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Rajesh Kumar,1 Mahesh Kumar Batra,1 Sanam Khowaja,1 Ali Ammar,1 Ashok Kumar,1 Jehangir Ali Shah,1 Jawaid Akbar Sial,1 Tahir Saghir,1 Musa Karim2 1Adult Cardiology Department, National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan; 2Research Department, National Institute of Cardiovascular Diseases (NICVD), Karachi, PakistanCorrespondence: Rajesh KumarNational Institute of Cardiovascular Diseases (NICVD), Karachi, PakistanEmail rajeshnarsoolal@gmail.comObjective: Promising results of CHA2DS2-VASc score have been reported for the prediction of contrast-induced acute kidney injury (CI-AKI) after percutaneous coronary intervention (PCI). However, data of its predictive strength in the context of primary PCI are not available. Therefore, in this study, we have assessed predictive value of CHA2DS2-VASc score for CI-AKI after primary PCI.Methods: This analytical cross-sectional study was conducted between January 2021 and June 2021 at the National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan. Inclusion criteria of the study was consecutive adult patients who had undergone primary PCI. Baseline CHA2DS2-VASc score was calculated, and either a 25% or 0.5 mg/dL increase in post-procedure serum creatinine level as compared to baseline level was categorized as CI-AKI.Results: A total of 691 patients were included, of which 82.1% (567) were male. CI-AKI after primary PCI was observed in 63 (9.1%) patients, out of which 66.7% (42) of patients had CHA2DS2-VASc score of ≥ 2. The area under the curve (AUC) for the score was 0.725 [0.662 to 0.788] with a sensitivity and specificity of 66.7% [63.1% to 70.2%] and 66.7% [53.7% to 78.1%], respectively, at a cut-off value of ≥ 2. In multivariable analysis, left ventricular ejection fraction ≤ 30% and CHA2DS2-VASc ≥ 2 were found to be independent predictors with adjusted odds ratios of 2.19 [1.06– 4.5] and 2.13 [1.13– 4.01], respectively.Conclusion: CHA2DS2-VASc score has a good predictive value for the prediction of CI-AKI after primary PCI. Criteria of CHA2DS2-VASc ≥ 2 can be used for the risk stratification of CI-AKI after primary PCI.Keywords: ST elevation myocardial infarction, STEMI, percutaneous coronary intervention, primary PCI, contrast-induced acute kidney injury, CI-AKI, CHA2DS2-VASc score, contrast-induced nephropathy, CIN

Access, demand, and acceptance of coronavirus disease 2019 (COVID-19) testing have varied globally. This study explored the sociodemographic and psychosocial risk factors that contribute to the uptake of COVID-19 testing in community settings in South Africa. This paper presents a cross-sectional secondary analysis using data from a cluster randomized controlled trial and a nested perception survey of COVID-19 antigen testing in communities located in urban (eThekwini, KwaZulu-Natal) and rural settings (Worcester, Eastern Cape) in South Africa. Individuals who were reluctant to get tested participated in the perception survey. Data were analyzed using descriptive statistics and multivariable logistic regression to assess linear associations and estimate adjusted odds ratios (ORs). The analysis was conducted on 3,074 individuals, of whom 2,509 (81.6%) provided consent for COVID-19 testing. Among those, 2,505 (81.5%) tested negative, and 4 (0.1%) tested positive for COVID-19. The mean age of participants was 38 (SD = 14.61), and 57% were male. Females (OR: 1.27; 95% CI = 1-1.6), individuals older than 56 years (OR: 1.95; 95% CI = 1.24-3.07), and those who were vaccinated (OR: 1.99; 95% CI = 1.53-2.60) were more likely to consent. Individuals who had previously tested positive for severe acute respiratory syndrome coronavirus 2 were less likely to consent to testing (OR: 0.64; 95% CI = 0.11-0.46). No link was found between depression, anxiety, substance use, and willingness to undergo COVID-19 testing. A perceptions survey involving 704 participants, which explored factors influencing testing willingness, found that older adults, and urban populations were less likely to undergo COVID-19 testing. Targeted health campaigns may improve testing rates. Larger-scale implementation research is required to explore best practices for improving testing rates and confidence in population-level detection within South Africa.

Pakistan is one of the five highest tuberculosis burden countries globally. We estimated prevalence of adult bacteriologically confirmed pulmonary tuberculosis and annual risk of Mycobacterium tuberculosis (M. tuberculosis) infection in children aged 2-4 years in Karachi, Pakistan. The survey design enabled exploration of tuberculosis burden by whether the population had previously been exposed to widespread tuberculosis active case-finding (ACF) activities or not. We conducted a concurrent adult pulmonary tuberculosis prevalence survey and a child M. tuberculosis infection survey using interferon gamma release assays in four districts (Korangi, South, West and Central). A cluster-based unequal probability random sampling method was employed with the a priori plan to oversample Korangi district which had been the focus of tuberculosis ACF activities since 2011. We defined Korangi district as the 'prior ACF' zone and remaining districts as the 'no prior ACF' zone. Between March 2018 and May 2019, 34,962 adults (78·5% of those eligible) and 1,505 children (59·9%) participated. Overall estimated prevalence of bacteriologically confirmed pulmonary tuberculosis was 387 cases per 100,000 population (95% CI 276-498) with a prevalence of 421 cases [95% CI 276-567] per 100,000 in the 'no prior ACF' and 279 cases [95% CI 155-403] per 100,000 in the 'prior ACF' zone. We estimated the annual risk of M. tuberculosis infection in children to be 1·1% (95% CI 0·7-1·5) in the 'no prior ACF' zone and 0·6% (95% CI 0·3-1·1) in the 'prior ACF' zone. We observed consistent differences in the population distribution of tuberculosis between the 'prior ACF' and 'no prior' ACF zones with a trend towards lower estimates of burden and M. tuberculosis transmission in the 'prior ACF' zone. A plausible explanation is that intensive ACF activities that have been ongoing in Korangi district for the preceding years have noticeably reduced the burden of tuberculosis and transmission., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Khan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Chronic intestinal pseudo-obstruction (CIPO) is a rare, severe, and often debilitating condition that can result in significant morbidity and mortality amongst the pediatric population. Eosinophilic myenteric ganglionitis (EMG) is a rare inflammatory neuropathy of the myenteric plexus with characteristic eosinophilic infiltration with and without hypogangliosis. The disorder has been previously documented as a cause of CIPO. We report the case of a 14-year-old male with no clear obstructive cause who, after multiple visits with a myriad of tests and workups, underwent surgical exploratory laparoscopy with the pathology returning a diagnosis of EMG with unique lymphocytic and eosinophilic cell components., Competing Interests: The authors declare no conflict of interest., (© 2024 The Author(s). JPGN Reports published by Wiley Periodicals LLC on behalf of The European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.)

Introduction: Infants are at a higher risk of severe illness with COVID-19 infection compared to older children. While COVID-19 vaccination is not recommended for young infants, they can acquire maternally-derived anti-SARS-CoV-2 antibodies passively through the placenta and breastmilk. We described the persistence of infection-induced maternal antibodies in infant circulation at 9-12 months of age., Methodology: This was a cross-sectional study nested within the INTERCOVID multinational cohort study. For each COVID positive pregnant woman, two unmatched consecutive COVID negative pregnant women were enrolled between April and September 2020. Women with a positive PCR test, radiographic signs consistent with COVID-19, or at least 2 predefined symptoms of COVID-19 were considered as COVID positive. For this nested cross-sectional study, all COVID positive and either one of the COVID negative participants recruited from the Aga Khan University, Pakistan were approached 9-12 months after delivery, and maternal and infant sera were collected for antibody detection., Results: Altogether, 83 mothers provided consent, of whom 32 (38.6 %) were COVID positive and 51 (61.4 %) were COVID negative during pregnancy. Anti-SARS-CoV-2 antibodies were present in 13 (41 %) infants born to COVID positive and 19 (39 %) infants born to COVID negative mothers (p = 0.87). The presence of reactive antibodies in infants at follow-up was associated with maternal antibodies at follow-up (OR:9.50, 95 % CI:2.03-44.42; p = 0.004). COVID infection occurred in 3 (6 %) infants born to COVID negative mothers while no infant born to a COVID positive mother had a history of infection (p = 0.27)., Conclusion: The presence of reactive anti-SARS-CoV-2 antibodies in infants at 9-12 months of age is associated with maternal seropositivity 9-12 months after delivery rather than maternal infection during pregnancy. Further studies are required to validate these findings and assess whether passive immunity in infants is protective against COVID-19 infection., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Taiwan Pediatric Association. Published by Elsevier B.V. All rights reserved.)

Tolvaptan is the first disease-modifying drug proven to slow eGFR decline in high-risk patients with ADPKD. However, barriers from the patient perspective to its use in real-life settings have not been systemically examined in a large cohort. This was a single-center, retrospective study of 523 existing or new patients with ADPKD followed at the Center for Innovative Management of PKD in Toronto, Ontario, between January 1, 2016 to December 31, 2018. All patients underwent clinical assessment including total kidney volume measurements and Mayo Clinic Imaging Class (MCIC). Those who were deemed to be at high risk were offered tolvaptan with their preference (yes or no) and reasons for their choices recorded. Overall, 315/523 (60%) patients had MCIC 1C-1E; however, only 96 (30%) of them were treated with tolvaptan at their last follow-up. Among these high-risk patients, those not treated versus treated with tolvaptan were more likely to have a higher eGFR (82 ± 26 vs. 61 ± 27 ml/min/1.73 m 2 ), CKD stages 1-2 (79% vs. 41%), and MCIC 1C (63% vs. 31%). The most common reasons provided for not taking tolvaptan were lifestyle preference related to the aquaretic effect (51%), older age ≥ 60 (12%), and pregnancy/family planning (6%). In this real-world experience, at least 60% of patients with ADPKD considered to be at high risk for progression to ESKD by imaging were not treated with tolvaptan; most of them had early stages of CKD with well-preserved eGFR and as such, were prime targets for tolvaptan therapy to slow disease progression. Given that the most common reason for tolvaptan refusal was the concern for intolerability of the aquaretic side-effect, strategies to mitigate this may help to reduce this barrier to tolvaptan therapy., (© 2023. The Author(s).)

Background: Scaling up a shorter preventive regimen such as weekly isoniazid and rifapentine (3HP) for 3 months is a priority for tuberculosis (TB) preventive treatment (TPT). However, there are limited data on 3HP acceptability and completion from high-burden-TB countries., Methods: We scaled up 3HP from 2018 to 2021 in 2 cities in Pakistan. Eligible participants were household contacts of persons diagnosed with TB disease. Participants were prescribed 3HP after ruling out TB disease. Treatment was self-administered. We analyzed the proportion who completed 3HP., Results: In Karachi, we verbally screened 22 054 household contacts of all ages. Of these, 83% were clinically evaluated and 3% were diagnosed with TB. Of household contacts without TB disease, 59% initiated the 3HP regimen, of which 69% completed treatment. In Peshawar, we verbally screened 6389 household contacts of all ages. We evaluated 95% of household contacts, of whom 2% were diagnosed with TB disease. Among those without TB disease, 65% initiated 3HP, of which 93% completed. Factors associated with higher 3HP completion included residence in Peshawar (risk ratio [RR], 1.35 [95% confidence interval {CI}: 1.32-1.37]), index patient being a male (RR, 1.03 [95% CI: 1.01-1.05]), and index patient with extrapulmonary TB compared to bacteriologically positive pulmonary TB (RR, 1.10 [95% CI: 1.06-1.14]). The age of the index patient was inversely associated with completion., Conclusions: We observed a high level of acceptance and completion of 3HP in programs implemented in 2 cities in Pakistan, with differences observed across the cities. These findings suggest that 3HP can be effectively scaled up in urban settings to improve the reach and impact of TPT., Competing Interests: Potential conflicts of interest. The authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Age- and height-adjusted total kidney volume is currently considered the best prognosticator in patients with autosomal dominant polycystic kidney disease. We tested the ratio of urinary epidermal growth factor and monocyte chemotactic peptide 1 for the prediction of the Mayo Clinic Imaging Classes., Methods: Urinary epidermal growth factor and monocyte chemotactic peptide 1 levels were measured in two independent cohorts (discovery, n = 74 and validation set, n = 177) and healthy controls (n = 59) by immunological assay. Magnetic resonance imaging parameters were used for total kidney volume calculation and the Mayo Clinic Imaging Classification defined slow (1A-1B) and fast progressors (1C-1E). Microarray and quantitative gene expression analysis were used to test epidermal growth factor and monocyte chemotactic peptide 1 gene expression., Results: Baseline ratio of urinary epidermal growth factor and monocyte chemotactic peptide 1 correlated with total kidney volume adjusted for height (r = - 0.6, p < 0.001), estimated glomerular filtration rate (r = 0.69 p < 0.001), discriminated between Mayo Clinic Imaging Classes (p < 0.001), and predicted the variation of estimated glomerular filtration rate at 10 years (r = - 0.51, p < 0.001). Conditional Inference Trees identified cut-off levels of the ratio of urinary epidermal growth factor and monocyte chemotactic peptide 1 for slow and fast progressors at > 132 (100% slow) and < 25.76 (89% and 86% fast, according to age), with 94% sensitivity and 66% specificity (p = 6.51E-16). Further, the ratio of urinary epidermal growth factor and monocyte chemotactic peptide 1 at baseline showed a positive correlation (p = 0.006, r = 0.36) with renal outcome (delta-estimated glomerular filtration rate per year, over a mean follow-up of 4.2 ± 1.2 years). Changes in the urinary epidermal growth factor and monocyte chemotactic peptide 1 were mirrored by gene expression levels in both human kidney cysts (epidermal growth factor: - 5.6-fold, fdr = 0.001; monocyte chemotactic peptide 1: 3.1-fold, fdr = 0.03) and Pkd1 knock-out mouse kidney (Egf: - 14.8-fold, fdr = 2.37E-20, Mcp1: 2.8-fold, fdr = 6.82E-15)., Conclusion: The ratio of urinary epidermal growth factor and monocyte chemotactic peptide 1 is a non-invasive pathophysiological biomarker that can be used for clinical risk stratification in autosomal dominant polycystic kidney disease., (© 2022. The Author(s).)

Objective: Knowledge regarding the short-term outcomes after same-day discharge (SDD) post primary percutaneous coronary intervention (PCI) is lacking. In this study, we evaluated 1-year major adverse cardiovascular events (MACE) among SDD patients after primary PCI., Design: 1-year follow-up analysis of a subset of patients from an existing prospective cohort study., Setting: Tertiary care cardiac hospital in Karachi, Pakistan., Participants: Consecutive patients, from August 2019 to July 2020, with ST segment elevation myocardial infarction who had undergone primary PCI with SDD (within 24 hours) after the procedure by the treating physician and with at least one successful follow-up up to 1 year., Outcome Measure: Cumulative MACE during follow-up at the intervals of 1 week, 1 month, 6 months and 1 year., Results: 489 patients were included, with a gender distribution of 83.2% (407) male patients and a mean age of 54.58±10.85 years. Overall MACE rate during the mean follow-up duration of 326.98±76.71 days was 10.8% (53), out of which 26.4% (14/53) events occurred within 6 months of discharge and the remaining 73.6% (39/53) occurred between 6 months and 1 year. MACE was significantly higher among patients with a Zwolle Risk Score (ZRS) ≥4 at baseline, with an incidence rate of 21.9% (16/73) vs 8.9% (37/416; p=0.001) in patients with ZRS≤3 (relative risk 2.88 (95% CI 1.5 to 5.5))., Conclusion: A significant burden of short-term MACE was identified among SDD patients after primary PCI; most of these events occurred after 6 months of SDD, mainly among patients with ZRS≥4. A systematic risk assessment based on risk stratification modalities such ZRS could be a viable option for SDD patients with primary PCI., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

In Pakistan, substantial changes to hepatitis C virus (HCV) programming and treatment have occurred since the 2008 nationwide serosurvey estimated a 4.8% anti-HCV prevalence. In the absence of an updated national study, this analysis uses provincial data to estimate a national prevalence and the interventions needed to achieve elimination. Using a Delphi process, epidemiologic HCV data for the four provinces of Pakistan (accounting for 97% of the population) were reviewed with 21 subject-matter experts in Pakistan. Province-level estimates were inputted into a mathematical model to estimate the national HCV disease burden in the absence of intervention (Base), and if the World Health Organization (WHO) elimination targets are achieved by 2030 (80% reduction in new infections, 90% diagnosis coverage, 80% treatment coverage, and 65% reduction in mortality: WHO Elimination). An estimated 9,746,000 (7,573,000-10,006,000) Pakistanis were living with viraemic HCV as of January 1, 2021; a viraemic prevalence of 4.3% (3.3-4.4). WHO Elimination would require an annual average of 18.8 million screens, 1.1 million treatments, and 46,700 new infections prevented anually between 2022 and 2030. Elimination would reduce total infections by 7,045,000, save 152,000 lives and prevent 104,000 incident cases of hepatocellular carcinoma from 2015 to 2030. Blood surveys, programmatic data, and expert panel input uncovered more HCV infections and lower treatment numbers in the provinces than estimated using national extrapolations, demonstrating the benefits of a bottom-up approach. Screening and treatment must increase 20 times and 5 times, respectively, to curb the HCV epidemic in Pakistan and achieve elimination by 2030., (© 2023 John Wiley & Sons Ltd.)

Tuberculosis (TB) is the leading cause of avoidable deaths from an infectious disease globally and a large of number of people who develop TB each year remain undiagnosed. Active case-finding has been recommended by the World Health Organization to bridge the case-detection gap for TB in high burden countries. However, concerns remain regarding their yield and cost-effectiveness. Data from mobile chest X-ray (CXR) supported active case-finding community camps conducted in Karachi, Pakistan from July 2018 to March 2020 was retrospectively analyzed. Frequency analysis was carried out at the camp-level and outcomes of interest for the spatial analyses were mycobacterium TB positivity (MTB+) and X-ray abnormality rates. The Global Moran's I statistic was used to test for spatial autocorrelation for MTB+ and abnormal X-rays within Union Councils (UCs) in Karachi. A total of 1161 (78.1%) camps yielded no MTB+ cases, 246 (16.5%) camps yielded 1 MTB+, 52 (3.5%) camps yielded 2 MTB+ and 27 (1.8%) yielded 3 or more MTB+. A total of 79 (5.3%) camps accounted for 193 (44.0%) of MTB+ cases detected. Statistically significant clustering for MTB positivity (Global Moran's I: 0.09) and abnormal chest X-rays (Global Moran's I: 0.36) rates was identified within UCs in Karachi. Clustering of UCs with high MTB positivity were identified in Karachi West district. Statistically significant spatial variation was identified in yield of bacteriologically positive TB cases and in abnormal CXR through active case-finding in Karachi. Cost-effectiveness of active case-finding programs can be improved by identifying and focusing interventions in hotspots and avoiding locations with no known TB cases reported through routine surveillance., (© 2023. The Author(s).)

Objective: This study was conducted to compare the predictive power of Shock Index (SI), TIMI Risk Index (TRI), LASH Score, and ACEF Score for the prediction of in-hospital mortality in a contemporary cohort of ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) at a tertiary care cardiac center of a developing country., Methods: Consecutive patients diagnosed with STEMI and undergoing primary PCI were included in this study. SI, TRI, LASH, and ACEF were computed and their predictive power was assessed as the area under the curve (AUC) on the receiver operating characteristics (ROC) curve analysis for in-hospital mortality., Results: We included 977 patients, 780 (79.8%) of which were male, and the mean age was 55.6 ± 11.5 years. The in-hospital mortality rate was 4.3% (42). AUC for TRI was 0.669 (optimal cutoff: ≥17.5, sensitivity: 76.2%, specificity: 45.6%). AUC for SI was 0.595 (optimal cutoff: ≥0.9, sensitivity: 21.4%, specificity: 89.8%). AUC for LASH score was 0.745 (optimal cutoff: ≥0, sensitivity: 76.2%, specificity: 66.9%). AUC for the ACEF score was 0.786 (optimal cutoff: ≥1.66, sensitivity: 71.4%, specificity: 73.5%)., Conclusion: In conclusion, ACEF showed sufficiently high predictive power with good sensitivity and specificity compared to other three scores. These simplified indices based on readily available hemodynamic parameters can be reliable alternatives to the computational complex scoring systems for the risk stratification of STEMI patients., Competing Interests: None., (AJCD Copyright © 2022.)

Objectives: The objective of this study was to compare the patterns of smoked and smokeless tobacco use among multimorbid and non-multimorbid middle-aged and older-aged individuals in Karachi, Pakistan., Study Design: This was an observational cross-sectional study conducted during 2015-2016., Study Setting and Participants: A total of 3250 participants aged 30 years and above, residing in the Gulshan-e-Iqbal town, Karachi, Pakistan were enrolled in the study through systematic random sampling. The selected area of residence represents diverse socioeconomic and ethnic groups of the city. People who could speak and write English or Urdu, and those who provided written informed consent were included in the study., Outcome Measures: The primary outcome measure of the study was to determine the differences in patterns of tobacco consumption among multimorbid and non-multimorbid adult individuals., Results: We found no difference in patterns of smoked (adjusted OR (aOR) 1.15, 95% CI 0.88 to 1.50, p=0.289) or smokeless tobacco (aOR 1.13, 95% CI 0.86 to 1.48, p= 0.379) use among multimorbid and non-multimorbid individuals. Individuals who perceived tobacco as a risk were less likely to consume smokeless tobacco products., Conclusion: There was no difference in tobacco consumption among individuals with and without multimorbidity. Evidenced-based guidelines are required to implement mental and behavioural interventions in patients with multiple chronic diseases to help them modify their behaviours., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Significant data gaps exist for children and adolescents with drug-resistant (DR) TB, particularly from high TB incidence settings. This report provides a descriptive analysis of programmatic outcomes among children and adolescents treated for DR-TB in Pakistan., Methods: We extracted programmatic data from January 2014 to December 2019 from a tertiary care hospital with specialised child and adolescent DR-TB services. A physician assessed all children and adolescents (0-19 years) with presumptive DR-TB, including details of exposure to DR-TB, medical history, radiology, and laboratory results. All patients received treatment as per national DR-TB management guidelines based on WHO recommendations., Results: There were 262 treatment episodes for 247 patients enrolled during the study period. The median age of the cohort was 16 years (IQR: 13-18 years) with 16 (6.1%) children being under 5 years; 237 (90.5%) patients had pulmonary TB. The majority of the patients (194 or 74.1%) experienced a favourable treatment outcome and 26 (9.9%) died while on treatment. Female patients (78.5%) were more likely to experience favourable outcomes compared to males (64.7%; chi-sqr p -value = 0.02)., Conclusions: We found high rates of favourable outcomes in children and adolescents treated for DR-TB. However, there were few young children in our cohort and there was a considerable gender gap that enhanced efforts to diagnose DR-TB in young children and to elucidate and mitigate the reasons for poor outcomes amongst males.

Background: High sound levels in the neonatal intensive care unit (NICU) can alter preterm newborn hemodynamics and cause long-term neuro-developmental delays and hearing loss. The study aims to collate data on sound levels in a level IV NICU of a tertiary care hospital, identify the factors associated with them, and compare them with the international standards set by the World Health Organization (WHO), Environmental Protection Agency (EPA), and American Academy of Pediatrics (AAP)., Methods: We carried out a cross-sectional study in NICU from 8th April 2019 to 30th June 2019. Sound levels were recorded for 480 h, using a portable sound meter, the Larson Davis 824. We captured sound levels on alternate days, during different shifts and shift changes and in open pods and single isolation rooms within the NICU. Additionally, we documented the total census, acuity of care, number of staff, number of procedures, and number of items of equipment used. The data was analyzed using t-test, ANOVA, and logistic regression., Results: The average sound level (Leq) and the maximum level (Lmax) recorded were 60.66 ± 2.99 dBA and 80.19 ± 2.63 dBA, respectively, which exceeds international recommendations. The sound level gradually decreased from morning to night hours. The major increase in sound was observed during nursing shift change. Similarly, a significant increase in sound was observed in open bays compared to isolation rooms. However, no difference in sound levels was recorded during weekdays and weekends. The number of healthcare professionals and the number of procedures performed were strongly associated with an increased noise level., Conclusion: Sound levels in NICU were beyond the safety range and international recommendations. We observed a significant sound increment during morning hours and at the time of nursing shift change. High sound levels were associated with increased number of healthcare workers and bedside procedures in NICU., Competing Interests: Declaration of competing interest The authors do not have any conflicts of interest to report., (Copyright © 2022 Taiwan Pediatric Association. Published by Elsevier B.V. All rights reserved.)

Background and Objectives: Total kidney volume is a validated prognostic biomarker for autosomal dominant polycystic kidney disease. Total kidney volume by magnetic resonance imaging (MRI) and manual segmentation is considered the "reference standard," but it is time consuming and not readily accessible. By contrast, three-dimensional (3D) ultrasound provides a promising technology for total kidney volume measurements with unknown potential. Here, we report a comparative study of total kidney volume measurements by 3D ultrasound versus the conventional methods by ultrasound ellipsoid and MRI ellipsoid., Design, Setting, Participants, & Measurements: This single-center prospective study included 142 patients who completed a standardized 3D ultrasound and MRI. Total kidney volumes by 3D ultrasound and ultrasound ellipsoid were compared with those by MRI. We assessed the agreement of total kidney volume measurements by Bland-Altman plots and misclassification of the Mayo Clinic imaging classes between the different imaging methods, and we assessed prediction of Mayo Clinic imaging classes 1C-1E by average ultrasound kidney length >16.5 cm., Results: Compared with MRI manual segmentation, MRI ellipsoid, 3D ultrasound, and ultrasound ellipsoid underestimated total kidney volume (mean difference: -3%, -9%, and -11%, respectively), with Mayo Clinic imaging classes misclassified in 11%, 21%, and 22% of patients, respectively; most misclassified cases by MRI ellipsoid (11 of 16), 3D ultrasound (23 of 30), and ultrasound ellipsoid (26 of 31) were placed into a lower Mayo Clinic imaging class. Predictions of the high-risk Mayo Clinic imaging classes (1C-1E) by MRI ellipsoid, 3D ultrasound, and ultrasound ellipsoid all yielded high positive predictive value (96%, 95%, and 98%, respectively) and specificity (96%, 96%, and 99%, respectively). However, both negative predictive value (90%, 88%, and 95%, respectively) and sensitivity (88%, 85%, and 94%, respectively) were lower for 3D ultrasound and ultrasound ellipsoid compared with MRI ellipsoid. An average ultrasound kidney length >16.5 cm was highly predictive of Mayo Clinic imaging classes 1C-1E only in patients aged ≤45 years., Conclusions: Total kidney volume measurements in autosomal dominant polycystic kidney disease by 3D ultrasound and ultrasound ellipsoid displayed similar bias and variability and are less accurate than MRI ellipsoid. Prediction of high-risk Mayo Clinic imaging classes (1C-1E) by all three methods provides high positive predictive value, but ultrasound ellipsoid is simpler to use and more readily available., (Copyright © 2022 by the American Society of Nephrology.)

Background: Aim of this study was to perform quantitative evaluation of high thrombus burden (Grade ≥4) as an independent predictor of slow/no reflow phenomenon during primary percutaneous coronary interventions (PCI) of patients with ST-segment elevation myocardial infarction (STEMI)., Methods: In this analytical cross-sectional study we included consecutive patients who have undergone primary PCI for STEMI at a tertiary care cardiac center of the Pakistan. High thrombus burden was defined as angiographic thrombus grade ≥4. The thrombolysis in myocardial infarction (TIMI) flow rate < III was defined as slow/no reflow phenomenon. Results of multivariate logistic regression analysis for slow/no reflow phenomenon were reported as odds ratio (OR)., Results: This analysis included 747 patients, 78.2% (584) patients were male and mean age was 55.82±11.54 years. High thrombus burden was observed in 68.1% (509) of the patients. Slow/no reflow phenomenon was observed in 33.6% (251) which was more common among patients in high thrombus burden group, 39.7% (202/509) vs. 20.6% (49/238); p<0.001. Adjusted OR of thrombus Grade ≥ 4 was 2.33 [1.6 -3.39]; p<0.001. Other significant variables were female gender (1.51 [1.01 -2.27]; p=0.045), left ventricular end-diastolic pressure (LVEDP) ≥20 mmHg (2.34 [1.69 -3.26]; p<0.001), total lesion length ≥20 cm (1.54 [1.09-2.16]; p=0.014), and neutrophil count ≥8.8 cells/μL (1.72 [1.22 -2.43]; p=0.002)., Conclusions: High thrombus burden (Grade ≥4) is a significant and an independent predictor of the slow/no reflow phenomenon. While predicting slow/no reflow phenomenon, thrombus burden should be given due importance along with other significant factors such as gender, LVEDP, lesion length, and neutrophil counts.

We describe gender-based differences in a community-wide TB screening programme in Karachi, Pakistan, in which 311 732 individuals were screened in mobile camps using symptom questionnaires and van-mounted digital chest X-ray, between 1 January 2018 and 31 December 2019. Only 22.4% (69 869) of camp attendees were women. Female attendees were less likely to have sputum collected and tested (31.5% (95% CI 30.4% to 32.7%) vs 38.5% (95% CI 37.6% to 39.1%)) or to initiate TB treatment (75.9% (95% CI 68.1% to 82.6%) vs 82.8% (95% CI 78.9% to 86.2%)), when indicated. Among the participants, the age-standardised prevalence of active TB was higher among women (prevalence ratio 1.4, 95% CI 1.1 to 1.7). These findings underscore the importance of integrating gender into the design and monitoring of TB screening programmes to ensure that women and men benefit equally from this important intervention., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Coronavirus disease 2019 (COVID-19) struck Pakistan with a magnitude that required micro- and macro-level adjustments at national and provincial levels. Access to medical consultation became a challenge; hospitals were flooded with cases beyond their capacity and transport was halted due to lockdown. Global Health Directorate of The Indus Health Network supported the provincial government by rolling out several walk-in community-based testing initiatives across Karachi. Results were conveyed to the patients through each district government. With a disproportionate rise in cases, an increasing delay in reporting results was observed. Methods: To help the district government bridge this gap, two physicians were engaged to convey timely results to patients who tested positive, through a helpline. Subsequently, proactive teleconsultation was initiated. We present a retrospective review of data collected during teleconsultation for COVID-19 cases identified through community-based testing between April 5 and June 10, 2020. Results: A total of 4,279 tests were conducted, revealing a 28% positivity rate (1,196 cases). Out of these, 752 (62.9%) baseline positive patients were contactable. Most patients identified either a close contact (46.8%) or a household contact (30.1%) as the source of infection. 41.8% patients were asymptomatic, 52.9% had mild to moderate illness, and 1.1% needed referral to the emergency department. 82.7% patients reported no comorbidities. Conclusion: The rapid surge of cases could not be handled by a small team and an institutional strategy of integration into an existing call center service was adopted. We share our insights to help develop evidence-based policies to effectively tackle current or future threats in similar settings.

Accurate and rapid diagnosis of coronavirus disease 2019 (COVID-19) is critical for proper care and identification of affected individuals. This led to early availability of many serological assays in the market, but with limited validation. In this study, we aimed to validate the serological assays based on different techniques. We evaluated 15 different assays based on four immunoassay techniques in 235 patients. The most sensitive kits employed were as follows: immunochromatography (Zybio severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] IgM/IgG Antibody Assay Kit - 83%), ELISA (Aeskulisa SARS-CoV-2 NP IgG -88.1%), chemiluminescence (Alinity SARS-CoV-2 IgG - 82.2%), and immunofluorescence (Lifotronic FA160 (Shenzhen SARS-CoV-2 Assay Kit [IgG]) - 88.9%). The kits by Uniper (Singuway Biotec COVID-19 IgM/IgG Presumptive Kit), Genrui 2019-nCoV IgM/IgG Test Kit, Wondfu SARS-CoV-2 Antibody Test, and Aeskulisa SARS-CoV-2 NP IgG exhibited 100% specificity, whereas IgG assay using Lifotronic FA160 (Shenzhen SARS-CoV-2 Assay Kit) exhibited the lowest specificity at 58%. Maximum agreement was observed between Aeskulisa SARS-CoV-2 NP IgG and Alinity SARS-CoV-2 IgG at 94%. Serological tests are practical alternatives, but their reliability depends on critical validation. The COVID-19 pandemic warranted investment in healthcare research at both the national and international levels.

As the COVID-19 pandemic surged, lockdowns led to the cancellation of essential health services. As part of our Zero TB activities in Karachi, we adapted our approach to integrate activities for TB and COVID-19 to decrease the impact on diagnosis and linkage to care for TB treatment. We implemented the following: (1) integrated COVID-19 screening and testing within existing TB program activities, along with the use of an artificial intelligence (AI) software reader on digital chest X-rays; (2) home delivery of medication; (3) use of telehealth and mental health counseling; (4) provision of PPE; (5) burnout monitoring of health workers; and (6) patient safety and disinfectant protocol. We used programmatic data for six districts of Karachi from January 2018 to March 2021 to explore the time trends in case notifications, the impact of the COVID-19 pandemic, and service adaptations in the city. The case notifications in all six districts in Karachi were over 80% of the trend-adjusted expected notifications with three districts having over 90% of the expected case notifications. Overall, Karachi reached 90% of the expected case notifications during the COVID-19 pandemic. The collaborative efforts by the provincial TB program and private sector partners facilitated this reduced loss in case notifications.

Objective: Promising results of CHA 2 DS 2 -VASc score have been reported for the prediction of contrast-induced acute kidney injury (CI-AKI) after percutaneous coronary intervention (PCI). However, data of its predictive strength in the context of primary PCI are not available. Therefore, in this study, we have assessed predictive value of CHA 2 DS 2 -VASc score for CI-AKI after primary PCI., Methods: This analytical cross-sectional study was conducted between January 2021 and June 2021 at the National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan. Inclusion criteria of the study was consecutive adult patients who had undergone primary PCI. Baseline CHA 2 DS 2 -VASc score was calculated, and either a 25% or 0.5 mg/dL increase in post-procedure serum creatinine level as compared to baseline level was categorized as CI-AKI., Results: A total of 691 patients were included, of which 82.1% (567) were male. CI-AKI after primary PCI was observed in 63 (9.1%) patients, out of which 66.7% (42) of patients had CHA 2 DS 2 -VASc score of ≥2. The area under the curve (AUC) for the score was 0.725 [0.662 to 0.788] with a sensitivity and specificity of 66.7% [63.1% to 70.2%] and 66.7% [53.7% to 78.1%], respectively, at a cut-off value of ≥2. In multivariable analysis, left ventricular ejection fraction ≤30% and CHA 2 DS 2 -VASc ≥2 were found to be independent predictors with adjusted odds ratios of 2.19 [1.06-4.5] and 2.13 [1.13-4.01], respectively., Conclusion: CHA 2 DS 2 -VASc score has a good predictive value for the prediction of CI-AKI after primary PCI. Criteria of CHA 2 DS 2 -VASc ≥2 can be used for the risk stratification of CI-AKI after primary PCI., Competing Interests: The authors report no conflicts of interest in this work., (© 2021 Kumar et al.)

Background: Significance of total ischemic time (TIT) in the context of ST-segment elevation myocardial infarction (STEMI) is still controversial. Therefore, in this study, we have evaluate the association of TIT with immediate outcomes in STEMI patients in whom recommended door to balloon (DTB) time of less than 90 min was achieved., Results: A total of 5730 patients were included in this study, out of which 80.9% were male and median age was 55 [61-48] years. The median DTB was observed to be 60 [75-45] min and onset of chest pain to emergency room (ER) arrival time was 180 [300-120] min. Prolonged TIT was associated with poor pre-procedure thrombolysis in myocardial infarction (TIMI) flow grade (p = 0.022), number of diseased vessels (p = 0.002), use of intra-aortic balloon pump (p = 0.003), and in-hospital mortality (p = 0.002). Mortality rate was 4.5%, 5.7%, and 7.8% for the patients with TIT of ≤ 120 min, 121 to 240 min, and > 240 min, respectively. Thirty days' risk of mortality on TIMI score was 4.97 ± 7.09%, 5.01 ± 6.99%, and 7.12 ± 8.64% for the patients with TIT of ≤ 120 min, 121 to 240 min, and > 240 min, respectively., Conclusions: Prolonged total ischemic was associated with higher in-hospital mortality. Therefore, TIT can also be considered in the matrix of focus, along with DTB time and other clinical determinants to improve the survival from STEMI., (© 2021. The Author(s).)