BACKGROUND: Despite a large burden of life-limitingillness, there exists a dearth of services of palliative care in Pakistan. International guidelines have questionable applicability in Pakistan due to the socioeconomic differences. We generated a protocol describing the process of developing comprehensive palliative care guidelines and palliative care referral pathways for primary care practitioners to adopt in Pakistan. METHODS: A GRADE-ADOLOPMENT approach with modification has been employed to create guidelines for a Pakistani context. The "National Comprehensive Cancer Network Guidelines Insights: Palliative Care, Version 2.2021" was used as the source guideline. Recommendations from the source guideline were reviewed by two local palliative care specialists to either "Adopt," "Adapt" or "Exclude". The finalized recommendations were incorporated into the local palliative care guideline. Clinical diagnosis and referral pathways were made from the finalized guideline. Any gaps in management found in the pathways were filled by taking existing recommendations from other credible guidelines. RESULTS: Twenty-seven recommendations were adopted without modification. No recommendations were deemed to be adapted and 15 were excluded. The referral care pathways created were reflective of the local guideline and included elements of initial assessment, preliminary management, reassessment, and referral. 6 additional recommendations were made. CONCLUSION: The described clinical practice guidelines and primary care clinical referral pathways will aid to standardize palliative care provision in Pakistan. These can be used by other resource constrained settings to develop guidelines within their own local context.
Palliative Care , Primary Health Care , Referral and Consultation , Humans , Pakistan , Palliative Care/standards , Palliative Care/methods , Referral and Consultation/standards , Primary Health Care/methods , Primary Health Care/standards , Practice Guidelines as Topic
OBJECTIVE: We aimed to assess the parent-reported screen time of children, identify the perceived risk factors for increased screen time and its relationship to psychological distress in children. MATERIALS AND METHOD: A cross sectional study was conducted at a teaching hospital in Karachi, Pakistan. A total of 230 employees from medical and non-medical departments were included. Participants were employees with child/children ages 4-12 year who consented to participate in the study, we included 135 fathers and 91 mothers. The questionnaire included (i) demographic data (ii) Media history exam form and (iii) parent reported strength and difficult questionnaire (SDQ). RESULT: The average daily screen time reported was 2.5 (1.5-5) hour for boys and 2 (1-4) hour for girls. Preschoolers had greater screen time as compared to school-aged children (Median (IQR): 3 (1.5-5.6) vs 2 (1-4), P = 0.46). The children owned devices with approximately equal distribution of preschoolers and school-aged children (19 (27.1%) and 48 (30%), P = 0.661 respectively). Emotional score was found higher in school-aged group in comparison to preschoolers (p = 0.036). Moreover, mother screen time and number of devices owned by a child were found to be positively associated with child's screen time. CONCLUSION: We conclude that as we are embracing the digital age providing a tech free zone to children is virtually impossible. Children screen time related activities in our part of the world exceeds the limitation. Parental awareness and co-viewing screen with their children are essential to avoid media related behavior problems.
OBJECTIVE: We aimed to study the extent of liver fibrosis in chronic hepatitis C patients with indeterminate APRI score of ≥ 0.5 - ≤2 (between higher and lower cut off value) and correlate it to transient elastography (TE) and FIB 4 index. METHOD: A cross-sectional study, 80 patients with CHC mono infection, APRI score ≥ 0.5 - ≤2 were interviewed from the cohort visiting the CHC program clinic at a tertiary care hospital in Karachi, Pakistan. Data were analyzed using STATA 14.0 and R 3.5.2 and SPSS 24.0 software according to their capabilities. RESULT: Of 80 patients, 50 (62.5%) were females and 30 (37.5%) were males with mean (±SD) ages of 41.73 (±11.5) years and 41.16 (±9.24) years respectively. The FIB 4 value among indeterminate APRI was reported as 1.47 (IQR 1.05-2.43). TE categories was reported: F0-F1 (n = 29; 36%), F1-F2 (n = 10; 12.5%), F2 (n = 9; 11.2%) F3 (n = 13; 16.2%), F3-F4 (n = 1; 1.2%) F4 (n = 18; 22.5%). FIB4 had a moderate positive correlation with TE while a weak positive correlation was found between APRI and TE (0.488, P < 0.0001 and 0.289, P < 0.001, respectively). TE was taken as a gold standard and compared with FIB4. The model constructed reported FIB4 as a good prediction for liver fibrosis with diagnostic accuracy 72%. CONCLUSION: The combination of two serum markers proves to be a low-cost noninvasive testing strategy for CHC patients having an indeterminate APRI score. By being readily accessible both biochemical scores can simplify liver assessment in lower middle-income countries (LMIC) and help family physicians to take appropriate decisions about treatment initiation with minimum delays.
Objective In this study, we aimed to compare the frequency of anemia, blood transfusions, and the use of antimicrobial therapy (AMT) before the implementation of standard protocols in obstetrics and gynecology with the data after one year of implementation at a teaching hospital. Methods In this retrospective observational study, the pre-intervention data (group A) were compared to the data after the implementation of standard protocols (group B). Data were retrieved from hospital electronic medical records and were entered and analyzed on SPSS Statistics version 24 (IBM, Armonk, NY). Results In obstetrics (n=829), anemia was observed in 43.1% vs. 26.8% (p<0.001) and transfusion rate in 5.4% vs. 0.6% (p<0.001) in the groups A and B respectively. In vaginal deliveries (VD), the use of AMT for >24 hours was 98% in group A vs. 9% in group B, and in cesarean deliveries (CD), it was 100% in group A vs. 54.5% in group B (p<0.001). The cost of AMT decreased by 78.4% in VD and by 51.1% in CD. In gynecology (n=221), the prevalence of anemia was 22.6% in group A vs. 17.9% in group B (p=NS). In minor procedures, the use of AMT for >24 hours was 76.7% vs. 8.4% (p<0.001), and in major procedures, it was 86.5% vs. 38% (p<0.001) between the two groups. The cost of AMT decreased by 79.5% in minor procedures and 26.4% in major procedures. Conclusion The implementation of quality standards can bring about significant improvements in clinical outcomes in a short period of time.
