Violence against Healthcare Workers during the COVID-19 Pandemic: A Review of Incidents from a Lower-Middle-Income Country.

Background: Healthcare workers (HCWs) across the globe have met tremendous challenges during the COVID-19 (coronavirus disease 2019) pandemic, such as shortages of personal protective equipment, extensive work hours, and constant fear of catching the virus or transmitting it to loved ones. Adding on to the already existing burnout, an increase in incidents of violence and aggression against HCWs was seen in Pakistan and globally. Objectives: Primarily to review cases of violence against HCWs in Pakistan, highlighting and comparing the instigating factors seen within the country and globally. Secondly, to enlist possible interventions to counter workplace violence in healthcare during a pandemic and in general. Methods: Incidents of violence towards HCWs in Pakistan during the COVID-19 pandemic occurring between April 7, 2020, and August 7, 2020, were included. The incidents reported from local newspapers were reviewed. Findings and Conclusion: A total of 29 incidents were identified, with perpetrators of violence most commonly being relatives of COVID-19 patients. Most frequent reasons included mistrust in HCWs, belief in conspiracy theories, hospitals' refusal to admit COVID-19 patients due to limited space, COVID-19 hospital policies, and the death of the COVID-19 patients. Protests by doctors and other HCWs for provision of adequate PPE, better quarantine conditions for doctors with suspected COVID-19, and better compensation for doctors on COVID-19 patient duty resulted in police violence towards HCWs. To avoid such incidents in the future, institutions, healthcare policymakers, media organisations, and law enforcement agencies must work together for widespread public awareness to counter misconceptions and to exhibit responsible journalism. In hospitals, measures such as de-escalation training and increased security must be implemented. Furthermore, law enforcement agencies must be trained in non-violent methods of crowd dispersal and control to manage peaceful protests by HCWs over legitimate issues.

Constrictive Pericarditis Presenting as Bilateral Pleural Effusion: A Report of Two Cases.

Constrictive pericarditis is a rare presentation. We need a very high index of clinical suspicion to diagnose the disease. It most commonly presents secondary to tuberculosis (TB) in the developing world and post-radiation therapy in the developed world. Classically, it presents with symptoms of heart failure and as pericardial thickening or calcification on imaging studies. In hospital settings, constrictive pericarditis is not usually considered as a differential in patients presenting with pleural effusion. According to the literature, associated pleural effusions in cases of constrictive pericarditis could be left-sided. Herein, we present two unusual presentations of cases with bilateral pleural effusions. One of our cases developed constrictive pericarditis with concurrent active tuberculosis. This is a rare presentation because, normally, constrictive pericarditis is a late complication of tuberculosis. We suggest that when dealing with cases of bilateral pleural effusion, the etiology of constrictive pericarditis should be considered.

Electronic cigarettes use and perception amongst medical students: a cross sectional survey from Sindh, Pakistan.

OBJECTIVE: The manufacturers of electronic cigarettes (e-cigarettes) are actively marketing their product through electronic and social media. Undergraduate medical students are expected to have better knowledge and awareness as they directly interact with patients in their training, The purpose of this study is therefore, to determine knowledge, use and perception regarding e-cigarettes among medical students from Sindh, Pakistan. RESULTS: A cross-sectional study was conducted between 1st July and 30th September 2016 at five different medical colleges situated in the second largest province of Sindh, Pakistan. The data was collected through a structured, self-administered questionnaire. Of the 500 students, the mean age was 21.5 ± 1.7 years and 58% were females. Over (65.6%) students were aware of e-cigarettes, 31 (6.2%) reported having used e-cigarettes, of whom 6 (1.2%) self-reported daily use. Users of conventional tobacco products were significantly more likely to have heard of e-cigarettes (87.6% vs 51.6%, p < 0.001) and having used them (13.9% vs 1.3%, p < 0.001). On multivariable logistic regression analysis we found a strong association of e-cigarette use with consumption of conventional cigarettes [OR: 10.6, 95% CI 3.6-30.8, p < 0.001], use of smokeless tobacco products [OR: 7.9, 95% CI 2.7-23.4, p < 0.001] however a weak association was observed for Shisha use [OR: 3.05, 95% CI 0.9-9.6, p = 0.05].

Association of hypercapnia on admission with increased length of hospital stay and severity in patients admitted with community-acquired pneumonia: a prospective observational study from Pakistan.

OBJECTIVE: To determine whether the presence of hypercapnia on admission in adult patients admitted to a university-based hospital in Karachi, Pakistan with community-acquired pneumonia (CAP) correlates with an increased length of hospital stay and severity compared with no hypercapnia on admission. STUDY DESIGN: A prospective observational study. SETTINGS: Tertiary care hospital in Karachi, Pakistan. METHODS: Patients who met the inclusion criteria were enrolled in the study. The severity of pneumonia was assessed by CURB-65 and PSI scores. An arterial blood gas analysis was obtained within 24 hours of admission. Based on arterial PaCO2 levels, patients were divided into three groups: hypocapnic (PaCO2 <35 mm Hg), hypercapnic (PaCO2 >45 mm Hg) and normocapnic (PaCO2 <35-45 mm Hg). OUTCOMES: The primary outcome was the association of hypercapnia on admission with mean length of hospital stay. Secondary outcomes were the need for mechanical ventilation, ICU admission and in-hospital mortality. RESULTS: A total of 295 patients of mean age 60.20±17.0 years (157 (53.22%) men) were enrolled over a 1-year period. Hypocapnia was found in 181 (61.35%) and hypercapnia in 57 (19.32%) patients. Hypercapnic patients had a longer hospital stay (mean 9.27±7.57 days), increased requirement for non-invasive mechanical ventilation (NIMV) on admission (n=45 (78.94%)) and longer mean time to clinical stability (4.39±2.0 days) compared with the other groups. Overall mortality was 41 (13.89%), but there was no statistically significant difference in mortality (p=0.35) and ICU admission (p=0.37) between the three groups. On multivariable analysis, increased length of hospital stay was associated with NIMV use, ICU admission, hypercapnia and normocapnia. CONCLUSION: Hypercapnia on admission is associated with severity of CAP, longer time to clinical stability, increased length of hospital stay and need for NIMV. It should be considered as an important criterion to label the severity of the illness and also a determinant of patients who will require a higher level of hospital care. However, further validation is required.

Pharmacological Threat to Lungs: A Case Series and Literature Review.

Drug-induced organ damage stands as a prevalent yet much-neglected issue globally. Keeping in view it's rising frequency, health care providers stand obliged to be well versed with the de-merits of the agents they prescribe. Drug therapies causing damage present with a non-specific clinical presentation, histological findings or radiology, which further elaborates on the necessity of a conscientious diagnosis. Pulmonary architecture ranging from the airways, lung parenchyma, mediastinum, pleura, pulmonary vasculature or the neuromuscular system, all can fall victim to the dreaded outcomes of this menace. In order to establish successful diagnosis, the definite temporal relation between initiation of drug therapy and the development of the respiratory symptoms needs to be drawn. The most common form of pharmacologically arising lung toxicity is drug-induced pneumonitis or interstitial lung disease. Unfortunately, there is no adequate data available to review the extensiveness of this medication-associated risk in Pakistan which further highlights the necessity of carefully monitoring this overlooked yet assessable malady. Furthermore, identification and surveillance of this drug attributed peril shall help diminish burden on healthcare resources of the country. We present three recent cases of different types of drug-induced lung damage under treatment at our University Hospital.

Poncet's disease: two case reports.

BACKGROUND: One of the rare presentations of active pulmonary or even extrapulmonary tuberculosis is polyarthropathy which is the involvement of multiple large and small joints in the body; a reactive constellation known as Poncet's disease. This may sometimes be the sole manifestation of the disease before more obvious features develop. The pain experienced during polyarthritis can be crippling thereby limiting the mobility and activities of patients. Polyarthritis as a symptom of active tuberculosis can be easily misinterpreted for more common causes of polyarthritis such as rheumatological diseases that present similarly. CASE PRESENTATION: We describe the case of a 25-year-old Asian woman and a 45-year-old Asian man who presented with active tuberculosis where polyarthralgia was the first and only symptom for many months followed by pulmonary and pleural manifestations. Both patients showed dramatic improvement with anti-tuberculous therapy. The total duration of therapy was 6 months. CONCLUSIONS: Based on our observations, we propose that tuberculosis be included among the differentials for patients with unusual presentation of joint pains, especially in endemic regions and/or susceptible populations.

Water Pipe (shisha) Use and Legislation Awareness Against Shisha Smoking Among Medical Students: A study from Karachi, Pakistan.

The aim of the study was to determine the prevalence of shisha smoking; its associated factors and awareness among medical students of Karachi, Pakistan following the imposition of nationwide shisha ban. A cross sectional study was conducted among medical students of two medical universities, namely Sindh Medical College and Aga Khan University Karachi, Pakistan from October till December 2014. A total of 422 participants were included. Data was collected via a self-administered questionnaire. The mean age was 21 ± 1.6 years and 229 (54.26 %) were females. Shisha smoking was found to be relatively common among medical students; the prevalence being 21.5 % out of which 73.62 % were males and belonged to a private medical college p value < 0.001. Majority of those who smoked shisha were aware that it contains tobacco (59.34 %), it has no filtration system (42.85 %), it is harmful (91.20 %) and 47.25 % held the opinion that shisha was not any better than cigarettes. It was alarming that majority students were aware of its harmful effects. However, a significant lack of awareness of the legislation against shisha was found among students.

Clinical manifestations and outcomes of pulmonary aspergillosis: experience from Pakistan.

INTRODUCTION: Pulmonary aspergillosis has variable course of illness, severity and outcomes depending on underlying conditions. There is limited data available on the clinical manifestations and outcome of pulmonary aspergillosis from Pakistan. METHODS: To determine the clinical manifestations and outcome of pulmonary aspergillosis in a tertiary care hospital a retrospective study was conducted from 2004 to 2014 in patients admitted with pulmonary aspergillosis at the Aga Khan University Hospital Karachi, Pakistan. RESULTS: Of the 280 cases with provisional diagnosis of aspergillosis 69 met the inclusion criteria. The mean age was 45±15.7 years, 48 (69.6%) were men and 21 (30.4%) had diabetes mellitus (DM). The average length of hospital stay (LOS) was 10.61±9.08 days. Aspergillus fumigatus was the most common (42.0%), followed by Aspergillus flavus (28.9%). More than one-third of patients previously had tuberculosis (TB) (39.13%). The commonest pulmonary manifestation was chronic pulmonary aspergillosis (CPA) 47 (68.1%) followed by invasive pulmonary aspergillosis (IPA) 12 (17.4%) and subacute invasive aspergillosis (SAIA) 8 (11.6%). Surgical excision was performed in 28 patients (40.57%). Intensive care unit admission was required for 18 patients (26.08%). Case fatality rate was 14/69 (20.3%). DM, mean LOS and hypoxic respiratory failure were identified as independent risk factors of mortality on multivariate analysis. CONCLUSION: A. fumigatus was the most frequent species found especially in patients with prior TB. CPA was the commonest pulmonary manifestation seen as post TB sequel. Diabetes, hypoxic respiratory failure and increased LOS were independent predictors of poor outcomes. Overall patients had good outcome with CPA compared with SAIA and IPA.

Prevalence of tobacco use among women: a cross sectional survey from a squatter settlement of Karachi, Pakistan.

BACKGROUND: While the prevalence of tobacco use has been slowly declining in the developed countries, rates have been steadily rising in the developing countries. This has led to a rapid rise in tobacco related lung diseases among women. OBJECTIVE: Determine the prevalence of tobacco use (both smoking and smokeless) among women in an urban squatter settlement (Orangi Town) in Karachi, Pakistan. METHODS: A cross-sectional survey was conducted on 19,325 females aged between 15 and 80 years in Orangi Town, an urban squatter settlement in Karachi, Pakistan. Modified questionnaire, developed by World Health Organization WHO and Global Adult Tobacco survey (GATS), was used in Urdu. A total of 16,987 women agreed to participate. RESULTS: The mean age was 37.3 ± 9.8 years amongst whom 15,255 (89.80%) were married, 9143 (53.82%) admitted that at least one person uses tobacco in some form in their homes. The prevalence of smokeless tobacco was 42.25% (7178). The prevalence of smoking tobacco was low as compared to smokeless tobacco i.e. 18.0% (3058). Among smokers, 85.47% (1789) admitted that they had tried to quit smoking during last 12 months but failed. CONCLUSION: Tobacco use among women in an urban squatter settlement is very high and alarming. Preventive and control measures against tobacco use are required in these communities.

Pulmonary hyalinising granuloma: a rare pulmonary disorder.

Pulmonary hyalinising granulomas are rare, noninfectious fibrosclerosing lesions of the lung which can mimic metastatic disease. It was first described in literature by Engleman et al in the year 1977. Its etiology is unknown but they may be caused by an exaggerated immune response. The patient typically presents with cough, chest pain. dyspnoea or haemoptysis in association with multiple bilateral parenchymal nodules. We report the case of a 20 years old male who presented with a 12-month history of worsening dry cough. His plain chest radiograph and subsequent CT scan revealed bilateral pulmonary nodules. A CT guided biopsy of the pulmonary lesions was consistent with Pulmonary Hyalinising Granuloma [PHG].

BCG vaccination is associated with decreased severity of tuberculosis in Pakistan.

Vaccination with Bacille Calmette-Guérin (BCG) is given at birth to protect against tuberculosis (TB) in Pakistan. The country ranks 6th amongst high-burden countries worldwide and has an incidence of 231/100,000 pyopulation. This was a cross-sectional multi-center hospital-based study. TB patients (n=218) with pulmonary (PTB, n=120) or extrapulmonary (ETB, 98) were recruited, and the presence of a BCG vaccination scar was documented. Cases were further classified into minimal, moderate and advanced PTB or less severe (L-ETB) or severe disseminated (D-ETB) disease. The association of age, gender and severity of TB infections with BCG vaccination of the individual TB cases was investigated. No difference was found of the BCG vaccination status of PTB and ETB cases, or in relation to age or gender. Patients under 29years of age comprised the largest group. There were more females with ETB than PTB. The largest group within ETB comprised those with tuberculous lymphadenitis (LNTB, 39%). A significantly greater number of LNTB cases had received BCG vaccinations than had those with pleural (unilateral) TB (p=0.004), and tuberculous meningitis (p=0.027) groups. Also, there were more immunized patients with pulmonary as compared with pleural disease (p=0.001). LNTB represents localized granulomatous disease and the observation of higher vaccination rates in this group suggests that BCG has protected against more severe forms of TB in this high-burden region.

Risk factors for multidrug-resistant tuberculosis in urban Pakistan: A multicenter case-control study.

OBJECTIVE: To evaluate risk factors for multidrug-resistant tuberculosis (MDR-TB) in an urban setting of Pakistan. DESIGN AND METHODS: In this multicenter case-control study, patients aged 15years old or older with sputum culture and sensitivity (C/S) diagnosed with pulmonary MDR-TB were defined as cases, whereas patients aged 15years old or older with sputum C/S diagnosed and susceptible to pulmonary TB were regarded as controls. Fifty cases and 75 controls were enrolled from three tertiary-care hospitals in Karachi. RESULTS: Multivariable logistic regression models showed that cases were more likely to have had a TB patient in the house prior to the diagnosis of MDR-TB (adjusted odds ratio [ORadj]=3.1, 95% confidence interval [CI]: 1.2, 8.3) or had a history of prior TB treatment (ORadj=4.2, 95% CI: 1.1, 15.4). Furthermore, cases compared with controls tended to be male (ORadj=3.6, 95% CI: 1.4, 9.7), 15-25years of age (ORadj=3.7, 95% CI: 1.2, 11.3), of Sindhi ethnicity (adjusted OR=9.1, 95% CI: 1.9, 43.4) or with low educational attainment (ORadj OR=5.5, 95% CI: 1.7-17.6, for no formal schooling; ORadj=3.8, 95% CI: 1.1-14.1, 1 for 1-5 school years). CONCLUSIONS: A TB patient in the house or a history of prior TB treatment was strongly associated with MDR-TB in this study. Furthermore, younger age, male gender, Sindhi ethnicity and poor educational attainment entailed a high risk for MDR-TB. Targeted educational intervention for patients and their contacts may minimize the noncompliance with prescribed TB treatment and lessen MDR-TB magnitude in settings like Karachi.

Causes of smoking in Pakistan: an analysis of social factors.

OBJECTIVE: To determine the factors contributing to the initiation and propagation of smoking in visitors to a major tertiary health center in Karachi, Pakistan. METHODS: Seven major contributing factors to the initiation and propagation of smoking were presented to consenting study participants (n=170) in a questionnaire. Participants were then requested to use their experience and opinion to rate each of the given factors on a scale of 1 to 5 regarding its importance as a causative factor in the initiation and propagation of smoking. Results were analyzed using SPSSv16.0. RESULTS: Preliminary analysis revealed occupational stress relief as the most important factor contributing to smoking with a mean score of 3.25 +/- 1.32. Peer pressure ranked second (Score 3.20 +/- 1.42). Domestic stress relief ranked third with a score of 3.19 +/- 1.32. Smokers gave lower rating than non-smokers to most factors. Younger participants gave higher ratings to peer pressure, and most participants were found to have begun smoking at a young age. CONCLUSIONS: Even though the addictive power of nicotine or stress may appear as a factor in middle aged smokers, the root of their habit lies in the initiation due to peer pressure.

Perceptions of anti-smoking messages amongst high school students in Pakistan.

BACKGROUND: Surveys have provided evidence that tobacco use is widely prevalent amongst the youth in Pakistan. Several reviews have evaluated the effectiveness of various tobacco control programs, however, few have taken into account the perceptions of students themselves regarding these measures. The aim of this study was to determine the most effective anti-smoking messages that can be delivered to high-school students in Pakistan, based on their self-rated perceptions. It also aimed to assess the impact of pictorial/multi-media messages compared with written health warnings and to discover differences in perceptions of smokers to those of non-smokers to health warning messages. METHODS: This study was carried out in five major cities of Pakistan in private English-medium schools. A presentation was delivered at each school that highlighted the well-established health consequences of smoking using both written health warnings and pictorial/multi-media health messages. Following the presentation, the participants filled out a graded questionnaire form, using which they rated the risk-factors and messages that they thought were most effective in stopping or preventing them from smoking. The Friedman test was used to rank responses to each of the questions in the form. The Wilcoxon Signed Rank test used to analyze the impact of pictorial/multi-media messages over written statements. The Mann Whitney U test was used to compare responses of smokers with those of non-smokers. RESULTS: Picture of an oral cavity cancer, videos of a cancer patient using an electronic voice box and a patient on a ventilator, were perceived to be the most effective anti-smoking messages by students. Addiction, harming others through passive smoking and impact of smoking on disposable incomes were perceived to be less effective messages. Pictorial/multi-media messages were perceived to be more effective than written health warnings. Health warnings were perceived as less effective amongst smokers compared to non-smokers. CONCLUSION: Graphic pictorial/multi-media health warnings that depict cosmetic and functional distortions were perceived as effective anti-smoking messages by English-medium high school students in Pakistan. Smokers demonstrated greater resistance to health promotion messages compared with non-smokers. Targeted interventions for high school students may be beneficial.

ESAT6-induced IFNgamma and CXCL9 can differentiate severity of tuberculosis.

BACKGROUND: Protective responses against Mycobacterium tuberculosis are dependent on appropriate T cell and macrophage activation. Mycobacterial antigen six kDa early secreted antigenic target (ESAT6) and culture filtrate protein 10 (CFP10) can detect M. tuberculosis specific IFNgamma responses. However, most studies have been performed in non-endemic regions and to study pulmonary tuberculosis (PTB). We have studied ESAT6 and CFP10 induced cytokine and chemokines responses in PTB and extrapulmonary (EPul) TB. METHODOLOGY: IFNgamma, IL10, CXCL9 and CCL2 responses were determined using an ex vivo whole blood assay system in PTB (n = 30) and EPulTB patients with limited (LNTB, n = 24) or severe (SevTB, n = 22) disease, and in healthy endemic controls (ECs). Responses to bacterial LPS were also determined. PRINCIPAL FINDINGS: ESAT6- and CFP10-induced IFNgamma was comparable between ECs and TB patients. Both ESAT6- and CFP10-induced IFNgamma secretion was greater in LNTB than PTB. ESAT6-induced CXCL9 was greater in EPulTB as compared with PTB, with an increase in SevTB as compared with LNTB. CFP10-induced CCL2 was higher in PTB than LNTB patients. LPS-stimulated CXCL9 was greatest in SevTB and LPS-induced CCL2 was increased in PTB as compared with LNTB patients. A positive correlation between ESAT6-induced IFNgamma and CXCL9 was present in all TB patients, but IFNgamma and CCL2 was only correlated in LNTB. ESAT-induced CCL2 and CXCL9 were significantly associated in LNTB while correlation in response to LPS was only present in SevTB. CONCLUSIONS: ESAT6 induced IFNgamma and CXCL9 can differentiate between limited and severe TB infections.

Socio-demographic correlates of exhaled breath carbon monoxide in Karachi's adult population.

OBJECTIVE: To examine the relationship between CO levels and putative factors including smoking status among residents of Karachi, an urban center with very high levels of air pollution. METHODS: Two hundred and eighteen volunteering subjects were asked to maximally exhale into a Smokerlyzer breath CO analyzer. Each of the volunteers was also asked to reply to a questionnaire-based interview seeking demographic information as well as details of exposure to tobacco, traffic fumes and other air pollutants. RESULTS: Out of the 218 participating subjects, 75% were males and 27% were current or ex-smokers. The mean CO level was 2.92 parts per million (ppm). Cigarette smoking was the only factor found to influence CO levels. Number of cigarettes smoked per day was directly related to CO levels, while time since the last smoke was inversely related. There was no difference in CO levels between ex-smokers and never-been-smokers. Years of residence in Karachi, quantitative exposure to traffic and perception of occupational exposure to air pollutants were not associated with CO levels. CONCLUSIONS: Smoking status, number of cigarettes smoked per day and time since last smoke correlated well with exhaled breath CO levels, in spite of high air pollution levels. This tool therefore continues to provide a valid and real-time assessment of a subject's current smoking status.

Static pulmonary nodules from thyroid malignancy.

Papillary carcinoma of thyroid tends to be indolent. This is an unusual case of papillary carcinoma of thyroid with asymptomatic pulmonary metastasis for more than a decade, finally presenting with mild respiratory symptoms in a 21-year-old female. Fine needle aspiration and cytology (FNA-C) of a nodule in the lungs revealed features consistent with a papillary carcinoma of thyroid. Confirmed on thyroidectomy specimen. She subsequently received Iodine-131 (I131). A follow-up radio-iodide scan, 48 hours after, revealed diffuse uptake within the lung parenchyma. With static nodular shadowing on radiograph, a metastatic origin, in particular that of the thyroid, should be considered. I131 scintigraphy can help support the diagnosis of carcinoma of thyroid.

Bilateral breast enlargement due to Trichophyton rubrum.

Gynecomastia is the most common cause of breast enlargement in males. Trichophyton rubrum is a common dermatophyte, is responsible for a variety of infections, and may rarely manifest as a dermatophytic pseudomycetoma. We report the case of a 52-year-old man who presented with progressive bilateral breast enlargement. This is the first reported case of bilateral breast pseudomycetoma due to T. rubrum. Long-term antifungal therapy with itraconazole was successful.