Cost-Effectiveness of Increased Use of Dual Antiplatelet Therapy After High-Risk Transient Ischemic Attack or Minor Stroke.

BACKGROUND: Rates of dual antiplatelet therapy (DAPT) after high-risk transient ischemic attack or minor ischemic stroke (TIAMIS) are suboptimal. We performed a cost-effectiveness analysis to characterize the parameters of a quality improvement (QI) intervention designed to increase DAPT use after TIAMIS. METHODS AND RESULTS: We constructed a decision tree model that compared current national rates of DAPT use after TIAMIS with rates after implementing a theoretical QI intervention designed to increase appropriate DAPT use. The base case assumed that a QI intervention increased the rate of DAPT use to 65% from 45%. Costs (payer and societal) and outcomes (stroke, myocardial infarction, major bleed, or death) were modeled using a lifetime horizon. An incremental cost-effectiveness ratio <$100 000 per quality-adjusted life year was considered cost-effective. Deterministic and probabilistic sensitivity analyses were performed. From the payer perspective, a QI intervention was associated with $9657 in lifetime cost savings and 0.18 more quality-adjusted life years compared with current national treatment rates. A QI intervention was cost-effective in 73% of probabilistic sensitivity analysis iterations. Results were similar from the societal perspective. The maximum acceptable, initial, 1-time payer cost of a QI intervention was $28 032 per patient. A QI intervention that increased DAPT use to at least 51% was cost-effective in the base case. CONCLUSIONS: Increasing DAPT use after TIAMIS with a QI intervention is cost-effective over a wide range of costs and proportion of patients with TIAMIS treated with DAPT after implementation of a QI intervention. Our results support the development of future interventions focused on increasing DAPT use after TIAMIS.

Challenges and health outcomes of the exposure to soybean dust in the harbor neighborhood of Karachi, Pakistan: a wake-up call.

BACKGROUND: Chemical disasters are common worldwide and result from technological failure, war, and terrorism activities. Pakistan imports huge quantities of hazardous chemicals to meet its industrial and energy needs. Hence there is a risk of chemical disaster at the ports, during transportation of such material and processing in the chemical industry. This study aimed to review the challenges and health outcomes of cases of soybean dust exposure in Kemari district (harbor neighborhood) of Karachi, Pakistan. METHODS: A cross-sectional survey was conducted with all the affected people from a chemical incident of soybean dust which was reported in the Keamari district of Karachi, Pakistan. Included patients ≥ 18 years who visited the two major tertiary care hospitals of Karachi, Pakistan after the incident between February 17 to 23, 2020. A total of 574 patients were brought to these two major tertiary care hospitals. We collected data on basic demographics, event details, and major signs and symptoms of the affected individuals. Calculated frequencies and percentages for categorical variables. Mean ± standard deviation (SD) was calculated for continuous variables. RESULTS: The mean ± (SD) age of the victims were 32 (13.5) years. Of the 574 patients, majority of the patients (n = 319, 56%) were males. In 28 cases (41%), the onset of symptoms occurred at home, in 27 cases (39%) the onset of symptoms started in the workplace and the remaining cases (n = 14, 20%) experienced the first symptoms while roaming around the roadside. The most common reported co-morbidity was a history of asthma (56%), followed by diabetes mellitus (22%). The most common clinical manifestation was shortness of breath, reported in 94% of the cases, followed by neurological symptoms such as drowsiness, unconsciousness, or seizures experienced by 10% of the victims. A total of 9 deaths (1.5%) were recorded. CONCLUSION: A multi-sectoral systematic approach is also required to address these incidents comprehensively including the trained and equipped pre-hospital system, integrated emergency medical response, and community-wide emergency response system.

Enhancing a Willingness to Respond to Disasters and Public Health Emergencies Among Health Care Workers, Using mHealth Intervention: A Multidisciplinary Approach.

Health care workers (HCWs) are increasingly faced with the continuous threat of confronting acute disasters, extreme weather-related events, and protracted public health emergencies. One of the major factors that determines emergency-department-based HCWs' willingness to respond during public health emergencies and disasters is self-efficacy. Despite increased public awareness of the threat of disasters and heightened possibility of future public health emergencies, the emphasis on preparing the health care workforce for such disasters is inadequate in low-and-middle-income countries (LMICs). Interventions for boosting self-efficacy and response willingness in public health emergencies and disasters have yet to be implemented or examined among emergency HCWs in LMICs. Mobile health (mHealth) technology seems to be a promising platform for such interventions, especially in a resource-constrained setting. This paper introduces an mHealth-focused project that demonstrates a model of multi-institutional and multidisciplinary collaboration for research and training to enhance disaster response willingness among emergency department workers in Pakistan.

Epidemiology of patients presenting to the emergency department with acute febrile illness in the summer months in Karachi, Pakistan: a cross-sectional study.

Low and middle-income countries, including Pakistan, encounter many acute, undifferentiated fevers in their emergency departments (EDs), especially in the summer. There is a need to understand the prevalence and etiologies of fever to create sustainable risk stratification systems and better identification processes for more efficient treatments. This study aims to determine the patterns, causes, and outcomes of patients presenting to the ED with a fever in the summer months in Karachi, Pakistan. Patients and methods: This was a cross-sectional surveillance study conducted in the summers of 2017 and 2018 in the EDs of four tertiary care hospitals in Karachi, Pakistan. Patients 18 years of age and older, both males and females, that presented with a fever within 48 h were enrolled in the study. The study sample was 5034. Prior comorbidities, medication history, and treatment offered for the illness and diagnosis were noted. The data were stratified by years, that is, 2017-2018. A χ 2-test and a one-way analysis of variance test were applied to check the association between fever presentation in years and covariates. Results: Of the 5034 patients, 3045 (60.5%) presented in 2017 and 1989 (39.5%) presented in 2018. Almost half of the patients who presented with fever to the ED were between 25 and 44 years of age [2383 (47.3%)]. A majority of those presenting were male [3049 (60.6%)]. Most of the patients had a fever recorded between 101 and 102°F [1038 (20.6%)]. The most common accompanying symptoms were headache [2636 (52.4%)] and nausea and vomiting [2274 (45.2%)]. The majority of the patients were diagnosed as viral fever [2390 (47.5%)]. Patients were managed with antibiotics [3342 (66.4%)] and intravenous fluids [2521 (50.1%)] and a majority of patients were discharged [4677 (93.8%)]. Conclusions: Fever is a common presentation in the ED. Understanding the frequency of the causative agent will help improve diagnosis and the judicious use of antibiotics.

Improvement in the diagnosis and practices of emergency healthcare providers for heat emergencies after HEAT (heat emergency awareness & treatment) an educational intervention: a multicenter quasi-experimental study.

BACKGROUND: The incidence of heat emergencies, including heat stroke and heat exhaustion, have increased recently due to climate change. This has affected global health and has become an issue of consideration for human health and well-being. Due to overlapping clinical manifestations with other diseases, and most of these emergencies occurring in an elderly patient, patients with a comorbid condition, or patients on poly medicine, diagnosing and managing them in the emergency department can be challenging. This study assessed whether an educational training on heat emergencies, defined as heat intervention in our study, could improve the diagnosis and management practices of ED healthcare providers in the ED setting. METHODS: A quasi-experimental study was conducted in the EDs of four hospitals in Karachi, Pakistan. Eight thousand two hundred three (8203) patients were enrolled at the ED triage based on symptoms of heat emergencies. The pre-intervention data were collected from May to July 2017, while the post-intervention data were collected from May to July 2018. The HEAT intervention, consisting of educational activities targeted toward ED healthcare providers, was implemented in April 2018. The outcomes assessed were improved recognition-measured by increased frequency of diagnosing heat emergencies and improved management-measured by increased temperature monitoring, external cooling measures, and intravenous fluids in the post-intervention period compared to pre-intervention. RESULTS: Four thousand one hundred eighty-two patients were enrolled in the pre-intervention period and 4022 in the post-intervention period, with at least one symptom falling under the criteria for diagnosis of a heat emergency. The diagnosis rate improved from 3% (n = 125/4181) to 7.5% (n = 7.5/4022) (p-value < 0.001), temperature monitoring improved from 0.9% (n = 41/4181) to 13% (n = 496/4022) (p-value < 0.001) and external cooling measure (water sponging) improved from 1.3% (n = 89/4181) to 3.4% (n = 210/4022) (p-value < 0.001) after the administration of the HEAT intervention. CONCLUSION: The HEAT intervention in our study improved ED healthcare providers' approach towards diagnosis and management practices of patients presenting with health emergencies (heat stroke or heat exhaustion) in the ED setting. The findings support the case of training ED healthcare providers to address emerging health issues due to rising temperatures/ climate change using standardized treatment algorithms.

Improvement in trauma care for road traffic injuries: an assessment of the effect on mortality in low-income and middle-income countries.

Over 90% of the annual 1·35 million worldwide deaths due to road traffic injuries (RTIs) occur in low-income and middle-income countries (LMICs). For this Series paper, our aim was two-fold. Firstly, to review evidence on effective interventions for victims of RTIs; and secondly, to estimate the potential number of lives saved by effective trauma care systems and clinical interventions in LMICs. We reviewed all the literature on trauma-related health systems and clinical interventions published during the past 20 years using MEDLINE, Embase, and Web of Science. We included studies in which mortality was the primary outcome and excluded studies in which trauma other than RTIs was the predominant injury. We used data from the Global Status Report on Road Safety 2018 and a Monte Carlo simulation technique to estimate the potential annual attributable number of lives saved in LMICs. Of the 1921 studies identified for our review of the literature, 62 (3·2%) met the inclusion criteria. Only 28 (1·5%) had data to calculate relative risk. We found that more than 200 000 lives per year can be saved globally with the implementation of a complete trauma system with 100% coverage in LMICs. Partial system improvements such as establishing trauma centres (>145 000 lives saved) and instituting and improving trauma teams (>115 000) were also effective. Emergency medical services had a wide range of effects on mortality, from increasing mortality to saving lives (>200 000 excess deaths to >200 000 lives saved per year). For clinical interventions, damage control resuscitation (>60 000 lives saved per year) and institution of interventional radiology (>50 000 lives saved per year) were the most effective interventions. On the basis of the scarce evidence available, a few key interventions have been identified to provide guidance to policy makers and clinicians on evidence-based interventions that can reduce deaths due to RTIs in LMICs. We also highlight important gaps in knowledge on the effects of other interventions.

Association of age and severe injury in young motorcycle riders: A cross-sectional study from Karachi, Pakistan.

INTRODUCTION: The burden imposed by motorcyclist deaths and injuries is high in low- and middle-income countries. Many injured motorcycle riders in these settings are underage. The aim of this study was to assess the association between age and severe injury in young motorcycle riders. METHODS: We analysed road traffic injury surveillance data from the emergency rooms of five hospitals in Karachi from 2007 to 2015. We used logistic regression to assess the association of motorcycle riders' age, categorised as underage (13-17 years), early licensing age (18-19 years) and late licensing age (20-24 years), with severe injury, defined as an Injury Severity Score (ISS) ≥ 16. RESULTS: The study sample included 45,366 motorcycle riders. There were 10115 (22.3%) motorcycle riders aged 13-17 years, 9899 (21.8%) aged 18-19 years and 25352 (55.9%) aged 20-24 years. Almost all were male (99%). Being aged 13-17 years (adjusted odds ratio 1.25; 95% CI 1.11, 1.42) and 18-19 years (adjusted odds ratio 1.26; 95% CI 1.10, 1.43) were associated with higher odds of severe injury compared with being aged 20-24 years. CONCLUSION: Motorcycle riders who presented to the hospital with injuries after road traffic crashes and were aged 13-17 years and 18-19 years had significantly higher odds of severe injury than those aged 20-24 years.

Global trends in adolescents' road traffic injury mortality, 1990-2019.

OBJECTIVE: The aim of this study was to determine the trends of road traffic injury (RTI) mortality among adolescents aged 10-14 years and 15-19 years across different country income levels with respect to the type of road users from 1990 to 2019. METHODS: We conducted an ecological study. Adolescents' mortality rates from RTIs at the level of high-income countries (HICs), upper-income to middle-income countries (UMICs), lower-income to middle-income countries and low-income countries were extracted from the Global Burden of Disease study. Time series were plotted to visualise the trends in mortality rates over the years. We also conducted Poisson regression using road traffic mortality rates as the dependent variable and year as the independent variable to model the trend of the change in the annual mean mortality rate, with incidence rate ratios (IRRs) and 95% CIs. RESULTS: There were downward mortality trends in all types of road users and income levels among adolescents from 1990 to 2019. HICs had more pronounced reductions in mortality rates than countries of any other income level. For example, the reduction in pedestrians in HICs was IRR 0.94 (95% CI 0.90 to 0.98), while that in UMICs was IRR 0.97 (95% CI 0.95 to 0.99) in adolescents aged 10-14 years. CONCLUSIONS: There are downward trends in RTI mortality in adolescents from 1990 to 2019 globally at all income levels for all types of road users. The decrease in mortality rates is small but a promising finding. However, prevention efforts should be continued as the burden is still high.

Initial estimates of COVID-19 infections in hospital workers in the United States during the first wave of pandemic.

OBJECTIVE: We estimated the number of hospital workers in the United States (US) that might be infected or die during the COVID-19 pandemic based on the data in the early phases of the pandemic. METHODS: We calculated infection and death rates amongst US hospital workers per 100 COVID-19-related deaths in the general population based on observed numbers in Hubei, China, and Italy. We used Monte Carlo simulations to compute point estimates with 95% confidence intervals for hospital worker (HW) infections in the US based on each of these two scenarios. We also assessed the impact of restricting hospital workers aged ≥ 60 years from performing patient care activities on these estimates. RESULTS: We estimated that about 53,000 hospital workers in the US could get infected, and 1579 could die due to COVID19. The availability of PPE for high-risk workers alone could reduce this number to about 28,000 infections and 850 deaths. Restricting high-risk hospital workers such as those aged ≥ 60 years from direct patient care could reduce counts to 2,000 healthcare worker infections and 60 deaths. CONCLUSION: We estimate that US hospital workers will bear a significant burden of illness due to COVID-19. Making PPE available to all hospital workers and reducing the exposure of hospital workers above the age of 60 could mitigate these risks.

Workplace Violence and Self-reported Psychological Health: Coping with Post-traumatic Stress, Mental Distress, and Burnout among Physicians Working in the Emergency Departments Compared to Other Specialties in Pakistan.

BACKGROUND: Little is known about the mental health impact of workplace violence (WPV) among emergency physicians (EPs) working in emergency departments (EDs) in Pakistan and whether this impact varies across specialties. OBJECTIVES: Our aim was to measure the prevalence of WPV among EPs in 4 of the largest hospitals in Karachi, Pakistan; to measure the association between the experience of WPV and self-report of post-traumatic stress disorder (PTSD), depression, anxiety, and burnout; to compare the same factors across medical specialties; and to explore the coping strategies used by physicians in dealing with job-related stressors. METHODS: A cross-sectional survey was conducted among 179 physicians from 5 specialties (response rate, 92.2%) using standard questionnaires for WPV, PTSD, burnout, current mental distress, and methods of coping. RESULTS: One in 6 physicians reported experiencing a physical attack and 3 in 5 verbal abuse on the job in the previous 12 months. Pathologists were less likely to report any form of WPV compared to all other specialties. There was, however, no difference in experience of WPV between EPs and internists, surgeons, or pediatricians. One in 6 physicians screened positive for PTSD, and 2 in 5 for current anxiety and depression. There was significant comorbidity of mental distress with PTSD. Those who reported experiencing physical attack were 6.7 times more likely to report PTSD symptoms. We also found high rates of burnout (42.4% emotional exhaustion; 72.9% depersonalization) among physicians. CONCLUSION: Experience of WPV was not uniform across specialties but was generally high among Pakistani physicians. Prevention of WPV should be a high priority for health care policy makers.

The Pakistan National Emergency Department Surveillance Study (Pak-NEDS): Introducing a pilot surveillance.

BACKGROUND: Evidence-based decision making is essential for appropriate prioritization and service provision by healthcare systems. Despite higher demands, data needs for this practice are not met in many cases in low- and middle-income countries because of underdeveloped sources, among other reasons. Emergency departments (EDs) provide an important channel for such information because of their strategic position within healthcare systems. This paper describes the design and pilot test of a national ED based surveillance system suitable for the Pakistani context. METHODS: The Pakistan National Emergency Department Surveillance Study (Pak-NEDS) was pilot tested in the emergency departments of seven major tertiary healthcare centres across the country. The Aga Khan University, Karachi, served as the coordinating centre. Key stakeholders and experts from all study institutes were involved in outlining data needs, development of the study questionnaire, and identification of appropriate surveillance mechanisms such as methods for data collection, monitoring, and quality assurance procedures. The surveillance system was operational between November 2010 and March 2011. Active surveillance was done 24 hours a day by data collectors hired and trained specifically for the study. All patients presenting to the study EDs were eligible participants. Over 270,000 cases were registered in the surveillance system over a period of four months. Coverage levels in the final month ranged from 91-100% and were highest in centres with the least volume of patients. Overall the coverage for the four months was 79% and crude operational costs were less than $0.20 per patient. CONCLUSIONS: Pak-NEDS is the first multi-centre ED based surveillance system successfully piloted in a sample of major EDs having some of the highest patient volumes in Pakistan. Despite the challenges identified, our pilot shows that the system is flexible and scalable, and could potentially be adapted for many other low- and middle-income settings.

Characteristics of chest pain and its acute management in a low-middle income country: analysis of emergency department surveillance data from Pakistan.

BACKGROUND: Chest pain is one of the most frequent causes of emergency department (ED) visits in high-income countries. Little is known about chest pain patients presenting to EDs of low- and middle-income countries (LMICs). The objective of this study was to describe the characteristics of chest pain patients presenting to emergency departments (EDs) of Pakistan and to determine the utilization of ED resources in the management of chest pain patients and their outcomes. METHODS: This study used pilot active surveillance data from seven major EDs in Pakistan. Data were collected on all patients presenting to the EDs of the participating sites to seek emergency care for chest pain. RESULTS: A total of 20,435 patients were admitted to the EDs with chest pain. The majority were males (M 60%, F 40%) and the mean age was 42 years (SD+/- 14). The great majority (97%, n = 19,164) of patients were admitted to the EDs of public hospitals compared to private hospitals and only 3% arrived by ambulance. Electrocardiograms (ECGs) were used in more than half of all chest pain patients (55%, n = 10,890) while cardiac enzymes were performed in less than 5% of cases. Chest X-rays were the most frequently performed radiological procedure (21%, n = 4,135); more than half of the admitted chest pain patients were discharged from the EDs and less than 1% died in the ED. CONCLUSION: Chest pain is a common presenting complaint in EDs in Pakistan. The majority received an ECG and the use of diagnostic testing, such as cardiac enzymes, is quite uncommon.

Bomb blast injuries: an exploration of patient characteristics and outcome using Pakistan National Emergency Departments Surveillance (Pak-NEDS) data.

BACKGROUND: Bomb blast injuries result in premature deaths and burdening of healthcare systems. The objective of this study was to explore the characteristics and outcome of patients presenting to the emergency departments in Pakistan with bomb blast injuries. METHODS: Active surveillance was conducted in seven major emergency departments of Pakistan from November 2010-March 2011. All the sites are tertiary care urban centers. All the patients who presented to the hospital's emergency department (ED) following a bomb blast injury as per self-report or the ambulance personnel were included in the study. Frequency of demographics, injury pattern, and outcomes were calculated. RESULTS: A total of 103 patients with bomb blast injuries presented to the selected emergency departments. The median age of patients was 30 years. Around three-fourth of the patients were males (n = 74, 74.7%). Most of the bomb blast patients were seen in Peshawar (n = 41, 39.8%) and Karachi city (n = 31, 30.1%) and the most common mode of arrival was non-ambulance transport (n = 71, 76.3%). Upper limb injuries (n = 12, 40%) were common in the under 18 age group and lower limb injuries (n = 31, 39.2%) in the 18 years and above group. There were a total of 8 (7.7%) deaths reported out of these 103 patients. CONCLUSION: Bomb blast injuries in Pakistan generally affect young males. Non-ambulance transport is the most common way to access emergency departments (ED). Overall ED mortality is high and capturing data during a disaster in an emergency department is challenging.

Fall-related injuries in a low-income setting: Results from a pilot injury surveillance system in Rawalpindi, Pakistan.

This study assessed the characteristics and emergency care outcomes of fall-related injuries in Pakistan. This study included all fall-related injury cases presenting to emergency departments (EDs) of the three teaching hospitals in Rawalpindi city from July 2007 to June 2008. Out of 62,530 injury cases, 43.4% (N=27,109) were due to falls. Children (0-15 years) accounted for about two out of five of all fall-related injuries. Compared with women aged 16-45 years, more men of the same age group presented with fall-related injuries (50% vs. 42%); however, compared with men aged 45 years or more, about twice as many women of the same age group presented with fall-related injuries (16% vs. 9%, P<0.001). For each reported death due to falls (n=57), 43 more were admitted (n=2443, 9%), and another 423 were discharged from the EDs (n=24,142, 91%). Factors associated with death or inpatient admission were: aged 0-15 years (adjusted odds ratio [aOR]=1.35), aged 45 years or more (aOR=1.94), male gender (aOR=1.15), falls occurring at home (aOR=3.38), in markets (aOR=1.43), on work sites (aOR=4.80), and during playing activities (aOR=1.68). This ED-based surveillance study indicated that fall prevention interventions in Pakistan should target children, older adult women, homes, and work sites.

Emergency and trauma care in Pakistan: a cross-sectional study of healthcare levels.

BACKGROUND: The importance of emergency medical care for the successful functioning of health systems has been increasingly recognised. This study aimed to evaluate emergency and trauma care facilities in four districts of the province of Sindh, Pakistan. METHOD: We conducted a cross-sectional health facility survey in four districts of the province of Sindh in Pakistan using a modified version of WHO's Guidelines for essential trauma care. 93 public health facilities (81 primary care facilities, nine secondary care hospitals, three tertiary hospitals) and 12 large private hospitals were surveyed. Interviews of healthcare providers and visual inspections of essential equipment and supplies as per guidelines were performed. A total of 141 physicians providing various levels of care were tested for their knowledge of basic emergency care using a validated instrument. RESULTS: Only 4 (44%) public secondary, 3 (25%) private secondary hospitals and all three tertiary care hospitals had designated emergency rooms. The majority of primary care health facilities had less than 60% of all essential equipments overall. Most of the secondary level public hospitals (78%) had less than 60% of essential equipments, and none had 80% or more. A fourth of private secondary care facilities and all tertiary care hospitals (n=3; 100%) had 80% or more essential equipments. The average percentage score on the physician knowledge test was 30%. None of the physicians scored above 60% correct responses. CONCLUSIONS: The study findings demonstrated a gap in both essential equipment and provider knowledge necessary for effective emergency and trauma care.

Clothing-related motorcycle injuries in Pakistan: findings from a surveillance study.

This study aims to assess the burden and patterns of clothing-related motorcycle injuries in Karachi, Pakistan. Data were extracted from an ongoing traffic injury surveillance system. In three years (2007-2009), out of 99155 road traffic injury cases there were 986 (0.9%) cases of clothing-related motorcycle injuries. Most cases were females (73.9%) and pillion riders (80.6%). The crashes involving clothing-related injuries were mostly single vehicle (98.5%), and largely resulted in injuries to the external body (60.3%), limbs (51.0%), head (41.5%) and face (35.9%). One-third of injuries were either moderate (26.7%) or severe (10.2%) while 10 (1.01%) deaths were reported. Female gender (11.4%), age ≥ 45 years (19.4%), pillion riding (11.3%) and crashes occurring at intersections (12.3%) were more likely to result in moderate or severe injury as compared to other users (P < 0.001). Injuries due to entanglement of loose fitting clothing in motorcycles are not uncommon in Karachi. Awareness campaigns for prevention of such injuries may involve promotion of appropriate dressing for motorcycle riding including close wrapping of clothes and encouraging installations of covers on the rear wheels and drive chains.

Health care personnel and workplace violence in the emergency departments of a volatile metropolis: results from Karachi, Pakistan.

BACKGROUND: Workplace violence (WPV) is an important challenge faced by health care personnel in the emergency department (ED). STUDY OBJECTIVES: To determine the prevalence and nature of WPV reported by physicians and nurses working in the EDs of four of the largest tertiary care hospitals in Karachi, Pakistan and to understand the mental health impact of experiencing WPV. METHODS: This cross-sectional survey was conducted between September and November 2008 using a widely used questionnaire developed by the World Health Organization. Overall, 266 (86% response rate) questionnaires were included in this study. RESULTS: A total of 44 (16.5%) physicians and nurses said they had been physically attacked, and 193 (72.5%) said that they had experienced verbal abuse in the last 12 months. Among those who reported physical attack, 29.6% reported that the last incident involved a weapon, and in 64% of cases the attacker was a patient's relative. Eighty-six percent thought that the last attack could have been prevented, and 64% said that no action was taken against the attacker. After adjusting for covariates, physicians were less likely than nurses to report physical attack (odds ratio [OR] 0.46; 95% confidence interval [CI] 0.2-1.0), and personnel with greater work experience (OR 4.8; 95% CI 2.0-11.7) and those who said that there were procedures to report WPV in their workplace (OR 3.2; 95% CI 1.6-6.5) were more likely to report verbal abuse. WPV was associated with mental health effects in the form of bothersome memories, super-alertness, and feelings of avoidance and futility. CONCLUSION: WPV is an important challenge in the EDs of large hospitals in Karachi. A majority of respondents feel that WPV is preventable, but only a minority of attackers face consequences.

A child an hour: burden of injury deaths among children under 5 in Pakistan.

BACKGROUND: Globally, more than 875 000 children under the age of 18 die due to injury every year. The rate of child injury death is 3.4 times higher in low-income and middle-income countries than in high-income countries. OBJECTIVES: To study injury mortality burden among children under the age of 5 in Pakistan. METHODS: Demographic and Health Survey in Pakistan was conducted from September 2006 until February 2007. It included 95 000 households, out of which 3232 households had death of a child under the age of 5 from January 2005 onwards. The Child Verbal Autopsy Questionnaire (CVAQ) was administered to these households with a response rate of 96%. RESULTS: For age group 0-5 years, injury was the sixth leading cause of death and was responsible for 2.5% of all deaths (n=73). For age group 1-5 years, injury was found to be the third leading cause of death (11%) after diarrhoea (18%) and pneumonia (17%). The overall under fives mortality rate due to injury was estimated at 39.5 per 100 000 per year in Pakistan. Drowning (22%), road traffic injuries (12%), burns (11%) and falls (10%) were the most common types of injury. The mortality rate was twice as high in rural areas (32 per 100 000; 95% CI 18 to 45), compared to the urban areas (15 per 100 000; 95% CI 0.3 to 29). CONCLUSIONS: Injury is the third leading cause of deaths among children 1-5 in Pakistan. The burden is twice as high in rural areas.

Variations in sub-national road traffic fatality trends in a low-income country.

BACKGROUND: In most low- and middle-income countries (LMICs), road traffic fatality (RTF) trends are presented in aggregated form at the national level. This practice omits important information regarding RTF risk at sub-national levels. OBJECTIVE: This ecological study assesses the extent of RTF variations at different sub-national levels in Pakistan, a low-income country. MATERIALS AND METHODS: Based on official statistics, significant variations in three RTF indicators i.e. per population, per registered vehicles, and per crash were compared by regression analyses at two sub-national levels i.e. provincially (2000-2009) and district-wise (2004). RESULTS: The national RTF counts are based on data from four provinces. From 2000 to 2009, RTF per population and per registered vehicles decreased in all provinces except Balochistan. RTF per crash in Punjab decreased from 0.61 to 0.56 (beta coefficient (ß) year = -0.0082, P = <0.001), whereas in Balochistan it increased from 0.40 to 0.58 (ß year = 0.0708, P = <0.001) over the same period. District-level comparisons were possible only in Punjab where RTF per crash varied from 0.25 to 2.15 and correlated (ß = 0.50, P = 0.003) with RTF per population. CONCLUSIONS: Sub-national RTF surveillance is necessary in LMICs like Pakistan in order to prioritize available resources on high-risk jurisdictions such as the Balochistan province and districts of Punjab where high RTF per population and per crash exist.