Impact of a pharmacist-led patient-centred care intervention along with textmessage reminders, on the management of newly diagnosed tubercular patients: A protocol for a randomized controlled trial.

Objectives: Non-adherence to tuberculosis (TB) treatment is the leading cause of the increase in drug resistance cases. This study will determine the effectiveness of pharmaceutical-care-based interventions coupled with short messages delivered by a pharmacist on treatment outcomes and adherence among TB patients. Methods: The study will be conducted in TB Control Center of Pakistan Institute of Medical Sciences Hospital, Islamabad and District Bannu TB Control Center time period will be from August 2019 to September 2021. The patients will be included into the control group (usual care) or the intervention group pharmaceutical care and SMS reminder. The primary outcome includes a change in mean score from baseline in treatment outcomes and adherence, measured by Morisky Medication Adherence Scale, and clinic appointment attendance registration. Secondary outcomes include health-related quality of life of patients, disease knowledge, and patient satisfaction with the intervention. Result: The major issues in patients with TB are cure rate and medication adherence. The method anticipated in this manuscript could set the foundation of pharmaceutical care and mobile SMS for the future provision of care to improve TB treatment outcomes. Conclusion: The study will make available fundamental information about the influence of the patient centered program on the adherence and clinical outcomes of patients with TB.Trial status and registration: Clinical Trials.gov assigned Identifier NCT04645836.

Assessment of health-related quality of life among Afghan refugees in Quetta, Pakistan.

The study aims to assess the health-related Quality of Life (HRQOL) and its association with socio-demographic factors among the Afghan refugees residing in Quetta, Pakistan. For this purpose, a cross-sectional, descriptive study design by adopting Euro QOL five dimensions questionnaire (EQ-5D) for the assessment of HRQOL was conducted by approaching Afghan refugees from the camp and other areas of Quetta, Pakistan. Furthermore, this study also involved descriptive analysis to expound participant's demographic characteristics while inferential statistics (Kruskal-Wallis and Mann-Whitney test, P < 0.05) were used to compare EQ-5D scale scores. All analyses were performed using SPSS v 20. Herein, a total of 729 participants were enrolled and were subsequently (n = 246, 33.7%) categorized based on their age of 22-31 years (31.30 ± 15.40). The results of mean EQ-5D descriptive score (0.85 ± 0.20) and EQ-VAS score (78.60 ± 11.10) indicated better HRQOL in the current study respondents as compared to studies conducted in other refugee camps around the globe. In addition, demographic characteristics including age, marital status, locality, years of living as refugees, life as a refugee residing out of Pakistan, place of residence in Afghanistan, educational qualification, occupation, and arrested for crime were the statistically significant predictors (P < 0.05) of EQ-5D index scores. However, gender, living status, monthly income, preferred place of treatment were non-significant predictors (P > 0.05). The results of current study provided evidence for a model that correlated with participant's socio-demographic information and HRQOL. Moreover, this study also revealed a baseline assessment for the health status of Afghan refugees, interestingly, these results could be applied for improving HRQOL of the given participants. In conclusion, the HRQOL of Afghan refugees residing in Quetta, Pakistan can largely be improved by providing adequate healthcare facilities, education and employment opportunities, mental and social support, and providing adequate housing and basic necessities of life.

Atypical Complications during the Course of COVID-19: A Comprehensive Review.

COVID-19 is primarily a respiratory disease, but numerous studies have indicated the involvement of various organ systems during the course of illness. We conducted a comprehensive review of atypical complications of COVID-19 with their incidence range (IR) and their impact on hospitalization and mortality rates. We identified 97 studies, including 55 research articles and 42 case studies. We reviewed four major body organ systems for various types of atypical complications: (i) Gastro-intestinal (GI) and hepatobiliary system, e.g., bowel ischemia/infarction (IR: 1.49-83.87%), GI bleeding/hemorrhage (IR: 0.47-10.6%), hepatic ischemia (IR: 1.0-7.4%); (ii) Neurological system, e.g., acute ischemic stroke/cerebral venous sinus thrombosis/cerebral hemorrhage (IR: 0.5-90.9%), anosmia (IR: 4.9-79.6%), dysgeusia (IR: 2.8-83.38%), encephalopathy/encephalitis with or without fever and hypoxia (IR: 0.19-35.2%); (iii) Renal system, e.g., acute kidney injury (AKI)/acute renal failure (IR: 0.5-68.8%); (iv) Cardiovascular system, e.g., acute cardiac injury/non-coronary myocardial injury (IR: 7.2-55.56%), arrhythmia/ventricular tachycardia/ventricular fibrillation (IR: 5.9-16.7%), and coagulopathy/venous thromboembolism (IR: 19-34.4%). This review encourages and informs healthcare practitioners to keenly monitor COVID-19 survivors for these atypical complications in all major organ systems and not only treat the respiratory symptoms of patients. Post-COVID effects should be monitored, and follow-up of patients should be performed on a regular basis to check for long-term complications.

Pharmacists' approach to oncology medicine shortages: results of a cross-sectional survey in Pakistan.

OBJECTIVES: The study estimated the shortages of oncology medicines in Pakistan, their causes, impacts, mitigation strategies, and possible interventions. DESIGN: Cross-sectional survey. SETTING: Oncology pharmacists working at 43 oncology settings (out of 80) from five regions of Pakistan (four provinces (Punjab, Sindh, Khyber Pakhtunkhwa and Baluchistan) and one federal territory (Islamabad)) were approached. PARTICIPANTS: Oncology pharmacists with more than 1 year of experience were selected using stratified random sampling, and data were collected using a questionnaire from September 2021 to January 2022. PRIMARY AND SECONDARY OUTCOME MEASURES: To estimate the prevalence of oncology medicine shortages in Pakistan and establish recommendations to overcome them. RESULTS: Of 167 responded pharmacists, 87% experienced shortages in their practice. Most respondents (50%) experienced both oncology and support agent shortages. It was a current problem in hospitals (58%) and increased with time, but the situation varied across regions (p=0.007). Mainly shortages occur half-yearly (p=0.001) and last for <3 months. Injectable (56.8%) and branded drugs (44.9%) were short. The most frequently mentioned drugs affected by shortages were etoposide, paclitaxel, dacarbazine, bleomycin and carboplatin. Usually, distributors (51.5%) notify the pharmacists about the shortages, and federal agencies (36%) are responsible for these shortages. Distributors (53.4%) were the main source of supply, and shortages were encountered by them as well. The impacts included delayed care (25%) and suboptimal outcomes (23%) on patients, extra time (32%) for staff, prioritisation issues (31%) for pharmacists, delayed clinical trials (60.5%) and increased drugs prices (52.1%). Some hospitals have reporting systems (39.5%) and recording (29.3%) drug shortages. The shortages were managed using available alternative options (21%) and redistributing (21%) the currently available stock. CONCLUSION: Pakistan's healthcare system is affected by oncology medicine shortages. The government should establish a cancer registry and drug shortage platform, revise drug prescribing/pricing policies and practice penalties for breaching regulations. Oncology medicines must be widely available to avoid the grey market.

Assessment of health-related quality of life among patients with obesity, hypertension and type 2 diabetes mellitus and its relationship with multimorbidity.

Obesity, hypertension (HTN) and type 2 diabetes (T2D) are among the multifactorial disorders that occur at higher prevalence in a population. This study aims to assess the health-related quality of life (HRQoL) of patients with obesity, HTN and T2D individually and in the form of multimorbidity. A questionnaire-based cross-sectional study was conducted among the patients in 15 private clinics of Punjab, Pakistan. A stratified random sampling technique was used to collect the data from patients with obesity, HTN and T2D or their comorbidity. A total of 1350 patients responded by completing the questionnaire. The HRQoL of these patients was assessed using the EQ-5D-5L questionnaire (a standardized instrument for measuring generic health status). Statistical analysis was performed using chi-square test, Mann-Whitney U test, and Kruskal-Wallis test. Multivariate linear regression model was used to model the visual analogue scale (VAS) score. In total, 15% of patients had combined obesity, HTN and T2D; 16.5% had HTN and T2D; 13.5% had obesity and HTN and 12.8% had obesity and T2D. Only 15.8% of patients had obesity, 14.3% had HTN, and 12% had T2D. Mann Whitney-U test gave the statistically significant (p = <0.001) HRQoL VAS score55.1 (±23.2) of patients with the obesity. HRQoL VAS scores of patients with obesity were found to be higher when compared to patients with both T2D 49.8 (±15.4) and HTN 48.2 (±21). Diagnosis of one, two and three diseases showed significant results in VAS with all variables including gender (p = 0.004), educational level (p = <0.001), marital status (p<0.001), residence (p = <0.001), financial situation (p = <0.001) and monthly income (p = <0.001). The most frequently observed extremely problematic dimension was anxiety/ depression (47%) and the self-care (10%) was the least affected. Patient HRQoL is decreased by T2D, HTN, and obesity. The impact of these diseases coexisting is more detrimental to HRQoL.

A randomized controlled trial to evaluate the impact of pharmacist-led clinical interventions on the health-related quality of life among TB patients.

Background: The study was designed to evaluate the impact of pharmacist-led clinical interventions on the health-related quality of life among tuberculosis patients in Pakistan. Methods: A randomized, controlled prospective study was carried out in a Pakistan Institute of Medical Sciences hospital tuberculosis (TB) control center. Participants who visited the TB center between September 2020 and December 2021 were randomly assigned to two clusters, the usual care group (UC group) vs. the intervention group (pharmaceutical care group), in a 1:1 ratio by a simple envelope technique. In the intervention group, a patient received centered care that encompassed informed decision-making, which can increase the quality of care and monitoring of adverse drug events. However, the control group received routine TB treatment at the hospital. The EuroQol-5D-3L instrument was used to assess the health-related quality of life (HRQoL) at the baseline and in the third and sixth months of the treatment time period. Results: A total of 503 patients were eligible, of which only 426 patients were included in this study. At the end of the study, n = 205 of the patients in the intervention group and n = 185 of those in the control group were analyzed. In the intervention group, the EQ-5D-3L health utility score improved significantly (p < 0.001) (from the baseline mean ± SD, 0.40 ± 0.36, to 6 months of treatment, 0.89 ± 0.09, while in the control group from 0.42 ± 0.35 to 0.78 ± 0.27). In multivariate regression analysis, the variables that remained statistically associated (p < 0.001) with the HRQoL (unstandardized ß [95% confidence interval]) of the control group were as follows: gender, female vs. male (-0.039 [-0.076 to -0.003]); body weight, less than 40 kg vs. more than 40 kg (-0.109 [-0.195 to -0.024]); patients with any comorbidity vs. without comorbidity (-0.136 [-0.252 to -0.020]); and smokers vs. non-smokers (-0.204 [-0.291 to -0.118]). The study did not find any statistically significant associations between the intervention group's variables and the HRQoL. Conclusion: Patient-centered care interventions led by pharmacists as part of care coordination enhanced the HRQoL for TB patients significantly. According to this study, clinical pharmacists should be included in the interdisciplinary clinical staff for TB patient management.

Trajectory of COVID-19 vaccine hesitancy post-vaccination and public's intention to take booster vaccines: A cross-sectional analysis.

Vaccine hesitancy (VH) is not a new phenomenon in Pakistan and is regarded as one of the primary causes of unsatisfactory vaccination campaigns. This study determined post-vaccination COVID-19 VH, factors influencing COVID-19 vaccine uptake, and public's intent to receive booster vaccinations. A cross-sectional study was conducted among adult population of Lahore, Pakistan. Participants were recruited via convenience sampling between March and May 2022. SPSS version 22 was used for the data analysis. A total of 650 participants were included in the study (age = 28.1 ± 9.7 years; male-to-female ratio nearly 1: 1). The majority of participants received Sinopharm followed by Sinovac vaccine. The top three reasons of vaccine uptake were "only vaccinated individuals are allowed at the workplace, and educational institutes" (Relative importance index (RII) = 0.749), "only vaccinated people are allowed to go to markets, malls and other public places" (RII = 0.746), and "protect myself from the infection" (RII = 0.742). The mean COVID-19 VH score was 24.5 ± 6.2 (95% CI 23.9-24.9), with not being pro-vaccines and poor economic status were the significant predictors of COVID-19 vaccine hesitancy among immunized individuals (p < .05). Acceptance of booster vaccines was negatively associated with younger age and a lower level of education. Furthermore, being pro-vaccine was associated with a greater likelihood of accepting booster vaccines (p = .001). The Pakistani public continues to express VH toward COVID-19 vaccines. Therefore, aggressive measures must be taken to combat the community factors that contribute to it.

Incidence, risk factors and outcomes of acute kidney injury among COVID-19 patients: A systematic review of systematic reviews.

The COVID-19 associated acute kidney injury (CAKI) has emerged as a potential intricacy during the management of patients. Navigating the rapidly growing body of scientific literature on CAKI is challenging, and ongoing critical appraisal of this complication is essential. This study aimed to summarize and critically appraise the systematic reviews (SRs) on CAKI to inform the healthcare providers about its prevalence, risk factors and outcomes. All the SRs were searched in major databases (PubMed, EMBASE, Web of Science) from inception date to December 2021. This study followed SR of SRs methodology, all the records were screened, extracted and subjected to quality assessment by assessing the methodological quality of systematic reviews (AMSTAR-2). The extracted data were qualitatively synthesized and tabulated. This review protocol was registered in PROSPERO (CRD42022299444). Of 3,833 records identified; 42 SRs were included in this overview. The quality appraisal of the studies showed that 17 SRs were of low quality, while 8 moderate and 17 were of high-quality SRs. The incidence of CAKI ranged from 4.3% to 36.4% in overall COVID-19 patients, 36%-50% in kidney transplant recipients (KTRs), and up to 53% in severe or critical illness. Old age, male gender, cardiovascular disease, chronic kidney disease, diabetes mellitus and hypertension were frequently reported risk factors of CAKI. The need of renal replacement therapy (RRT) was up to 26.4% in overall COVID-19 patients, and 39% among those having CAKI. The occurrence of acute kidney injury (AKI) was found independent predictor of death, where mortality rate among CAKI patients ranged from 50% to 93%. This overview of SRs underscores that CAKI occurs frequently among COVID-19 patients and associated with high mortality, need of RRT and adverse outcomes. However, the confidence of these results is moderate to low which warrants the need of more SRs having established methodological standards. Systematic review registration: [https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=299444], identifier [CRD42022299444].

Evaluation of knowledge and barriers of influenza vaccine uptake among university students in Saudi Arabia; a cross-sectional analysis.

Background: Influenza vaccine hesitancy is a significant threat to global maneuvers for reducing the burden of seasonal and pandemic influenza. This study estimated the vaccine uptake, barriers, and willingness for influenza vaccines among university students in Saudi Arabia. Methods: A cross-sectional survey was conducted among health science (HS) and non-health science (NHS) university students. A 31-item questionnaire was used to ascertain the vaccination rate, barriers, and willingness for the flu vaccine. Results: This study included 790 students (mean age: 21.40 ± 1.94 years), 246 (31.1%) from HS and 544 (68.9%) from NHS disciplines. About 70% did not take flu shots before the arrival of the winter. The mean knowledge score was 7.81 ± 1.96, where 20.4%, 67.6%, and 12% of respondents had good, moderate, and poor knowledge regarding flu vaccines. The relative importance index (RII) analysis showed a lack of recommendation from physicians (51.5%, RI ranked: 1) was a top-ranked barrier to vaccine uptake, followed by negative perceptions and accessibility issues. Only 36.6% of the participants were willing to get vaccinated every year, 70% were willing to receive a vaccine on their doctor's recommendations, and 46% agreed to vaccinate if vaccines were freely available in the university. The knowledge, barriers, and willingness widely varied across students from two disciplines. Conclusions: Our analysis underscored low flu vaccine uptake among university students. In addition, the study participants' knowledge was unsatisfactory, and they were less inclined to receive the flu vaccine in the future. Lack of recommendation from the physicians, negative perceptions towards the flu vaccine, and difficult accessibility were found as significant barriers to the vaccine uptake. A multidimensional approach at educational institutes to cover the knowledge gap and address the barriers curtailing the vaccination rate among students is recommended.

Assessment of antibiotic storage practices, knowledge, and awareness related to antibiotic uses and antibiotic resistance among household members in post-conflict areas of Pakistan: Bi-central study.

Background: The storage of antimicrobials at home is frequently in-practice in various developing countries, resulting an irrational use, antibiotic resistance, and toxicities. This condition may worsen more in conflict zones where health facilities are limited. This study aimed to determine the storage and use of leftover antibiotics among households (HHs) along with knowledge and awareness about antibiotics and antibiotic resistance (ABR). Methods: A descriptive cross-sectional study design was employed. Members of HHs were invited to participate in the survey while using a convenient sampling technique. The data were obtained using a validated questionnaire and analyzed through SPSS. Results: A total of 96 HHs were randomly selected from two districts (n = 50, n = 46), with most of the participants being men between the ages of 18 and 28 (n = 45, 46.9%) years. The majority of HHs (n = 32, 33.3%) had six to eight total family members, with one to two chronic diseases (n = 63, 65.6%), individual families (n = 60, 62.5%), and with (n = 35, 36.5%) LRTIs (lower respiratory tract infections). The HHs were aware of the word "antibiotic" (n = 59, 61.5%) and gave correct replies to amoxicillin as an antibiotic (n = 42, 43.8%); on the other hand, HHs also thought of paracetamol as an antibiotic (n = 45, 47.9%). They identified the most common brands of antibiotics easily, and a majority of them (n = 69, 71.9%) had never heard of ABR before and had lower levels of awareness. The most stored antibiotic at home (n=38, 39.6%) was azithromycin (J01FA10). In addition, they had multiple needless (1-2, n = 62, 64.6%; 3-4, n = 29, 30.2%) and antibiotics in their houses. Age had a strong association (p = 0.017, H = 12) affected the mean knowledge scores related to antibiotic use. Association of education levels (p = 0.001, H = 52.8) and occupation (p = 0.04, H = 10) with proper antibiotics use were found to be significant. However, family members with more than one chronic illness (p = 0.09, H = 0.8) showed a significant relationship with their awareness of antibiotics. Conclusion: Participants generally stored various antibiotics of different classes in their homes. Lack of knowledge related to the appropriate usage of antibiotics, use of leftover antibiotics, and awareness related to ABR were unknown to the participants.

Evaluation of Consumers Perspective on the Consumption of Antibiotics, Antibiotic Resistance, and Recommendations to Improve the Rational use of Antibiotics: An Exploratory Qualitative Study From Post-Conflicted Region of Pakistan.

Background: Antibiotics misuse is a global challenge, and the situation is likely to deteriorate in conflict zones with insufficient health services. The misuse of antibiotics is not only associated with antimicrobial resistance but may also lead to serious consequences. This study was aimed to investigate the knowledge, attitude, and practices on antibiotic consumption, antibiotic resistance (ABR), and related suggestions among residents of conflicted zones in Pakistan. Methods: Semi-structured interviews were conducted at community pharmacies between June 2020 and January 2021. The primary findings were ascertained through thematic content analysis. Themes, sub-themes, and categories were drawn from the final analysis. Data analysis was carried out in six steps from getting to know the data to final report development. Results: A total of 20 consumers were interviewed with a mean interview duration of 25.4 min. The average age of participants was 35.1 years, and most of them were males. ABR was unfamiliar to the participants. Most of the participants understood the term "antibiotics," but they did not know how to use them properly. The participants were unable to distinguish between bacterial and viral illnesses. Thirteen participants believed that antibiotics have a faster effect than any other drug. Most of the participants perceived that every antibiotic could cause diarrhea, and pharmacy staff sometimes prefer other medicines such as multivitamins. Consumer practices regarding antibiotic usage and ABR were found to be poor. Most participants recommended that health officials must ensure qualified staff at pharmacies with strict regulations. Five participants said that a leaflet with antibiotic instructions in Urdu (national language) is usually beneficial, especially when making solutions from powder. Conclusions: This study underscored poor knowledge, attitude, and practices among residents of conflicted zones towards antibiotics and ABR. Low literacy rate, unavailability of healthcare facilities, absence of pharmacists at community pharmacies, and uncontrolled sales of antibiotics are some factors attributed to serious hazards, ABR, and irrational use of drugs.

Assessment of Adverse Drug Events, Their Risk Factors, and Management Among Patients Treated for Multidrug-Resistant TB: A Prospective Cohort Study From Pakistan.

Background: Multidrug-resistant tuberculosis (MDR-TB) is a growing public health problem. Treatment regimens used against MDR-TB are costly, prolonged, and associated with more side effects as compared with the drug-susceptible tuberculosis. This study was framed to determine the incidence of adverse drug events, risk factors, and their management in MDR-TB patients. Methods: This prospective follow-up cohort study was conducted at the site of programmatic management of drug-resistant TB located at the Pakistan Institute of Medical Sciences, Islamabad. All patients, irrespective of their age, gender, and ethnicity, were included in the study. Adverse drug events were observed in patients at different time points during the study. Patients enrolled for the treatment from January 2018 were prospectively followed till December 2020 up to their end treatment outcomes. Results: Out of 126 MDR-TB patients enrolled for treatment, 116 met the inclusion criteria and were included in the final analysis. Most patients (50.9%) were between 18 and 45 years of age. A minimum of one adverse event was experienced by (50.9%) patients. Of all the adverse events, gastrointestinal disorders were more frequent (47.4%), followed by arthralgia (28.4%) and psychiatric disturbance (20.6%). Furthermore, multivariate analysis showed a significant association with the incidence of adverse events in patients with age group above 60 years (odds ratio (OR) 4.50; 95% CI 1.05-19.2), active smokers (OR 4.20; 95% CI 1.31-13.4), delayed reporting to the TB center (OR 4.03; 95% CI 1.34-12.1), and treatment without bedaquiline regime (OR 3.54; 95% CI 1.23-10.1). Most of the patients (94.6%), counseled by the pharmacist, were found to be satisfied with the information provided and looked for more pharmacist counseling opportunities in the management of MDR-TB. Conclusion: Current findings recommend that ADEs might be well managed by timely identification and reporting. Bedaquiline coupled with other active medications lowered the chance of ADEs in MDR-TB patients. Elderly patients, active smoking behavior, and those who have a delay in the treatment initiation are more prone to ADEs. Clinical pharmacist's contribution to TB control programs may help caregivers and patients concerning the rational use of medication, early detection, and management of ADEs.

Adjunctive vitamin D therapy in various diseases in children: a scenario according to standard guideline.

BACKGROUND: Adherence to standard guidelines is imperative when question comes to disease management. The present study aimed to evaluate the administration of adjunctive vitamin D therapy in various diseases, its adherence to standard guideline and the effect of socioeconomic status on the consumption of vitamin D in children. METHODS: Cross sectional observational study was conducted among 400 ambulatory pediatric patients at Children's Hospital, Pakistan Institute of Medical Sciences Islamabad, from November 2017 to June 2018. Data were collected by a self-designed structured questionnaire from the patient's medical chart. Adjunctive vitamin D therapy adherence was evaluated by the U. S endocrinology clinical practice guideline of vitamin D deficiency. The association between socioeconomic status and consumption of vitamin D was examined by chi-square. Alpha value (p ≤ 0.005) was considered statistically significant. Statistical analysis was done by SPSS version 25. RESULTS: In 400 patients, 9 diseases and 21 comorbid conditions were identified, in which adjunctive vitamin D therapy was prescribed. Adherence to vitamin D testing in high-risk vitamin D deficiency diseases as; seizures (3.8%), bone deformities (13.3%), steroid-resistant nephrotic syndrome (0.0%), cerebral palsy (5.9%) and meningitis (14.3%). Adherence to prescribed vitamin D dose was in (41.3%) patients in various diseases. Significant association (p < 0.05) was found between socioeconomic status and consumption of vitamin D in children and mothers. CONCLUSIONS: It was found that adjunctive vitamin D was being prescribed in various diseases and comorbidities. Overall poor adherence to the standard guideline was observed in disease management in children. Low socioeconomic status affects vitamin D supplementation consumption in children.

Understanding of Future Prescribers About Antimicrobial Resistance and Their Preparedness Towards Antimicrobial Stewardship Activities in Pakistan: Findings and Implications.

Background: Insufficient antimicrobial-related training for physicians during their undergraduate education could have a negative impact on their prescribing. Unlike previous studies, this study not only explored the understanding and perception of Pakistani medical students about antibiotics and resistance, but also their preparedness towards antimicrobial stewardship programs. Methods: An online cross-sectional study was undertaken with final-year medical students using a validated questionnaire from January 2021 to May 2021. Descriptive and inference statistics were applied for data analysis. Results: Of 411 students, only 6.3% had undergone antimicrobial resistance (AMR) training. 16.1% of students believed that antibiotics are effective for viral ailments. More than half of the students agreed that AMR is a major healthcare problem in Pakistan (65.9%). Most students viewed poor infection control practices (66.9%), the use of too many broad-spectrum antibiotics (68.4%) for a longer duration (62.8%) with inadequate doses (67.9%) as the causes of AMR. The student's preparation was insufficient in interpreting microbiological and pathological results (26.3%), selecting the correct antibiotics (22.1%), and awareness of the antibiotic spectrum (20.9%). The median preparedness score showed significant differences with sex (p = 0.049), age (p < 0.001), institute type (p = 0.014), and family income (p = 0.006). Conclusion: Pakistani medical students showed adequate understanding of antibiotics, but lacked preparedness for several components of ASPs, including interpretation of microbiological results and spectrum of antibiotics. More steps need to be taken to prepare medical students for AMR and stewardship initiatives adequately.

Exploring the factors and barriers of healthcare professionals in tertiary care hospitals toward pharmacovigilance: a multicenter study from Khyber Pakhtunkhwa, Pakistan.

BACKGROUND: Spontaneous Adverse drug reactions (ADRs) reporting is a cornerstone for a successful pharmacovigilance program as under-reporting of ADRs remains a major issue around the globe. The current study aimed to assess the knowledge attitude and practices of health care professionals regarding pharmacovigilance along with barriers and factors to encourage ADR reporting at tertiary care hospitals of Khyber-Pakhtunkhwa, Pakistan. METHODS: A questionnaire-based cross-sectional survey was conducted, using the convenience sampling method to collect the data from doctors, nurses, and pharmacists working in seven tertiary care hospitals from seven districts of Khyber-Pakhtunkhwa province, Pakistan, between July 2019 and March 2020. RESULTS: During the study, a total of 830 questionnaires were distributed, out of which 669 were returned (response rate 80.6%). Overall, Healthcare professionals exhibited poor knowledge (79.5%) about ADR reporting and pharmacovigilance however, 73.5% of pharmacists were more knowledgeable as compared to 18.7% doctors and 13.8% nurses (p < .001). Moreover, poor reporting practices were displayed by 95.6% doctors, 94.4% nurses, 94.4 and 75.5% pharmacists (p < .001). However, the majority of healthcare professionals showed an overall positive attitude (94%) toward ADR reporting. The most frequently cited barriers were unavailability of reporting forms (92.5%), absence of a professional environment to discuss ADRs (82.5%), and lack of training (81.8%) whereas, most common factors to encourage ADR reporting were obligatory reporting (85.9%) and provision of ADR management guidelines and training (84.3%). A significant relation was found between the healthcare professionals and their professional status with the overall knowledge, attitude, and practice (KAP) scores (p < .001) whereas a medium, positive correlation was found between the knowledge and practice of pharmacovigilance and ADR reporting by the healthcare professionals (r = 0.321, n = 669, p < .001). CONCLUSION: There is an overall lack of knowledge and poor reporting practices among health care professionals on ADR reporting and pharmacovigilance. Hence the study suggests that strategies should be devised by all the stakeholders to properly educate and train the healthcare professionals in this area to enhance overall patient safety and safe use of medicines.

Assessment of Factors Associated with Unfavorable Outcomes among Drug-Resistant TB Patients: A 6-Year Retrospective Study from Pakistan.

The spread of drug-resistant tuberculosis (DR TB) poses significant challenges to the control and successful eradication of TB globally. The current retrospective study was designed to evaluate the treatment outcomes and identify the risk factors associated with unsuccessful outcomes among DR TB patients. A total of 277/308 eligible DR TB patients were enrolled for treatment at the programmatic management unit of DR TB at the Pakistan Institute of Medical Sciences, Islamabad between January 2014 and July 2019. Treatment outcomes were defined according to the WHO recommendations. Death, treatment failure, and lost to follow-up (LTFU) were collectively grouped as unsuccessful treatment outcomes, whereas cured and treatment completed were summed up together as successful treatment outcomes. Out of the total 277 patients, 265 (95.67%) were multidrug/rifampicin-resistant TB (MDR/RR-TB) cases, 8 (2.89%) were isoniazid resistant cases, and 4 (1.44%) were extensively drug-resistant ones. In the current cohort, a total of 177 (63.9%) achieved successful treatment outcomes. Among them, 153 (55.2%) were declared cured and 24 (8.7%) completed their treatment. Of the remaining 100 (36.1%) patients with unsuccessful outcomes, 60 (21.7%) died, 32 (11.5%) were LTFU, and 8 (2.9%) had failed treatment. The proportion of male patients was relatively higher (55.2%), within the age group of 21-40 years (47.3%) and lived in rural areas (66.8%). The multivariate analysis revealed that unsuccessful outcomes had a statistically significant association with being male (adjusted odds ratio, AOR: 1.92, 95% confidence interval (CI): 1.10-3.36), being in an age group above 60 years (AOR: 3.34, 95% CI: 1.09-10.1), suffering from any comorbidity (AOR: 2.69, 95% CI: 1.35-5.38), and the history of use of second-line drugs (AOR; 3.51, 95% CI 1.35-9.12). In conclusion, treatment outcomes among DR TB patients at the study site were poor and did not achieve the treatment success target (≥75%) set by the World Health Organization.

Assessment of without prescription antibiotic dispensing at community pharmacies in Hazara Division, Pakistan: A simulated client's study.

Antibiotics dispensing without a prescription is an irrational practice and can increase the risk of antibiotic resistance, which is a significant public health concern around the globe. This study was aimed to determine the extent to which antibiotics are supplied without prescription in the community pharmacies (CPs) at Hazara Division from November 2020 to February 2021. The simulated client method (SCM) was used, and the data were gathered, recorded, and analyzed through different statistical methods with descriptive and inferential techniques. The antibiotic dispensing was observed in CPs (90.5%), the most dispensed antibiotics were azithromycin (29.4%) and ciprofloxacin (46.5%) respectively. Furthermore, visited medical stores/ drug outlets, 9.5% of the visited stores denied dispensing of antibiotics because they preferred a referral to visit physicians (23. 9%) and (12.8%) did not had the antibiotics at the time of visits. Antibiotics were more obtainable in retail medical stores (AOR = 8.6, 95 percent Cl: 3.0-24.7; p = 0.001) than in pharmacies. In rural areas antibiotics dispensing was more (p = 0.004) as compared to urban areas. Staff members also had asked about patient's (17.7%) symptoms and drug allergies (12.3% and 3.9%), and (1.5%) they consoled them about their medications. The findings of this study indicate that nonprescription antibiotic sales are very common, despite national rules prohibiting this activity. When the simulated Client requested for any medication to relieve his or her discomfort, many antibiotics were given out without a prescription. Pharmacies/medical stores in Hazara Division selling antibiotics without a prescription are worrying and need immediate action by regulators.

Impact of the COVID-19 outbreak on mental health status and associated factors among general population: a cross-sectional study from Pakistan.

The recent outbreak of coronavirus disease (COVID-19) has significantly affected the mental health of people globally. This study aimed to investigate the mental health status and associated factors among residents of Pakistan. An online questionnaire survey was conducted from April 3 to May 7, 2020, using convenience and snowball sampling techniques. Data regarding demographics, physical health status and contact history during the last 2 weeks were collected. Furthermore, the Depression, Anxiety, and Stress scales (DASS-21) were utilized to measure the mental health of the participants. The analyses included descriptive statistics and regression analysis. Of the 1663 participants who completed this survey, 1598 met the inclusion criteria. The results revealed mild to moderate depression among 390 participants (24.4%), mild to moderate anxiety among 490 participants (30.7%) and mild to moderate stress among 52 participants (3.3%). A majority of the participants rated their health as good (n = 751, 47.0%). Moreover, students reported significantly higher scores on depression (B = 1.29, 95% CI = 0.71-1.88; p < 0.05), anxiety (B = 0.56, 95% CI = -0.06 to 1.18; p < 0.05) and stress (B = 0.56, 95% CI = -0.12 to 1.23; p < 0.05). Physical symptoms, including fever, cough and myalgia, and contact history in the last 14 days reported significant associations with depression, anxiety and stress (p < 0.05). The mental health status of the people was noted to be affected during the COVID-19 outbreak. Assessment of several factors with significant associations with depression, anxiety and stress may aid in developing psychological interventions for vulnerable groups.

Point Prevalence Survey of Antimicrobial Use during the COVID-19 Pandemic among Different Hospitals in Pakistan: Findings and Implications.

The COVID-19 pandemic has significantly influenced antimicrobial use in hospitals, raising concerns regarding increased antimicrobial resistance (AMR) through their overuse. The objective of this study was to assess patterns of antimicrobial prescribing during the current COVID-19 pandemic among hospitals in Pakistan, including the prevalence of COVID-19. A point prevalence survey (PPS) was performed among 11 different hospitals from November 2020 to January 2021. The study included all hospitalized patients receiving an antibiotic on the day of the PPS. The Global-PPS web-based application was used for data entry and analysis. Out of 1024 hospitalized patients, 662 (64.64%) received antimicrobials. The top three most common indications for antimicrobial use were pneumonia (13.3%), central nervous system infections (10.4%) and gastrointestinal indications (10.4%). Ceftriaxone (26.6%), metronidazole (9.7%) and vancomycin (7.9%) were the top three most commonly prescribed antimicrobials among surveyed patients, with the majority of antibiotics administered empirically (97.9%). Most antimicrobials for surgical prophylaxis were given for more than one day, which is a concern. Overall, a high percentage of antimicrobial use, including broad-spectrums, was seen among the different hospitals in Pakistan during the current COVID-19 pandemic. Multifaceted interventions are needed to enhance rational antimicrobial prescribing including limiting their prescribing post-operatively for surgical prophylaxis.