Determinants of Adherence to Antihypertension Medications Among Patients at a Tertiary Care Hospital in Islamabad, Pakistan, 2019.

INTRODUCTION: Medication nonadherence leads to poor health outcomes, frequent complications, and high economic impact. Our objective was to assess the determinants of adherence to medication regimens among patients with hypertension. METHODS: We conducted a cross-sectional study of patients with hypertension attending the cardiology clinic of a tertiary care hospital in Islamabad, Pakistan. Data were collected by using semistructured questionnaires. A score of 7 or 8 on the 8-item Morisky Medication Adherence Scale was classified as good adherence, 6 as moderate, and less than 6 as nonadherence. Logistic regression was performed to determine covariates associated with medication adherence. RESULTS: We enrolled 450 patients with hypertension (mean age, 54.5 y; SD, 10.6). Medication adherence was good among 115 (25.6%) patients and moderate among 165 (36.7%); 170 (37.8%) patients were nonadherent. Most patients (72.7%) had uncontrolled hypertension. Nearly half (49.6%) were unable to afford monthly medication. In bivariate analysis, nonadherence was associated with female sex (odds ratio [OR], 1.44; P = .003) and long waiting times in the health care facility (OR, 2.93; P = .005); the presence of comorbidities (OR, 0.62; P = .01) was associated with good adherence. In multivariate analysis, nonadherence was associated with unaffordability of treatment (OR, 2.25; P = .002) and uncontrolled hypertension (OR, 3.16; P < .001). Good adherence determinants included adequate counseling (OR, 0.29; P < .001) and education (OR, 0.61; P = .02). CONCLUSION: Addressing identified barriers, including medication affordability and patient counseling, should be included in Pakistan's national policy on noncommunicable disease.

Modelling the impact of climate change on dengue outbreaks and future spatiotemporal shift in Pakistan.

Climate change has a significant impact on the intensity and spread of dengue outbreaks. The objective of this study is to assess the number of dengue transmission suitable days (DTSD) in Pakistan for the baseline (1976-2005) and future (2006-2035, 2041-2070, and 2071-2099) periods under Representative Concentration Pathway (RCP4.5 and RCP8.5) scenarios. Moreover, potential spatiotemporal shift and future hotspots of DTSD due to climate change were also identified. The analysis is based on fourteen CMIP5 models that have been downscaled and bias-corrected with quantile delta mapping technique, which addresses data stationarity constraints while preserving future climate signal. The results show a higher DTSD during the monsoon season in the baseline in the study area except for Sindh (SN) and South Punjab (SP). In future periods, there is a temporal shift (extension) towards pre- and post-monsoon. During the baseline period, the top ten hotspot cities with a higher frequency of DTSD are Karachi, Hyderabad, Sialkot, Jhelum, Lahore, Islamabad, Balakot, Peshawar, Kohat, and Faisalabad. However, as a result of climate change, there is an elevation-dependent shift in DTSD to high-altitude cities, e.g. in the 2020s, Kotli, Muzaffarabad, and Drosh; in the 2050s, Garhi Dopatta, Quetta, and Zhob; and in the 2080s, Chitral and Bunji. Karachi, Islamabad, and Balakot will remain highly vulnerable to dengue outbreaks for all the future periods of the twenty-first century. Our findings also indicate that DTSD would spread across Pakistan, particularly in areas where we have never seen dengue infections previously. The good news is that the DTSD in current hotspot cities is projected to decrease in the future due to climate change. There is also a temporal shift in the region during the post- and pre-monsoon season, which provides suitable breeding conditions for dengue mosquitos due to freshwater; therefore, local authorities need to take adaption and mitigation actions.

Validity of reported indicators of pesticide exposure and relevance for cytotoxic and genotoxic effects on buccal cells.

Higher rates of nuclear anomalies in buccal cells of coffee workers exposed to pesticides in comparison to their unexposed peers were detected in our field study. Here, we extend our findings by examining other exposure indicators in this sample. Occupational exposure of 38 exposed and 33 non-exposed farmworkers was assessed as exposure days in the last month (0-25 days) and as years of exposure (0-47 years). Genotoxic and cytotoxic markers in buccal cells were analysed following standard procedures for buccal micronucleus cytome assay. Both exposure markers were associated with a higher frequency of nuclear anomalies with odds ratios more than 1. After restricting the analysis to the exposed workers only, this association remained only with the marker of recent exposure. In a secondary analysis also environmental exposure defined as proximity of the home to the nearest sprayed field (distance <1000 m) was assessed. Proximity led to increased rates (with odds ratios more than 3) of genotoxic but not cytotoxic nuclear anomalies. Reported recent frequency and intensity of pesticide use and application are a valid exposure marker relevant for cytological pathologies in the buccal mucosa. The exposure metric for environmental exposure was rather crude and confounding by some unmeasured factor cannot be fully excluded. Nevertheless, simple exposure indicators that can even be obtained under rather difficult field conditions do provide health-relevant and valid information.

Nuclear anomalies in exfoliated buccal cells in Pakistani cotton weavers.

Cotton workers in small weaving household factories (power looms) in Pakistan are typically exposed to high levels of cotton dusts. Working in the textile manufacturing industry has been classified as a possible human carcinogen (group 2B) by the International Agency for Research on Cancer. The study set out to determine potential cytotoxic and genotoxic effects of occupational exposure to cotton dusts in exfoliated buccal cells of exposed cotton workers. Nuclear anomalies reflecting cytotoxic and genotoxic effects were evaluated in a representative sample of 51 exposed male cotton weavers and in the same number of age-matched male non-exposed subjects applying the micronucleus cytome assay. Nuclear anomalies reflecting cytotoxicity (karyolysis, karyorrhexis, condensed chromatin and pyknosis) were significantly elevated in exposed cotton workers. The frequency of micronucleated cells increased significantly with increasing years of work in power looms (odds ratio = 1.043 per year; 95% confidence interval: 1.012-1.076, P = 0.007). Results were consistent with the typical inflammatory pattern and injury in epithelia due to unprotected occupational exposure to cotton dusts and other toxic, allergic and infectious substances in the working areas of the cotton industry. Occupational exposure in power looms induces cytotoxic effects and, upon chronic exposure, DNA damage. This may eventually result in typical obstructive patterns of pulmonary symptoms and in a clinical condition called byssinosis in exposed cotton workers. Long exposure may lead to chronic inflammation and cumulative damage of DNA in buccal stem cells that may indicate an increased risk of oropharyngeal cancer.

Diminished pulmonary function in long-term workers exposed to cotton dust determined in a cross-sectional study in small Pakistani enterprises.

PURPOSE: While large cotton industry plants producing for the foreign market have undergone improvements of occupational hygiene lately, working conditions in power looms producing mainly for the local market are still poor. The respiratory health in workers of power looms has not been studied so far. METHODS: In a cross-sectional study, 51 male cotton workers from power looms, 58 from large cotton factories and 52 controls were investigated by spirometry and a symptoms questionnaire. Spirometric measurements and respiratory symptoms were related to exposure duration in large and small factories by multivariate linear regression and logistic regression, respectively, with smoking, age and anthropometric parameters considered as confounders. RESULTS: Work duration in power looms was associated with declines in forced expiratory volume in 1 s, peak flow, maximum midexpiratory flow and forced expiratory flow 75 and an increased risk of obstruction (OR 1.09/year; 95% CI: 1.002 to 1.18) by applying the Global Lung Initiative equations. Except cough that was only associated with smoking, all respiratory symptoms (chest tightness, shortness of breath, fever) increased as a function of duration of exposure in power looms but not in large factories. CONCLUSIONS: Despite limitations inherent in the cross-sectional approach, there is evidence for workers in small weaving factories to face an increased risk of pulmonary function loss and respiratory symptoms. Industrial hygiene measures in these small enterprises should be encouraged. Failure to detect adverse respiratory outcomes from occupation in large factories could be due to a 'survivor' (healthy worker) effect.

Non-Invasive Predictive Biomarkers for Immune-Related Adverse Events Due to Immune Checkpoint Inhibitors.

Immune-related adverse events (irAEs) are the most common complication of immune checkpoint inhibitor (ICI) therapy. With the widespread use of ICIs in patients with solid tumors, up to 40% of the patients develop irAEs within five months of treatment, and 11% develop severe irAEs requiring interventions. A predictive test for irAEs would be a crucial tool for monitoring for complications during and after ICI therapy. We performed an extensive review of potential predictive biomarkers for irAEs in patients who received ICI therapy. Currently, only thyroid-stimulating hormone is utilized in common clinical practice. This is due to the unavailability of commercial tests and unclear predictive values from various studies. Given the lack of single strong predictive biomarkers, some novel approaches using composite scores using genomic, transcriptomics, cytokine levels, or clinical parameters appear appealing. Still, these have yet to be validated and incorporated into clinical practice. Further research conducted to validate the models before implementing them into real-world settings will be of the utmost importance for irAE prediction.

Primary leiomyosarcoma of thyroid with pulmonary metastasis: A diagnostic odyssey.

The presented primary thyroid leiomyosarcoma (TL) case report underscores the importance of recognizing and addressing the diagnostic challenges and management complexities associated with this exceedingly rare malignancy. Given the limited effective therapeutic strategies available, timely intervention, thorough diagnostics, and vigilant follow-up are paramount in managing such intricate tumors. Further research focusing on molecular-based treatment modalities is imperative to improve patient outcomes in cases of primary TL.

Tissue characterization of benign cardiac tumors by cardiac magnetic resonance imaging, a review of core imaging protocol and benign cardiac tumors.

Generally, cardiac masses are initially suspected on routine echocardiography. Cardiac magnetic resonance (CMR) imaging is further performed to differentiate tumors from pseudo-tumors and to characterize the cardiac masses based on their appearance on T1/T2-weighted images, detection of perfusion and demonstration of gadolinium-based contrast agent uptake on early and late gadolinium enhancement images. Further evaluation of cardiac masses by CMR is critical because unnecessary surgery can be avoided by better tissue characterization. Different cardiac tissues have different T1 and T2 relaxation times, principally owing to different internal biochemical environments surrounding the protons. In CMR, the signal intensity from a particular tissue depends on its T1 and T2 relaxation times and its proton density. CMR uses this principle to differentiate between various tissue types by weighting images based on their T1 or T2 relaxation times. Generally, tumor cells are larger, edematous, and have associated inflammatory reactions. Higher free water content of the neoplastic cells and other changes in tissue composition lead to prolonged T1/T2 relaxation times and thus an inherent contrast between tumors and normal tissue exists. Overall, these biochemical changes create an environment where different cardiac masses produce different signal intensity on their T1- weighted and T2- weighted images that help to discriminate between them. In this review article, we have provided a detailed description of the core CMR imaging protocol for evaluation of cardiac masses. We have also discussed the basic features of benign cardiac tumors as well as the role of CMR in evaluation and further tissue characterization of these tumors.

Perceived individual and community barriers in the provision of family planning services by lady health workers in Tehsil Gujar Khan.

OBJECTIVES: To identify contextual barriers (social, cultural, geographic and economic), faced by Lady Health Workers (LHWs) and to assess their strategies at different levels (individual, community and system) in the provision of family planning services to their clients in Tehsil Gujar Khan. METHODS: The mixed model cross-sectional study was conducted from April 1 to July 10, 2010, in Tehsil Gujar Khan, Punbjab, Pakistan. It was carried out in two phases: in the first phase 10 in-depth interviews were conducted with the workers, followed by two focus group discussions. On the basis of findings, a structured questionnaire was developed and administered to 111 workers in the second phase. Of the total, 97 responses were used for analysis. Data analysis was done by SPSS-16. RESULTS: Majority of the respondents reported barriers at the community level: religious barriers 69% (n = 67), sociocultural barriers 58% (n = 56), transport 54% (n = 52), communication and economic reasons 25% (n = 24). Individual level barriers were female gender, experience and low education. System-level barriers were increased workload, National immunization days/sub-national immunization days, late supply, stock shortage (especially injectables), problems for referred clients and lack of proper incentives. CONCLUSION: Lady health workers still face barriers at individual, family, community and system level in the delivery of Family Planning services.

Are patients with pulmonary tuberculosis identified by active and by passive case detection different? A cross-sectional study in Pakistan.

OBJECTIVES: Our objective was to compare the characteristics of patients with pulmonary tuberculosis (TB) identified through "extended contact screening" (ECS) with those of patients identified through routine passive case finding (PCF). METHODS: Active TB case finding by ECS was tested from 2013-2015. This was a cross-sectional study based on data collected from ECS and routine program data from Lahore, Faisalabad, and Rawalpindi districts, and Islamabad in 2015. Characteristics of patients identified through ECS and PCF were compared. RESULTS: Of the 12,114 patients with pulmonary TB in the study, 4604 (38%) were identified through ECS, of whom 4052 (88%) had bacteriological confirmation. Male patients comprised 56.2% (95% confidence interval [CI] 54.8-57.6) of patients with pulmonary TB identified through ECS and 49.7% (95% CI 48.6-50.8) of those identified through PCF. The proportion of bacteriologically confirmed cases was 88.0% (95% CI 87.1-88.9) in the ECS group and 50.3% (95% CI 49.2-51.4) in the PCF group. By regression analysis we found that compared with patients aged 15-44 years, children aged <15 years had higher chances of being identified through ECS (adjusted odds ratio 2.69; 95% CI 2.21-3.28). There was a higher chance of cases being detected by ECS in Faisalabad (adjusted odds ratio 2.57; 95% CI 2.01-3.29) than in Islamabad. CONCLUSION: ECS identified a higher proportion of male and child patients with pulmonary TB than routine case finding; both of these groups are more often unidentified through routine TB control.

Comparative effectiveness of individualized longer and standardized shorter regimens in the treatment of multidrug resistant tuberculosis in a high burden country.

Objective: To compare the effectiveness of second line injectables containing shorter (duration 9-12 months) and longer treatment regimens (LTR, duration ≥ 20 months) among multidrug-resistant tuberculosis (MDR-TB) patients with no documented resistance and history of treatment with any second-line anti-TB drug (SLD) for ≥ 1 month. Methods: This was an observational cohort study of MDR-TB patients treated at eight PMDT units in Pakistan. Patients' data from baseline until treatment outcomes were collected from Electronic Nominal Recording and Reporting System. The treatment outcomes of "cured" and "treatment completed" were grouped together as successful, whereas "death," "treatment failure," and "lost to follow-up" were collectively grouped as unsuccessful outcomes. Time to sputum culture conversion (SCC) was analyzed using the Kaplan-Meier method and the differences between groups were compared through the log-rank test. Multivariate Cox proportional hazards and binary logistic regression analyses were used to find predictors of time to SCC and unsuccessful treatment outcomes. A p-value < 0.05 was considered statistically significant. Results: A total 701 eligible MDR-TB patients [313 treated with shorter treatment regimen (STR) and 388 treated with LTR at eight centres in Pakistan were evaluated]. Time to achieve SCC was significantly shorter in STR group [mean: 2.03 months, 95% confidence interval (CI):1.79-2.26] than in LTR group (mean: 2.69 months, 95% CI: 2.35-3.03) (p-value<0.001, Log-rank test). Treatment success was higher in STR (83.7%) than in LTR (73.2%) group (p-value <0.001) due to high cure (79.9% vs. 70.9%, p-value = 0.006) and low death (9.9% vs. 18.3%, p-value = 0.002) rates with STR. Treatment with STR emerged the only predictor of early SCC [adjusted Hazards ratio (aHR) = 0.815, p-value = 0.014], whereas, patient's age of 41-60 (OR = 2.62, p-value<0.001) and >60 years (OR = 5.84, p-value<0.001), baseline body weight of 31-60 (OR = 0.36, p-value = 0.001) and >60 kg (OR = 0.23, p-value <0.001), and treatment with LTR (OR = 1.88, p-value = 0.001) had statistically significant association with unsuccessful treatment outcomes. Conclusion: STR exhibited superior anti-microbial activity against MDR-TB. When compared LTR, treatment with STR resulted in significantly early SCC, high cure, and lower death rates among MDR-TB patients who had no documented resistance and history of treatment with any SLD ≥ 1 month.

Geographic accessibility to childhood tuberculosis care in Pakistan.

BACKGROUND: Tuberculosis (TB) in children is difficult to detect and often needs specialists to diagnose; the health system is supposed to refer to higher level of health care when diagnosis is not settled in a sick child. In Pakistan, the primary health care level can usually not diagnose childhood TB and will refer to a paediatricians working at a secondary or tertiary care hospital. We aimed to determine the health services access to child TB services in Pakistan. OBJECTIVE: We aimed to determine the geographical access to child TB services in Pakistan. METHOD: We used geospatial analysis to calculate the distance from the nearest public health facility to settlements, using qGIS, as well as population living within the World Health Organization's (WHO) recommended 5-km distance. RESULT: At primary health care level, 14.1% of facilities report child TB cases to national tuberculosis program and 74% of the population had geographical access to general primary health care within 5-km radius. To secondary- and tertiary-level health care, 33.5% of the population had geographical access within 5-km radius. The average distance from a facility for diagnosis of childhood TB was 26.3 km from all settlement to the nearest child TB sites. The population of one province (Balochistan) had longer distances to health care services. CONCLUSION: With fairly good coverage of primary health care but lower coverage of specialist care for childhood TB, the health system depends heavily on a good referral system from the communities.

Acute Hepatitis as a Rare Presentation of COVID-19.

Coronavirus disease 2019 (COVID-19) initially emerged in Wuhan, China, in December 2019, and now it has been declared a pandemic by the World Health Organization. COVID-19 commonly presents with respiratory manifestations like fever, cough, body aches, and shortness of breath. Neurological, myocardial, renal and gastrointestinal complications secondary to SARS-CoV-2 infection have been reported in the literature. Gastrointestinal symptoms reported with COVID-19 are mostly nausea, vomiting, and diarrhea. COVID-19 can rarely present with acute hepatitis. Here, we report a case of a 45-year male who presented with signs and symptoms of acute hepatitis secondary to SARS-CoV-2 infection. Key Words: SARS-CoV-2, COVID-19, Acute hepatitis.

Forecasting daily new infections, deaths and recovery cases due to COVID-19 in Pakistan by using Bayesian Dynamic Linear Models.

The COVID-19 has caused the deadliest pandemic around the globe, emerged from the city of Wuhan, China by the end of 2019 and affected all continents of the world, with severe health implications and as well as financial-damage. Pakistan is also amongst the top badly effected countries in terms of casualties and financial loss due to COVID-19. By 20th March, 2021, Pakistan reported 623,135 total confirmed cases and 13,799 deaths. A state space model called 'Bayesian Dynamic Linear Model' (BDLM) was used for the forecast of daily new infections, deaths and recover cases regarding COVID-19. For the estimation of states of the models and forecasting new observations, the recursive Kalman filter was used. Twenty days ahead forecast show that the maximum number of new infections are 4,031 per day with 95% prediction interval (3,319-4,743). Death forecast shows that the maximum number of the deaths with 95% prediction interval are 81 and (67-93), respectively. Maximum daily recoveries are 3,464 with 95% prediction interval (2,887-5,423) in the next 20 days. The average number of new infections, deaths and recover cases are 3,282, 52 and 1,840, respectively, in the upcoming 20 days. As the data generation processes based on the latest data has been identified, therefore it can be updated with the availability of new data to provide latest forecast.

COVID-19-Induced Mesenteric Thrombosis.

Gastrointestinal symptoms, such as diarrhea (most common among gastrointestinal symptoms), nausea/vomiting, anorexia, abdominal pain, abnormal liver enzymes, and pancreatitis, are being increasingly recognized in patients with coronavirus disease 2019 (COVID-19). Moreover, COVID-19 has also been implicated in coagulopathy, especially in patients with severe disease. Here, we report a case of acute intestinal ischemia secondary to superior mesenteric thrombosis in a young female patient with mild COVID-19.

Can COVID-19 Cause Pancreatitis? A Rare Complication of SARS-CoV-2 Infection.

Coronavirus disease-2019 (COVID-19) emerged as a cluster of atypical pneumonia in Wuhan, China in December 2019. This disease has been declared a pandemic by the World Health Organization. COVID-19 patients mostly present with upper respiratory symptoms like dyspnea, cough and fever. Various neurological, myocardial, renal and gastrointestinal complications have been reported associated with SARS-CoV-2. Acute pancreatitis is one of the common causes of upper abdominal pain, caused by alcohol consumption, gall stones and various viruses and drugs. We present a case of a young female, who was recently diagnosed as COVID-19 and later on developed acute pancreatitis without any other risk factors.  Key Words: COVID-19, SARS-CoV-2, Acute pancreatitis.

COVID-19-induced Guillain-Barre Syndrome: A Rare Complication of SARS-CoV-2 Infection.

SARS-CoV-2 causing COVID-19 initially began in Wuhan, China and now has been declared a pandemic by the World Health Organization (WHO). In addition to respiratory symptoms, it can cause various complications ranging from neurological to myocardial injuries. Guillain-Barre Syndrome (GBS) is an acute polyradiculoneuropathy affecting more often lower limbs than upper limbs and is often related to previous infectious diseases. We, herein, describe a case of a young female who presented with typical symptoms of GBS after having COVID-19 and was later on confirmed with nerve conduction study and lumbar puncture. Key Words: COVID-19, SARS-CoV-2, Guillain-barre syndrome.

Management of Spontaneous Chylothorax in a Neonate: A Medical Challenge.

Chylothorax or collection of lymphatic fluid in the pleural space is an exceedingly rare cause of pleural effusion and respiratory distress in neonates. In adults, prompt diagnosis and effective treatment regimen can aid in the resolution of chylothorax; however, in neonates treating the condition can be an onerous challenge for the pediatricians due to the rarity and perplexing clinical presentation. We elucidate a case of spontaneous chylothorax in a 15-day-old neonate who presented to us with respiratory distress, chest indrawing, and cyanosis for nine days. The prenatal and birth history of the patient were insignificant. The detailed laboratory and radiological assessment of the patient divulged a diagnosis of spontaneous chylothorax for which the patient was intubated. Unfortunately, the patient deteriorated and eventually expired on the 23rd postnatal day due to the complications of respiratory acidosis and hypoxemia.

Pulmonary arterial hypertension post COVID-19: A sequala of SARS-CoV-2 infection?

It has been suggested that pulmonary arterial hypertension (PAH) could be a potential sequela of coronavirus disease 2019 (COVID-19) in particular in those with hypertension; however, development of PAH after the course of COVID-19 in normotensive individuals are rarely reported. Here, we report a patient who developed PAH two months post-COVID-19. The patient was a 55-year-old female and normotensive, tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), developed mild respiratory distress syndrome and necessitated continuous positive airway pressure during the treatment in the hospital. After two months discharged from the hospital with RT-PCR negative for SARS-CoV-2, the patient presented with exertional dyspnea, dry cough, fatigue and episodes of syncope during exertion. Based on clinical presentation, electrocardiography, computed tomography, and transthoracic echocardiography assessment, PAH diagnosis was made. To our knowledge, this is a rare PAH case and this highlights the possible of PAH as sequala that might present in post COVID-19 patients.