Flood in Pakistan and Infectious Diseases - The Way Forward.

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Usefulness of Routine Laboratory Tests for Follow up of Patients Receiving Outpatient Parenteral Antimicrobial Therapy Run by Infectious Diseases Fellows.

BACKGROUND: The infectious disease society of America (IDSA) recommends routine laboratory tests for all patients receiving outpatient parenteral antimicrobial therapy (OPAT) to monitor for adverse events. There are no data to support how often patients should take monitoring laboratory tests. In addition, the relevance of different laboratory tests commonly used for OPAT follow up is not clearly known. METHODS: We conducted a retrospective observational cohort study over a 7-year study interval (1 January 2014 to 31 December 2021). Clinical data were obtained to identify the risk factors associated with abnormal laboratory tests and determine if abnormal laboratory tests led to antibiotic change or hospital readmission. RESULTS: Two hundred and forty-six patients met the inclusion criteria for this study. In our multivariate analysis, the Charlson comorbidity index (CCI) of 0-4 (aOR 0.39, 95%Cl 0.18-0.86), the use of ceftriaxone without vancomycin (aOR 0.47, 95%Cl 0.24-0.91) and an OPAT duration of 2-4 weeks (aOR 0.47, 95%Cl 0.24-0.91) were associated with a lower risk of OPAT complications. A CCI of 5 or more (aOR 2.5, 95%Cl (1.1-5.7)) and an OPAT duration of 5 or more weeks (aOR 2.7, 95% Cl 1.3-5.6) were associated with a higher risk of OPAT complications. An abnormal complete metabolic panel or vancomycin levels, but not an abnormal complete blood count, were associated with antibiotic change or readmission. CONCLUSION: Patients with fewer comorbidities, ceftriaxone and short OPAT durations are at lower risk for OPAT complications. These patients could be followed with less frequent laboratory monitoring.

Effect of frequency of parent to child maltreatment on symptoms of anxiety disorder in Pakistani adolescents: A community based cohort study.

OBJECTIVE: To investigate the association between Parent to Child Maltreatment and the occurrence of anxiety disorder symptoms among Pakistani adolescents under 18 years. METHOD: A prospective study was conducted to examine the effect of frequency of Parent to child maltreatment (PTC) on the occurrence of anxiety disorders in a community setting. A sample of 800 adolescents who reported none to rare, occasional, and frequent were followed for the occurrence of anxiety disorder symptoms over two years. PTC was evaluated using ICAST-C (International child abuse screening tool). Anxiety disorder symptoms were evaluated using the SCARED (Screen for children anxiety-related disorders) tool. Risk ratios were estimated using Cox Proportional Algorithm. RESULTS: The risk of occurrence of anxiety disorder symptoms in adolescents who have exposure to frequent PTC is 3.8 times (2.9, 4.9) as compared to those with none to rare exposure to PTC. Among adolescents suffering frequent PTC whose, mothers also reported a history of domestic violence, the risk of anxiety disorder symptoms is 3 times (2.2, 4.1) higher. Female gender (RR 1.5; 1.2-1.9), stressful home environment (RR 1.4; 1.1-1.8), and parental substance abuse (RR 1.6; 1.2-2.0) are significant predictors of anxiety disorder symptoms. CONCLUSION: Frequent PTC is significantly associated with the occurrence of anxiety disorder symptoms among Pakistani adolescents. Given these findings, there is a dire need to develop specific interventions to address anxiety disorder symptoms among adolescents and to develop programs to prevent parent to child maltreatment.

Pharmacological Interventions for the Treatment and Control of Shivering in Adult Patients Undergoing Elective Surgery Under Regional Anaesthesia: A Systematic Review and Meta-Analysis.

Intraoperative shivering is quite common after regional anaesthesia, which not only increases the total body oxygen requirement but also causes discomfort to the patients. The aim of this systematic review is to determine the effectiveness of pharmacological agents administered intra-operatively for treating shivering in adult patients who are undergoing elective surgery under regional (i.e., central neuraxial) anaesthesia so that an optimal choice of an agent can be recommended for clinical application. A literature search was carried out using PubMed, Cochrane Library, CINAHL databases, and hand searches to identify relevant studies. After literature screening and information extraction, a systematic review was performed. Meta-analysis was performed for the primary outcome. The primary outcome was to evaluate the effectiveness of pharmacological agents used for the treatment and control of intraoperative shivering and the time taken to control shivering. The secondary outcome includes recurrence of shivering after pharmacological intervention and identification of common adverse effects related to them. In total, 10 studies (791 patients) were included. Common interventions were opioids, central α2 receptor agonist, and few other medications like magnesium sulfate, ondansetron, nefopam, and amitriptyline. Tramadol and dexmedetomidine were the most frequently documented drugs compared with other drugs to resolve shivering. The most effective drug with approximately 100% response rate was dexmedetomidine with the dose of 0.5 µg kg-1 intravenously given just after the appearance of shivering. Studies showed that tramadol is also an effective drug used to control shivering in most patients, and its effect is comparable with the pethidine.

Role of COVID-19 pandemic in the academic life and well-being of private sector university students: an exploratory qualitative study.

OBJECTIVE: The advent of the COVID-19 pandemic has caused a drastic impact on students' life, causing physical and emotional sufferings. Considering the relevance of unprecedented conditions, we explored perceptions and attitudes of students towards their academic life and well-being amid the COVID-19 pandemic. SETTING: We conducted an exploratory qualitative study using a purposive sampling approach conducted at a single-centre private nursing institution in Karachi, Pakistan. PARTICIPANTS: The current study used in-depth interviews with female university students. Study data were analysed manually using the thematic analysis approach. PRIMARY OUTCOME: The primary outcome is to explore perception of students on academic life and well-being amidst the COVID-19 pandemic. RESULTS: A total of 10 in-depth interviews were conducted between August and September 2020. Four overarching themes were identified: (1) impact of COVID-19 on students' well-being; (2) effect of COVID-19 on students' academic life; (3) current coping mechanisms adopted by students and (4) recommendations to address students' concerns. The pandemic-related stressors served as a major impediment on students' motivation, concentration span and socioeconomic conditions which negatively influenced their well-being and academic life. However, students have adopted diverse coping mechanisms to combat unstable circumstances that include connecting with family and relatives, indulging in diverse activities, and getting academic support from faculty, senior students, and university administration. Students also recommended the need for arranging online mental health services, integrating e-learning mediums in existing academia, and constant efforts by the government to address electricity and internet connectivity issues to promote virtual learning. CONCLUSION: University students have been struck hard due to rapid pandemic-related transitions in their life. The study finding served as the potential guide for educational institutions and government officials to employ appropriate psychological interventions and provide infrastructure and technical facilities to provide support with their academic journey and overcoming the ongoing pandemic repercussions.

Role of the Telemental Health Services During the COVID-19 Pandemic: A Systematic Review. / COVID-19 Pandemisi Sirasinda Tele-Psikiyatri Hizmetlerinin Rolü Hakkinda Sistematik Derleme.

OBJECTIVE: The COVID-19 pandemic has directed the use of telemedicine and digital mental health services to meet the needs of people in order to maintain physical distancing by preventing person to person contact. The aim of this review is to highlight the role of telemental health services during the COVID-19 pandemic. METHOD: An electronic search was carried out between January 01, 2020 and October 31, 2020 to explore the utilization of telehealth services for mental health problems among adults during the COVID-19 pandemic. The primary source of literature was the structured search of major electronic databases from the MEDLINE (PubMed), CINAHL Plus, Science Direct and the Web of Science. We included nine published studies meeting the the eligibility criteria. RESULTS: The role of telehealth identified in this review mainly focused on the applicability of this modality for assessing and managing various mental health problems in these unprecedented times. It also pointed out that the provision of telemental health support reduced the burden of mental health diseases and promoted the wellbeing of the individual. Further, it was witnessed that patients preferred remote consultation as compared to face-to-face visits in order to avoid contracting the virus and found online mental health interventions and psychological counseling very helpful to cope up with the current crisis. CONCLUSION: The current COVID-19 lockdown has changed the management of the mental health problems of patients. The use of this innovative modality prevents transmission of infection and provides timely treatment to the community members most in need.

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

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

The Relation of ABO Blood Group to the Severity of Coronavirus Disease: A Cross-Sectional Study From a Tertiary Care Hospital in Karachi.

Background Blood groups are considered to have an impact on the occurrence and severity of coronavirus disease. While among Chinese and Caucasian, blood group O individuals were less and group A were more likely to have severe disease and mortality, data on South Asians aren't available.  Objective This study aimed to find out the association of disease severity with blood group among coronavirus disease 2019 (COVID-19) patients. Materials and methodology Data were collected on a predesigned questionnaire containing details of patient demographics, medical comorbidities, clinical presentation, and laboratory parameters. Multiple logistic regression was used to determine the association of the blood group with the severity of coronavirus disease. Result Among the study participants, blood group B has the highest distribution (39.8%), followed by O (30.0), A (21.9%), and AB (8.1%). About three-fourths (69.9%) had mild to moderate disease while 30.0% had severe disease. Age, gender, hypertension, diabetes mellitus, and hemoglobin level were all associated with disease severity among COVID-19 patients in univariate analysis on P-value for selection (<0.25). The final model showed that the odds of disease severity is 3.62 times higher among males (OR: 3.62, 95% CI: 2.15-6.08) and 2.00 times higher among diabetic patients (OR: 2.00, 95% CI: 1.10-3.01) as compared to female and non-diabetic respectively. However, there was no significant association found between blood group and disease severity. Conclusion Blood groups don't have any role in forecasting the severity of coronavirus disease. However, the male gender and diabetics are prone to have severe disease.

Exploring community perceptions, attitudes and practices regarding the COVID-19 pandemic in Karachi, Pakistan.

BACKGROUND: The Government of Pakistan is facing difficulty to contain the surge of COVID-19 due to the country's social, political, economical and cultural context. Experiences from the previous epidemic suggest that community perceptions, social norms and cultural practices can impede COVID-19 containment. To understand social responses towards COVID-19, the study aims to explore the understanding of COVID-19 and the acceptance of control measures among community members. METHODS: We conducted an exploratory qualitative study using a purposive sampling approach, at two communities of Karachi, Pakistan. In-depth interviews were conducted with community members including, young, middle-aged and older adults of both genders. Study data were analysed manually using the conventional content analysis technique. RESULTS: A total of 27 in-depth virtual interviews were conducted, between May and June 2020. Six overarching themes were identified: (1) community knowledge and perceptions around COVID-19; (2) trusted and preferred sources of health information; (3) initial thoughts and feeling towards COVID-19 pandemic; (4) community practices to prevent exposure from COVID-19; (5) perceived risks associated with poor adherence to infection control practices; and (6) future preparedness of community to avoid the second wave of the outbreak. Generally, community members had good knowledge about COVID-19, and positive behaviour and attitude towards using standard precautions. The knowledge is mainly acquired through electronic, print and social media platforms, which have pros and cons. However, some community members including younger individuals had poor adherence to safety measures. This may necessitate concentrated efforts to raise awareness through community mobilisation and sensitisation activities. CONCLUSION: This study provides an initial evidence base of communities' perceptions, and attitudes towards COVID-19 in an early stage of pandemic. The study emphasises that sufficient knowledge and awareness about COVID-19, adequate training and drills, and adherence to safety measures, are necessary to better prepare for the second wave of COVID-19.

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

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

When COVID-19 enters in a community setting: an exploratory qualitative study of community perspectives on COVID-19 affecting mental well-being.

OBJECTIVE: The COVID-19 pandemic has resulted in an increased level of anxiety and fear among the general population related to its management and infection spread. Considering the relevance of present circumstances, we explored perceptions and attitudes of community members towards their mental well-being during the COVID-19 pandemic. SETTING: We conducted an exploratory qualitative study using a purposive sampling approach, at two communities of Karachi, Pakistan. PARTICIPANTS: In-depth interviews were conducted with community members including, young adults, middle-aged adults and older adults of both genders. Study data were analysed manually using the thematic analysis technique. PRIMARY OUTCOME: The primary outcome is assessing community perception towards their mental well-being amidst the COVID-19 pandemic. RESULTS: A total of 27 in-depth interviews were conducted, between May and June 2020. Three overarching themes were identified: (1) impact of COVID-19 on the mental health of the general communities; (2) current coping mechanisms to adapt to the new reality and (3) recommendations to address the mental health of communities. Generally, community members underwent increased anxiety and fear due to the contagious nature of the virus. Alongside, social, financial and religious repercussions of the pandemic have also heightened psychological distress among community members. However, community members were able to point out some of the coping mechanisms such as getting closer to God, connecting with family, participating in mental health sessions and resetting lives by indulging in diverse activities. Simultaneously, they also recommended the need for remote mental health services for elders and continuous efforts by the government to address the mental health needs of the community. CONCLUSION: COVID-19-associated mental health consequences have hit every individual in society. The study finding has the potential to guide the development of context-specific innovative mental health programmes to overcome the pandemic repercussions.

Digitalisation provisions for controlling depression in developing countries: Short review.

Depression is a global health issue which is associated with disability, absenteeism, decreased productivity and high suicide rates. It is the fourth most common cause of disability globally and by the year 2020 it will be the second leading cause of disease burden. In Pakistan, the prevalence of depression is 45.9%. A unique and promising method for addressing the issue is mobile health (m-health). It refers to the utilisation of mobile technology to support various aspects of healthcare. Electronic record, SMS, internet, wearable devices and mobile applications are some of the digitalisation approaches used to bridge the treatment gap in depression through assuring privacy of patients, improving accessibility, reducing taboos related to depression, save cost for patients and reduce hospital burden and consultation time; these will be accessible in remote areas as well. Therefore, this short review is aimed to highlight the m-health forecasting for controlling depression and positional use in developing countries.

Using mobile phones to improve young people sexual and reproductive health in low and middle-income countries: a systematic review to identify barriers, facilitators, and range of mHealth solutions.

BACKGROUND: Globally, reproductive health programs have used mHealth to provide sexual and reproductive health (SRH) education and services to young people, through diverse communication channels. However, few attempts have been made to systematically review the mHealth programs targeted to improve young people SRH in low-and-middle-income countries (LMICs). This review aims to identify a range of different mHealth solutions that can be used for improving young people SRH in LMICs and highlight facilitators and barriers for adopting mHealth interventions designed to target SRH of young people. METHODS: Databases including PubMed, CINAHL Plus, Science Direct, Cochrane Central, and grey literature were searched between January 01, 2005 and March 31, 2020 to identify various types of mHealth interventions that are used to improve SRH services for young people in LMICs. Of 2948 titles screened after duplication, 374 potentially relevant abstracts were obtained. Out of 374 abstracts, 75 abstracts were shortlisted. Full text of 75 studies were reviewed using a pre-defined data extraction sheet. A total of 15 full-text studies were included in the final analysis. RESULTS: The final 15 studies were categorized into three main mHealth applications including client education and behavior change communication, data collection and reporting, and financial transactions and incentives. The most reported use of mHealth was for client education and behavior change communication [n = 14, 93%] followed by financial transactions and incentives, and data collection and reporting Little evidence exists on other types of mHealth applications described in Labrique et al. framework. Included studies evaluated the impact of mHealth interventions on access to SRH services (n = 9) and SRH outcomes (n = 6). mHealth interventions in included studies addressed barriers of provider prejudice, stigmatization, discrimination, fear of refusal, lack of privacy, and confidentiality. The studies also identified barriers to uptake of mHealth interventions for SRH including decreased technological literacy, inferior network coverage, and lower linguistic competency. CONCLUSION: The review provides detailed information about the implementation of mobile phones at different levels of the healthcare system for improving young people SRH outcomes. This systematic review recommends that barriers to uptake mHealth interventions be adequately addressed to increase the potential use of mobile phones for improving access to SRH awareness and services. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018087585 (Feb 5, 2018).

Physical Maltreatment and Its Associated Factors Among Adolescents in Karachi, Pakistan.

In many developing countries, physical child maltreatment is considered as an acceptable disciplinary strategy. The aim of this study was to identify factors associated with physical maltreatment among adolescents in Karachi, Pakistan. A survey of 800 adolescents was done using a structured questionnaire adopted by The International Society for the Prevention of Child Abuse and Neglect. Multiple linear regression methods were used to measure the factors associated with child physical maltreatment. The mean physical score was 17.5 ± 4.9, whereas the minimum and maximum score was 11 and 40, respectively. The total variability in physical scores was found to be 42% explained by child's gender, child's age, sibling abuse, verbal abuse/ quarreling within family, child's height, socioeconomic wealth index, marital status, interaction between parental exposure to childhood abuse and physical fighting using hard object, interaction between parental education and age of mother, and interaction between parental history of psychiatric illness and physical fighting by parents.

Neutrophils to Lymphocyte Ratio: Earliest and Efficacious Markers of Sepsis.

Background Neutrophil to lymphocyte ratio (NLR) can be easily calculated from the white cell differential count and is considered an auspicious marker for predicting different diseases, including sepsis. In this study, we aimed to compare the efficacy of NLR as a sepsis marker by comparing it with other markers of sepsis, such as C-reactive protein (CRP), procalcitonin, and the Sequential Organ Failure Assessment (SOFA) score. Methods A cross-sectional analytical study was conducted at the Aga Khan University Hospital from July 2019 to December 2019. A total of 168 patients who were admitted to the medicine department with a diagnosis of sepsis on arrival or during the hospital stay were enrolled. The neutrophil to lymphocyte ratio was calculated to form venous samples taken on admission and compared to the level of CRP, procalcitonin, culture reports, and the SOFA score as a predictor of sepsis. Results Out of 168 patients, 55.3% were male. The median age of the participants was 68.40 (interquartile range (IQR): 19.5) years in males and 64.0 (IQR: 18.0) in females. Procalcitonin was performed in 121 (72%) and CRP performed in 61 (36.3%) patients. The NLR showed significant associations with all the tested lab parameters of sepsis, such as CRP (p = 0.02), procalcitonin (p = 0.01), and SOFA score (p = 0.01). Values when analyzed according to culture-positive showed higher values in culture-positive samples but were not statistically significant. Conclusion Neutrophil to lymphocyte ratio is a cheap and rapidly available predictor of sepsis and has shown a significant correlation with other relatively expensive and non-rapidly existing markers of inflammation and sepsis. However, large prospective studies are needed to prove its real effectiveness as a marker of sepsis and its prognosis.