Preparedness and impact of COVID 19 infection at tertiary care neurology centers in Pakistan.

OBJECTIVE: We aimed to assess the response and impact of covid 19 pandemic at tertiary care centers in Pakistan especially pertaining to neurological care, facilities and training. METHODS: A pre-tested survey form was sent to 40 neurology tertiary care centers in all the provinces in the country in the first week of July 2020. 33 filled forms were received, out of which 18 were public (government) and 15 were private hospitals. RESULTS: Estimated 1300 HCW (faculty, medical officers, trainees and nurses) work at these 33 participating centers. There were 17 deaths among HCW (1.3%) at ten centers. Sufficient personal protective equipment (PPE) were provided to 158 HCW (12%). 129 (10%)HCW tested positive for COVID 19 at 31 centers including trainees/medical officers (39), consultants (29) and nursing and other staff (61). Due to low neurology admissions, 23/33 hospitals (70%) posted neurology trainees in COVID 19 units to contribute to covid care. Less than 50% hospitals did covid screening PCR before admission to neurology wards. Only 10% hospitals provide training and regular update to HCW. Neurology tele-health services were started for clinically stable patients at 15 (45%) centers. Only 60% neurology training programs were able to start online training. Ongoing research studies and trials focusing neurological manifestations of COVID-19 were done at 10 (30%) centers. Modification of facilities for COVID patients showed that 24(72%) hospitals strictly reduced the number of attendants accompanying patients. Only 10 (30%) centers had neurophysiological tests being conducted on COVID-19 patients. Mental health support services to HCW were provided at 12 (36%) centers. CONCLUSIONS: Among HCW 10% tested positive for covid and 1.3% died. Mental health support services offered for HCW were available in 36% institutions. Neurology training was substantially affected due to low admissions, limited ward rounds and limited availability of online training.

Association of long non-coding RNA MIAT and MALAT1 expression profiles in peripheral blood of coronary artery disease patients with previous cardiac events.

Long non-coding RNAs (lncRNAs) are implicated in various cellular and pathological processes. Two lncRNAs, myocardial infarction-associated transcript (MIAT) and metastasis-associated lung adenocarcinoma transcript 1 (MALAT1), may be involved in the pathogenesis of coronary artery disease (CAD). Here, we aimed to determine the relative circulating levels of MIAT and MALAT1 in 110 stable CAD patients and 117 controls and to correlate their levels with the clinical and laboratory data. Peripheral blood expression levels were quantified by Real-Time qPCR. The median MIAT expression level in CAD patients was significantly 12-fold higher than controls (p<0.001). Otherwise, the median MALAT1 expression level was comparable in patient and control groups. Both lncRNAs showed significantly higher relative expression levels in patients with positive history of previous cardiac ischemic events, and MIAT showed significantly higher expression in diabetic CAD patients. The area under the curve of MIAT (0.888 ± 0.02 with sensitivity 95.5% and specificity 72.7%), was significantly larger than that of MALAT1 (0.601 ± 0.04 with sensitivity 50% and specificity 63.6%) for detecting the presence of significant CAD. The current findings suggest that lncRNA MIAT could have a diagnostic significance in CAD patients. MALAT1 levels, however, are not sufficiently reliable to have much clinical use in our cases.

Perspective About Mental Illnesses: A Survey Of Health Care Providers Of Abbottabad.

BACKGROUND: Mental Health problems are widespread globally and are the leading causes of disability. The lives of people living with mental illnesses are often drastically altered by the symptoms of the illness and made worse by the society's reaction. Stigmatizing attitude among general population is prevalent. Relatively less research has been done to explore the attitude of health care providers towards mental illness especially so in Pakistan. This study aims to investigate views of healthcare providers of Abbottabad regarding mental illnesses. METHODS: A cross-sectional study was conducted in major hospitals and medical institutes of Abbottabad wherein 640 selfadministered questionnaires based on Opening Minds Scale for Healthcare Providers (OMS-HC) were distributed among healthcare providers selected through non-probability convenience sampling; 553 (86.41%) were returned. Data was collected from June to September 2016 and analyzed using SPSS-16.0. RESULTS: The mean age of the participants is 26.12 years±7.612. Majority 346 (62%) were medical students, 60 (10.8%) were teachers, 50 (9%) were house officers, 70 (12.7%) were trainee medical officers, 27 (4.9%) were consultants. There were 313 (56.6%) females. The highest degree of stigma was observed among the 'Attitudes' of the people while it was relatively lower in Disclosure and Help Seeking domain and least in the factor of Social Distance. CONCLUSIONS: Stigma associated with mental illness is prevalent among healthcare providers..

Hyperammonemia Is Associated with Increasing Severity of Both Liver Cirrhosis and Hepatic Encephalopathy.

Background. Hyperammonemia resulting from chronic liver disease (CLD) can potentially challenge and damage any organ system of the body, particularly the brain. However, there is still some controversy regarding the diagnostic or prognostic values of serum ammonia in patients with over hepatic encephalopathy, especially in the setting of acute-on-chronic or chronic liver failure. Moreover, the association of serum ammonia with worsening Child-Pugh grade of liver cirrhosis has not been studied. Objective. This study was conducted to solve the controversy regarding the association between hyperammonemia and cirrhosis, especially hepatic encephalopathy in chronically failed liver. Material and Methods. In this study, 171 cirrhotic patients had their serum ammonia measured and analyzed by SPSS version 16. Chi-squared test and one-way ANOVA were applied. Results. The study had 110 male and 61 female participants. The mean age of all the participants in years was 42.33 ± 7.60. The mean duration (years) of CLD was 10.15 ± 3.53 while the mean Child-Pugh (CP) score was 8.84 ± 3.30. Chronic viral hepatitis alone was responsible for 71.3% of the cases. Moreover, 86.5% of participants had hepatic encephalopathy (HE). The frequency of hyperammonemia was 67.3%, more frequent in males (N = 81, z-score = 2.4, and P < 0.05) than in females (N = 34, z-score = 2.4, and P < 0.05), and had a statistically significant relationship with increasing CP grade of cirrhosis (χ2(2) = 27.46, P < 0.001, Phi = 0.40, and P < 0.001). Furthermore, serum ammonia level was higher in patients with hepatic encephalopathy than in those without it; P < 0.001. Conclusion. Hyperammonemia is associated with both increasing Child-Pugh grade of liver cirrhosis and hepatic encephalopathy.

And Yet One More Adds To The Sorrow.

Chikungunya is one of the vector borne diseases. It is caused by Chikungunya virus, an alpha virus, spread by the bite of female Aedes mosquito. Chikungunya is a non-fatal, self-limiting Dengue like illness which is characterized by high grade fever, headache, skin rash, and prolong debilitating arthralgia mostly affecting peripheral small joints. Treatment is usually supportive for the symptoms which includes antipyretic, analgesics and anti-inflammatory drugs. Current outbreak in Karachi is the first declared outbreak in Pakistan. To control the current outbreak, integrated vector management approach must be used to control Aedes not only to combat the current outbreak but also to reduce the endemicity and to prevent introduction of other Aedes borne diseases.

NAEGLARIA FOWLERI: THE BRAIN EATING AMOEBA OR AN ENIGMA?

Naeglaria fowleri (N. fowleri), popularly known as the brain eating amoeba is the causative agent of the fulminant disease, primary amoebic meningoencephalitis (PAM). Although a rare disease, it is a threat to human health with a case fatality rate ranging from 95-99%. PAM cases have been reported from the United States of America, Australia, Europe and Asia. From 1962 to 2014, 133 people have been infected by N. fowleri in the USA, out of which only three have survived. None of the PAM cases reported in Pakistan so far has survived. This underscores the importance to identify factors, which have led to the failure in decreasing case fatality associated with N. fowleri despite major advances in medical technology, health care; and prevention and control strategies since the first reported case in 1965. We need to focus on eliciting risk factors of the disease prevalent in our part of the world, which are at variance with the developed world. A predominant number. of PAM cases in the West are reported in young males who had participated in recreational activities. However, majority of cases reported in Pakistan are also among young males but they were linked with the religious practice of ablution. What is required to better understand and hence manage this enigma is further research. Further research is to be conducted to discover potent antimicrobials, to test the effectiveness of the new transcribial device in managing PAM, and to identify host factors, which make an individual susceptible to N. fowleri. Investigation of environmental factors related to N. fowleri also needs to be done. Doing so is of paramount importance, as it will help identify the preventive strategies to be employed against N. fowleri.

RUBELLA--SHOULD IT BE A PRIORITY IN THE NATIONAL IMMUNIZATION PROGRAMMES?

Rubella is a mild infection of childhood and young adults with 75% of cases occurring in age group 15-45 years. In unvaccinated populations, rubella usually occurs in spring with epidemics in 6-9 years cycles. Rubella has devastating effects on growing foetus if contracted by women in the first trimester of pregnancy. Perinatal infection of Rubella contributes to 2-3% of all congenital anomalies. Over the past three decades many resource risk countries have introduced universal or selective immunization programs against rubella with evidence that such interventions reduce the incidence of congenital rubella syndrome. In Pakistan the schedules of the Expanded Program on Immunization (EPI) do not include immunization against rubella and evidence is needed to estimate the risk of congenital rubella with a view to start immunization programmes to combat the menace of Congenital Rubella Syndrome (CRS). Logistically it is easy to add rubella vaccine to the already existing EPI schedules as measles is given on 9th and 15 month with little implications for cost, resulting in great reduction in CRS.

National program for family planning and primary health care Pakistan: a SWOT analysis.

BACKGROUND: The National Program for Family Planning and Primary Healthcare was launched in 1994. It is one of the largest community based programs in the world, providing primary healthcare services to about 80 million people, most of which is rural poor. The program has been instrumental in improving health related indicators of maternal and child health in the last two decades. METHODS: SWOT analysis was used by making recourse to the structure and dynamics of the program as well as searching the literature. SWOT ANALYSIS: Strengths of the program include: comprehensive design of planning, implementation and supervision mechanisms aided by an MIS, selection and recruitments processes and evidence created through improving health impact indicators. Weaknesses identified are slow progress, poor integration of the program with health services at local levels including MIS, and de-motivational factors such as job insecurity and non-payment of salaries in time. Opportunities include further widening the coverage of services, its potential contribution to health system research, and its use in areas other than health like women empowerment and poverty alleviation. Threats the program may face are: political interference, lack of funds, social threats and implications for professional malpractices. CONCLUSION: Strengthening of the program will necessitate a strong political commitment, sustained funding and a just remuneration to this bare foot doctor of Pakistan, the Lady Health Worker.

Awareness among barbers about health hazards associated with their profession.

BACKGROUND: Barbers are important professionals of the community which are still owned, cared and financed by the community especially the rural one. Barbers besides performing duties in social events like marriage, circumcision etc is also responsible for hair and nail cutting. In urban settings they have developed their profession by incorporating facial massage and make-up. It is the need of their profession to utilize instruments like knife, blades etc. The objective of the study was to assess awareness among barbers regarding health hazards related to their profession and to identify professional practices linked with infection transmission. METHODS: This descriptive cross sectional study was conducted in Kharian city of district Gujrat, located almost mid-way between Lahore and Islamabad, from June 2003 to September 2003. Sample of 50 barbers were selected by simple random sampling technique. Data was collected by using a semi-structured questionnaire and a checklist. Data was analyzed using SPSS 10. RESULTS: The mean age of barbers interviewed was 33.3 years with SD +/- 8.3. It was found that 29 (58%) barbers denied about any health hazards associated with their profession whereas 21 (42%) had knew about hepatitis, AIDS; they also described the role of contaminated blades, clips, towels, apron, and combs in causing skin problems. It was observed that 90% of barbers did not wash hands, 80% did not change the apron, 66% did not change towel during barbering services to different customers. Besides 7 (14%) barbers were also performing minor surgeries like circumcision, in growing toe nail excision and abscess drainage. There was significant difference in level of awareness among barbers in respect of age; educational status and duration of working. Age group (15-25) had better knowledge about the health hazards than barbers in age group (26-50). There is a significant difference (p < 0.05) in the awareness of those who got formal education. As for the effect of media on the knowledge of these workers, it was observed that 78% of them had the access to TV and out of these 69% had significant knowledge about health hazards related to barbering profession. CONCLUSION: The level of knowledge among barbers about health hazards associated with their profession is very poor. Majority of them do not have any perception of unhealthy working practices in barbering. Awareness about threat of receiving hazardous infection from their customers is also unsatisfactory.

Etiology, presentation and management outcome of pneumothorax.

BACKGROUND: This study was carried to determine etiology, presentation, complications and management outcomes of pneumothorax in patients presenting at two hospitals in NWFP province of Pakistan.. METHODS: Pneumothorax patients reporting at the chest unit of Post Graduate Medical Institute, Lady Reading Hospital, Peshawar, and Pulmonology unit of Ayub Teaching Hospital, Abbottabad from 1999 to 2002 were included in the study. Patients of all ages were included. They were admitted and followed up to the full recovery/late complications. RESULTS: A total of 146 pneumothorax patients reported during this period. Majority of the patients were diagnosed to have pneumothorax due to pulmonary tuberculosis making about 36.30% of the total cases. Second most common cause was primary spontaneous pneumotihorax (19.86%). Bacterial infections were also sizeable at 16.43%. Other causes included COPD, Asthma, latrogenic, Interstitial lung disease, tuberous sclerosis and bronchiectasis. CONCLUSION: It was concluded from this study that pulmonary tuberculosis is the commonest cause of pneumothorax in our setup.