Tertiary Hospitals In Pakistan Research Articles

KNOWLEDGE, ATTITUDE AND SKILLS OF NURSING STUDENTS REGARDING EVIDENCE BASED PRACTICE IN TERTIARY HOSPITALS

Evidence-based practice (EBP) is essential for improving healthcare outcomes by integrating clinical expertise, patient preferences, and research evidence. However, the adoption of EBP remains challenging, particularly in developing countries like Pakistan. Objective: To assess the knowledge, attitudes, and skills of nursing students regarding EBP in tertiary hospitals in Pakistan. Methods: A descriptive cross-sectional study was conducted among 150 nursing students using purposive sampling. Data were collected through a validated questionnaire and analyzed using SPSS version 26. Descriptive statistics were used to summarize demographic variables and EBP-related responses. Results: The majority of participants (46.2%) were aged 26-30 years, and most held a BSN qualification (43.1%). Knowledge about EBP was limited, with only 28.5% correctly defining it and 46.9% recognizing clinical practice guidelines as the most useful knowledge source. Attitudes were predominantly negative, with only 26.2% agreeing that EBP aids clinical decision-making. Skills assessment revealed that while 66.2% were confident in evaluating scientific articles, only 34.5% could formulate clinical questions for evidence searching. Conclusion: The findings highlight substantial gaps in EBP-related competencies among nursing students in Pakistan. Curriculum enhancements, mentorship programs, and improved access to research resources are urgently needed to address these deficiencies and promote the integration of EBP into nursing practice.

Incidence of colistin heteroresistance among carbapenem-resistant Acinetobacter baumannii clinical isolates in a tertiary care hospital in Pakistan.

The emergence of colistin-resistant and heteroresistant strains of carbapenem-resistant Acinetobacter baumannii (CRAB) complicates treatment and exacerbates the global health crisis of drug-resistant bacteria. This study aims to investigate the incidence and clinical implications of colistin heteroresistance in carbapenem-resistant Acinetobacter baumannii isolates from a tertiary hospital in Pakistan. A total of 130 CRAB isolates were collected from December 2022 to December 2023. Colistin susceptibility was assessed using broth microdilution, and heteroresistance was detected through population analysis profiling. Heteroresistance (HR) was identified in 31.5% (41/130) of the isolates, while 7.7% were colistin-resistant, despite initial susceptibility indicated by broth microdilution. Clinical data revealed that HR was associated with significant 14-day clinical failure but not with 30-day all-cause mortality. Heteroresistant strains showed extensive multidrug resistance, posing a serious threat to effective treatment. The study highlights the critical need for accurate detection of colistin HR to prevent treatment failure and improve patient outcomes. The prevalence of colistin HR underscores the necessity for revised diagnostic and treatment strategies in Pakistan, emphasizing the importance of recognizing and addressing this emerging threat in healthcare settings.

Antibiotic Resistance in Salmonella typhi Strains Isolated From Patients in Pakistan: A Hospital Database Study.

The surge in antibiotic-resistant Salmonella enterica serotype Typhistrains has led to heightened morbidity, mortality, and treatment expenses. This study aims to assess the resistance patterns of Salmonella Typhi to diverse antibiotics among patients seeking care at a tertiary hospital in Pakistan. A database from a tertiary care hospital in Pakistan was reviewed, and data on blood cultures that isolated Salmonella enterica serotype Typhi were collected. Data were collected and analyzed using Microsoft Excel (Microsoft Corporation, USA) and IBM SPSS software (IBM Corp., Armonk, NY). Demographic information of the selected data was retrieved from the hospital database, and the results showed that 63.7% were male, 36.1% were female, and 0.2% were categorized as neutered. Regarding antibiotic resistance, ampicillin exhibited the highest resistance rate (91.50%), while meropenem demonstrated the lowest (3.00%). Antibiotic sensitivity patterns also varied across different age groups, although statistical analysis indicated no significant differences. Significant associations were found between antibiotic resistance and comorbidities, as well as previous antibiotic use. Salmonella enterica serotype Typhi showed a high resistancetoampicillin and fluoroquinolones, such as ciprofloxacin. The emergence of resistance and decreased sensitivity to current first-line antibiotics necessitates a shift towards alternative options, such as third-generation cephalosporins, azithromycin, and newer antibiotics like meropenem.

Virtual Leadership and Nurses' Psychological Stress during COVID-19 in the Tertiary Hospitals of Pakistan: The Role of Emotional Intelligence.

Although intelligence has been widely examined in the literature, the correlation of emotional intelligence (EI) has with virtual leadership, work stress, work burnout, and job performance in the nursing profession needs further consideration. Prior studies have confirmed that leadership style and emotional intelligence massively contribute to better outcomes in the nursing profession. Based on these confirmations, this research intended to explore the impact of virtual leadership and EI on work stress, work burnout, and job performance among nurses during the COVID-19 pandemic. A convenient sampling technique was adopted to select the data sample. To analyze our hypotheses, 274 self-reported surveys were distributed in five tertiary hospitals in Pakistan through a cross-sectional quantitative research design. The hypotheses were tested with SmartPLS-3.3.9. Our findings revealed that virtual leadership and EI have considerably influenced nurses' work stress, burnout level, and job performance. The study concludes that EI significantly moderates virtual leadership and psychological stress among nurses.

Inhumanity, a heinous crime against health personnel in Pakistan: challenges and recommendations.

Respected Sir, Violence is the utilization of actual power that either result in or has high possibilitys of causing injury, death, psychological mischief, or hardship. The World Health Organization estimates that physical violence affects 8–38 percent of healthcare employees at some time in their professional lives(1). An innumerable large number of health personals are verbally abused. Intolerance and hostility toward doctors are global phenomena. In1996, the Forty-Ninth World Health Assembly proclaimed violence as a significant public health issue(2). Violence is becoming more common in many professions, but it is known to be particularly prevalent in the medical area. Doctors have been the target of violence for a long time, as observed worldwide, and it is nothing new in Pakistan. In fact, because of the already common political violence and a fragile law enforcement system, countries like Pakistan are at a greater risk of violence. Exposure to violence in the medical fraternity consequences in accelerated tiers of anxiety, stress, insomnia, and depression which has a direct impact on the quality of treatment delivered to patients and can even end in a patient's death. A cross-sectional study was carried out within the emergency departments of nine predominant tertiary hospitals in Pakistan, which revealed a significant problem, with nearly 77 per cent of physicians dealing with verbal or bodily abuse from patients and their attendants(3). According to the Pakistan Medical Association (PMA), An independent organization that addresses the problems of healthcare providers, 54 doctors were killed in Karachi between 2010 and 2014 for various reasons. Most incidents were reported in 2014, when approximately 17 doctors were killed(4). This is the only figure that is reported; many more go unreported. There are complicated motives in the back of the violence toward Health Care Personnel (HCP); as a result, medical disputes and, at times, violence have increased. However, the primary motives are poor medical service quality and communication between HCPs and patients. Inadequate security and funds can also lead to violence. Awareness campaigns to improve HCPs' communication skills, better health care facilities, patient satisfaction, and attendants should be kept in the loop at every medical step, and security should be maintained in hospitals to protect the staff are among the preventative measures that can significantly reduce incidents of violence against HCPs.

Does Inclusive Leadership Improve the Sustainability of Employee Relations? Test of Justice Theory and Employee Perceived Insider Status

The concept of inclusion has moved beyond being a social construct and has received widespread attention from organisational scholars and practitioners due to its varied effects on employee behaviours and sustainable organisational outcomes. This study tests the impact of inclusive leadership on the withdrawal behaviours of employees. Perceived insider status is used as a mediator and distributive justice as a moderator. This study has collected data from nurses, physicians, and paramedics of selected tertiary hospitals in Pakistan. A convenience sampling technique was used to collect data. A total of 264 responses were analysed using the PLS-SEM approach. Results found that inclusive leadership was positively related to perceived insider status and negatively related to employee withdrawal. Perceived insider status mediated the link. The impact of inclusive leadership on perceived insider status was stronger when distributive justice was high. This study offers multiple theoretical and practical implications, as it uses justice theory as a mechanism to explain boundary conditions around the effects of inclusive leadership on employee perceptions of being insiders, managing employee withdrawals, and improving sustainability in employee relations.

Anti-cancer medicine shortages in an oncology tertiary hospital of Pakistan: A five-year retrospective study.

Anti-cancer medicine shortages are advancing challenges for patients and hospitals. This study aims to evaluate anti-cancer and supportive medicine shortages in a tertiary hospital in Pakistan and propose solutions. A retrospective observational research was performed in a tertiary care hospital in Pakistan from 2016 to 2020. Data was retrieved from the hospital database using a questionnaire regarding short medicines' generic name, brand, dosage, source, total source, frequency, causes, impact, management, and analyzed by Microsoft Excel 2013. Between January 2016 and December 2020, 43 individual medicine shortages were observed, with an average of 8.6 shortages per year. There were shortages of 22 medicines, including 8 anti-cancer (36.4%) and 14 supportive agents (63.6%). Total shortage days were 27,100, with an average of 1232 days (SD 757) per medicine. Supportive medicines' shortages were frequent, but oncology agents' shortages were constant. The most affected dosage form was injection. Cardiovascular drugs and alkylating agents were the most affected class in supportive and anti-cancer medicines, respectively. The use of "alternative medicine" and "patient needs based importation" were the most common mitigation strategies. Shortages of oncology medicines are challenging in Pakistan. The most prominent causes are the lack of updated governmental regulations, registration, and import issues. The tertiary care hospital has very few sources of supply, so it imports these drugs on a need basis to manage the shortages. But it is still concerning because of the huge financial burden on patients and institutions due to expensive import, and therapy become delayed as the import process takes time. Moreover, the most affected drug class was alkylating agents, and dosage was both injectable and oral medicines.

Thrombolytic Efficacy Of Enoxaparin Compared With Unfractionated Heparins In Cardiac Emergency

Background: Antithrombotic treatment with heparin together with antiplatelet agents reduces the incidence of ischemia in patients with coronary artery disease. associated with fewer adverse reactions. Aim: To evaluate and compare the clinical and obtained results of the use of enoxaparin and standard unfractionated heparin in patients with coronary heart disease. Methods: This is a non-invasive planned surveillance demonstration conducted at a tertiary hospital in Pakistan. Adult male and female patients with coronary artery infection (CAD) between the ages of 30 and 70 were recently analyzed or included patients with a history of heart cancer. The intermediate layer is injected with enoxaparin for 5 days. Resting the ECG position, prothrombin time, and ADRs were measured individually in all patients from 1 to 21 days. Result: Compared to the patient's unfractionated heparin, normal prothrombin times were generally higher (P and <0.002), while total hypokalemia was lower. (P and <0.04) in the patient's enoxaparin stratification. Angina pectoris and side effects such as death, morbidity, encephalopathy and sudden onset were less common in the patient's enoxaparin fraction than in the unfractionated heparin fraction, and the contrast was negligible Conclusions: Antithrombotic therapy with enoxaparin and aspirin is safer and more convincing than unfractionated heparin and headache drugs because it reduces the incidence of ischemic events in patients with unstable or tissue angina. The myocardium dies in the early stages. Keywords: Anticoagulant, coronary heart disease, enoxaparin, safety, and efficacy, unfractionated heparin

SPECTRUM OF RHEUMATOID ARTHRITIS PATIENTS PRESENTING TO A TERTIARY CARE HOSPITAL IN PAKISTAN

Objective: To describe the demographic, clinical, serological and radiological scores in patients with rheumatoid arthritis (RA) presenting in a tertiary hospital in Pakistan.
 Study Design: Cross sectional study.
 Place and Duration of Study: Department of Rheumatology, Fauji Foundation Hospital (FFH), Rawalpindi, from Sep 2018 to Feb 2019.
 Methodology: The study included 52 female patients with RA between the ages of 18 and 80 years. Data were obtained from FFH Rawalpindi's outpatient department. Demographic details, reference data, and serological status were recorded. The joints involved in the onset of the disease, joint deformities, clinical disease activity index (CDAI) and overall functional status were evaluated. Extra-articular manifestations of rheumatoid arthritis have also been examined during a detailed physical examination. The patient's bone mineral density was calculated by the use of dual energy absorptiometry (DEXA scan). Radiological scores were evaluated using modified sharp score.
 Results: Mean age of the patient was 55.08 ± 8.79 and mean duration of disease 9 .73 ± 7.54. The most common co-morbidity in rheumatoid arthritis patients was hypertension 20 (38.5%). Twenty four (11.7%) patients had osteoporosis. Wrist was the first joint involved in 17 (32.7%) patients. Ulnar deviation was the most common deformity in 12 (23.1%) patients. Sharp score for joint space narrowing was 61.09 ± 36.90 and sharp score joint erosions were 36.90 ± 42.41. Most common extra articular manifestation was anemia.
 Conclusion: Rheumatoid arthritis as a variable spectrum of disease with different manifestations. Patients had radiological damage as demonstrated by high sharp score even before starting.................

Early Experience with Percutaneous Transpedicular Screw Fixation for Thoracolumbar Fractures at a Tertiary Hospital in Pakistan.

Objective: To present our early experience with percutaneous transpedicular screw fixation for thoracolumbar fractures at a tertiary care hospital in Pakistan.
 Material & Methods: A case series of 20 patients with thoracolumbar fractures, who met the inclusion and exclusion criteria were followed for up to six months to evaluate their functional status using the Oswestry Disability Index (ODI). Kendall’s tau, Spearman’s rho and Pearson correlations were conducted to draw useful conclusions.
 Results: 85% patients’ injury was reported from ‘fall from height’. 55% of the fracture was the dorsal-lumbar junction (T12-L1). Burst type morphology was reported in maximum number of patients (65%). 55% of patients were reported to be neurologically intact. ODI score’s mean percentage decreased from 40% to 23% during the first week to six months, indicates an improvement in the disabilities. A significant (p<0.050) positive correlation was found between fracture morphology and ODI. All patients had an accurate screw trajectory postoperatively and no postoperative complications were documented. Neurology was stable for all patients at 1, 3 and 6 months.
 Conclusion: Percutaneous transpedicular screw fixation can be a viable approach for thoracolumbar burst fractures with intact posterior ligamentous complex in all types of thoracolumbar fractures, including type C and leads to an improvement the quality of life. Fracture morphology has a significantly positive correlation with a higher disability index score, with more severe fracture morphologies as per the Thoracolumbar Injury Classification and Severity (TLICS) score having a higher disability.

Young medical doctors\u2019 perspectives on professionalism: a qualitative study conducted in public hospitals in Pakistan

BackgroundProfessionalism is amongst the major dimensions determining the competence of medical doctors. Poor professionalism affects the overall outcome of healthcare services. This study explores the perspectives of young medical doctors on professionalism in Pakistan.MethodsA qualitative study based on in-depth interviews was conducted with 60 young medical doctors, aged less than 40 years, who had studied medicine in Pakistani universities, were Pakistani nationals, and were employed at various hierarchical levels, from house officer to consultant specialist, in public tertiary hospitals in Pakistan. The respondents were identified through a multistage maximum heterogeneity sampling strategy. A semi-structured interview guide was developed based on a previous extensive literature review. Written consent was obtained from the hospitals and study participants. Qualitative thematic analysis was applied to analyse the data.ResultsThe data analysis revealed that rigidity of opinions, unacceptability of contrasting perspectives, false pride, and perceived superiority over other professions and patients were major components of poor medical professionalism. Most of the young doctors believed that there is no need to include professionalism and humanity course modules in the medical curriculum, because topics related to social sciences are deemed irrelevant to medicine and judged to be common sense. The doctors recognised good professionalism in themselves, while reporting unprofessional behaviour demonstrated by their colleagues and paramedics. Other factors contributing to poor medical professionalism included the use of social media applications during duty hours, ridiculing patients, substance use such as smoking cigarettes in the office, referrals of complicated cases to other hospitals, freeing up beds before holidays, lack of cooperation from paramedical staff, and inadequate role models.ConclusionsPoor medical professionalism among young doctors needs to be addressed by policymakers. There is a need to revisit the medical curriculum to strengthen professionalism. It is essential to develop the qualities of tolerance, teachability, and acceptance in doctors in order to facilitate interprofessional collaborations and avoid medical errors.

Prevalence and treatment of neurological and psychiatric disorders among tertiary hospitals in Pakistan; findings and implications

ABSTRACT Introduction Mental health and neurological disorders are prevalent in Pakistan. However, there are considerable concerns with their management due to issues of access, availability of trained personnel and stigma alongside paucity of such data. Consequently, there is a need to document current treatment approaches starting with tertiary hospitals in Pakistan where patients with more severe mental and neurological disorders are typically treated. Subsequently, use the findings to help direct future policies and initiatives. Methods Multi-centered, cross-sectional, prospective study principally evaluating current medicine usage among patients attending tertiary hospitals in Pakistan with psychiatric and neurological disorders. In addition, possible factors contributing to the prevalence of these disorders in this population to help with future care. All 23 tertiary care hospitals in the ten major Districts in Pakistan were included, which cover 75% of the population. Results 57,664 patients were evaluated of which 35.3% were females. Both females and males had multiple brain disorders and multiple co-morbidities. Schizophrenia was the most prevalent disorder overall among both females (25.2%) and males (30.4%). A median of six medicines were prescribed per patient, with antipsychotics and antidepressants the most prescribed medicines. Clozapine was the most prescribed medicine in males (12.25%) and females (11.83%) including for psychiatric disorders, with sodium valproate the most prescribed medicine in epilepsy in males (42.44% of all anti-epileptic medicines) as well as females (46.38%). There was a greater prevalence of both disorders among the lower classes. A greater prevalence of schizophrenia was seen in patients abusing alcohol and smokers. The divorce rate was higher among the studied patients and the prevalence of depression was higher among the widowed population. Conclusions There were concerns with the quality of prescribing including the extent of polypharmacy as well as possible overuse of clozapine especially in patients with epilepsy, both of which need addressing.

Outcome of heat stroke patients referred to a tertiary hospital in Pakistan: a retrospective study.

Climate change has heightened the threat of heat stroke in previously temperate zones. This study aimed to assess the outcome of patients in relation to mortality and the role of effect modifiers among heatstroke patients presenting to a tertiary care hospital in Karachi during June 2015. A retrospective observational study was conducted on heatstroke patients 20-27 June 2015 at the Emergency Room(ER) of a private hospital in Karachi, Pakistan. Patients' demographic data, disease severity, presentation and outcomes were determined. Statistical data was reported as numbers, percentages and mean ± SD. In total, 315 patients reported to ER; 76.6% patients survived, 23% expired. Males were 55% and 60% patients were fully mobile. Hypertension was the most frequent concurrent disorder. Fever documented in 79.4% and CNS derangement in 73.3% patients were the top most presenting features. Fever and disease severity were found to exert significant impact on disease outcome. Mortality rate dropped from 26 June onwards from 24.35% to 15.9% by using evaporative cooling technique combined with air conduction and maintaining room temperature at 22-24°C. Poor outcome during heatstroke can be minimized by advance planning and timely intervention in lowand middle-income countries.

The experiences of breastfeeding mothers returning to work as hospital nurses in Pakistan: A qualitative study

BackgroundPakistan has a higher infant mortality rate than countries with comparable economies, with around half of all under-5 deaths occurring in the first month of life. Breastfeeding is known to improve infant morbidity and mortality, but rates of formula feeding in Pakistan are increasing. Maternal employment is recognised globally as a major barrier to the continuation of breastfeeding. AimTo describe the attitudes and experiences of breastfeeding mothers returning to full-time work as nurses in a tertiary hospital in Pakistan. MethodsA qualitative study was conducted using semi-structured interviews with seven purposively sampled participants who were breastfeeding at the time of return to work. Interviews were audio recorded, transcribed and analysed thematically. ResultsThree major themes were identified: belief in a child’s right to breastfeed, conflict with institutional power and the importance of family support in maintaining breastfeeding. Antenatally mothers described breastfeeding as the preferred infant feeding option and the child’s right. When returning to work mothers encountered rigid hospital policies and practices, such as a short and non-negotiable period of maternity leave, inflexible shift patterns, and lack of childcare provision. Parents’ strategies to continue breastfeeding included some mothers bringing babies to hospital wards while they worked, and babies’ fathers bringing the baby to the hospital for feeds. ConclusionThis study highlighted the barriers to breastfeeding experienced by mothers working as hospital nurses in Pakistan. Babies can be put at risk due to the strategies parents adopt to reconcile continued breastfeeding with maternal employment.

A multicentered pharmacoepidemiological approach to evaluate clinically significant potential drug–drug interactions in medical intensive care settings in Pakistan

Background: Iatrogenic injuries due to drug–drug interactions are particularly significant in critical care units because of the severely compromised state of the patient. The risk further increases with the use of multiple drugs, increasing age, and stay of the patient. Objective: The aim was to assess potential drug–drug interactions, evaluate clinically significant potential drug–drug interactions and their predictors in medical intensive care units of tertiary hospitals in Pakistan. Methods: Analysis of patient data collected from medical intensive care units of tertiary hospitals in Pakistan were carried out using Micromedex DrugReax. Various statistical tools were applied to identify the significance of associated predictors. Results: In a total of 830 patients, prevalence of potential drug–drug interactions was found to be 39%. These attributed to 190 drug combinations, of which 15.4% were clinically significant. A significant association of potential drug–drug interactions was present with number of prescribed drugs, age, and gender. In terms of clinically significant potential drug–drug interactions, the association was significant with increasing age. Moreover, one-way analysis of variance revealed a significant difference in the means of potential drug–drug interactions among the four hospitals. Conclusion: A prevalence of 39% potential drug–drug interactions was observed in patients of medical intensive care unit, with 22.8% being clinically significant. These attributed to nine drug pairs and could easily be avoided to reduce the risk of adverse effects from potential drug–drug interactions.

Health-related quality of life in congenital heart disease surgery patients in Pakistan: protocol for a mixed-methods study

IntroductionReduced health-related quality of life (HRQOL) has been reported in postoperative patients with congenital heart disease (CHD). However, there is a paucity of data from low-income and middle-income countries (LMIC)....

Prescribing Pattern and Drug–Drug Interactions of Analgesics Prescribed For Pain Management in a Pakistani Tertiary Hospital

Background: The main strategy of analgesic therapy is to diminish the intensity of pain to bearable level. Guidelines have been established by WHO to reduce the possible medication error in analgesic therapy. However, in most of the hospitals in Pakistan, analgesics are not prescribed rationally in accordance with standard guidelines. Objectives: The purpose of this study is to analyze therapeutic strategy of pain management in patients hospitalized at a tertiary hospital, as an exemplary assessment of prescribing pattern of analgesics, and to estimate the prevalence of potential drug–drug interaction there in. Methodology: This is a non-interventional cross sectional study of patients hospitalized in surgical and oncology wards of an urban Pakistani tertiary care hospital. The prescriptions were analyzed for physicians' preferences for the choice of analgesics and number of analgesics prescribed. Moreover, general observation was made whether pain intensity assessment tools were employed before prescribing analgesics. The effectiveness of prescribed analgesics was assessed by interviewing the patients post analgesic therapy. Furthermore, potential drug–drug interactions were also studied using reference books and Medscape Multi Drug interaction checker. Results: In the study population of n=45 inpatient (24 male and 21 female). Tramadol was the most frequently prescribed analgesic. In none of the case pain intensity was assessed before prescribing analgesics, hence, 53.3% subjects complained about severe pain even after analgesic therapy. Potential drug–drug interactions were present in all the prescriptions. Ultimately, 276 interactions were found in 45 prescriptions, among which 60% were of major severity. Conclusion: In current study, poor management of pain was identified in a tertiary hospital in Pakistan. The analgesics were prescribed without actually assessing the pain intensity. Improper analgesic regimen was selected and too many interacting drugs were prescribed simultaneously.

Clinical characteristics of childhood cancer in emergency room in a tertiary hospital in Pakistan.

Worldwide, cancer is an important cause of mortality in children aged over 1 year.[1] Numerically, the major cancers include acute lymphoblastic leukemia, CNS tumors and lymphomas.[2–6] Cancer incidence is increasing in children globally as well as in Pakistan but the etiology is poorly understood.[7] There are an estimated 160 000 new cases and 90 000 deaths per year worldwide in children aged under 15 years.[8] The exact incidence in Pakistan is not known as there is no national tumor registry. Early diagnosis in childhood is vital in terms of outcome.[9–14] However, presentations are non-specific which may lead to a delay in both diagnosis and treatment and a poorer outcome.[15–17] Knowledge of common presentation and initial management of oncological emergencies is, therefore, essential for the emergency department (ED) care provider. Common oncological emergencies with which the emergency physician might encounter include tumor lysis syndrome, coagulopathy, hyperleukocytosis, mediastinal mass with airway obstruction and spinal cord compression all of which have substantial morbidity and mortality if left untreated. There is no previous data available on frequency and clinical presentations of childhood cancer in the emergency room from Pakistan, so our goal was to identify the presentation of childhood malignancy in ED.

Intraoperative frozen section analysis of sentinel lymph nodes in breast carcinoma patients in a tertiary hospital in Pakistan

Intraoperative evaluation of sentinel lymph nodes has become routine in many units that manage early breast carcinoma. The procedure is associated with minimal morbidity and can be cost effective, avoiding re operation and reducing hospital stay as an axillary clearance can be performed under the same anesthetic after a positive intraoperative diagnosis without awaiting conventional paraffin histology. In negative cases extensive axillary lymph node dissection and its associated side effects can be avoided altogether. With careful patient selection, the expertise of surgeons and pathologists can increase the sensitivity and specificity of the technique with a reduction in false negatives. A number of international studies have established the usefulness of intraoperative sentinel lymph node evaluation. However, no local study has assessed the accuracy of frozen section in evaluating sentinel lymph node biopsy. The purpose of our study was to compare the two techniques (frozen section versus conventional paraffin histology) of the sentinel lymph node examination and to present our local data highlighting its usefulness and pitfalls, comparing the results with those in published studies. From the results obtained, we strongly recommend intraoperative assessment of the sentinel lymph nodes in breast carcinoma patients; frozen section microscopy can be a reliable and accurate technique in the hands of an experienced histopathologist.

Comparison of Oral Amoxicillin with Placebo for the Treatment of World Health Organization-Defined Nonsevere Pneumonia in Children Aged 2-59 Months: A Multicenter, Double-Blind, Randomized, Placebo-Controlled Trial in Pakistan

world Health Organization (WHO) acute respiratory illness case management guidelines classify children with fast breathing as having pneumonia and recommend treatment with an antibiotic. There is concern that many of these children may not have pneumonia and are receiving antibiotics unnecessarily. This could increase antibiotic resistance in the community. The aim was to compare the clinical outcome at 72 h in children with WHO-defined nonsevere pneumonia when treated with amoxicillin, compared with placebo. we performed a double-blind, randomized, equivalence trial in 4 tertiary hospitals in Pakistan. Nine hundred children aged 2-59 months with WHO defined nonsevere pneumonia were randomized to receive either 3 days of oral amoxicillin (45mg/kg/day) or placebo; 873 children completed the study. All children were followed up on days 3, 5, and 14. The primary outcome was therapy failure defined a priori at 72 h. in per-protocol analysis at day 3, 31 (7.2%) of the 431 children in the amoxicillin arm and 37 (8.3%) of the 442 in placebo group had therapy failure. This difference was not statistically significant (odds ratio [OR], .85; 95%CI, .50-1.43; P = .60). The multivariate analysis identified history of difficult breathing (OR, 2.86; 95% CI, 1.29-7.23; P = .027) and temperature >37.5°C 100°F at presentation (OR, 1.99; 95% CI, 1.37-2.90; P = .0001) as risk factors for treatment failure by day 5. clinical outcome in children aged 2-59 months with WHO-defined nonsevere pneumonia is not different when treated with an antibiotic or placebo. Similar trials are needed in countries with a high burden of pneumonia to rationalize the use of antibiotics in these communities.