Correlation of inflammatory indices with staging of esophageal carcinoma: A prospective study at Dr. Ruth K. M. Pfau Civil Hospital, Karachi.

Objectives: To determine the correlation between inflammatory indices and the Tumour-Node-Metastasis stage of oesophageal carcinoma. METHODS: The prospective study was conducted from January 2021 to January 2023 at the Department of Upper Gastrointestinal Surgery, Dr Ruth K.M. Pfau Civil Hospital, Karachi, and comprised patients of either gender aged 18- 60 years with biopsy-proven oesophageal cancer. Blood samples were drawn and on the basis of plasma obtained, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, C-reactive protein-to-albumin ratio, lymphocyte-tomonocyte ratio and platelet-to red cell distribution width ratio were calculated. Modified Glasgow Prognostic Score was calculated on the basis of C-reactive protein and albumin levels. Values were compared with tumour length, depth of invasion, lymph node status, vascular involvement, metastasis, pathological subtype and grade of differentiation. Data was analysed using SPSS 24. RESULTS: Of the 220 patients aged 46.1±14.2 years, 120(54%) were females and 100(46%) were males. C-reactive protein-to-albumin ratio demonstrated the highest predictive power for advanced disease stage (p=0.003). Elevated neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio (p=0.010 and p=0.044) were positively correlated with node stage, while elevated platelet-to-lymphocyte ratio was associated with advanced clinical stage (p=0.046). C-reactive protein-to-albumin ratio exhibited positive association with higher tumour stage (p=0.033), node stage (p<0.001) and clinical stage IV (p<0.001). Modified Glasgow Prognostic Score was significantly associated with advanced clinical stage (p<0.001). Conclusion: Neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, C-reactive protein-to-albumin ratio, and Modified Glasgow Prognostic Score could be used effectively as a predictor of advanced oesophageal cancer.

Delivering non-communicable disease services through primary health care in selected south Asian countries: are health systems prepared?

In the south Asian region, delivering non-communicable disease (NCD) prevention and control services through existing primary health-care (PHC) facilities is urgently required yet currently challenging. As the first point of contact with the health-care system, PHC offers an ideal window for prevention and continuity of care over the life course, yet the implementation of PHC to address NCDs is insufficient. This review considers evidence from five south Asian countries to derive policy-relevant recommendations for designing integrated PHC systems that include NCD care. Findings reveal high political commitment but poor multisectoral engagement and health systems preparedness for tackling chronic diseases at the PHC level. There is a shortage of skilled human resources, requisite infrastructure, essential NCD medicines and technologies, and dedicated financing. Although innovations supporting integrated interventions exist, such as innovations focusing on community-centric approaches, scaling up remains problematic. To deliver NCD services sustainably, governments must aim for increased financing and a redesign of PHC service.

Lived experiences of mothers with postnatal anxiety: a qualitative phenomenology study from Pakistan.

OBJECTIVE: The prevalence of postnatal anxiety is high among women during the first year of childbirth globally. Rates are higher in low and middle-income countries (LMICs), that is, 24%. Existing literature on maternal mood and its impact on child development has largely focused on postnatal depression. Postnatal anxiety has been recognised to have significant independent effects similar to those of postnatal depression, including negative effects on various aspects of maternal well-being including quality of life, parent-child interaction and child development. The evidence exploring lived experiences of postnatal anxiety is limited from LMICs. This study explored the lived experiences of anxiety in postnatal mothers in Pakistan. DESIGN: A phenomenological approach was used for this qualitative study. The audio-recorded interviews were transcribed and analysed using the process of thematic analysis. SETTINGS: The study was conducted in two community settings in Karachi, Pakistan; the Bin Qasim and Gadap town. PARTICIPANTS: Women who were 18 years of age or older, had a live childbirth within the previous 12 months and had a score of 10 or higher on the Generalised Anxiety Disorder-7. RESULTS: In-depth, one-to-one interviews were conducted with 10 participants. The qualitative data comprised of three themes. Theme one: Factors perceived to be associated with postnatal anxiety, Theme two: The perceived impact of postnatal anxiety and Theme three: Support needs. The first theme was further subdivided into two subthemes, that is, Mothers' perception of navigating domestic responsibilities and sociocultural norms of motherhood and financial constraints. CONCLUSION: Despite the high prevalence of postnatal anxiety in LMICs there is not any published evidence on exploring this phenomenon through in-depth research in Pakistan. Understanding the lived experiences will help health professionals to identify women at risk of developing postnatal anxiety and to develop effective culturally appropriate interventions for women with anxiety during this postnatal period.

Effect of smoking cessation interventions on abstinence and tuberculosis treatment outcomes among newly diagnosed patients: a randomized controlled trial.

The study evaluates the effectiveness of smoking cessation interventions [Behavioral Change Communication (BCC) and Behavioral Change Communication plus bupropion (BCC+)] compared to conventional Directly Observed Therapy Short Course (DOT) treatment in improving pulmonary tuberculosis treatment outcomes and abstinence among newly diagnosed pulmonary tuberculosis (PTB) patients, highlighting the scarcity of robust experimental studies. The current randomized controlled trial, conducted at Ojha Institute of Chest Diseases between October 2017 and June 2019, randomized 292 patients who were current smokers with newly diagnosed pulmonary tuberculosis into three arms: control (n = 97), BCC (n = 97), and BCC+ (n = 98) arms. The outcomes of the interventions were compared in terms of favorable treatment outcomes and abstinence achieved at the end of 6 months. Baseline characteristics were compared between groups. Cox regression quantified the effect size of interventions for both outcome variables and reported as (crude and adjusted) hazard ratios with 95% confidence intervals (CI). No statistically significant difference was observed in baseline characteristics in each arm. Both BCC+ and BCC showed a statistically significant effect in achieving favorable PTB outcomes at 6 months (aHR 2.37, 95% CI 1.52-3.70 and aHR 2.34, 95% CI 1.51-3.60), as well as for abstinence from smoking at 6 months (BCC+: aHR 4.03, 95% CI 2.18-7.44 and BCC: aHR 3.87, 95% CI 2.12-7.05) compared to the control arm. Both BCC and BCC+ aided by pharmacologic agents such as bupropion when incorporated with conventional DOTs were found to be significantly effective in attaining favorable tuberculosis treatment outcomes as well as in attaining smoking abstinence at the end of the 6-month treatment.This study shows that adding smoking cessation programs (with or without extra drugs like bupropion) to standard Directly Observed Treatment Short Course (DOTs) treatment for people who have recently been diagnosed with pulmonary tuberculosis has a great positive impact on how well the overall antituberculosis treatment works. Our trial shows very promising results for such a combined therapy (DOTs and smoking cessation) in a country where the burden of both tuberculosis and smoking is very high.

Prevalence of undiagnosed metabolic syndrome using three different definitions and identifying associated risk factors among apparently healthy adults in Karachi, Pakistan: a cross-sectional survey in the year 2022.

OBJECTIVE: To determine the prevalence and associated risk factors of undiagnosed metabolic syndrome (MetS) using three different definitions among apparently healthy adults of Karachi, Pakistan. METHODS: This community-based cross-sectional survey was conducted in Karachi, Pakistan, from January 2022 to August 2022. A total of 1065 healthy individuals aged 25-80 years of any gender were consecutively included. MetS was assessed using the National Cholesterol Education Program for Adult Treatment Panel (NCEP-ATP) III guidelines, International Diabetes Federation (IDF), and modified NCEP-ATP III. RESULTS: The prevalence of MetS was highest with the modified NCEP-ATP III definition at 33.9% (95% CI: 31-36), followed by the IDF definition at 32.2% (95% CI: 29-35). In contrast, the prevalence was lower at 22.4% (95% CI: 19-25) when using the NCEP ATP III definition. The risk of MetS significantly increases with higher BMI, as defined by the IDF criteria (adjusted OR [ORadj] 1.13, 95% CI 1.09-2.43), NCEP-ATP III criteria (ORadj 1.15, 95% CI 1.11-1.19), and modified NCEP-ATP III criteria (ORadj 1.16, 95% CI 1.12-1.20). Current smokers had significantly higher odds of MetS according to the IDF (ORadj 2.72, 95% CI 1.84-4.03), NCEP-ATP III (ORadj 3.93, 95% CI 2.55-6.06), and modified NCEP-ATP III (ORadj 0.62, 95% CI 0.43-0.88). Areca nut use was associated with higher odds of MetS according to both IDF (ORadj 1.71, 95% CI 1.19-2.47) and modified NCEP-ATP III criteria (ORadj 1.58, 95% CI 1.10-2.72). Furthermore, low physical activity had significantly higher odds of MetS according to the NCEP-ATP III (ORadj 1.36, 95% CI 1.01-1.84) and modified NCEP-ATP III criteria (ORadj 1.56, 95% CI 1.08-2.26). CONCLUSION: One-third of the healthy individuals were diagnosed with MetS based on IDF, NCEP-ATP III, and modified NCEP-ATP III criteria. A higher BMI, current smoking, areca nut use, and low physical activity were significant factors.

Association between residential green spaces and pregnancy outcomes: a systematic review and meta-analysis.

Residential exposure to greenness has shown positive influences on pregnancy outcomes like birth weight, preterm births, and small to gestational age (SGA) deliveries. We aimed to comprehensively review and investigate these associations by conducting a systematic review with meta-analysis. Relevant studies were retrieved from PubMed, EMBASE, ScienceDirect, and Google Scholar databases before June 2023. Summary effect estimates included birth weight, low birth weight (LBW), preterm births, and SGA which were calculated for 0.1 unit increase in residential greenness exposure. Overall quality of the evidence was examined through Joanna Briggs Institute (JBI) critical appraisal tool. The review included 31 articles and found a statistically significant increase in birth weight measured at 250 m buffer distance (ß = 8.95, 95% CI = 1.63-16.27). Green spaces were also associated with lower odds of LBW (OR = 0.97, 95% CI = 0.96-0.98). Residential greenness had positive impacts on pregnancy outcomes that calls for emphasis on urban planning, especially in developing countries.

Three-staged minimally invasive esophagectomy with end-to-end esophago-gastric anastomosis for thoracic esophageal cancers: An experience from a low middle-income country.

BACKGROUND: Esophageal cancer is on a steady rise and carries significant mortality and morbidity. Depending upon the clinical stage at presentation, either chemotherapy, radiotherapy with or without surgical resection is the treatments in practice. Traditionally, open esophagectomy was performed but over time, the importance of minimally invasive esophagectomy has been established. In this study, we aimed to report our data of totally minimally invasive esophagectomies performed for thoracic esophageal cancers in last four years. METHODOLOGY: A prospective cross-sectional study was conducted at the Department of Upper GI Surgery, Dow University of Health Sciences, Karachi. All diagnosed cases of esophageal carcinoma undergoing minimally invasive esophagectomy, from 2019 to 2022 were included in this study. Outcomes measured were operative time, intra operative complications, conversion rate to open, postoperative complications, number of lymph nodes harvested, margin clearance, in-hospital mortality and 90-days mortality. RESULTS: A total of 53 cases were included in the study, the most prevalent histological type was squamous cell carcinoma 42(79.2%) as compared to adenocarcinoma 8(15.1%). Most common tumor site was lower thoracic esophagus (30-38 cm) in 20 (56.6%) cases. Neo-adjuvant chemotherapy was given in all 53(100%) cases, whereas neo-adjuvant radiation therapy was offered to 49(92.5%) patients. There was a significant and favorable patient response to the neo-adjuvant treatment in 37(69.8%) cases, leading to a decrease in tumor size. Laparoscopic McKeown Esophagectomies were performed in 44 (83.0%) and 9(17.0%) were Robot-assisted Minimally Invasive esophagectomy (RAMIE). Intraoperative injuries (i.e., lung parenchymal injury and bleeding) were reported in only 2(3.8%) patients. Post-operative complications were recorded in 12(22.6%) patients. Margin clearance was observed in 53 (100%) of the patients. The 90-day mortality rate was 3(5.7%), one due to bleeding and other two mortalities were due to COVID related respiratory complications. CONCLUSION: Minimally invasive esophagectomy was found to be safe and feasible technique with encouraging results in terms of decreased intraoperative and post operative complications as well as achieving the standard oncological surgery with acceptable lymph node yield and margin clearance and in hospital and 90 days mortality.

Employing telepsychiatry services to assess the prevalence and identify mental health disorders using the PHQ-9 and GAD-7 in resource-constrained regions of Dadar Mansehra, Pakistan: an observational cross-sectional study.

OBJECTIVE: This study aims to measure the prevalence of mental health disorders in low-resource settings through telepsychiatry and evaluate data from Pakistan's Sehat Kahani nurse-assisted online clinics serving low-income communities. This will help to understand the magnitude and nature of the demand for contextual therapies to promote mental health. The paper will discuss the challenges faced in these settings, such as limited access to mental health facilities, stigma and opportunities telemedicine brings. DESIGN: An observational cross-sectional study of telepsychiatry consultations using Patient Health Questionnaire-9 and Generalised Anxiety Disorder-7 to screen for depression and anxiety was conducted between October and December 2022. SETTING: This research was conducted at Dadar Mansehra e-health clinics of Sehat Kahani with telepsychiatry services in Pakistan. PARTICIPANTS: The study included 2660 participants who visited Sehat Kahani e-health clinics between October and December 2022 and voluntarily completed the questionnaire for data collection. RESULTS: The study was comprised of 2660 participants with a mean age of 34.3 years. The study findings show that the majority of participants were females (98.4%), 16.9% of participants had moderate depression, and 20.8% had severe depression. Furthermore, the participants who were widowed/divorced were more likely to have depression than those who were single (OR=3.3, 95% CI (2.0 to 5.2)). CONCLUSIONS: Based on the findings, most study participants were female, and their mental health was negatively impacted. Women in Pakistan are disproportionately affected by the rising rates of depression and anxiety, and telepsychiatry therapies effectively respond to this growing need. Potentially, it is a game-changer for dealing with mental health problems. Telepsychiatry can help policymakers and mental health professionals to develop effective low-income mental health initiatives.

Role of anthropometric indices as a screening tool for predicting metabolic syndrome among apparently healthy individuals of Karachi, Pakistan.

Introduction: Anthropometric indices are affordable and non-invasive methods for screening metabolic syndrome (MetS). However, determining the most effective index for screening can be challenging. Objective: To investigate the accuracy of anthropometric indices as a screening tool for predicting MetS among apparently healthy individuals in Karachi, Pakistan. Methods: A community-based cross-sectional survey was conducted in Karachi, Pakistan, from February 2022 to August 2022. A total of 1,065 apparently healthy individuals aged 25 years and above were included. MetS was diagnosed using International Diabetes Federation guidelines. Anthropometric indices were defined based on body mass index (BMI), neck circumference (NC), mid-upper arm circumference (MUAC), waist circumference (WC), waist to height ratio (WHtR), conicity index, reciprocal ponderal index (RPI), body shape index (BSI), and visceral adiposity index (VAI). The analysis involved the utilization of Pearson's correlation test and independent t-test to examine inferential statistics. The receiver operating characteristic (ROC) analysis was also applied to evaluate the predictive capacities of various anthropometric indices regarding metabolic risk factors. Moreover, the area under the curve (AUC) was computed, and the chosen anthropometric indices' optimal cutoff values were determined. Results: All anthropometric indices, except for RPI in males and BSI in females, were significantly higher in MetS than those without MetS. VAI [AUC 0.820 (95% CI 0.78-0.86)], WC [AUC 0.751 (95% CI 0.72-0.79)], WHtR [AUC 0.732 (95% CI 0.69-0.77)], and BMI [AUC 0.708 (95% CI 0.66-0.75)] had significantly higher AUC for predicting MetS in males, whereas VAI [AUC 0.693 (95% CI 0.64-0.75)], WHtR [AUC 0.649 (95% CI 0.59-0.70)], WC [AUC 0.646 (95% CI 0.59-0.61)], BMI [AUC 0.641 (95% CI 0.59-0.69)], and MUAC [AUC 0.626 (95% CI 0.57-0.68)] had significantly higher AUC for predicting MetS in females. The AUC of NC for males was 0.656 (95% CI 0.61-0.70), while that for females was 0.580 (95% CI 0.52-0.64). The optimal cutoff points for all anthropometric indices exhibited a high degree of sensitivity and specificity in predicting the onset of MetS. Conclusion: BMI, WC, WHtR, and VAI were the most important anthropometric predictors for MetS in apparently healthy individuals of Pakistan, while BSI was found to be the weakest indicator.

Risk Assessment for Cardiovascular Disease Using the Framingham Risk Score and Globorisk Score Among Newly Diagnosed Metabolic Syndrome Patients.

Purpose: The presence of metabolic syndrome (MetS) is linked to an increased risk of cardiovascular disease (CVD) development. In this study, CVD risk was calculated among individuals with newly diagnosed MetS using the Framingham Risk Score (FRS) and Globorisk Score. The FRS and Globorisk score are particularly relevant in predicting CVD risk as these scores include key MetS-related risk factors like blood pressure, cholesterol levels, and age. Patients and Methods: A community-based cross-sectional study was conducted at various sites in Karachi, Pakistan, from February 2022 to August 2022. Newly diagnosed cases of MetS with no physical disability, known illness, and not taking any regular medication were recruited. MetS was defined based on the definition of International Diabetes Federation. The major outcome was 10-year risk for CVD using the FRS and Globorisk Score. Results: Of 304 patients, 59.2% were classified as low risk according to FRS, while 20.4% were classified as moderate and high risk each. Using the Globorisk score, 44.6% of 224 patients were classified as low risk, 34.4% as moderate risk, and 21.0% as high risk. A moderate positive correlation was observed between the two CVD risk scores (r = 0.651, 95% CI 0.58-0.71). Both risk scores have reported age, gender, and current smokers as significant risk factors in predicting CVD in 10-years (P < 0.05). Conclusion: The outcome of both CVD risk scores predicted moderate-to-high risk of CVD in 10-years in almost half of the newly diagnosed patients with MetS. In particular, the risk of development of CVD in 10-years in newly diagnosed MetS is higher with increasing age, in male gender, and current smokers.

Does Lifestyle Behaviour Trigger Cardiovascular Risk Factors Among School-Going Adolescents In Pakistan?

OBJECTIVE: To explore the association of gender with risk factors for cardiovascular diseases among adolescents. Method: The cross-sectional study was conducted 2016-2019 in low-income schools in Karachi after approval from the ethics review board of Dow University of Health Sciences, and comprised adolescents of both genders aged 11-17 years. Anthropometric measurements and lifestyle behaviours were used to generate risk profile for cardiovascular diseases. Data was analysed using SPSS 16. RESULTS: Of the 1195 subjects, 468(39.2%) were boys and 727(60.8%) were girls. The mean age was 13.9±1.6 years. Mean family size was 5.9±3.64. Overall, 989(91.3%) participants consumed soft drinks, 44(4%) were smokers, 340(48.4%) consumed betel nut, 215(32.9%) Pan, 125(21.2%) Gutka and 9(1.7%) Bidi. Of the total, 867(83.3%) participants were physically less active than recommended, and daily screen time was >2 hours among 513(45.7%) participants. Body mass index and body fat percentage were significantly higher among girls (p<0.05). Higher rates of diastolic and systolic blood pressure and hand grip strength were observed in boys compared to girls (p<0.05). CONCLUSIONS: Interventional programmes in schools should emphasise the need for healthy lifestyle behaviours, increased physical activity, good eating habits and smoking cessation.

Determinants of Covid vaccine uptake and perinatal outcome in pregnant women at a tertiary care center.

OBJECTIVE: To determine the factors for hesitancy and uptake of coronavirus disease-2019 vaccine, and to compare perinatal outcomes in vaccinated and nonvaccinated pregnant women. METHODS: The cross-sectional study was conducted from November 2021 to February 2022 at the Ruth Pfau Civil Hospital, Karachi, and the Holy Family Hospital, Karachi, and comprised pregnant women admitted in delivery suite for operative or vaginal delivery. Data was collected using a self-designed questionnaire which also explored knowledge about vaccine, contextual factors and reasons for and against vaccination. Perinatal outcomes included stillbirth, preterm delivery, low birth weight and Appearance-Pulse-Grimace-Activity-Respiration score. Also, 3cc blood was collected from the umbilical cord at the time of delivery, and enzyme-linked immunosorbent assay technique was used for antibodies titre. Data was analysed using SPSS 24. RESULTS: Of the 186 women, 114(61.3%) with mean age 27.9±4.1 years were vaccinated, and 72(38.7%) with mean age 27.5±5.2 years were not vaccinated. Physician's advise 104 (91.2%), vaccine safety and its effect on foetus 52(72.2%) were main determinants for vaccine uptake and refusal, repectively. Family and peer pressure was also responsible in 19(26.4%) cases for vaccine refusal. Body mass index, parity, level of education, socioeconomic status, history of coronavirus disease-2019 infection, booking status and presence of gestational diabetes mellitus were significantly different between the vaccinated and unvaccinated groups (p<0.05). Antibody titers and Appearance-Pulse-Grimace-Activity-Respiration score at 1 minute were significantly higher in the group of vaccinated women (p<0.05). CONCLUSIONS: Vaccine uptake was found to be low. Safety concern against vaccine, and doctor's advice were the main determinants for hesitancy and uptake. Antibody titers in newborns were higher in the group of vaccinated women.

Prevalence of Metabolic Syndrome among Apparently Healthy Adult Population in Pakistan: A Systematic Review and Meta-Analysis.

BACKGROUND: Metabolic syndrome (MetS) is considerably higher worldwide. It varies greatly in different populations geographically and based on criteria used to diagnose the disease. This review was conducted to determine the prevalence of MetS among apparently healthy adults of Pakistan. A systematic review was performed on Medline/PubMed, SCOPUS, ScienceDirect, Google Scholar, and Web of Science databases until July 2022. Articles published on Pakistani healthy adult population reporting MetS were included. Pooled prevalence was reported with 95% confidence interval (CI). Of 440 articles, 20 articles met the eligibility. RESULTS: The pooled prevalence of MetS was 28.8% (95% CI: 17.8-39.7). The maximum prevalence was from a sub-urban village of Punjab (68%, 95% CI: 66.6-69.3) and Sindh province (63.7%, 95% CI: 61.1-66.3). International Diabetes Federation guidelines had shown 33.2% (95% CI: 18.5-48.0) whereas National Cholesterol Education Program guidelines showed 23.9% (95% CI: 8.0-39.8) prevalence of MetS. Furthermore, individuals with low high-density lipoprotein (HDL) 48.2% (95% CI: 30.8-65.6), central obesity 37.1% (95% CI: 23.7-50.5), and high triglyceride 35.8% (95% CI: 24.3-47.3) showed higher prevalence. CONCLUSION: A considerably higher prevalence of MetS was observed among apparently healthy individuals in Pakistan. High triglyceride, low HDL, and central obesity were found as significant risk factors. (Registration # CRD42022335528).

Fludarabine/Cyclophosphamide Conditioning Regimen in Aplastic Anemia Patients Receiving Matched-Sibling Donor Transplant Is Non-inferior to ATG/Cyclophosphamide: A Single-Center Experience from Pakistan.

The successful outcome of allogeneic hematopoietic stem cell transplant (HSCT) in aplastic anemia patients is driven by suitable donor selection, appropriate conditioning regimen, early intervention, and optimal supportive care after transplant. Pakistan, being a developing country, faces grave economic challenges due to meager health care budget; therefore, cost constraints remain the foremost impediment in optimizing transplant facilities for socioeconomically deprived patients. We conducted a single-center retrospective analysis of aplastic anemia patients (N = 130), who received matched sibling donor transplants from 2011 to 2019, treated with either fludarabine/cyclophosphamide (Flu/Cy) or antithymocyte globulin/cyclophosphamide (ATG/CY) conditioning regimen. Median age was 16 years (IQR, 11-20), and it ranged from 3 to 48 years. The median time from diagnosis to transplant was 3 months (IQR, 2 to 4), and it ranged from 1 to 8 months. The estimated overall survival (OS), relapse-free survival (RFS), and GvHD-free survival (GFS) were found to be 69.0%, 66.7%, and 64.3% in the ATG/Cy group while 76.1%, 72.7%, and 62.5% in the Flu/Cy group, respectively, after a median follow-up of 30 months (IQR, 8 to 55), and it ranged from 0 to 98 months for the study groups. The Flu/Cy regimen was well tolerated and was not associated with increased risk of GvHD. Hence, it may be an appropriate alternative conditioning regimen for developing countries with limited health care resources.

Latent class trajectories of biochemical parameters and their relationship with risk of mortality in ICU among acute organophosphorus poisoning patients.

Acute poisoning is a global public health challenge. Several factors played role in high mortality among acute organophosphorus poisoning (OP) poisoning patients including clinical, vitals, and biochemical properties. The traditional analysis techniques use baseline measurements whereas latent profile analysis is a person-centered approach using repeated measurements. To determine varying biochemical parameters and their relationship with intensive care unit (ICU) mortality among acute organophosphorus poisoning patients through a latent class trajectory analysis. The study design was a retrospective cohort and we enrolled data of 299 patients admitted between Aug'10 to Sep'16 to ICU of Dr. Ruth K. M. Pfau, Civil Hospital, Karachi. The dependent variable was ICU-mortality among OP poisoning patients accounting for ICU stay, elapsed time since poison ingestion, age, gender, and biochemical parameters (including electrolytes (potassium, chloride, sodium), creatinine, urea, and random blood sugar). Longitudinal latent profile analysis is used to form the trajectories of parameters. In determining and comparing the risk of ICU-mortality we used Cox-Proportional-Hazards models, repeated measures and trajectories were used as independent variables. The patients' mean age was 25.4 ± 9.7 years and ICU-mortality was (13.7%, n = 41). In trajectory analysis, patients with trajectories (normal-increasing and high-declining creatinine, high-remitting sodium, normal-increasing, and high-remitting urea) observed the highest ICU-mortality i.e. 75% (6/8), 67% (2/3), 80% (4/5), 75% (6/8), and 67% (2/3) respectively compared with other trajectories. On multivariable analysis, compared with patients who had normal consistent creatinine levels, patients in normal-increasing creatinine class were 15 times [HR:15.2, 95% CI 4.2-54.6], and the high-declining class was 16-times [HR 15.7, 95% CI 3.4-71.6], more likely to die. Patients in with high-remitting sodium, the trajectory was six-times [HR 5.6, 95% CI 2.0-15.8], normal-increasing urea trajectory was four times [HR 3.9, 95% CI 1.4-11.5], and in extremely high-remitting urea trajectory was 15-times [HR 15.4, 95% CI 3.4-69.7], more likely to die compared with those who were in normal-consistent trajectories of sodium and urea respectively. Among OP poisoning patients an increased risk of ICU-mortality were significantly associated with biochemical parameters (sodium, urea, creatinine levels) using latent profile technique.

Public perception of isolation, quarantine, social distancing and community containment during COVID-19 pandemic.

BACKGROUND: Effective strategies of prevention have been and can aid in reducing and overcoming contagious diseases including COVID-19, still there is dearth of knowledge regarding general public awareness and perception. The current study aims to determine the existing knowledge and perception of people living in Karachi about isolation, quarantine, social distancing and community containment. METHODS: This cross-sectional online survey was conducted during the months of March and April 2020. The study included men and women of age 18 years and above quarantined during COVID-19. Convenience sampling followed by snowball sampling technique was used. An online structured questionnaire was developed using Google Form. It included questions on socio demographic information, public knowledge and perception about isolation, quarantine, social distancing and community containment. Chi-square test was used for categorical variables and p value of < 0.05 was considered statistically significant. RESULTS: A total of 548 participants were involved in this survey, 34% (n = 184) males with a mean age of 28 ± 10 years ranging from 18 to 75 years. The major source of hearing about COVID-19 was social media (72%, n = 393). Overall knowledge scores revealed that 27% (n = 146) participants had excellent knowledge about symptoms and prevention of the COVID-19. Excellent knowledge of quarantining, isolation and community containment and social distancing was 38% among participants. Participants who had good and excellent knowledge were more likely to have positive perception of isolation (p-value < 0.001). Majority participants (89%, n = 487) felt isolation may or may not be against human rights and this perception was found significantly associated with moderate to excellent knowledge about community mitigation measures (p-value = 0.009). CONCLUSION: This study concludes that optimal public knowledge and perception related to certain aspects of isolation, quarantine, social distancing and community containment exists however knowledge gaps and misperceptions prevail that need to be addressed.

Exploring context specific anti-smoking warning labels on cigarette packs: A quasi-experiment.

OBJECTIVE: To evaluate the impact of introducing newly-designed warning labels in relation to the available conventional cigarette packs. METHODS: The quasi-experimental study was conducted at four co-educational academic institutions selected using cluster random sampling technique in Gulshan-e-Iqbal town of Karachi from September 2016 to October 2017. The respondents, aged 16-24 years, were exposed with an experimental condition using five graphic cards; each comprising of two separate labels; label 1 being a cigarette pack currently rotated, and label 2 being the newly designed graphic and text warning label. Each participant responded over efficacy measures for each label separately. The difference in the efficacy scores between the two labels was assessed using repeated measure ANOVA with Bonferroni correction in analysis. RESULTS: Of the 388 students, 256(66%) were males and 132(34%) were females. The overall mean age was 18±2.76 years. Also, 188(48.5%) subjects were studying in higher secondary, 179(46.1%) undergraduate and 21(5.4%) postgraduate level. Of them, 104(26.8%) were ever-smokers and 284(73.2%) reported to be never-smokers. A difference was observed in the efficacy of the newly designed label "poverty" compared with current cigarette pack on the measure of not to start smoking(p=0.006). Never-smoking males perceived newly-designed label element 'dead person' as fear-arousing (p=0.045), while never-smoking females considered 'look after family' as efficacious (p=0.024). CONCLUSIONS: There was some evidence of variation in efficacy scores after stratifying on gender and smoking status. A more holistic approach is needed in this regard.

Patterns of smoked and smokeless tobacco use among multimorbid and non-multimorbid middle-aged and older-aged adults in Karachi, Pakistan: a cross-sectional survey.

OBJECTIVES: The objective of this study was to compare the patterns of smoked and smokeless tobacco use among multimorbid and non-multimorbid middle-aged and older-aged individuals in Karachi, Pakistan. STUDY DESIGN: This was an observational cross-sectional study conducted during 2015-2016. STUDY SETTING AND PARTICIPANTS: A total of 3250 participants aged 30 years and above, residing in the Gulshan-e-Iqbal town, Karachi, Pakistan were enrolled in the study through systematic random sampling. The selected area of residence represents diverse socioeconomic and ethnic groups of the city. People who could speak and write English or Urdu, and those who provided written informed consent were included in the study. OUTCOME MEASURES: The primary outcome measure of the study was to determine the differences in patterns of tobacco consumption among multimorbid and non-multimorbid adult individuals. RESULTS: We found no difference in patterns of smoked (adjusted OR (aOR) 1.15, 95% CI 0.88 to 1.50, p=0.289) or smokeless tobacco (aOR 1.13, 95% CI 0.86 to 1.48, p= 0.379) use among multimorbid and non-multimorbid individuals. Individuals who perceived tobacco as a risk were less likely to consume smokeless tobacco products. CONCLUSION: There was no difference in tobacco consumption among individuals with and without multimorbidity. Evidenced-based guidelines are required to implement mental and behavioural interventions in patients with multiple chronic diseases to help them modify their behaviours.

Ramadan Fasting: Perception and maternal outcomes during Pregnancy.

OBJECTIVES: To see perception and knowledge of women about Ramadan fasting and maternal effects of fasting. METHODS: The study design was prospective, case-controlled. This study was conducted at Holy Family Hospital from 1st May 2020 to July 2020. Pregnant women with spontaneous conception and singleton pregnancies, who fasted for seven or more days, were cases, and those who did not fast were taken as controls. Questionnaire was filled regarding perception of women about maternal fasting. Primary maternal outcomes included preterm delivery, pregnancy induced hypertension, and gestational diabetes mellitus. The analysis was conducted using Statistical Package for Social Sciences version 16.0. RESULTS: A total of 215 women were included in the study, 123 women fasted, and 92 women did not fast. Only 2.8% of women knew that fasting is forbidden in pregnancy. Sixty five percent of women reported weakness as the main reason for not fasting. The rate of gestational diabetes, pregnancy induced hypertension and preterm delivery was higher among women who fasted (17% vs 14%, 7% vs 2%, 9% vs 9%) respectively, compared to non-fasting women, but were not found statistically significant. There was no difference in anthropometric measurements of newborn, among both groups. CONCLUSION: Ramadan fasting does not affect maternal outcomes during pregnancy.

Association between Dietary Diversity and Food Insecurity in Urban Households: A Cross-Sectional Survey of Various Ethnic Populations of Karachi, Pakistan.

BACKGROUND AND PURPOSE: The world is experiencing a nutritional transition, yet some regions of South East Asia are still living under the shadows of catastrophic nutritional indicators. Pakistan bears a high dual burden of both communicable and chronic diseases. However, a major contributing factor of both is poor diet and nutrition. The causal pathway of stunting, underweight, wasting, and micronutrient deficiencies has beginnings in less dietary diversity and food insecurity. Current literature on Pakistan and other South Asian countries regarding food insecurity and dietary diversity largely focus on women and children aged less than 5 years; however, ethnic and cultural dynamics of the populace concerning their food and dietary practices in Pakistan have not been well explored. It is essential to have a clear insight into the factors involving malnutrition in different clusters, especially different cultures and ethnicities to target specific areas of interventional strategies versus a uniform approach for all. This study aimed to explore the level of food insecurity and dietary diversity in all major ethnic groups of Karachi, the largest city of Pakistan. METHODS: Using the multistage random sampling, 535 households from five major ethnic groups residing in Karachi were included in the study. To measure food insecurity and dietary diversity (primary and secondary outcome, respectively), we used a FAO standardized questionnaire (version 3, 2007) that was translated first into local languages, piloted, and employed to collect information. RESULTS: Severe food insecurity levels had an inverse relationship with the household dietary diversity, which persisted even after adjusting for other variables (ß=-0.31, 95% CI=-0.65, -0.07). There was no statistically significant association of age, marital status, or education level on food diversity. The most food secure cultural people were those whose ancestors had migrated from India and were Urdu speaking communities, while Sindhi speakers were the least food secure community. CONCLUSION: It is imperative to investigate more on the cultural causal factors leading to food insecurity to address the root causes of malnutrition and design new cultural-specific interventions that should be employed in large urban centers where different communities reside together.