Presentation, management, and early outcomes of young acute coronary syndrome patients- analysis of 23,560 South Asian patients from 2012 to 2021.

BACKGROUND: There is dearth of literature addressing early outcomes of acute coronary syndrome (ACS) among young patients, particularly South Asians descent who are predisposed to premature coronary artery disease (CAD). Therefore, we compared presentation, management, and early outcomes of young vs. old ACS patients and explored predictors of in-hospital mortality. METHODS: We extracted data of 23,560 ACS patients who presented at Tabba Heart Institute, Karachi, Pakistan, from July 2012-June 2020, from the Chest pain-MI-Registry™. We categorized data into young ≤ 45 and old ACS patients > 45 years. Chi-sq/Fischer exact tests were used to assess the difference between presentation, disease management, and in-hospital mortality between both groups. Logistic regression was used to determine odds ratio along with 95% confidence interval of factors associated with early mortality. RESULTS: The younger patients were 12.2% and women 23.5%. The prevalence of dyslipidemia (34.5% vs. 22.4%), diabetes (52.1% vs. 27.4%), and hypertension (68.3% vs. 42.9%) was higher in older patients. Family history of premature CAD (18.1% vs. 32.7%), smoking (40.0% vs. 22.9%), and smokeless tobacco use (6.5% vs. 8.4%) were lower in older patients compared to younger ones. Younger patients were more likely to present with STEMI (33.2% vs. 45%). The median symptom-to-door time was 125 min longer (p-value < 0.01) in the young patients compared to the older age group. In-hospital mortality (4.3% vs. 1.7%), cardiac arrest (1.9% vs. 0.7%), cardiogenic shock (1.9% vs. 0.9%), and heart failure (1% vs. 0.6%) were more common in older patients. After adjusting for other factors, younger age (AOR 0.6, 95% CI 1.5-3.7) had significantly lesser odds of in-hospital mortality. Other factors associated with early mortality included women, family history of premature CAD, STEMI, Killip class III and IV, coronary angiography, revascularization, CABG, and use of aspirin and beta blockers within the first 24 h. CONCLUSION: We found every tenth ACS patient was younger than 45 years of age despite a lesser number of comorbidities such as hypertension and diabetes. Overall, the in-hospital prognosis of young patients was more favorable than that of older patients. The study emphasizes the need for tailored primary prevention programs for ACS, considering the varying risks among different age groups.

Predicting the Length of Stay of Cardiac Patients Based on Pre-Operative Variables-Bayesian Models vs. Machine Learning Models.

Length of stay (LoS) prediction is deemed important for a medical institution's operational and logistical efficiency. Sound estimates of a patient's stay increase clinical preparedness and reduce aberrations. Various statistical methods and techniques are used to quantify and predict the LoS of a patient based on pre-operative clinical features. This study evaluates and compares the results of Bayesian (simple Bayesian regression and hierarchical Bayesian regression) models and machine learning (ML) regression models against multiple evaluation metrics for the problem of LoS prediction of cardiac patients admitted to Tabba Heart Institute, Karachi, Pakistan (THI) between 2015 and 2020. In addition, the study also presents the use of hierarchical Bayesian regression to account for data variability and skewness without homogenizing the data (by removing outliers). LoS estimates from the hierarchical Bayesian regression model resulted in a root mean squared error (RMSE) and mean absolute error (MAE) of 1.49 and 1.16, respectively. Simple Bayesian regression (without hierarchy) achieved an RMSE and MAE of 3.36 and 2.05, respectively. The average RMSE and MAE of ML models remained at 3.36 and 1.98, respectively.

COVID-19 pandemic impacted internet use and anxiety among general public during COVID-19 pandemic in Pakistan.

Objective: To determine the association between internet use and anxiety among people during the coronavirus disease- 2019 pandemic. METHODS: The cross-sectional study was conducted across Pakistan from January 14 to February 21, 2021, which was the active phase of the coronavirus disease-2019 pandemic in Pakistan. The participants were aged at least 13 years having internet access regardless of gender or their location across Pakistan. The anonymous web-based survey was conducted using a questionnaire generated on Google Forms and disseminated through various social media platforms and WhatsApp groups. Anxiety symptoms were screened using the Depression, Anxiety and Stress Scale-21, while the Young Internet Addiction Test was used to evaluate symptoms of internet addiction. Data was analysed using STATA 16. RESULTS: Of the 1,145 subjects, 686(60%) were females and 459(40%) were males. A total of 257(22.5%) participants were found to have extremely severe anxiety and internet usage pattern was significantly associated with the level of anxiety (p<0.05). Age, gender, social class and marital status were not significantly different (p>0.05), while family income and area of living were significantly different (p<0.05) in terms of anxiety levels. The odd of addictive internet use was 10.2 (95% confidence interval: 5.7-18.5) times greater in extreme anxiety individuals compared to individuals having no anxiety after controlling for other sociodemographic, health-related, behavioural and environmental factors during the pandemic. Conclusion: A significant association of anxiety was found with internet addiction during the coronavirus disease-2019 pandemic.

PAKistan Study of prEmature coronary atHerosclerosis in young AdulTs (PAK-SEHAT): a prospective longitudinal study protocol investigating the prevalence, severity and determinants of atherosclerotic cardiovascular disease in the young adult Pakistani population.

INTRODUCTION: Atherosclerotic cardiovascular disease (ASCVD) is a major cause of morbidity, mortality and health expenditures worldwide. Despite having higher ASCVD in the Pakistani population, data on subclinical coronary atherosclerosis in young Pakistanis remain scarce. The PAKistan Study of prEmature coronary atHerosclerosis in young AdulTs (PAK-SEHAT) aims to assess the prevalence, severity and determinants of subclinical coronary atherosclerosis among Pakistani men (35-60 years) and women (35-65 years) free of clinically symptomatic ASCVD and will assess 5-year rates of ASCVD events. METHODS AND ANALYSIS: PAK-SEHAT is an ongoing prospective cohort study with 2000 participants from all provinces of Pakistan who will be interviewed at the baseline along with phlebotomy, measurement of carotid intima-media thickness (CIMT) and coronary CT angiography (CCTA). Phlebotomy will be repeated at 2.5 years, whereas CIMT and CCTA will be repeated at 5 years. We will report the frequency of maximal coronary stenosis ≥50% and ≥70%, number of coronary vessels with plaque and the number of coronary segments affected per participant on CCTA. We will use Cox proportional hazards regression models to evaluate the association between baseline characteristics and incident ASCVD events during follow-up. These associations will be presented as HRs with 95% CIs. ETHICS AND DISSEMINATION: The study protocol was approved by the Tabba Heart Institute Institutional Review Board (THI/IRB/FQ/22-09-2021/016). All study procedures are consistent with the principles of the Declaration of Helsinki. Findings of the study will be disseminated via peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: NCT05156736.

Association of depressive symptoms and quality of life in Pakistani youth (15-24 years) with polycystic ovarian syndrome: a web-based analytical cross-sectional study.

Introduction: Polycystic ovarian syndrome (PCOS) is associated with impaired quality of life (QOL) of individuals, predominantly in youth, who are most vulnerable to its impact. Psychological morbidity could be one of the factors influencing QOL. The study investigated the association between depressive symptoms and QOL in Pakistani youth (15-24 years) with PCOS and determined other factors associated with QOL. Methods: We conducted an analytical-cross-sectional survey on 213 single Pakistani females aged 15-24 years recruited via a web-based approach. Depression and QOL were assessed through Center-of-Epidemiological-Studies-Depression tool and Polycystic-ovarian-syndrome-quality-of-life-scale. Multiple-linear-regression was used to determine factors associated with QOL, and adjusted regression-coefficients along with a 95% confidence interval were reported. Results: The mean QOL score: 2.9 ± 1.1. The domain of obesity had the lowest mean score (2.5 ± 1.6) whereas domain of hirsutism had the highest (3.2 ± 1.9). 172/213 (80%) participants were screened positive for depressive symptoms. Participants with depressive symptoms reported reduced mean QOL scores than respondents with no such symptoms (2.8 ± 1.0 vs. 3.4 ± 1.3, p < 0.001). No differences were found in overall QOL and individual domains between participants 15-19 years (n = 36, 17%) and participants >19-24 years (n = 177, 83%) (2.9 ± 1.1 vs. 2.9 ± 1.1) (p > 0.05). We found a significant interaction between depressive symptoms and PCOS duration, indicating that the estimated mean overall QOL score decreases by 25.1 (-36.6, -13.6) for every year increase in PCOS duration among participants screened positive for depressive symptoms. Furthermore, for those respondents who had family history of PCOS and were not satisfied with their healthcare provider treating PCOS, the estimated mean QOL score was 17.47 (-26.1, -8.8) lower than participants who had no family history of PCOS and were satisfied with their healthcare provider. Other factors associated with reduced quality of life included societal pressure to improve appearance affected by PCOS, parental criticism related to PCOS, education, socioeconomic status, working status and BMI. Conclusion: Depressive symptoms with increasing duration of PCOS were significantly associated with reduced QOL. Therefore, to improve the overall QOL of PCOS youth, screening and timely addressing of psychological morbidities should be considered.

Clinical characteristics, management, and 5-year survival compared between no standard modifiable risk factor (SMuRFless) and ≥ 1 SMuRF ACS cases: an analysis of 15,051 cases from Pakistan.

BACKGROUND: There has been an increase in Acute Coronary Syndrome (ACS) patients without standard modifiable risk factors i.e. hypertension, diabetes, dyslipidemia, and tobacco use (SMuRFless) compared to the patients with ≥ 1 SMuRF but this has not been studied in South Asia despite them being a high-risk population. We conducted a comparative analysis of first episodes of ACS cases admitted to a tertiary cardiac center in Pakistan between SMuRFless and ≥ 1 SMuRF patients for clinical presentation, management, in-hospital, and 5-year mortality. METHODS: We undertook a retrospective study and data of 15,051 patients admitted at Tabba Heart Institute (THI) with the first episode of ACS was extracted from Chest Pain-MI™, and the CathPCI Registry® registry affiliated with the National Cardiovascular Data Registry (NCDR®), USA. Logistic regression and Cox proportional algorithm yielded odds ratio (OR) and hazard ratios (HR) with 95% confidence interval (CI) for associated factors of in-patient and 5-year mortality. RESULTS: There were 15% SMuRFless cases and in-hospital mortality was 4.1% in SMuRFless vs. 3.9% in the ≥ 1 SMuRF group (p-0.59), the difference remained insignificant after adjusting for age, gender, Killip class, multivessel disease, type of ACS, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) (Adjusted OR:1.1 [0.8, 1.3]. Unadjusted 5-year mortality was 40% lower in the SMuRFless group but the difference was insignificant after adjusting for age, gender, disease at presentation, its severity, and management (Adjusted HR 0.7 95% CI[0.5, 1.0]). STEMI, NSTEMI, Killip class, and multivessel disease increased the risk of overall 5-year mortality. CONCLUSION: In-hospital and 5-year mortality was not different between the SMuRFless and ≥ 1 SMuRF group, there is a need to understand mediators of immediate and long-term mortality risk in SMuRFless patients.

Predictors of Non-Obstructive Coronary Artery Disease in Patients Undergoing Elective Coronary Angiography.

Background: Appropriate patient selection for coronary angiography (CAG) is essential to minimize the unnecessary risk of morbidities and exposure to radiation and iodinated contrast. This becomes even more relevant in low-to-middle-income settings where most health expenditures are out-of-pocket due to lack of medical insurance. We determined predictors of non-obstructive coronaries (NOC) in patients undergoing elective CAG. Methods: CathPCI Registry®, single-center data was extracted for 25,472 patients who had CAG over an eight year period. After excluding patients for compelling conditions or known CAD, 2,984 (11.7%) patients were included in this study. Non-Obstructive Coronaries was defined as <50% left main coronary artery and major epicardial vessel stenosis. Multiple Cox proportional algorithm was employed to report prevalence ratios (PR) of predictors of NOC along with 95% confidence interval. Results: Mean age of patients was 57.9 ± 9.7 years, 23.5% were women. Preprocedural non-invasive testing (NIT) was performed in 46% of the patients; of which 95.5% reported to be positive but only 67.3% were stratified as high risk. Of 2,984 patients undergoing elective CAG, 711 (24%) had NOC. Predictors of NOC included younger age <50 years (PR: 1.3, CI: 1.0-1.5), Women (1.8, 1.5-2.1), low (1.9, 1.5-2.5) and intermediate risk stratification (1.3, 1.0-1.6) on Modified Framingham Risk Score and inappropriate (2.7, 1.6-4.3) and uncertain (1.3, 1.1-1.6) classification of CAG on Appropriate Use Criteria. Patients with heart failure as an indication of CAG (1.7, 1.4-2.0) and No NIT or positive low risk NIT (1.8, 1.5-2.2) were more likely to have NOC. Conclusion: Approximately one out of four patients undergoing elective CAG had NOC. Yield of diagnostic catheterization can be improved by adjudicating NIT especially in younger patients, women, patients with heart failure as an indication of CAG, patients classified as inappropriate on Appropriate Use Criteria and patients categorized as low or intermediate risk on MFRS.

Gender Differences in Clinical Outcomes After Percutaneous Coronary Intervention-Analysis of 15,106 Patients from the Cardiac Registry of Pakistan Database.

There is a scarcity of data on gender differences in outcomes during and after percutaneous coronary intervention (PCI) in the South Asian population. We assessed the gender differences in in-hospital mortality and complications in patients who underwent PCI. We conducted a cross-sectional study of 15,106 patients from the CROP (Cardiac Registry of Pakistan) CathPCI database. Logistic regression was used to determine factors associated with in-hospital mortality (primary outcome), access site hematoma, and bleeding complications. Approximately 19.6% were women. Women were older (mean age = 57.3 vs 54.4 years) and had a higher prevalence of diabetes (49.3% vs 32.6%), hypertension (72.8% vs 56.4%), peripheral arterial disease (1.5% vs 1%), and cerebrovascular accident (1.2% vs 0.8%) than men (p <0.05).Unadjusted in-hospital mortality was higher in women than in men (odds ratio [OR]: 1.6, 95% confidence interval [CI] 1.1 to 2.2); however, after adjusting for age, hypertension, diabetes, history of cerebrovascular accident, and ST-elevation myocardial infarction at presentation in the multiple logistic regression model, in-hospital mortality was comparable between men and women (adjusted OR [AOR] 1.2, 95% CI 0.8 to 1.7). The results remained consistent after propensity score matching of 5,904 patients (2,952 in each group, OR 1.3, 95% CI 0.9 to 2.0 for in-hospital mortality). Bleeding complications (1.2% vs 0.4%, AOR 2.6, 95% CI 1.4 to 4.5) and access site hematoma (2% vs 0.6%, AOR 2.8, 95% CI 1.8 to 4.5) were higher in women than in men. In conclusion, the incidence of in-hospital mortality was higher for women versus men, but adjusted risks were similar, likely driven by a greater co-morbidity burden among women.

Demographic and Psychosocial Factors associated with Internet Addiction among the Pakistani Population during COVID-19: A Web-Based Survey.

This study aims to determine the burden of COVID19-induced internet addiction and related psychosocial factors among the Pakistani sample. A web-based cross-sectional survey was conducted from January to March 2021. An analytical cross-sectional survey was broadcast on the internet via a Google form completed by 1145 Pakistanis. Individuals aged 13 years and above with competency to comprehend English or Urdu language, currently residing in any province of Pakistan, having access to the questionnaire, and willing to participate were eligible to participate. Overseas Pakistanis were excluded from the study. The outcome is COVID19-induced internet addiction was measured using the validated tool Young's Internet Addiction Test (IAT). In addition, symptoms of depression, anxiety, stress, and other psychosocial factors were assessed using the validated tool Depression, Anxiety, and Stress Scale-21 (DASS-21). Adjusted odds ratios with a 95% confidence interval were reported using multinomial logistic regression. Most participants were females and youth (between 20 and 24 years). The prevalence of problematic internet users (PIU) and addictive internet users (AIU) was 27.3% and 11.3%, respectively. The odds of extremely severe anxiety among AIU were approximately three times (Adj OR: 2.6 (1.1-7.1), followed by the odds of having extremely severe stress being about five times higher among AIU (Adj OR: 5.4 (1.6-17.6)) as compared to normal internet users (NIU). Amid COVID-19, the burden of internet addiction has surged among the Pakistani populace. This study identified that gender, marital status, depression, stress, anxiety, work situation, and mood changes during the COVID-19 pandemic are significantly correlated with problematic and addictive internet use. Preventative measures against the addictive use of the internet are needed to avoid or mitigate any serious mental health problems.

Management and outcome of post-myocardial infarction ventricular septal rupture-A Low-Middle-Income Country Experience.

BACKGROUND: Ventricular septal rupture (VSR) is a rare complication after acute myocardial infarction (AMI) especially in the reperfusion era but its associated mortality has remained high. This case series evaluated in-hospital and intermediate-term mortality in VSR patients. Additionally, we also analyzed risk factors, clinical presentation, intervention, and predictors of in-hospital mortality in VSR patients. METHODS: Data of 67 patients with echocardiography confirmed diagnosis of VSR from January 2011 to April 2020 was extracted from hospital medical records. Records were also reviewed to document 30 day and 1-year mortality, recurrent heart failure admission, repeat myocardial infarction, and revascularization. In addition, telephonic follow-up was done to assess health-related quality of life(HRQOL) assessed by KCCQ-12. SCAI shock classification was used to categorize severity of cardiogenic shock. Univariate and multivariable logistic regression was used to determine predictors of in-hospital mortality. Survival function was presented using the Kaplan-Meier survival curve. RESULTS: Mean age of patients was 62.7 ± 11.1 years, 62.7% were males. 65.7% of the patients presented more than 24 hours after MI and did not receive reperfusion therapy. Median time from AMI to VSR diagnosis was 2 (1-5) days. VSR closure was attempted in 53.7% patients. In-hospital mortality was 65.7%. At univariate level, predictors of in-hospital mortality were non-surgical management, basal VSR, right ventricular dysfunction, early VSR post-MI, and severe cardiogenic shock at admission (class C, D, or E). Adjusted predictors of in-hospital mortality included non-surgical management, basal VSR and advanced cardiogenic shock. There were 5 deaths during median followup of 44.1 months. HRQOL in patients available on followup was good (54.5%) or excellent (45.5%). CONCLUSION: High in-hospital mortality was seen in VSR patients. VSR closure is the preferred treatment to get long-term survival, however, timing of repair as well as severity of cardiogenic shock plays a significant role in determining prognosis.

Burden and factors associated with perceived stress amidst COVID-19: a population web-based study in Pakistan.

OBJECTIVE: This study aims to determine the burden and factors associated with perceived stress in the Pakistani population amidst the COVID-19 pandemic. SETTING: A web-based cross-sectional survey was conducted from April to August 2020. POPULATION: This survey was broadcasted on the web using a Google form link and 1654 Pakistani residents had completed this survey. Individuals belonging to any province, city, village, or district of Pakistan irrespective of any age, having internet access and a link of Google form, with English/Urdu competency, consent to participate, and currently residing in Pakistan were eligible to participate. OUTCOME MEASURE: Perceived stress was measured using a validated tool of perceived stress scale-10. Multiple ordinal regression was used, and an adjusted OR along with a 95% CI are reported. RESULTS: The mean score of perceived stress was 19.32 (SD ±6.67). Most of the participants screened positive for moderate (69%) and high levels (14%) of stress, respectively. The odds of high-perceived stress among severely anxious participants were 44.67 (95% CI: 21.33 to 93.53) times than participants with no/minimal generalised anxiety during the complete lockdown. However, the odds of high levels of perceived stress among moderately anxious respondents were 15.79 (95% CI: 10.19 to 24.28) times compared with participants with no/minimal anxiety during the smart lockdown. CONCLUSION: This study evidence that the pandemic was highly distressing for the Pakistani population causing the maximum level of perceived stress in more than half of the population. Adequate and timely interventions are needed before high-stress levels culminate into psychological disorders.

Cases of acute coronary syndrome and presumed cardiac death prior to arrival at an urban tertiary care hospital in Pakistan during the COVID-19 pandemic.

BACKGROUND: A reduction in overall acute coronary syndrome (ACS) cases, increases in the severity of ACS presentation, and increased rates of out-of-hospital cardiac arrest (OHCA) have been reported from multiple countries during the COVID-19 pandemic. The attributed factors include COVID-19 infection, fear of COVID-19 and resultant avoidance of health care facilities, and restrictions on mobility. Pakistan, a country with a high burden of cardiovascular disease (CVD) and challenges related to health care access, will be expected to demonstrate these same findings. Therefore, we compared ACS hospitalization, ACS severity, and patients who have already died (dead on arrival, or DOA) due to presumed OHCA at a tertiary cardiac hospital during pre-pandemic and intra-pandemic periods in Pakistan. METHODS: Standardized data elements were extracted from the charts of patients with ACS, and telephonic verbal autopsies (VA) using a validated tool were conducted for patients who were arrived DOA. As a comparison, cases during the same months prior to the COVID-19 were analyzed for respective waves. Events were counted, and proportions and frequencies are reported for each time period. RESULTS: A total of 4,480 ACS cases were reviewed; 1,216 cases during March-July 2019, 804 cases in the same months of 2020 (33.8% decrease); 1,304 cases in August 2019-January 2020 and 1,157 in the corresponding months of 2020 and 2021 (11.2% decrease). There was no observed change in the baseline characteristics of patients with ACS or their symptom-to-door time, and in-hospital mortality was unchanged across all time periods. There were 218 DOA cases in pre-pandemic months and 360 cases during the pandemic. The pre-pandemic rate of DOA was 12/1000 emergency patients (95% CI 10-13) compared to 22/1000 (95% CI 22-27) during the pandemic (30/1000in the 1st wave and 17/1000 during 2nd wave). On VA, CVD was found to be the major cause of death during both time periods. CONCLUSION: At a cardiac hospital in Pakistan, the COVID-19 pandemic was associated with a reduction in ACS hospitalization and an increased DOA rate.

The role of parent-to-child maltreatment in the pathway of self-reported depressive symptoms in Pakistani adolescents.

BACKGROUND: Parent-to-child maltreatment has been demonstrated to drastically affect a child's mental well-being and plays a significant role in developing depressive symptoms. However, little is established about the effect of frequency of parent-to-child maltreatment on the development of depressive symptoms among Pakistani adolescents. METHODS: A longitudinal prospective study was conducted, from 2015 to 2017, with 800 adolescents aged 11-17 years old recruited from 32 systematically selected urban and peri-urban areas of Karachi. First, these adolescents were screened for parent-to-child maltreatment in 2015 in a cross-sectional survey. Children with diagnosed psychiatric conditions were excluded from the study. In the second phase, these individuals were followed for 2 years to investigate the symptoms of depressive disorder using a validated tool, "CES-D (Center for Epidemiological Studies) Depression scale." The Cox proportional algorithm was used to examine the relationship between the frequency of parent-to-child maltreatment and depressive symptoms. RESULTS: Approximately 11% of frequently, 9% of occasionally parent-to-child, and 7%of negligibly maltreated adolescents reported depressive symptoms over 2 years. The other significant predictors of depressive symptoms were no formal education of the child (RR: 3.15, 95% CI: 1.35-7.34), presence of stressful home environment (RR: 2.19, 95% CI: 1.22-3.94), and having both uneducated parents (RR: 1.70, 95% CI: 0.90-3.21). The frequently maltreated females were found to have 4 times the higher risk compared to rarely maltreated males. In addition, frequently maltreated males were twice likely to develop depressive symptoms. CONCLUSION: The results suggested that frequent parent-to-child maltreatment occurring during childhood leads to the development of depressive symptoms later in the adolescence period. Thus, there is a dire need for interventions to raise awareness among the society on the issue of parent-to-child mistreatment to minimize later mental health consequences.

Longitudinal association between parental-to-child-Maltreatment and self-reported Generalized Anxiety Disorder symptoms in Pakistani Adolescents.

BACKGROUND: Parent-to-child maltreatment is considered one of the risk factors for Generalized Anxiety Disorder (GAD) symptoms, but this hypothesis has not been adequately tested in Pakistani settings. AIM: This study aimed to examine the association between parent-to-child maltreatment and the risk of developing GAD symptoms among adolescents. METHODS: The association of none to rare, occasionally, and frequently parent-to-child maltreatment with the incidence of GAD symptoms was investigated in a sample of 800 adolescents aged 11-17 years who were followed for two years. Parent-to-child maltreatment was assessed using ICAST-C (International child abuse screening tool). GAD Symptoms were determined by SCARED (Screen for children anxiety-related disorders). Cox Proportional Algorithm was used to estimate risk ratios. RESULTS: Among children with both uneducated parents, frequently maltreatment was associated with 7.31 (2.20-24.04) times the risk of GAD symptoms compared to none to rare maltreatment. In contrast, the risk of GAD symptoms in frequently maltreated children was 5.58 times (1.40-21.97) than negligibly maltreated children with either educated parent. CONCLUSION: The frequency of parent-to-child maltreatment is significantly associated with an increased risk of developing GAD symptoms in which parental education plays a crucial role. Parents should be imparted with the awareness of the consequences of child maltreatment. In Pakistani settings the need to have this awareness is even more necessary due to the culturally acceptable disciplinary measures used by parents.

Effect of parent-child relationship on physical aggression among adolescents: Global school-based student health survey.

Data from the Global School-based Student Health Survey (GSHS) conducted in 2009 consisting of 5192 Pakistani school-going adolescents was used to assess the association between parent-child-relationship and physical-aggression. A multilevel-weighted-cox-proportional-algorithm was performed. The overall prevalence of physical-aggression was 41% of which 27% had a poor parent-child relationship. Male adolescents who have a poor bond with their parents had two times the prevalence of physical-aggression (95% CI: 1.82, 3.00) than those female adolescents with the strong parent-child-bonding. The findings of this study implicated that the poor parental bond and the role of gender as potential factors in physically aggressive adolescents.