Juanita Hatcher

Association of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality in general population cohorts: a collaborative meta-analysis.

BACKGROUND Substantial controversy surrounds the use of estimated glomerular filtration rate (eGFR) and albuminuria to define chronic kidney disease and assign its stages. We undertook a meta-analysis to assess the independent and combined associations of eGFR and albuminuria with mortality. METHODS In this collaborative meta-analysis of general population cohorts, we pooled standardised data for all-cause and cardiovascular mortality from studies containing at least 1000 participants and baseline information about eGFR and urine albumin concentrations. Cox proportional hazards models were used to estimate hazard ratios (HRs) for all-cause and cardiovascular mortality associated with eGFR and albuminuria, adjusted for potential confounders. FINDINGS The analysis included 105,872 participants (730,577 person-years) from 14 studies with urine albumin-to-creatinine ratio (ACR) measurements and 1,128,310 participants (4,732,110 person-years) from seven studies with urine protein dipstick measurements. In studies with ACR measurements, risk of mortality was unrelated to eGFR between 75 mL/min/1.73 m(2) and 105 mL/min/1.73 m(2) and increased at lower eGFRs. Compared with eGFR 95 mL/min/1.73 m(2), adjusted HRs for all-cause mortality were 1.18 (95% CI 1.05-1.32) for eGFR 60 mL/min/1.73 m(2), 1.57 (1.39-1.78) for 45 mL/min/1.73 m(2), and 3.14 (2.39-4.13) for 15 mL/min/1.73 m(2). ACR was associated with risk of mortality linearly on the log-log scale without threshold effects. Compared with ACR 0.6 mg/mmol, adjusted HRs for all-cause mortality were 1.20 (1.15-1.26) for ACR 1.1 mg/mmol, 1.63 (1.50-1.77) for 3.4 mg/mmol, and 2.22 (1.97-2.51) for 33.9 mg/mmol. eGFR and ACR were multiplicatively associated with risk of mortality without evidence of interaction. Similar findings were recorded for cardiovascular mortality and in studies with dipstick measurements. INTERPRETATION eGFR less than 60 mL/min/1.73 m(2) and ACR 1.1 mg/mmol (10 mg/g) or more are independent predictors of mortality risk in the general population. This study provides quantitative data for use of both kidney measures for risk assessment and definition and staging of chronic kidney disease. FUNDING Kidney Disease: Improving Global Outcomes (KDIGO), US National Kidney Foundation, and Dutch Kidney Foundation.Background A comprehensive evaluation of the independent and combined associations of estimated glomerular filtration rate (eGFR) and albuminuria with mortality is required for assessment of the impact of kidney function on risk in the general population, with implications for improving the definition and staging of chronic kidney disease (CKD).

Prevalence and Factors Associated with Intestinal Parasitic Infection among Children in an Urban Slum of Karachi

Background Intestinal parasitic infections are endemic worldwide and have been described as constituting the greatest single worldwide cause of illness and disease. Poverty, illiteracy, poor hygiene, lack of access to potable water and hot and humid tropical climate are the factors associated with intestinal parasitic infections. The study aimed to estimate prevalence and identify factors associated with intestinal parasitic infections among 1 to 5 years old children residing in an urban slum of Karachi Pakistan. Methods and Principal Findings A cross sectional survey was conducted from February to June 2006 in Ghosia Colony Gulshan Town Karachi, Pakistan. A simple random sample of 350 children aged 1–5 years was collected. The study used structured pre-tested questionnaire, anthropometric tools and stool tests to obtain epidemiological and disease data. Data were analyzed using appropriate descriptive, univariate and multivariable logistic regression methods. The mean age of participants was 2.8 years and 53% were male. The proportions of wasted, stunted and underweight children were 10.4%, 58.9% and 32.7% respectively. The prevalence of Intestinal parasitic infections was estimated to be 52.8% (95% CI: 46.1; 59.4). Giardia lamblia was the most common parasite followed by Ascaris lumbricoides, Blastocystis hominis and Hymenolepis nana. About 43% children were infected with single parasite and 10% with multiple parasites. Age {Adjusted Odds Ratio (aOR) = 1.5; 95% CI: 1.1; 1.9}, living in rented households (aOR = 2.0; 95% CI: 1.0; 3.9) and history of excessive crying (aOR = 1.9; 95% CI: 1.0; 3.4) were significantly associated with intestinal parasitic infections. Conclusions Intestinal parasites are highly prevalent in this setting and poverty was implicated as an important risk factor for infection. Effective poverty reduction programmes and promotion of deworming could reduce intestinal parasite carriage. There is a need for mass scale campaigns to create awareness about health and hygiene.

Children in South Asia Have Higher Body Mass–Adjusted Blood Pressure Levels Than White Children in the United States A Comparative Study

Background—Blood pressure during childhood is an established predictor of adult blood pressure, which in turn increases mortality as a result of cardiovascular disease. Adult South Asian populations are particularly predisposed to cardiovascular disease compared with whites, but the prevalence of high blood pressure and determinants of blood pressure in South Asian children have not been explored or compared with those of white children. Methods and Results—Analyses were performed on 5641 South Asian children 5 to 14 years old included in the nationally representative National Health Survey of Pakistan (NHSP) (1990–1994) and on 4756 white children 5 to 14 years old included in Third National Health and Nutrition Examination Survey (NHANES III) (1988–1994). Anthropometric measurements were obtained. Blood pressure was measured twice in the seated position with a mercury sphygmomanometer and an appropriate-size cuff. High blood pressure was defined as a systolic or diastolic blood pressure level that was ≥95th percentile of age-, sex-, and height-percentile–specific reference level for the US population. Mean body mass index (BMI)–adjusted blood pressure values were compared among children in 2 data sets by use of linear regression analysis. The overall prevalence (95% CI) of high blood pressure in South Asian children 5 to 14 years old was 12.2% (11.3% to 13.1%): 15.8% (14.5% to 17.1%) in boys and 8.7% (7.6% to 9.8%) in girls. This is in sharp contrast with the predicted 5% prevalence of high blood pressure in children in the United States (P<0.001). The mean BMI-adjusted systolic blood pressure levels (SD) were 100 (11) versus 99 (11) mm Hg (P<0.001), and diastolic blood pressure levels (SD) were 63 (10) versus 52 (12) mm Hg (P<0.001) in NHSP versus NHANES III, respectively. Conclusions—South Asian children have higher body-mass–adjusted blood pressure levels than white children in the United States. Further studies are needed to determine factors responsible for these differences. Immediate attention is needed to address high blood pressure and its risk factors in native South Asian children.

Community-based interventions to promote blood pressure control in a developing country: a cluster randomized trial.

Context Physician education and community-based interventions to educate people with hypertension may improve hypertension care in resource-poor settings. Contribution Among 1341 patients living in 12 communities in Pakistan that were randomly assigned to general practitioner education, home health visits by trained lay workers, both, or neither, patients in communities assigned to both interventions had the greatest improvements in systolic blood pressure (10.8 mm Hg) after 2 years. Improvements were similar in all other groups (about 5 mm Hg). Caution Twenty-two percent of patients were lost to follow-up. Implication Home visits by trained lay workers plus physician education deserves further study as a way to improve hypertension control in resource-poor settings. The Editors Cardiovascular disease has, in just a few decades, become the leading cause of death in adults worldwide, accounting for 1 in 5 deaths. Hypertension confers the highest attributable risk for death and disease associated with cardiovascular disease (1, 2). Despite the demonstrated benefits of effective drug treatment (3, 4) and the existence of many clinical practice guidelines (5), hypertension prevention, treatment, and control rates remain suboptimal worldwide (6). The situation is particularly acute in developing countries, such as Pakistan, India, and China, where hypertension has reached epidemic proportionsaffecting more than 20% of the adult population (7)yet control rates are less than 6% (8). Poor health literacy and unhealthy lifestyles, compounded by lack of awareness of hypertension (7), are part of the cause. In addition, the health systems in these countries are often dysfunctional: More than 80% of the expenditure for chronic disease care is out-of-pocket; private care general practitioners (GPs), who primarily treat acute conditions, are the front-line service providers; and national programs for preventing and controlling hypertension are inadequate. Serious deficiencies in management of hypertension also have been identified in the knowledge and practice of health care providers. (9) However, evidence for public health interventions to improve hypertension control rates through patient or physician education in Indo-Asian countries is lacking. We conducted the COBRA-1 (Control of Blood Pressure and Risk Attenuation-1) trial in Karachi, Pakistan, to test the effectiveness of 2 community-based strategies: family-based home health education (HHE), delivered by trained community health workers, to improve population-level health literacy and behaviors, and hypertension management training for GPs. We tested the effect of these interventions, alone and in combination, on blood pressure in adults with hypertension. We hypothesized that HHE would be more effective than no education, that the specially trained GPs would provide more effective care than that usually received in Karachi, and that the combined interventions would provide additional benefit. Methods Study Design and Setting We performed a cluster randomized, controlled trial with a 22 factorial design to determine the effect of family-based HHE and special training for GPs on blood pressure in adults 40 years or older with hypertension. We used a cluster approach because our objective was to assess the effectiveness of both HHE and GP training as health system interventions at a population level, and an individual approach would be prone to contamination of interventions and biased outcomes (10). The Aga Khan University Ethics Review Committee granted ethical approval. The sampling frame is described elsewhere (11). In brief, we used a multistage random sampling technique to select 12 of 4200 low- to middle-income, geographic census-based clusters (mean household monthly income,

Complementary and Alternative Medicine in Pakistan: Prospects and Limitations

70; about 250 households in each cluster) in Karachi, the most populous city in Pakistan (about 16 million inhabitants). We ensured at least a 10-km distance between clusters to minimize the risk for contamination by the intervention. Participants Persons 40 years or older who resided in the 12 clusters and had known hypertension or consistently elevated blood pressure on 2 separate visits (mean of 2 of past 3 measurements of systolic blood pressure 140 mm Hg or diastolic blood pressure 90 mm Hg) were eligible for inclusion. We excluded pregnant women, persons who could not give informed consent, and bed-bound persons. Randomization and Intervention We used computer-generated codes to randomly assign 3 clusters each to the following groups: HHE alone, GP alone, HHE and GP combined, and no intervention. Home Health Education We trained 6 community health workers (1 for each cluster) over 6 weeks in methods for using behavior-changing communication strategies to convey standardized health education messages to all households in clusters assigned to receive HHE. The education status of the workers we employed was consistent with the requirements of the government-sponsored Lady Health Workers Programme of Pakistan (8 or preferably 10 years of schooling) (12). Salary scales and assigned workload were similarly consistent. The health messages included information on the deleterious effects of hypertension and nonpharmacologic interventions for preventing and controlling hypertension and cardiovascular disease, as well as advice on the importance of engaging in moderate physical activity; maintaining normal body weight; reducing salt intake; consuming a diet rich in fruit, vegetables, and low-fat dairy products; reducing intake of saturated and total fat (including suggestions on sample recipes for culturally acceptable and economically feasible food products); and smoking cessation (Appendix 1). The importance of achieving blood pressure targets and adhering to medication and physician follow-up was emphasized. The first HHE session, lasting 90 minutes, was held at a time when all members of the household could be present. Follow-up reinforcement visits of 30 minutes were made every 3 months. Appendix 1. Training Manual for Community Health Workers General Practitioner Education We invited all GPs in the 6 study areas assigned to this intervention to receive training, with the aim of training at least two thirds of the GPs in each area. We considered this proportion to be feasible both for future uptake of the strategy and for assessing the effectiveness of training. Training was a 1-day session that focused on standard treatment algorithms for the stepped-care management of hypertension, which were based on the seventh report of the Joint National Committee (3) and the Fourth Working Party of the British Hypertension Society guidelines (4) and modified for the Indo-Asian population (Appendix 2). The course included components on nonpharmacologic (diet, exercise, weight loss, and smoking cessation) and pharmacologic interventions, prescription of low-cost and appropriate generic drugs, preferential use of single-dose drug regimens, scheduled follow-up visits guided by blood pressure, the stepped-care approach for titrating drugs to achieve target blood pressure, and satisfactory consultation sessions for patients, with explanations of treatment and use of appropriate communication strategies. For managing persons with known hypertension, GPs were advised to review medication and blood pressure; simplify regimens; and aim to return to a regimen that was in line, as reasonably as possible, with that recommended for those with newly diagnosed hypertension. The recommended target blood pressure was <140/90 mm Hg for all patients. Although this diverges from recent guidelines for special subgroups (such as diabetic persons or those with end-organ damage), we reasoned that we needed to keep the intervention, guidelines, and targets simple for both patients and practitioners in a setting where blood pressure control rates are less than 3% (7). The training sessions for GPs used a case-based curriculum and were interactive. We provided a certificate of training at the end of the course. Appendix 2. Training Manual for General Practitioner All study participants were advised to consult a local GP. If participants in the clusters randomly assigned to a trained GP group did not already have a preferred GP, we gave them a list of trained GPs in their cluster from which to choose. However, it remained the participants choice whether they attended a physician on the list. We did not provide for medications or fee-for-health care services. Participants were blinded to intervention status (training of GP). Neither the patients nor the GPs received reimbursement for participation. Screening and Recruitment All households in each cluster were visited, and we obtained informed consent for screening from all adults 40 years and older, whose blood pressure was then measured 3 times with a calibrated automated device (Omron HEM-737 IntelliSense; Omron Healthcare, Vernon Hills, Illinois) in the sitting position after 5 minutes of rest. Those with known hypertension were invited to participate. Those with elevated blood pressure who were not receiving antihypertensive medication were visited again for remeasurement of blood pressure 1 to 4 weeks after the initial visit. If mean blood pressure remained elevated, these persons were also invited to participate. A routine physical examination was performed, and the following information was collected: smoking status, food frequency, and physical activity by questionnaire, the latter by using the international physical activity questionnaire; blood pressure, measured as described above; anthropometric characteristics (height, weight, and waist and hip circumferences); and fasting blood glucose level (Synchron Cx-7/Delta, Beckman Coulter, Fullerton, California) and lipid profile (Hitachi-912, Roche, Basel, Switzerland) (11). Follow-up Procedures Trained outcomes assessors (who were not part of and had no relationship with the community health worker team) evaluated part

Rise in childhood obesity with persistently high rates of undernutrition among urban school-aged Indo-Asian children

Despite all the marvelous advancements in modern medicine, traditional medicine has always been practiced. More than 70% of the developing worlds population still depends on the complementary and alternative systems of medicine (CAM). Cultural beliefs and practices often lead to self-care or home remedies in rural areas and consultation with traditional healers. Evidence-based CAM therapies have shown remarkable success in healing acute as well as chronic diseases. Alternative therapies have been utilized by people in Pakistan who have faith in spiritual healers, clergymen, hakeems, homeopaths or even many quacks. These are the first choice for problems such as infertility, epilepsy, psychosomatic troubles, depression and many other ailments. The traditional medicine sector has become an important source of health care, especially in rural and tribal areas of the country. The main reasons for consulting a CAM healer is the proximity, affordable fee, availability, family pressure and the strong opinion of the community. Pakistan has a very rich tradition in the use of medicinal plants for the treatment of various ailments. It necessitates the integration of the modern and CAM systems in terms of evidence-based information sharing. The health-seeking behavior of the people especially in developing countries calls for bringing all CAM healers into the mainstream by providing them with proper training, facilities and back-up for referral. A positive interaction between the two systems has to be harnessed to work for the common goal of improving health of the people.

Effect of general practitioner education on adherence to antihypertensive drugs: cluster randomised controlled trial

Background: Childhood obesity is an emerging global public health challenge. Evidence for the transition in nutrition in Indo-Asian developing countries is lacking. We conducted these analyses to determine the trends in nutritional status of school-aged children in urban Pakistan. Methods: Data on the nutritional status of children aged 5 to 14 years from two independent population-based representative surveys, the urban component of the National Health Survey of Pakistan (NHSP; 1990–1994) and the Karachi survey (2004–2005), were analysed. Using normative data from children in the United States as the reference, trends for age- and gender-standardised prevalence (95% CI) of underweight (more than 2 SD below the weight-for-age reference), stunted (more than 2 SD below the height-for-age reference) and overweight and obese (body mass index (BMI) 85th percentile or greater) children were compared for the two surveys. The association between physical activity and being overweight or obese was analysed in the Karachi survey using logistical regression analysis. Results: 2074 children were included in the urban NHSP and 1675 in the Karachi survey. The prevalence of underweight children was 29.7% versus 27.3% (p = 0.12), stunting was 16.7% versus 14.3% (p = 0.05), and prevalence of overweight and obese children was 3.0 versus 5.7 (p<0.001) in the NHSP and Karachi surveys, respectively. Physical activity was inversely correlated with being overweight or obese (odds ratio, 95% CI, 0.51, 0.32–0.80 for those who engaged in more than 30 minutes of physical activity versus those engaged in less than 30 minutes’ activity). Conclusions: Our study highlights the challenge faced by Pakistani school-aged children. There has been a rapid rise in the number of overweight and obsese children despite a persistently high burden of undernutrition. Focus on prevention of obesity in children must include strategies for promoting physical activity.

A prevalence study of ear problems in school children in Kiambu district, Kenya, May 1992

Objective To determine the impact of a simple educational package for general practitioners on adherence to antihypertensive drugs. Design Cluster randomised controlled trial. Setting Six randomly selected communities in Karachi, Pakistan. Participants 200 patients with hypertension taking antihypertensive drugs; 78 general practitioners. Intervention Care by general practitioners specially trained in management of hypertension compared with usual care. Main outcome measure Correct dosing, defined as percentage of prescribed doses taken, measured with electronic medication event monitoring system (MEMS) bottle. Results 200 patients were enrolled, and 178 (89%) successfully completed six weeks of follow-up. Adherence was significantly greater in the special care group than in the usual care group (unadjusted mean percentage days with correct dose 48.1%, 95% confidence interval 35.8% to 60.4%, versus 32.4%, 22.6% to 42.3%; P=0.048). Adherence was also higher among patients who had higher levels of education (P<0.001), were encouraged by family members (P<0.001), believed in the effect of drugs (P<0.001), and had the purpose of the drugs explained to them (P<0.001). Conclusions Special training of general practitioners in management of hypertension, emphasising good communication between doctors and patients, is more effective than usual care provided in the communities in Karachi. Such simple interventions should be adopted by other developing countries that are now facing an increasing burden of hypertension. Trial registration Clinical trials NCT00330408.

Breast cancer risk factor knowledge among nurses in teaching hospitals of Karachi, Pakistan: a cross-sectional study

Information on the prevalence of hearing impairment and related ear pathologies in children in sub-Saharan Africa is scarce. A pilot study for a clinical trial of simple treatments for chronic suppurative otitis media (CSOM) in school children in Kiambu district, Kenya, provided information on the prevalence of hearing impairment and ear pathologies. Five-thousand-three-hundred-sixty-eight children from 57 randomly chosen primary schools in Kiambu district were examined. Simple otoscopy was performed by clinical officers with specialty training in ENT, and hering testing was performed by trained nurses, using a hand held field audiometer. Microbiological specimens were obtained from those children with CSOM. Five-point-six percent of the children had a hearing impairment of > 30 dB HL in one or both ears, with 2.2% having bilateral hearing impairment. Two-point-four percent had at least one perforated tympanic membrane, and 1.1% had CSOM. Eight-point-six percent of the children had wax obstructing the tympanic membrane. There is evidence of a relationship between hearing impairment and both CSOM and wax obstructing the tympanic membrane. The most common organisms found were Pseudomonas spp. (34%), Proteus spp. (34%) and Eschericia coli (19%). These results are comparable with other studies in Africa and indicate a considerable burden of ear disease in Kiambu district, Kenya.

Randomised controlled trial of treatment of chronic suppurative otitis media in Kenyan schoolchildren

BackgroundBreast cancer is the most common cancer among women in both the developed and the developing world. The incidence of breast cancer in Karachi, Pakistan is 69.1 per 100,000 with breast cancer presentation in stages III and IV being common (≥ 50%). The most pragmatic solution to early detection lies in breast cancer education of women. Nurses constitute a special group having characteristics most suited for disseminating breast cancer information to the women. We assessed the level of knowledge of breast cancer risk factors among registered female nurses in teaching hospitals of Karachi. We also identified whether selected factors among nurses were associated with their knowledge of breast cancer risk factors, so that relevant measures to improve knowledge of nurses could be implemented.MethodsA cross-sectional survey was conducted in seven teaching hospitals of Karachi using stratified random sampling with proportional allocation. A total of 609 registered female nurses were interviewed using a structured questionnaire adapted from the Stagers Comprehensive Breast Cancer Knowledge Test. Knowledge of breast cancer risk factors was categorized into good, fair and poor categories. Ordinal regression was used to identify factors associated with risk knowledge among nurses.ResultsThirty five percent of nurses had good knowledge of risk factors. Graduates from private nursing schools (aOR = 4.23, 95% CI: 2.93, 6.10), nurses who had cared for breast cancer patients (aOR = 1.41, 95% CI: 1.00, 1.99), those having received a breast examination themselves (aOR = 1.56, 95% CI: 1.08, 2.26) or those who ever examined a patients breast (aOR = 1.87, 95% CI: 1.34, 2.61) were more likely to have good knowledge.ConclusionA relatively small proportion of the nursing population had good level of knowledge of the breast cancer risk factors. This knowledge is associated with nursing school status, professional breast cancer exposure and self history of clinical breast examination. Since only about one-third of the nurses had good knowledge about risk factors, there is a need to introduce breast cancer education in nursing schools particularly in the public sector. Continuing nursing education at the workplace can be of additional benefit.