Vaccine Trends in Pakistan: A Review of Immunization Challenges and Setbacks Prompted by Inadequate Disaster Management

Pakistan bears an incredible burden of vaccine-preventable diseases, and efforts to improve widespread immunization have been hindered by inadequate public health management following disasters and other health emergencies. Through a brief review of Pakistan's health system, an understanding of routine immunization challenges is sought based on the organizational changes made to the planning and delivery of immunization activities. Further, recent immunization trends of measles, polio, and tuberculosis are examined in correspondence to health emergencies prompted by climate change and the COVID-19 pandemic. The national public health response to each disease is discussed, and insight is given to how the devolution of Pakistan's health system may have influenced the severity of each emergency. Focus is given to the potential immunization challenges and how they may impact future initiatives for the control of vaccine-preventable diseases. Although incidence rates suggest increased cases of certain vaccine-preventable diseases and disruptions of immunization activities following recent disasters, further studies may need to be conducted to establish a stronger understanding of the immunization trends noted within this review.

Comparison of Efficacy of Topical Betamethasone Dipropionate and Topical Minoxidil in Patients With Alopecia Areata

Background and objective Alopecia areata (AA) is a reiterative and nonscarring type of hair loss that can affect any hairy area of the body, particularly the scalp. It manifests as patchy or confluent hair loss with variations in demographics and ethnicity. There are numerous treatment options available, including topical and systemic steroids, topical minoxidil, dithranol, tacrolimus, psoralen and ultraviolet therapy (PUVA), contact immunotherapy, and oral immunosuppressive drugs. However, no previous contrast for efficacy is present between the topical betamethasone versus topical minoxidil alone in our population. This study aims to compare the efficacy of topical betamethasone dipropionate versus topical minoxidil in patients with AA. Methodology A nonrandomized controlled study was conducted at the Department of Dermatology, Jinnah Hospital Lahore, incorporating the data of patients between July 26, 2016, and January 26, 2017, after obtaining institutional ethical approval. One hundred patients with alopecia, either on the scalp or any other hairy part, from both genders, aged between 18 and 50 years, were included in the study. Two groups were created, and patients were assigned to these groups based on the clinician's choice. Group A patients were administered betamethasone dipropionate (0.05%) lotion twice daily on affected areas for 12 weeks. Group B patients were administered minoxidil (5%) solution twice daily on affected areas for 12 weeks. A four-week follow-up plan was followed. A five-point scale score system was used for alopecia grading. After 12 weeks, the hair regrowth score (RGS) was used to compare the efficacy of treatment between the two groups. Results A total of 100 patients with grades S1 to S3 AA of less than three months duration were enrolled. Two groups were created, with 50 patients in each group. The mean age in Group A was 29.08 ± 6.51 years, while in Group B, it was 29.38 ± 6.62 years. In Group A, there were 76% males and 24% females, while in Group B, there were 74% males and 26% females. Comparison of efficacy of topical betamethasone dipropionate versus topical minoxidil in patients with AA demonstrated a greater efficacy of 74% (Grade 3 and Grade 4 responses) in Group A, while in Group B, only 42% of patients showed efficacy. A statistically significant difference was found, with a P-value of 0.001. No serious side effects were noted. Conclusions Our study concluded that topical betamethasone dipropionate (0.05%) lotion has statistically significantly higher efficacy compared to topical minoxidil (5%) solution in patients with AA.

Diphtheria's Dual Threat: Amplifying Awareness of Cardiac Complications for Enhanced Intervention

Even though immunization can prevent illness, diphtheria, which is caused by toxic strains of Corynebacterium diphtheriae, remains a serious public health risk. Although the worldwide incidence has declined, it still poses a serious hazard in developing countries, such as Pakistan, where new data suggest an increase in cases. A significant proportion of patients with respiratory diphtheria experience cardiac complications, specifically myocarditis, which carries a high death risk of 50% to 75%. The diphtheria toxin's affinity for cardiac tissues is the cause of these consequences, which include arrhythmias and myocardial dysfunction. Recent studies from Lady Reading Hospital in Peshawar show the seriousness of the situation, with 73 patients presenting with cardiac complications in just one year, resulting in a devastating fatality rate despite early management. This highlights the pressing need for increased awareness and all-encompassing immunization campaigns, particularly for children who have received insufficient vaccinations. Timely vaccination and booster doses are critical for reducing myocarditis-related mortality, mandating prioritizing immunization efforts to defend susceptible populations globally.

Addressing the Crimean-Congo Hemorrhagic Fever Crisis in Pakistan's Healthcare System: An Urgent Call for Holistic Action

The recent resurgence of the Crimean-Congo hemorrhagic fever (CCHF) in Pakistan's Balochistan province has significantly impacted both the medical community and the general population. Initially perceived as a concerning development, the situation has deteriorated, culminating in the infection and mortality of healthcare workers directly engaged in managing this virulent outbreak. This critical situation necessitates an urgent and collective response, transcending national boundaries to involve the international healthcare community.

The Diagnostic Association of Radiological and Clinicopathological Parameters in Community-Acquired Pneumonia in Children: A Cross-Sectional Study

Background Globally, pneumonia is one of the significant causes of death in children under the age of five years. Assessment of disease severity is essential for clinical decision-making. Clinicians in resource-limited settings use the WHO Integrated Management of Childhood Illness (IMNCI) guidelines to diagnose and treat pneumonia. Chest X-rays and blood biomarkers are frequently performed in children presenting with pneumonia, but their role in clinical decision-making is limited. Objective To evaluate the association of chest X-ray results, clinical parameters, and blood inflammatory biomarkers with the severity of community-acquired pneumonia (CAP) in children to decide which tests are helpful in accurately classifying the severity of pneumonia. Methods This cross-sectional, analytical study was conducted at the Combined Military Hospital, Lahore, among 421 children aged two months to five years who were admitted with complaints of cough and difficulty breathing and were COVID-19 negative. Data was collected through a structured questionnaire, including demographic information and clinical categorization of pneumonia severity using WHO criteria, SpO2 levels, chest X-rays, complete blood count (CBC), and C-reactive protein (CRP) levels obtained within 24 hours of admission. Statistical evaluation of 323 children was done using SPSS version 26, and analysis of variance (ANOVA), chi-square test, and Fisher's exact test were applied to determine statistical significance. p-Value <0.05 was considered significant. Results The median age of the study population was eight months (IQR: 3-20 months); 113 (33.1%) were girls and 127 (37.2%) were underweight children. Eighteen (5.3%) patients had no pneumonia, 245 (71.8%) patients had non-severe pneumonia, and 78 (22.9%) patients had severe pneumonia. The clinical features of severe pneumonia were more common in children with radiologic findings of alveolar CAP than non-alveolar CAP (36.2% and 20%, respectively, p: 0.05). A higher percentage of patients with alveolar CAP had CRP >6 mg/dL than non-alveolar CAP (69.9% and 35%, respectively, p < 0.001). Patients with undernutrition (WAZ <-2 SD), hypoxemia (SpO2 <95%), and having CRP >6 mg/dL were associated with clinical features of severe pneumonia (46.1% vs. 33.8%, 100% vs 47.3%, and 67.9% vs 48.5%, respectively, p < 0.05). A significantly greater frequency of a bilateral multifocal distribution (p = 0.020), and the involvement of the right paracardiac region (p = 0.043) and the left lower lobe (p = 0.007) in those with severe pneumonia was observed. Conclusion Clinical diagnosis of pneumonia, along with the assessment of risk factors, including undernutrition and hypoxemia, should be adequate to diagnose pneumonia in children. Chest X-rays and CRP levels can be helpful in hospitalized children for whom physicians have difficulty deciding about antibiotic prescriptions, but their role in routinely classifying the severity of pneumonia in children is limited.

Health-Related Quality of Life Assessment for Liver Cirrhosis Patients at a Tertiary Care Hospital in Karachi, Pakistan

Background The global health challenge of cirrhosis affects millions of individuals. Still, there is a notable lack of research on the health-related quality of life (HRQOL) of cirrhosis patients, especially in specific regions. This study aims to assess the impact of cirrhosis on HRQOL, including factors influencing it in a tertiary care setting in Pakistan. Methodology A cross-sectional study was conducted on a cohort of 115 patients diagnosed with cirrhosis, confirmed on imaging. HRQOL was measured using the short-form 36 (SF-36) survey. Furthermore, socioeconomic factors and self-rated health perceptions regarding HRQOL were recorded. Factors Influencing HRQOL domains in liver cirrhosis patients were also analyzed. Results Among 115 liver cirrhosis patients, 63.5% (N=73) were aged 40-60 years, and 73.9% (N=85) lived primarily in urban areas. HRQOL assessments highlighted moderate disability in physical functioning (62.6 ± 26.5) and notable impacts on mental health, emotional well-being, and bodily pain. Statistical analysis demonstrated the complexity of factors influencing HRQOL. Physical functioning was significantly associated with a higher Child-Turcotte-Pugh class, diabetes mellitus, hypertension, smoking status, and family monthly income (p-value < 0.05). While the duration of liver cirrhosis showed a significant association with bodily pain (p < 0.05). Additionally, residence status with social well-being (p-value = 0.01), and family monthly income with vitality (p-value < 0.05).  Conclusion Our study in Pakistan highlights significant impacts on the HRQOL of liver cirrhosis patients, affecting physical function, mental health, emotional well-being, and bodily pain. Factors influencing HRQOL include liver disease severity, comorbidities, and socio-economic status. Recommendations include educational programs and specialized nursing care to address diverse challenges. The findings stress the importance of a personalized approach to patient care, urging urgent, targeted efforts to improve the health-related standard of life for cirrhotic patients.

Disaster after disaster: the outbreak of infectious diseases in Pakistan in the wake of 2022 floods

In June 2022, Pakistan witnessed catastrophic floods, affecting millions of people. The ensuing epidemics of cholera, cryptosporidiosis, rotavirus infections, generalized diarrhoea, typhoid and paratyphoid fevers, as well as the frequency of vector-borne diseases including malaria and dengue fever, are studied in this investigation. It also explores the latest outbreak of poliomyelitis and the frequency of respiratory diseases such COVID-19, diphtheria, and tuberculosis, as well as how floods have contributed to skin and eye problems. The report also describes the obstacles governments must overcome in order to manage these health emergencies and offers possible solutions for reducing the effects of ongoing and anticipated epidemics. This flood emphasizes the pressing need for international action and acts as an alarming indicator of the significant impact of climate change. It emphasizes how crucial it is to have effective flood response and preparation strategies in developing nations that are vulnerable to natural disasters.

Laparoscopic Transabdominal Pre-peritoneal Repair of a Bilateral Inguinal Hernia in a Pediatric Female Patient in Pakistan: A Case Report

Inguinal hernias, although a common occurrence, pose a significant threat to the surgical community on account of their complexity and socioeconomic consequences. Bilateral inguinal hernias, which are a rare subtype of inguinal hernias, in particular, are problematic since there are no existing definitive international guidelines for their repair. It is estimated that between 8% and 30% of inguinal hernia patients have bilateral hernias, but there is still no clarity as to whether a bilateral hernia represents a special type of inguinal hernia or two different hernias in one patient. The transabdominal pre-peritoneal repair (TAPP), totally extra-peritoneal repair (TEP), and Lichtenstein repair techniques are commonly employed depending on the resources and surgical expertise available, but there is a need to conduct large-scale, prospective, randomized-controlled trials to guide the formation of evidence-based guidelines that could be followed globally. Herein, we present the first known case of a bilateral inguinal hernia in a female pediatric patient repaired by the laparoscopic TAPP technique from Pakistan.

COVID-19 Testing Trend: A Retrospective Analysis of the Three Major Pandemic Waves in Punjab, Pakistan

BACKGROUND/OBJECTIVES

There is some evidence in the literature of under-testing of COVID-19 cases in Pakistan. This study aims to explore COVID-19 testing trends and the factors affecting them in a lower middle-income country for future infectious disease policy-making and intervention strategies.

METHODOLOGY

The study was conducted as a serial cross-sectional study during the three major peaks from March 2020 to June 2021 on 1616 participants in Punjab, Pakistan. This is the first study to explore COVID-19 testing trends in association with flu-like symptoms (FLS) and the factors affecting all three major waves in Pakistan.

RESULTS

The results show that in all three waves, only 18.8% reported COVID-19 tested despite that 86.7% thought they had already had COVID-19, with 51.3% reporting having FLS and 35.6% with exposure to FLS from their families and 19.8% of positive testing rate among their family members. Out of the survey participants, 66% received vaccination, and over 80% had their eligible family members immunized. Fear of contracting COVID-19 was 69.7% in all three waves. Factors positively associated with the uptake of testing were the age group of 31-40 years with an adjusted odds ratio of 3.27 (95% confidence interval (CI): 2.09-5.12) for the second wave and an adjusted odds ratio of 13.75 (95% CI: 9.43-20.01) for the third wave and traveling abroad with odds of 3.08 times when the reference was inland traveling. The adjusted odds ratio to test for FLS was 1.62 (95% CI: 1.21-2.16).

CONCLUSION

In this study, there is convincing evidence of COVID-19 under-testing and thus under-reporting. This study also suggests that fear-based interventions may be counterproductive; however, economic factors such as education, employment, and traveling are significant in guiding the behavior for infectious disease prevention and management.

Non-compliance of Spectacle Wear in School-Going Children With Refractive Errors

Background Uncorrected refractive errors are the most common cause of avoidable visual impairment in children worldwide. The school screening of refractive errors is one of the most important initiatives outlined in WHO Vision 2020 targets for control of avoidable visual impairment in children. However, the benefit depends on the compliance of the spectacle worn by children. Objective To determine non-compliance of spectacle wear and its predisposing factors among school-going children in Lahore, Pakistan. Methods This cross-sectional analytical study was conducted among 200 school-going children (5-16 years), with spectacle prescription for at least the last six months studying in primary and secondary schools of Lahore, by using convenience sampling. We collected data with the help of a standardized, self-administered, close-ended questionnaire determining age, gender, class, and non-compliance and its reasons. Data were subjected to statistical evaluation using Statistical Product and Service Solutions (SPSS, version 26; IBM SPSS Statistics for Windows, Armonk, NY), and a chi-square test was applied to determine the statistical significance. p-value 0.05 was considered significant. Results Of the 200 children, 42 were boys, and 158 were girls, with a mean age of 12 years with a standard deviation of 2.6. The proportion of spectacle wear non-compliance was 19.5% (n=39). Children with non-compliance were more likely in the age group of 14-16 years (n=20{51.3%}; p=0.039). The main reasons for non-compliance were dislike to wear spectacles (28.2%), broken spectacles (23.1%), spectacles causing headache (20.5%), spectacles lost and parents' disapproval (20.5%), and peer pressure/teasing (15.4%). Significant difficulties faced while wearing spectacles were pressure on the nose due to worn-out nose pads (36.4%), pressure on ears causing pain in the temple and headache (34.1%), repeated cleaning of spectacles (29.5%), heavy spectacles (18.2%), excessive glare and pain in the eyes (12.5%), and improper fitting of spectacles (11.4%). Conclusions We found that non-compliance was more significant in school-going children aged 14-16 years and girls. The main reasons were unlikeness to wear, broken spectacles, headache, and spectacles lost. School children were not compliant because of many issues that should be addressed, and this information will be used for better eye care in school-going children with refractive errors.

Knowledge, Attitudes, Anxiety, and Preventive Behaviors Related to COVID-19 Among Healthcare Providers: A Developing Country's Perspective

Background In early 2020, the rapid global spread of coronavirus disease 2019 (COVID-19) presented healthcare workers (HCWs) with an unprecedented challenge. The constant influx of new information about the virus created knowledge gaps, and the relentless demands of their work schedules left many feeling overwhelmed. This paper explores the knowledge, attitudes, anxiety levels, and preventive behaviors of HCWs in the twin cities of Pakistan, Rawalpindi and Islamabad, related to the COVID-19 pandemic. In the face of this crisis, it is essential to gain insights into the experiences and needs of these frontline heroes. Methodology We conducted a descriptive web-based cross-sectional study among healthcare professionals to delve into the multifaceted aspects of their experiences. This included analyzing sociodemographic characteristics, knowledge levels, attitudes, practices, and the psychological implications of the pandemic. By employing both quantitative and qualitative analysis, we aimed to provide a comprehensive understanding of these parameters. Results Out of the 1150 responses collected, it became evident that breathing problems were the most recognized symptom of COVID-19 among HCWs. Impressively, 95.7% of participants believed in the primarily symptomatic nature of treatment, although 37% held the misconception that antibiotics were effective against the virus. Another noteworthy discovery was that 68.2% of HCWs favored testing before initiating treatment, yet a concerning 22.7% of treated patients received no testing. A significant proportion, approximately 19.6%, experienced heightened anxiety levels during the pandemic, leading to an increased frequency of handwashing. In terms of preventive behaviors, a majority of respondents displayed a heightened sense of caution. Nearly 59.1% reported avoiding the use of others' accessories and emphasized not reusing face masks. Furthermore, 84.1% of participants preferred staying at home during quarantine. Conclusion The study reveals the profound impact of COVID-19 on healthcare providers in Pakistan's twin cities, highlighting elevated anxiety levels among most. This underscores the urgent need for mental health support. Beyond physical effects, the pandemic significantly strains their psychological well-being. To address this stress, vital strategies include workload reduction, structured shifts, stressor minimization, and improved knowledge sharing. Cultivating a healthy work environment is equally crucial for healthcare providers' overall well-being. These insights are essential for crafting policies and interventions to better protect and support frontline workers in a developing nation like Pakistan, demonstrating healthcare professionals' resilience and dedication amid unprecedented challenges.

Practices of Informed Consent for Emergency Procedures at a Tertiary Care Hospital in Lahore, Pakistan

Background The purpose of obtaining informed consent is to ensure that patients undergoing any medical or surgical intervention are neither deceived nor coerced. Accurately estimating surgical risks is critical for shared decision-making and informed consent. Probable complications and alternative procedures should be presented to the patient so that they can freely choose an operative option. However, this factor is difficult to carry on in emergencies where an urgent decision is required. Objective This study aimed to assess the ongoing clinical practices of informed consent in emergency surgeries at a tertiary care facility. Materials and methods A cross-sectional survey was carried out from March 2022 to June 2022 at the Department of General Surgery, Lahore General Hospital, Lahore, Pakistan, with patients who had undergone surgical procedures under local, spinal, or general anesthesia within 24 hours of presentation. A Google Form (Google Inc., Mountainview, CA) was designed, containing a predefined set of 32 standard questions, and patients were interviewed in their native language to assess their satisfaction regarding the pattern and components of emergency informed consent. Categorical data were assessed using measures of central tendency, frequencies, and percentages. Results A total of 169 patients were selected for the study. Only 1.6% of them signed the consent form themselves, while 93.5% of the forms were signed by their first-degree relatives. Verbal consent was taken in 4.8% of cases. In 88% of cases, informed consent was obtained by the house surgeons. The majority of patients, i.e., 78.2%, were not able to read the written consent form; however, 83.1% understood the verbal information. About 66.3% of patients agreed that they were informed about the nature of their disease, while 67.5%, 14.8%, and 13.7% affirmed that they were explained the nature of surgical intervention, associated risks, and type of anesthesia, respectively. Overall, 59.5% of patients felt satisfied with the process of informed consent. About 91.1% of the patients believed that their decisions were unaffected by the procurement of informed consent. Conclusion The existing practices of informed consent and comprehension by the population were found to be substandard. Physicians seem to ignore bioethics, and patients appear to be unaware of their basic rights. Although practiced at our center, not all components of informed consent were communicated to the patients. The risks of the procedures and the mode of anesthesia used were not well addressed by doctors. There is a grave need to educate the medical community about the legal and ethical aspects of informed consent, as well as the public masses regarding their rights.

Patient Safety Culture: A Healthcare Provider's Prospect

INTRODUCTION AND OBJECTIVE

Safe care is a challenge around the globe, especially in developing countries. In resource-limited settings achieving patient safety is an additional complexity. Patient safety is now considered a significant public health concern worldwide. Despite a vital role in delivering quality care, little attention has been given to describe healthcare professionals' perceptions of the patient safety culture in Pakistan. This study aimed to assess the patient safety culture at a tertiary care public hospital in Lahore from the perspectives of doctors and nurses.

METHODS

During this cross-sectional study, data were collected from 290 nurses and doctors using a validated safety assessment survey tool of the Hospital Survey of Patient Safety Culture (HSOPSC). The respondent's demographic characteristics and study variables influencing patient safety culture were presented, and a chi-square test was applied to identify the variables influencing patient safety.

RESULTS

A total of 114 medical doctors (39.3%) and 176 registered nurses (60.7%) participated in assessing patient safety culture (PSC) across tertiary care public healthcare centers in Lahore. The dimensions of organizational learning and continuous improvement (90.6%) and teamwork within units (86.6%) were the highest. Other dimensions include feedback and communication about the error (71.8%), teamwork across units (74.9%), management support for patient safety (67.3%), supervisor/manager expectations, and actions promoting patient safety (64.6%), communication openness (64.5%), overall perceptions of patient safety (65.3%), frequency of events reported (58.7%), and handoffs and transitions (60.9%) showed moderate status. The dimensions of staffing (35.8%) and non-punitive response to errors (39.1%) had the lowest score.

CONCLUSIONS

The present public hospital survey results revealed that medical staff working in a healthcare setting have a less positive perception of patient safety culture.

Insights Into Cystic Fibrosis Gene Mutation Frequency, Clinical Findings, and Complications Among Pakistani Patients

Background Cystic fibrosis (CF) is a genetic disorder with diverse symptoms. Understanding its genetic basis and prevalence is crucial for effective management and treatment. Objective The study aimed to provide comprehensive insights into the frequency of CF gene mutations, clinical presentations, and complications among the Pakistani population. Methodology A cohort comprising 892 patients, ranging in age from 18 to more than 40 years, was selected on the basis of clinical and genetic criteria for the diagnosis of CF. Polymerase chain reaction (PCR) was used to look for 34 variants in the CFTR gene in blood samples. Statistical analysis, which included figuring out the number of mutations, the average age of diagnosis, and the genetic diversity of the samples, was performed to analyze the percentage of patients with specific mutations, offering insights into the genetic diversity. Results In our comprehensive analysis of 892 patient samples, 77.47% (n=691) displayed consanguinity, indicating a family history. The prevailing symptoms included chronic cough (88.67%; n=791), recurrent respiratory infections (76.68%; n=684), and fatigue (73.76%; n=658). The major complications comprised pulmonary infections (22%; n=197), cystic fibrosis-related diabetes (21%; n=187), and malabsorption (20%: n=178). A paired t-test revealed a mean difference of 5.750 with a standard deviation of 9.147, a 95% confidence interval from -0.061 to 11.561, a t-value of 2.178 with 11 degrees of freedom, and a two-tailed p-value of 0.052, suggesting a potential trend towards significance. Nevertheless, the asymptotic significance values of 1.000 and 0.998 for both groups indicate no significant difference. Furthermore, the study identified 12 cystic fibrosis gene mutations, with F508del and N1303K being the most prevalent. Conclusion This research revealed significant consanguinity, confirmed typical CF symptoms, and identified common complications and prevalent CFTR gene mutations (with F508del and N1303K being the most common), providing insights for genetic guidance and treatment in the Pakistani community.

Exploring the Indications, Levels, and Outcomes of Lower Extremity Amputation at a Tertiary Care Hospital in Pakistan

BACKGROUND

Lower extremity amputation (LEA) is a surgical procedure performed to remove either a part or the entire lower limb due to medical conditions such as trauma, infection, peripheral vascular disease, or malignancy. The procedure is becoming increasingly common in Pakistan, with a bulk of patients presenting from rural areas in tertiary care centers. Understanding the indications, levels, and outcomes of LEA is essential for improving patient care and adopting preventive strategies, especially in developing countries.

METHODOLOGY

This study was conducted at Dow University Hospital in Karachi, Pakistan. Retrospective data of 384 patients who underwent non-traumatic lower extremity amputations between January 2016 and December 2020 was collected to include relevant history and characteristics, amputation indication and level, type of anesthesia used, and outcome within hospital stay. The data was analyzed using descriptive statistics.

RESULTS

The data is composed of a wide age range (18 to 91 years) of patients, including a male majority (76.3%, n = 293). The employment status of the patients was taken into consideration, with a reported high number of unemployed individuals (60.4%, n = 232). Diabetes mellitus (84.4%, n = 324) was a commonly reported past medical condition, followed by hypertension (4.4%, n = 17). Indications for amputation exceedingly recorded were diabetic foot ulcers (84.4%, n = 324), followed by infections (9.4%, n = 36) and peripheral arterial disease (3.6%, n = 14). The anesthetic approach that was observed most in these patients was regional anesthesia (74.7%, n = 287). Right-sided amputations (52.9%, n = 203) were dominant, with below-knee amputations leading by the level of amputation performed (42.5%, n = 163). Many patients delayed seeking treatment (71.6%, n = 275) and indicated denial of severity (18%, n = 69) as a reason for the delay. Regarding outcome, many patients were successfully discharged following treatment (85.9%, n = 330).

CONCLUSION

Overall, LEAs are being frequently performed in developing countries, such as Pakistan, especially with a large population living with diabetes mellitus. The implications of this disease are reflected in this study population, with the majority of patients reporting delays in treatment due to reasons such as the unknown severity of the disease or financial burdens. The challenges faced by these individuals, especially in this country, can be tackled with widespread affordability and availability of care and education on early management.

Outcome of patients with primary and secondary hemophagocytic lymphohistiocytosis: A retrospective analysis from a tertiary care center

Hemophagocytic lymphohistiocytosis (HLH) is a progressive and potentially life-threatening disorder. It is classified into primary and secondary HLH. The objective of our study was to determine the outcome of primary and secondary HLH in pediatric and adult patients based on HScore and treatment modality. We conducted a retrospective analysis done from July 2010 to June 2020. Variables analyzed included age, gender and history of death in siblings. HScore was used for disease classification while clinical and laboratory findings which were required to fulfill the HScore diagnostic criteria were also recorded. Continuous variables were summarized as median and categorical variables as frequencies and percentages. Categorical variables were compared using chi-square test and Fisher Exact test. Significance of different variables between primary and secondary HLH was calculated using independent-samples t test. A P value of < .05 was taken as significant. A total of 51 patients were included in the analysis (41 in primary and 10 in secondary HLH group). In primary HLH, 36 patients were in the pediatric age group and 12.2% had a history of death in sibling. All 41 patients had increased ferritin and decreased fibrinogen levels. The overall survival in primary HLH was 44%. In the secondary HLH group, viral infections were the most common etiology and ferritin was increased as well. The overall survival in secondary HLH was 60%. The median survival was 15 ± 4.8 months. The overall survival of both groups combined was 53%. Primary HLH should be considered in pediatric patients who present with pancytopenia and hepatosplenomegaly. In centers where genetic testing is not available, HScore along with serum ferritin and fibrinogen is a good substitute for disease classification.

Clinical and Genetic Description of Hereditary Chronic Pancreatitis in Pakistani Children

BACKGROUND/AIMS

The purpose of this study was to identify the spectrum and frequency of pathogenic variants as well as the clinical and genetic insight of hereditary chronic pancreatitis in Pakistani children.

MATERIALS AND METHODS

The deoxyribonucleic acid of affected probands of 44 unrelated Pakistani families, having hereditary chronic pancreatitis-affected children, were subjected to massive parallel sequencing for candidate reported genes (SPINK1, PRSS1, CFTR, CPA1, CTRC, CBS, AGL, PHKB, and LPL). Data were analyzed using different bioinformatics tools for the variants and in-silico analysis. All the identified variants were validated by direct sequencing of the targeted exons in the probands and their parents.

RESULTS

There were 50 patients included in this study with confirmed hereditary chronic pancreatitis. Nine known mutations in SPINK1, PRSS1, CFTR, CTRC, CBS, and AGL genes, and 10 novel variants in LPL, CFTR, CTR, and PHKB genes were identified. The identified variants were found in heterozygous, compound heterozygous, and trans-heterozygous forms, with rare allele frequency in the normal population. The novel variants were [c.378C>T(p.Lys126Asn) and c.719G>A(p.Arg240Gln) in CTRC, c.586-3C>A and c.763A>G(p.Arg255Gly) in CPA1, c.1160_1161insT(p.Lys387Asnfs*26), c.784C>T(p.Gln262*), c.1139+1G>A, c.175G>A(p.Gly59Arg) in LPL, c.388C>G(p.leu130val) in CFTR, and c.2327G>A(p.Arg776His in PHKB)]. The phenotypic characteristics were variable and correlated with the relevant variant.

CONCLUSIONS

The genetic composition plays a significant role in the predisposition of hereditary chronic pancreatitis. The clinical presentation varies with the genetic determinant involved. This information would help in building up a diagnostic algorithm for our population that can be used for genetic screening services in affected cohorts.

Prevalence and Risk Factors of Delirium in Patients Admitted to Intensive Care Units: A Multicentric Cross-Sectional Study

Background Delirium is a common and serious complication among critically ill patients in the intensive care unit. Knowledge of the risk factors of delirium can help tremendously in the diagnosis of delirium. Methods In April of 2023, a cross-sectional multicenter study was conducted in eight intensive care units (ICUs) across Pakistan. Delirium was assessed using the intensive care delirium screening checklist. Demographic and clinical data were collected, and multivariable logistic regression analysis was performed to identify predictors of delirium. A total of 256 patients were enrolled in the study. Results The mean age of participants was 56 (S.D. 12) years. The point prevalence of delirium was 39%, and the point prevalence did not vary significantly among the participating intensive care units. Advanced age, higher Acute Physiology and Chronic Health Evaluation - IV (APACHE IV) scores, and higher Richmond Agitation-Sedation Scale (RASS) scores at enrollment were identified as significant predictors of delirium. Conclusion The high prevalence of delirium, observed at 39.0%, emphasizes the importance of proactive screening and effective management strategies in the ICU setting. Healthcare providers in Pakistan should be mindful of these risk factors and implement preventive measures to minimize the occurrence of delirium in critically ill patients. Further research and implementation of targeted interventions are warranted to improve patient outcomes and enhance the overall quality of care in this population.

Knowledge, Attitude, and Practices Regarding Vitamin D in Middle-Aged Pakistani Population and the Impact of Sun Exposure on Their Serum Vitamin D Levels

OBJECTIVE

This study aimed to assess the knowledge, attitude, and practices regarding vitamin D (D-KAP) among middle-aged individuals in Pakistan and examine the impact of sun exposure on their serum vitamin D levels.

METHODOLOGY

A cross-sectional study was conducted, involving 80 middle-aged individuals from Lahore, Pakistan. Data on demographics, sun exposure, and D-KAP were collected. Serum vitamin D levels were measured using enzyme-linked immunosorbent assay (ELISA) kits.

RESULTS

The study revealed inadequate knowledge and awareness of vitamin D among the participants. There was a positive correlation between sun exposure duration and serum vitamin D levels, indicating the importance of sun exposure for maintaining optimal vitamin D status. However, there was no significant difference in practice scores between groups, highlighting the need for interventions to bridge the gap between knowledge and practice.

CONCLUSION

The study emphasizes the need to improve D-KAP in the middle-aged Pakistani population. Public health initiatives should focus on promoting accurate information, addressing cultural beliefs, and encouraging responsible sun exposure practices. Collaborative efforts are crucial to address vitamin D deficiency and its associated health consequences.

Psychiatric Illnesses, Somatic Complaints, and Treatments in a Tertiary Care Hospital in Khyber Pakhtunkhwa, Pakistan: A Cross-Sectional Study

BACKGROUND

Psychiatric disorders differ in frequency and symptoms based on the cultural and ethnic background of patients. This can make diagnosing and treating patients challenging globally. In Pakistan, most psychiatric patients report multiple somatic complaints. Our goal was to investigate the causes of these complaints, identify common psychiatric conditions, and analyze their various manifestations in clinical practice. We also aimed to identify ways to improve the quality of care provided to our patients.

METHODOLOGY

We collected and organized data by utilizing predetermined tables from a sample of 231 patients who visited the outpatient clinics. Inpatients were not included in this study because of the absence of a psychiatric unit at our facility. Patients' past medical and psychiatric records were thoroughly examined, and pertinent information was extracted. The most common psychiatric disorders within the studied population were diagnosed based on the International Classification of Diseases, Tenth Revision (ICD-10) diagnostic criteria.

RESULTS

In this study, a sample size of 231 was examined to determine the most common diseases (ICD-10) in males and females. In males, the most prevalent diseases were mixed anxiety and depression (MAD), depression, generalized anxiety disorder (GAD), bipolar affective disorder (BPAD), social phobia, and obsessive-compulsive disorder (OCD). Females, on the other hand, presented more with depression, GAD, mixed anxiety and depression, conversion or dissociative disorder, OCD, and panic attacks. Headaches were the most frequently reported symptom, experienced by 61.9% the of participants, followed by lethargy, extremity pains, palpitations, loss of appetite, heartburn or acidity, heaviness on the head, shoulder pains, bloating, dizziness, chest pains, hot flashes or shivering, and constipation. Meanwhile, a quarter of the males did not complain of any somatic symptoms, compared to 10% of the females. Additionally, 7.3% of females reported more than six somatic symptoms, compared to 5.7% of males. When it came to treatment preferences, 73.6% of the participants preferred medication over psychotherapy and over a combination of both. The Statistical Product and Service Solutions (SPSS) Statistics version 22 (IBM SPSS Statistics, Armonk, NY, USA) was used to conduct a chi-square test of independence to analyze the obtained data. For post hoc analysis of quantitative data (i.e., the number of somatic symptoms reported by participants), one-way analysis of variance (ANOVA) was applied, followed by Tukey's honestly significant difference (HSD) test.

CONCLUSIONS

This is the first comprehensive study of its kind for this population and region. It emphasizes that clinicians should be aware of the variety of somatic symptoms and psychiatric presentations among this population. Such awareness can improve clinical practices and reduce the burden on health services.

Cervical Cancer Awareness and Attitude Towards Cervical Cancer Screening and Human Papillomavirus Vaccines Among Urban Women of Karachi, Pakistan

Cervical cancer is the second most common cancer among women under 50 years of age in Pakistan. The current study was designed to assess the level of awareness through educational outreach presentations about cervical cancer, Papanicolaou (Pap) smear test, and human papillomavirus (HPV) vaccination in Karachi, Pakistan. Women from different urban hospitals were enrolled. Participants participated in a 45-minute presentation on cervical cancer awareness led by student pharmacists from Nazeer Hussain University, Karachi. A pre-and post-test was administered to assess the impact of the intervention. Descriptive statistics were used to summarize the findings, and a t-test was used for matched comparison, and a p-value <0.05 for statistical significance. A total of 150 women participated in the study. The study found that Pakistani women living in urban settings were less knowledgeable about the causes of cervical cancer and prevention. After the presentation, we observed a 45% increase in knowledge, and 31% of participants said they would obtain a Pap smear test in the next six months. Supervised pharmacy student-led presentations on cervical cancer educational awareness that significantly impacted women participants. Pharmacists can play a key role in reducing cervical cancer deaths through increased awareness, education, prevention, and immunization.

Retrospective Analysis of Biologic Agent Utilization in Severe Asthma: Impact on Exacerbation Rates, Forced Expiratory Volume in the First Second (FEV1), Eosinophils, and IgE Levels

Introduction Severe uncontrolled asthma is challenging to manage and impacts lung function and symptoms. Biologic agents targeting inflammatory pathways have transformed asthma management. This retrospective chart review aimed to assess biologic therapy in severe uncontrolled asthma patients and evaluate outcomes. Methods The study analyzed medical records of 30 patients receiving biologic therapy for severe asthma at a tertiary care center in Peshawar, Pakistan, from December 2022 to Jun 2023. Ethical approval was obtained, and patient demographics, biologic agent usage, and clinical parameters were collected. Clinical outcomes were evaluated after six months, including forced expiratory volume in the first second (FEV1), eosinophil count, IgE levels, and exacerbation rates. Results After six months, biologic treatment significantly improved FEV1 (48.7% to 62.4%), reduced eosinophils (540 cells/μL to 290 cells/μL) and IgE levels (410 IU/mL to 280 IU/mL), and decreased exacerbations (4.6 to 1.9). Subgroup analysis based on age and sex showed consistent lung function improvements. Conclusion Biologic agents effectively targeted inflammatory pathways, improving asthma control in severe uncontrolled asthma patients. This study provides valuable insights into biologic therapy for severe asthma, offering new possibilities for patient outcomes. Larger studies are needed to validate findings and optimize personalized treatment strategies.

Comparison of Postoperative Complications of Open Versus Laparoscopic Cholecystectomy According to the Modified Clavien-Dindo Classification System

BACKGROUND

Though laparoscopic cholecystectomy has become a gold standard management technique for gallbladder diseases, an open approach can also be used for patients having complicated gallbladder disease. Post-cholecystectomy complications are well-documented in existing English scientific literature but are not well understood according to the grade of intervention required to treat those complications.

OBJECTIVE

To compare the postoperative complications of laparoscopic versus open cholecystectomy according to the modified Clavien-Dindo classification (MCDC) system.

MATERIALS AND METHODS

 A retrospective study was conducted at the Department of General Surgery, Unit - III, Lahore General Hospital, Lahore, comprising the data of patients operated between July 01, 2021, and December 31, 2021, after departmental approval # SU-III/73/LGH, dated April 1, 2022. Patients with the definitive diagnosis of acute cholecystitis, chronic cholecystitis, cholelithiasis, and cholecysto-duodenal fistula were included, while cases of choledocholithiasis and, gall bladder carcinoma were excluded from this study. Eighty patients met the inclusion criteria, with 40 patients in each group of open and laparoscopic cholecystectomy. Information for the data set of age, gender, history of surgical procedure, immediate and late outcome, length of surgery, and MCDC grade were collected. Low-grade complications were Grade I and Grade II, while Grades III to V were high-grade.

RESULTS

The mean age of included patients was 42.52 ± 8.76 and 40.025 ± 8.12 years, in the open and laparoscopic group, with 80% and 90% female preponderance, respectively. Grade I and Grade II complications occurred in both groups of patients, with Grade III only in patients who underwent open cholecystectomy. None of the patients from each group developed Grade IV or Grade V complications. Among 40 patients who underwent laparoscopic cholecystectomy, 35% of the patients developed low-grade complications, whereas 40% of the patients developed low-grade complications after open cholecystectomy, with respiratory complications being the most common. High-grade complications after open cholecystectomy were found among 2.5% of patients, whereas no patients developed high-grade complications following the laparoscopic approach.

CONCLUSION

Patients who underwent laparoscopic cholecystectomy are less prone to develop complications than patients undergoing open cholecystectomy, hence requiring low-grade interventions of surgical and non-surgical types. MCDC is a valuable tool for assessing surgical complications and can help improve patient outcomes by providing a standardized method for reporting and comparing complication rates.

Antibiotic Use for Febrile Children in a Tertiary Care Hospital's Outpatient Department: A Cross-Sectional Study

Background Irrational prescription of antibiotics is contributing to the antimicrobial resistance crisis in low and middle-income countries. Antibiotic stewardship programs need to be implemented to rationalize the use of antibiotics, but data on antibiotic prescriptions in pediatric outpatient departments is minimal. This study aimed to determine the frequency of antibiotic prescriptions in febrile children attending the Paediatric Outpatient Department (OPD) at Combined Military Hospital, Lahore, and observe the factors affecting the decision to prescribe antibiotics. Methodology A cross-sectional, descriptive study with non-probability sampling in the Department of Paediatrics at the Combined Military Hospital (CMH), Lahore, was conducted over two years. The confidence limit was 95%, and the anticipated population proportion was 32%. The primary outcome was the proportion of children aged two months to 10 years presenting to the OPD with fever who received antibiotics. Further analysis included the effect of patient-level risk factors on antibiotic prescription, especially in children with respiratory tract infections (RTIs). Results Of the 225 children analyzed, 137 (61%) received antibiotics. Of these antibiotic prescriptions, 123 (90%) were second-line antibiotics. Older age (odds ratio (OR) = 2.3, 1.18-4.46), high fever (OR = 2.48, 1.37-4.5), presenting in autumn and winter seasons (OR = 2.85, 1.53-5.3), ill appearance (OR = 2.71, 1.12-6.55), tachycardia (OR = 4.28, 1.22-15.01), and tachypnea (OR = 4.01, 1.14-14.12) were associated with increased likelihood of antibiotic prescription. Antibiotic prescriptions in children with RTIs were associated with lower RTI (OR = 12.96, 3.49-48.08), probable bacterial infection (OR = 12.37, 4.77-30.05), tachycardia (OR = 10.88, 1.28-92.24), tachypnea (OR = 14.73, 3.14-68.99), and increased work of breathing (OR = 7.8, 2.05-29.56). Conclusions The evidence of the widespread inappropriate use of antibiotics in OPDs, particularly for upper RTIs, highlights the need for an antibiotic stewardship program. Antibiotic overprescription promotes antibiotic resistance, prolonging illness and increasing healthcare costs.

Public Knowledge About COVID-19 Booster Vaccines in Pakistan: A Study Conducted in a Tertiary Care Hospital in Karachi

The coronavirus disease 2019 (COVID-19) pandemic has deteriorated the healthcare system and economy worldwide. Globally, by making the primary vaccination against the coronavirus necessary, the surge in cases waned, but as the effects of this vaccination decreased after some time, to prevent another pandemic, vaccination was still necessary. As a result, receiving a COVID-19 booster shot can boost immunity against the coronavirus. This study aimed to assess knowledge of COVID-19 booster vaccines in Pakistan among the general public and understand the factors affecting the vaccination process in the state. In this cross-sectional study, non-probability convenience sampling was done. Its physical data collection was conducted in September 2022 in a tertiary care hospital in Karachi, Pakistan. Data were collected from 384 individuals who visited the hospital with consent before filling out the questionnaire. The mean age of respondents was 35.81 (standard deviation (SD) = ±13.006), and 98.7% of individuals were primarily vaccinated for COVID-19, but out of these, only 60.1% received the booster jab. The most commonly reported side effects of primary doses of COVID-19 and its booster were pain at the injection site, fatigue, and fever, but these effects did not appear to have as much of an impact on the vaccination process as education did. The results are evident that out of primarily vaccinated individuals against COVID-19, 40.16% are reluctant to receive its booster. Therefore, it is essential to create awareness among the masses about vaccination and its importance.

Factors Related to Anemia Prevalence Among Women of Childbearing Age in the Period of Global Pandemic

Background Health authorities in Pakistan in collaboration with local and foreign non-government organizations are working hard to achieve the targets set by World Health Organization in 2012, that is, to reduce anemia prevalence and its related factors. However, due to the prevailing COVID-19 crisis, all resources and attention were diverted toward it, which led to ignorance of existing basic health issues. Objective This study assesses anemia prevalence and its related factors among women of childbearing age in the period of global pandemic. Methods A time-lagged, cross-sectional survey was conducted using a self-administered questionnaire among 1,702 volunteer women aged between 15 and 49 years across five major cities of Pakistan from January 2021 to December 2021 using the non-probability consecutive sampling technique. Blood sample results were analyzed to determine prevalence and anemia severity. The chi-squared test and multiple logistic regression were performed to examine the relationship and effect of related factors with hemoglobin levels using SPSS version 26. Results Among the 1,702 respondents, 788 (46.3%) were non-anemic and 914 (53.7%) were anemic. Anemia prevalence in Karachi was slightly greater (n=294, 55.48%) compared to other cities, and the mean hemoglobin level was 11.98 ± 0.92 g/dL. The chi-square test and multiple logistic regression indicated that the respondents' employment status, mother's profession, family income, living conditions, chronic health conditions, use of iron and folic acid supplements, junk food, source of drinking water, and knowledge about anemia and its preventive measures were associated significantly with anemia during the pandemic. Conclusion Results confirmed that anemia is a multi-factor health problem and that it was totally ignored during the COVID-19 pandemic, as the prevalence increased during the pandemic. Therefore, more attention should be paid to anemia surveillance, anemia awareness programs, and mobilization of community health workers and volunteers to reach a wide range of the population, including women of childbearing age even during the pandemic.

Crimean-Congo Hemorrhagic Fever Presented in Dengue Epidemic: A Case Report

In Pakistan, hemorrhagic diseases, including dengue and Crimean-Congo hemorrhagic fever (CCHF), are common. Therefore, an accurate diagnosis is challenging in the early stages of sickness owing to geographic overlap and early clinical similarities between the two disorders. A 35-year-old man who had previously experienced hematemesis and high-grade fever presented to our hospital. Despite receiving supportive care for a preliminary diagnosis of dengue hemorrhagic fever, the patient's condition worsened. The results of the dengue IgM antibody test were negative. On the fourth day of admission, a qualitative polymerase chain reaction test for CCHF virus RNA was performed, and the result returned positive. All medical personnel and attendants who had contact with the patient had to receive ribavirin prophylaxis, which required significant investment in resources. Because CCHF can have long-term financial and health repercussions for contacts, including healthcare personnel in developing nations, it is essential to identify and treat it as soon as possible. It is necessary to keep track of dengue and CCHF cases more closely to develop predictors of disease diagnosis that are reasonably trustworthy, affordable, and quick. These predictors can aid in directing future choices regarding the care of similar situations. Ultimately, such an approach might result in improved cost control in environments with limited resources. Consideration should also be given to patients who receive ribavirin prophylaxis.

Unraveling the Myths Around Epilepsy: A Cross-Sectional Study of Knowledge, Attitude, and Practices Among Pakistani Individuals

INTRODUCTION

Across its historical trajectory, epilepsy has frequently been linked to evil forces, particularly in the sub-continent. This research was created to find out if educated Pakistanis still believe that epilepsy is caused by being possessed by spirits (Jinns). The objective of the study is to assess the knowledge, attitudes, and practices (KAP) regarding epilepsy within the educated populace of Pakistan.

METHOD

 After approval from the Ethical Review Committee, a population-based cross-sectional design was conducted in Chakwal District, Pakistan between February 1, 2018, and June 1, 2020, to evaluate the general knowledge and attitudes of the public toward epilepsy. A non-probability convenience sampling technique was utilized to recruit participants from different socioeconomic backgrounds across Chakwal District, and only individuals aged 18 years or older with at least 12 years of education were eligible to participate. A previously validated structured questionnaire was used to document findings. The study focused on several variables, such as knowledge about epilepsy and the percentage of people who have witnessed seizures, as well as sources of knowledge, subjective causes of epilepsy, beliefs in cure, transmission, and treatment options.

RESULTS

The survey included 512 participants, and the age distribution was as follows: 18-29 years old accounted for 18% of the respondents, 30-44 years old accounted for 35%, and 45-60 years old accounted for 31%. There was a female predominance with a frequency of 312 (60.9%). When asked about their sources of knowledge about epilepsy, the majority of participants (59.57%) reported learning about epilepsy from friends and relatives. A smaller percentage (18.36%) reported learning about epilepsy from schools, while another 20.31% heard about epilepsy from media and relatives.

CONCLUSION

The results of this research show that the general populace of Pakistan has a serious dearth of comprehension and information about epilepsy. Participants frequently held misconceptions about epilepsy being a hereditary disease and a mental condition, highlighting the need for focused education and information efforts to dispel these falsehoods. The fact that most participants got their knowledge about epilepsy from peers and family also emphasizes the value of peer education and social networks in spreading awareness of the disease.

Study protocol of DIVERGE, the first genetic epidemiological study of major depressive disorder in Pakistan

INTRODUCTION

Globally, 80% of the burdenof major depressive disorder (MDD) pertains to low- and middle-income countries. Research into genetic and environmental risk factors has the potential to uncover disease mechanisms that may contribute to better diagnosis and treatment of mental illness, yet has so far been largely limited to participants with European ancestry from high-income countries. The DIVERGE study was established to help overcome this gap and investigate genetic and environmental risk factors for MDD in Pakistan.

METHODS

DIVERGE aims to enrol 9000 cases and 4000 controls in hospitals across the country. Here, we provide the rationale for DIVERGE, describe the study protocol and characterise the sample using data from the first 500 cases. Exploratory data analysis is performed to describe demographics, socioeconomic status, environmental risk factors, family history of mental illness and psychopathology.

RESULTS AND DISCUSSION

Many participants had severe depression with 74% of patients who experienced multiple depressive episodes. It was a common practice to seek help for mental health struggles from faith healers and religious leaders. Socioeconomic variables reflected the local context with a large proportion of women not having access to any education and the majority of participants reporting no savings.

CONCLUSION

DIVERGE is a carefully designed case-control study of MDD in Pakistan that captures diverse risk factors. As the largest genetic study in Pakistan, DIVERGE helps address the severe underrepresentation of people from South Asian countries in genetic as well as psychiatric research.

Molecular Genetic Analysis of the Autosomal Recessive Non-Syndromic Inherited Retinitis Pigmentosa

INTRODUCTION

90% of visually impaired people live in developing countries. There are various types of vision impairment, but the focus of the current study is retinitis pigmentosa (RP). Up to now, 150 mutations have been reported that are linked with RP.

METHODOLOGY

Healthy and affected members from two Pakistani families (RP01 and RP02) segregating autosomal recessive RP were selected for DNA extraction. PCR was conducted, and the amplified PCR products were analyzed using Polyacrylamide Gel Electrophoresis (PAGE) and visualized in the Gel Doc system for linkage analysis. The Gene Hunter 2.1r5 tool in the Simple Linkage v5.052 beta software suite was used to conduct multipoint parametric linkage analysis on the two consanguineous families examined on the 6K Illumina array. Exons and intron-exon borders of all known arRP genes found in homozygous areas were sequenced in the matching probands using a 3130 automated sequencer and the Big Dye Terminator Cycle Sequencing Kit v3.1. The mutation study was carried out using the AlaMut 1.5 program.

RESULTS

In both families, linkage analysis was performed using microsatellite marker DIS422 for gene crumbs homolog 1 (CRB1) and microsatellite marker D8S2332 for gene Retinitis Pigmentosa 1 (RP1). Multipoint linkage analysis identifies genomic regions that could potentially contain the genetic defect. In family RP01, only a single peak with a maximal multipoint LOD score of 3.00 was identified on chromosome 1, whereas in family RP02, multiple peaks with multipoint LOD scores of 1.80 were identified on chromosome 8. Analysis of the CRB1 gene revealed a homozygous substitution of glycine for valine (c.1152T>G; p.V243G), whereas the RP1 gene demonstrated that leucine was substituted for proline as a result of cytosine to thymine transfer (c.3419C>T; p. P1035L).  Conclusion: Homozygosity mapping is a powerful method for finding genetic abnormalities that are both precise and comprehensive for identifying harmful variations in consanguineous families. This method is invaluable for providing accurate clinical diagnostic and genetic advice in remote regions of Pakistan while also increasing knowledge about autosomal recessive diseases and the dangers of mixing.

Current Practices and Perceived Role of Community Pharmacists in Type 2 Diabetes Services in Pakistan

Background Diabetes mellitus is a chronic illness which is becoming more prevalent in developing countries, and it is being managed mostly in hospitals or clinics in underdeveloped nations. Other strategies for treatment delivery in emerging nations must be considered as the number of diabetic patients grows. Community pharmacists are a valuable choice for diabetes care. However, only developed countries have data on community pharmacists' diabetes treatment practices. Methodology A non-probability consecutive sampling strategy was used to gather a self-administered questionnaire from 289 community pharmacists. Six points Likert scale was employed to score current practices and pharmacists' perceived role. A response rate of 55% was attained. Characteristics associated with present behaviors and perceived roles were analyzed using Chi-square and logistic regression. Results The majority of the respondents were males, 234 (81.0%). Out of 289, 229 (79.2%) were of 25-30 years of age and were pharmacists as well as qualified persons (QP) 189 (65.4%). A QP is one who has the legal authority to sell drugs to customers. The majority had <5 years of working experience as a community pharmacist, 268 (92.7%), and did not have diabetes training, 237 (82.0%). Most community pharmacies were stand-alone, 110 (38.1%), and had a single or a group of proprietors, 248 (85.8%). Open hours of most of the pharmacies were 16-20 hours per day, 202 (69.8%), and most had one pharmacist, 243 (84.1%), i.e., working as a pharmacist as well as a qualified person. Approximately 203 (70.2%) of the pharmacies had customers >2000 in a month and >100 customers purchased anti-diabetes medications per month. Only 44 (15.2%) community pharmacies had a designated room or space for patient counselling. The majority of pharmacists were also in favor of providing services other than dispensing such as counselling the patients about prescribed medicines, direction of use, use of devices for insulin administration, training on self-monitoring of glucose, and healthy lifestyle and diet practices. Pharmacy setting, ownership, patient counseling area, and the number of customers per month were key factors in the provision of diabetes services. The main obstacles identified were a lack of pharmacist availability and academic competency. Conclusion In Rawalpindi and Islamabad, most community pharmacies only provide a basic dispensing service for diabetes patients. Most of the community pharmacists agreed to extend their duties. The expansion of pharmacist professional responsibilities would help control the rising diabetes burden. The facilitators and hurdles identified would serve as a foundation for the introduction of diabetic care in community pharmacies.

Assessing the older population acceptance of healthcare wearable in a developing Country: an extended PMT model

Wearable healthcare devices (HWDs) got prominence, especially during the COVID-19 pandemic. Aiming to know the proliferation of the HWDS, this study tries to evaluate the intentions of the old-age population to use the devices. To this end, the protection motivation theory (PMT) coupled with health information accuracy, perceived novelty, perceived ease of use, hedonic motivation, health anxiety, and health consciousness were investigated as predictors of HWDs among senior Pakistani citizens. A total of 310 participants who knew how the smartwatches could be used as a health monitoring device, were surveyed to empirically test the model. The required data were then analyzed using structural equation modeling. The findings reveal that the protective, utilitarian, and personal attributes of HWDs play a significant role in choosing the HWDs. While addressing their healthcare issues, senior citizens are highly receptive to perceived usefulness, accurate information accuracy, self-efficacy, perceived severity, health consciousness, and perceived vulnerability during COVID-19. These factors have a positive impact on their willingness to use HWDs. The study educates healthcare management and users to focus on the determining factors that can enhance the use of HWDs.

Estimation of seasonal influenza disease burden using sentinel site data in Pakistan 2017–2019: A cross‐sectional study

Background

The influenza A(H1N1)pdm09 pandemic highlighted the need for reliable disease burden estimation from low‐ and middle‐income countries like Pakistan. We designed retrospective age‐stratified estimation of influenza‐related severe acute respiratory infections (SARIs) incidence in Islamabad Pakistan 2017–2019.

Materials and Methods

The catchment area was mapped on SARI data from one designated influenza sentinel site and other healthcare facilities in the Islamabad region. The incidence rate was calculated as per 100,000 for each age group with 95% confidence interval.

Results

The catchment population for the sentinel site was 0.7 million against the total denominator of 1.015 million, and incidence rates were adjusted. During January 2017 to December 2019, among 13,905 hospitalizations, 6715 (48%) patients were enrolled; 1208 of these (18%) were positive for influenza. During 2017, influenza A/H3 dominated with 52% detections followed by A(H1N1)pdm09 (35%) and influenza B (13%). Furthermore, elderly 65+ years age group had highest hospitalizations and influenza positive. The incidence rates of all cause respiratory and influenza‐related SARI were highest among children >5 years; highest incidence was found in 0 to 11 month/year group with 424/100,000 cases and lowest in 5–15 years 56/100,000. The estimated average annual influenza‐associated hospitalization percentage was 29.3% during the study period.

Conclusion

Influenza accounts for a significant proportion of respiratory morbidity and hospitalization. These estimates would enable governments for evidence‐based decisions and priority allocation of health resources. It is necessary to test for other respiratory pathogens for more clear disease burden estimation.

COVID-19: Exacerbating Pakistan's economic problems – a critical analysis using the dependency paradigm

Pandemics have been a recurrent phenomenon throughout the course of history. However, the levels of fear and hysteria brought by the COVID-19 outbreak, forcing regimes across the globe to impose stringent lockdowns, had never been witnessed before. While these lockdowns proved beneficial in reducing both the infection and mortality rate, they created an impossible environment for governments across the globe to effectively and efficiently govern, which in turn gave birth to numerous economic challenges, especially in developing countries like Pakistan. In Pakistan, where the common person was already finding it very difficult to makes ends meet, the pandemic incurred tremendous economic hardships like unemployment, poverty and decline in per capita income. Consequently, Pakistan's economy struggled as it experienced a negative economic growth rate, inflation and a significant reduction in exports. As a by-product of the economic crunch, the flawed Pakistani governance system came under the spotlight, as it found itself struggling to tackle the day-by-day worsening situation. Strikingly, due to the infamous longstanding province–centre rift, Pakistan was neither able to promulgate an effective unified lockdown strategy nor to provide basic necessities to its citizens. This article analyses the governance and economic problems faced by Pakistan due to the COVID-19 outbreak from the prism of the dependency paradigm, which highlights the exploitative nature of developed–developing/underdeveloped states. Also, it provides policy prescriptions to strengthen Pakistan's economic system to deter future pandemics.

Routine Immunization Coverage and Immunization Card Retention in Pakistan: Results From a Cross-sectional National Survey

BACKGROUND

Immunization is one of the most successful public health interventions available, saving millions of lives from death and disability each year. Therefore, improving immunization coverage is a high priority for the Government of Pakistan and essential to progress toward universal health coverage. This survey reports the national and provincial/regional coverage and determinants of fully, partially, and not-vaccinated children 12-23 months of age, antigen-wise coverage, percentage of home-based vaccination records (HBR) retention, and reasons for nonretention; dropout, timeliness, and prevalence of missed opportunities for simultaneous vaccination (MOSV).

METHODS

The survey was a descriptive cross-sectional national household survey carried out across Pakistan. The survey included 110,790 children 12-23 months old and their caregivers. A World Health Organization (WHO)-Expanded Program on Immunization (EPI) Survey questionnaire was adapted to collect information. Data were analyzed using the WHO Vaccination Coverage Quality Indicators (VCQI) software and Stata version 17.

RESULTS

Nationally excluding Azad Jammu and Kashmir (AJK) and Gilgit Baltistan (GB), the coverage of fully vaccinated children was 76.5%. The likelihood of being fully vaccinated was higher among children of educated parents who belonged to higher wealth quintiles and resided in any province/region other than Balochistan. The main reasons for unimmunization were no faith in immunization, rumors about vaccines, and distance to the facility. About two-thirds (66.2%) of the children had their HBR available, and the main reasons for not having a card were never visiting a health facility and having no awareness about the importance of a card. Dropout was discernible for later doses of vaccines compared with earlier ones. Higher proportions of children received the last doses late by more than two months. Of the 218,002 vaccination visits documented on HBR in the provinces, MOSVs occurred in 17.6% of the visits.

CONCLUSION

The immunization coverage rates provide a direction to strategize the progress to improve the vaccination rates in Pakistan. The country needs to outline the immediate and long-term actions to combat vaccine-preventable diseases, such as escalating integrated immunization campaigns and outreach activities, provision of mobility support, and deploying behavioral interventions as a cross-cutting strategy to improve awareness and reduce misconceptions.

Aftermath of the COVID-19 Pandemic on Mental Health and Well-Being of Patients With Thalassemia Major in Pakistan: A Qualitative Study

Background and aim Chronic patients with thalassemia major were mainly recognized as more prone to poor mental health during this global pandemic. This study aims to evaluate causal relationships leading to poor outcomes and how they manage to tackle this. Methods In-depth face-to-face semi-structured interviews were conducted with 21 thalassemia patients selected through probability consecutive sampling from Pakistan Thalassemia Welfare Society Centers. The following criteria served as the basis for the interview: (1) solitude at home, (2) interruption of transfusion services, (3) alteration of appetite and interests, (4) lack of control and uncertainty, (5) extensive media coverage, (6) deterioration of pre-existing health issues, difficulty in sleeping, (7) practicing gratitude, (8) participation in activities and hobbies, (9) connectivity with others, and (10) ability to recognize social support. All interviews were recorded, transcribed, and analyzed with reflexive thematic analysis. Results The commonly described mental health conditions were depression and concern about the overall health status. The following seven elements associated with the pandemic contributed to the deterioration of mental health: (1) isolation at home, (2) disruption in transfusion services, (3) change in appetite and interests, (4) lack of control and uncertainty, (5) intensive media reporting, (6) worsening of pre-existing health problems, and (7) difficulty in sleeping. The following four coping strategies were identified for maintaining mental issues: (1) practicing gratitude, (2) involvement in activities and hobbies, (3) connectivity with others, and (4) discerning social support. Conclusions Thalassemia major patients had been negatively affected during the pandemic. Only a small number of people modified their management techniques to maintain steady well-being.

Linking job crafting, innovation performance, and career satisfaction: The mediating role of work engagement

BACKGROUND

The demand for innovation and satisfaction is increasing rapidly due to technological advancement and the fast-changing business environment.

OBJECTIVE

The purpose of this article is to investigate how job crafting augments work outputs (i.e., innovation performance and career satisfaction) through work engagement.

METHODS

Data were collected from 477 workers working in the Pakistan manufacturing sector. A structural equation modeling technique was used to investigate the mediation model.

RESULTS

Job crafting has a direct and indirect association with innovation performance and career satisfaction - via employees' work engagement. Additionally, the mediating impact was stronger for innovation performance than for career satisfaction. The findings advocate that managers should pay attention to employees' job crafting to improve employees' work engagement in manufacturing organizations. To improve employees' innovation performance and career satisfaction via work engagement, it is important to improve organization-wide job crafting in traditional manufacturing organizations. Strategic and managerial actions related to job crafting might boost employees' engagement in the organization that environments provide incessantly better outcomes.

CONCLUSION

By linking job crafting and work engagement to their attitude towards career satisfaction and innovation performance in Pakistani manufacturing firms, this study adds a new dimension to the study of Pakistani manufacturing employees and typically to the best practices in career debates. This knowledge is important and unique because it accentuates that in addition to work engagement, which focuses primarily on employee growth in the organization, job crafting should also be given equal importance to advance manufacturing employees' outcomes.

Soft computing techniques for forecasting of COVID-19 in Pakistan

Novel Pandemic COVID-19 led globally to severe health barriers and financial issues in different parts of the world. The forecast on COVID-19 infections is significant. Demeanor vital data will help in executing policies to reduce the number of cases efficiently. Filtering techniques are appropriate for dynamic model structures as it provide reasonable estimates over the recursive Bayesian updates. Kalman Filters, used for controlling epidemics, are valuable in knowing contagious infections. Artificial Neural Networks (ANN) have generally been used for classification and forecasting problems. ANN models show an essential role in several successful applications of neural networks and are commonly used in economic and business studies. Long short-term memory (LSTM) model is one of the most popular technique used in time series analysis. This paper aims to forecast COVID-19 on the basis of ANN, KF, LSTM and SVM methods. We applied ANN, KF, LSTM and SVM for the COVID-19 data in Pakistan to find the number of deaths, confirm cases, and cases of recovery. The three methods were used for prediction, and the results showed the performance of LSTM to be better than that of ANN and KF method. ANN, KF, LSTM and SVM endorsed the COVID-19 data in closely all three scenarios. LSTM, ANN and KF followed the fluctuations of the original data and made close COVID-19 predictions. The results of the three methods helped significantly in the decision-making direction for short term strategies and in the control of the COVID-19 outbreak.

Endocrine Abnormalities in Children With Traumatic Brain Injury at a Tertiary Care Center

Objective Accidental traumatic brain injury (TBI) can lead to severe complications such as endocrine abnormalities and long-term morbidities and can negatively impact patient lives. These conditions are also associated with a high cost of treatment over a lifetime, a significant concern in low-to-middle-income countries (LMICs). In Pakistan, the prevalence of children with endocrine abnormalities secondary to TBI remains largely unexplored. We conducted a retrospective cross-sectional study to estimate the burden of endocrine abnormalities due to TBI among children in our population. Methods Twenty patients previously admitted with head injury between September and October 2019 were retrospectively reviewed with tests for baseline serum sodium, plasma osmolality, cortisol, adrenocorticotropin (ACTH), free thyroxine (fT4), growth hormone (GH), insulin growth factor-1 (IGF-1), follicle-stimulating hormone (FSH), luteinizing hormone (LH), thyroid-stimulating hormone (TSH), prolactin, estradiol, and testosterone. Data were collated from the electronic Health and Information Management System (HIMS) and analyzed using SPSS v25. Chi-square and t-tests were used to identify associations between variable groups. Outcomes of interest included correlations between hormonal levels and demographic factors, interventions and hormonal levels, and complication rates and hormonal levels. Results Our study reports three (15% of the total cohort) patients with pituitary hormone deficits (two with low IGF-1 and one with low TSH). High serum IGF-1 and ACTH levels were also observed in three (15%) children. High IGF-1 was associated with female gender (p=0.007), mechanical ventilation (p=0.038), and falls (p=0.028). IGF-1 (p=0.035) and GH (p=0.049) levels were associated with improvement in Extended Glasgow Outcome Scale (GOS-E) score. Testosterone was positively correlated with a high percentile for height (p=0.005) and GOS-E scores on follow-up (p=0.030). High testosterone levels (592.12 ± 102.28 ng/dl) were associated with good functional outcomes in post-pubescent patients (p<0.05). Serum fT4 was linked with a high GOS-E score at discharge in prepubescent patients (p=0.034). Neurosurgical decompression was the only risk factor for hormone deficiency, comprising 67% of the group with hormone deficiencies (p=0.028). The learning difficulties were observed exclusively in children with hormonal deficiencies (7 patients, p=0.000).  Conclusion Hormonal dysfunction due to TBI in children can lead to poor outcomes. High serum IGF-1, testosterone, and free T4 levels were associated with improved functional outcomes in children with TBI. Limited follow-up and resources in LMICs are significant barriers to addressing the morbidity associated with these conditions and need to be addressed at a health policy level.

Does political risk undermine environment and economic development in Pakistan? Empirical evidence from China–Pakistan economic corridor

China–Pakistan Economic Corridor (CPEC) invests \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${\text{US}}\$ 62$$\end{document}US$62 billion in Pakistan’s energy, infrastructure, and other development projects to step toward Eurasia’s economic integration. However, CPEC may exacerbate climate change vulnerabilities for Pakistan’s struggling economy due to potential environmental hazards and consequences. In this context, the current study seeks to examine the impact of political risk on carbon emissions and economic growth in Pakistan while also considering the relevance of trade openness, Chinese outward Foreign Direct Investment \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$(\text{FDI})$$\end{document}(FDI), and One Belt One Road \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\left( \text{OBOR} \right)$$\end{document}OBOR policy. To investigate this impact, we use the autoregressive distributed lag technique to cointegration and the fully modified ordinary least squares estimator for robustness results, using data spanning \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$2000\,\, {\text{to }}\,\,2020$$\end{document}2000to2020. Our empirical findings reveal that trade openness, FDI, and OBOR policy contribute to pollution and economic growth, but political stability slows the rate of environmental deterioration and increases economic growth. Furthermore, the existence of robust political stability mitigates the negative impacts of FDI and trade openness on the environment, while strong political stability aids the positive effects of FDI and trade openness on economic growth. Also, the findings confirmed that a better political environment promotes economic development while simultaneously lowering carbon emissions. Our results may assist the Government of Pakistan in transforming \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\text{CPEC}$$\end{document}CPEC into a model green \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\text{OBOR}$$\end{document}OBOR initiative in the region.

Pakistan's COVID-19 Prevention and Control Response Using the World Health Organization's Guidelines for Epidemic Response Interventions

Massive coronavirus disease 2019 (COVID-19) devastation was anticipated in Pakistan due to poor track record of responding to epidemics. However, by adopting effective and timely response measures under strong government leadership, Pakistan averted a significant number of infections. We present the government of Pakistan's efforts to curb the spread of COVID-19, using the World Health Organization's guidelines for epidemic response intervention. The sequence of interventions is presented under the epidemic response stages, namely anticipation, early detection, containment-control, and mitigation. Key factors of Pakistan's response included decisive political leadership and implementation of a coordinated and evidence-informed strategy. Moreover, early control measures, mobilization of front-line health workers for contact tracing, public awareness campaigns, 'smart lockdowns', and massive vaccination drives are key strategies that helped flatten the curve. These interventions and lessons learnt can help countries and regions struggling with COVID-19 to develop successful strategies to flatten the curve and enhance disease response preparedness.

An Insight Into the Acceptance and Hesitancy of COVID-19 Vaccines in Pakistan: A Cross-Sectional Survey

BACKGROUND

COVID-19 vaccines are found to be effective interventions to tackle COVID-19. However, the hesitancy towards its acceptance has been rising in Pakistan. This study highlights the opinion of the general population in Pakistan regarding the acceptance and hesitancy of COVID-19 vaccination.

METHODS

A descriptive cross-sectional survey study was conducted among Pakistanis from December 2021 to January 2022. Adult respondents that have and have not received COVID-19 vaccinations were included in this study. Data collection was obtained through questionnaires that assessed acceptance and hesitancy toward COVID-19 vaccines. Statistical analysis was performed using IBM SPSS software version 25 for Windows.

RESULTS

We obtained 367 respondents with 333 respondents completing the questionnaire. There were 259 respondents who have been vaccinated. A total of 67.9% of responses agreed that vaccines could control the COVID-19 pandemic. The reasons for not getting vaccination were afraid of adverse effects (48.6%) and COVID-19 vaccines not being tested thoroughly (30.9%). The main reason for vaccine acceptance was awareness about vaccines (23.1%), a belief that vaccines can stop severe COVID-19 disease (16.8%), and self-protection (14.7%).

CONCLUSION

Most Pakistanis agreed that vaccines could manage the pandemic. Vaccine acceptance was contributed by the awareness and belief regarding the protective effects of vaccines while vaccine hesitancy was due to the public's doubt about the vaccines' side effects and testing. The Pakistan government should focus on emphasizing knowledge about vaccines, educating the vaccines' adverse effects, and utilizing social media in doing so.

Quality of Life of Post-renal Transplant Patients in Rawalpindi

Objectives The objective is to assess the overall quality of life (QoL) in patients who had undergone renal transplant within the last three years and correlate this index with various demographic variables such as age, gender, marital status, and education level and to correlate the QoL score calculated vs. the health status perceived by the patients themselves Materials and methods This was an analytical cross-sectional study, carried out over a period of five months. A total of 123 patients were targeted among which data from 79 patients were gathered including all the patients that underwent kidney transplantation in the past three years at a renal transplant center in CMH, Rawalpindi, Pakistan. Non- Probability convenience sampling was used, and data were collected using the WHOQOL-BREF tool that contained 25 questions targeted to four domains (physical, psychological, social, and environmental). The Questionnaire was administered over the phone with proper consent taken beforehand. Data were analyzed using Excel and SPSS version 23. Results A total of 79 patients were administered the questionnaire with the mean age of our study population being 35±11 years out of which 84.5% were male and 15.5% were female. Patients received the kidney from relative donors (98.4%) with the highest percentage being sister donors (30.9%). The majority of patients reported from Punjab (54.4%), with the rest from far-flung rural areas. An estimated 62.5% of the patients presented with other systemic/psychological disorders such as DM+, IHD, HTN, Hepatitis C, depression, etc. The mean global score of these patients was 79.21 which can be broken down into four domains, physical domain 80.40, psychological domain 78.99, social domain 82.70, and environmental domain 74.75. Conclusion In a developing country such as Pakistan, with most of the patients belonging to lower or middle socioeconomic groups, we believe that the patient's own sense of QoL is overshadowed by the mere exuberance of being given a second chance at life which was portrayed by the discrepancies in the perceived vs actual QoL graph. One common recurring theme that was noticed whilst interviewing the patients was that the difficulties they might have faced post-transplant paled in comparison to how grateful they were to live another day. A positive trend was noticed between the time since transplant and the QoL score which could be attributed to various factors such as the use of aggressive immunosuppressants, fear of injury, fear of transplant rejection, etc. in the first-year post-transplant. Demographic variables such as income, age, location, etc. did not affect the scores of these patients on a great scale. The present study aims to guide clinicians in the improvement of long-term outcomes of renal transplantation in Pakistan.

Demographic Factors, Conspiracy Theories, and Beliefs Associated With COVID-19 Vaccine Hesitancy Among Pakistani Population: A Cross-Sectional Study

Introduction The coverage of coronavirus disease 2019 (COVID-19) immunization uptake has been impacted by the acceptance of regular vaccine uptake and, like many other vaccination attempts in the past, it also faces issues of vaccine hesitancy. Through this study, we hoped to assess the conspiracy theories and beliefs attached to the COVID-19 vaccination efforts in Pakistan Methods This study was conducted among the general population of Pakistan, aged 16 and above, from April 29 to May 29, 2021. The data was collected through English and Urdu questionnaires by a method of convenient sampling. A total of 600 participants were asked to fill in 34 questions pertaining to vaccine hesitancy and conspiracies. We used the Modified Kuppuswamy Socioeconomic Scale, Kuppuswamy Socioeconomic Scale, Conspiracy Mentality Questionnaire (CMQ), and Vaccine Conspiracy Belief Scale (VCBS) as our questions. Results A total of 591 participants responded to our questionnaire. The majority were females (56.7%), had an undergraduate degree (41.5%), and belonged to the upper middle socioeconomic class (40%). Factors like occupation (p=0.001), education (p=0.001), socioeconomic status (p<0.001), any family member who contracted coronavirus (p=0.016), source of knowledge (p=0.002), and total monthly income (p<0.001) were found to be statistically significant. Conclusion The findings of this study suggest that conspiracy theories and misinformation about vaccinations are prevalent in our region. They are influenced by propaganda and negative cultural values among the population To combat and restrict the spread of this problem, our study can provide useful data to develop more appropriate policy measures.

The likelihood approach for potential role of "GABRG2 (C588T, C315T) gene polymorphisms" on the poor response to carbamazepine therapy in Pakhtun population of Pakistan

BACKGROUND

Gamma-aminobutyric acid A receptor, gamma 2 gene (GABRG2) encode the GABAA receptor which is responsible for fast neuronal inhibition. Polymorphisms in GABGR2 gene affect the clinical response of anti-epileptic drugs (AEDs). Therefore, we carried out an updated study to find the association GABRG2 gene polymorphisms with carbamazepine (CBZ) non-responsive therapy in the Pakhtun population.

METHODS

A clinical prospective cohort study was conducted in 79 CBZ treated patients upon consent after the approval of Khyber Medical University Advanced Study and Research Board. Blood sample were taken at optimal dose of CBZ at base line, third and sixth months of the treatment. Blood level of CBZ was measure through reverse phase high performance liquid chromatography (HPLC). Restriction fragment length polymorphisms techniques were used to genotype GABRG2 gene in these patients. CBZ responses were evaluated on three and six months of study by measuring the decrease in frequency of seizure per week.

RESULTS

The average maximum dose of CBZ was 455 ± 133 mg/day at baseline, 479 ± 142 mg/day at third month and 495 ± 133 mg/day at sixth month of the treatment. CBZ level was found within therapeutic range (4-12 mg/L) without any significant (P > .5) variations among the CC, CT and TT genotypes of GABRG2 (C588T and C315T) gene. But the poor clinical response during CBZ treatment was linked (P < .05) with CT and TT genotypes of GABRG2 (C588T and C315T) gene in Pakhtun Population.

CONCLUSION

A poor response to CBZ was found in variant genotypes (CT and TT) of GABRG2 (C588T and C315T) gene in Pakhtun Population.

Comparison of Clinical Characteristics and Outcome Between Vaccinated and Non-Vaccinated Patients of Covid-19 During the Delta Variant-Dominated Fourth Wave in a Tertiary Care Hospital in Karachi, Pakistan

Introduction

In Pakistan, the fourth wave of coronavirus disease 2019 (Covid-19) started around July 2021, which was dominated by the Delta variant of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. The vaccination drive to immunize the people of Pakistan against Covid-19 was also going on during this period. There were multiple types of vaccines being administered to the people of Pakistan, as the vaccines had been procured from multiple sources. Some people had apprehensions about different vaccines being administered in the country. The purpose of this study was to compare the clinical characteristics and outcome of the patients vaccinated against Covid-19 with those of the non-vaccinated patients during the fourth wave of Covid-19 in Pakistan Naval Ship (PNS) Shifa Hospital.

Methods

The cross-sectional descriptive study was performed at PNS Shifa Hospital Karachi, from July to October 2021. All the Covid-19 patients treated in PNS Shifa Hospital during the “fourth Covid-19 wave” were interviewed. Their medical records were accessed, and they were followed up till their discharge from the hospital. The vaccinated and non-vaccinated patients were compared for differences in their age or gender distribution, the severity of illness, comorbidities, and mortality.

Results

There were 884 participants in the study: 664 (75.11%) men and 220 (24.89%) women. There were 493 patients below 40 years of age, 233 were 40-59 years old, and 158 were aged 60 and above. One hundred and sixty-nine patients had one or more comorbidities, including hypertension, diabetes mellitus, ischemic heart disease, various malignancies, bronchial asthma, and chronic kidney disease. There were 63 (7.13%) obese patients, 28 of whom developed severe disease.

Five hundred and four (57%) patients were vaccinated and 380 (47%) were non-vaccinated. Among the vaccinated patients, the effect of Covid-19 was mild in 58.37%, moderate in 36.11%, severe in 0.79%, and critical in 4.37%. Among the non-vaccinated patients, the effect of Covid-19 was mild in 40.26%, moderate in 46.58%, severe in 3.16%, and critical in 10%. The difference in disease severity between the two groups was statistically significant (p<0.05).

Conclusion

Vaccinated Covid-19 patients had significantly lower severity of disease and displayed better outcomes when compared to non-vaccinated patients during the fourth Covid-19 wave dominated by the Delta variant of the SARS-CoV-2 virus.

Pressure Ulcers in Admitted Patients at a Tertiary Care Hospital

Background Pressure ulcers (PUs) occur when the skin covering a weight-bearing part of the body is compressed for a long time between bone, any other part of the body, bed, chair, or any other hard surface. This study aimed to determine the prevalence of pressure ulcers at a tertiary care hospital in all specialty departments including COVID-19. Methods A retrospective study was conducted at North West General Hospital and Research Center, Peshawar, Pakistan. After obtaining ethical approval, data were obtained from the hospital database from July 2020 to June 2021. The keywords "bed sore," "pressure sore," and "pressure ulcer" were used to search for relevant cases, and patient demographics, including age and gender, site of pressure ulcer, stage of pressure ulcer, whether the pressure ulcer was single or multiple, length of stay at the hospital, and specialty department, were collected. Results In total, 99 patients met the inclusion criteria, of which 65 (65.7%) were males, while 34 (34.3%) were females. The age of the patients ranged from 15 to 92 years, with a mean age of 59.93 years. Of the patients, 87 (87.9%) had acquired only a single pressure ulcer. Stage 2 pressure ulcers were the most documented, making up 43.1% of the total cases reported, while stage 4 cases were only 3.3%. The sites most frequently affected by pressure ulcers were the gluteal and sacral regions, accounting for 34.4% and 30.3%, respectively. The incidence of pressure ulcers was the highest in the COVID-19 ward, i.e., 25.3%, followed by the neurosurgery ward with a 20.2% incidence. Conclusion Pressure ulcers occur frequently in almost all the specialty departments of a healthcare setting, especially in COVID-19 and neurosurgery wards, and impose significant physical, psychological, and financial burdens. The prevention of pressure ulcers is the best approach to avert patients and their families from all the burdens associated with pressure ulcers.

Prevalence of Risk Factors of the Female Athlete Triad among Young Elite Athletes of Pakistan

BACKGROUND

Female athletes who are not vigilant about their food choices and choose extraneous physical activities may head towards negative health effects.

PURPOSE

The purpose was to determine the prevalence of risk factors that may lead to the Female Athlete Triad among young elite athletes in Pakistan.

STUDY DESIGN & METHODS

A cross sectional questionnaire-based study was conducted in 2018 at Pakistan Sports Board to investigate the risk factors of The Female Athlete Triad among young elite athletes based in national training camps of major metropolitan cities. Trained and professional female elite athletes of age 18 - 25 years, able to comprehend questionnaire in English were included. Athletes completed the questionnaire including demographics, educational qualifications, Body Mass Index, sports participation, and playing hours. The Eating Aptitude Test-26 (EAT-26) and questionnaires on risks of amenorrhea and risks of low bone mineral density were completed. Individual prevalence of the risk factors of three components was assessed. The data were analyzed using SPSS-20 and descriptive statistics applied.

RESULTS

A sample of 60 elite athletes, (23.57 + 2.37 years, BMI 21.97 +1.90) who participated in various sports were included. EAT-26 results indicated that 50% of athletes were at risk of an eating disorder. Disordered Eating behaviors in need of referral were identified in 83.3%. Risks for amenorrhea were identified in 15%, and concerning low Bone Mineral Density, no risks were identified, except the intake of caffeinated beverages in 51.7%.

CONCLUSION

The prevalence of risk for disordered eating was found to be significant among female elite athletes of Pakistan, but risk of amenorrhea and low bone mineral density were not of major concern.

LEVEL OF EVIDENCE

3b.

Pseudo-pheochromocytoma due to obstructive sleep apnea: a case report

SUMMARY

Obstructive sleep apnea (OSA) is a condition of intermittent nocturnal upper airway obstruction. OSA increases sympathetic drive which may result in clinical and biochemical features suggestive of pheochromocytoma. We present the case of a 65-year-old male with a 2.9-cm left adrenal incidentaloma on CT, hypertension, symptoms of headache, anxiety and diaphoresis, and persistently elevated 24-h urine norepinephrine (initially 818 nmol/day (89-470)) and normetanephrine (initially 11.2 µmol/day (0.6-2.7)). He was started on prazosin and underwent left adrenalectomy. Pathology revealed an adrenal corticoadenoma with no evidence of pheochromocytoma. Over the next 2 years, urine norepinephrine and normetanephrine remained significantly elevated with no MIBG avid disease. Years later, he was diagnosed with severe OSA and treated with continuous positive airway pressure. Urine testing done once OSA was well controlled revealed complete normalization of urine norepinephrine and normetanephrine with substantial symptom improvement. It was concluded that the patient never had a pheochromocytoma but rather an adrenal adenoma with biochemistry and symptoms suggestive of pheochromocytoma due to untreated severe OSA. Pseudo-pheochromocytoma is a rare presentation of OSA and should be considered on the differential of elevated urine catecholamines and metanephrines in the right clinical setting.

LEARNING POINTS

Obstructive sleep apnea (OSA) is a common condition among adults. OSA may rarely present as pseudo-pheochromocytoma with symptoms of pallor, palpitations, perspiration, headache, or anxiety. OSA should be considered on the differential of elevated urine catecholamines and metanephrines, especially in patients with negative metaiodobenzylguanidine (MIBG) scan results.