Obesity and Risk of Hypertension in Preadolescent Urban School Children: Insights from a Developing Country.

Background: Childhood obesity and hypertension are growing concerns globally, especially in developing countries. This study investigated the association between overall and central obesity at baseline, and prehypertension or hypertension at follow-up among preadolescent school children in Karachi, Pakistan. Methods: This is a sub study with cohort design embedded within a feasibility trial on School Health Education Program in Pakistan (SHEPP) in preadolescent aged 6-11 years, attending two private schools, were enrolled from 2017 to 2019. Hypertension or prehypertension at follow-up were the outcomes and obesity or central obesity at baseline were the exposure variables. Hypertension was defined as systolic blood pressure and/or diastolic blood pressure ≥ 95th percentile for age, sex, and height. Obesity was defined as body mass index for-age and sex ≥ 95th percentile, whereas central obesity was determined by waist circumference measurements ≥ 85th percentile of age, sex, and height specific cut-offs. Logistic regression analysis was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) to identify risk factors for hypertension and prehypertension. Results: Analysis was conducted for 908 participants, evenly distributed with 454 boys and 454 girls. Hypertension was observed in 19.8% of the preadolescents, with rates of 18.5% in boys and 21.0% in girls. Prehypertension was found in 16.8% of preadolescents, with 18% among boys and 16% among girls. Additionally, 12.8% of preadolescents were classified as obese and 29.8% had central obesity. Obesity at baseline was associated with hypertension (OR 8.7, 95% CI 3.5, 20.4) in the final model after adjusting for age, gender, physical activity, sedentary behavior, fruits, vegetable intake and hypertension at baseline. Central obesity at baseline also yielded high odds, with prehypertension (OR 1.9, 95% CI 1.4, 2.8) and hypertension (OR 2.7, 95% CI 1.9, 3.9) in the final model. Conclusion: This study highlights a concerning prevalence of hypertension and prehypertension among preadolescent school-going children. Obesity and central obesity at baseline emerged as significant predictive factors for hypertension within this cohort. The findings emphasize the urgency of implementing comprehensive school health education programs aimed at early detection and effective management of hypertension during childhood and adolescence in school settings.

Acute physiology and chronic health evaluation score and mortality of patients admitted to intermediate care units of a hospital in a low- and middle-income country: A cross-sectional study from Pakistan.

Background: Intermediate care units (IMCUs) serve as a bridge between general wards and intensive care units by providing close monitoring and rapid response to medical emergencies. We aim to identify the common acute medical conditions in patients admitted to IMCU and compare the predicted mortality of these conditions by acute physiology and chronic health evaluation-II (APACHE-II) score with actual mortality. Methods: A cross-sectional study was conducted at a tertiary care hospital from 2017 to 2019. All adult internal medicine patients admitted to IMCUs were included. Acute conditions were defined as those of short duration (<3 weeks) that require hospitalization. The APACHE-II score was used to determine the severity of these patients' illnesses. Results: Mean (standard deviation [SD]) age was 62 (16.5) years, and 493 (49.2%) patients were male. The top three acute medical conditions were acute and chronic kidney disease in 399 (39.8%), pneumonia in 303 (30.2%), and urinary tract infections (UTIs) in 211 (21.1%). The mean (SD) APACHE-II score of these patients was 12.5 (5.4). The highest mean APACHE-II (SD) score was for acute kidney injury (14.7 ± 4.8), followed by sepsis/septic shock (13.6 ± 5.1) and UTI (13.4 ± 5.1). Sepsis/septic shock was associated with the greatest mortality (odds ratio [OR]: 6.9 [95% CI (confidence interval): 4.5-10.6]), followed by stroke (OR: 3.9 [95% CI: 1.9-8.3]) and pneumonia (OR: 3.0 [95% CI: 2.0-4.5]). Conclusions: Sepsis/septic shock, stroke, and pneumonia are the leading causes of death in our IMCUs. The APACHE-II score predicted mortality for most acute medical conditions but underestimated the risk for sepsis and stroke.

Global Cardiovascular Research: Gaps and Opportunities.

PURPOSE OF REVIEW: Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. CVDs contribute to a large health and economic burden on a global scale. We aim to describe the current landscape of global cardiovascular research, highlight significant findings, and identify potential opportunities for further studies. RECENT FINDINGS: There has been remarkable research output regarding cardiovascular health in recent decades. Large-scale collaborative studies have made impactful strides in identifying modifiable risk factors and forming evidence-based guidelines to facilitate improved cardiovascular care and outcomes. However, there are significant CVD disparities between high- and low- income countries which require interventions to mitigate these inequalities. Encouraging collaborative partnerships, strengthening research capacity in low-resource settings, and promoting equity in research are fundamental strategic approaches to help improve global cardiovascular research.

School Health Education Program in Pakistan (SHEPP): findings from a feasibility trial in pre-adolescent school children from a lower middle-income country.

BACKGROUND: The school environment plays an essential role in promoting health education and physical activity for children and adolescents. We aim to assess the feasibility of threefold health education program in children and its potential efficacy on physical activity and diet and cardiometabolic risk factors including blood pressure, body mass index (BMI), and waist circumference. METHODS: The SHEPP was a parallel group feasibility intervention trial conducted in two schools over 23 months. All children aged 9-11 years enrolled in the schools were included. The SHEPP intervention comprised of health education on healthy lifestyle and physical activity sessions for children, training of teachers, and awareness sessions for parents conducted over 10 months. One school received the intervention of SHEPP while the other school continued routine activity. The primary outcome was the feasibility of SHEPP in terms of recruitment, retention, and treatment fidelity. Secondary outcomes were physical activity levels, dietary intake (of fruits and vegetables), and cardiometabolic risk factors (blood pressure, BMI, and waist circumference (WC)). RESULTS: A total of 1280 preadolescent children were assessed for eligibility and 1191 were found eligible. The overall recruitment n (%) was 982/1191(82.5%) with 505(51.4) from SHEPP intervention school and 477(48.6) in routine activity school. The overall retention rate n (%) at 10-month follow-up was 912/982(92.8), with 465/505(92) in SHEPP intervention school and 447/477(93.7) in routine activity school. In treatment fidelity, 132/144(92) %). Physical activity sessions and all (100%) health education sessions were conducted for each of the twelve classes. Mean (SD) Seven-day Physical activity increased by 134 (196) min in the SHEPP intervention school v 29.8(177) in the routine activity school (P value < 0.001) from baseline to follow-up. Overall, there was an increase in vegetable intake (> 3 serving /day) in SHEPP intervention school of 5.5 to 21.4% from baseline to follow-up compared to 7.5 to 14.9% in routine activity school. The mean change (SD) in systolic blood pressure was 1.3(12) mmHg, 2.2(19.0) mm Hg in in diastolic blood pressure, - 0.09(5.4) kg/m2 in BMI and 6.2 cm in waist circumference in the intervention arm versus - 3.4(11.1) mm Hg in SBP, - 4.3(9.9) mm Hg in DBP, - 0.04((4.6) kg/m2 in BMI, and 3.8 cm in WC in the control arm. CONCLUSION: We found that intervention using SHEPP is feasible in schools and may help children to adopt a healthy lifestyle as they age by increasing physical activity. However, the potentially beneficial effect on diet, MI, and BP needs further exploration and a longer follow-up, more specifically at the juncture of teenage and adulthood. TRIAL REGISTRATION: NCT03303287.

Challenges of managing hypertension in Pakistan - a review.

BACKGROUND: This review aims to describe existing evidence on the state of hypertension in Pakistan, including the prevalence, associated risk factors, preventive strategies, and challenges in the management of hypertension. METHODS: A comprehensive literature search was conducted electronically using PubMed and Google Scholar. Using specific screening methodology, 55 articles were selected to be included. RESULTS: We found from this extensive review that several small studies report high prevalence of hypertension but there is a lack of population based prevalence of hypertension in Pakistan. Lifestyle risk factors such as obesity, unhealthy diet, decreased physical activity, low socioeconomic status, and lack of access to care were the main associated factors with hypertension. Lack of blood pressure monitoring practices and medication non-adherence were also linked to uncontrolled hypertension in Pakistan and were more evident in primary care setups. The evidence presented is essential for delineating the burden of the disease, hence allowing for better management of this underserved population. CONCLUSION: There is a need for updated surveys to depict the true prevalence and management of hypertension in Pakistan. Cost-effective implementation strategies and policies at the national level are needed for both prevention and control of hypertension.

Medication Adherence in Patients With Uncontrolled Hypertension & Hypertensive Crisis Presenting to a Hospital Setting in Karachi, Pakistan.

BACKGROUND: Hypertension is an established risk factor for cardiovascular disease. Non-adherence to antihypertensive medications contributes to poorly controlled hypertension while also increasing the risk of hypertensive crisis. The aim of our study was thus to estimate the frequency of adherence to antihypertensive medications in our population and also see if an association exists between adherence and the development of a hypertensive crisis. METHODS: This cross-sectional study was undertaken on patients admitted to Aga Khan University Hospital, Karachi, Pakistan, between July 2020 and March 2022. All patients with uncontrolled hypertension with systolic blood pressure >140 and diastolic blood pressure >90 who were admitted through the emergency department were included. A systolic blood pressure over 180mmHg or diastolic blood pressure over 120mmHg, with or without end-organ damage was used to define a hypertensive crisis. Adherence to medications was assessed using the 4-item Morisky Green Levine (MGL) scale. Each item was scored as 1 and then added together to get a final score out of 4 with a score of ≥3 signifying adherence while a cumulative score of 0, 1, or 2 was classified as non-adherence. RESULTS: We found that 64% of the cohort were adherent to their medications while 93 (36%) were non-adherent. The most common comorbid condition was found to be diabetes mellitus (54.8%). Around 146 (64.6%) patients were on a single anti-hypertensive agent. Depression as calculated according to the hospital anxiety and depression scale (HADS) was seen in 133 (51.2%) of our cohort while 147 (56.5%) had anxiety. Similar rates of adherence were seen amongst males (49.1%) and females (50.9%). The highest level of adherence was seen in the 61 to 75 years age group (34.9%) and in those with university-level education (30.6%). We also found a statistically significant association between adherence to antihypertensive medications with anxiety (p-value=0.048). Moreover, in the hypertensive crisis group, 40.7% of the patients were adherent to their antihypertensive medications while 54.8% were found to be non-adherent, with the p-value reaching statistical significance (p-value=0.028). CONCLUSION: We found a higher rate of adherence (64%) in this inpatient hypertensive population as compared to previous studies in our population. We also found that non-adherence is a risk factor for the development of a hypertensive crisis. Therefore, at clinic visits, physicians should assess their patient's adherence to antihypertensive medications to prevent the development of a hypertensive crisis.

Opportunities and challenges to non-communicable disease (NCD) research and training in Pakistan: a qualitative study from Pakistan.

INTRODUCTION: Most of the global non-communicable disease (NCD)-related death burden is borne by low and middle-income countries (LMICs). In LMICs like Pakistan, however, a major gap in responding to NCDs is a lack of high-quality research leading to policy development and implementation of NCDs. To assess institutional opportunities and constraints to NCD research and training we conducted a situational analysis for NCD research and training at Aga Khan University Pakistan. METHODS: We conducted a descriptive exploratory study using grounded theory as a qualitative approach: semistructured interviews of 16 NCD stakeholders (three excluded) and two focus group discussions with postgraduate and undergraduate trainees were conducted. A simple thematic analysis was done where themes were identified, and then recurring ideas were critically placed in their specific themes and refined based on the consensus of the investigators. RESULTS: The major themes derived were priority research areas in NCDs; methods to improve NCD research integration; barriers to NCD research in LMICs like Pakistan; design of NCD research programme and career paths; and NCD prevention at mass level, policy and link to the government. In general, participants opined that while there was an appetite for NCD research and training, but few high-quality research training programmes in NCDs existed, such programmes needed to be established. The ideal NCD research and training programmes would have in-built protected time, career guidance and dedicated mentorship. Most participants identified cardiovascular diseases as a priority thematic area and health information technology and data science as key methodological approaches to be introduced into research training. CONCLUSION: We conclude from this qualitative study on NCD research and training that high-quality research training programmes for NCDs are rare. Such programmes need to be established with in-built protected time, career guidance and mentorship for the trainees to improve their research capacity in Pakistan.

Association of Depression and Anxiety With Hypertensive Crisis: A Cross-Sectional Study From a Hospital Setting in Karachi, Pakistan.

Introduction Hypertension, a leading risk factor for cardiovascular death, has been closely linked with depression and anxiety. The aim of this study was to examine the association of depression or anxiety with hypertensive crisis in patients and also see if the association is affected by age group or gender. This was carried out in a hospital setting. Methods This cross-sectional study was conducted between July 2019 and March 2022 on 290 patients admitted to the Aga Khan University Hospital (AKUH), Karachi, Pakistan. All adult patients more than 18 years of age admitted with uncontrolled hypertension with a systolic blood pressure of >140 and a diastolic blood pressure of >90 admitted through emergency were included. A hypertensive crisis was defined as a systolic blood pressure greater than 180 mm Hg or a diastolic blood pressure greater than or equal to 120 mm Hg, with or without accompanying end organ damage. Symptoms of depression and anxiety were evaluated using the Hospital Anxiety and Depression Scale (HADS), with a cut-off score ≥8. Results Of the patients identified with uncontrolled hypertension, a total of 140 (48.3%) of the patients presented with a hypertensive crisis, while 150 (51.3%) did not have a hypertensive crisis at presentation. In the hypertensive crisis group, 60 (49.3%) had HADS scores consistent with depression, while 83 (59.3%) had HADS scores consistent with anxiety. In patients with hypertensive crisis, HADS depression and anxiety were most prevalent in the 61-75 age group (39.7%). In the comparison of gender, it was found that males and females with hypertensive crisis had an almost equal prevalence of anxiety (49.4% in males versus 50.6% in females). A slightly higher prevalence of depression was seen in females with hypertensive crises when compared to males. Conclusion We found no association between depression or anxiety with hypertensive crisis, and the association is not affected by age group or gender. However, do note that half of the patients with hypertensive crises had depression or anxiety. Future large multicentered studies are required to study the link in greater detail.

Colchicine and the combination of rivaroxaban and aspirin in patients hospitalised with COVID-19 (ACT): an open-label, factorial, randomised, controlled trial.

BACKGROUND: COVID-19 disease is accompanied by a dysregulated immune response and hypercoagulability. The Anti-Coronavirus Therapies (ACT) inpatient trial aimed to evaluate anti-inflammatory therapy with colchicine and antithrombotic therapy with the combination of rivaroxaban and aspirin for prevention of disease progression in patients hospitalised with COVID-19. METHODS: The ACT inpatient, open-label, 2 × 2 factorial, randomised, controlled trial was done at 62 clinical centres in 11 countries. Patients aged at least 18 years with symptomatic, laboratory confirmed COVID-19 who were within 72 h of hospitalisation or worsening clinically if already hospitalised were randomly assigned (1:1) to receive colchicine 1·2 mg followed by 0·6 mg 2 h later and then 0·6 mg twice daily for 28 days versus usual care; and in a second (1:1) randomisation, to the combination of rivaroxaban 2·5 mg twice daily plus aspirin 100 mg once daily for 28 days versus usual care. Investigators and patients were not masked to treatment allocation. The primary outcome, assessed at 45 days in the intention-to-treat population, for the colchicine randomisation was the composite of the need for high-flow oxygen, mechanical ventilation, or death; and for the rivaroxaban plus aspirin randomisation was the composite of major thrombosis (myocardial infarction, stroke, acute limb ischaemia, or pulmonary embolism), the need for high-flow oxygen, mechanical ventilation, or death. The trial is registered at www. CLINICALTRIALS: gov, NCT04324463 and is ongoing. FINDINGS: Between Oct 2, 2020, and Feb 10, 2022, at 62 sites in 11 countries, 2749 patients were randomly assigned to colchicine or control and the combination of rivaroxaban and aspirin or to the control. 2611 patients were included in the analysis of colchicine (n=1304) versus control (n=1307); 2119 patients were included in the analysis of rivaroxaban and aspirin (n=1063) versus control (n=1056). Follow-up was more than 98% complete. Overall, 368 (28·2%) of 1304 patients allocated to colchicine and 356 (27·2%) of 1307 allocated to control had a primary outcome (hazard ratio [HR] 1·04, 95% CI 0·90-1·21, p=0·58); and 281 (26·4%) of 1063 patients allocated to the combination of rivaroxaban and aspirin and 300 (28·4%) of 1056 allocated to control had a primary outcome (HR 0·92, 95% CI 0·78-1·09, p=0·32). Results were consistent in subgroups defined by vaccination status, disease severity at baseline, and timing of randomisation in relation to onset of symptoms. There was no increase in the number of patients who had at least one serious adverse event for colchicine versus control groups (87 [6·7%] of 1304 vs 90 [6·9%] of 1307) or with rivaroxaban and aspirin versus control groups (85 [8·0%] vs 91 [8·6%]). Among patients assigned to colchicine, 8 (0·61%) had adverse events that led to discontinuation of study drug, mostly gastrointestinal in nature. 17 (1·6%) patients assigned to the combination of rivaroxaban and aspirin had bleeding compared with seven (0·66%) of those allocated to control (p=0·042); the number of serious bleeding events was two (0·19%) versus six (0·57%), respectively (p=0·18). No patients assigned to rivaroxaban and aspirin had serious adverse events that led to discontinuation of study drug. INTERPRETATION: Among patients hospitalised with COVID-19, neither colchicine nor the combination of rivaroxaban and aspirin prevent disease progression or death. FUNDING: Canadian Institutes for Health Research, Bayer, Population Health Research Institute, Hamilton Health Sciences Research Institute, Thistledown Foundation. TRANSLATIONS: For the Portuguese, Russian and Spanish translations of the abstract see Supplementary Materials section.

Hypertension in Women: A South-Asian Perspective.

Introduction: Hypertension is an important contributor to cardiovascular disease related morbidity and mortality. Despite the magnitude of its negative impact on cardiovascular outcomes, treatment and control of hypertension remain suboptimal in both men and women. Materials and Methods: Numerous databases, i.e., PubMed, ScienceDirect, etc., were searched using keywords to identify relevant studies to our narrative review. The findings from the most pertinent articles were summarized and integrated into our narrative review on hypertension in women. Results: The pathophysiology of essential hypertension is still being delineated in both men and women; there are multiple sex specific factors in association with the development of hypertension in women, including age, combined oral contraceptives (COCs), polycystic ovarian syndrome (PCOS), preeclampsia, etc. There are several sex specific considerations in antihypertensives drug choices. Discussion: Despite the magnitude of its negative impact on cardiovascular outcomes, treatment and control of hypertension remain suboptimal in women. Medical treatment and adherence is uniquely challenging for South Asian women due to a variety of socio-cultural-economic factors. Further research is warranted to identify optimal sex-specific treatment options that will improve the control of hypertension and decrease the risk of subsequent cardiovascular disease in both genders.

Tocilizumab in critically ill COVID-19 patients: An observational study.

Tocilizumab decreases inflammatory response in the cytokine storm which is one of the mechanisms behind the development of ARDS in COVID-19 patients. The objective of our study was to determine response of tocilizumab in patients suffering from COVID-19 by analyzing clinical parameters and inflammatory markers. A single-arm observational retrospective study was conducted from March 15, 2020 to March 15, 2021. Clinical outcomes in terms of mortality, weaning from mechanical ventilator, improvement in laboratory parameters including inflammatory cytokines, and length of hospital stay were documented. Reduction in values of inflammatory markers, and patients discharged home in stable condition were defined as an improvement after tocilizumab administration. A total of 514 patients received tocilizumab, majority of whom were critically sick 333 (64.8%). Out of the total sample 363 (70.6%) patients were discharged home in stable condition. Overall mean length of stay was 11.50 ± 8.4 days. There was significant difference in length of stay of patients who required invasive mechanical ventilation as compared to those who were kept only on supplemental oxygen (p < 0.05). Patients who were discharged home showed significant improvement in inflammatory markers and neutrophil to lymphocyte ratio as compared to those who expired (p < 0.05). A total of 21 (4.1%) patients had positive blood culture while 57 (11.1%) had positive culture of tracheal aspirate. Hence, tocilizumab is found to be a reasonable therapeutic option for worsening COVID-19 pneumonia by decreasing the need for mechanical ventilation. However, it is associated with adverse events including bacterial and fungal infections.

Assessment of macronutrients consumption in the diet of adolescent school children in four seasons: a longitudinal study from an urban city in Pakistan.

BACKGROUND: A healthy diet in the adolescence period is essential for physical, mental, and immunological development. We aimed to assess macronutrient consumption in the diet of adolescent school children using 24 h recalls in four seasons of the year. METHOD: This was a longitudinal study conducted from February 2014 to June 2015. The study population included 155 school children aged 7-14 years from an urban school in Karachi. 24HR recall was conducted on 4 random days of the 4 main seasons. A food composition table was developed where the weight, calories, carbohydrate, fat, and protein content of the food items were listed. Macronutrients quantification was calculated by using proportional weight from the food composition table. Food groups were also assigned to each food item including vegetables, fruits, grains, protein foods, dairy products, and oils. RESULTS: A total of 155 adolescent children aged between 7 and 14 years were approached. Out of the 155 preadolescents and adolescents, 150 (96.7%) agreed to participate. The mean (SD) age of the children was 11.31 (1.6) years, and 59% of all the children were males. Overall mean (SD) daily intake for all seasons was 195.31 (86.87) grams of carbohydrates, 94.77 (71.87) grams of proteins, and 55.87 (30.79) grams of fats. Carbohydrates formed 48.16%, protein 21.92%, and fat 29.93% of the total caloric intake. The mean (SD) daily caloric intake was 1517 (644) grams. Overall, the highest source of calories was from carbohydrate 781 (347) Kilocalories (Kcal), followed by fat 502 (277) Kcal and protein 379 (287). The Carbohydrate intake in 24 h was highest in the autumn; 212.81 (85.37), and there was a significant difference in carbohydrate intake in all seasons (p value 0.003). Consumption of discretionary food group was high (31.3%), and consumption of fruits and vegetables was low (29%). CONCLUSION: The study reports a suboptimal caloric intake of fewer than 2000 cal/day among the adolescents from school. The highest source of calories was from carbohydrates.The highest consumption of food was in autumn and the least in summer. Fruits and vegetable intake was low, and discretionary food intake was high.

Three Hours Ambulatory Blood Pressure: A Surrogate for Daytime Ambulatory Blood Pressure Assessment in the Pakistani Population.

Background Office blood pressure (BP) measurement is affected by the white-coat phenomenon and shows a weaker correlation with the gold standard ambulatory blood pressure monitoring (ABPM). To overcome this limitation, 24-hour ABPM is recommended by the guidelines for the diagnosis of hypertension. However, 24-hour ABPM is expensive and cumbersome, which limits its use in low to middle-income countries like Pakistan. We aimed to assess if an abbreviated ABPM interval can be utilized to diagnose hypertension effectively in our population. Methods A cross-sectional study, involving 150 participants as part of the Post Clinic Ambulatory Blood Pressure (PC-ABP) study, was conducted in the cardiology clinics. Participants ≥18 years of age, who were either hypertensive or referred for assessment of hypertension, were included. Blood pressure (BP) readings were taken with an ambulatory BP monitor over a 24-hour period. After excluding the first hour called the 'white-coat window,' the mean of the first six systolic readings taken every half hour during the daytime was calculated and was called systolic three-hour ABPM. Pearson correlation coefficients were calculated and Bland-Altman plots were constructed to determine the correlation and limits of agreement between mean systolic three-hour ABPM and daytime-ABPM. Receiver operating characteristic (ROC) curve for systolic and diastolic three-hour daytime ABPM and area under the curve (AUC) were analyzed for the level of accuracy in predicting hypertension. Results Of the 150 participants, 49% were male, and 76% of all were hypertensive. The mean age of participants was 60.3 ± 11.9 years. The mean systolic three-hour ABPM was 135.0 ± 16 mmHg. The mean systolic daytime ABPM was 134.7 ± 15 mmHg. Pearson correlation coefficient between mean systolic three-hour ABPM and mean systolic daytime ABPM was 0.85 (p-value <0.001). The limits of agreement were 18 mmHg to -17 mmHg between the two readings on Bland-Altman plots and the area under the curve of the receiver operating characteristic (ROC) was 0.96, suggesting that three-hour systolic ABPM is a good predictor of hypertension. Conclusion Three-hour ABPM correlates well with 24-hour ABPM in the Pakistani population. We recommend considering the use of this abbreviated ABPM to screen hypertension where a full-length ABPM cannot be used. Further studies can be conducted on a larger sample size to determine the prognostic implications of this shortened ABPM.

Triggering and protective factors of burnout in medical resident physicians in a lower-middle-income country: A cross-sectional study.

BACKGROUND: Residents and interns are prone to emotional and physical exhaustion, also known as burnout. Burnout has not been studied much in physicians working in lower-middle income countries. We conducted this study to determine the burden of burnout among internal medicine residents and to identify triggering and protective factors associated with burnout. MATERIALS AND METHODS: A cross-sectional study was conducted at two institutes in Karachi from 2018 to 2019. All residents registered in the internal medicine program for at least 6 months were invited to participate via an online survey. An abbreviated version of the Maslach Burnout scale was used to measure burnout, and protective and triggering factors were recorded according to known factors. RESULTS: A total of 71 out of 92 (77%) residents participated. The mean (SD) age of the participants was 28 (3.1) years, 51 (71.8%) were females and 51 (71.8%) were junior residents. A total of 33 (46.5%) residents had burnout. Burnout and emotional exhaustion were more in female residents (p < 0.05). None of the triggering factors attained statistical significance. The protective factors for burnout which showed significant association were good relationship with friends (OR 0.1-95% CI 0.0, 0.6), exercise and extra-curricular activities (OR 0.2-95% CI 0.0, 0.7), celebrating accomplishments (OR 0.2-95% CI 0.0, 0.7), having enough money (OR 0.2-95% CI 0.0, 0.4), and ability to plan for future (OR 0.1-95% CI 0.0, 0.6). CONCLUSION: More than a third of medicine residents suffered from burnout. We need to focus on rejuvenating activities for medicine residents to decrease burnout among them. If not addressed adequately this may result in a compromise in the quality of care being provided to patients.

Acuity level of care as a predictor of case fatality and prolonged hospital stay in patients with COVID-19: a hospital-based observational follow-up study from Pakistan.

OBJECTIVES: To determine if there is an association between acuity level of care (ALC), case fatality and length of stay in patients admitted to hospital due to COVID-19. DESIGN: A hospital-based observational follow-up study. SETTING: Internal Medicine Service of the Aga Khan University Hospital, Pakistan, from 26 February 2020 to 30 June 2020. PARTICIPANTS: Adult patients with confirmed COVID-19, aged ≥18 years. METHODS: ALC was categorised into low, intermediate and high level and patients were triaged using the standard emergency severity illness score. All patients were followed until the end of hospital admission for the outcome of case fatality and length of stay. RESULTS: A total of 822 patients with COVID-19 were admitted during the study period and 699 met inclusion criteria. The mean age was 54.5 years and 67% were males; 50.4% were triaged to low, 42.5% to intermediate and 7.2% to high acuity care. The overall case-fatality rate was 11.6%, with the highest (52%) in high acuity level followed by 16.2% in intermediate and 2% in low acuity care. Acuity level was associated with case fatality, with an HR (95% CI) of 5.0 (2.0 to 12.1) for high versus low acuity care and an HR of 2.7 (1.2, 6.4) for intermediate versus low acuity care, after adjusting for age, sex and common comorbidities including diabetes, hypertension, ischaemic heart disease and chronic lung disease. Similarly, acuity level was also associated with length of hospital stay. CONCLUSION: High and intermediate acuity level is associated with higher case fatality rate and prolonged length of hospital stay in patients admitted with COVID-19. In resource-limited settings where the provision of high acuity care is limited, the intermediate care acuity could serve as a useful strategy to treat relatively less critical patients with COVID-19.

Disparities in Cardiovascular Research Output and Disease Outcomes among High-, Middle- and Low-Income Countries - An Analysis of Global Cardiovascular Publications over the Last Decade (2008-2017).

Background: Cardiovascular disease (CVD) is the leading cause of death and disability worldwide. Health research is crucial to managing disease burden. Previous work has highlighted marked discrepancies in research output and disease burden between high-income countries (HICs) and low- and lower-middle-income countries (LI-LMICs) and there is little data to understand whether this gap has bridged in recent years. We conducted a global, country level bibliometric analysis of CVD publications with respect to trends in disease burden and county development indicators. Methods: A search filter with a precision and recall of 0.92 and 0.91 respectively was developed to extract cardiovascular publications from the Web of Science (WOS) for the years 2008-2017. Data for disease burden and country development indicators were extracted from the Global Burden of Disease and the World Bank database respectively. Results: Our search revealed 847,708 CVD publications for the period 2008-17, with a 43.4% increase over the decade. HICs contributed 81.1% of the global CVD research output and accounted for 8.1% and 8.5% of global CVD DALY losses deaths respectively. LI-LMICs contributed 2.8% of the total output and accounted for 59.5% and 57.1% global CVD DALY losses and death rates. Conclusions: A glaring disparity in research output and disease burden persists. While LI-LMICs contribute to the majority of DALYs and mortality from CVD globally, their contribution to research output remains the lowest. These data call on national health budgets and international funding support to allocate funds to strengthen research capacity and translational research to impact CVD burden in LI-LMICs.