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Background: The Zindagi Mehfooz (safe life; ZM) electronic immunization registry (EIR) is a comprehensive suite of digital health interventions that aims to improve equitable access, timeliness, and coverage of child immunizations through a smartphone-based app for vaccinators, web-based dashboards for supervisors and managers, text message alerts and reminders for caregivers, and a call center. It has been implemented at scale in Sindh Province, Pakistan., Objective: This study aimed to present findings from an evaluation of the ZM-EIR suite of digital health interventions in order to improve data availability and use as a contribution, among other immunization program interventions, to enhanced immunization outcomes for children aged 12-23 months in Sindh Province., Methods: The mixed methods study included (1) analysis of ZM-EIR system data to identify high-, moderate-, and low-adoption and compliance sites; (2) in-depth interviews with caregivers, vaccinators, supervisors, and managers in the Expanded Program for Immunization (EPI); and (3) pre-post outcome evaluation using vaccine coverage from the Multiple Indicator Cluster Surveys (MICS) 2014 and 2018-2019. Key outcomes of interest were improved data availability, use and contribution to immunization outcomes, including receipt of individual antigens (Bacillus Calmette-Guérin [BCG], pentavalent [Penta] 1-3, measles), full immunization (all antigens), and zero-dose children defined as children aged 6-23 months who have not received the first dosage of the diphtheria-pertussis-tetanus 1/Penta vaccine., Results: By registering newborns, providing alerts and reminders, and tracking their immunization completion, the ZM-EIR improved data availability and use in the EPI. The ZM-EIR was well received by EPI administrators, supervisors, vaccinators, and caregivers. The key benefit highlighted by ZM-EIR users was a list of children who missed scheduled vaccines (defaulters). Through greater availability and use of data, the ZM-EIR implementation, as part of a broader package of immunization program-strengthening activities in Sindh Province, may have contributed to an increase in immunization coverage and timeliness for BCG vaccinations and a decrease in zero-dose children in 2018-2019 from 2014. Additional findings from the study included the dual burden of reporting on paper and gender-related considerations of female caregivers not wanting to provide their phone numbers to male vaccinators, creating barriers to greater uptake of the ZM-EIR., Conclusions: The ZM-EIR is a promising technology platform that has increased the availability and use of immunization data, which may have contributed, along with other intensive immunization program interventions, to improvements in immunization outcomes through systematic registration of children, alerts and reminders, and increased use of data for planning and monitoring by the EPI., Trial Registration: ISRCTN Registry ISRCTN23078223; https://doi.org/10.1186/ISRCTN23078223., (©Patricia Mechael, Sara Gilani, Ahsan Ahmad, Amnesty LeFevre, Diwakar Mohan, Asra Memon, Mubarak Taighoon Shah, Danya Arif Siddiqi, Subhash Chandir, Riswana Soundardjee. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 11.10.2024.)

Lady health workers (LHWs) provide lifesaving maternal and child health services to >60% of Pakistan's population but are poorly compensated and overburdened. Moreover, LHWs' training does not incorporate efforts to nurture attributes necessary for equitable and holistic healthcare delivery. We developed an interdisciplinary humanities curriculum, deriving its strengths from local art and literature, to enhance character virtues such as empathy and connection, interpersonal communication skills, compassion and purpose among LHWs. We tested the curriculum's feasibility and impact to enhance character strengths among LHWs.We conducted a multiphase mixed-methods pilot study in two towns of Karachi, Pakistan. We delivered the humanities curriculum to 48 LHWs via 12 weekly sessions, from 15 June to 2 September 2021. We developed a multiconstruct character strength survey that was administered preintervention and postintervention to assess the impact of the training. In-depth interviews were conducted with a subset of randomly selected participating LHWs.Of 48 participants, 47 (98%) completed the training, and 34 (71%) attended all 12 sessions. Scores for all outcomes increased between baseline and endline, with highest increase (10.0 points, 95% CI 2.91 to 17.02; p=0.006) observed for empathy/connection. LHWs provided positive feedback on the training and its impact in terms of improving their confidence, empathy/connection and ability to communicate with clients. Participants also rated the sessions highly in terms of the content's usefulness (mean: 9.7/10; SD: 0.16), the success of the sessions (mean: 9.7/10; SD: 0.17) and overall satisfaction (mean: 8.2/10; SD: 3.3).A humanities-based training for front-line health workers is a feasible intervention with demonstrated impact of nurturing key character strengths, notably empathy/connection and interpersonal communication. Evidence from this study highlights the value of a humanities-based training, grounded in local literature and cultural values, that can ultimately translate to improved well-being of LHWs thus contributing to better health outcomes among the populations they serve., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Poor accessibility of immunization services coupled with limited options for transportation and socio-cultural norms that hinder women's mobility are among the key factors contributing to poor immunization coverage in rural areas. We assessed the feasibility and acceptability of establishing a free-of-cost, women-only carpool service for immunization in a rural setting in Pakistan and evaluated its preliminary impact on immunization coverage and timeliness among children., Methods: We conducted a feasibility study in four selected immunization facilities in Shikarpur District, Sindh. A local transport vehicle was hired and branded as an immunization carpool service. Women having un- or under-immunized children aged ≤2 years were invited to visit immunization facilities using carpool vehicles. Information on demographic indicators and service experience was collected. Child immunization details were extracted using the government's provincial electronic immunization registry to estimate immunization coverage and timeliness., Results: Between January and October 2020, six immunization carpool vehicles provided uninterrupted service and transported 2422 women-child pairs, completing 4691 immunization visits. Majority of women reported that the carpool service improved accessibility (99.6%) by offering group travel (82.9%) and reducing their dependency on family members (93.4%). Preliminary estimates reported an increase in immunization coverage and timeliness across antigens among participating children compared to non-participating children, with significant increase in proportion for BCG coverage (38.1%; p < 0.001, CI: 32.8%, 43.4%) and measles-2 timeliness (18%; p < 0.001, CI: 13.3%, 22.4%)., Conclusion: A women-only immunization carpool service implemented within a rural setting is feasible and highly acceptable. Key factors contributing to the model's success include increased mobility and independence of women, cost-savings, and a culturally and contextually appropriate mechanism of transport embedded within the local setting. Increased accessibility to health services also contributed to improved immunization coverage and timeliness among children., Competing Interests: All the authors of this article confirm that no personal, financial, or other related interests have influenced the findings presented in this paper., (© 2024 Published by Elsevier Ltd.)

Recovery capital is a construct central to the substance use disorder treatment and recovery field. Lack of structured instrument for its assessment in the local context necessitated the translation of the English self-assessment version of the "Brief Assessment of Recovery Capital" (BARC-10) scale to Bangla and the study of its psychometric properties. The objective was to develop a culturally adapted and validated Bangla version of the BARC-10 scale for substance use disorders patients. This study conducted in the period of January 2021 to March 2022 in the department of Psychiatry of a tertiary hospital and central drug addiction treatment center. Initially BARC-10 questionnaire was translated into Bangla (T1 and T2) by 2 separate translators and then synthesis of a single version (T12) was done based on the previous translations. After that 2 back translations (BT1 and BT2) were done by 2 more translators based on the synthesized version (T12). By reviewing all these forward and backward translations, an expert committee made the pre-final version after making some linguistic modification. Then data collection was done among 100 subjects who were selected purposively. Reliability was assessed by Cronbach alpha. Content validity, face validity and Construct validity by factor analysis were measured. Internal consistency measured by Cronbach alpha found was 0.846. No significant change in Cronbach alpha was observed following deleting any item. Confirmatory factor analysis revealed a good fit to data by a chi-square/df value1.33, RMSEA value 0.058. Kaiser-Meyer-Olkin value (.840) showed sampling adequacy. Exploratory factor analysis of the principal component identified 2 factors which had eigenvalues of more than 1. Scree plot also revealed similar factors. These 2 factors together explained 53.1% of the variance. All items were loaded under 2 factors after varimax rotation. The validated Bangla version of the BARC-10 demonstrated high internal reliability and validity. It can potentially be applied in "recovery-oriented" deaddiction service., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Gaps in information access impede immunization uptake, especially in low-resource settings where cutting-edge and innovative digital interventions are limited given the digital inequity. Our objective was to develop an Artificially Intelligent (AI) chatbot to respond to caregiver's immunization-related queries in Pakistan and investigate its feasibility and acceptability in a low-resource, low-literacy setting., Methods: We developed Bablibot (Babybot), a local language immunization chatbot, using Natural Language Processing (NLP) and Machine Learning (ML) technologies with Human in the Loop feature. We evaluated the bot through a sequential mixed-methods study. We enrolled caregivers visiting the 12 selected immunization centers for routine childhood vaccines. Additional caregivers were reached through targeted text message communication. We assessed Bablibot's feasibility and acceptability by tracking user engagement and technological metrics, and through thematic analysis of in-depth interviews with 20 caregivers., Findings: Between March 9, 2020, and April 15, 2021, 2,202 caregivers were enrolled in the study, of which, 677 (30.7%) interacted with Bablibot (users). Bablibot responded to 1,877 messages through 874 conversations. Conversation topics included vaccination due dates (32.4%; 283/874), side-effect management (15.7%;137/874), or delaying vaccination due to child's illness or COVID-lockdown (16.8%;147/874). Over 90% (277/307) of responses to text-based exit surveys indicated satisfaction with Bablibot. Qualitative analysis showed caregivers appreciated Bablibot's usefulness and provided feedback for further improvement of the system., Conclusion: Our results demonstrate the feasibility and acceptability of local-language NLP chatbots in providing real-time immunization information in low-resource settings. Text-based chatbots canminimize the workload on helpline operators, in addition to instantaneously resolving caregiver queries that otherwise lead to delay or default., 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 © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Despite the potential of geospatial technologies to track and monitor coverage, they are underutilized for guiding immunization program strategy and implementation, especially in low-and-middle-income countries. We conducted geospatial analysis to explore the geographic and temporal trends of immunization coverage, and examined the pattern of immunization service access (outreach and facility based) by children., Methodology: We extracted data to analyze coverage rates across different dimensions (by enrolment year, birth year and vaccination year) from 2018 till 2020 in Karachi, Pakistan using the Sindh Electronic Immunization Registry (SEIR). We conducted geospatial analysis to assess variation in coverage rates of BCG, Pentavalent (Penta)-1, Penta-3, and Measles-1 vaccines using Government targets. We also analyzed the proportion of children receiving their routine vaccinations at fixed centers and outreach and examined whether children received vaccinations at the same or multiple immunization centers., Results: A total of 1,298,555 children were born, enrolled or vaccinated from 2018 till 2020. At the district level, analysis by enrollment and birth year showed coverage increased between 2018 and 2019 and declined in 2020, while analysis by vaccination year showed consistent increase in coverage. However, micro-geographic analysis revealed pockets where coverage persistently declined. Notably 27/168, 39/168 and 3/156 Union councils showed consistently declining coverage when analyzing by enrollment, birth and vaccination year respectively. More than half (52.2%, 678,280/1,298,555) of the children received all their vaccinations exclusively through fixed centers and, 71.7% (499,391/696,701) received all vaccinations from the same centers., Conclusion: Despite overall improving vaccination coverage between 2018 and 2020, certain geographic areas have consistently declining coverage rates, which is detrimental for equity. Making immunization inequities visible through geospatial analysis is the first step to ensure resources are allocated optimally. Our study provides impetus for immunization programs to develop and invest in geospatial technologies, harnessing its potential for improved coverage and equity., 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 © 2023. Published by Elsevier Ltd.)

Gender-based inequities in immunization impede the universal coverage of childhood vaccines. Leveraging data from the Government of Sindh's Electronic Immunization Registry (SEIR), we estimated inequalities in immunization for males and females from the 2019-2022 birth cohorts in Pakistan. We computed male-to-female (M:F) and gender inequality ratios (GIR) Tfor enrollment, vaccine coverage, and timeliness. We also explored the inequities by maternal literacy, geographic location, mode of vaccination delivery, and gender of vaccinators. Between 1 January 2019, and 31 December 2022, 6,235,305 children were enrolled in the SEIR, 52.2% males and 47.8% females. We observed a median M:F ratio of 1.03 at enrollment and at Penta-1, Penta-3, and Measles-1 vaccinations, indicating more males were enrolled in the immunization system than females. Once enrolled, a median GIR of 1.00 indicated similar coverage for females and males over time; however, females experienced a delay in their vaccination timeliness. Low maternal education; residing in remote-rural, rural, and slum regions; and receiving vaccines at fixed sites, as compared to outreach, were associated with fewer females being vaccinated, as compared to males. Our findings suggeste the need to tailor and implement gender-sensitive policies and strategies for improving equity in immunization, especially in vulnerable geographies with persistently high inequalities.

Background: Missed opportunities for vaccination (MOVs), that is, when children interact with the health system but fail to receive age-eligible vaccines, pose a crucial challenge for equitable and universal immunization coverage. Inaccurate interpretations of complex catch-up schedules by health workers contribute to MOVs., Objective: We assessed the feasibility of a mobile-based immunization decision support system (iDSS) to automatically construct age-appropriate vaccination schedules for children and to prevent MOVs., Methods: A sequential exploratory mixed methods study was conducted at 6 immunization centers in Pakistan and Bangladesh. An android-based iDSS that is packaged in the form of an application programming interface constructed age-appropriate immunization schedules for eligible children. The diagnostic accuracy of the iDSS was measured by comparing the schedules constructed by the iDSS with the gold standard of evaluation (World Health Organization-recommended Expanded Programme on Immunization schedule constructed by a vaccines expert). Preliminary estimates were collected on the number of MOVs among visiting children (caused by inaccurate vaccination scheduling by vaccinators) that could be reduced through iDSS by comparing the manual schedules constructed by vaccinators with the gold standard. Finally, the vaccinators' understanding, perceived usability, and acceptability of the iDSS were determined through interviews with key informants., Results: From July 5, 2019, to April 11, 2020, a total of 6241 immunization visits were recorded from 4613 eligible children. Data were collected for 17,961 immunization doses for all antigens. The iDSS correctly scheduled 99.8% (17,932/17,961) of all age-appropriate immunization doses compared with the gold standard. In comparison, vaccinators correctly scheduled 96.8% (17,378/17,961) of all immunization doses. A total of 3.2% (583/17,961) of all due doses (across antigens) were missed in age-eligible children by the vaccinators across both countries. Vaccinators reported positively on the usefulness of iDSS, as well as the understanding and benefits of the technology., Conclusions: This study demonstrated the feasibility of a mobile-based iDSS to accurately construct age-appropriate vaccination schedules for children aged 0 to 23 months across multicountry and low- and middle-income country settings, and underscores its potential to increase immunization coverage and timeliness by eliminating MOVs., (©Danya Arif Siddiqi, Rozina Feroz Ali, Mubarak Taighoon Shah, Vijay Kumar Dharma, Anokhi Ali Khan, Tapash Roy, Subhash Chandir. Originally published in JMIR Pediatrics and Parenting (https://pediatrics.jmir.org), 17.02.2023.)

Microbial fuel cell (MFC) is an emerging technology which has been immensely investigated for wastewater treatment along with electricity generation. In the present study, the treatment efficiency of MFC was investigated for hydrocarbon containing wastewater by optimizing various parameters of MFC. Mediator-less MFC (1·2 l) was constructed, and its performance was compared with mediated MFC with Escherichia coli as a biocatalyst. MFC with electrode having biofilm proved to be better compared with MFC inoculated with suspended cells. Analysis of increasing surface area of electrode by increasing their numbers indicated increase in COD reduction from 55 to 75%. Catholyte volume was optimized to be 750 ml. Sodium benzoate (0·721 g l -1 ) and actual common effluent treatment plant (CETP) wastewater as anolyte produced 0·8 and 0·6 V voltage and 89 and 50% COD reduction, respectively, when a novel consortium of four bacterial strains were used. Twenty MFC systems with the developed consortium when electrically connected in series-parallel connection were able to generate 2·3 V and 0·5 mA current. This is the first report demonstrating the application of CETP wastewater in the MFC system, which shows potential of the system towards degradation of complex organic components present in industrial wastewater., (© 2021 The Society for Applied Microbiology.)

Objective: To describe a systematic process of transforming paper registers into a digital system optimized to enhance service provision and fulfil reporting requirements., Methods: We designed a formative study around primary health workers providing reproductive, maternal, newborn and child health services in three countries in Bangladesh, Indonesia and Pakistan. The study ran from November 2014 to June 2018. We developed a prototype digital application after conducting a needs assessment of health workers' responsibilities, workflows, routine data requirements and service delivery needs. Methods included desk reviews, focus group discussions, in-depth interviews; data mapping of paper registers; observations of health workers; co-design workshops with health workers; and usability testing. Finally, we conducted an observational feasibility assessment to monitor uptake of the application., Findings: Researchers reviewed a total of 17 paper registers across the sites, which we transformed into seven modules within a digital application running on mobile devices. Modules corresponded to the services provided, including household enumeration, antenatal care, family planning, immunization, nutrition and child health. A total of 65 health workers used the modules during the feasibility assessment, and average weekly form submissions ranged from 8 to 234, depending on the health worker and their responsibilities. We also observed variability in the use of modules, requiring consistent monitoring support for health workers., Conclusion: Lessons learnt from this study shaped key global initiatives and resulted in a software global good. The deployment of digital systems requires well-designed applications, change management and strengthening human resources to realize and sustain health system gains., ((c) 2022 The authors; licensee World Health Organization.)

Background: Routine childhood immunization coverage in Pakistan remains sub-par, in part, due to suboptimal utilization of existing vaccination services. Quality of vaccine delivery can affect both supply and demand for immunization, but data for immunization center quality in Pakistan is sparse and in Sindh province in Southern Pakistan, no comprehensive health facility assessment has ever been conducted at a provincial level. We assessed health facilities, specifically immunization centers, and their associated health workers throughout the province to summarize quality of immunization centers.  METHODS: An exhaustive list of health facilities obtained from Sindh's provincial government was included in our analysis, comprising a total of 1396 public, private, and public-private health facilities. We adapted a health facility and health worker assessment survey developed by BASICS and EPI-Sindh to record indicators pertaining to health facility infrastructure, processes and human resources. Using expert panel ranking, we developed critical criteria (the presence of a cold box/refrigerator, vaccinator and vaccination equipment at the immunization center) to indicate the bare minimum items required by immunization centers to vaccinate children. We also categorized other infrastructure, process, and human resource items to determine high, low and moderate function requirements to ascertain quality. We evaluated presence of critical criteria, calculated scores for high, moderate and low function requirements, and displayed frequencies of infrastructure, process and human resource indicators for all immunization centers across Sindh. We analyzed results at the division level and utilized a two-sample independent clustered t-test to test differences in average function requirement scores between facilities that met critical criteria and those that did not., Results: Out of the 1396 health facilities assessed across Sindh province from October 2017 to January 2018, 1236 (88.5%) were operational while 1209 (86.6%) offered vaccination services (immunization centers). Only 793 (65.6%; 793/1209) immunization centers met the critical criteria of having all the following items: vaccinator, a cold box or refrigerator and vaccine supplies. Of the 416 (34.4%; 416/1209) immunization centers that did not meet the critical criteria, most of the centers did not have a cold box or refrigerator (28.3%; 342/1209), followed by lack of vaccines (19.9%; 240/1209), and a vaccinator (13.0%; 157/1209). Of the 2153 healthcare workers interviewed, 1875 (87.1%) were vaccinators, of which 1745 (81.0%; 1745/2153) were male, and had an average of 12.4 years of schooling. A total of 1805 (96.3%; 1805/1875), 1655 (88.3%; 1655/1875) and 1387 (74.0%; 1387/1875) of the vaccinators were trained in vaccination, cold chain and inventory management respectively., Conclusion: One out of three immunization centers in Sindh lack the critical components essential for quality vaccination services. While the majority of health workers (>80%) were trained on vaccination and cold chain management, the proportion trained on inventory management was comparatively low. Our findings therefore suggest that suboptimal immunization center quality is partly due to inadequate infrastructure and inefficient processes contributed to an extent, by low levels of inventory management training among vaccinators. Our study presents critical research findings with high-impact policy implications for identifying and addressing gaps to improve vaccination uptake within a low-middle income country setting., (© 2022. The Author(s).)

Microbial Fuel Cell (MFC) is an innovative bio-electrochemical approach which converts biochemical energy inherent in wastewater into electrical energy, thus contributing to circular economy. Five electrogenic bacteria, Kocuria rosea (GTPAS76), two strains of Bacillus circulans (GTPO28 and GTPAS54), and two strains of Corynebacterium vitaeruminis (GTPO38 and GTPO42) were isolated from a common effluent treatment plant (CETP) and were used individually as well as in consortium form to run double chambered "H" type microbial fuel cell. Individually they could produce voltage in the range of 0.4-0.7 V in the MFC systems. Consortium developed using GTPO28, GTPO38, GTPAS54 and GTPAS76 were capable of producing voltage output of 0.8 V with 81.81 % and 64 % COD and BOD reduction, respectively. The EPS production capacity and electricity generation by the isolated bacteria correlated significantly (r = 0.72). Various parameters like, effect of preformed biofilm, length of salt bridge and its reuse, aeration, substrate concentration and external resistance were studied in detail. The study emphasizes on improving the commercialization aspect of MFC with repeated use of salt bridge and improving wastewater treatment potential after optimization of MFC system. Polarization curve and power density trends were studied in optimized MFC. A maximum power density and current density achieved were 18.15 mW/m 2 and 370.37 mA/m 2 , respectively using 5 mM sodium benzoate. This study reports the use of sodium benzoate as a substrate along with reusing of the salt bridge in MFC study with promising results for BOD and COD reduction, proving it to be futuristic technology for bio-based circular ecosystem development., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Active tuberculosis (TB) during pregnancy has an adverse effect on maternal and neonatal outcomes. This study analysed the results of a pilot project integrating TB screening into antenatal care (ANC) visits in a high-TB-burden, low-resource setting., Methods: Data were extracted from the TB screening pilot in obstetrician-gynaecologist clinics of six tertiary care facilities in Karachi, Pakistan from April to December 2017. Data from the verbal symptom screening conducted at each ANC visit for all women and the Xpert MTB/RIF testing for all symptomatic women to investigate TB yield were analysed by assessing the numbers screened, presumptive patients and active TB diagnoses among pregnant women and neonates., Results: Symptom screening was performed on 113,078 pregnant women, 2,965 (2.6%) of whom reported at least one TB symptom. Sputum samples were collected from 2,896 (97.7%) symptomatic women. Of the 27 (0.9%) newly diagnosed bacteriologically positive TB patients, 25 (93%) initiated TB treatment. No case of vertical TB transmission was reported among 26 live births., Discussion: TB screening is feasible and should be implemented during routine ANC visits in high-TB-burden settings. There is a need to explore a multi-faceted approach with inclusion of clinical examination and chest X-rays to diagnose TB in pregnant women., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Despite the proliferation of digital interventions such as Electronic Immunization Registries (EIR), currently, there is little evidence regarding the use of EIR data to improve immunization outcomes in resource-constrained settings. To achieve the Sustainable Development Goal (SDG) of ensuring healthy lives and well-being for all ages, particularly for newborns and children under the age of 5 (goal 3b), it is essential to generate and use quality data for evidence-based decision making to overcome barriers inherent in immunization systems. In Pakistan, only 66 % of children receive all basic vaccinations, and in Sindh province, the number is even lower at 49 %. In 2012, IRD developed and piloted Zindagi Mehfooz (Safe Life; ZM) ElR, an Android-based platform that records and analyses individual-level child data in real-time. In 2017 in collaboration with Expanded Programme for Immunization (EPI) Sindh, ZM was scaled-up across the entire Sindh province and is currently being used by 2521 government vaccinators in 1539 basic health facilities, serving >48 million population., Objective: The study aims to demonstrate how big immunization data from the ZM-EIR is being leveraged in Sindh, Pakistan for actionable decision making via three use cases (a) improving performance management of vaccinators to increase geographical coverage, (b) quantifying the impact of provincial accelerated outreach activities, and (c) examining the impact of the COVID-19 pandemic on routine immunization coverage to help devise a tailored approach for future efforts., Methods: From October 2017 to April 2020, more than 2.9 million children and 0.9 million women have been enrolled, and more than 22 million immunization events have been recorded in the ZM-EIR. We extracted de-identified data from ZM-EIR for January 1, 2019 - April 20, 2020, period. Given the needs of each use case, monthly and daily indicators on vaccinator performance (attendance and compliance), daily immunization visits, and the number of antigens administered were calculated. Geo-coordinate data of antigen administration was extracted and displayed on geographic maps using QGIS. All generated reports were shared at fixed frequency with various stakeholders, such as partners at EPI-Sindh, for utilization in decision making and informing policy., Result: Our use-cases demonstrate the use of EIR data for data-driven decision making. From January - December 2019, the monthly monitoring of program indicators helped increase the vaccinator attendance from 44% to 88%, while an 85 % increase in geographical coverage was observed in a polio-endemic super high-risk union council (SHRUC) in Karachi. The analysis of daily average antigens administered during accelerated outreach efforts (AOE) as compared to routine activities showed an increase in average daily Pentavalent-3, Measles-1, and Measles-2 vaccines administered by 103%, 154%, and 180% respectively. These findings helped decide to continue the accelerated effort in high-risk areas (compared to the entire province) rather than discontinuing the activity due to high costs. During COVID-19 lockdown, the daily average number of child immunizations reduced from 16,649 to 4335 per day, a decline of 74% compared to 6 months preceding COVID-19 lockdown. ZM-EIR data is currently helping to shape the planning and implementation of critical strategies to mitigate the impact of the COVID-19 pandemic., Conclusion: The big data for vaccines generated through EIRs is a powerful tool to monitor immunization work-force and ensure chronically missed communities are identified and covered through targeted strategies. Geospatial data availability and analysis is changing the way EPI review meetings occur with stakeholders, taking data-driven decisions for better planning and resource allocation. In the fight against COVID-19 pandemic, as governments gradually begin to shift from containing the outbreak to strategizing a plan for sustaining the essential health services, the countries that will emerge most successful are likely the ones who can best use technology and real-time data for targeted efforts., (Copyright © 2021 Elsevier B.V. All rights reserved.)

This article describes the preparation of Fe 3 O 4 nanoparticles and its decoration with a layer of tiny Ag nanoparticles at room temperature. Later on, the synthesized Fe 3 O 4 @Ag heterostructures were protected with Silica and finally modified with Poly(N-isopropyl acrylamide) (PNIPA) nanogels through post-synthesis method to get multifunctional (superparamagnetic, plasmonic and thermosensitive) nanocomposite. The structural characteristics of Fe 3 O 4 @Ag@SiO 2 -PNIPA nanogels composite were investigated by instrumental techniques such as Transmission Electron Microscopy (TEM), Scanning Electron Microscopy (SEM), Fourier Transform Infrared Spectroscopy (FT-IR), X-ray Diffraction (XRD) and Vibrating Sample Magnetometer (VSM). The average particles diameter was calculated from XRD data through Scherer formula and it was found as 14 nm. The Fe 3 O 4 @Ag@SiO 2 -PNIPA polymeric composites were assessed for the adsorption of Bovine Serum Albumin (BSA) and Human Serum Albumin (HSA) proteins from aqueous media. The adsorption data of BSA and HSA were best explained by Langmuir isotherm model with maximum adsorption capacities of 322 and 166 (mg/g) respectively showing mono-layer adsorption. The kinetics data for both the proteins were fairly interpreted by pseudo-second-order model. Thermodynamics studies revealed that the adsorption phenomena of BSA and HSA on the surface of Fe 3 O 4 @Ag@SiO 2 -PNIPA nanogels composite are spontaneous and exothermic., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: COVID-19 pandemic has affected routine immunization globally. Impact will likely be higher in low and middle-income countries with limited healthcare resources and fragile health systems. We quantified the impact, spatial heterogeneity, and determinants for childhood immunizations of 48 million population affected in the Sindh province of Pakistan., Methods: We extracted individual immunization records from real-time provincial Electronic Immunization Registry from September 23, 2019, to July 11, 2020. Comparing baseline (6 months preceding the lockdown) and the COVID-19 lockdown period, we analyzed the impact on daily immunization coverage rate for each antigen by geographical area. We used multivariable logistic regression to explore the predictors associated with immunizations during the lockdown., Results: There was a 52.5% decline in the daily average total number of vaccinations administered during lockdown compared to baseline. The highest decline was seen for Bacille Cal-mette Guérin (BCG) (40.6% (958/2360) immunization at fixed sites. Around 8438 children/day were missing immunization during the lockdown. Enrollments declined furthest in rural districts, urban sub-districts with large slums, and polio-endemic super high-risk sub-districts. Pentavalent-3 (penta-3) immunization rates were higher in infants born in hospitals (RR: 1.09; 95% CI: 1.04-1.15) and those with mothers having higher education (RR: 1.19-1.50; 95% CI: 1.13-1.65). Likelihood of penta-3 immunization was reduced by 5% for each week of delayed enrollment into the immunization program., Conclusion: One out of every two children in Sindh province has missed their routine vaccinations during the provincial COVID-19 lockdown. The pool of un-immunized children is expanding during lockdown, leaving them susceptible to vaccine-preventable diseases. There is a need for tailored interventions to promote immunization visits and safe service delivery. Higher maternal education, facility-based births, and early enrollment into the immunization program continue to show a positive association with immunization uptake, even during a challenging lockdown., 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 © 2020 Elsevier Ltd. All rights reserved.)

Background: Inability to track children's vaccination history coupled with parents' lack of awareness of vaccination due dates compounds the problem of low immunization coverage and timeliness in developing countries. We evaluated the impact of two types of silicone immunization reminder bracelets for children in improving immunization coverage and timeliness of Pentavalent-3 and the Measles-1 vaccines., Methods: Children < 3 months were enrolled in either of the 2 intervention groups (Alma Sana Bracelet Group and Star Bracelet Group) or the Control group. Children in the intervention groups were provided the two different bracelets at the time of recruitment. Each time the child visited the immunization center, a hole was perforated in the silicone bracelet to denote vaccine administration. Each child was followed up till administration of Measles-1 vaccine or till 12 months of age (if they did not come to the center for vaccination). Data was analyzed using the intention-to-treat population between groups. The unadjusted and adjusted Risk Ratios (RR) and 95% confidence interval (CI) for Pentavalent-3 and Measles-1 coverage at 12 months of age were estimated through bivariate and multivariate analysis. Time-to-Pentavalent-3 and Measles-1 immunization curves were calculated using the Kaplan-Meier method., Results: A total of 1,445 children were enrolled in the study between July 19, 2017 and October 10, 2017. Baseline characteristics among the three groups were similar. Up-to-date coverage for the Pentavalent-3 /Measles-1 vaccine at 12 months of age was 84.6%/72.0%, 85.4%/70.5% and 83.0%/68.5% in Alma Sana Bracelet group, Star Bracelet group and Control group respectively but the differences were not statistically significant. In the multivariate analysis, neither the Alma Sana bracelet (adjusted RR = 1.01; 95% CI: 0.96-1.06), (adjusted RR: 1.05; 95% CI: 0.97-1.13) nor the Star bracelet (adjusted RR = 1.01; 95% CI: 0.96-1.06) (adjusted RR: 1.03; 95% CI: 0.95-1.11) was significantly associated with Pentavalent-3 vaccination or Measles-1 vaccination., Conclusion: Although we did not observe any significant impact of the bracelets on improved immunization coverage and timeliness, our findings add to the existing literature on innovative, low cost reminders for health and make several suggestions for enhancing practical implementation of these tools., Trial Registration: ClinicalTrials.gov NCT03310762 . Retrospectively Registered on October 16, 2017.

Background: Inability to track children's vaccination history coupled with parents' lack of awareness of vaccination due dates compounds the problem of low immunization coverage and timeliness in developing countries. Traditional Reminder/Recall (RR) interventions such as paper-based immunization cards or mHealth based platforms do not yield optimal results in resource-constrained settings. There is thus a need for a low-cost intervention that can simultaneously stimulate demand and track immunization history to help reduce drop-outs and improve immunization coverage and timeliness. The objective of this study is to evaluate the impact of low-cost vaccine reminder and tracker bracelets for improving routine childhood immunization coverage and timeliness in Pakistani children under 2 years of age., Methods: The study is an individually randomized, three-arm parallel Randomized Controlled Trial with two intervention groups and one control group. Infants in the two intervention groups will be given two different types of silicone bracelets at the time of recruitment, while infants in the control group will not receive any intervention. The two types of bracelets consist of symbols and/or numbers to denote the EPI vaccination schedule and each time the child will come for vaccination, the study staff will perforate a hole in the appropriate symbol to denote vaccine administration. Therefore, by looking at the bracelet, caregivers will be able to see how many vaccines have been received. Our primary outcome measure is the increase in coverage and timeliness of Pentavalent-3/PCV-3/Polio-3 and Measles-1 vaccine in the intervention versus control groups. A total of 1446 participants will be recruited from 4 Expanded Program on Immunization (EPI) centers in Landhi Town, Karachi. Each enrolled child will be followed up till the Measles-1 vaccine is administered, or till eleven months have elapsed since enrolment., Discussion: Participant recruitment commenced on July 19, 2017, and was completed on October 10, 2017. Proposed duration of the study is 18 months and expected end date is December 1, 2018. This study constitutes one of the first attempts to rigorously evaluate an innovative, low-cost vaccine reminder bracelet., Trial Registration: ClinicalTrials.gov NCT03310762 . Retrospectively Registered on October 16, 2017.

Tuning the adsorption and desorption rate constant of proteins is a hot topic for broad range of applications in biotechnology and medical science; especially controlled drug delivery and protein separation are the prominent examples in this field. In this study, Gel-MNPs (Poly(N-isopropylacrylamid) PNIPA-Magnetic Nano Particles) composites were synthesized by using different concentrations of monomer and cross-linker to observe the effect of gel morphology on the adsorption and desorption rate constant and kinetics of lysozyme protein. The synthesized composites were characterized by XRD, VSM, SEM and FTIR techniques. The characterization results showed that superparamagnetic Fe 3 O 4 nanoparticles were synthesized inside the temperature sensitive PNIPA hydrogels. Fluorescence measurements were performed for monitoring the adsorption and desorption of lysozyme through Gel-MNPs composites. The adsorption process obeyed pseudo first and second order kinetic models at above and below the lower critical solution temperature (LCST) of PNIPA gels. Pseudo first order kinetic indicates physisorption, between the lysozyme and composite material for both adsorption and desorption. The adsorption was effective below LCST, but it was not effective at a temperatures higher than LCST; the adsorption rate constant was found between 0.59 and 0.082 s -1 at 22 °C. On the other side, samples show well desorption ability at the temperature above than LCST; the desorption rate constant was found between 0.080 and 0.092 s -1 at 45 °C. Moreover, the effects of monomer and cross-linker concentration on the adsorption and desorption kinetics are determined and discussed at the end of the manuscript., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Endotracheal intubation is one of the basic prerequisites of general anaesthesia. Recovery of patients is delayed due to the development of post-operative nausea, vomiting, sore throat and shivering. This study was conducted to determine role of dexamethasone for improved recovery of patients., Methods: This randomized controlled trial was performed in the Department of Anaesthesia, Ayub Teaching Hospital, Abbottabad from June to November 2018. One hundred and twenty-two consenting patients of both genders, aged between 18-60 years, American Society of Anaesthesiologists (ASA) I and II, scheduled for general surgeries of 60-180 minutes duration under general anaesthesia were included. Patients with long duration surgeries, anticipated difficult airways, nasogastric tube in situ, upper respiratory tract infections, on steroid therapy and critically ill and emergency surgeries were excluded. They were randomly allocated into two groups by lottery method as dexamethasone (group A, n=61) or Placebo (group B, n=61). Postoperative nausea, vomiting, sore throat was observed at 2, 12 and 24 hours, shivering was observed at 2 hours only and patient satisfaction at 24 hours post-operatively., Results: Group A patients had statistically proven better outcomes at 2, 12 and 24 hours for post-operative sore throat, nausea and vomiting, shivering was controlled in 24.5% p-value (0.006). Patient satisfaction was found in 83.6% of group A patients.., Conclusions: Thus, dexamethasone is effective drug for prevention of postoperative nausea, vomiting, sore throat and shivering in general surgical procedures thus improving patient satisfaction and their early discharge.

Background: Parents have reported that they want to learn how to reduce pain in infants during vaccinations. Our objective was to compare different levels of intensity of postnatal education about pain mitigation on parental self-reported use of interventions at future infant vaccinations., Methods: We conducted a longitudinal, 3-group parallel, add-on, randomized controlled trial on the postnatal ward of a hospital. New mothers, unaware of the hypothesis, were randomly assigned to 1 of 3 intervention groups and 3 follow-up groups (i.e., 9 groups, 3 × 3). The 3 intervention groups were control (general immunization information), pain pamphlet (pain mitigation information), and pain pamphlet and pain video (pain mitigation information). Both pain mitigation education groups also received general immunization information. The 3 follow-up groups were 2-, 4- and 6-month infant vaccinations. Mothers reported use of breastfeeding, sucrose and topical anesthetics during infant vaccinations in a telephone survey., Results: Of 3420 participants, follow-up was available for 2549 (75%): 36.1%, 34.2% and 29.7% reported on pain mitigation practices at 2-, 4- and 6-month vaccinations, respectively ( p = 0.9). Maternal characteristics did not differ ( p > 0.05): mean age, 33.6 years; 58% were primipara. Utilization of any intervention (breastfeeding, sucrose or topical anesthetics) was 53.2%, 61.4% and 63.0% for control, pain pamphlet, and pain pamphlet and pain video groups, respectively ( p < 0.001); both pain education groups had higher utilization than the control group, but did not differ from one another. Uptake differed among intervention groups at 2 and 4 months but not at 6 months., Interpretation: Hospital-based postnatal education increased parental use of pain interventions at infant vaccinations and can be added to existing education., Trial Registration: ClinicalTrials.gov, no. NCT01937143., Competing Interests: Competing interests: Anna Taddio has received a research grant from Pfizer (investigator initiated) and supplies for a separate study from Natus Medical and Ferndale Pharma Group. Lucie Bucci has received research grants from Pfizer Canada, Merck Canada, Sanofi Pasteur, GlaxoSmithKline and Seqirus Canada. No other competing interests were declared., (© 2018 Joule Inc. or its licensors.)

Background: Despite the availability of free routine immunizations in low- and middle-income countries, many children are not completely vaccinated, vaccinated late for age, or drop out from the course of the immunization schedule. Without the technology to model and visualize risk of large datasets, vaccinators and policy makers are unable to identify target groups and individuals at high risk of dropping out; thus default rates remain high, preventing universal immunization coverage. Predictive analytics algorithm leverages artificial intelligence and uses statistical modeling, machine learning, and multidimensional data mining to accurately identify children who are most likely to delay or miss their follow-up immunization visits., Objective: This study aimed to conduct feasibility testing and validation of a predictive analytics algorithm to identify the children who are likely to default on subsequent immunization visits for any vaccine included in the routine immunization schedule., Methods: The algorithm was developed using 47,554 longitudinal immunization records, which were classified into the training and validation cohorts. Four machine learning models (random forest; recursive partitioning; support vector machines, SVMs; and C-forest) were used to generate the algorithm that predicts the likelihood of each child defaulting from the follow-up immunization visit. The following variables were used in the models as predictors of defaulting: gender of the child, language spoken at the child's house, place of residence of the child (town or city), enrollment vaccine, timeliness of vaccination, enrolling staff (vaccinator or others), date of birth (accurate or estimated), and age group of the child. The models were encapsulated in the predictive engine, which identified the most appropriate method to use in a given case. Each of the models was assessed in terms of accuracy, precision (positive predictive value), sensitivity, specificity and negative predictive value, and area under the curve (AUC)., Results: Out of 11,889 cases in the validation dataset, the random forest model correctly predicted 8994 cases, yielding 94.9% sensitivity and 54.9% specificity. The C-forest model, SVMs, and recursive partitioning models improved prediction by achieving 352, 376, and 389 correctly predicted cases, respectively, above the predictions made by the random forest model. All models had a C-statistic of 0.750 or above, whereas the highest statistic (AUC 0.791, 95% CI 0.784-0.798) was observed in the recursive partitioning algorithm., Conclusions: This feasibility study demonstrates that predictive analytics can accurately identify children who are at a higher risk for defaulting on follow-up immunization visits. Correct identification of potential defaulters opens a window for evidence-based targeted interventions in resource limited settings to achieve optimal immunization coverage and timeliness., (©Subhash Chandir, Danya Arif Siddiqi, Owais Ahmed Hussain, Tahira Niazi, Mubarak Taighoon Shah, Vijay Kumar Dharma, Ali Habib, Aamir Javed Khan. Originally published in JMIR Public Health and Surveillance (http://publichealth.jmir.org), 04.09.2018.)

This study investigates the mercury (Hg) contaminations in soil and foodstuffs along the artisanal gold mining areas, Gilgit-Baltistan Province, Pakistan. For this purpose, soils were analyzed for Hg concentrations and evaluated for the enrichment/contamination using enrichment factor or contamination factors (CF). The CF values ranged from 18.9 to 153 showed multifold higher levels of Hg contamination as compared to background or reference site. Foodstuffs including vegetables, seeds or grains and fish muscles showed Hg accumulation. Results revealed that Hg concentrations in foodstuffs were higher than the critical human health value set by European Union. The Hg in foodstuffs was consumed and, therefore, evaluated for the risk assessment indices using the daily intake (DI) and health risk index (HRI) for the exposed human population both children and adults. Results of this study revealed that cumulative HRI values through foodstuffs consumption were <1 (within safe limit), but if the current practices continued, then the Hg contamination could pose potential threat to exposed population in near future.

In this study, differently coated superparamagnetic Fe 3 O 4 (magnetite) nanoparticles were synthesized, characterized and used for lysozyme (Ly) and bovine serum albumin (BSA) adsorption. SiO 2 , carbon nanotubes (CNTs) and graphene were used for covering the readily synthesized magnetite nanoparticles to elucidate the effect of cover layer on the protein adsorption kinetics and capacities of nanostructure. XRD, FTIR, AFM, SEM, VSM and fluorescence measurements were used for the characterization of the samples and investigating the adsorption kinetics of Ly and BSA by these nanoparticles. The average particle size of the Fe 3 O 4 nanoparticles are approximately found as 10nm and VSM measurement shows that the Fe 3 O 4 particles have superparamagnetic behavior with no hysteresis and remnant. The adsorption kinetic of proteins on nanosized material is followed via fluorescence method. All the nanostructures with different cover layers obey pseudo first order kinetics and SiO 2 coated nanoparticles show the fastest kinetics and capabilities for Ly and BSA adsorption., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Rapid urbanization and industrialization result in serious contamination of soil with toxic metals such as lead (Pb) and cadmium (Cd), which can lead to deleterious health impacts in the exposed population. This study aimed to investigate Pb and Cd contamination in agricultural soils and vegetables in five different agricultural sites in Pakistan. The metal transfer from soil-to-plant, average daily intake of metals, and health risk index (HRI) were also characterized. The Pb concentrations for all soils were below the maximum allowable limits (MAL 350 mg kg -1 ) set by State Environmental Protection Administration of China (SEPA), for soils in China, while Cd concentrations in the soils were exceeded the MAL (61.7-73.7% and 4.39-34.3%) set by SEPA (0.6 mg kg - ), and European Union, (1.5 mg kg -1 ) respectively. The mean Pb concentration in edible parts of vegetables ranged from 1.8 to 11 mg kg -1 . The Pb concentrations for leafy vegetables were higher than the fruiting and pulpy vegetables. The Pb concentrations exceeded the MAL (0.3 mg kg -1 ) for leafy vegetables and the 0.1 mg kg -1 MAL for fruity and rooty/tuber vegetables set by FAO/WHO-CODEX. Likewise, all vegetables except Pisum sativum (0.12 mg kg -1 ) contained Cd concentrations that exceeded the MAL set by SEPA. The HRI values for Pb and Cd were <1 for both adults and children for most of the vegetable species except Luffa acutangula, Solanum lycopersicum, Benincasa hispada, Momordi charantia, Aesculantus malvaceae, Cucumis sativus, Praecitrullus fistulosus, Brassica oleracea, and Colocasia esculanta for children. Based on these results, consumption of these Pb and Cd contaminated vegetables poses a potential health risk to the local consumers., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Clinical video telehealth provides a means for increasing access to psychotherapy. Insomnia is prevalent, is associated with a number of negative sequelae, and can be effectively managed with cognitive behavioral treatment of insomnia (CBT-I). Telehealth technologies can provide a means for increasing access to CBT-I., Materials and Methods: The Tele-Insomnia program is a Veterans Health Administration (VHA) initiative in which CBT-I is delivered in a group format by telehealth. Veterans received six weekly sessions of group CBT-I, completing the Insomnia Severity Index (ISI) and daily sleep diaries throughout treatment. Paired-samples t-tests were used to examine differences in each measure from the first to the last session of treatment., Results: There were statistically and clinically significant improvements in the ISI and all sleep diary variables with the exception of total sleep time. Video quality was excellent, and there were few connectivity problems., Conclusions: Clinical video telehealth technology can be used to deliver group CBT-I in a manner that produces clinically significant improvement. This model is scalable and has been used to develop a national clinical telehealth program.

Human exposures to arsenic (As) through different pathways (dietary and non-dietary) are considered to be one of the primary worldwide environmental health risks to humans. This study was conducted to investigate the presence of As in soil and vegetable samples collected from agricultural lands located in selected southern districts of Khyber Pakhtunkhwa (KPK) Province, Pakistan. We examined the concentrations of total arsenic (TAs), organic species of As such as monomethylarsonic acid (MMA) and dimethylarsonic acid (DMA), and inorganic species including arsenite (AsIII) and arsenate (AsV) in both soil and vegetables. The data were used to determine several parameters to evaluate human health risk, including bioconcentration factor (BCF) from soil to plant, average daily intake (ADI), health risk index (HRI), incremental lifetime cancer risk (ILTCR), and hazard quotient (HQ). The total As concentration in soil samples of the five districts ranged from 3.0-3.9mgkg(-1), exhibiting minimal variations from site to site. The mean As concentration in edible portions of vegetable samples ranged from 0.03-1.38mgkg(-1). It was observed that As concentrations in 75% of the vegetable samples exceeded the safe maximum allowable limit (0.1mgkg(-1)) set by WHO/FAO. The highest value of ADI for As was measured for Momordica charantia, while the lowest was for Allium chinense. The results of this study revealed minimal health risk (HI<1) associated with consumption of vegetables for the local inhabitants. The ILTCR values for inorganic As indicated a minimal potential cancer risk through ingestion of vegetables. In addition, the HQ values for total As were <1, indicating minimal non-cancer risk., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Background: Examine interactive relations of race and poverty status with cardiovascular disease (CVD) risk factors in a socioeconomically diverse sample of urban-dwelling African American (AA) and White adults., Methods: Participants were 2,270 AAs and Whites (57% AA; 57% female; ages 30-64 years) who completed the first wave of the Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study. CVD risk factors assessed included body mass index (BMI), waist circumference (WC), total cholesterol (TC), high- and low-density lipoprotein cholesterol (HDL-C, LDL-C), triglycerides (TG), glycated hemoglobin (HbA1c), high-sensitivity C-reactive protein (CRP), and systolic, diastolic, and pulse pressure (SBP, DBP, PP). Interactive and independent relations of race, poverty status, and sex were examined for each outcome via ordinary least squares regression adjusted for age, education, literacy, substance use, depressive symptoms, perceived health care barriers, medical co-morbidities, and medications., Results: Significant interactions of race and poverty status (p's < .05) indicated that AAs living in poverty had lower BMI and WC and higher HDL-C than non-poverty AAs, whereas Whites living in poverty had higher BMI and WC and lower HDL-C than non-poverty Whites. Main effects of race revealed that AAs had higher levels of HbA1c, SBP, and PP, and Whites had higher levels of TC, LDL-C and TG (p's < .05)., Conclusion: Poverty status moderated race differences for BMI, WC, and HDL-C, conveying increased risk among Whites living in poverty, but reduced risk in their AA counterparts. Race differences for six additional risk factors withstood extensive statistical adjustments including SES indicators.

The present study was conducted to investigate the physico-chemical characteristics in drinking water of Mardan District, Pakistan. Furthermore, water quality was evaluated for the risk assessment of arsenic and heavy metals (HMs) and their contamination sources. Representative groundwater samples of shallow and deep sources were collected in the study area. These samples were analyzed for physical parameters, anions, light metals (LMs) and HMs. Results were compared with the drinking water guideline values set by the World Health Organization and the US Environmental Protection Agency. Average concentrations of anions, LMs and HMs were found within the maximum allowable contaminant levels except for bicarbonates, Fe, Cu, and Pb. Results revealed that hazard quotients >1 were observed for shallow groundwater for 10% samples only, suggesting potential health risk from water consumption. Correlation analysis and principal component analysis showed a relationship among various physico-chemical parameters in both shallow and deep groundwater. Statistical analyses suggested the geogenic and anthropogenic sources for possible enhancement of various physico-chemical parameters in the aquifer system of the study area.

This study investigates the drinking water (groundwater and surface water) quality and potential risk assessment along mafic and ultramafic rocks in the Swat district of Khyber Pakhtunkhwa Provence, Pakistan. For this purpose, 82 groundwater and 33 surface water samples were collected and analyzed for physico-chemical parameters. Results showed that the majority of the physico-chemical parameters were found to be within the drinking water guidelines set by the World Health Organization. However, major cationic metals such as magnesium (Mg), and trace metals (TM) including iron (Fe), manganese (Mn), nickel (Ni), chromium (Cr) and cobalt (Co) showed exceeded concentrations in 13%, 4%, 2%, 20%, 20% and 55% of water samples, respectively. Health risk assessment revealed that the non-carcinogenic effects or hazard quotient values through the oral ingestion pathway of water consumption for the TM (viz., Fe, Cr and Mn) were found to be greater than 1, could result in chronic risk to the exposed population. Results of statistical analyses revealed that mafic and ultramafic rocks are the main sources of metal contamination in drinking water, especially Ni and Cr. Both Ni and Cr have toxic health effects and therefore this study suggests that contaminated sites should be avoided or treated for drinking and domestic purposes.

This study aimed to investigate the lead (Pb) and cadmium (Cd) concentrations in the soil and plants (medicinal and fodder) grown in chromite mining-affected areas, Northern Pakistan. Soil and plant samples were collected and analyzed for Pb and Cd concentrations using atomic absorption spectrometer. Soil pollution load indices (PLIs) were greater than 2 for both Cd and Pb, indicating high level of contamination in the study area. Furthermore, Cd concentrations in the soil surrounding the mining sites exceeded the maximum allowable limit (MAL) (0.6 mg kg(-1)), while the concentrations of Pb were lower than the MAL (350 mg kg(-1)) set by State Environmental Protection Administration (SEPA) for agriculture soil. The concentrations of Cd and Pb were significantly higher (P < 0.001) in the soil of the mining-contaminated sites as compared to the reference site, which can be attributed to the dispersion of toxic heavy metals, present in the bed rocks and waste of the mines. The concentrations of Pb and Cd in majority of medicinal and fodder plant species grown in surrounding areas of mines were higher than their MALs set by World Health Organization/Food Agriculture Organization (WHO/FAO) for herbal (10 and 0.3 mg kg(-1), respectively) and edible (0.3 and 0.2 mg kg(-1), respectively) plants. The high concentrations of Cd and Pb may cause contamination of the food chain and health risk.

Background: We sought to assess the availability of technology-related equipment for trauma care in Nepal and to identify factors leading to optimal availability as well as deficiencies. We also sought to identify potential solutions addressing the deficits in terms of health systems management and product development., Methods: Thirty-two items for large hospitals and sixteen items for small hospitals related to the technological aspect of trauma care were selected from the World Health Organization's Guidelines for Essential Trauma Care for the current study. Fifty-six small and 29 large hospitals were assessed for availability of these items in the study area. Site visits included direct inspection and interviews with administrative, clinical, and bioengineering staff., Results: Deficiencies of many specific items were noted, including many that were inexpensive and which could have been easily supplied. Shortage of electricity was identified as a major infrastructural deficiency present in all parts of the country. Deficiencies of pulse oximetry and ventilators were observed in most hospitals, attributed in most part to frequent breakdowns and long downtimes because of lack of vendor-based service contracts or in-house maintenance staff. Sub-optimal oxygen supply was identified as a major and frequent deficiency contributing to disruption of services. All equipment was imported except for a small percent of suction machines and haemoglobinometers., Conclusions: The study identified a range of items which were deficient and whose availability could be improved cost-effectively and sustainably by better planning and organisation. The electricity deficit has been dealt with successfully in a few hospitals via direct feeder lines and installation of solar panels; wider implementation of these methods would help solve a large portion of the technological deficiencies. From a health systems management view-point, strengthening procurement and stocking of low cost items especially in remote parts of the country is needed. From a product development view-point, there is a need for robust pulse-oximeters and ventilators that are lower cost and which have longer durability and less need for repairs. Increasing capabilities for local manufacture is another potential method to increase availability of a range of equipment and spare parts., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objectives: To explore whether there are differences in sleep duration between blacks and whites residing in similar urban neighborhoods and examine whether the relationship between sleep durations and sociodemographic and/or health indices are consistent for blacks and whites., Methods: A total of 1,207 participants from the Healthy Aging in Neighborhoods of Disparities across the Life Span study (age: mean = 47, standard deviation = 8.74). Sleep duration was assessed by a self-report of hours of nightly sleep in the past month. Sociodemographic measures included age, sex, education, poverty status, and perceived neighborhood disorder. Health status was assessed using measures of vigilance, depression, perceived stress, coronary artery disease, diabetes, blood pressure, and inflammation., Results: There were no significant racial group differences in sleep duration. Whites, however, were more likely than blacks to report sleep durations of <6/6-7 hr compared with >7 hr with increasing stress and education levels. Blacks were more likely than whites to report short sleep durations (i.e., 6-7 hr vs. >7 hr of sleep) with increasing inflammation levels., Discussion: Although racial disparities in sleep duration are minimized when the environment is equivalent between blacks and whites, the underlying demographic and health explanations for short sleep durations may vary between whites and blacks., (Published by Oxford University Press on behalf of the Gerontological Society of America 2013.)

Magnetite nanoparticles were successfully synthesized and effectively employed as heterogeneous catalyst for hydrogenation of ketone moiety to alcohol moiety by NaBH4 under the microwave radiation process. The improvement was achieved in percent recovery of isopropyl alcohol by varying and optimizing reaction time, power of microwave radiations and amount of catalyst. The catalytic study revealed that acetone would be converted into isopropyl alcohol (IPA) with 99.5% yield in short period of reaction time, using 10 μg of magnetite NPs (Fe3O4). It was observed that the catalytic hydrogenation reaction, followed second-order of reaction and the Langmuir-Hinshelwood kinetic mechanism, which elucidated that both reactants get adsorb onto the surface of silica coated magnetite nanocatalyst to react. Consequently, the rate-determining step was the surface reaction of acetone and sodium borohydride. The current study revealed an environment friendly conversion of acetone to IPA on the basis of its fast, efficient, and highly economical method of utilization of microwave irradiation process and easy catalyst recovery.

Background: We sought to assess the status of availability of technology for trauma care in a state in India and to identify factors contributing to both adequate levels of availability and to deficiencies. We also sought to identify potential solutions to deficiencies in terms of health system management and product development., Methods: Thirty-two technology-related items were selected from the World Health Organization's Guidelines for Essential Trauma Care. The status of these items was assessed at 43 small and large hospitals in Gujarat State. Site visits utilized direct inspection and interviews with administrative, clinical, and bioengineering staff., Results: Many specific individual items could be better supplied, including many that were very low cost (e.g., chest tubes). Many deficiencies arose because of mismatch of resources, such as availability of equipment in the absence of personnel trained to use it. Several locally manufactured items were fairly well supplied: pulse oximetry, image intensification, and X-ray machines. Ventilators were often deficient because of inadequate numbers of units and frequent breakdowns., Conclusions: Availability of a range of lower-cost items could be improved by better organization and planning, such as: better procurement and stock management; eliminating mismatch of resources, including optimizing training for use of existing resources; and by strengthening service contracts and in-house repair capabilities. From a product development viewpoint, there is a need for lower cost, more durable, and easier to repair ventilators. Promoting increased capacity for local manufacturing should also be considered as a potential method to decrease cost and increase availability of a range of equipment.

Several anthropogenic and natural sources are considered as the primary sources of toxic metals in the environment. The current study investigates the level of heavy metals contamination in the flora associated with serpentine soil along the Mafic and Ultramafic rocks northern-Pakistan. Soil and wild native plant species were collected from chromites mining affected areas and analyzed for heavy metals (Cr, Ni, Fe, Mn, Co, Cu and Zn) using atomic absorption spectrometer (AAS-PEA-700). The heavy metal concentrations were significantly (p < 0.01) higher in mine affected soil as compared to reference soil, however Cr and Ni exceeded maximum allowable limit (250 and 60 mg kg(-1), respectively) set by SEPA for soil. Inter-metal correlations between soil, roots and shoots showed that the sources of contamination of heavy metals were mainly associated with chromites mining. All the plant species accumulated significantly higher concentrations of heavy metals as compared to reference plant. The open dumping of mine wastes can create serious problems (food crops and drinking water contamination with heavy metals) for local community of the study area. The native wild plant species (Nepeta cataria, Impatiens bicolor royle, Tegetis minuta) growing on mining affected sites may be used for soil reclamation contaminated with heavy metals.

Background: The associations between nutritional biomarkers and measures of sleep quantity and quality remain unclear., Methods: Cross-sectional data from the National Health and Nutrition Examination Surveys (NHANES) 2005-2006 were used. We selected 2,459 adults aged 20-85, with complete data on key variables. Five sleep measures were constructed as primary outcomes: (A) Sleep duration; (B) Sleep disorder; (C) Three factors obtained from factor analysis of 15 items and labeled as "Poor sleep-related daytime dysfunction" (Factor 1), "Sleepiness" (Factor 2) and "Sleep disturbance" (Factor 3). Main exposures were serum concentrations of key nutrients, namely retinol, retinyl esters, carotenoids (α-carotene, β-carotene, β-cryptoxanthin, lutein+zeaxanthin, lycopene), folate, vitamin B-12, total homocysteine (tHcy), vitamin C, 25-hydroxyvitamin D (25(OH)D) and vitamin E. Main analyses consisted of multiple linear, logistic and multinomial logit models., Results: Among key findings, independent inverse associations were found between serum vitamin B-12 and sleep duration, 25(OH)D and sleepiness (as well as insomnia), and between folate and sleep disturbance. Serum total carotenoids concentration was linked to higher odds of short sleep duration (i.e. 5-6 h per night) compared to normal sleep duration (7-8 h per night)., Conclusions: A few of the selected serum nutritional biomarkers were associated with sleep quantity and quality. Longitudinal studies are needed to ascertain temporality and assess putative causal relationships.

Pancreatic pseudocysts are the most common cystic lesions of the pancreas and may complicate acute pancreatitis, chronic pancreatitis, or pancreatic trauma. While the majority of acute pseudocysts resolve spontaneously, few may require drainage. On the other hand, pancreatic cystic tumors, which usually require extirpation, may disguise as pseudocysts. Hence, the distinction between the two entities is crucial for a successful outcome. We conducted this study to highlight the fundamental differences between pancreatic pseudocysts and cystic tumors so that relevant management plans can be devised. We reviewed the data of patients with pancreatic cystic lesions that underwent intervention between June 2007 and December 2010 in our hospital. We identified 9 patients (5 males and 4 females) with a median age of 40 years (range, 30-70 years). Five patients had pseudocysts, 2 had cystic tumors, and 2 had diseases of undetermined pathology. Pancreatic pseudocysts were treated by pseudocystogastrostomy in 2 cases and percutaneous drainage in 3 cases. One case recurred after percutaneous drainage and required pseudocystogastrostomy. The true pancreatic cysts were serous cystadenoma, which was treated by distal pancreatectomy, and mucinous cystadenocarcinoma, which was initially treated by drainage, like a pseudocyst, and then by distal pancreatectomy when its true nature was revealed. We conclude that every effort should be exerted to distinguish between pancreatic pseudocysts and cystic tumors of the pancreas to avoid the serious misjudgement of draining rather than extirpating a pancreatic cystic tumor. Additionally, percutaneous drainage of a pancreatic pseudocyst is a useful adjunct that may substitute for surgical drainage.

Muslims throughout the world observe dawn to dusk fast in the month of Holy Ramadan. This study aims to investigate the effect of fasting on serum lithium levels in an animal model under typical conditions of Ramadan. Animals were categorized into oral and intraperitoneal groups. Each group was divided into fasting and non fasting groups along with their controls having six animals each. Mean serum lithium levels of non-fasting and fasting rats were assessed. Mean serum lithium levels of oral non-fasting rats was 0.23±0.004 mequiv/L, (n=6) compared to oral fasting rats 0.20+0.002 mequiv/L, (n=6) mean difference=0.003. The mean difference between mean serum lithium level of intraperitoneal non fasting (0.246±0.015 mequiv/L, n = 6) and intraperitoneal fasting rats (0.206±0.020 mequiv/L, n = 6) was 0.02. These differences were statistically non significant (P>0.05). The mean serum lithium is not grossly affected by fasting in rats under 25ºC and fasting for almost 12 hours which is consistent with a previous clinical study. Lithium can be used by fasting bipolar patients but, will require careful supervision.

Background: Longitudinal associations between depressive symptoms and blood pressure have been inconsistent. Most studies have examined incident hypertension as an outcome, and few have examined effect modification., Methods: This study examined moderating influences of sex and age on coincident trajectories of depressive symptoms and blood pressure among 2,087 participants from the Baltimore Longitudinal Study of Aging (aged 19-97 years; 53% men; 74% white). Participants underwent clinical blood pressure measurement and completed the Center for Epidemiological Studies-Depression (CES-D) scale on up to 14 occasions (mean = 3.8; SD = 2.6) over up to 29 years (mean = 7.8; SD = 6.4). CES-D was log-transformed (CES-D(log)) for analyses., Results: Mixed-effects regression revealed that prospective relations of CES-D(log) to diastolic blood pressure differed by age in women (b = 0.095; P = 0.001) but not men; greater CES-D(log) attenuated the expected age-related decline in diastolic blood pressure. Across all testing sessions, greater CES-D(log) was associated significantly with higher average systolic blood pressure for women (b = 2.238; P = 0.006) but not men. Age-stratified analyses showed that greater CES-D(log) was associated significantly with higher average systolic (b = 3.348; P = 0.02) and diastolic (b = 1.730; P < 0.03) blood pressure for older adults (≥58.8 years at first visit). In the younger age cohort, sex moderated the relation of CES-D(log) to systolic blood pressure (b = -3.563; P = 0.007); greater CES-D(log) in women, but lesser CES-D(log) in men, was associated with higher systolic blood pressure., Conclusions: Results demonstrate sex and age differences in the relation between depressive symptoms and blood pressure. Findings suggest the potential importance of preventing, detecting, and lowering depressive symptoms to prevent hypertension among women and older adults.

This study investigates the wild plant species for their phytoremediation potential of macro and trace metals (MTM). For this purpose, soil and wild plant species samples were collected along mafic and ultramafic terrain in the Jijal, Dubair, and Alpuri areas of Kohistan region, northern Pakistan. These samples were analyzed for the concentrations of MTM (Na, K, Ca, Mg, Fe, Mn, Pb, Zn, Cd, Cu, Cr, Ni, and Co) using atomic absorption spectrometer (AAS-PEA-700). Soil showed significant (P < .001) contamination level, while plants had greater variability in metal uptake from the contaminated sites. Plant species such as Selaginella jacquemontii, Rumex hastatus, and Plectranthus rugosus showed multifold enrichment factor (EF) of Fe, Mn, Cr, Ni, and Co as compared to background area. Results revealed that these wild plant species have the ability to uptake and accumulate higher metals concentration. Therefore, these plant species may be used for phytoremediation of metals contaminated soil. However, higher MTM concentrations in the wild plant species could cause environmental hazards in the study area, as selected metals (Fe, Mn, Cr, Ni, Co, and Pb) have toxicological concerns.

Introduction: Intra-abdominal hemorrhage after open heart surgery is very uncommon in routine clinical practice. There are case reports of having bleeding from spleen or liver after starting low molecular weight heparin (LMWH) postoperatively., Presentation of Case: Our patient is a 58-year-old man with mitral valve regurgitation, who underwent mitral valve repair and developed intra-abdominal hemorrhage 8h after open heart surgery. The exploratory laparotomy revealed the source of bleeding from ruptured sub-capsular liver hematoma and oozing from raw areas of the liver surface. Liver packing was done to control the bleeding., Discussion: The gastrointestinal complications after open heart surgery are rare and spontaneous bleeding from spleen has been reported. This is the first case from our hospital to have intra-abdominal hemorrhage after open heart surgery., Conclusion: Spontaneous bleeding from liver is a possible complication after open heart surgery. We submit the case for the academic interest and to discuss the possible cause of hemorrhage., (Copyright © 2013 The Authors. Published by Elsevier Ltd.. All rights reserved.)

This study was conducted to investigate the concentrations of heavy metals in soil and vegetables, and human health risks through ingestion of contaminated vegetables. Soil and vegetable samples were collected from different locations in Gilgit, northern Pakistan, and analyzed for Cd, Cu, Ni, Pb and Zn. Plant transfer factors (PTF), daily intake of metals (DIM) and health risk index (HRI) were also calculated. The concentrations of Cd, Cu and Zn exceeded their respective permissible limits in soil samples. The highest concentrations of Cu, Ni, Pb and Zn were observed in the edible parts of Malva neglecta, Brassica oleracea, Mintha sylvestris and Brassica campestris, respectively. PTF values were lower for all the selected heavy metals, except for Cd. Furthermore, the HRI values were within the safe limit (<1) except for Pb; therefore, the health risks of metals through ingestion of vegetables were of great concern in the study area., (Copyright © 2010 Elsevier Inc. All rights reserved.)