The effects of alendronate treatment in the diagnosis and management of proximal femur osteoporosis: A real-life scenario.

Currently the increased focus is being given to reforming osteoporosis regimens. Optimizing the evaluation of pharmacological intervention occurs once a medicine has been approved. There is literature available on the use of alendronate in bone loss. The current study focuses on the efficacy assessment of alendronate on proximal femur bone density loss. Current work was carried out to analyze the data of the BMD. The study comprised of females who had received at least six months of Alendronate (70mg/week) for proximal femur osteoporosis. SPSS version-22 was used for analysis and a comparative change was regarded therapeutically significant. The reliability of the research was ensured by reporting cover-up and withdrawals. Among all the study participants who received Alendronate therapy the median height of females in centimeters (cms) was 155 (IQR=16) and the median weight was 55.5 Kilograms (Kgs) (IQR=15). The mean age of the population was 50.59±14.714. The study found the median T-score before therapy was -2.9 (IQR=0.7) and the median T-score after therapy was -2.51(IQR=1). The estimated difference of mean rank was statistically significant for pre- and post-therapy T-score (p=0.008). Hence, the results of this study indicate an improvement in BMD as a result of therapy. Alendronate at 70 mg per week is effective in reducing hip osteoporosis.

Strengthening supportive supervision: A case study of the Expanded Programme on Immunization in Sindh, Pakistan.

BACKGROUND: Sindh, one of the provinces of Pakistan, has been showing a consistently low coverage of immunization. Evidence supports the independent role of supportive supervision in improving the performance of immunization services. However, there is a dearth of evidence regarding the implementation of supportive supervision by the Expanded Programme on Immunization (EPI) Sindh and factors affecting its implementation in the local context. METHODS: An exploratory case study was conducted in two districts of the province, Sindh ie, Hyderabad and Thatta. In total, 11 key informant interviews (KII) and 5 focus group discussions (FGDs) were conducted to obtain perspectives of various stakeholders of EPI, who play different roles in implementation of supportive supervision. Observations of EPI Checklist and review of current EPI policy and Module-4 of 'Mid-Level Manager training' by World Health Organization (WHO) for supportive supervision was also conducted. RESULTS: This study reveals a lack of clarity regarding the potential role of supportive supervision amongst the stakeholders. Lack of human resources, limited competencies of supervisors, lack of specific training of concerned personnel and feedback mechanisms are major bottlenecks affecting the implementation of supportive supervision by EPI Sindh. CONCLUSIONS: The study concludes that supportive supervision is severely affected by challenges such as a lack of comprehensive EPI policy, unavailability of selection criteria for supervisors, training guidelines and proper logistic support to supervisors. There is a lack of training, motivation, and accountability amongst EPI personnel.

Frequency of depression and anxiety among patients with chronic spontaneous urticaria visiting a tertiary care hospital in Karachi, Pakistan.

OBJECTIVE: To determine the frequency of anxiety and depression among chronic spontaneous urticarial patients presenting at a tertiary care hospital. METHODS: The prospective, cross-sectional study was conducted at the Aga Khan University Hospital, Karachi, from February to August 2015, and comprised patients diagnosed with chronic spontaneous urticaria at the dermatology clinic. All the participants were assessed for anxiety and depression using Aga Khan University-Anxiety Depression Scale. Data was collected in face-to-face interview using a structured questionnaire. The association of the condition with different characteristics were calculated after stratification for age, gender, occupation and monthly income. SPSS 19 was used for data analysis.. RESULTS: Of the 146 study participants, 84(57.5%) were males and 62(42.5%) were females. The overall mean age was 39±15.6 years. Of the total, 39(26.7%) had depression and anxiety. Depression and anxiety were more frequent among patients with a positive family history of mental disorders (p=0.02). CONCLUSION: Anxiety and depression were found to be considerably common among chronic spontaneous urticaria patients, with patients having a positive family history for mental illnesses particularly vulnerable.

Out of pocket payment for diabetes mellitus in a public hospital of Karachi.

OBJECTIVE: To estimate the out-of-pocket payment on routine management of type 2 diabetes in patients attending a public-sector facility. METHODS: The cross-sectional study was conducted from December 2016 to May 2017 at Jinnah Postgraduate Medical Centre, Karachi, and comprised of persons with type 2 diabeties. A pretested questionnaire was administered to collect data from the patients. Comparisons of average out-of-pocket expenditure were done across different groups on the basis of gender, education, monthly income and duration of disease. SPSS 20 was used for data analysis. RESULTS: Of the 336 subjects, 178(53%) were males and 158(47%) were females. Overall mean age was 52.20+/-12.64 years, and 170(50.6%) were illiterate. The monthly mean cost on diabetes care was PKR2227}2217.70. People with academic level matriculation or higher spent more on the disease (p<0.001). Expenditure increased with the increase in number of years of disease (p<0.001). Participants with income of less than PKR15000 spent higher percentage of their income compared to the participants earning more (p<0.001). CONCLUSIONS: High out-of-pocket expenditure was incurred by people with diabeties. The coverage of social security nets and individual insurance should be broadened to help improve diabetes management.

Breaking Bad News: A contextual model for Pakistan.

OBJECTIVES: The purpose of the study was to identify the sequence of violence that ensues after breaking bad news and develop a contextual model of breaking bad news and develop a model contextual for Pakistan. METHODS: A qualitative exploratory study was conducted using Six FGDs and 14 IDIs with healthcare providers working in the emergency and the obstetrics and gynecology departments of tertiary care hospitals of Karachi, Pakistan. Data was transcribed and analyzed to identify emerging themes and subthemes using thematic content analysis. RESULTS: Impatience or lack of tolerance, lack of respect towards healthcare providers, unrealistic expectations from healthcare facility or healthcare staff were identified as main reasons that provoked violence after breaking bad news. A conceptual five step model was developed to guide communication of bad news by the health care providers. On initial testing the model was found to be effective in de-escalation of violence. CONCLUSION: Communication of bad news requires application of specific approaches to deal with contextual challenges for reducing violence against healthcare.

Internet addiction among social networking sites users: Emerging mental health concern among medical undergraduates of Karachi.

OBJECTIVE: To determine the frequency and intensity of Internet Addiction (IA) among medical undergraduates, using Social Networking Sites (SNS), in Karachi. METHODS: A cross-sectional survey was conducted in March-June '16 in a private and government medical college of Karachi. Self-administered, Young's Internet Addiction Test was implemented by 340 medical students to assess the frequency and intensity of IA among SNS profile users for past three years. The structured questionnaire further enquired regarding the social and behaviour patterns relevant to IA and SNS use. Data was analyzed using SPSS 16. RESULTS: Internet Addiction (IA) was found in 85% (n=289) of all study participants. Among them, 65.6% (n=223) were 'minimally addicted', 18.5% (n=63) were 'moderately addicted', whereas 0.9% (n=3) were found to be 'severely addicted'. Burden of IA was relatively higher among female medical students as compared to male medical students (p=0.02). There was no significant difference between type of medical college attended and IA (p=0.45). However, statistically significant differences were observed in certain behavioural patterns among addicted and non-addicted medical students. CONCLUSION: Internet Addiction (IA) is an emerging mental health concern affecting social behaviour patterns of medical undergraduates. However, the burden of IA is relatively higher among female medical students.

Effectiveness of training on de-escalation of violence and management of aggressive behavior faced by health care providers in a public sector hospital of Karachi.

BACKGROUND & OBJECTIVE: Considering high burden of violence against healthcare workers in Pakistan APPNA Institute of Public Health developed a training to prevent reactive violence among healthcare providers. The purpose of this training was to equip healthcare providers with skills essential to control aggressive behaviors and prevent verbal and non-verbal violence in workplace settings. This study assesses the effectiveness of training in prevention, de-escalation and management of violence in healthcare settings. METHODS: A quasi-experimental study was conducted in October, 2016 using mixed method concurrent embedded design. The study assessed effectiveness of de-escalation trainings among health care providers working in emergency and gynecology and obstetrics departments of two teaching hospitals in Karachi. Quantitative assessment was done through structured interviews and qualitative through Focus Group Discussions. Healthcare providers` confidence in coping with patient aggression was also measured using a standard validated tool". RESULTS: The overall self-perceived mean score of Confidence in Coping with Patient Aggression Instrument "(CCPAI)" scale was significantly higher in intervention group (Mean= 27.49, SD=3.53) as compared to control group (Mean= 23.92, SD=4.52) (p<0.001). No statistically significant difference was observed between intervention and control groups with regard to frequency of violence faced by HCPs post training and major perpetrators of violence.. CONCLUSION: De-escalation of violence training was effective in improving confidence of healthcare providers in coping with patient aggression.

Obesity, An Emerging Epidemic In Pakistan-A Review Of Evidence.

BACKGROUND: In Pakistan, the disease pattern is facing a huge changeover from acute and communicable diseases to the non-communicable diseases. Moreover, an emerging epidemic of obesity is still under recognized in Pakistan. A detailed review and dissemination of the existing knowledge to determine the extent of burden of obesity can help understand this important public health issue. METHODS: A detailed literature review was conducted through PubMed search engines, regarding obesity burden in Pakistan. The original peer reviewed research articles, reports of WHO in English language, non-government organizations reports were included in the review. "Obesity AND Pakistan" were used as a search terms. RESULTS: Pakistan is suffering from epidemic of obesity, affecting all age groups. Urban population, particularly women shows considerable higher burden of obesity as compared to men and women from rural population. However, among children and adolescents there is variation in prevalence of obesity. Girls from all age groups are predominantly more obese as compared to boys. Most of the studies have estimated child obesity among school going children of different age groups and need careful interpretation. CONCLUSIONS: Pakistan is currently suffering from an emerging epidemic of obesity. The rising burden of obesity is widespread among adults (man and women) and children. The burden of obesity is higher among females in all age groups as compare to males. Effective interventions are required at population level to prevent and control this emerging public health issue.

Low prevalence of asthma among textile workers in Karachi, Pakistan.

OBJECTIVE: To determine the prevalence of asthma in textile workers through post-bronchodilator spirometry and to compare the differences in prevalence based on different criteria used to assess asthma. METHODS: The cross-sectional study was conducted between July and December 2013 in Karachi, Pakistan, and comprised workers from15 textile mills in the city and its outskirts. Asthma and associated respiratory symptoms were assessed using the American Thoracic Society Division of Lung Diseases Questionnaire, and post-bronchodilator spirometry. SPSS 19 was used for statistical analysis. RESULTS: Among the 372 workers in the study, asthma was found in 19(5%) as diagnosed on post-bronchodilator spirometry. The prevalence of self-reported and physician-diagnosed asthma was 15(4%) and 8(2%) respectively. Work in the spinning section, age ≥38 years, duration of work ≥10 years in textile industry, history of smoking, and ≥10 pack years of smoking were found to be important predictors of asthma. CONCLUSIONS: Textile industry workers had low prevalence of asthma, assessed through post-bronchodilator spirometry, compared to estimates for the general population. This could possibly be due to some protective effect of endotoxin exposure although further evaluation with better exposure assessment is warranted.

Burden of asthma among children in a developing megacity: childhood asthma study, Pakistan.

OBJECTIVES: Global burden of childhood asthma has increased in the past few decades, particularly in low-income countries. In Pakistan, there is a lack of community-based epidemiological studies estimating the burden of asthma among children. This study determined the prevalence and predictors of asthma among children 3-17 years of age in Karachi, Pakistan. METHODS: A two-stage community-based representative cross-sectional survey was conducted in Karachi from March 2012 to April 2013 comprising 1046 children aged 3-17 years. Of 7500 clusters, 80 were randomly selected, and of these, 15 children per cluster were enrolled randomly. A translated and pre-tested version of International Study of Asthma and Allergies in Children questionnaire was administered. RESULTS: The overall prevalence of asthma among study participants was 10.2% (95% CI: 8.4-12.0). Asthma was more likely to occur among boys (adj. OR: 2.5, 95% CI: 1.6-4.0), children in the younger age group (3-7 years) (adj. OR: 2.9, 95% CI: 1.7-4.8), those living in households with ill-ventilated kitchens (adj. OR: 1.8, 95% CI: 1.1-3.1), having family history of asthma (adj. OR: 2.3, 95% CI: 1.3-3.9) and those of the Sindhi ethnicity (adj. OR: 2.2, 95% CI: 1.1-4.4). CONCLUSION: This study is the first robust evidence regarding asthma among children in Pakistan, reporting a high burden in this group. Family history, male gender, Sindhi ethnicity and ill-ventilated kitchen were identified as important predictors of asthma. Targeted preventive measures and intervention studies are required to better understand and reduce the burden of asthma among children in Pakistan.

A case study of outsourced primary healthcare services in Sindh, Pakistan: is this a real reform?

BACKGROUND: Since a decade, low and middle income countries have a rising trend of contracting their primary healthcare services to NGOs. In Pakistan, public sector often lacks capacity to effectively & equitably manage the healthcare services. It led the government to outsource the administration of primary health care services to a semi-autonomous government entity i.e. Peoples' Primary Healthcare Initiative (PPHI). This small scale study has assessed the quality of healthcare services at the contracted Basic Health Units (BHUs) with the PPHI and compared it with those managed by the local district government in the province of Sindh. METHODS: A cross-sectional mix methods survey was conducted in November 2011. Two BHUs of each type were selected from the districts Karachi and Thatta in Sindh province. BHUs were selected randomly and a purposive sampling technique was used to recruit the study participants at the two study sites. Focus group discussions were conducted with patients visiting the facility while in-depth interviews were conducted with service providers. An observation based resource availability checklist was also administered. RESULTS: There was a significant difference between the PPHI and the district government administered BHUs with regard to infrastructure, availability of essential medicines, basic medical appliances, mini-lab facilities and vehicles for referrals. These BHUs were found to have sufficient number of trained clinical staff and no punctuality and retention issues whatsoever. The district government administered BHUs presented a dismal picture in all the aspects. CONCLUSION: Out-sourcing of primary healthcare facilities has resulted in significantly improved certain aspects quality and responsiveness of primary healthcare services. This strategy is likely to achieve an efficient and perhaps an equitable healthcare delivery in low and middle income countries where governments have limited capacity to manage healthcare services.