVM among the four clinical categories.

Conclusion(s): Histological examination of the placenta, especially for malperfusion disorders, is crucial in elucidating pathways to fetal death and likely for neonatal death in preterm infants. Possibly more important is the potential to focus on placental MVM and FVM during pregnancy as a means to identify fetuses at risk and to reduce the risk of fetal death by early delivery. It is our additional hope that the increased risk of fetal and neonatal death in these pregnancies can be reduced by development of an intervention to reduce the likelihood of developing MVM and/or FVM in the first place.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajog.2021.06.001DOI Listing
June 2021

Clinical signs predictive of severe illness in young Pakistani infants.

BMC Res Notes 2021 Feb 24;14(1):71. Epub 2021 Feb 24.

Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan.

Objective: Early detection of specific signs and symptoms to predict severe illness is essential to prevent infant mortality. As a continuation of the results from the multicenter Young Infants Clinical Signs and Symptoms (YICSS) study, we present here the performance of the seven-sign algorithm in 3 age categories (0-6 days, 7-27 days and 28-59 days) in Pakistani infants aged 0-59 days.

Results: From September 2003 to November 2004, 2950 infants were enrolled (age group 0-6 days = 1633, 7-27 days = 817, 28-59 days = 500). The common reason for seeking care was umbilical redness or discharge (29.2%) in the 0-6 days group. Older age groups presented with cough (16.9%) in the 7-27 age group and (26.9%) infants in the 28-59 days group. Severe infection/sepsis was the most common primary diagnoses in infants requiring hospitalization across all age groups. The algorithm performed well in every age group, with a sensitivity of 85.9% and specificity of 71.6% in the 0-6 days age group and a sensitivity of 80.5% and specificity of 80.2% in the 28-59 days group; the sensitivity was slightly lower in the 7-27 age group (72.4%) but the specificity remained high (83.1%).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s13104-021-05486-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903754PMC
February 2021

Relationship Between Foot Length and Gestational Age in Pakistan.

Glob Pediatr Health 2020 20;7:2333794X20974206. Epub 2020 Nov 20.

The Aga Khan University, Karachi, Pakistan.

Preterm births have a high risk of mortality. Therefore, knowledge of the gestational age (GA) at birth is crucial to guide the appropriate management of a newborn. Common methods for estimating GA such as the last menstrual period, ultrasonography, and post-natal Ballard scoring have some limitations. This study aimed to determine the relationship between foot length and GA to develop and validate an equation for predicting GA of Pakistani newborns. We conducted a prospective study in a large obstetric hospital in Pakistan. Data for this analysis were extracted from the hospital files of eligible women by trained study midwives. Midwives were also trained in performing the Ballard examination and taking foot length using a disposable measuring tape within an hour of the birth. The GA was calculated using an android-based GA calculator. Simple and multiple linear regression were used to construct predicting equations for GA. Both the foot length and GA were available for 1542 cases. The median GA was 34.5 (IQR 4.7) weeks and the median foot length was 7 cm (IQR 1.4). There was a positive linear relationship between foot length and GA ( 81.7%, -value < .001). Stratified analysis showed an of 81.7% for males and 81.6% for females. The for stillbirths was 84.1% and, 82.3% for live births. The for macerated stillbirths was 88.6% and 90.6% for fresh stillbirths. In resource poor settings, the use of foot length can estimate GA in both live births and stillbirths and can easily identify preterm infants.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2333794X20974206DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7683835PMC
November 2020

Stillbirth 2010-2018: a prospective, population-based, multi-country study from the Global Network.

Reprod Health 2020 Nov 30;17(Suppl 2):146. Epub 2020 Nov 30.

Department of Obstetrics and Gynecology, Columbia University School of Medicine, New York, NY, USA.

Background: Stillbirth rates are high and represent a substantial proportion of the under-5 mortality in low and middle-income countries (LMIC). In LMIC, where nearly 98% of stillbirths worldwide occur, few population-based studies have documented cause of stillbirths or the trends in rate of stillbirth over time.

Methods: We undertook a prospective, population-based multi-country research study of all pregnant women in defined geographic areas across 7 sites in low-resource settings (Kenya, Zambia, Democratic Republic of Congo, India, Pakistan, and Guatemala). Staff collected demographic and health care characteristics with outcomes obtained at delivery. Cause of stillbirth was assigned by algorithm.

Results: From 2010 through 2018, 573,148 women were enrolled with delivery data obtained. Of the 552,547 births that reached 500 g or 20 weeks gestation, 15,604 were stillbirths; a rate of 28.2 stillbirths per 1000 births. The stillbirth rates were 19.3 in the Guatemala site, 23.8 in the African sites, and 33.3 in the Asian sites. Specifically, stillbirth rates were highest in the Pakistan site, which also documented a substantial decrease in stillbirth rates over the study period, from 56.0 per 1000 (95% CI 51.0, 61.0) in 2010 to 44.4 per 1000 (95% CI 39.1, 49.7) in 2018. The Nagpur, India site also documented a substantial decrease in stillbirths from 32.5 (95% CI 29.0, 36.1) to 16.9 (95% CI 13.9, 19.9) per 1000 in 2018; however, other sites had only small declines in stillbirth over the same period. Women who were less educated and older as well as those with less access to antenatal care and with vaginal assisted delivery were at increased risk of stillbirth. The major fetal causes of stillbirth were birth asphyxia (44.0% of stillbirths) and infectious causes (22.2%). The maternal conditions that were observed among those with stillbirth were obstructed or prolonged labor, antepartum hemorrhage and maternal infections.

Conclusions: Over the study period, stillbirth rates have remained relatively high across all sites. With the exceptions of the Pakistan and Nagpur sites, Global Network sites did not observe substantial changes in their stillbirth rates. Women who were less educated and had less access to antenatal and obstetric care remained at the highest burden of stillbirth.

Study Registration: Clinicaltrials.gov (ID# NCT01073475).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12978-020-00991-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7706249PMC
November 2020

Neonatal deaths in infants born weighing ≥ 2500 g in low and middle-income countries.

Reprod Health 2020 Nov 30;17(Suppl 2):158. Epub 2020 Nov 30.

Department of Obstetrics and Gynecology, Columbia University School of Medicine, New York, NY, USA.

Background: Babies born weighing ≥ 2500 g account for more than 80% of the births in most resource-limited locations and for nearly 50% of the 28-day neonatal deaths. In contrast, in high-resource settings, 28-day neonatal mortality among this group represents only a small fraction of the neonatal deaths. Yet mortality risks for birth weight of ≥ 2500 g is limited. Knowledge regarding the factors associated with mortality in these babies will help in identifying interventions that can reduce mortality.

Methods: The Global Network's Maternal Newborn Health Registry (MNHR) is a prospective, population-based observational study that includes all pregnant women and their pregnancy outcomes in defined geographic communities that has been conducted in research sites in six low-middle income countries (India, Pakistan, Democratic Republic of Congo, Guatemala, Kenya and Zambia). Study staff enroll all pregnant women as early as possible during pregnancy and conduct follow-up visits to ascertain delivery and 28-day neonatal outcomes. We analyzed the neonatal mortality rates (NMR) and risk factors for deaths by 28 days among all live-born babies with a birthweight ≥ 2500 g from 2010 to 2018 across the Global Network sites.

Results: Babies born in the Global Network sites from 2010 to 2018 with a birthweight ≥ 2500 g accounted for 84.8% of the births and 45.4% of the 28-day neonatal deaths. Among this group, the overall NMR was 13.1/1000 live births. The overall 28-day NMR for ongoing clusters was highest in Pakistan (29.7/1000 live births) and lowest in the Zambian/Kenyan sites (9.3/1000) for ≥ 2500 g infants. ≥ 2500 g NMRs declined for Zambia/Kenya and India. For Pakistan and Guatemala, the NMR remained almost unchanged over the period. The ≥ 2500 g risks related to maternal, delivery and newborn characteristics varied by site. Maternal factors that increased risk and were common for all sites included nulliparity, hypertensive disease, previous stillbirth, maternal death, obstructed labor, severe postpartum hemorrhage, and abnormal fetal presentation. Neonatal characteristics including resuscitation, hospitalization, congenital anomalies and male sex, as well as lower gestational ages and birthweights were also associated with increased mortality.

Conclusions: Nearly half of neonatal deaths in the Global Network sites occurred in infants born weighing ≥ 2500 g. The NMR for those infants was 13.1 per 1000 live births, much higher than rates usually seen in high-income countries. The changes in NMR over time varied across the sites. Even among babies born ≥ 2500 g, lower gestational age and birthweight were largely associated with increased risk of mortality. Since many of these deaths should be preventable, attention to preventing mortality in these infants should have an important impact on overall NMR.

Trial Registration: https://ClinicalTrials.gov Identifier: NCT01073475.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12978-020-01013-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7706246PMC
November 2020

Hemoglobin concentrations and adverse birth outcomes in South Asian pregnant women: findings from a prospective Maternal and Neonatal Health Registry.

Reprod Health 2020 Nov 30;17(Suppl 2):154. Epub 2020 Nov 30.

Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA.

Background: While the relationship between hemoglobin (Hb) concentrations and pregnancy outcomes has been studied often, most reports have focused on a specific Hb cutoff used to define anemia. Fewer studies have evaluated pregnancy outcomes across the entire range of Hb values. Moreover, to date, most studies of the relationship of Hb concentrations to pregnancy outcomes have been done in high-income countries. Thus, we have sought to determine the relationship between the range of maternal Hb concentrations and adverse birth outcomes among South Asian pregnant women.

Methods: For this study, we used data collected from two South Asian countries (Pakistan - Sindh Province and two sites in India - Belagavi and Nagpur) in a prospective maternal and newborn health registry study. To assess the association between Hb concentrations and various maternal and fetal outcomes, we classified the Hb concentrations into seven categories. Regression analyses adjusting for multiple potential confounders were performed to assess adverse pregnancy outcomes across the range of Hb concentrations.

Findings: Between January 2012 and December 2018, 130,888 pregnant women were enrolled in the South Asian sites had a Hb measurement available, delivered and were included in the analyses. Overall, the mean Hb concentration of pregnant women from the sites was 9.9 g/dL, 10.0 g/dL in the Indian sites and 9.5 g/dL in the Pakistan site. Hb concentrations < 7 g/dL were observed in 6.9% of the pregnant Pakistani women and 0.2% of the Indian women. In both the Pakistani and Indian sites, women with higher parity and women with no formal education had lower Hb concentrations. In the Pakistani site, women > 35 years of age, women with ≥4 children and those who enrolled in the third trimester were more likely to have Hb concentrations of < 7 g/dL but these associations were not found for the Indian sites. When adjusting for potential confounders, for both India and Pakistan, lower Hb concentrations were associated with stillbirth, preterm birth, lower mean birthweight, and increased risk of low birthweight. In the Pakistani site, there was evidence of a U-shaped relationship between Hb concentrations and low birth weight, and neonatal mortality, and in India with hypertensive disease.

Interpretation: This study documented the relationship between maternal Hb concentrations and adverse pregnancy outcomes in women from the Pakistani and Indian sites across the range of Hb values. Both low and high Hb concentrations were associated with risk of at least some adverse outcomes. Hence, both low and high values of Hb should be considered risk factors for the mother and fetus.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12978-020-01006-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7706196PMC
November 2020

Maternal infection and stillbirth: a review.

J Matern Fetal Neonatal Med 2020 Nov 24:1-9. Epub 2020 Nov 24.

Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA.

Maternal infections likely are an important cause of stillbirths, especially in sub-Saharan Africa and south Asia, where the burden is highest. Due to the lack of routine testing for infection, which can be complex and often expensive, the prevalence of infection during pregnancy and the association of many infections with stillbirth are not well-documented, especially in low-resource countries. Following an extensive literature review of infection and stillbirth initially published in 2010, we conducted a review of literature in the last 10 years to identify infections associated with stillbirth, focused on those in low-resource settings. During the last 10 years, over 40 bacterial, viral and other pathogens have been associated with stillbirth. Newly emerging viral infections such as Denge as well as several well-established, but not yet eliminated infections such as rubella have been associated with stillbirth. Two of the maternal infections most strongly associated with stillbirth, each with about a 2-fold risk, are malaria and syphilis but others have been associated with risk in a range of studies. With a lack of routine antenatal screening, many pathogens are identified as associated with stillbirth only through case reports. Infection remains an important, yet understudied, cause of stillbirth. Research studies to determine definitive associations between various infections and stillbirth are important to better understand the role of infections and strategies to reduce infection-related stillbirth. This review explores the association between infections and stillbirths focusing on low-income country studies published in the last 10 years. Much information about these relationships comes from case reports. Research resulting in a better understanding of the causes and strategies to reduce infection-related stillbirth is necessary.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/14767058.2020.1852206DOI Listing
November 2020

A comparison of MITS counseling and informed consent processes in Pakistan, India, Bangladesh, Kenya, and Ethiopia.

Reprod Health 2020 Aug 12;17(1):120. Epub 2020 Aug 12.

Columbia University - Department of Obstetrics and Gynecology, New York, USA.

Globally, more than 5 million stillbirths and neonatal deaths occur annually. For many, the cause of death (CoD) is unknown. Minimally invasive tissue sampling (MITS) has been increasingly used in postmortem examinations for ascertaining the CoD in stillbirths and neonates. Our study compared the counseling and consent methods used in MITS projects in five countries in Africa and south Asia. Key informant interviews were conducted with researchers to describe the characteristics and backgrounds of counselors, the environment and timing of consent and perceived facilitators and barriers encountered during the consent process. Counselors at all sites had backgrounds in social science, psychology and counseling or clinical expertise in obstetrics/gynecology or pediatrics. All counsellors received training about techniques for building rapport and offering emotional support to families; training duration and methods differed across sites. Counselling environments varied significantly; some sites allocated a separate room, others counselled families at the bedside or nursing stations. All counsellors had a central role in explaining the MITS procedure to families in their local languages. Most sites did not use visual aids during the process, relying solely on verbal descriptions. In most sites, parents were approached within one hour of death. The time needed for decision making by families varied from a few minutes to 24 h. In most sites, extended family took part in the decision making. Because many parents wanted burial as soon as possible, counsellors ensured that MITS would be conducted promptly after receiving consent. Barriers to consent included decreased comprehension of information due to the emotional and psychological impact of grief. Moreover, having more family members engaged in decision-making increased the complexity of counselling and achieving consensus to consent for the procedure. While each site adapted their approach to fit the context, consistencies and similarities across sites were observed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12978-020-00969-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7425595PMC
August 2020

Exploring women and traditional birth attendants' perceptions and experiences of stillbirths in district Thatta, Sindh, Pakistan: a qualitative study.

Reprod Health 2020 Jan 13;17(1). Epub 2020 Jan 13.

Department of Obstetrics and Gynecology, Columbia University, New York, USA.

Background: Pakistan reports the highest stillbirth rate in the world at 43 per thousand births with more than three-quarters occurring in rural areas. The Global Network for Women's and Children's Health maintains a Maternal and Newborn Health Registry (MNHR) in 14 study clusters of district Thatta, Sindh Pakistan. For the last 10 years, the MNHR has recorded a high stillbirths rate with a slow decline. This exploratory study was designed to understand the perspectives of women and traditional birth attendants regarding the high occurrence of stillbirth in Thatta district.

Methods: We used an exploratory qualitative study design by conducting in-depth interviews (IDIs) and focus group discussions (FGDs) using semi-structured interview guide with rural women (FGDs = 4; n = 29) and traditional birth attendants (FGDs = 4; n = 14) who were permanent residents of Thatta. In addition, in-depth interviews were conducted with women who had experienced a stillbirth (IDIs = 4). This study presents perceptions and experiences of women and TBAs regarding high rate of stillbirth in Thatta district, Karachi.

Results: Women showed reluctance to receive skilled/ standard care when in need due to apprehensions towards operative delivery, poor attitude of skilled health care providers, and poor quality of care as service delivery factors. High cost of care, far distance to facility, lack of transport and need of an escort from the family or village to visit a health facility were additional important factors for not seeking care resulting in stillbirth. The easy availability of unskilled provider in the form of traditional birth attendant is then preferred over a skilled health care provider. TBAs shared their husband or family members restrict them to visit or consult a doctor during pregnancy. According to TBAs after delivering a macerated fetus, women are given herbs to remove infection from woman's body and uterus. Further women are advised to conceive soon so that they get rid of infections.

Conclusion: Women of this rural community carry lots of apprehension against skilled medical care and as a result follow traditional practices. Conscious efforts are required to increase the awareness of women to develop positive health seeking behavior during pregnancy, delivery and the post-partum period. Alongside, provision of respectful maternity care needs to be emphasized especially at public health facilities.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12978-020-0852-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6958748PMC
January 2020

Perceptions of health professionals regarding minimally invasive tissue sampling (MITS) to identify the cause of death in stillbirths and neonates: results from a qualitative study.

Matern Health Neonatol Perinatol 2019 25;5:17. Epub 2019 Oct 25.

1Department of Community Health Sciences, The Aga Khan University, Stadium Road, PO Box 3500, Karachi, 74800 Pakistan.

Background: Pakistan is considered to be one of the riskiest places in the world for childbirth as measured by its high stillbirth and neonatal mortality rates. Complete diagnostic autopsy remains the gold standard to determine the cause of death (CoD); however, it is not routinely implemented due to religious objections, sociocultural beliefs, limited resources and low demand from physicians and families. Recently, minimally invasive tissue sampling (MITS) using needle biopsies of multiple tissues to obtain tissue for histological examination and organism identification with PCR has been developed and promoted to determine CoD in low-resource areas. To ensure successful implementation of MITS, it is important to understand health professionals' attitudes and perceptions related to MITS.

Methods: A qualitative study was conducted at the National Institute of Child Health (NICH), Karachi, Pakistan. Focus group discussions (FGDs) and Key-informant interviews (KIIs) were conducted with health professionals including doctors, nurses, trainees, clinicians, bioethics experts and public health experts to explore their perceptions and views on acceptability of MITS. Data were analyzed using NVivo 10 software.

Results: A total of 12 interviews (FGDs = 4; KIIs = 8) were conducted. Four overarching themes were identified: (I) acceptability of MITS; (II) perceived benefits of the MITS procedure; (III) factors facilitating the implementation of MITS; and (IV) health system requirements for implementing the MITS procedure. Generally, MITS was considered as a positive development for the health system. Diagnostic accuracy and identification of less common causes of death were highlighted as two main benefits of the MITS procedure. The study highlighted a number of facilitators for the acceptability of MITS including effective counseling, building trust with parents, fast procedure time, and approaching families within a few hours of death. In addition, lack of skilled staff, poorly equipped healthcare facilities and the potential high cost to conduct MITS were identified as challenges for the implementation of MITS.

Conclusions: This formative research provided a unique opportunity to explore health professionals' views and attitudes towards the MITS procedure. Such insights are crucial to ensure successful implementation and integration of a new technique into the existing health system. The research identified the factors influencing the acceptability of MITS among health professionals in Pakistan. The study also informed factors that could help facilitate the implementation of the MITS procedures in the context of Pakistan and similar settings.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s40748-019-0112-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6814094PMC
October 2019

Perceptions of parents and religious leaders regarding minimal invasive tissue sampling to identify the cause of death in stillbirths and neonates: results from a qualitative study.

Reprod Health 2019 May 10;16(1):53. Epub 2019 May 10.

Department of Community Health Sciences, The Aga Khan University, Stadium Road, Box 3500, Karachi, PO, 74800, Pakistan.

Background: Recently, the minimal invasive tissue sampling (MITS) procedure has been developed to support determination of the cause of death as an alternate to conventional autopsy, especially in countries where complete diagnostic autopsy is not routine. To assess the feasibility of implementation of the MITS procedure for a study to determine cause of death in premature births and stillbirths in south Asia, we explored the views and perceptions of parents and religious leaders on the acceptability of MITS.

Methods: A qualitative study was conducted at the National Institute of Child Health (NICH) hospital of Karachi, Pakistan. Focus group discussions (FGDs) were conducted with parents of newborns who visited well-baby clinics of the NICH hospital for post-natal check-ups. Key-informant interviews (KIIs) were conducted with religious leaders. Data were analyzed using NVivo 10 software.

Results: A total of 13 interviews (FGDs = 8; KIIs = 5) were conducted. Three overarching themes were identified: (I) acceptability of MITS; (II) concerns affecting the implementation of MITS; and (III) religious and cultural perspectives. Participants' acceptance of MITS was based on personal, religious, cultural and social beliefs. Parents widely recognized the need for this procedure in cases where the couple had experienced multiple stillbirths, neonatal deaths and miscarriages. Counseling of parents was considered vital to address emotional concerns of the parents and the family. Religious leaders indicated acceptability of the MITS procedure from a religious perspective and advised that respect for the deceased and consent of the guardians is mandatory when performing MITS.

Conclusions: This qualitative study provided a unique opportunity to understand the views of parents and religious leaders towards the use of MITS. Generally, MITS appears to be an acceptable method for identifying the cause of death in neonates and stillbirths, provided that the deceased is respected and buried as soon as possible without any delays and parents are counseled appropriately. Findings from this research are essential in approaching families for consent for MITS.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12978-019-0730-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6509850PMC
May 2019

Trends of antenatal care during pregnancy in low- and middle-income countries: Findings from the global network maternal and newborn health registry.

Semin Perinatol 2019 08 16;43(5):297-307. Epub 2019 Mar 16.

Columbia University, New York, NY, United States.

Background: Antenatal care (ANC) is an important opportunity to diagnose and treat pregnancy-related complications and to deliver interventions aimed at improving health and survival of both mother and the infant. Multiple individual studies and national surveys have assessed antenatal care utilization at a single point in time across different countries, but ANC trends have not often been studied in rural areas of low-middle income countries (LMICs). The objective of this analysis was to study the trends of antenatal care use in LMICs over a seven-year period.

Methods: Using a prospective maternal and newborn health registry study, we analyzed data collected from 2011 to 2017 across five countries (Guatemala, India [2 sites], Kenya, Pakistan, and Zambia). Utilization of any ANC along with use of select services, including vitamins/iron, tetanus toxoid vaccine and HIV testing, were assessed. We used a generalized linear regression model to examine the trends of women receiving at least one and at least four antenatal care visits by site and year, controlling for maternal age, education and parity.

Results: Between January 2011 and December 2017, 313,663 women were enrolled and included in the analysis. For all six sites, a high proportion of women received at least one ANC visit across this period. Over the years, there was a trend for an increasing proportion of women receiving at least one and at least four ANC visits in all sites, except for Guatemala where a decline in ANC was observed. Regarding utilization of specific services, in India almost 100% of women reported receiving tetanus toxoid vaccine, vitamins/iron supplementation and HIV testing services for all study years. In Kenya, a small increase in the proportion of women receiving tetanus toxoid vaccine was observed, while for Zambia, tetanus toxoid use declined from 97% in 2011 to 89% in 2017. No trends for tetanus toxoid use were observed for Pakistan and Guatemala. Across all countries an increasing trend was observed for use of vitamins/iron and HIV testing. However, HIV testing remained very low (<0.1%) for Pakistan.

Conclusion: In a range of LMICs, from 2011 to 2017 nearly all women received at least one ANC visit, and a significant increase in the proportion of women who received at least four ANC visits was observed across all sites except Guatemala. Moreover, there were variations regarding the utilization of preventive care services across all sites except for India where rates were generally high. More research is required to understand the quality and influences of ANC.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1053/j.semperi.2019.03.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7027164PMC
August 2019

Perceptions of parents and healthcare professionals regarding minimal invasive tissue sampling to identify the cause of death in stillbirths and neonates: a qualitative study protocol.

Reprod Health 2018 Oct 22;15(1):179. Epub 2018 Oct 22.

Department of Community Health Sciences, The Aga Khan University, Stadium Road, PO Box 3500, Karachi, 74800, Pakistan.

Background: Globally, around 2.6 million neonatal deaths occur world-wide every year and the numbers of stillbirths is almost similar. Pakistan is ranked among the highest countries in the world for neonatal mortality. In 2016, for every 1000 babies born in Pakistan, 46 died before the end of the first month of life. Also, Pakistan had the highest rate of stillbirths (43.1/1000 births) in 2015. To meet sustainable development (SDG) targets of reducing neonatal mortality and stillbirths, it is essential to gain understanding about the causes of neonatal death and stillbirths. In Pakistan, full autopsies are conducted only in medico-legal cases and are very rarely performed to identify a definitive cause of death (CoD) and because of cost and insufficient staff are generally not feasible. Recently, minimally invasive tissue sampling (MITS) has been used to determine CoD in neonates and stillbirths as it addresses some of the socio-cultural and religious barriers to autopsy. However, it is not known how families and communities will perceive this procedure; therefore, exploring family and healthcare professionals' perceptions regarding MITS is essential in determining acceptable and feasible approaches for Pakistan.

Methods: The study will employ an exploratory qualitative research design. The study will be conducted at the National Institute of Child Health (NICH) hospital of Karachi. The data collection method will consist of key-informant interviews (KIIs) and focus group discussions (FGDs). FGDs will be conducted with the families and relatives of newborns who are visiting the outpatient department (OPD) and well-baby clinics of NICH hospital. KIIs will be conducted with the NICH - medical director, healthcare providers, professionals involved in proceedings related to death and dying, religious leaders, health sector representatives from the government, public health experts, maternal and child health (MCH) specialists, obstetricians and neonatologists and experts from the bioethics committee. Study data will be analyzed using NVivo 10 software.

Discussion: The research will help explore specific cultural, religious and socio-behavioral factors that may increase or decrease the acceptability of MITS for identifying COD in neonates and stillbirths. The findings of the qualitative study will provide a better understanding of parents' and healthcare professionals' attitudes towards the use of MITS on neonatal deaths and stillborns.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12978-018-0626-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6198378PMC
October 2018

Frequency of bloodstream infection in febrile neutropenic patients, experience from a developing country.

Ann Med Surg (Lond) 2018 Oct 12;34:71-74. Epub 2018 Sep 12.

Department of Medicine, Abbasi Shaheed Hospital, Karachi, 74700, Pakistan.

Introduction: About 20% of febrile neutropenic patients are presented with bloodstream infection which is a leading cause of mortality among these patients. Awareness of the locally prevalent pathogens and their susceptibility pattern is important for proper treatment of infection which improves survival in these patients. The objective of this study was to determine the frequency of bloodstream infection in patients with febrile neutropenia admitted in Abbasi Shaheed Hospital.

Methods: This cross-sectional study was conducted in the Medical wards in Abbasi Shaheed Hospital, Karachi from 21-2-2016 to 20-8-2017. Patients of over 15 years of age of either gender with severe neutropenia were included in this study. Patients with noninfectious cause of fever, or fever prior to neutropenia were excluded. Patients meeting inclusion criteria were enrolled after taking informed consent. About 2-5 ml blood was collected under aseptic measures in Bactac culture bottles. Blood samples were sent to lab within 30 min of collection. Antimicrobial sensitivity testing of all isolates was performed on diagnostic Sensitivity test plates by Kerby - Bauer Method. Patients were referred back to treating physician if blood culture is positive. The data was analyzed using SPSS version 20.

Results: Of 200 patients, the mean age was 25.8 ± 5.7 years, 120 (60%) were male with male to female ratio of 1.5:1, 89 (44.5%) had low grade fever (Temp. ≤102 °C) and 111 (55.5%) had high grade fever(Temp. >102 °C). The frequency of was 16%, was 14.5%, 8.5% and 15.5.

Conclusions: It is concluded that the frequency of was 16%, was 14.5%, 8.5% and 15.5.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amsu.2018.09.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6153262PMC
October 2018

Monitoring of birth registry coverage and data quality utilizing lot quality assurance sampling methodology: A pilot study.

J Family Med Prim Care 2018 May-Jun;7(3):522-525

Department of Obstetrics and Gynecology, University of Columbia, New York, USA.

Background: Effectively monitoring the coverage and quality of data in low-resource settings is challenging. Lot quality assurance sampling (LQAS) is a method to classify coverage as adequate or inadequate. The aim of this pilot study is sought to determine the coverage and quality of a birth registry in a rural district in Pakistan.

Methods: This survey was conducted in 14 clusters of Thatta, Pakistan. LQAS methodology was used to monitor the birth registry from December 2015 to February 2016. We randomly selected 19 villages from each cluster. We used a short questionnaire to review the quality of data collection for select variables. Frequency and percentages were reported for categorical variables. For data validation, Kappa statistics (κ) were applied to assess the agreement between categorical observations, and the Bland-Altman test was used to assess agreement for continuous data.

Results: Of the 14 clusters sampled, 12 clusters had adequate coverage. Agreement of hemoglobin performance between the women's response and information in birth registry data was good (κ = 0.718) (95% confidence interval [CI]: 0.58-0.82); agreement on birth outcome recorded by the workers in the registry and as mentioned by women was very good (κ = 1.0); and agreement whether birth weight was assessed within 48 h of delivery was good (κ = 0.648) (0.37-0.92).

Conclusion: LQAS is a powerful tool to monitor coverage and data quality of the birth registry maintained by the global network for women's and children's health in Pakistan and potentially for data from other surveillance systems.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4103/jfmpc.jfmpc_59_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6069668PMC
August 2018

The project to understand and research preterm pregnancy outcomes and stillbirths in South Asia (PURPOSe): a protocol of a prospective, cohort study of causes of mortality among preterm births and stillbirths.

Reprod Health 2018 Jun 22;15(Suppl 1):89. Epub 2018 Jun 22.

Columbia University, New York, NY, USA.

Background: In South Asia, where most stillbirths and neonatal deaths occur, much remains unknown about the causes of these deaths. About one-third of neonatal deaths are attributed to prematurity, yet the specific conditions which cause these deaths are often unclear as is the etiology of stillbirths. In low-resource settings, most women are not routinely tested for infections and autopsy is rare.

Methods: This prospective, cohort study will be conducted in hospitals in Davengere, India and Karachi, Pakistan. All women who deliver either a stillbirth or a preterm birth at one of the hospitals will be eligible for enrollment. With consent, the participant and, when applicable, her offspring, will be followed to 28-days post-delivery. A series of research tests will be conducted to determine infection and presence of other conditions which may contribute to the death. In addition, all routine clinical investigations will be documented. For both stillbirths and preterm neonates who die ≤ 28 days, with consent, a standard autopsy as well as minimally invasive tissue sampling will be conducted. Finally, an expert panel will review all available data for stillbirths and neonatal deaths to determine the primary and contributing causes of death using pre-specified guidance.

Conclusion: This will be among the first studies to prospectively obtain detailed information on causes of stillbirth and preterm neonatal death in low-resource settings in Asia. Determining the primary causes of death will be important to inform strategies most likely to reduce the high mortality rates in South Asia.

Trial Registration: Clinicaltrials.gov ( NCT03438110 ) Clinical Trial Registry of India ( CTRI/2018/03/012281 ).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12978-018-0528-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6020001PMC
June 2018

Trends and determinants of stillbirth in developing countries: results from the Global Network's Population-Based Birth Registry.

Reprod Health 2018 Jun 22;15(Suppl 1):100. Epub 2018 Jun 22.

Columbia University Medical Center, New York, NY, USA.

Background: Stillbirth rates remain high, especially in low and middle-income countries, where rates are 25 per 1000, ten-fold higher than in high-income countries. The United Nations' Every Newborn Action Plan has set a goal of 12 stillbirths per 1000 births by 2030 for all countries.

Methods: From a population-based pregnancy outcome registry, including data from 2010 to 2016 from two sites each in Africa (Zambia and Kenya) and India (Nagpur and Belagavi), as well as sites in Pakistan and Guatemala, we evaluated the stillbirth rates and rates of annual decline as well as risk factors for 427,111 births of which 12,181 were stillbirths.

Results: The mean stillbirth rates for the sites were 21.3 per 1000 births for Africa, 25.3 per 1000 births for India, 56.9 per 1000 births for Pakistan and 19.9 per 1000 births for Guatemala. From 2010 to 2016, across all sites, the mean stillbirth rate declined from 31.7 per 1000 births to 26.4 per 1000 births for an average annual decline of 3.0%. Risk factors for stillbirth were similar across the sites and included maternal age < 20 years and age > 35 years. Compared to parity 1-2, zero parity and parity > 3 were both associated with increased stillbirth risk and compared to women with any prenatal care, women with no prenatal care had significantly increased risk of stillbirth in all sites.

Conclusions: At the current rates of decline, stillbirth rates in these sites will not reach the Every Newborn Action Plan goal of 12 per 1000 births by 2030. More attention to the risk factors and treating the causes of stillbirths will be required to reach the Every Newborn Action Plan goal of stillbirth reduction.

Trial Registration: NCT01073475 .
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12978-018-0526-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6019981PMC
June 2018

Screening for G6PD Deficiency Among Neonates with Neonatal Jaundice Admitted to Tertiary Care Center: A Need in Disguise.

J Coll Physicians Surg Pak 2015 Aug;25(8):625-6

Clinical Laboratory, The Aga Khan University Hospital, Karachi.

This study was conducted to determine the association of Glucose-6-Phosphate Dehydrogenase (G-6-PD) deficiency among neonates admitted with jaundice at the neonatal intensive care unit, well baby nursery and neonatal step down nursery of the Aga Khan University Hospital, Karachi, Pakistan, from January to June 2010. A total of 205 neonates following the selection criteria were included. All selected neonates have their venous blood drawn, saved in EDTA bottle and sent to laboratory of The Aga Khan University Hospital (AKUH). The laboratory results of whether G-6-PD deficiency was present or not was recorded in the proforma. G-6-PD was deficient in 19 neonates (9.3%). All neonates were male.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/08.2015/JCPSP.625626DOI Listing
August 2015

Predictors and outcome of tetanus in newborns in slum areas of Karachi City: a case control study.

BMC Res Notes 2015 Aug 7;8:338. Epub 2015 Aug 7.

Department of Paediatrics, Salisbury District Hospital, Salisbury, Wiltshire, UK.

Background: Tetanus in newborns, is an under-reported public health problem and a major cause of mortality in developing countries. This study aimed to determine the predictors and outcome of tetanus in newborn infants in the slums of Bin-Qasim town, Karachi, Pakistan.

Methods: We conducted a case-control study at primary health care centers of slums of Bin-Qasim town, area located adjacent to Bin Qasim seaport in Karachi, from January 2003 to December 2013. Cases were infants aged ≤30 days with tetanus, as defined by the World Health Organization. Controls were newborn infants aged ≤30 days without Tetanus, who were referred for a checkup or minor illnesses. The case to control ratio was 1:2.

Results: We analyzed 26 cases and 52 controls. The case fatality was 70.8%. We identified four independent predictors of Tetanus in newborns: maternal education (only religious education with no formal education OR 51.95; 95% CI 3.69-731), maternal non-vaccination (OR 24.55; 95% CI 1.01-131.77), lack of a skilled birth attendant (OR 44.00; 95% CI 2.30-840.99), and delivery at home (OR 11.54; 95% CI 1.01-131.77).

Conclusions: We identified several potentially modifiable socio-demographic risk factors for Tetanus in newborns, including maternal education and immunization status, birth site, and lack of a skilled birth attendant. Prioritization of these risk factors could be useful for planning preventive and cost-effective measures.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s13104-015-1301-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4527233PMC
August 2015

Frequency of retinopathy of prematurity in premature neonates with a birth weight below 1500 grams and a gestational age less than 32 weeks: a study from a tertiary care hospital in a lower-middle income country….

PLoS One 2014 2;9(7):e100785. Epub 2014 Jul 2.

Department of Paediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan.

Introduction: Retinopathy of prematurity (ROP) is a treatable cause of blindness in neonates. In Pakistan, ROP is often not recognized early because screening and treatment programs are not yet in place in most neonatal units, even in tertiary care hospitals. It is hoped that this report will help inform medical professionals of the magnitude of the problem and help to design appropriate management strategies.

Objectives: The aim was to determine the frequency of ROP in premature and very low birth weight (BW) neonates (BW<1500 g and gestational age (GA) <32 weeks).

Study Design: Cross-sectional study.

Study Setting: Neonatal intensive care unit (NICU) of a tertiary care hospital in Karachi, Pakistan.

Study Duration: From June 2009 to May 2010.

Subjects And Methods: Neonates with a Birth weight (BW) <1500 g and Gestational Age (GA) <32 weeks who were admitted to the NICU and received an eye examination, or were referred for a ROP eye examination as an outpatient, were included in the study. GA was estimated from intrauterine ultrasound findings. Neonates with major congenital malformations, syndromes or congenital cataracts or tumors of the eyes, and those that died before the eye examination or did not attend the out patients department for an eye examination, were excluded. The neonatal eye examination was performed by a trained ophthalmologist at 4 or 6 weeks of age.

Results: Out of 86 neonates, ROP was identified in nine neonates (10.5%) at the first eye examination. ROP was significantly associated with BW (P = 0.037), GA (P = 0.033), and chronological age (P<0.001).

Conclusions: we identified ROP in 10.5% of neonates at first eye examination. Significant associations between ROP and a GA<32 weeks and a BW<1500 g were also observed.we also stress that serial follow-up of neonates at risk for ROP is important when making a final diagnosis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0100785PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4079563PMC
February 2015

Risk of hearing loss in children exposed to gentamicin for the treatment of sepsis in young infancy: a community based cohort study in Pakistan.

J Pak Med Assoc 2013 Oct;63(10):1226-9

Department of Paediatrics and Child Health, Aga Khan University, Karachi.

Objective: To determine the safety of gentamicin when used in a community setting to treat neonatal sepsis.

Methods: The study was conducted in peri-urban areas of Karachi from September 2009 to April 2010. The exposed group consisted of children 6 months to 3 years of age who were treated for sepsis during 0-2 months of age in the community, with a regimen that included gentamicin for at least five days.The control group included children from the same area who never received gentamicin. The outcome measure was hearing loss, which was assessed by Brainstem Evoked Response Audiometry.

Results: Of the 255 children enrolled, 125 (49%) received gentamicin, while 130 (51%) were not exposed to gentamicin. Children in the gentamicin exposed group were not at increased risk for hearing loss compared to controls (n = 30; 30.9% vs. n = 33; 31.4%, RR 0.98; 95% Cl: 0.60-1.61). Children with history of ear discharge (RR 1.7) and children with family history of deafness (RR 2.0) were more at risk for having hearing loss.

Conclusion: No association was found between hearing loss and gentamicin exposure in a community setting for the management of sepsis in the first two months of life.
View Article and Find Full Text PDF

Download full-text PDF

Source
October 2013

Health care use patterns for diarrhea in children in low-income periurban communities of Karachi, Pakistan.

Am J Trop Med Hyg 2013 Jul 29;89(1 Suppl):49-55. Epub 2013 Apr 29.

Diarrhea causes 16% of all child deaths in Pakistan. We assessed patterns of healthcare use among caretakers of a randomly selected sample of 959 children ages 0-59 months in low-income periurban settlements of Karachi through a cross-sectional survey. A diarrheal episode was reported to have occurred in the previous 2 weeks among 298 (31.1%) children. Overall, 280 (80.3%) children sought care. Oral rehydration solution and zinc were used by 40.8% and 2%, respectively; 11% were admitted or received intravenous rehydration, and 29% sought care at health centers identified as sentinel centers for recruiting cases of diarrhea for a planned multicenter diarrheal etiology case-control study. Odds ratios for independent predictors of care-seeking behavior were lethargy, 4.14 (95% confidence interval = 1.45-11.77); fever, 2.67 (1.27-5.59); and stool frequency more than six per day, 2.29 (1.03-5.09). Perception of high cost of care and use of home antibiotics were associated with reduced care seeking: odds ratio = 0.28 (0.1-0.78) and 0.29 (0.11-0.82), respectively. There is a need for standardized, affordable, and accessible treatment of diarrhea as well as community education regarding appropriate care in areas with high diarrheal burden.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4269/ajtmh.12-0757DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3748501PMC
July 2013