Haider J. Warraich

Utility of a transesophageal echocardiographic simulator as a teaching tool.

OBJECTIVE This study was designed to test the hypothesis that simulator-based transesophageal echocardiographic training was a more effective method of training anesthesia residents with no prior experience in echocardiography as compared with conventional methods of training (books, articles, and web-based resources). STUDY DESIGN A prospective randomized study. SETTING An academic medical center (teaching hospital). PARTICIPANTS The participants consisted of first-year anesthesia residents. INTERVENTION The study design was composed of 2 groups: a control group (group 1, conventional group) and a study group (group 2, simulator group). The residents belonging to group 2 (simulator group) received a 90-minute simulator-based teaching session moderated by a faculty experienced in transesophageal echocardiography. Residents belonging to group 1 (conventional group) were asked to review the guidelines of the comprehensive intraoperative transesophageal echocardiographic examination published by the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. They also were encouraged to use other learning resources (eg, textbooks, electronic media, and web-based resources) to understand the underlying concepts of echocardiography. Written pre- and post-test was administered to both groups. MEASUREMENTS AND MAIN RESULTS The groups were compared for the pretest scores by the nonparametric Mann-Whitney U test. Pre- and post-test scores were compared with a Wilcoxon paired test in the individual groups. The results showed a statistically significant difference between the scores of the 2 groups with better scores in the simulation group in the post-training test. CONCLUSION The simulator-based teaching model for transesophageal echocardiography is a better method of teaching the basic concepts of transesophageal echocardiography like anatomic correlation, structure identification, and image acquisition.

Prevalence of obesity in school-going children of Karachi.

Background Obesity is an emerging problem in Pakistan. The authors sought to determine prevalence of obesity and malnutrition in school-going children, from grades 6th to 8th of different schools of Karachi and assess associations that affect the weight of the children. Methodology/Principal Findings A cross sectional study design with children studying in grades 6th to 8th grade, in different schools of Karachi. We visited 10 schools of which 4 consented; two subsidized government schools and two private schools. A questionnaire was developed in consultation with a qualified nutritionist. Height and weight were measured on calibrated scales. A modified BMI criterion for Asian populations was used. Data was collected from 284 students. Of our sample, 52% were found to be underweight whereas 34% of all the children were normal. Of the population, 6% was obese and 8% overweight. Of all obese children, 70% belonged to the higher socio-economic status (SES) group, while of the underweight children, 63.3% were in the lower SES. Amongst obese children in our study, 65% ate meat every day, compared to 33% of normal kids. Conclusion Obesity and undernutrition co-exist in Pakistani school-children. Our study shows that socio-economic factors are important since obesity and overweight increase with SES. Higher SES groups should be targeted for overweight while underweight is a problem of lower SES. Meat intake and lack of physical activity are some of the other factors that have been highlighted in our study.

Dynamic 3-Dimensional Echocardiographic Assessment of Mitral Annular Geometry in Patients With Functional Mitral Regurgitation

BACKGROUND Mitral valve (MV) annular dynamics have been well described in animal models of functional mitral regurgitation (FMR). Despite this, little if any data exist regarding the dynamic MV annular geometry in humans with FMR. In the current study we hypothesized that 3-dimensional (3D) echocardiography, in conjunction with commercially available software, could be used to quantify the dynamic changes in MV annular geometry associated with FMR. METHODS Intraoperative 3D transesophageal echocardiographic data obtained from 34 patients with FMR and 15 controls undergoing cardiac operations were dynamically analyzed for differences in mitral annular geometry with TomTec 4D MV Assessment 2.0 software (TomTec Imaging Systems GmbH, Munich, Germany). RESULTS In patients with FMR, the mean mitral annular area (14.6 cm(2) versus 9.6 cm(2)), circumference (14.1 cm versus 11.4 cm), anteroposterior (4.0 cm versus 3.0 cm) and anterolateral-posteromedial (4.3 cm versus 3.6 cm) diameters, tenting volume (6.2 mm(3) versus 3.5 mm(3)) and nonplanarity angle (NPA) (154 degrees ± 15 versus 136 degrees ± 11) were greater at all points during systole compared with controls (p < 0.01). Vertical mitral annular displacement (5.8 mm versus 8.3 mm) was reduced in FMR compared with controls (p < 0.01). CONCLUSIONS There are significant differences in dynamic mitral annular geometry between patients with FMR and those without. We were able to analyze these changes in a clinically feasible fashion. Ready availability of this information has the potential to aid comprehensive quantification of mitral annular function and possibly assist in both clinical decision making and annuloplasty ring selection.

HIV and homosexuality in Pakistan.

In Pakistan, seven times more men are reported to be infected with HIV than women. Among the Pakistani population, modes of HIV transmission include infection through sexual contact, contaminated blood and blood products, injecting drug use, and mother-to-child transmission. Although most sexual transmission of HIV results from unsafe heterosexual contact, homosexual and bisexual contact also represent important modes of transmission. According to unpublished reports, the prevalence of HIV among homosexual and bisexual Pakistani men is reaching alarming proportions. We describe the Pakistani homosexual and bisexual culture, review statistics regarding HIV prevalence and risk behaviour, and identify areas of improvement in the HIV policy with specific focus on men who have sex with men.

Religious opposition to polio vaccination.

To the Editor: In 1988, the Global Polio Eradication Initiative was formed, with the aim of reducing infection with poliomyelitis virus. Two decades later in 2008, a total of 1,625 children contracted acute flaccid paralysis caused by poliovirus infection (1). This finding represented a 150% increase over the number of cases in 2007 (1) and resulted in the reemergence of polio as one of the world’s deadliest infections. As of 2009, polio remains endemic to 4 countries (India, Nigeria, Pakistan, and Afghanistan); in 2008, cases were also detected in 14 other countries. Religious opposition by Muslim fundamentalists is a major factor in the failure of immunization programs against polio in Nigeria (2), Pakistan (3) and Afghanistan (4). This religious conflict in the tribal areas of Pakistan is one of the biggest hindrances to effective polio vaccination. Epidemiologists have detected transmission of wild poliovirus from polio-endemic districts in Afghanistan, most of which are located in the southern region of this country bordering Pakistan, to tribal areas of Pakistan (4). This transmission has resulted in new cases of polio in previously polio-free districts. The local Taliban have issued fatwas denouncing vaccination as an American ploy to sterilize Muslim populations. Another common superstition spread by extremists is that vaccination is an attempt to avert the will of Allah. The Taliban have assassinated vaccination officials, including Abdul Ghani Marwat, who was the head of the government’s vaccination campaign in Bajaur Agency in the Pakistani tribal areas, on his way back from meeting a religious cleric (5). Over the past year, several kidnappings and beatings of vaccinators have been reported. Vaccination campaigns in Nigeria and Afghanistan have also been hampered by Islamic extremists, especially in the Nigerian province of Kano in 2003, which has resulted in the infection returning to 8 previously polio-free countries in Africa (2). Before the Global Polio Eradication Initiative in 1988, a total of 1,000 persons/day were infected with a virus that would cripple them for the rest of their lives (6). To eradicate the disease, 1 major factor will be to gain support of those susceptible to fundamentalist propaganda. Islam is a progressive religion, and religious leaders should be asked to support polio eradication programs. The Imam of the Ka’aba and other influential religious figures should be asked to highlight the plight of children with polio. Vaccinators operating in conflict-ridden areas should be provided protection so that they are better able to perform their duties. Not only will children in these areas be safer, but the disease will not be exported to areas where wild polio transmission has been interrupted by vaccination. Further study of the attitudes of Muslim populations toward vaccination is needed.

National Trends in Statin Use and Expenditures in the US Adult Population From 2002 to 2013: Insights From the Medical Expenditure Panel Survey

Importance Statins remain a mainstay in the prevention and treatment of atherosclerotic cardiovascular disease (ASCVD). Objective To detail the trends in use and total and out-of-pocket (OOP) expenditures associated with statins in a representative US adult population from 2002 to 2013. Design, Setting, and Participants This retrospective longitudinal cohort study was conducted from January 2002 to December 2013. Demographic, medical condition, and prescribed medicine information of adults 40 years and older between 2002 and 2013 were obtained from the Medical Expenditure Panel Survey database. Main Outcomes and Measures Estimated trends in statin use, total expenditure, and OOP share among the general adult population, those with established ASCVD, and those at risk for ASCVD. Costs were adjusted to 2013 US dollars using the Gross Domestic Product Index. Results From 2002 to 2013, more than 157 000 Medical Expenditure Panel Survey participants were eligible for the study (mean [SD] age, 57.7 [39.9] years; 52.1% female). Overall, statin use among US adults 40 years of age and older in the general population increased 79.8% from 21.8 million individuals (17.9%) in 2002-2003 (134 million prescriptions) to 39.2 million individuals (27.8%) in 2012-2013 (221 million prescriptions). Among those with established ASCVD, statin use was 49.8% and 58.1% in 2002-2003 and 2012-2013, respectively, and less than one-third were prescribed as a high-intensity dose. Across all subgroups, statin use was significantly lower in women (odds ratio, 0.81; 95% CI, 0.79-0.85), racial/ethnic minorities (odds ratio, 0.65; 95% CI, 0.61-0.70), and the uninsured (odds ratio, 0.33; 95% CI, 0.30-0.37). The proportion of generic statin use increased substantially, from 8.4% in 2002-2003 to 81.8% in 2012-2013. Gross domestic product–adjusted total cost for statins decreased from

Community-based Treatment of Serious Bacterial Infections in Newborns and Young Infants A Randomized Controlled Trial Assessing Three Antibiotic Regimens

17.2 billion (OOP cost,

Floods in Pakistan: a public health crisis

7.6 billion) in 2002-2003 to

HIV/AIDS in Pakistan: the battle begins

16.9 billion (OOP cost,

Systematic review on noninvasive assessment of subclinical cardiovascular disease in obstructive sleep apnea: new kid on the block!

3.9 billion) in 2012-2013, and the mean annual OOP costs for patients decreased from