Cohort study on immune checkpoint inhibitor-associated acute kidney injury: Incidence, risk factors, and management strategies.

INTRODUCTION: Case studies and retrospective chart reviews of health system data have demonstrated an increased risk of nephrotoxicity in patients receiving immune checkpoint inhibitors compared to clinical trials. This study investigated the frequency, causes, and risk factors for acute kidney injury in a real-world, rural setting. METHODS: This was a retrospective cohort study of patients who received at least one dose of a checkpoint inhibitor at a rural health system from May 2013 to February 2020 and who received at least one dose of a checkpoint inhibitor. Electronic and manual chart review helped to determine the incidence of, risk factors for, and renal outcomes and management strategies of checkpoint inhibitor-related acute kidney injury. Multivariable Fine and Gray subdistribution hazard models were used to assess the impact of patient characteristics on the incidence of sustained acute kidney injury and checkpoint inhibitor-induced acute kidney injury. RESULTS: After exclusion criteria, 906 patients who received at least one dose of a checkpoint inhibitor at Marshfield Clinic Health System during the study period were included. The incidence of acute kidney injury of any duration and due to any cause was 36.1%, while sustained acute kidney injury occurred in 28.7% of patients. Checkpoint inhibitor-related acute kidney injury was thought to have occurred in 2.7% of patients. Baseline estimated glomerular filtration rate < 60 was the sole predictor of checkpoint inhibitors-related acute kidney injury. Most patients with suspected checkpoint inhibitor-related acute kidney injury were managed with corticosteroids, and 62.5% experienced complete renal recovery. CONCLUSIONS: Ours is the first retrospective cohort study to test whether baseline Eastern Cooperative Oncology Group score and checkpoint inhibitor place in therapy were associated with checkpoint inhibitor-related acute kidney injury, and neither of these data points were found to be predictive. Even after expanding the parameters and methodologies of our study as compared to other retrospective cohort studies, we found only three baseline characteristics to be predictive of sustained acute kidney injury: Baseline eGFR, loop diuretic, and spironolactone use. For checkpoint inhibitor-related baseline, eGFR alone was predictive.

Single-Dose Intraprocedural Steroid Administration Does Not Impact Early Atrial Fibrillation Recurrence.

PURPOSE: To evaluate the effect of single-dose intravenous dexamethasone on atrial fibrillation (AF) recurrence following radiofrequency catheter ablation. METHODS: A cohort of 84 adult patients (> 18 years) underwent catheter ablation at Mayo Clinic Rochester from January to March 2019. Only first-time ablation patients were included, with all re-do ablations excluded to minimize heterogeneity. Administration of intraoperative dexamethasone 4 mg or 8 mg was determined by chart review from the procedure. At our institution, intraoperative intravenous steroids are administered for postoperative nausea and vomiting (PONV) prophylaxis at the discretion of the anesthesiologist. AF recurrence was determined by ECG or cardiac monitoring within 3 months or between 3 and 12 months post-ablation with an in-person follow-up visit. RESULTS: A total of 31 (36.9%) patients received intravenous dexamethasone compared to 54 (63.1%) who did not (approximating a 2:1 comparison group). The incidence of documented AF or atrial flutter, lasting greater than 30 s, within the first 3 months post-ablation was 29.0% in the dexamethasone group versus 24.5% in the non-dexamethasone group (p value 0.80). AF or atrial flutter recurrence at 3-12 months post-ablation was 3.2% in the dexamethasone group compared to 9.4% in the non-dexamethasone group (p value 0.41). CONCLUSION: These data suggest that intraoperative intravenous dexamethasone administered during AF ablation for postoperative nausea and vomiting prophylaxis may not have a significant effect on AF recurrence rates.

Interdisciplinary Deprescribing of Aspirin Through Prescriber Education and Provision of Patient-Specific Recommendations.

BACKGROUND: Inappropriate aspirin use can lead to increased frequency of bleeding events and poor patient outcomes. OBJECTIVES: Compare current aspirin prescribing to guideline recommendations and analyze the impact of pharmacist education for clinicians with provision of patient-specific recommendations. METHODS: Internal medicine residents received 1 educational session on appropriate aspirin use. Over a 5-month period post-education, 100 patients on aspirin with a clinic appointment were screened and their charts reviewed. Aspirin use was classified based on guideline recommendations as follows: (1) recommended, (2) weigh the risk and benefits, (3) not recommended, (4) dose change recommended, or (5) outside of guideline recommendation. A recommendation for aspirin deprescribing was then communicated to the clinician prior to the patient's appointment. Prescriber practice following the appointment was collected and analyzed. RESULTS: Inappropriate aspirin use occurred in 29% (n = 29) of patients prior to their appointment. Of these, aspirin was not recommended in 65.5% (n = 19), and a dose reduction from 325 mg to 81 mg was recommended in 34.5% (n = 10). Of the 81 patients who kept their appointment, pharmacist recommendations to deprescribe aspirin were communicated to the clincian for 20 patients (24.7%) and resulted in a 55% aspirin deprescription. CONCLUSIONS: The majority of patients identified as using aspirin inappropriately fell into 3 groups: (1) patients taking 325 mg aspirin, (2) patients taking aspirin for primary prevention, and (3) patients taking aspirin concomitantly with an anticoagulant. Strategies that may lead to optimization of aspirin use include lectures and patient-specific chart reviews with pharmacist recommendation.

Psychological Well-Being and Coping Strategies among Pakistani Heads of Households during COVID-19 Pandemic: An Online Survey.

Background: Coronavirus Disease (COVID-19) pandemic can affect mental health. Heads of the household are at higher risk of this effect because of their financial and social responsibilities. This study aimed to assess the psychological well-being and its associated factors during the COVID-19 pandemic among heads of households in Pakistan. Methods: We conducted an online survey in May 2020. A convenience sampling strategy was used to enroll the heads of the households from all regions of Pakistan. A validated English and Urdu version of the WHO-5 well-being scale was used to assess well-being. The prevalence of poor well-being and its associated factors among heads of the households was measured using logistic regression. Results: A total of 509 heads of households participated in the survey. About 35% of the participants were dependent on financial sources other than salary. The news was considered a source of fear as 70% assumed that avoiding such news may reduce the fear. The most common coping strategies used during lockdown were; spending quality time with family, eating healthy foods, adequate sleep and talking to friends on the phone. The prevalence of poor well-being was found to be 41% (95% CI: 36.62-45.51). Individuals with any chronic illness were at a higher risk of poor wellbeing adjusted odds ratio of 1.64 (95% CI: 1.04-2.59). Worriedness was also found to be associated with a higher risk of poor wellbeing adjusted OR 1.13 (95% CI: 1.06-1.19). Reading books showed a protective association with poor mental wellbeing adjusted OR 0.64 (95% CI: 0.42-0.98). Conclusion: There was a high prevalence of poor mental wellbeing among heads of households in Pakistan. Worriedness related to the pandemic and having chronic illness were significant predictors of poor psychological wellbeing. Actions are required in the form of targeted mass psychological support systems for the heads of the families to improve their mental health during the COVID-19 crises.

Novel insights into the substrate involved in maintenance of ventricular fibrillation: results from continuous multipolar mapping in a canine model.

BACKGROUND: While the triggers for ventricular fibrillation (VF) are well-known, the substrate required for its maintenance remains elusive. We have previously demonstrated dynamic spatiotemporal changes across VF from electrical induction of VF to asystole. Those data suggested that VF drivers seemed to reside in the distal RV and LV. However, signals from these areas were not recorded continuously. The aim of this study was to map these regions of significance with stationary basket electrodes from induction to asystole to provide further insights into the critical substrate for VF rhythm sustenance in canines. METHODS: In six healthy canines, three multipolar basket catheters were positioned in the distal right ventricle (RV), RV outflow tract, and distal left ventricle (LV), and remained in place throughout the study. VF was induced via direct current application from an electrophysiologic catheter. Surface and intracardiac electrograms were recorded simultaneously and continuously from baseline, throughout VF, and until asystole, in order to get a complete electrophysiologic analysis of VF. Focused data analysis was also performed via two defined stages of VF: early VF (immediately after induction of VF to 10 min) and late VF (after 10 min up to VF termination and asystole). RESULTS: VF was continuously mapped for a mean duration of 54 ± 9 min (range 42-70 min). Immediately after initiation of VF in the early phase, the distal LV region appeared to drive the maintenance of VF. Towards the terminal stage of VF, the distal RV region appeared to be responsible for VF persistence. In all canines, we noted local termination of VF in the LV, while VF on surface ECG continued; conversely, subsequent spontaneous termination of VF in the RV was associated with termination of VF on surface ECG into a ventricular escape rhythm. Continuous mapping of VF showed trends towards an increase in peak-to-peak ventricular electrogram cycle length (p = 0.06) and a decrease in the ventricular electrogram amplitude (p = 0.06) after 40 min. Once we could no longer discern surface QRS activity, we demonstrated local ventricular myocardial capture in both the RV and LV but could not reinitiate sustained VF despite aggressive ventricular burst pacing. CONCLUSIONS: This study describes the evolution of VF from electrical initiation to spontaneous VF termination without hemodynamic support in healthy canines. These data are hypothesis-generating and suggest that critical substrate for VF maintenance may reside in both the distal RV and LV depending on stage of VF. Further studies are needed to replicate these findings with hemodynamic support and to translate such findings into clinical practice. Ventricular fibrillation maintenance may be dependent on critical structures in the distal RV. ECG: electrocardiogram; LV: left ventricle; RV: right ventricle; RVOT: right ventricular outflow tract; VF: ventricular fibrillation.

Safety and efficacy outcomes of atrial fibrillation ablation in patients with rheumatoid arthritis.

Background: Rheumatoid arthritis (RA) is an immune-mediated inflammatory disease associated with atrial fibrillation (AF) and stroke. Objective: The purpose of this study was to evaluate the safety and efficacy of AF ablation in patients with RA. Methods: All patients with RA undergoing AF ablation at our institution from 2010 to 2021 were propensity matched to patients without RA using 9 baseline characteristics. The primary outcome was procedural efficacy defined by clinical AF recurrence, the need for antiarrhythmic drugs (AADs), and repeat catheter ablation. Secondary outcome was safety. Results: A total of 45 patients with RA (age 66.3 ± 7.7 years) were matched to 45 patients without a history of RA (age 68.0 ± 7.3 years). Both groups had similar procedural and periprocedural characteristics. Before ablation, RA patients had statistically higher C-reactive protein (CRP) levels (P ≤.01) and erythrocyte sedimentation rates (ESRs) (P <.05) compared to non-RA patients. After ablation, RA patients had statistically significant higher rates of AF recurrence (P = .006), were more likely to be taking AADs (P <.05), and more likely to undergo repeat ablations (P <.05). The use of immunosuppression or corticosteroids at the time of ablation did not influence the primary endpoint of AF recurrence, AADs, or repeat ablation. Multivariate regression analysis showed CRP and ESR were independent predictors of AF recurrence. CRP was an independent predictor of repeat ablation. Conclusion: Patients with RA are at higher risk of clinical AF recurrence, and are more likely to be taking AADs and require repeat ablation. Preablation CRP and ESR are independent predictors of AF recurrence, and CRP is an independent predictor of repeat catheter ablation.

Ventricular nanosecond pulsed electric field delivery using active fixation leads: a proof-of-concept preclinical study.

BACKGROUND: Mid-myocardial ventricular arrhythmias are challenging to treat. Cardiac electroporation via pulsed electric fields (PEFs) offers significant promise. We therefore tested PEF delivery using screw-in pacemaker leads as proof-of-concept. METHODS: In 5 canine models, we applied nanosecond PEF (pulse width 300 ns) across the right ventricular (RV) septum using a single lead bipolar configuration (n = 2) and between two leads (n = 3). We recorded electrograms (EGMs) prior to, immediately post, and 5 min after PEF. Cardiac magnetic resonance imaging (cMRI) and histopathology were performed at 2 weeks and 1 month. RESULTS: Nanosecond PEF induced minimal extracardiac stimulation and frequent ventricular ectopy that terminated post-treatment; no canines died with PEF delivery. With 1 lead, energy delivery ranged from 0.64 to 7.28 J. Transient ST elevations were seen post-PEF. No myocardial delayed enhancement (MDE) was seen on cMRI. No lesions were noted on the RV septum at autopsy. With 2 leads, energy delivery ranged from 56.3 to 144.9 J. Persistent ST elevations and marked EGM amplitude decreases developed post-PEF. MDE was seen along the septum 2 weeks and 1 month post-PEF. There were discrete fibrotic lesions along the septum; pathology revealed dense connective tissue with < 5% residual cardiomyocytes. CONCLUSIONS: Ventricular electroporation is feasible and safe with an active fixation device. Reversible changes were seen with lower energy PEF delivery, whereas durable lesions were created at higher energies. Central illustration: pulsed electric field delivery into ventricular myocardium with active fixation leads.

Gender Difference In Awareness And Behaviours Of Medical And Dental Students About Corona Virus Disease (Covid-19) In Pakistan.

BACKGROUND: Medical and dental students are the future of health workforce and a potential volunteer pool in the COVID-19 crises. This study aimed to assess the level and gender differences in the awareness, attitude and behaviours of medical and dentals students about COVID-19 in Pakistan. METHODS: An online cross-sectional survey was conducted among medical and dental undergraduate students in Khyber Pakhtunkhwa province. Data was collected using a structured questionnaire having four sections: socio-demographics, knowledge, attitude and practices. RESULTS: A total of 1770 medical and dental students participated and completed the questionnaire. About 1239 (70%) of the respondents were female and 1526 (87%) were MBBS students. We found that 1685 (95%) of the students had adequate knowledge. Majority, 1565 (89%) of the students was concerned about COVID-19 and 1480 (84%) believed that disease will ultimately be controlled. Only about 1129 (64%) of the participants in our study had adequate practices. Male gender was associated with higher risk of inadequate practices. CONCLUSIONS: There were good knowledge and attitudes about COVID-19 among medical and dental students. However, one third of the participants did not have adequate practices and female had better practices than male students. This gap in the knowledge and practice calls for urgent interventions to improve practices.

Blastomycosis-Induced Acute Respiratory Distress Syndrome.

Blastomycosis is a systemic mycosis endemic to the Midwestern and South Central United States. Infection is caused by inhaling spores of Blastomyces dermatitidis (B. dermatitidis) that inhabit soil. Acute respiratory distress syndrome (ARDS) is a rare complication of pulmonary blastomycosis with a significantly high mortality rate. We present a case of blastomycosis associated with severe ARDS treated with traditional prone position ventilation (PPV) and neurally adjusted ventilator assist (NAVA) along with antifungal therapy, steroids, and supportive care in a rural setting with no access to extracorporeal membrane oxygenation (ECMO). This case demonstrates that traditional therapies such as prone position ventilation can help patients with blastomycosis-associated ARDS especially in rural settings where advanced therapies such as ECMO are lacking. The use of NAVA in blastomycosis-associated ARDS needs further research.

Factors associated with quality of life among joint and nuclear families: a population-based study.

BACKGROUND: Advantages and disadvantages associated with joint and nuclear family systems can affect quality of life (QOL). However, there is scarcity of literature about QOL among joint and nuclear family systems. This study aimed to assess the factors associated with QOL in joint and nuclear family systems. METHODS: We conducted a population based cross sectional study in all 52 Union Councils (UCs) of District Abbottabad, Khyber Pakhtunkhwa province, Pakistan from March 2015 to August 2015. Multistage cluster sampling technique was used to select participants from both nuclear and joint family houses. The validated Urdu version of World Health Organization Quality of Life Questionnaire-Brief Version (WHOQOL-BREF) was used to assess quality of life among participants. Univariate and multivariate analyses were performed to explore the associations of different socio demographic variables with QOL among both family systems. Also a multilevel linear regression using backward analysis to obtain final model for each domain was performed to find out the variables that are associated with QOL score in each of family systems. RESULTS: A total of 2063 participants were included in this study (51.0% joint family, 49.0% nuclear family) with the response rate of 97.4%. In multiple linear regression analysis of each domain for joint and nuclear family systems, rural residence compared to urban (p < 0.001), being female (p < 0.001), older age (p < 0.001), having comorbidity (p < 0.001) and lower socioeconomic status (p < 0.001) were found to be a strong predictor of poorer QOL. Furthermore, social capital (p < 0.001) had a positive effect on joint and nuclear family QOL scores. CONCLUSION: This study was the first of its kind which determined the factors of QOL in joint and nuclear families using the validated Urdu version of WHOQOL-BREF in Pakistan. Male gender, urban residence, younger age, higher socioeconomic status and social capital were positive predictors of QOL score while older age and presence of illness were associated with lower QOL scores among both family systems.

Assessment of knowledge and foot self-care practices among diabetes mellitus patients in a tertiary care centre in Makkah, Saudi Arabia: a cross-sectional analytical study.

Introduction: diabetic foot is a common long-term complication of uncontrolled diabetes mellitus. Knowledge about foot self-care practices among diabetic patients in Saudi Arabia is limited. Thus, the aim of this study was to assess the level of patients´ knowledge and practices regarding self-care of diabetic foot among diabetic patients. Methods: a cross-sectional analytical study was conducted using a sample of diabetic patients attending outpatient clinics at Heraa Diabetic Center, Ministry of Health, Makkah City, Saudi Arabia from June 2020 to July 2020. The participants were interviewed through a self-administered questionnaire inquiring sociodemographic factors, patients´ knowledge and practices regarding foot self-care. Results: a total of 409 patients were included in this study. Respondents' ages ranged between 6 and 75 years with a mean of 42.5 years and standard deviation of 13.9 years. Females represented 51.1% of the participants. Type 2 diabetes represented 85.6% of the responses. Overall, most of the participants (72.4%) had a poor level of knowledge whereas only 4.2% expressed a good level of knowledge. Being employed (P = 0.046), type II diabetes patients (P = 0.047) and those whose main source of information was health staff (P = 0.026) were more knowledgeable compared to their peers. Almost two-thirds (63.3%) of patients showed a poor level of practice related to diabetic foot self-care. Conclusion: low level of knowledge and practice of foot care are prevalent among diabetic patients attending outpatient clinics at Heraa Diabetic Center. Designed interventions should be implemented to enhance diabetic foot self-care.

Impact Of The COVID-19 Pandemic On Quality Of Life Of Health Care Workers In Pakistan.

BACKGROUND: Health care workers (HCWs) working on frontlines in COVID-19 pandemic are highly vulnerable to deteriorating physical and mental health. The quality of life of health care workers plays an important role in their skilful delivery of work. Our study assesses their quality of life (QOL) during COVID-19 pandemic so that appropriate measures can be taken to improve their well-being. METHODS: This was an online crosssectional survey among healthcare workers of COVID-19 designated government hospitals in districts Abbottabad, Manshera and Haripur, Khyber Pakhtunkhwa, Pakistan from 23rdJune till 25thJuly, 2020. QOL was assessed using validated WHO QOL BREF. Univariate and multivariate linear regression were used to assess the factors associated with QOL among HCWs. RESULTS: A total of 362 HCWs participated in the study. The mean scores of physical, psychological, social relationships, environmental domains were 60.7 (±17.40), 59.70 (±17.30), 67.90 (±17.90), and 58.20 (±18.40) respectively. Hospital where the respondents were working was the consistent predictor of QOL scores in all four domains with generally lower scores associated with other hospitals compared to Ayub Medical Hospital. Years of experience were positively associated with psychological, social relationship and environmental domains. Designation was associated with social relationship domain only. The scores were lower for trainee medical officers (adjusted ß - 11.5) and higher for house officer (adjusted ß 10.0) and nurses and technicians (adjusted ß 7.0) compared to heads of departments and specialists. CONCLUSION: Quality of life of health care workers has been affected negatively in hospitals of Abbottabad, Pakistan during COVID-19. This calls for hospital administrations, policymakers and the government to take necessary actions to protect the wellbeing of the backbone of the healthcare system.

Psychometric properties of the Urdu version of the Hospital Anxiety and Depression Scale (HADS) among pregnant women in Abbottabad, Pakistan.

BACKGROUND: The Hospital Anxiety and Depression Scale (HADS) is a widely used instrument to measure anxiety and depression symptoms. AIMS: This study aimed to translate, validate and test the applicability of the Urdu version of the Hospital Anxiety and Depression Scale (HADS/UV) among pregnant women. METHODS: The original English version of the HADS was translated into Urdu by three bilingual experts and retranslated to English using the forward-backward approach. The questionnaire was administered to a sample of 200 pregnant women availing obstetrics and gynaecology services for routine prenatal check-ups of Ayub Teaching Hospital, Abbottabad, Pakistan. Psychometric properties of the instrument, including reliability (internal consistency, test-retest analysis and interitems correlation), were tested. Face and content validity were also assessed. Content Validity Index (CVI) was determined using the average approach and Item-Level Content Validity Index (I-CVI) and Scale-Level Content Validity Index (S-CVI) were calculated accordingly. Construct validity was examined through exploratory factor analysis. RESULTS: Cronbach's alpha coefficient has been found to be 0.82 for the anxiety subscale and 0.64 for the depression subscale, while overall alpha of the HADS/UV is 0.84. The Urdu version is content valid, and the S-CVI of anxiety subscale, depression subscale and HADS/UV are 0.947, 948 and 0.947, respectively. Test-retest reliability is 0.884 and 0.934 as measured by Pearson correlation and intraclass correlation, respectively. HADS/UV items correlated positively with the whole scale (p<0.001). Factor analysis with varimax rotation revealed that two factors explained 42.75% of the variance. Items' distribution was quite similar to the original HADS. CONCLUSION: The HADS/UV is a psychometrically sound instrument with satisfactory measurement, including good internal consistency. The instrument shows promise to be a sound tool to assess anxiety and depression in pregnancy.

Spinal epidural abscess due to Pasteurella multocida infection.

Pasteurella multocida (P. multocida) is a gram-negative coccobacillus that comprises the normal oral, upper respiratory, and gastrointestinal flora of many wild and domestic animals. Disease transmission primarily occurs via animal bites, scratches, and licks on broken skin. P. multocida most commonly causes skin and soft tissue infection and local abscess formation; however, we report a unique case of spinal epidural abscess due to P. multocida infection in a patient with a history of recent epidural steroid injection and repeated cat bites. There is little documentation of P. multocida infection causing spinal epidural abscesses in any patient population, particularly in immunocompetent hosts. This case demonstrates that P. multocida may cause a spinal epidural abscess in a healthy individual without manifesting any other signs or symptoms of the disease process. Thus, it is important to elicit a detailed history regarding animal contact and associated injury. Unless overt sepsis or clinical stability necessitate blood cultures with corresponding administration of broad-spectrum antimicrobials, targeted IV antimicrobial therapy should be initiated after collection and culture of the epidural abscess aspirate.

Calcium Channel Blocker Toxicity Causing Acute Respiratory Distress Syndrome: A Commonly Used Drug Triggering a Life-Threatening Condition.

INTRODUCTION: Calcium channel blockers (CCBs) are commonly used but have the potential to cause substantial toxicity. One such underreported toxicity of CCB use is the development of acute respiratory distress syndrome (ARDS). CASE PRESENTATION: 44-year-old previously healthy woman presented to the emergency department (ED) having taken 60 tablets of 125 mg extended-release verapamil and 90 tablets of 0.25 mg clonazepam with the intent to commit suicide. On presentation to the ED, she was sedated and intubated for airway protection. She received aggressive medical resuscitation and was ventilated using low tidal volume mechanical ventilation. The hospital course was complicated by worsening hypoxia and a chest x-ray demonstrating bilateral patchy geographic areas of airspace opacities consistent with ARDS. On day 5 of hospitalization, the patient's clinical status improved significantly, and she was subsequently weaned off vasopressors and extubated. DISCUSSION: CCB toxicity can result in profound hypotension, shock, bradycardia, and conduction blocks, as well as hyperglycemia, acidosis and acute kidney injury, and ARDS. It is important for clinicians to understand the signs and symptoms of CCB toxicity, as well as how to treat it.

Prior Heart Failure Hospitalization and Outcomes in Patients with Heart Failure with Preserved and Reduced Ejection Fraction.

BACKGROUND: A prior hospitalization resulting from heart failure is associated with poor outcomes in ambulatory patients with heart failure. Less is known about this association in hospitalized patients with heart failure and whether it varies by ejection fraction. METHODS: Of the 25,345 hospitalized patients in the Medicare-linked OPTIMIZE-HF registry, 22,491 had known heart failure, of whom 7648 and 9558 had heart failure with preserved (≥50%) and reduced (≤40%) ejection fraction (HFpEF and HFrEF), respectively. Overall, 927 and 1862 patients with HFpEF and HFrEF had hospitalizations for heart failure during the 6 months before the index hospitalization, respectively. Using propensity scores for prior heart failure hospitalization, we assembled two matched cohorts of 924 pairs and 1844 pairs of patients with HFpEF and HFrEF, respectively, each balanced for 58 baseline characteristics. Cox regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes during 6 years of follow-up. RESULTS: Among 1848 matched patients with HFpEF, HRs (95% CIs) for all-cause mortality, all-cause readmission, and heart failure readmission were 1.35 (1.21-1.50; P <0.001), 1.34 (1.21-1.47; P <0.001), and 1.90 (1.67-2.16; P <0.001), respectively. Respective HRs (95% CIs) in 3688 matched patients with HFrEF were 1.17 (1.09-1.26; P <0.001), 1.32 (1.23-1.41; P <0.001), and 1.48 (1.37-1.61; P <0.001). CONCLUSIONS: Among hospitalized patients with heart failure, a previous hospitalization for heart failure is associated with higher risks of mortality and readmission in both HFpEF and HFrEF. The relative risks of death and heart failure readmission appear to be higher in HFpEF than in HFrEF.

Impact of Coronavirus Disease (COVID-19) Pandemic on Psychological Well-Being of the Pakistani General Population.

Background and Objectives: In order to curb the spread of coronavirus disease 2019 (COVID-19), the countries took preventive measures such as lockdown and restrictions of movements. This can lead to effects on mental health of the population. We studied the impact of COVID-19 on psychological well-being and associated factors among the Pakistani general population. Methods: An online cross-sectional survey was conducted between 26th April and 15th May and included participants from all over the Pakistan. Attitudes and worriedness about COVID-19 pandemic were assessed using a structured questionnaire. A validated English and Urdu version of the World Health Organization Well-Being Index (WHO-5) was used to assess the well-being. Factor analysis was done to extract the attitude item domains. Logistic regression was used to assess the factors associated with poor well-being. Results: A total of 1,756 people participated in the survey. Almost half 50% of the participants were male, and a similar proportion was employed. About 41% of the participants were dependent on financial sources other than salary. News was considered a source of fear as 72% assumed that avoiding such news may reduce the fear. About 68% of the population was worried about contracting the disease. The most common coping strategies used during lockdown were spending quality time with family, eating healthy food, adequate sleep, and talking to friends on phone. Prevalence of poor well-being was found to be 41.2%. Female gender, being unemployed, living in Sindh and Islamabad Capital Territory (ICT), fear of COVID-19, and having chronic illness were significantly associated with poor well-being. Similarly, coping strategies during lockdown (doing exercise; spending time with family; eating healthy food; having good sleep; contributing in social welfare work and spending time on hobbies) were also significantly associated with mental well-being. Conclusion: We found a high prevalence 41.2% of poor well-being among the Pakistani general population. We also investigated risk factors of poor well-being which included female gender, unemployment, being resident of ICT and Sindh, fear, chronic illness, and absence of coping strategies. This calls for immediate action at population level in the form of targeted mass psychological support programs to improve the mental health of population during the COVID-19 crises.

Level of satisfaction and its predictors among joint and nuclear family systems in District Abbottabad, Pakistan.

Background: Family system has been found to affect the satisfaction level among the family members. The objective of our study was to determine the satisfaction level and its predictors among joint and nuclear family systems in District Abbottabad, Pakistan. Methods: We conducted a population-based cross-sectional study in all 52 Union Councils (UCs) of District Abbottabad, Khyber Pakhtunkhwa province, Pakistan from March 2015 to August 2015. Multistage cluster sampling technique was used to select 2063 participants from both nuclear and joint family houses. Proportionate sampling was done for selecting mohalla from each UCs, and then subsequently households from respective mohalla's. Simple random sampling was done for selecting the 18 years and above-aged participant for the study. A structured demographic questionnaire was used to collect information from study participants. Univariate and multivariate logistic regression analysis was done to find out the predictors of satisfaction level among joint and nuclear family systems using SPSS version 20 A p-value of <0.05 was considered as significant. Results: Level of satisfaction was found to be higher among people living in the joint family system i.e., 87.5 % v/s 81 % (<0.001) compared to the nuclear family system. Multivariate regression analysis of nuclear family system showed that people having higher education level and higher socioeconomic status (SES) were more satisfied as compared to no education & low SES respectively. While, in the joint family system, only high SES was a significant predictor of satisfaction in the joint family system as compared to low SES. Conclusion: Our study reported a high level of satisfaction among joint and nuclear family systems in Pakistan. High education level and high SES were identified as important predictors of satisfaction among both systems.

Variation In Haematological Profile Of Pregnant Women Attending Combined Military Hospital Quetta.

BACKGROUND: World Health Organization recommends eight antenatal visits throughout pregnancy. Along with full blood count and fasting blood sugar tests, thirty-nine recommendations are given. The objective of this study was to find out significance of difference in haematological profile of pregnant women. METHODS: This cross-sectional study on 384 pregnant women attending outpatient department of combined military hospital Quetta, Pakistan, was conducted from 1st November 2017 to 28th February 2018. Simple random sampling technique through random number table was used. Data collected through structured questionnaire from participants and their laboratory reports was grouped trimester wise. Apart from descriptive statistics, one-way ANOVA with post hoc Tukey test was used to find out significant difference at p≤0.05. SPSS Version 20 and MS Excel 2007 were used for data analysis and plotting graphs. Principles of research ethics were exercised. RESULTS: Mean age (±SD) of the study participants was 27.5 (±4.8) years. Statistically significant difference was found for variables like haemoglobin, haematocrit and MCHC in different trimesters. Only 2 (0.5%) of the total participants had gestational diabetes mellitus. CONCLUSIONS: For getting normal reference ranges in our setting, large population-based studies are needed.