A Nationwide Survey Following the Devastating 2022 Floods in Pakistan: Current State of Knowledge, Attitude, and Perception Toward Climate Change and Its Health Consequences.

BACKGROUND:  Climate change (CC) persists as a critical public health concern, vividly demonstrated by Pakistan's severe unprecedented flooding from June to October 2022. The interplay between floods and CC highlights the urgent need to comprehend their complex dynamics. Given Pakistan's significant geographical vulnerability to CC events, assessing public awareness of CC becomes essential. This study aims to evaluate public knowledge, attitudes, and perception (KAP) regarding CC and its implications for overall health, reflecting onto governmental policies and community-based guidelines and enhancing preparedness for future natural calamities of similar magnitude. METHODS:  A nationwide cross-sectional survey of Pakistani adults covering all provinces of the country was conducted from January to March 2023 using a prevalidated questionnaire. A purposive sampling strategy was used to enroll participants in the study. Where appropriate, the chi-square test or Fisher's exact test was used to compare KAP among the sociodemographic groups. Multivariate analysis was used to explore predictors of knowledge. Crude and adjusted odds ratios (ORs) were calculated considering a p value of ≤0.05 as significant. RESULTS:  Among the 714 respondents, 265 (37.1%) of the respondents' residential areas were affected by the floods in Pakistan. A total of 663 (92.9%) of the participants had heard of CC, with 302 (42.3%) choosing "social media/WhatsApp" as their source of information. Increased flooding and changes in rainfall patterns were selected by 679 (95.1%) and 661 (92.6%) participants, respectively, as the most recognized CC. "Deforestation" was the most indicated reason for CC by 675 (94.5%) participants. Multivariate analysis revealed that females (OR: 1.31, 95% CI: 1.16-2.00; p < 0.001), individuals who were affected by recent floods (OR: 1.13, 95% CI: 1.05-3.34; p = 0.003), and individuals who were medical students/healthcare workers (OR: 1.49, 95% CI: 1.24-2.48; p < 0.001) had greater knowledge of CC than their counterparts. CONCLUSIONS:  The study reported an encouraging prevalence of knowledge of CC, positive attitudes, and practices toward CC, with an interest in learning and doing more to address the health effects of CC. With the ongoing global CC and a monsoon season forecast of similar intensity for the years to come in Pakistan, identifying groups with less knowledge of CC warrants a targeted education program to maximize awareness. Based on the study findings, social media platforms and interventions in educational institutes should be essential to mitigate the CC events in Pakistan and other vulnerable regions in the area.

Diffuse pulmonary arteriovenous malformation presenting with secondary polycythemia and headaches: a case report.

BACKGROUND: Pulmonary arteriovenous malformations are a relatively uncommon medical condition, affecting roughly 1 in every 2500 individuals. Of those suffering from pulmonary arteriovenous malformations, 80% have an underlying genetic condition: hereditary hemorrhagic telangiectasia. CASE PRESENTATION: We present the case of a 20-year-old Pakistani male with a history of persistent slower-onset frontal headaches that increased in severity within the course of the day. His hemoglobin was 18 g/dl, indicating polycythemia, for which he had undergone seven venesections in a month previously. His physical examination was unremarkable. His computed tomography scan depicted multiple dilated tortuous vessels with branching linear opacities in the right lower lobe of the lungs. The multiple feeding arteries were supplied by the right main pulmonary artery, and the large draining veins led to the right inferior pulmonary vein. This was identified as a diffuse pulmonary arteriovenous malformation. He was recommended for a right pulmonary artery angiogram. It showed multiple tortuous vessels with a nidus and large draining veins-features of a diffuse arteriovenous malformation in the right lower lobe of the lung consistent with the computed tomography scan. Embolization of two of these vessels feeding the arteriovenous malformation was conducted, using Amplatzer Vascular plug 2, whereas multiple pushable coils (five coils) were used for embolizing the third feeding vessel. This achieved 70-80% successful embolization of right pulmonary AVM; however, some residual flow was still seen in the arteriovenous malformation given the complexity of the lesion. Immediately after, his oxygen saturation improved from 78% to 96%. CONCLUSION: Diffuse pulmonary arteriovenous malformations, as seen in this patient, are rare, accounting for less than 5% of total pulmonary arteriovenous malformations diagnosed. The patient presented with a complaint of progressive frontal headaches, which can be attributed to low oxygen saturation or the presence of a cerebral arteriovenous malformation. There was no history of hereditary hemorrhagic telangiectasia in the patient's family. Furthermore, although most patients with hereditary hemorrhagic telangiectasia and hence pulmonary arteriovenous malformation have complaints of iron-deficiency anemia, our patient in contrast was suffering from polycythemia. This can be explained as a compensatory mechanism in hypoxemic conditions. Moreover, the patient had no complaint of hemoptysis or epistaxis, giving a varied presentation in comparison with a typical pulmonary arteriovenous malformation.

Heated tobacco products- well known or well understood? A national cross-sectional study on knowledge, attitudes and usage in Pakistan.

BACKGROUND: Heated tobacco products (HTPs) are reshaping the tobacco industry and just recently, a plan was sought to regularize HTPs in Pakistan. Pakistan provides an intriguing case study in this context, as tobacco use is deeply ingrained in public use. To ensure that future evidence-based policy recommendations are grounded in the public's knowledge, attitudes, and usage of HTPs, a nationwide survey must be conducted. METHODS: A cross-sectional study was conducted using an online-based questionnaire nationwide in Pakistan. The questionnaire was validated and distributed through convenience sampling. The questionnaire assessed participants' knowledge, attitudes, and usage of HTPs. Descriptive statistics was used to describe participants' response and linear regression was performed at a p-value of < 0.05 using SPSS version 26. RESULTS: In our sample of 1195 respondents (mean age of 33 years, 41.8% males and 58.2% females), 54.7% had previously heard about HTPs and 16.9% reported using HTPs at least once. Additionally, 38.24% were unsure of the legality of HTP use. Those with monthly household incomes of PKR 100,000 to 500,000, were more likely to have higher knowledge scores (OR:1.80[1.07-3.04]). On the other hand, males (OR:0.70 [0.55-0.89]) and respondents from Balochistan (OR:0.40 [0.22-0.71]) were more likely to have lower knowledge scores. The strongest motivators were the enjoyability of HTPs (55.73%) and usage as a cigarette alternative (54.64%), while the strongest deterrents were the negative health effects (82.68%) and potential for addiction (81.01%). CONCLUSION: Our study underscores the need for awareness campaigns and interventions concerning HTPs, given prevalent preconceived notions and mixed attitudes among respondents. It was found that women and households with higher incomes scored higher on knowledge. Subjective enjoyment and a substitute for cigarettes were important motivators, but the most mentioned deterrents were the possibility of addiction and the detrimental effects on health. These insights form the basis for informed policy making for non-cigarette tobacco products.

Post-COVID-19 sequelae of the respiratory system. A single-centre experience reporting the compromise of the airway, alveolar and vascular components.

The long-term sequelae of COVID-19 have now become more common and appreciable. The SARS-CoV-2 virus can cause a variety of infectious and non-infectious pulmonary complications. The purpose of this study is to raise awareness about post-COVID-19 pulmonary sequelae, both infectious and non-infectious, in this geographical area. A retrospective study was conducted from July 1st 2020 to December 20th 2020. A total of 1200 patients were evaluated, with 83 suffering from post-COVID-19 pulmonary complications. The patients' mean age was 62 years (IQR 55-69), with 63 (75.9%) being male. The most common co-morbid illnesses were hypertension (49, 59%) and diabetes (45, 54.2%). The majority of them (37, 44.6%) had severe COVID-19, followed by critical COVID-19 (33, 39.8%). There was no statistically significant difference in recurrence of respiratory symptoms or duration of current illness between non-severe, severe, and critical COVID-19 patients. Non-infectious complications were observed in the majority of patients (n=76, 91.5%), including organizing pneumonia/ground glass opacities in 71 (88%) patients, fibrosis in 44 (55%), pulmonary embolism in 10 (12.5%), pneumomediastinum in 6 (7.4%) and pneumothorax in 7 (8.6%). Infective complications (25, 30.1%) included aspergillus infection in 10 (12.0%) and bacterial infection in 5 (8.47%), with more gram-negative infections and one patient developing Mycobacterium tuberculosis. Post COVID-19 mortality was 11 (13.3%). The long-term pulmonary sequelae of COVID-19 are not rare. Cryptogenic organizing pneumonia, ground glass opacities, and fibrosis were common post-COVID-19 sequelae in our patients. This necessitates frequent close monitoring of these patients in order to initiate early appropriate management and prevent further morbidity and eventual mortality.

Behavioural support and nicotine replacement therapy for smokeless tobacco cessation: protocol for a pilot randomised-controlled multi-country trial.

BACKGROUND: Smokeless tobacco (ST) is consumed globally by more than 350 million people, with approximately 85% of all users based in South and Southeast Asia. In this region, ST products are cheap and easily accessible. Evidence-based interventions to people quit ST use are lacking. This study aims to test the feasibility of conducting a future definitive trial of ST cessation, using a culturally adapted behavioural intervention, and/or nicotine replacement therapy (NRT) in three South Asian countries. METHODS: We will conduct a factorial design, randomised-controlled pilot trial in Bangladesh, India and Pakistan. Daily ST users will be recruited from primary health care settings in Dhaka, Noida and Karachi. Participants will be individually randomised to receive intervention A (4 or 6 mg NRT chewing gum for 8-weeks), intervention B (BISCA: face-to-face behavioural support for ST cessation), a combination of interventions A and B or usual care (Very Brief Advice - VBA). The participants will provide demographic and ST use related data at baseline, and at 6, 12 and 26 weeks of follow-up. Salivary cotinine samples will be collected at baseline and 26 weeks. The analyses will undertake an assessment of the feasibility of recruitment, randomisation, data collection and participant retention, as well as the feasibility of intervention delivery. We will also identify potential cessation outcomes to inform the main trial, understand the implementation, context and mechanisms of impact through a process evaluation and, thirdly, establish health resource use and impact on the quality of life through health economic data. DISCUSSION: The widespread and continued use of ST products in South Asia is consistent with a high rate of associated diseases and negative impact on the quality of life. The identification of feasible, effective and cost-effective interventions for ST is necessary to inform national and regional efforts to reduce ST use at the population level. The findings of this pilot trial will inform the development of larger trials for ST cessation among South Asian users, with relevance to wider regions and populations having high rates of ST use. TRIAL REGISTRATION: ISRCTN identifier 65109397.

Residual symptoms and the quality of life in individuals recovered from COVID-19 infection: A survey from Pakistan.

BACKGROUND: There remains scarcity of literature regarding the patient's health status post-COVID-19 infection. This study analyzes the prevalence of residual symptoms and quality of life (QoL) after COVID-19. METHODS: An anonymous online survey was administrated in Pakistan from November 2020 to April 2021 in COVID-19 survivors. The questionnaire used the 12-Item Short Form Health Survey (SF-12) to assess mental and physical QoL. Multivariate linear regression was used to explore factors associated with mental and physical QoL scores. RESULTS: A total of 331 COVID-19 survivors participated in our survey. Around 42.0% of the cohort reported within 1-3 months of diagnosis of COVID-19. The common residual symptoms were body aches (39.9%), low mood (32.6%), and cough (30.2%). Better physical QoL was associated with being male (adjusted beta: 3.328) and having no residual symptoms (6.955). However, suffering from nausea/vomiting during initial COVID-19 infection (-4.026), being admitted to the ICU during COVID-19 infection (-9.164), and suffering from residual body aches (-5.209) and low mood (-2.959) was associated with poorer QoL. Better mental QoL was associated with being asymptomatic during initial COVID-19 infection (6.149) and post-COVID (6.685), while experiencing low mood post-COVID was associated with poorer mental QoL (-8.253 [-10.914, -5.592]). CONCLUSION: Despite presumed "recovery" from COVID-19, patients still face a wide range of residual symptoms months after initial infection, which contributes towards poorer QoL. Healthcare professionals must remain alert to the long-lasting effects of COVID-19 infection and aim to address them appropriately to improve patients' QoL.

The effect of ivermectin on non-severe and severe COVID-19 disease and gender-based difference of its effectiveness.

The COVID-19 pandemic has led to mortality and morbidity since December 2019. Many possible treatment options have been advised till date. The role of ivermectin in the treatment of COVID-19 disease remains controversial. The aim of our study was to evaluate the effect of ivermectin in hospitalized patients with non-severe and severe COVID-19 disease. We conducted a retrospective cohort study that compared outcomes in 2 groups of COVID-19 patients hospitalized at the largest tertiary care center of Pakistan. The study group was given ivermectin along with standard treatment of covid-19 disease; the comparison group was not. Data on mortality, inflammatory markers such as C-reactive protein (CRP) and ferritin, length of hospital stay and baseline characteristics were collected from Aga Khan University's database from October 2020 till February 2021. Statistical analysis was done to determine the effectiveness of ivermectin in non-severe and severe COVID-19. Comparison of effectiveness of Ivermectin in both the genders was also conducted. The cohort included 188 patients out of which 90 were treated with ivermectin. Mortality and length of hospitalization was not found to be significantly different in the study group compared with the control group (5.6% vs 5.1%; p=0.87 and 5 days vs 4 days; p=0.27). Analysis of secondary outcomes did not yield statistically significant results, apart from ferritin levels which were significantly less in patients treated with ivermectin (547.1 vs 756.7; p=0.03). The ferritin and CRP levels in affected males were higher than in females on admission and discharge. Our findings suggest ivermectin does not significantly affect all-cause mortality, length of hospitalization and CRP levels in hospitalized COVID-19 patients. Large scale randomized controlled trials (RCTs) are required to further evaluate the role of ivermectin in covid-19 disease.

Acceptance of COVID-19 Vaccine in Pakistan: A Nationwide Cross-Sectional Study.

Introduction The coronavirus disease 2019 (COVID-19) vaccine is available across various countries worldwide, with public-private partnerships ensuring all individuals are vaccinated through a phased approach. Irrespective of the geographical spread, several myths pertaining to the COVID-19 vaccine have stemmed, ultimately limiting the national administration of vaccines and rollouts. This study assessed the acceptance of the COVID-19 vaccine among the general public in Pakistan. Methods A pre-validated questionnaire was administered from January 2021 to February 2021 to assess the public attitude and acceptance of the COVID-19 vaccine. Logistic regression analyses were run to identify factors associated with the acceptance among the population. Results A total of 936 responses were elicited, where 15% perceived their risk of being infected at 20-30% with an overall 70% agreeing to be vaccinated if recommended. Multivariate analysis identified higher acceptance in the male gender, healthcare workers, and students. Of all, 66% respondents chose healthcare workers and public officials, whereas 15.6% chose scientific literature, and 12.9% chose social media as the most reliable source of COVID-19 information. Conclusion Given the relatively greater trust in healthcare providers for information regarding COVID-19, healthcare workers ought to be on the frontline for vaccine campaigns and public outreach efforts, with governmental efforts in addition to the promotion of scientific materials for population-level understanding.

Factors motivating smoking cessation: a cross-sectional study in a lower-middle-income country.

INTRODUCTION: Only one-quarter of smokers in Pakistan attempt to quit smoking, and less than 3% are successful. In the absence of any literature from the country, this study aimed to explore factors motivating and strategies employed in successful smoking cessation attempts in Pakistan, a lower-middle-income country. METHODS: A survey was carried out in Karachi, Pakistan, amongst adult (≥ 18 years) former smokers (individuals who had smoked ≥100 cigarettes in their lifetime but who had successfully quit smoking for > 1 month at the time of survey). Multivariable logistic regression, with number of quit attempts (single vs. multiple) as the dependent variable, was performed while adjusting for age, sex, monthly family income, years smoked, cigarettes/day before quitting, and having suffered from a smoking-related health problem. RESULTS: Out of 330 former smokers, 50.3% quit successfully on their first attempt with 62.1% quitting "cold turkey". Only 10.9% used a cessation aid (most commonly nicotine replacement therapy: 8.2%). Motivations for quitting included self-health (74.5%), promptings by one's family (43%), and family's health (14.8%). Other social pressures included peer-pressure to quit smoking (31.2%) and social avoidance by non-smokers (22.7%). Successful smoking cessation on one's first attempt was associated with being married (OR: 4.47 [95% CI: 2.32-8.61]), employing an abrupt cessation mode of quitting (4.12 [2.48-6.84]), and telling oneself that one has the willpower to quit (1.68 [1.04-2.71]). CONCLUSION: In Pakistan, smoking cessation is motivated by concern for self-health and family's health, family's support, and social pressures. Our results lay a comprehensive foundation for the development of smoking-cessation interventions tailored to the population of the country. IMPLICATIONS: Little is known about the patterns and strategies employed by smokers who are attempting to quit smoking, especially in lower-middle-income countries like Pakistan. Likewise, there are very few smoking cessation programs designed to assist in quitting. Our study will allow for a better understanding of the culture-specific motivating factors and strategies that most contributed to successful quit attempts. Based on these results, evidence based smoking cessation interventions can be developed tailored to the socioeconomic demographic of our country and region, including smoking cessation clinics and public outreach and media campaigns highlighting key elements of successful smoking cessation.

Idiopathic pulmonary hemosiderosis - A rare cause of chronic anemia.

Idiopathic pulmonary hemosiderosis (IPH) is a rare disease marked by alveolar bleeding and accumulation of hemosiderin in the lungs. Here we present three cases of IPH. The first case is of a 26-year-old male with anemia, hemoptysis and dyspnea. Bronchoscopy confirmed diffuse alveolar hemorrhage (DAH). A diagnosis of IPH was made after ruling out other causes of DAH and observing good response to steroids. The patient's condition improved with prednisolone and azathioprine. The second case is of 26-year-old female with severe anemia. Imaging suggested IPH and lung biopsy confirmed it. She died shortly afterwards. The third case is of a 7-year-old male with chronic anemia. CT was suggestive of IPH and lung biopsy confirmed the diagnosis. Later, patient developed posterior reversible encephalopathy syndrome (PRES). This patient is stable on azathioprine and prednisolone. We aim to emphasize the importance of considering IPH as a differential in patients with DAH or chronic anemia.

Cystic echinococcosis: a 10-year experience from a middle-income country.

Cystic echinococcosis (CE), or hydatid disease, is a neglected tropical disease (NTD) afflicting one million people globally. This study aims to elucidate the presentation, treatment and outcomes of the disease in Pakistan. A review of charts of 225 patients (median age = 42.3 years) with CE admitted at Aga Khan Hospital, Karachi during 2007-2017, was carried out. Abdominal pain was present in 34.7% followed by fever in 26.2%. There were 142 (63.1%) cases of hepatic cysts and 55 (24.4%) of pulmonary hydatid cysts. Combined surgical and medical therapy was given to 130 (57.8%) patients. Surgery only was performed in 23 (10.2%) patients, medical therapy only was given to 35 (15.6%) patients, and puncture, aspiration, injection and reaspiration (PAIR) with medical therapy was given to 15 (6.7%) patients. Recurrence occurred in 14 (6.2%) patients and mortality in 7 (3.1%) patients. Owing to its non-specific presentation, a high index of suspicion is required to diagnose and treat CE in a timely manner.

Solitary Endobronchial Papilloma: A Rare Entity.

Solitary papillomas of the lower airways are uncommon clinical entities that present a diagnostic challenge because they are not usually considered among the differential diagnoses. Reliable clinical data about their presentation and treatment remain scarce. We describe a case of an elderly male who presented to us with cough and hemoptysis. He had been a smoker for 50 years. Chest radiograph revealed hyperinflated lungs and slight hilar enlargement on the right side. Bronchoscopy revealed a polypoid mass at the origin of the right upper lobe bronchus. Biopsy showed it to be a papillomatous growth composed of squamous epithelial cells. No malignant cells were detected microscopically. Patient declined surgical removal of this papilloma. He was fine on followup visits during the subsequent months. In patients with hemoptysis, solitary endobronchial papilloma should also be considered in the differential diagnosis.

Granulomatosis With Polyangiitis: A 17 Year Experience From A Tertiary Care Hospital In Pakistan.

Granulomatosis with Polyangitis (GPA) is an uncommon immunologically mediated necrotizing vasculitis affecting the small and medium sized systemic blood vessels. We previously reported our experience with this condition and herein, we document our study findings and compare them to the clinical and radiological findings of various studies from around the world. By doing so we hope to further create awareness of this condition afflicting not only our part of the population but is part of a larger global phenomenon.

Primary pulmonary plasmacytoma presenting with rare IgG lambda monoclonal gammopathy.

Extramedullaryplasmacytoma (EMP) represents a peculiar and typically progressive malignancy that can originate outside the bone marrow. Primary pulmonary plasmacytoma (PPP) is a rare subset of EMP, confined to the lung. A 55-year-old man, diabetic, non-smoker presented to our clinic with a right chest wall swelling. A routine chest radiograph showed a well-circumscribed opacity in the right upper lung zone. A CT of the chest revealed a large right upper lobe mass with extensive local infiltration. Biopsy and immunohistochemical evaluation led to a diagnosis of PPP. Screening for multiple myeloma was negative. Serum immunofixation showed an IgG lambda monoclonal gammopathy, found in a minority of PPP patients. In view of disease extent, treatment with chemotherapy and radiotherapy was initiated. The patient is currently in out patient follow-up and has shown a favourable response to the treatment with a considerable decrease in serum IgG levels.

Invasive mediastinal aspergillosis presenting as superior vena cava syndrome in an immunocompetent patient.

Invasive aspergillosis (IA) is a disease of the immunocompromised with a predilection for the lungs, although dissemination to all organs is possible. Its diagnosis remains a challenge due to the absence of specific clinical manifestations and laboratory findings. In most cases, diagnosis is eventually made via invasive methods. It carries with it a high mortality due to late diagnosis and delayed treatment. Here, we report a fascinating case of a young, otherwise healthy, immunocompetent patient that presented to us with superior vena cava syndrome and a mediastinal mass. It was anticipated that a malignancy would be found on further workup but, in fact, what was eventually discovered was a case of IA. Our report accentuates the significance of including IA as a differential while diagnosing a mediastinal mass in an immunocompetent host as patient outcome is determined by timely diagnosis and treatment.

Awareness, use and perceptions about E-cigarettes among adult smokers in Karachi, Pakistan.

OBJECTIVE: To estimate the prevalence of awareness, current use and intention to use of e-cigarettes among adult smokers. METHODS: This cross-sectional survey was carried out at the Aga Khan University Hospital, Karachi, from July to August 2016, and comprised people aged above 18 years who had smoked more than 100 cigarettes in their lifetime. Convenience sampling method was used. A self-administered questionnaire was used to collect data. SPSS 22 was used for data analysis.. RESULTS: Of the 387 participants, 359(92.8%) were male. The overall mean age was 32.4±12.6 years. Moreover, 215(55.5%) respondents belonged to the middle socio-economic class. Besides, 249(64.3%) respondents were aware of e-cigarettes while 39(10.1%) used them, and 81(20.9%) wanted to use them. Socio-economic status was the best predictor for awareness about e-cigarettes (p<0.001), while gender (p=0.001), occupation

Assessment of inhalation technique among patients of chronic respiratory disorders in Civil Hospital Karachi: A cross sectional study.

OBJECTIVE: To evaluate the inhaler technique of patients and the awareness acquired during pulmonary teachings given in the beginning of the treatment. METHODS: This cross-sectional study was conducted at Civil Hospital, Karachi, from December 2013 to July 2014, and comprised patients diagnosed with obstructive broncho-pulmonary diseases and who were using inhaler therapy. A questionnaire was designed to assess the technique by an inhaler technique checklist, which was pilot-tested and was filled after obtaining verbal consent. SPSS 19 was used for data analysis. RESULTS: Of the 202 participants, 110(54.45%) were women and 92(45.54%) were men. Moreover, 168(83.2%) used metered-dose inhaler while 34(16.8%) used dry-powder inhaler. Besides, 134(79.8%) patients showed incorrect technique while using metered-dose inhaler while 22(61.1%) used dry-powder inhaler improperly. CONCLUSIONS: In spite of the guidelines given, improper inhalation technique persisted in population leading to uncontrolled asthma and poor treatment compliance.

Tobacco control laws in Pakistan and their implementation: A pilot study in Karachi.

OBJECTIVE: In order to limit the high prevalence of tobacco use in Pakistan various tobacco control laws have been implemented. The objective of this study is to serve as a pilot study to assess the implementation of these laws in the largest city of Pakistan, Karachi. METHODS: A cross-sectional study was conducted in Karachi. The implementation of tobacco control laws in 'smoke-free' places, the adherence of tobacco companies to these laws, the regulation of cigarette sale, and the awareness and views of the general public regarding tobacco control laws were assessed via direct observation by visits and through self-administered questionnaires. RESULTS: The implementation of tobacco control laws in 'smoke-free' public places was found to be poor. Out of 37, only 23(62%) brands displayed pictorial warnings on their packs. 3(8%) of the brands were available in two different kinds of packs, both with and without pictorial warnings. Cigarette sale to minors was taking place at 80(85%) of the visited cigarette outlets. 50(53%) of the outlets displayed cigarette advertisements in the form of posters. 46(40%) of the persons questioned had awareness regarding the existence of ban on smoking in public places and 126(90%) of these were in favour of it. CONCLUSIONS: The implementation of tobacco control law in Pakistan is poor. Non adherence to the law in public places was alarmingly high. Also, the study demonstrates the poor compliance to the tobacco control laws by tobacco companies. The sale of cigarettes is almost unregulated.

Pulmonary arteriovascular malformation: a rare cause of unexplained hypoxia and acute dyspnoea in young patients.

Pulmonary arteriovenous malformations (PAVMs) are anomalous vascular connections between arteries and veins in the lung and comprise of two types, simple and complex. PAVMs are associated with congenital conditions such as hereditary haemorrhagic telengiectasia along with acquired causes. We present a case of a 26-year-old man who presented with dyspnoea, palpitations and decreased oxygen saturation as an initial presentation of PAVM, which was treated successively with embolisation.