Publications (55)112.66 Total impact
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Article: Invasive Candidiasis in Pakistan: Clinical characteristics, species distribution and antifungal susceptibility.
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ABSTRACT: This study reports for the first time descriptive epidemiologic data of 188 invasive Candida isolates from Pakistan, including species identification and antifungal susceptibility against fluconazole, itraconazole, voriconazole, caspofungin, micafungin, anidulafungin and amphotericin. Risk factors for invasive candidiasis (IC) were determined for 96 patients from Karachi, Pakistan. In adults and neonates, Candida tropicalis (38 and 36% respectively) was the most common species, followed in adults by C. parapsilosis (17.8%), C. glabrata (15.9%) and C. albicans (12.3%). C. albicans (21%) was second-most common in neonates. In children, C. albicans (31.9%), C. tropicalis (26.4%) and C. parapsilosis (19.4%) were most common. C.albicans IC was significantly associated with paediatric age (COR: 3.46, 95% CI: 1.63-7.32). Rare species made up 17.5% of total isolates studied. Resistance to fluconazole was seen in C. glabrata (15%) and C. krusei (100%). Only one isolate (C.glabrata) was resistant to all three echinocandins. Low MICs to fluconazole in 98% (184/188) of isolates tested support its continued use as empiric therapy for IC. Non- C. albicans IC was associated with use of beta-lactam inhibitor combinations (COR: 3.16, 95% CI: 1.05-9.57). Usage of health-care devices was documented in 86.5% of IC patients, while 75% had been admitted to special care units. Surprisingly 66.7% of patients with IC were not obviously immunosuppressed. The high frequency of modifiable risk factors in our population indicates that candidemia can be reduced with stringent antibiotic and infection control measures. These data will be useful for empiric selection of antifungals in Karachi, and contribute to global assessments of antifungal resistance.Journal of Medical Microbiology 10/2012; · 2.50 Impact Factor -
Article: Is nalidixic acid screening still valid for the detection of reduced susceptibility of fluoroquinolone with SalmonellaTyphi?
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ABSTRACT: Considering the limitations of screening with nalidixic acid to detect reduced susceptibility to fluoroquinolones of Salmonella enterica serovar Typhi (S.Typhi) strains, we evaluated the use of a 30 µg nalidixic acid disc screening method in Pakistan. Non duplicate nalidixic acid susceptible S. Typhi isolates (246) from 2003-2008 were retrieved from the Salmonella strain bank. Minimum inhibitory concentrations of ciprofloxacin for all strains were determined by agar dilution and further rechecked by ciprofloxacin E-tests.E. coli ATCC 25922 was used as the control strain. The MIC data for ciprofloxacin were compared with nalidixic acid disk (30µg) zone diameters. Repeat testing of all S. Typhi isolates with a nalidixic acid (30µg) disk showed 100% susceptibility with an average zone diameter of 26 mm. Agar dilution testing revealed reduced susceptibility to ciprofloxacin, with MICs of 0.125 µg /ml for three (1.2%) isolates only. Zone sizes of strains with higher MICs were significantly lower than the strains with lower MICs (20 versus 26 mm) (p value < 0.001). Conclusion: Estimation of fluoroquinolone MICs on every nalidixic acid susceptible S. Typhi strain is not cost effective in our setting; the proportion of strains with high fluoroquinolone MICs was found to be very low. We recommend periodic fluoroquinolone MIC determination to include all isolates with a nalidixic acid borderline zone (size 20-22 mm).The Journal of Infection in Developing Countries 01/2012; 6(10):700-3. · 1.19 Impact Factor -
Article: Necrotising fasciitis due to Absidia corymbifera in wounds dressed with non sterile bandages.
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ABSTRACT: We present three cases of Absidia corymbifera necrotising fasciitis presenting to our centre within 1 month of each other. All patients had wound dressings with non sterile crepe bandages at peripheral centres. One patient was lost to follow-up, another improved on timely antifungal therapy, while the last patient succumbed to disseminated infection. We propose that traumatic and deep wounds be dressed with sterile roller bandages to prevent outbreaks of wound zygomycosis.International Wound Journal 08/2011; 8(6):651-5. · 1.46 Impact Factor -
Article: Comparison of chromogenic urinary tract infection medium with cysteine lactose electrolyte deficient media in a resource limited setting.
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ABSTRACT: To compare the chromogenic UTI medium (CUM) with cysteine lactose electrolyte deficient medium (CLED) in terms of isolation of uropathogens, turnaround time and cost. A total of 251 urine samples were selected and inoculated on both CLED and CUM, growth was observed after 24 and 48 hours of incubation. Isolates were identified by colony's colour and biochemical tests. Turnaround time for identification and cost was calculated till final identification of microorganisms. A discrepancy in isolation was observed in seven samples with growth on CUM in 24 hours while in 48 hours on CLED. There was 100% agreement in identification by both media. Almost 50% samples were identified within 24 hours by using CUM in contrast to CLED where most samples were identified in 48 hours. Total number of reagents used and total cost for processing of a specimen including technologist and consultant time by using CUM is significantly low in comparison to CLED. CUM can replace CLED as a primary isolation media for urine culture in clinical laboratories in Pakistan as it is user friendly, facilitates early reporting and saves cost.Journal of the Pakistan Medical Association 07/2011; 61(7):632-5. -
Article: Evaluation of prevalence of low and high level mupirocin resistance in methicillin resistant Staphylococcus aureus isolates at a tertiary care hospital.
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ABSTRACT: To evaluate the trend of mupirocin resistance in MRSA, isolated at the Clinical Microbiology Laboratory of a tertiary care hospital. A total of 200 MRSA strains recovered over a 2 year period from various body sites were tested using the 5 and 200 microg discs of mupirocin to detect its resistance. High level and low level mupirocin resistance were detected in zero and 1% of MRSA strains, respectively. Resistance to other non beta lactam antibiotics was also high. No MRSA strains were found to be resistant to vancomycin and tegicycline. Mupirocin resistance was found to be very low among local clinical isolates of MRSA. Its judicious use to decolonize nasal carriers should be promoted among hospitalized patients to avoid further transmission and infections due to prevalent endemic MRSA strains in any health care setting. Concomitantly, regular surveillance and effective infection control initiatives are desirable to reduce the incidence of health care associated infections due to MRSA and also of mupirocin resistance.Journal of the Pakistan Medical Association 06/2011; 61(6):519-21. -
Article: Evaluation of predominant Neisseria gonorrhoeae strain types and its correlation with fluoroquinolone resistance in Pakistan.
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ABSTRACT: To study the predominant Neisseria gonorrhoeae strain types in Pakistan and to evaluate their correlation with fluoroquinolone resistance. A total of 314 strains were collected from 2007-2009. Of these 112 strains were randomly selected for serotyping via the coagglutination technique. Fluoroquinolone susceptibility was checked through the E-test method. Chi square was performed to assess the correlation between the strain type and fluoroquinolone resistance pattern. N. gonorrhoeae isolates were typed in two serogroups and 28 serovars. Serogroup WI comprised 40% (n = 45) whereas WII/WIII was 60% (n = 67). Most commonly isolated serovar belonged to serogroup WI namely Aorst (10%). The other predominant circulating serovars of the serogroup WI were Aost (9%) and Ast (8%) and Bsy (8%), Bopyt (5%) and Bprt (4.5%) in the serogroup WII/III. Fluoroquinolone resistance was 98%, with an MIC of 2 microg/mL in 47%, 4 microg/mL in 36% and > 32 microg/mL in 12% of the isolates. On inferential analysis no significant correlation was observed between fluoroquinolone resistance and any particular serovars. A diverse population of N. gonorrhoeae serovars suggesting influx of a variety of gonococcal strains with high fluoroquinolone resistance was identified. This resistance was not associated with any particular serovars, so we speculated inappropriate use of fluoroquinolones in the community to be a major cause. Injudicious fluoroquinolone use in the community should be strongly discouraged to curtail increase in antimicrobial resistance. Furthermore, continuous surveillance of prevalent serovars will be critical to assess genetic alterations of endemic and imported strains to design effective disease control measures.Journal of the Pakistan Medical Association 05/2011; 61(5):446-9. -
Article: In vitro susceptibility of typhoidal Salmonellae against newer antimicrobial agents: a search for alternate treatment options.
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ABSTRACT: To determine the minimum inhibitory concentrations (MICs) of ceftriaxone, azithromycin, pefloxacin, cefipime and imipenem for Salmonella Typhi (S. Typhi) and Paratyphi. One hundred and fifty four isolates of Salmonella Typhi and S. Paratyphi A, B and C growing in blood culture were selected. MICs of ceftriaxone, azithromycin, pefloxacin, cefipime and imipenem were performed by agar dilution method as recommended by clinical laboratory standard institutes. MIC90 of azithromycin and pefloxacin was 8 microg/ml, cefipime was 0.06 microg/ml and imipenem was 0.5 microg/ml. None of the strains were found to be resistant to ceftriaxone but 3 isolates showed higher MIC value of 2 microg/ml. Azithromycin appears a suitable alternate for the treatment of typhoid in the community. Imipenem and cefipime are good options in complicated cases to be treated in hospital settings. Pefloxacin cannot be used as MICs are higher. Presence of isolates with higher MIC of ceftriaxone is serious and stresses upon continuous laboratory surveillance to guide clinicians appropriately.Journal of the Pakistan Medical Association 05/2011; 61(5):462-5. -
Article: Knowledge and beliefs among health care workers regarding hepatitis B infection and needle stick injuries at a tertiary care hospital, karachi.
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ABSTRACT: Hepatitis B virus (HBV) infection is a recognized occupational risk for health care workers (HCWs). This study aimed to assess the knowledge and beliefs of HCWs regarding HBV transmission and needle stick injuries (NSIs). A cross-sectional questionnaire based KAP study was conducted at Civil Hospital, Karachi, during the period of January to September 2006. HCWs were inquired about possible modes of HBV transmission and association with NSIs. Data were entered using EpiInfo 6.04d software. Statistical analysis was performed using SPSS 12.5 software. A total of 343 HCWs participated, and those answered at least 5 correct modes of HBV transmission were considered knowledgeable. Knowledgeable group was more likely to report NSIs (p < 0.006), more vaccinated (p < 0.001) and were also more likely to attend awareness session (p < 0.009). Overall knowledge were inadequate and behaviour and attitude towards clinical practices were found compromised. To reduce the occupational risk, effort should be focused to establish effective infection control program and training of staff.Journal of the College of Physicians and Surgeons--Pakistan: JCPSP 05/2011; 21(5):317-8. · 0.34 Impact Factor -
Article: A comparison of disease caused by Shigella and Campylobacter species: 24 months community based surveillance in 4 slums of Karachi, Pakistan.
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ABSTRACT: Despite the efforts of the international community diarrheal diseases still pose a major threat to children in children less than five years of age. Bacterial diarrhea has also emerged as a public health concern due to the proliferation of drug resistant species in many parts of the world. There is a paucity of population-based data about the incidence of shigellosis and Campylobacter infections in Pakistan. We report country specific results for Shigella diarrhea that were derived from a multicenter study conducted in six Asian countries. Disease surveillance was conducted over a 24 month period in urban slums of Karachi, Pakistan, a city with a population of 59,584. Cases were detected through passive detection in study treatment centers. Stool specimens or rectal swabs were collected from all consenting patients. Between January 2002 and December 2003 10,540 enteric infection cases were detected. The incidence rate of treated diarrhea in children under 5 was 488/1000/year. In children, 5 years and older, the diarrhea rate was 22/1000/year. 576 (7%) Campylobacter isolates were detected. The pre-dominant Campylobacter species was C. jenuni with an increase of 29/1000 year in children under 5 years. Shigella species were isolated from 394 of 8032 children under 5 years of age. Shigella flexneri was the dominant species (10/1000/year in children under 5 years) followed by Shigella sonnei (3.9/1000/year), Shigella boydii (2.0/1000/year) and Shigella dysenteriae (1.3/1000/year). Shigellosis and Campylobacter infection rates peaked during the second year of life. The incidence rate of shigellosis increased in old age but such a trend was not observed in Campylobacter infections. Of 394 shigellosis patients 123 (31%) presented with dysentery in contrast to only 54 (9%) of 576 patients with Campylobacter infections (p<0.001). Both Campylobacter infections and shigellosis are common in community settings of Pakistan but shigellosis presented more frequently with abdominal pain and dysentery than Campylobacter infections indicating that shigellosis may be a more severe illness than Campylobacter infections. Due to the increased and disease severity, drug resistant shigella have become a significant health problem; moreover it is a disease of poor and impoverished people who do not have the access to standard water and sanitary conditions, health care services or optimal treatment. In the face of these facts it is empirically important to develop a low cost effective vaccine that can protect these populations for a longer duration.Journal of infection and public health. 03/2011; 4(1):12-21. -
Article: Primary amebic meningoencephalitis caused by Naegleria fowleri, Karachi, Pakistan.
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ABSTRACT: We report 13 cases of Naegleria fowleri primary amebic meningoencephalitis in persons in Karachi, Pakistan, who had no history of aquatic activities. Infection likely occurred through ablution with tap water. An increase in primary amebic meningoencephalitis cases may be attributed to rising temperatures, reduced levels of chlorine in potable water, or deteriorating water distribution systems.Emerging Infectious Diseases 02/2011; 17(2):258-61. · 6.79 Impact Factor -
Article: Isolation frequency and susceptibility patterns of Nocardia species at a tertiary hospital laboratory in Karachi, Pakistan.
The Journal of Infection in Developing Countries 01/2011; 5(6):499-501. · 1.19 Impact Factor -
Article: Increasing Trend of Resistance to Penicillin, Tetracycline, and Fluoroquinolone Resistance in Neisseria gonorrhoeae from Pakistan (1992-2009).
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ABSTRACT: Emergence and spread of drug resistant Neisseria gonorrhoeae is global concern. We evaluated trends of antimicrobial resistance in Neisseria gonorrhoeae over years 1992-2009 in Pakistan. Resistance rates were compared between years (2007-2009) and (1992-2006). Antimicrobial susceptibility testing was performed and interpreted according to Clinical Laboratory Standards Institute (CLSI) criteria using the disk diffusion methodology against penicillin, ceftriaxone, tetracycline and ofloxacin. Additional antibiotics tested in 100 strains isolated during 2007-2009, included cefotaxime, cefoxitin, cefuroxime, cefipime, ceftazidime, ceftizoxime, cefixime, cefpodoxime, spectinomycin and azithromycin. Neisseria gonorrhoeae ATCC 49226 was used as control. Chi-square for trend analysis was conducted to assess resistance trend over the study period. During study period significant increase in combined resistance to penicillin, tetracycline and ofloxacin was observed (P value <0.01). Resistance rates during the two study period also increased significantly (P value <0.01). Ceftriaxone resistance was not observed. None of the isolates were found to be resistant or with intermediate sensitivity to additional antibiotics. Our findings suggest that penicillin, ciprofloxacin, tetracycline should not be used in the empirical treatment of gonorrhea in Pakistan. Ceftriaxone and cefixime should be the first line therapy; however periodic MICs should be determined to identify emergence of strains with reduced susceptibility.Journal of Tropical Medicine 01/2011; 2011:960501. -
Article: Plant root hair in tap water: a potential cause for diagnostic confusion.
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ABSTRACT: Plant root hairs are commonly found artifacts in parasitology specimens and may be confused with helminthes by an untrained eye. We report a case of brain tuberculoma where the tissue sample was contaminated with root hair derived from tap water; the presence of this root hair, which mimicked a larva, led to diagnostic confusion. Therefore, tap water should be considered a source of root hair and vegetable matter.The Korean Journal of Laboratory Medicine 01/2011; 31(1):44-6. · 0.63 Impact Factor -
Article: Rhinocladiella mackenziei as an emerging cause of cerebral phaeohyphomycosis in Pakistan: a case series.
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ABSTRACT: Six cases of Rhinocladiella mackenziei cerebral phaeohyphomycosis are being reported for the first time in Pakistan. Identification was confirmed by DNA sequencing (isolates and fixed tissue). Diabetes, head trauma, immunosuppressive treatment, and postpartum state were present in 4 cases. Two survivals and 3 fatalities occurred, with 1 patient lost to follow-up.Clinical Infectious Diseases 01/2011; 52(2):213-7. · 9.15 Impact Factor -
Article: Clonal dissemination of vanA positive Enterococcus species in tertiary care hospitals in Karachi, Pakistan.
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ABSTRACT: To perform molecular typing of vancomycin resistant Enterococcus spp. (VRE) strains endemic in various hospitals of Karachi, to characterize the mechanism of glycopeptide resistance and assess the genetic relatedness, for understanding its transmission locally. This was a cross sectional study conducted in the clinical and research laboratory of Aga Khan University Hospital (AKUH), Karachi, Pakistan from October 2007 to September 2008. Non-duplicate 86 (65 AKUH and 21 non-AKUH) VRE strains were included. Molecular typing of nosocomial isolates of VRE was carried out by using Pulsed field gel electrophoresis (PFGE) and identification of vanA and vanB genes were performed by conventional Polymerase Chain Reaction (PCR). Analysis of PFGE data by Tenover scheme showed single major pulsotype A with its subtypes A1, A2 and A3 present among different tertiary hospitals in Karachi. The dice coefficient of similarity among AKUH, non-AKUH and total 86 (AKUH and non-AKUH) had a value of 90%, 88% and 89% reflecting their clonal relatedness. In all 60/65 (92%) and 19/21 (90%) AKUH and non-AKUH isolates had vanA gene respectively. None had vanB gene. Molecular typing suggested that VRE isolates had same clonal origin indicating nosocomial transmission. Institution of strict infection control measures with active surveillance should be taken to avoid its further spread.Journal of the Pakistan Medical Association 10/2010; 60(10):805-9. -
Article: Prevalent genotypes of meticillin-resistant Staphylococcus aureus: report from Pakistan.
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ABSTRACT: Meticillin-resistant Staphylococcus aureus (MRSA) is a major nosocomial pathogen in Pakistan and is emerging in the community. This is one of the first reports of the prevalent genotypes of MRSA in both hospital and community settings in Pakistan. Isolates collected in 2006-2007 were characterized by PFGE, staphylococcal cassette chromosome mec (SCCmec) typing and multilocus sequence typing (MLST). PFGE identified nine pulsotypes, the majority of isolates belonging to pulsotypes A (n=70) and B (n=38), which were predominant among hospital-onset MRSA (HO-MRSA) and community-onset MRSA (CO-MRSA) isolates, respectively. Among the HO-MRSA isolates, variants of SCCmec type III were prevalent, whilst SCCmec type IV or variants were predominant in the CO-MRSA isolates. MLST identified two principal sequence types, ST8 and ST239. An association was observed between ST8, PFGE pulsotype B and SCCmec type IV in the CO-MRSA (ST8-MRSA-IV). Similarly, ST239, PFGE pulsotype A and SCCmec type III were associated with HO-MRSA (ST239-MRSA-III). Therefore, the prevalent genotypes circulating in Pakistan at the time of study were ST8-MRSA-IV and ST239-MRSA-III in the community and hospital settings, respectively. A set of HO-MRSA isolates collected in 1997 were characterized by PFGE and SCCmec typing for comparison. The isolates belonged to two PFGE pulsotypes (A, n=28; B, n=11) and contained just two SCCmec types. These results suggest that an increase in genetic diversity occurred over the period 1997-2007 as a result of either microevolution or the importation of strains from surrounding areas.Journal of Medical Microbiology 09/2010; 60(Pt 1):56-62. · 2.50 Impact Factor -
Article: Inducible clindamycin resistance due to expression of erm genes in Staphylococcus aureus: report from a tertiary care Hospital Karachi, Pakistan.
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ABSTRACT: To assess the frequency of phenotypic expression of inducible resistance of clindamycin due to expression of erm genes, in clinical isolates of Staphylococcus aureus (S. aureus), by double disk diffusion test (D-test). This was a cross sectional study conducted in the clinical laboratory of Aga Khan University Hospital, Karachi. A total of 2432, non duplicate clinical isolates of S. aureus, consisting of 1562 methicillin sensitive S. aureus (MSSA) and 870 methicillin resistant S. aureus (MRSA), were selected from February 2007 to January 2008. One hundred and thirty eight isolates of S. aureus were selected based on discordant resistance pattern (erythromycin resistant and clindamycin sensitive) on Kirby Bauer Disk Diffusion test and phenotypic expression of inducible resistance was assessed using D-test. Analysis of 2432 isolates showed that 64% (n=1553) were susceptible to both clindamycin and erythromycin by disc diffusion method, while 30% (n=741) showed constitutive resistance (in vitro resistance to both drugs). 6% (n=138) isolates showed clindamycin-erythromycin discordance on disc diffusion (in vitro sensitive to clindamycin and resistant to erythromycin). Among the discordant isolates 72% (n=99) had inducible resistance phenotype detected by D-test and of these 85 isolates (62%) were MRSA. Inducible resistance is common in our clinical isolates; D-test (a simple phenotypic test) should be performed on all S. aureus isolates showing clindamycin-erythromycin discordance on disc diffusion, to avoid erroneous reporting resulting in treatment failure.Journal of the Pakistan Medical Association 09/2010; 60(9):750-3. -
Article: Vibrio cholerae O1 bacteremia in Pakistan: analysis of eight cases.
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ABSTRACT: Bacteremia caused by Vibrio cholerae O1 has been a rare phenomenon. We report on eight cases of V. cholerae O1 bacteremia from Pakistan which occurred during 1992-2008. Six of the cases were seen in children (two neonates and four infants) and seven of the eight patients were female. Urogenital malignancy, hepatitis B virus-associated end-stage liver disease, concurrent Campylobacter enteritis and prematurity were the underlying conditions in four patients. Two of the eight patients died and one was lost to follow up and this outcome may be due to prior immunity leading to less severe illness.Transactions of the Royal Society of Tropical Medicine and Hygiene 08/2010; 104(8):563-5. · 2.16 Impact Factor -
Article: Emergence of CTX-M Group 1-ESBL producing Klebsiella pneumonia from a tertiary care centre in Karachi, Pakistan.
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ABSTRACT: Extended-spectrum beta-lactamase (ESBL)-producing Klebsiella pneumoniae have been reported previously from Pakistan but the genotypic characteristics of these enzymes is not known. Hence the aim of the study was first to characterise the genotypic content of these beta-lactamases and secondly to assess the clonal relationship of these isolates. We analysed 65 non-duplicate ESBL positive, K. pneumoniae isolates prospectively collected based on phenotype as detected using the two-disc method. Isolates were collected from different sources: blood cultures (46.15%; n = 30); tracheal aspirates (24.6%; n = 16); urine (10.7%; n = 7); wound swabs, pus and tissue (18.4%; n = 12). ESBL production was confirmed by the ESBL E-test method and the presence of the blaCTX-M encoding genes was confirmed by polymerase chain reaction. The clonal relationship of clinical isolates was studied by Pulsed Field Gel Electrophoresis. The results showed that 93.84% (n = 61) isolates of K. pneumoniae were positive for the blaCTX-M-1 group. One isolate showed PCR signals for blaCTX-M-25 group. None of our isolates were positive for CTX-M groups 2, 8 and 9. The majority of blaCTX-M positive isolates were genetically unrelated and no epidemic clones were identified. This study reports the emergence of CTX-M groups 1 and 25 producing isolates of K. pneumoniae with genetic diversity in Karachi, Pakistan.The Journal of Infection in Developing Countries 08/2010; 4(8):472-6. · 1.19 Impact Factor -
Article: Increased isolation of ESBL producing Klebsiella pneumoniae with emergence of carbapenem resistant isolates in Pakistan: report from a tertiary care hospital.
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ABSTRACT: To report trends of extended spectrum beta lactamase (ESBL), multidrug resistant (MDR) ESBL and emergence of carbapenem resistant ESBL producing isolates of K. pneumoniae from Pakistan. Retrospective analysis of laboratory data was conducted (2002-2007). K. pneumoniae were isolated and identified from clinical samples using standard microbiological techniques. Antimicrobial susceptibility testing was performed by Kirby Bauer. ESBL was detected using combined disc method. Statistical analysis was performed using SPSS version 13. 15914 K. pneumoniae isolates (2002-2007) were analyzed. Significant increase in ESBL and MDR ESBL producing K. pneumoniae (p = or < 0.0001) was observed. We found significant association of ESBL positive K. pneumoniae with age less than 10 years, males and blood isolates (p = 0.001). 0.4% (n=23) of ESBL positive isolates were carbapenem resistant. Increase in ESBL and carbapenem resistant K. pneumoniae is a serious threat to public health requiring continuous surveillance and use of appropriate screening tests for laboratory detection.Journal of the Pakistan Medical Association 03/2010; 60(3):186-90.
Top co-authors
Top Journals
Institutions
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2005–2012
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Aga Khan University Hospital, Karachi
Karachi, Sindh, Pakistan -
Imperial College London
- Centre for Molecular Microbiology and Infection
London, ENG, United Kingdom
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2011
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Aga Khan University, Pakistan
- Department of Paediatrics and Child Health, Pakistan
Karachi, Sindh, Pakistan
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2008
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Postgraduate Medical Institute
Lahore, Punjab, Pakistan -
Lady Reading Hospital
Peshāwar, North West Frontier Province, Pakistan
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