Air pollution we breathe: Assessing the air quality and human health impact in a megacity of Southeast Asia.

With 24 million inhabitants and 6.6 million vehicles on the roads, Karachi, Pakistan ranks among the world's most polluted cities due to high levels of fine particulate matter (PM2.5). This study aims to investigate PM2.5 mass, seasonal and temporal variability, chemical characterization, source apportionment, and health risk assessment at two urban sites in Karachi. Samples were analyzed using ion chromatography and dual-wavelength optical transmissometer for various inorganic components (anions, cations, and trace elements) and black carbon (BC). Several PM2.5 pollution episodes were frequently observed, with annual mean concentrations at Kemari (140 ± 179 µg/m3) and Malir (95 ± 40.9 µg/m3) being significantly above the World Health Organization's guidelines of 5 µg/m3. Chemical composition at both sites exhibited seasonal variability, with higher pollution levels in winter and fall and lower concentrations in summer. The annual average BC concentrations were 4.86 ± 5.29 µg/m3 and 4.52 ± 3.68 µg/m3, respectively. A Positive Matrix Factorization (PMF) analysis identified 5 factors, crustal, sea salt, vehicular exhaust, fossil-fuel combustion, and industrial emission. The health risk assessment indicated a higher number of deaths in colder seasons (fall and winter) at the Kemari (328,794 and 287,814) and Malir (228,406 and 165,737) sites and potential non-carcinogenic and carcinogenic risks to children from metals. The non-carcinogenic risk of PM2.5 bound Pb, Fe, Zn, Mn, Cr, Cu and Ni via inhalation exposure were within the acceptable level (<1) for adults. However, potential non-carcinogenic and carcinogenic health risk posed by Pb and Cr through inhalation were observed for children. The findings exhibit critical levels of air pollution that exceed the safe limits in Karachi, posing significant health risks to children and sensitive groups. Our study underscores the urgent need for effective emission control strategies and policy interventions to mitigate these air pollution risks.

Risk Factors Of Idiopathic Pulmonary Fibrosis In Pakistani Population: A Matched Case-Control Studyy.

OBJECTIVE: To evaluate the factors associated with idiopathic pulmonary fibrosisrisk. Methods: The case-controlstudywas conductedfromJanuary 5, 2017,toSeptember 4, 2018, attheprivate-sectorAga Khan University Hospital and the public-sector Jinnah Postgraduate Medical Centre, two large tertiary care centres in Karachi, andcomprisedadultpatientsof eithergenderwithdiagnosedidiopathicpulmonary fibrosis, asdefinedby the IndianChest Registry. Subjects without idiopathic pulmonary fibrosis but registered with the department of pulmonology of the two hospitalswere enrolledas controls.Datawas collectedusinga structuredquestionnaire, andanthropometricmeasurements were noted for each subject. Gastroesophageal reflux disease was assessed using GerdQ. This wasfollowed by serological evaluations and spirometry. Data was analysed using SPSS 21. RESULTS: Of the 459 subjects, 154(33.6%)were cases and305(66.4%)were controls.Amongthe cases, 81(52.6%)were females and 73(47.4%) were males with mean age 66.1±10.9 years. Among the controls, 162(53.1%) were females and 143(46.9%) were males with mean age 64.6±11.1 years(p>0.05.)The most common ethnicity wasUrdu-speaking; 89(58%) among the cases and 150(49%) among the controls (p<0.05). Ethnicity, number of persons in the household per room, and type of house were significantly associated with the risk of developing idiopathic pulmonary fibrosis(p<0.05). CONCLUSIONS: Ethnicity,type of house and the number of personsin a household perroom were found to be the significant risk factorsfor idiopathic pulmonary fibrosisIPF.

Pesticides Use and Impaired Lung Function Among Male Agricultural Farmers in Rural Sindh, Pakistan.

Use of pesticides implicated in decrement in lung function, manifested as restrictive or obstructive dysfunction or both. Using comparative cross-sectional study design, authors conducted the study to determine an association of pesticide use with impairment in lung function (restrictive/obstructive pattern of lung function) among agricultural farmers. The data were collected using modified American Thoracic Society Division of Lung Disease (ATS-DLD-78A) questionnaire and spirometer measurements. Using multinomial logistic regression, the risk of both restrictive and obstructive lung dysfunction was found to be almost twice among pesticides users with each increasing year of exposure to pesticides (1.92 and 1.95, respectively) after adjusting for other covariates. There is a need for reliable monitoring and reporting procedures along with appropriate environmental policies and regulations for handling of pesticides. Interventional studies are needed where farmers could be trained on the proper use of personal protective equipment (PPE) to limit the exposure to pesticides.

Levels and Determinants of Fine Particulate Matter and Carbon Monoxide in Kitchens Using Biomass and Non-Biomass Fuel for Cooking.

To assist interpretation of a study in rural Pakistan on the use of biomass for cooking and the risk of coronary heart disease, we continuously monitored airborne concentrations of fine particulate matter (PM2.5) and carbon monoxide (CO) for up to 48 h in the kitchens of households randomly selected from the parent study. Satisfactory data on PM2.5 and CO respectively were obtained for 16 and 17 households using biomass, and 19 and 17 using natural gas. Linear regression analysis indicated that in comparison with kitchens using natural gas, daily average PM2.5 concentrations were substantially higher in kitchens that used biomass in either a chimney stove (mean difference 611, 95% CI: 359, 863 µg/m3) or traditional three-stone stove (mean difference 389, 95% CI: 231, 548 µg/m3). Daily average concentrations of CO were significantly increased when biomass was used in a traditional stove (mean difference from natural gas 3.7, 95% CI: 0.8, 6.7 ppm), but not when it was used in a chimney stove (mean difference -0.8, 95% CI: -4.8, 3.2 ppm). Any impact of smoking by household members was smaller than that of using biomass, and not clearly discernible. In the population studied, cooking with biomass as compared with natural gas should serve as a good proxy for higher personal exposure to PM2.5.

Prevalence of dyslipidaemia and factors associated with dyslipidaemia among South Asian adults: The Center for Cardiometabolic Risk Reduction in South Asia Cohort Study.

Background: . The pattern of dyslipidaemia in South Asia is believed to be different from that in other parts of the world. Nonetheless, limited population-based data are available from the region. We assessed the prevalence, types of, and factors associated with dyslipidaemia among South Asians. Methods: . We used baseline data (2010-11) of the Center for Cardiometabolic Risk Reduction in South Asia (CARRS) cohort of 16 287 representative urban adults aged ≥20 years from Chennai and Delhi in India and Karachi in Pakistan. Total cholesterol (TC) was measured by the enzymatic-cholesterol oxidase peroxidase method, high-density lipoprotein-cholesterol (HDL-C) by the direct homogeneous method and triglycerides (TG) by enzymatic methods. Low-density lipoprotein-cholesterol (LDL-C) was calculated using Friedewald's formula. We defined high TC ≥200 mg/dl or on medication; hypertriglyceridaemia ≥150 mg/dl, high LDL-C ≥130 mg/dl or on medication and low HDL-C <40 mg/dl for males, <50 mg/dl for females. Multivariate logistic regression was carried out to assess the factors associated with dyslipidaemia. Results: . The prevalence of any dyslipidaemia was 76.4%, 64.3% and 68.5% among males and 89.3%, 74.4% and 79.4% among females in Chennai, Delhi and Karachi, respectively. The prevalence of elevated TC was higher in Chennai compared to Delhi and Karachi (31.3%, 28.8% and 22.9%, respectively); males had a significantly greater prevalence of high TG, whereas females had a greater prevalence of low HDL-C in all the three cities. The most common lipid abnormality in all three cities was low HDL-C, which was seen in 67.1%, 49.7% and 61.3% in Chennai, Delhi and Karachi, respectively. Only 2% of the participants were on lipid-lowering drugs. Adjusted for other factors, dyslipidaemia was positively associated with age, female sex, obesity, hypertension, diabetes and tobacco use. Discussion: . Overall, almost seven in ten adults in urban South Asia have some form of dyslipidaemia, and the predominant subtypes were low HDL-C and high TG.

Epidemiology of asthma and associated factors in an urban Pakistani population: adult asthma study-Karachi.

BACKGROUND: This study was conducted in order to determine the prevalence of asthma and associated risk factors in the adult population of Karachi, Pakistan. METHODS: This multi-stage, cross-sectional survey was conducted from May 2014-August 2015; comprising 1629 adults in 75 randomly selected clusters in Karachi, Pakistan. Definitions included: 'self-reported asthma', 'reversibility in FEV1' and 'respiratory symptoms and reversibility in FEV1'. RESULTS: Prevalence of asthma was 1.8% (self-reported) (95% CI: 1.0-2.6), 11.3% (reversibility in FEV1) (95% CI: 9.4-13.3) and 6.6% (symptoms and reversibility in FEV1) (95% CI: 5.1-8.1). Asthmatics were more likely to belong to the age group ≥38 years according to 'reversibility in FEV1' and 'respiratory symptoms and reversibility in FEV1' (AOR: 1.9, 95% CI: 1.2-3.3) and (AOR: 2.1, 95% CI: 1.1-4.2), respectively. Asthmatics were more likely to report history of allergies (AOR: 1.9, 95% CI: 1.2-2.9) and (AOR: 2.8, 95% CI: 1.7-4.8); and were exposed to environmental tobacco smoke (AOR: 1.6, 95% CI: 1.1-2.5) and (AOR: 1.9, 95% CI: 1.1-3.3) according to 'reversibility in FEV1' and 'respiratory symptoms and reversibility in FEV1', respectively. Asthmatics were more likely to report pack years of smoking ≥5 (AOR: 2.3, 95% CI: 1.1-4.7) according to 'respiratory symptoms and reversibility in FEV1'. CONCLUSION: This study reports a high prevalence of asthma among Pakistani adults and calls for developing appropriate public health policies for prevention and control of asthma in the country. Further studies should be conducted to determine the national prevalence as well as follow-up studies to identify preventable causes for adult asthma.

Chronic Bronchitis and Chronic Obstructive Pulmonary Disease (COPD) Among Textile Workers in Karachi, Pakistan.

OBJECTIVE: To determine the frequency and predictors of chronic bronchitis and COPD among textile workers in Karachi, Pakistan. STUDY DESIGN: Cross-sectional survey. PLACE AND DURATION OF STUDY: Karachi, Pakistan, from October to December 2009. METHODOLOGY: Male textile workers from 15 mills of Karachi were inducted. Data was collected using American Thoracic Society respiratory questionnaire (ATS-DLD-78-a) and spirometry. RESULTS: Out of 372 participants, 29 (7.8%) workers had chronic bronchitis (4, 9.1% aged ≥40 years) and 25 (6.7%) had COPD (12, 27.2% aged ≥40 years). Workers with chronic bronchitis had significantly decreased lung function compared to the healthy workers. Those reporting severe self-perceived dust exposure at work, ≥ 10 pack years of smoking, uneducated, longer duration of work (≥11 years), and ever smokers were more likely to have chronic bronchitis or COPD. In the multivariate analyses, severe self-perceived dust exposure at work (AOR = 7.4; 95% CI: 1.9, 28.0), family history of respiratory illness/symptoms (AOR = 4.8; 95% CI: 1.1, 20.9) and lack of education (AOR = 4.2; 95% CI: 1.1, 16.9) were significant predictors of chronic bronchitis. Duration of work ≥11 years (AOR = 5.5; 95% CI: 1.5, 19.7) and pack years of smoking ≥10 years (AOR = 3.5; 95% CI: 1.1, 11.7) were strong predictors for COPD. CONCLUSION: There is a high frequency of chronic bronchitis and COPD among textile workers. Multiple important predictors for prevention are identified.

Coronary heart disease and household air pollution from use of solid fuel: a systematic review.

BACKGROUND: Evidence is emerging that indoor air pollution (IAP) from use of solid fuels for cooking and heating may be an important risk factor for coronary heart disease (CHD). SOURCES OF DATA: We searched the Ovid Medline, Embase Classic, Embase and Web of Science databases from inception through to June 12, 2015, to identify reports of primary epidemiological research concerning the relationship of CHD to IAP from solid fuel, the likely magnitude of any increase in risk, and potential pathogenic mechanisms. AREAS OF AGREEMENT: The current balance of epidemiological evidence points to an increased risk of CHD from IAP as a consequence of using solid, and especially biomass, fuels for cooking and heating. Relative risks from long-term exposure could be 2- to 4-fold. AREAS OF CONTROVERSY: The evidence base is still limited, and although an association of CHD with such IAP from solid fuel is consistent with the known hazards from smoking, environmental tobacco smoke and ambient air pollution, and supported by evidence of effects on inflammatory processes, atherosclerosis and blood pressure, it requires confirmation by larger and more robust studies. GROWING POINTS: The completion of two relatively small case-control studies on CHD and IAP from use of biomass fuel demonstrates the feasibility of such research, and is an encouragement to further, larger studies using similar methods. AREAS TIMELY FOR DEVELOPING RESEARCH: The need for such research is particularly pressing because the incidence of CHD in developing countries is rising, and IAP may interact synergistically with the risk factors that are driving that increase. Furthermore, relatively cheap methods are available to reduce IAP from use of solid fuels, and there are indications from intervention studies that these may impact beneficially on CHD as well as other diseases caused by such pollution.

Is the "South Asian Phenotype" Unique to South Asians?: Comparing Cardiometabolic Risk Factors in the CARRS and NHANES Studies.

BACKGROUND: In the context of rising obesity in South Asia, it is unclear whether the "South Asian phenotype"(described as high glucose, low high-density lipoprotein cholesterol, and high triglycerides at normal ranges of body weight) continues to be disproportionately exhibited by contemporary South Asians relative to other race/ethnic groups. OBJECTIVES: We assessed the distinctiveness of the South Asian cardiometabolic profile by comparing the prevalence of combined high glucose, high triglycerides, and low high-density lipoprotein cholesterol (combined dysglycemia and dyslipidemia) in resident South Asians with 4 race/ethnic groups in the United States (Asians, black persons, Hispanics, and white persons) overall and by body mass index (BMI) category. METHODS: South Asian data were from the 2010 to 2011 Center for Cardiometabolic Risk Reduction in South Asia Study, representative of Chennai and New Delhi, India and Karachi, Pakistan. U.S. data were from the 2011 to 2012 National Health and Nutrition Examination Survey, representative of the U.S. POPULATION: Combined dysglycemia and dyslipidemia was defined as fasting blood glucose ≥126 mg/dl and triglyceride/high-density lipoprotein cholesterol ratio >4. Logistic regression was used to estimate the relative odds and 95% confidence intervals of combined dysglycemia and dyslipidemia associated with each race/ethnic group (referent, U.S. white persons). Models were estimated among adults aged 20 to 79 years by sex and BMI category and accounted for age, education, and tobacco use. Data from 8,448 resident South Asians, 274 U.S. Asians, 404 U.S. black persons, 308 U.S. Hispanics, and 703 U.S. white persons without previously known diabetes were analyzed. RESULTS: In the normal body weight range of BMI 18.5 to 24.9 kg/m(2), the prevalence of combined dysglycemia and dyslipidemia among men and women, respectively, was 33% and 11% in resident South Asians, 15% and 1% in U.S. Asians, 5% and 2% in U.S. black persons, 11% and 2% in U.S. Hispanics, and 8% and 2% in U.S. white persons. Compared with U.S. whites persons, South Asians were more likely to present with combined dysglycemia and dyslipidemia at all categories of BMI for men and at BMI 18.5 to 29.9 for women in adjusted models. The most pronounced difference between South Asians and U.S. white persons was observed at normal weight (adjusted odds ratio: 4.98; 95% confidence interval: 2.46 to 10.07 for men) (adjusted odds ratio: 9.09; 95% confidence interval: 2.48 to 33.29 for women). CONCLUSIONS: Between 8% and 15% of U.S. men and 1% and 2% of U.S. women of diverse race/ethnic backgrounds exhibited dysglycemia and dyslipidemia at levels of body weight considered "healthy," consistent with the cardiometabolic profile described as the "South Asian Phenotype." Urban South Asians, however, were 5 to 9 times more likely to exhibit dysglycemia and dyslipidemia in the "healthy" BMI range compared with any other U.S. race/ethnic group.

Socioeconomic status and cardiovascular risk in urban South Asia: The CARRS Study.

BACKGROUND: Although South Asians experience cardiovascular disease (CVD) and risk factors at an early age, the distribution of CVD risks across the socioeconomic spectrum remains unclear. METHODS: We analysed the 2011 Centre for Cardiometabolic Risk Reduction in South Asia survey data including 16,288 non-pregnant adults (≥20 years) that are representative of Chennai and Delhi, India, and Karachi, Pakistan. Socioeconomic status (SES) was defined by highest education (primary schooling, high/secondary schooling, college graduate or greater); wealth tertiles (low, middle, high household assets) and occupation (not working outside home, semi/unskilled, skilled, white-collar work). We estimated age and sex-standardized prevalence of behavioural (daily fruit/vegetables; tobacco use), weight (body mass index; waist-to-height ratio) and metabolic risk factors (diabetes, hypertension, hypercholesterolaemia; hypo-HDL; and hypertriglyceridaemia) by each SES category. RESULTS: Across cities, 61.2% and 16.1% completed secondary and college educations, respectively; 52.8% reported not working, 22.9% were unskilled; 21.3% were skilled and 3.1% were white-collar workers. For behavioural risk factors, low fruit/vegetable intake, smoked and smokeless tobacco use were more prevalent in lowest education, wealthy and occupation (for men only) groups compared to higher SES counterparts, while weight-related risks (body mass index 25.0-29.9 and ≥30 kg/m(2); waist-to-height ratio ≥0.5) were more common in higher educated and wealthy groups, and technical/professional men. For metabolic risks, a higher prevalence of diabetes, hypertension and dyslipidaemias was observed in more educated and affluent groups, with unclear patterns across occupation groups. CONCLUSIONS: SES-CVD patterns are heterogeneous, suggesting customized interventions for different SES groups may be warranted. Different behavioural, weight, and metabolic risk factor prevalence patterns across SES indicators may signal on-going epidemiological transition in South Asia.

A cross-sectional study of the prevalence and correlates of tobacco use in Chennai, Delhi, and Karachi: data from the CARRS study.

BACKGROUND: Tobacco burdens in India and Pakistan require continued efforts to quantify tobacco use and its impacts. We examined the prevalence and sociodemographic and health-related correlates of tobacco use in Delhi, Chennai (India), and Karachi (Pakistan). METHODS: Analysis of representative surveys of 11,260 participants (selected through multistage cluster random sampling; stratified by gender and age) in 2011 measured socio-demographics, tobacco use history, comorbid health conditions, and salivary cotinine. We used bivariate and multivariate regression analyses to examine factors associated with tobacco use. RESULTS: Overall, 51.8 % were females, and 61.6 % were below the age of 45 years. Lifetime (ever) tobacco use prevalence (standardized for world population) was 45.0 %, 41.3 %, and 42.5 % among males, and 7.6 %, 8.5 %, and 19.7 % among females in Chennai, Delhi, and Karachi, respectively. Past 6 month tobacco use prevalence (standardized for world population) was 38.6 %, 36.1 %, and 39.1 % among males, and 7.3 %, 7.1 %, and 18.6 % among females in Chennai, Delhi, and Karachi, respectively. In multivariable regression analyses, residing in Delhi or Karachi versus Chennai; older age; lower education; earning less income; lower BMI; were each associated with tobacco use in both sexes. In addition, semi-skilled occupation versus not working and alcohol use were associated with tobacco use in males, and having newly diagnosed dyslipidemia was associated with lower odds of tobacco use among females. Mean salivary cotinine levels were higher among tobacco users versus nonusers (235.4; CI: 187.0-283.8 vs. 29.7; CI: 4.2, 55.2, respectively). CONCLUSION: High prevalence of tobacco use in the South Asian region, particularly among men, highlights the urgency to address this serious public health problem. Our analyses suggest targeted prevention and cessation interventions focused on lower socioeconomic groups may be particularly important.

Burden of asthma among children in a developing megacity: childhood asthma study, Pakistan.

OBJECTIVES: Global burden of childhood asthma has increased in the past few decades, particularly in low-income countries. In Pakistan, there is a lack of community-based epidemiological studies estimating the burden of asthma among children. This study determined the prevalence and predictors of asthma among children 3-17 years of age in Karachi, Pakistan. METHODS: A two-stage community-based representative cross-sectional survey was conducted in Karachi from March 2012 to April 2013 comprising 1046 children aged 3-17 years. Of 7500 clusters, 80 were randomly selected, and of these, 15 children per cluster were enrolled randomly. A translated and pre-tested version of International Study of Asthma and Allergies in Children questionnaire was administered. RESULTS: The overall prevalence of asthma among study participants was 10.2% (95% CI: 8.4-12.0). Asthma was more likely to occur among boys (adj. OR: 2.5, 95% CI: 1.6-4.0), children in the younger age group (3-7 years) (adj. OR: 2.9, 95% CI: 1.7-4.8), those living in households with ill-ventilated kitchens (adj. OR: 1.8, 95% CI: 1.1-3.1), having family history of asthma (adj. OR: 2.3, 95% CI: 1.3-3.9) and those of the Sindhi ethnicity (adj. OR: 2.2, 95% CI: 1.1-4.4). CONCLUSION: This study is the first robust evidence regarding asthma among children in Pakistan, reporting a high burden in this group. Family history, male gender, Sindhi ethnicity and ill-ventilated kitchen were identified as important predictors of asthma. Targeted preventive measures and intervention studies are required to better understand and reduce the burden of asthma among children in Pakistan.

Correlation of arsenic exposure through drinking groundwater and urinary arsenic excretion among adults in Pakistan.

Long-term exposure to arsenic has been associated with manifestation of skin lesions (melanosis/keratosis) and increased risk of internal cancers (lung/bladder). The objective of the study described here was to determine the relationship between exposure of arsenic through drinking groundwater and urinary arsenic excretion among adults > or =15 years of age living in Khairpur district, Pakistan. Total arsenic was determined in drinking groundwater and in spot urine samples of 465 randomly selected individuals through hydride generation-atomic absorption spectrometry. Spearman's rank correlation coefficient was calculated between arsenic in drinking groundwater and arsenic excreted in urine. The median arsenic concentration in drinking water was 2.1 microg/L (range: 0.1-350), and in urine was 28.5 microg/L (range: 0.1-848). Positive correlation was found between total arsenic in drinking water and in urine (r = .52, p < .01). Urinary arsenic may be used as a biomarker of arsenic exposure through drinking water.

Self-perceived health among school going adolescents in Pakistan: influence of individual, parental and life style factors?

BACKGROUND: Adolescents are at substantial risk of acquiring behaviors which might influence their health status. This study was aimed to assess the proportion of school going adolescents (both males and females) with poor self-perceived health and its associated factors. METHODOLOGY: A cross-sectional study was conducted in three major cities of Pakistan i.e. Karachi, Lahore and Quetta. From each city, six (6) secondary schools were randomly selected (3 public and 3 private). Pre-tested, self-administered questionnaire was distributed to students. Binary logistic regression analysis was conducted to determine independent factors associated with poor self-perceived health. RESULTS: Approximately 29% adolescents (119/414) reported poor self-perceived health. Individual and parental factors significantly associated with poor self-perceived health were being male (AOR = 1.75, 95% CI: 1.09 - 2.79), living in extended family (AOR = 2.65, 95% CI: 1.66 - 4.22), unskilled employment of father (AOR = 2.17, 95% CI: 1.35 - 3.48), lack of parental-child communication (AOR = 1.74, 95% CI: 1.03 - 2.91) and unfair treatment by parents (AOR = 1.80, 95% CI: 1.09 - 2.96). Life style factors such as use of smokeless tobacco (AOR = 2.14, 95% CI: 1.26 - 3.96) and unhealthy diet (AOR = 3.60, 95% CI: 1.76 - 7.33) were associated with poor self-perceived health. CONCLUSION: Better employment opportunities for father, parental counseling and increase awareness for adolescents about healthy diet are recommended to improve adolescent self-perceived health in Pakistan.

Thalassemia and premarital screening: potential for implementation of a screening program among young people in Pakistan.

Pakistan has a high prevalence of ß-thalassemia (ß-thal) but lacks a screening program for its prevention. This questionnaire-based cross-sectional study was conducted in six randomly chosen non medical universities to assess the students' knowledge of ß-thal and premarital screening, and their attitude towards such a program. Comparison was made between the respondents' attitude towards premarital screening before and after providing them some information regarding the disease. Only 54.5% (207) of 380 students had heard of ß-thal, with a mean knowledge score of 13.0 ± 4.4 out of 27 questions. Most respondents were aware of the concept of premarital screening. Out of 207 students, 60.4% wanted to know if they were carriers, 69.1% wanted to know their spouse's carrier status and 59.4% wanted premarital screening to be made mandatory in Pakistan. These figures increased to 72.5, 78.3 and 67.6%, respectively after provision of written information (p values: 0.03, 0.02, and 0.01, respectively). The positive attitude towards premarital screening with low background knowledge of the disease highlights the need of a mass awareness campaign and subsequent implementation of a premarital screening program.

Disparities in access to surgical care within a lower income country: an alarming inequity.

BACKGROUND: Surgical care is not uniformly available worldwide. Inequities in surgical care and access may also vary within countries, and the present study aimed to explore these disparities in Pakistan. METHODS: The National Health Survey of Pakistan was analyzed. The proportion of people with a history of abdominal surgery (AS) was calculated and associated factors were determined by weighted multivariate logistic regression. Factors tested were age, gender, urban/rural residence, province, literacy, community development index (CDI), and economic status (ES). The CDI was developed for each sampling unit from select household and individual data. The ES was constructed from ownership of assets. RESULTS: A total of 59 million adults were represented. Abdominal surgery had been performed in 3.2 % adults (95 % confidence interval [CI] = 2.67, 3.84), which corresponded to an annual rate of 85.9 abdominal surgeries per 100,000 population. Wide disparities were noted, with annual rates of AS varying from 37.8 to 215.6 per 100,000 population. Urban residents were independently twice as likely as rural populations to have had AS (95 % CI = 1.3, 2.8). Higher age (OR = 2.6; 95 % CI = 1.7, 4.0), female gender (OR = 1.5; 95 % CI = 1.1, 2.1), and higher ES (OR = 1.9; 95 % CI = 1.2, 2.9) were also independently associated with AS. In rural populations ES was the only factor associated with surgery, whereas in urban populations gender and CDI had important roles to play. CONCLUSIONS: Access to surgical care is disparate and grossly inadequate in Pakistan. This likely contributes to significant preventable morbidity and death. Physical access to surgical facilities, especially in rural areas and for those with a low CDI, is an important concern and should be prioritized in any forthcoming national policies.

Correlates of morbidity and mortality in severe necrotizing pancreatitis.

Acute severe pancreatitis is associated with a high morbidity and mortality and frequently is accompanied by underlying pancreatic parenchymal necrosis. Patients with pancreatic necrosis must be identified, because the morbidity and mortality rate in this subgroup is much higher. Our objective was to compare the clinical outcomes of these patients based on the degree of pancreatic necrosis. A total of 35 patients were noted to have pancreatic necrosis. These were divided into 2 groups based on extent of necrosis: group A had less than 50% necrosis and group B had more than 50% necrosis. The rate of mortality (5% versus 40%) was significantly higher in group B. The rate of organ dysfunction also rose along with the rates of other morbidities and variables that were related to a patient's hospital stay. Only APACHE II significantly correlated with the degree of necrosis, wherein the chances of substantial necrosis rose by 20% with each unit increase of APACHE II score. APACHE II Score could be employed and studied further prospectively to help identify patients with pancreatic necrosis.

Indoor air pollution (PM2.5) due to secondhand smoke in selected hospitality and entertainment venues of Karachi, Pakistan.

OBJECTIVE: To determine particulate matter smaller than 2.5 µm (PM(2.5)) levels at various hospitality and entertainment venues of Karachi, Pakistan. METHODS: This was a descriptive cross-sectional study conducted at various locations in Karachi, during July 2009. Sampling was performed at 20 enclosed public places, including hospitality (restaurants and cafés) and entertainment (snooker/billiard clubs and gaming zones) venues. PM(2.5) levels were measured using an aerosol monitor. RESULTS: All entertainment venues had higher indoor PM(2.5) levels as compared to the immediate outdoors. The indoor PM(2.5) levels ranged from 25 to 390 µg/m(3) and the outdoor PM(2.5) levels ranged from 18 to 96 µg/m(3). The overall mean indoor PM(2.5) level was 138.8 µg/m(3) (± 112.8). Among the four types of venues, the highest mean indoor PM(2.5) level was reported from snooker/billiard clubs: 264.7 µg/m(3) (± 85.4) and the lowest from restaurants: 66.4 µg/m(3) (± 57.6) while the indoor/outdoor ratio ranged from 0.97 to 10.2, highest being at the snooker/billiard clubs. The smoking density ranged from 0.21 to 0.57, highest being at gaming zones. The indoor PM(2.5) concentration and smoking density were not significantly correlated (Spearman's correlation coefficient = 0.113; p = 0.636). CONCLUSIONS: This study demonstrates unacceptably high levels of PM(2.5) exposure associated with secondhand smoke (SHS) at various entertainment venues of Karachi even after 8 years since the promulgation of smoke-free ordinance (2002) in Pakistan; however, better compliance may be evident at hospitality venues. The results of this study call for effective implementation and enforcement of smoke-free environment at public places in the country.

Preventable lifestyle risk factors for non-communicable diseases in the Pakistan Adolescents Schools Study 1 (PASS-1).

OBJECTIVES: The rising burden of preventable risk factors for non-communicable diseases (NCDs) among adolescents is a major public health challenge worldwide. We identified the preventable risk factors for NCDs in adolescents. METHODS: In a school-based study, pre-tested structured questionnaires were completed by 414 adolescents (14 to 17 years) at six schools in three cities in Pakistan. The chi-squared test and adjusted odds ratio (aOR) with 95% confidence interval (CI) were calculated in a multinomial logistic regression analysis. RESULTS: Over 80% of the adolescents had unhealthy diets, and 54% were physically inactive. Most adolescents were exposed to passive smoking, and 14% were also current smokers. More than one-third of participants chewed betel nut, and one-quarter used oral tobacco. More girls were physically inactive (OR, 4.07; 95% CI, 2.69 to 6.17), whereas a greater proportion of boys were current smokers (OR, 2.17; 95% CI, 1.19 to 3.91), exposed to passive smoking (OR, 2.57; 95% CI, 1.72 to 3.83), and using betel nut (OR, 2.03; 95% CI, 1.34 to 3.06). Only 3.1% of the participants were without any preventable lifestyle risk factor for NCDs, and over 80% had ≥2 factors. Co-existence of risk factors was independently associated with fathers being blue-collar workers (aOR, 3.57; 95% CI, 1.07 to 11.92) and parents not treating their child fairly (aOR, 5.05; 95% CI, 1.29 to 19.78). CONCLUSIONS: Most of the adolescents studied had preventable risk factors for NCDs. These results warrant comprehensive and integrated interventions to prevent lifestyle risk factors, and parents are front-line stakeholders.

Lung function decrement with arsenic exposure to drinking groundwater along River Indus: a comparative cross-sectional study.

This study was designed to determine the association between chronic arsenic exposure through drinking groundwater and decrement in lung function, particularly among individuals who do not have signs of arsenic lesions, among an adult population. This was a comparative cross-sectional study conducted during the months of January to March 2009. One hundred participants ≥15 years of age in each group, i.e. exposed (≥100 µg/l) and unexposed (≤10 µg/l) to arsenic, determined by testing drinking water samples (using portable kits), were compared for effects on lung function using spirometry. A structured and validated questionnaire was administered. Examination for arsenic skin lesions was also done. There was a decline in the mean adjusted FEV1 of 154.3 ml (95% CI: -324.7, 16.0; p = 0.076), in mean adjusted FVC of 221.9 ml (95% CI: -419.5, -24.3; p = 0.028), and in FEV1/FVC ratio of 2.0 (95% CI: -25.3, 29.4; p = 0.884) among participants who were exposed to arsenic compared to those unexposed. A separate model comprising a total of 160 participants, 60 exposed to arsenic concentrations ≥250 µg/l and 100 unexposed at arsenic concentrations of ≤10 µg/l, showed a decrement in mean adjusted FEV1 of 226.4 ml (95% CI: -430.4, -22.4; p = 0.030), in mean adjusted FVC of 354.8 ml (95% CI: -583.6, -126.0; p = 0.003), and in FEV1/FVC ratio of 9.9 (95% CI: -21.8, 41.6; p = 0.539) among participants who were exposed to arsenic in drinking groundwater. This study demonstrated that decrement in lung function is associated with chronic exposure to arsenic in drinking groundwater, occurring independently, and even before any manifestation, of arsenic skin lesions or respiratory symptoms. The study also demonstrated a dose-response effect of arsenic exposure and lung function decrement.