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An integrated analysis of large-scale survey data and detailed ethnography is presented to examine the patterns of women's mobility and their relationships with contraceptive and antenatal care use in Pakistan. Findings confirm that women's mobility is circumscribed but also illustrate the complex and contested nature of female movement. No direct relationship between a woman's unaccompanied mobility and her use of either contraception or antenatal care is found. In contrast, accompanied mobility does appear to play a role in the uptake of antenatal care, and is found to reflect the strength of a woman's social resources. Class and gender hierarchies interact to pattern women's experience. Poor women's higher unaccompanied mobility was associated with a loss of prestige and susceptibility to sexual violence. Among richer women, such movement did not constitute a legitimate target for male exploitation, nor did it lead to a loss of status on the part of their families. The findings caution against the use of western notions of 'freedom of movement' and associated quantitative indicators. At the same time, the wider impact of mobility restrictions on women's reproductive health is acknowledged and policy implications are identified. [ABSTRACT FROM AUTHOR]

In Pakistan, despite an elaborate network of over 5000 basic health units and rural health centres, supported by higher-level facilities, primary health care activities have not brought about expected improvements in health status, especially of rural population groups. A poorly functioning referral system may be partly to blame. System analysis of patient referral was conducted in a district of Punjab province (Attock) for the purpose of identifying major shortcomings, if any, in this domain. Respondents from 225 households were interviewed. Of the households experiencing serious illnesses less than half were taken to a nearest first-level care facility (FLCF). Major reasons included dissatisfaction with quality of care offered, non-availability of physician, and patients being too ill to be taken to the FLCF. The FLCF utilization rate was less than 0.6 patient visits/person/year. The mean number of patients referred per FLCF during the previous 3 months was 6.5 +/- 5.0. Only 15% of patients were referred on the prescribed referral form. None of the higher-level facilities provided feedback to FLCFS: Records of higher-level facilities revealed lack of information on either patient referrals or feedback. There were no surgical or emergency obstetric services available at any of the first-level referral facilities. Seventy-five percent of the patients attending the first-level referral facilities and 44% of the patients attending higher-level facilities had a problem of a primary nature that could well have been managed at the FLCF. As a result of the study findings, eight principal criteria were identified that need to be satisfied before a referral system may be considered functional. [ABSTRACT FROM AUTHOR]

In the context of limited effectiveness of iron supplementation programs, intermittent iron supplementation is currently under debate as a possible alternative strategy that may enhance the effectiveness of operational programs. This field-based trial assessed the outcome of twice weekly iron supplementation compared to daily in Pakistan. A double-blind, randomized, clinical trial was conducted in Northern Pakistan. Anemic pregnant women (n = 191) were assigned to receive daily (200 mg ferrous sulfate) or twice weekly (2 x 200 mg ferrous sulfate) iron supplementation. Hemoglobin was measured at baseline and at 4-wk intervals for up to 12 wk. Serum ferritin was measured at baseline and 8 or 12 wk. Analysis was by intention to treat. The two groups did not differ in age, parity, sociodemographic characteristics, hemoglobin or serum ferritin concentrations at baseline. Women who received iron daily had a greater rise in hemoglobin compared with women who received iron twice weekly (17.8 +/- 1.8 vs. 3.8 +/- 1.2 g/L, P < 0.001). The serum ferritin concentrations increased by 17.7 +/- 3.9 microgram/L (P < 0.001) in the daily supplemented group and did not change in the twice weekly group. Daily iron supplementation remained superior to twice weekly supplementation after controlling initial hemoglobin Z-scores and duration of treatment. The body mass index (BMI) modified the effect of daily versus twice weekly iron supplementation. For every unit increase in BMI, the difference between the two treatment groups was reduced by 0.0014 (final hemoglobin Z-score; P = 0.027). We recommend continuation of daily iron supplementation as opposed to intermittent iron supplementation in pregnant women in developing countries. [ABSTRACT FROM AUTHOR]

Classification of viruses carries important implications in terms of understanding their evolution and the designing of interventions. This study introduces ViroNia as a novel LSTM-based system specifically meant for high-accuracy classification of viral proteins. Although originally developed for generative tasks, LSTM architectures have been found to be highly efficient for classification tasks as well; the model demonstrates this capability. It outperforms the deep architectures, such as Simple RNN, GRU, 1d CNN and Bidirectional LSTM, with the advantage of using pairwise sequence similarity and efficient data handling. ViroNia, with a dataset of 2250 protein sequences from both the NCBI and BVBRC databases, shows great performance at accuracy levels of 99.7 % and 99.6 % for broad as well as detail-level classifications, respectively. Cross-validation was carried out on the data provided for the fivefold strategy, achieving average accuracies of 92.29 % (±1.55 %) and 90.31 % (±5.41 %), respectively, at both the broad and detail level. The architecture allows for real-time data processing and automatic feature extraction, addressing the scalability limitations faced by BLAST (Basic Local Alignment Search Tool). The comparative analysis revealed that, although existing deep learning models share similar training parameters, ViroNia significantly enhanced classification outcomes. It finds specific applications in those areas that demand real-time analysis and learning on extra viral protein datasets, and hence, contributes broadly to ongoing viral research., 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 Elsevier Ltd. All rights reserved.)

Background: Skeletal muscle injury in Ebola virus disease (EVD) has been reported, but its association with morbidity and mortality remains poorly defined., Methods: This retrospective study included patients admitted to 2 EVD treatment units over an 8-month period in 2019 during an EVD epidemic in the Democratic Republic of the Congo., Results: An overall 333 patients (median age, 30 years; 58% female) had at least 1 creatine kinase (CK) measurement (n = 2229; median, 5/patient [IQR, 1-11]). Among patients, 271 (81%) had an elevated CK level (>380 U/L); 202 (61%) had rhabdomyolysis (CK >1000 IU/L); and 45 (14%) had severe rhabdomyolysis (≥5000 U/L). Among survivors, the maximum CK level was a median 1600 (IQR, 550-3400), peaking 3.4 days after admission (IQR, 2.3-5.5) and decreasing thereafter. Among fatal cases, the CK rose monotonically until death, with a median maximum CK level of 2900 U/L (IQR, 1500-4900). Rhabdomyolysis at admission was an independent predictor of acute kidney injury (adjusted odds ratio, 2.2 [95% CI, 1.2-3.8]; P = .0065) and mortality (adjusted hazard ratio, 1.7 [95% CI, 1.03-2.9]; P = .037)., Conclusions: Rhabdomyolysis is associated with acute kidney injury and mortality in patients with EVD. These findings may inform clinical practice by identifying laboratory monitoring priorities and highlighting the importance of fluid management., Competing Interests: Potential conflicts of interest. All authors: No reported conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

A comprehensive and systematic examination of dengue virus (DENV) evolution is essential in Pakistan, where the virus poses a significant public health challenge due to its ability to adapt and evolve. To shed light on the intricate evolutionary patterns of all four DENV serotypes, we analyzed complete genome sequences (n = 43) and Envelope (E) gene sequences (n = 44) of all four DENV serotypes collected in Pakistan from 1994 to 2023, providing a holistic view of their genetic evolution. Our findings revealed that all four serotypes of DENV co-circulate in Pakistan with a close evolutionary relationship between DENV-1 and DENV-3. Among the genetically distinct serotypes DENV-2 and DENV-4, DENV-4 stands out as the most genetically different, while DENV-2 exhibits greater complexity due to the presence of multiple genotypes and the possibility of temporal fluctuations in genotype prevalence. Selective pressure analysis of the Envelope (E) gene revealed heterogeneity among sequences (n = 44), highlighting 46 codons in the genome experiencing selective pressure, characterized by a bias toward balancing selection, indicating genetic stability of the virus. Furthermore, our study suggested an intriguing evolutionary shift of DENV-4 toward the DENV-2 clade, potentially influenced by antibodies with cross-reactivity to multiple serotypes, providing a critical insight into the complex factors, shaping DENV evolution and contributing to the emergence of new serotypes., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Evolutionary Biology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Ebola virus disease (EVD) is associated with multisystem organ failure and high mortality. Severe hypoglycaemia is common, life-threatening, and correctable in critically ill patients, but glucose monitoring may be limited in EVD treatment units., Methods: We conducted a retrospective review of patients admitted to EVD treatment units in Butembo and Katwa, Eastern DRC. Glucose measurements were done using a handheld glucometer at the bedside or using the Piccolo xpress Chemistry Analyzer on venous samples., Findings: 384 patients (median age 30 years (interquartile range, IQR, 20-45), 57% female) and 6422 glucose measurements (median 11 per patient, IQR 4-22) were included in the analysis. Severe hypoglycaemia (≤2.2 mmol/L) and hyperglycaemia (>10 mmol/L) were recorded at least once during the ETU admission in 97 (25%) and 225 (59%) patients, respectively. A total of 2004 infusions of glucose-containing intravenous solutions were administered to 302 patients (79%) with a median cumulative dose of 175g (IQR 100-411). The overall case fatality rate was 157/384 (41%) and was 2.2-fold higher (95% CI 1.3-3.8) in patients with severe hypoglycaemia than those without hypoglycaemia (p = 0.0042). In a multivariable Cox proportional hazards model, periods of severe hypoglycaemia (adjusted hazard ratio (aHR) 6.2, 95% CI 3.2-12, p < 0.0001) and moderate hypoglycaemia (aHR 3.0, 95% CI 1.9-4.8, p < 0.0001) were associated with elevated mortality., Interpretation: Hypoglycaemia is common in EVD, requires repeated correction with intravenous dextrose solutions, and is associated with mortality., Funding: This study was not supported by any specific funding., Competing Interests: Declaration of interests SM is employed by Ridgeback Biotherapeutics, and is listed as inventor on the patent application for mAb 114, US Application No.62/087, 087 (PCT Application No. PCT/US2015/060,733) related to anti-Ebola virus antibodies and their use. SM receives royalties paid by the NIH Office of Financial Management (OFM)., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

The incongruity between South Asia's economic growth and extreme poverty has led to a growing interest in social protection and subsequent implementation of anti-poverty initiatives. However, many programs have consistently fallen short of their full potential in reaching the poor. We reviewed the literature to understand the factors behind this failure. A search of EconLit, Global Health Database, MEDLINE and SocINDEX, supplemented by an external search, yielded 42 papers evaluating 23 programs. Inclusion criteria included social and political determinants of program outcomes. Articles were assessed for quality using the GRADE and GRADE CERQual criteria and analyzed using Thomas & Harding's thematic synthesis approach. We identified five themes: (1) structurally flawed program theories overlook the complexities of poverty and are rooted in simplistic cause-and-effect approaches; (2) elite capture through appropriation of benefits, powerful positioning in program implementation, and gatekeeping through relationships of patronage; (3) insufficient targeting strategies to reach the poorest; (4) neglect of gendered restrictions, hidden costs, lack of legal documentation, and physical and social exclusion; (5) active self-exclusion from social protection to maintain dignity, a perception that programs are substandard, and a lack of resources required. The review highlights the well-documented disconnect between South Asian social protection program designs and the ground realities of their 'ideal' beneficiaries. This stems from a dominance of Western-led poverty discourse that disregards the influence of caste, the challenge of effective engagement with a group whose identity remains unclear, and fast-paced funding calls that do not lend themselves to meaningful identification and collaboration with the invisible poor. We suggest this disconnect is intentional and reflects a broader power dynamic rooted in geopolitical interests and national priorities. Study limitations reflect the shortcomings of the existing literature, which largely uses quantitative research methods that fail to capture the multidimensional experiences of the poor., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Javed, Mumtaz. 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.)

Evolution remains an incessant process in viruses, allowing them to elude the host immune response and induce severe diseases, impacting the diagnostic and vaccine effectiveness. Emerging and re-emerging diseases are among the significant public health concerns globally. The revival of dengue is mainly due to the potential for naturally arising mutations to induce genotypic alterations in serotypes. These transformations could lead to future outbreaks, underscoring the significance of studying DENV evolution in endemic regions. Predicting the emerging Dengue Virus (DENV) genome is crucial as the virus disrupts host cells, leading to fatal outcomes. Deep learning has been applied to predict dengue fever cases; there has been relatively less emphasis on its significance in forecasting emerging DENV serotypes. While Recurrent Neural Networks (RNN) were initially designed for modeling temporal sequences, our proposed DL-DVE generative and classification model, trained on complete genome data of DENV, transcends traditional approaches by learning semantic relationships between nucleotides in a continuous vector space instead of representing the contextual meaning of nucleotide characters. Leveraging 2000 publicly available DENV complete genome sequences, our Long Short-Term Memory (LSTM) based generative and Feedforward Neural Network (FNN) based classification DL-DVE model showcases proficiency in learning intricate patterns and generating sequences for emerging serotype of DENV. The generated sequences were analyzed along with available DENV serotype sequences to find conserved motifs in the genome through MEME Suite (version 5.5.5). The generative model showed an accuracy of 93 %, and the classification model provided insight into the specific serotype label, corroborated by BLAST search verification. Evaluation metrics such as ROC-AUC value 0.818, accuracy, precision, recall and F1 score, all to be around 99.00 %, demonstrating the classification model's reliability. Our model classified the generated sequences as DENV-4, exhibiting 65.99 % similarity to DENV-4 and around 63-65 % similarity with other serotypes, indicating notable distinction from other serotypes. Moreover, the intra-serotype divergence of sequences with a minimum of 90 % similarity underscored their uniqueness., Competing Interests: We declare that we have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors. Published by Elsevier Ltd.)

Background: Obstetric ultrasound imaging is a relatively new, but rapidly expanding, technology in low- and middle-income countries (LMICs). Given that new technologies modify practices, the influence of ultrasound on pregnancy management in LMICs is not comprehensively understood., Objectives: To map how ultrasound technology may be modulating the culture of pregnancy management in LMICs., Search Strategy: A search of five databases up to November 18, 2022., Selection Criteria: Original, peer-reviewed articles from LMICs, published in English from 2000 to 2022., Data Collection and Analysis: All articles were assessed for quality using the GRADE approach. Data were analyzed thematically to generate new interpretive constructs and explanations., Results: Forty articles involving 113 000 respondents suggests that obstetric ultrasound is becoming the preferred method of pregnancy surveillance, replacing clinically important components of prenatal care. Mothers overestimate ultrasound as an all-powerful diagnostic and "therapeutic" tool that can deliver the perfect baby. For-profit providers are driving medically unnecessary scans while the poor do not receive the recommended scans., Conclusion: Ultrasound technology has modified the culture of pregnancy management in LMICs in unintended and possibly harmful ways. Private health services are pushing the detrimental trends. Limitations include generalizability of qualitative studies and insufficient attention to inequities., (© 2023 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Conventional diagnostic techniques are based on the utilization of analyte sampling, sensing and signaling on separate platforms for detection purposes, which must be integrated to a single step procedure in point of care (POC) testing devices. Due to the expeditious nature of microfluidic platforms, the trend has been shifted toward the implementation of these systems for the detection of analytes in biochemical, clinical and food technology. Microfluidic systems molded with substances such as polymers or glass offer the specific and sensitive detection of infectious and noninfectious diseases by providing innumerable benefits, including less cost, good biological affinity, strong capillary action and simple process of fabrication. In the case of nanosensors for nucleic acid detection, some challenges need to be addressed, such as cellular lysis, isolation and amplification of nucleic acid before its detection. To avoid the utilization of laborious steps for executing these processes, advances have been deployed in this perspective for on-chip sample preparation, amplification and detection by the introduction of an emerging field of modular microfluidics that has multiple advantages over integrated microfluidics. This review emphasizes the significance of microfluidic technology for the nucleic acid detection of infectious and non-infectious diseases. The implementation of isothermal amplification in conjunction with the lateral flow assay greatly increases the binding efficiency of nanoparticles and biomolecules and improves the limit of detection and sensitivity. Most importantly, the deployment of paper-based material made of cellulose reduces the overall cost. Microfluidic technology in nucleic acid testing has been discussed by explicating its applications in different fields. Next-generation diagnostic methods can be improved by using CRISPR/Cas technology in microfluidic systems. This review concludes with the comparison and future prospects of various microfluidic systems, detection methods and plasma separation techniques used in microfluidic devices.

Background: Pakistan's maternal mortality rate remains persistently high at 186/100,000 live births. The country's government-run first-level healthcare facilities, the basic health units (BHUs), are an important source of maternity care for rural women. However,BHUsonly operate on working days from 8:00 am to 2:00 pm. Recognizing that this severely constrains access to maternity services, the government is implementing the "24/7 BHU" initiative to upgrade BHUs to provide round-the-clock care. Although based on a successful pilot project, initial reports reveal challenges in scaling up the initiative. This implementation research project aims to address a key concern of the Government of Punjab: How can the 24/7 BHU initiative be successfully implemented at scale to provide high-quality, round-the-clock skilled maternity care in rural Punjab?, Methods: The project consists of two overlapping work packages (WP). WP1 includes three modules generating data at the directorate, district and BHU levels. Module 1 uses document analysis and policy-maker interviews to explicateprogrammetheory and begin to build a system model. Module 2 compares government-collected data with data generated from a survey of 1500 births to assess BHU performance. Module 3 uses institutional ethnographies in 4-5 BHUs in three districts to provide a detailed system for understanding and identifying processes that influence scale-up. WP2 includes two modules. First, two workshops and regular meetings with stakeholders integrate WP1 findings, identify feasible changes and establish priorities. Next, "change ideas" are selected for testing in one district and 2-3 BHUs through carefully documented pilots using the PDSA (plan-do-study-act) improvement approach. An integrated knowledge translation approach will engage key policy and practice stakeholders throughout the project., Discussion: This theory-driven implementation research project willcoproducesignificant new understandings of the wider system in which the 24/7 BHU initiative is being implemented, and actionable knowledge that will highlight ways the implementation processes might be modified to enable BHUs to meet service provision goals. This study will also produce insights that will be relevant for other South Asian and low- and middle-income countries (LMICs) that experience similar challenges of programme scale-up and delivery of maternal health services to remote and marginalized communities., (© 2022. The Author(s).)

Papaya (Carica papaya L.) is grown widely in tropical and sub-tropical regions (Ahmed et al. 2008). In Pakistan, papaya production and consumption are increasing due to its medicinal, nutritional, pharmacological properties and a rich source of antioxidant, vitamin B, potassium, and magnesium. In November 2021, 26 to 35% incidence of fruit rot was observed in 15 fields of Lahore, a district of Punjab, Pakistan. Affected fruit developed circular, gray-to-brown lesions (8 to 10 mm in diameter) with white mycelia forming on the surface of lesions. In advanced stages of the disease, the lesions enlarged in size and led to the rot of entire fruit. To isolate the causal agent, small tissue segments (1 to 2 cm) were excised from 15 symptomatic fruit, surface disinfected with 1% NaClO for 30 s, rinsed with sterile distilled water three times, air dried in laminar flow hood, aseptically transferred onto petri dishes containing potato dextrose agar (PDA) and incubated at 25℃ for 5 days with a 12-h photoperiod. Eleven isolates were obtained that produced white mycelia on PDA. Flask-shaped, dark-pigmented pycnidia formed on PDA after 18 days of incubation at 25°C, which produced α-conidia measuring 4.1 to 7.2 × 1.5 to 3.0 μm and β-conidia measuring 16.4 to 25.5 × 1.0 to 1.6 μm (n = 40). α-conidia were hyaline, fusiform, and single-celled, whereas β-conidia were one-celled, hyaline, and filiform. The morphological characteristics of the fungus were compatible with a Diaporthe species (Gomes et al. 2013). The internal transcribed spacer region (ITS) (OM865414 and OM865415), translation elongation factor 1-alpha (tef1) (OM831226 and OM831229), and histone H3 (HIS) (OM831227 and OM831228) of two representative isolates (UO02 and UO03) were amplified and sequenced using primers ITS1/ITS4 (White et al. 1990), EF1-728F/EF1-986R (Carbone and Kohn 1999), and CYLH3F/H3-1b (Chaisiri et al. 2021), respectively. Blast searches showed 99 to 100% nucleotide identity with reference sequences of several Diaporthe amygdali deposited in NCBI GenBank, including the ex-type strain CBS 126679. A pathogenicity test was also performed on harvested fruit of papaya cv. Bombay using isolates UO02 and UO03. Ten mature and healthy papaya fruit were surface disinfected with 1% NaClO solution for 1 min, rinsed with sterile water and dried. Each fruit was wounded twice with a sterile scalpel (4 to 5 mm incision on the peel) and a 5-mm agar disc with mycelia of each isolate was separately placed in each wound. The wounds were wrapped with Parafilm following inoculation. Sterile PDA plugs were used in separate inoculated controls. All wounds were sealed with parafilm. All fruit were maintained in plastic boxes at 25°C with 80% relative humidity. After 6 days of incubation, rot symptoms similar to those appearing on naturally-infected fruit were observed on inoculated fruits while controls remained asymptomatic. The experiment was repeated twice with similar findings. Diaporthe amygdali was re-isolated (100%) from inoculated fruit and the pathogen identification was confirmed by morphological and molecular analysis, thus fulfilling Koch's postulates. Previously, the pathogen has been reported as a causal agent of canker and shoot blight disease in other countries (Ko and Sun, 2003; Beluzan et al. 2021). To our knowledge, this is the first report of D. amygdali on papaya in Punjab Province of Pakistan. Papaya is an emerging fruit crop in Punjab Province and it is important to further investigate the presence of this pathogen in other papaya orchards of the province since D. amygdali may cause rapid disease outbreaks resulting in severe losses.

Background: Granulomatous cardiomyopathy (GCM) is relatively uncommon in patients presenting with ventricular tachycardia (VT). Sarcoidosis and tuberculosis are the most common causes of GCM with VT. The aim of study was to evaluate their clinical characteristics and the long-term outcomes., Methods: We retrospectively analyzed patients from March 2004 to January 2020, presenting with VT and subsequently diagnosed to have GCM. Patients were divided into three groups (sarcoid, tuberculosis and indeterminate) based on serologic tests, imaging and histopathology. The response to anti-arrhythmic and disease specific therapy on long-term follow-up were analyzed., Results: There were 52 patients, comprising 27 males and 25 females, age 40 ± 10 years. The follow-up period was 5.9 ± 3.9 years. Sarcoidosis was diagnosed in 20 (38%); tuberculosis (TB) in 15(29%) and 17(33%) patients were indeterminate. Left ventricular ejection fraction (LVEF) of the entire cohort was 0.45 ± 0.14. Erythrocyte Sedimentation Rate(ESR) was found to be significantly higher in TB(43.6 ± 18.4) patients vs sarcoid(18.9 ± 6.7)p < 0.0001, but not the indeterminate group (36.2 ± 21.1), p = 0.3. Implantable Cardioverter Defibrillator (ICD) implantation was performed in 12/20(60%) patients in the sarcoid group, in 4/15(27%) patients in the TB group and in 10/17(59%) patients in the indeterminate group. At a mean follow-up of six years, VT recurrences were noted in 6, 2, and 7 patients in the sarcoid, TB and indeterminate groups respectively., Conclusion: Despite the advances in diagnostic modalities for tuberculosis and sarcoidosis, in real-world practice, almost one-third of the patients with VT and GCM have uncertain etiology. Long term outcomes of patients presenting with GCM and VT with mild left ventricle dysfunction treated appropriately seems favorable., Competing Interests: Declaration of competing interest The authors report no relationships that could be construed as a conflict of interest., (Copyright © 2022 Indian Heart Rhythm Society. Published by Elsevier B.V. All rights reserved.)

ABSTRACT A key objective of Pakistan's family planning program has been to increase awareness of the benefits of a small family. Despite five decades of effort, family size ideals of four children persist. Research suggests a preference for large families and many sons is driven by an economic and gender order that situates sons, and subsequent large families, as a form of financial and social capital. We argue an additional factor promoting large family size in Pakistan is precarity. Drawing upon 13 months' of ethnographic work from a village in Khyber Pakhtunkhwa, our data show our respondents' preference for large families with several sons was a rational response to precarity, created by economic insecurity and persistent conflict. While child mortality has reduced, the risk of an untimely conflict-related death of adult sons remains high and continues to play a crucial role in our respondents' family size calculations. Our research contributes to the body of literature listing the forces pushing large family sizes and provides an additional explanation for Pakistan's stagnating modern contraceptive prevalence rate. It also provides policy direction for reducing Pakistan's high fertility rate, suggesting a need to address the upstream factors that contribute to the continuing need for large families.

The failure to reduce maternal mortality rates in high-burden countries has led to calls for a greater understanding of structural determinants of inequities in access to maternal health services. Caste is a socially constructed identity that imposes structural disadvantages on subordinate groups. Although a South Asian construct, the existence of caste as a structural social stratifier is actively rejected in Muslim Pakistan as a regressive symbol of Hinduism. In this inimical context, the possibility of caste as a driver of maternal health care inequities is not acknowledged and has, therefore, remained unexplored in Pakistan. The objective of the present study is to quantitatively assess the variation in the use of maternity services across different caste groups in Pakistan. The research also contributes to methodological innovation in modelling relationships between caste, mediating and/or confounding socio-economic factors and maternal health service indicators. A clustered, stratified survey sampled 1457 mothers in districts Jhelum and Layyah. Multivariable, multi-level (confounder-adjusted) logistic regression analysis showed "Low" caste mothers had higher odds of landlessness, no education, working in unskilled occupations, asset poverty, no antenatal care and a home-based birth with an unskilled attendant compared to "High" or "Middling" caste individuals. Despite the important role of caste in patterning socio-economic disadvantage, its indirect causal effect on maternal health care was predominantly mediated through mothers' education and household assets. Our findings suggest a need for group-specific policies, including constructing schools in low-caste dominant settlements, affirmative action with job quotas, redistributing agricultural lands and promoting industrial development in the poorer districts.

In young adults, chronic atrioventricular (AV) block has scant systematic documentation in India. This prospective study included patients 18-40 years old, presenting with AV block without a reversible cause. There were 27 patients, aged 32 +/- 6.3 years, with 16 males. All patients had complete AV block with a narrow QRS escape rhythm (rate 40.5 ± 6.5 beats/min). Three patients were ANA positive and of these, 2 patients were anti ds DNA positive. The ESR and CRP levels were mildly elevated in 12 and 8 patients respectively. The rest of the tests were unremarkable. Despite performing multiple tests, the etiology remained idiopathic in most., Competing Interests: Declaration of competing interest None., (Copyright © 2021 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Public health scholars describe "culture of quality" in terms of desired values, attitudes, and practices, but this literature rarely includes explicitly stated theories of culture formation. In this article, we apply Fredrik Barth's transactional model to demonstrate how taking a theory-centered approach can help to identify what would be necessary to foster "cultures of quality" outlined in the public health literature. We draw on data from a study of the Republic of Malawi's Performance and Quality Improvement for Reproductive Health initiative. These data were generated in 2017-2018 through a 6-month organizational ethnography in three facilities selected to represent a range of districts with differing social and economic contexts. Our analysis revealed facility-level organizational cultures in which staff valued providing care, but responded to structural constraints by normalizing divergence from quality-of-care protocols. These findings indicate that sustaining a quality-oriented organizational culture requires addressing underlying conditions that generate routine experiences and practices.

We prospectively studied whether left atrial (LA) fibrosis is a determinant of atrial fibrillation (AF) in mitral stenosis in patients who underwent balloon mitral valvotomy. There were 2 groups: Group A (n = 16), with AF and Group B (n = 27), without AF. Fibrosis was assessed by MRI. Patients underwent cardioversion before MRI. There were 27 females and 16 males, aged 29 ± 6 years. The LA areas in Groups A and B were 54.3 ± 4.4 mm 2 and 39.4 ± 2.3 mm 2 (p < 0.05) and the LA volume index was 46.2 ± 2.9 ml/m 2 vs 33 ± 3 ml/m 2 respectively (p < 0.0001). The presence of LA scarring was not statistically different in the two groups., Competing Interests: Declaration of competing interest Nil., (Copyright © 2021 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Introduction: Myocarditis remains an under-diagnosed entity among children. We evaluated the spectrum of electrocardiogram (ECG) changes and arrhythmias in children with myocarditis., Methods: A single-center prospective observational study was conducted over a period of 18 months at a public university hospital, which included all cases with myocarditis from the ages of 1 month to 12 years. Myocarditis was diagnosed according to standard criteria. Arrhythmias were detected by 12-lead ECG or by multiparameter monitors., Results: There were 63 children with myocarditis. Sinus tachycardia remained the most important ECG finding (61, 96.8%) followed by ST-T changes (30, 47.6%), low voltage QRS complexes (23, 36.5%), and premature complexes (11, 17.4%). Sustained arrhythmias were seen in 14/63 (22.2%) of the children (Group A), while the remaining 49 patients were designated as Group B. There were 11 (17.5%) cases with sustained tachyarrhythmias, comprising 5 with supraventricular tachycardia, 4 with ventricular tachycardia, and 2 with atrial flutter/fibrillation. Bradyarrhythmias were seen in 3 patients, including 2 children with atrioventricular block and 1 with severe sinus bradycardia. A longer hospital stay of 18.5 (4.75) days vs. 13 (4) days, P = 0.001), and more ST-T changes [12 (85.7%) vs. 18 (36.73%), P = 0.003] were seen in Group A. Multivariate regression analysis found only the presence of ST-T changes as predictors for arrhythmia., Conclusions: A variety of arrhythmias and other ECG changes were commonly seen in children with myocarditis. Sustained arrhythmias were seen in one-fifth of the patients, being associated with ST-T changes and a longer hospital stay., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Annals of Pediatric Cardiology.)

Governments in many low- and middle-income countries have increasingly turned to the private sector to address the gap in skilled birth attendance in rural areas. They draw on limited, but emerging evidence that the poor also seek private healthcare services. A question not addressed in this policy and strategy is: Can poor women pay the fees required for private-sector maternity care providers to financially sustain their practices? This article examined the financial viability of private-sector midwifery practices established to provide skilled birth services to Afghan refugee women in Baluchistan, Pakistan. An international non-governmental organization established 45 midwifery practices as part of a poverty alleviation project aimed at providing market-based solutions for female poverty. A retrospective micro-cost analysis was conducted on a sample of 11 practices. In-depth interviews were conducted with 33 stakeholders to explore the midwives' experiences of operating private practices, and the facilitators and barriers they experienced. The single midwife-practices saw a mean of 8.7 ANC patients (range 1-19), attended 2.9 births (range 0-10) and provided care to 1.6 postnatal patients (range 0-7). The average net income of the 11 practices in May 2014 was US$81, but the median was just US$12. To contextualize these incomes, the midwives earned, on average, 25% of Pakistan's minimum monthly living wage. The financial analysis showed only 3 out of 11 sampled practices could be considered financially viable. The qualitative data revealed that even in practices with reasonable client volumes, the patients' inability to pay was the critical factor in the midwife practices' low net incomes. The research provides empirical evidence of a potential pitfall of private funding models in resource-poor settings where providers rely on impoverished clients to pay user-fees. Such financial models essentially shift the government's responsibility to provide safe childbirth services onto providers who can least afford to offer such care., (© The Author(s) 2021. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background Hypothyroidism can be a cause of sinus bradycardia. However, thyroid laboratory evaluation is often performed routinely in patients with complete heart block (CHB) though there is little data to support this practice. This study aimed to assess the frequency of thyroid dysfunction in patients presenting with CHB without clinical features of hypothyroidism. Methodology All patients referred for permanent pacemaker implantation for CHB were included in this cross-sectional study. Patients with known thyroid disorder or clinical features of thyroid disorder were excluded. Demographic, electrocardiography (EKG), and routine thyroid stimulating hormone (TSH) screening results were recorded. Results A total of 102 patients with complete atrioventricular (AV) block were enrolled in the study of which 50.0% (51) were male. The mean age was 61.09 ± 11.74. Co-morbidities included diabetes mellitus 44.1% (45), smoking 36.3% (37), and hypertension 55.9% (57). Mean EKG atrial rate was 82.97 ± 31.31 mmHg with a mean ventricular escape rate of 36.17 ± 5.93. Permanent pacemakers were implanted in all of the patients. Only one patient had an abnormal TSH. Conclusions We found a very low prevalence of thyroid dysfunction among patients without clinical features of thyroid dysfunction presenting with third-degree AV block. This calls for cautious prescription of thyroid testing in clinically euthyroid patients., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Faisal et al.)