'Those whom I have to talk to, I can't talk to': Perceived social isolation in the context of anxiety symptoms among pregnant women in Pakistan.

Anxiety during pregnancy is highly prevalent in low- and middle-income countries. The relative importance of different sources and types of perceived support in the Pakistani context is unknown. We explored social support during pregnancy and the role of social isolation in Pakistani women's experiences of antenatal anxiety. We conducted semi-structured interviews with 19 pregnant women with symptoms of anxiety and 10 female healthcare providers at a public urban hospital. We used inductive and deductive thematic coding to analyse the data. Many pregnant women reported feelings of physical and social isolation, even when living in joint families with larger social networks. Often fearing censure by their in-laws and peers for sharing or seeking help with pregnancy-related anxieties, women reported relying on husbands or natal family members. Normative expectations around pregnancy such as male gender preference, perceived immutability of wives' domestic responsibilities and expectations of accompanied travel by women may serve as sources of disconnectedness in the antenatal period. Providers viewed social isolation and deficits in social support during pregnancy as contributing to worse anxiety symptoms, reduced access to care and poorer health behaviours. One limitation is that the hospital setting for this study may have resulted in underreporting of abuse or neglect and limited inclusion of pregnant women who do not utilise facility-based antenatal care. In conclusion, husbands and natal families were key in reducing social isolation in pregnancy and mitigating anxiety, while in-laws did not always confer support. Targeted strategies should enhance existing support and strengthen in-law family relationships in pregnancy.

Intersections between patient-provider communication and antenatal anxiety in a public healthcare setting in Pakistan.

This study explores pregnant women's and healthcare providers' perspectives on the role of patient-provider communication in experiences of antenatal anxiety within a low-resource setting. In 2017-18, we consecutively sampled pregnant women (n = 19) with at least mild anxiety and purposively sampled antenatal care providers (n = 10) from a public hospital in Punjab Province, Pakistan. We then conducted in-depth interviews and thematically coded them with a combination of inductive and deductive coding methodologies. We found that patients expressed a desire for warm, empathetic communication from providers who demonstrate respect, attentiveness, and a shared lived experience. Providers revealed an awareness that their heavy caseloads, high stress levels, and discourteous tones adversely influenced communication with pregnant women and may exacerbate their anxieties, but also reported that compassionately addressing women's concerns, providing financial problem-solving and/or assistance, and moderating conflicting healthcare desires between patients and their families could alleviate anxiety in pregnant women. Patients reported feelings of anxiety stemming from a belief that they received lower quality communication from antenatal providers at public hospitals than patients received from antenatal providers at private hospitals, an experience that they partially attributed to their low socioeconomic status. Meanwhile, some providers disclosed potentially stigmatizing views of women from particular sociocultural backgrounds or low socioeconomic status, including perceptions that appeared to shape communication with these patients in antenatal care encounters. Our findings provide preliminary evidence that communication between pregnant women and antenatal providers that is warm, normalizes patient fears, and integrates patients' interpersonal and financial considerations can mitigate pregnant women's experiences of anxiety and reduce barriers to accessing antenatal care in Pakistan's public healthcare facilities.

"A Woman Is a Puppet." Women's Disempowerment and Prenatal Anxiety in Pakistan: A Qualitative Study of Sources, Mitigators, and Coping Strategies for Anxiety in Pregnancy.

Common mental disorders are highly prevalent among pregnant women in low- and middle-income countries, yet prenatal anxiety remains poorly understood, particularly in the sociocultural context of South Asia. Our study explored sources, mitigators, and coping strategies for anxiety among symptomatic pregnant women in Pakistan, particularly in relation to autonomy in decision-making and social support. We interviewed 19 pregnant married women aged 18-37 years recruited from 2017-2018 at a public hospital in Rawalpindi who screened positive for anxiety. Thematic analysis was based on both inductive emergent codes and deductive a priori constructs of pregnancy-related empowerment. Gender norms emerged as an important dimension of Pakistani women's social environment in both constraining pregnancy-related agency and contributing to prenatal anxiety. Women's avenues of self-advocacy were largely limited to indirect means such as appeals to the husband for intercession or return to her natal home. The levels of autonomy during pregnancy depended on the area of decision-making, and peer/family support was a critical protective factor and enabling resource for maternal mental health. Women's disempowerment is a key contextual factor in the sociocultural experience of prenatal maternal anxiety in South Asia, and further examination of the intersections between empowerment and perinatal mental illness might help inform the development of more context-specific preventive approaches.

Hemoglobin structure at higher levels of hemoglobin A1C in type 2 diabetes and associated complications.

BACKGROUND: Fourier transform infrared (FTIR) spectroscopy technique has not been used as a diagnostic tool for diabetes in clinical practice. This study was linked to structural changes in hemoglobin (Hb) in type 2 diabetes patients at higher levels of HbA1C using FTIR spectroscopy. METHODS: Fifty-three diabetic patients from the Bahawal Victoria Hospital, Bahawalpur, Pakistan were categorized as group A (6% < HbA1C < 7%; n = 25) and group B (HbA1C ≥9%; n = 28). Another group (group N) of twenty blood samples was taken from healthy people from the Islamia University Bahawalpur, Pakistan. Data from all groups were collected from January 1, 2018 to March 31, 2019. The structure of Hb was studied by FTIR spectroscopy and impact of glucose on the fine structure of HbA1C was estimated. RESULTS: Hb secondary structure erythrocyte parameters were altered by changing glucose concentrations. From FTIR spectra of all three groups it was found that Hb structure was slightly altered in group A, but significantly changed in group B (P < 0.05). There was an increase in ß-sheet structure and a reduction in α-helix structure at elevated levels of HbA1C (group B) in type 2 diabetes. CONCLUSION: We suggest that higher level of glycation reflected by increased HbA1C might be a contributing factor to structural changes in Hb in type 2 diabetic patients. FTIR spectroscopy can be a novel technique to find pathogenesis in type 2 diabetes.

Development of a Psychological Intervention to Address Anxiety During Pregnancy in a Low-Income Country.

Background: One in five women suffer from anxiety during pregnancy. Untreated anxiety is a risk factor for postnatal depression and is associated with adverse birth outcomes. Despite the high prevalence of prenatal anxiety in low- and middle-income countries (LMICs), efforts to develop and evaluate context-specific interventions in these settings are lacking. We aimed to develop a culturally appropriate, feasible, and acceptable psychological intervention for perinatal anxiety in the context of a low-income population in Pakistan. Methods: We conducted this research in Rawalpindi District at the Obstetrics Department of the Holy Family Hospital, Rawalpindi Medical University a government facility catering to a mixture of low-income urban, peri-urban, and rural populations. We used a mixture of research methods to: a) investigate the clinical, cultural, and health-service delivery context of perinatal anxiety; b) select an evidence-based approach that suited the population and health-delivery system; c) develop an intervention with extensive reference documentation/manuals; and d) examine issues involved in its implementation. Qualitative data were collected through in-depth interviews and focus group discussions, and analyzed using framework analysis. Results: Informed by the qualitative findings and review of existing evidence-based practices, we developed the "Happy Mother, Healthy Baby" intervention, which was based on principles of cognitive behavior therapy. Its evidence-based elements included: developing an empathetic relationship, challenging thoughts, behavior activation, problem solving, and involving family. These elements were applied using a three-step approach: 1) learning to identify unhealthy or unhelpful thinking and behavior; 2) learning to replace unhealthy or unhelpful thinking and behavior with helpful thinking and behavior; and 3) practicing thinking and acting healthy. Delivered by non-specialist providers, the intervention used culturally appropriate illustrations and examples of healthy activities to set tasks in collaboration with the women to encourage engagement in helpful behaviors. Feedback from the non-specialist providers indicated that the intervention was acceptable, feasible, and perceived to be helpful by the women receiving it. Conclusion: This new psychosocial intervention for perinatal anxiety, based on principles of cognitive behavior therapy and delivered by non-specialists, has the potential to address this important but neglected condition in LMICs.

Attenuated total reflectance spectroscopy to diagnose skin cancer and to distinguish different metastatic potential of melanoma cell.

Early diagnosing of skin cancer and investigation of metastatic potential of cancer cells are very important to treat it appropriately. Infrared spectroscopy of biological tissues is an emerging technique which gives the spectral differences between healthy and diseased cells. In this work, we have demonstrated that attenuated total reflectance Fourier transform (ATR-FTIR) spectroscopy can be used in diagnostic of skin cancer and in differentiating metastatic potential of cancer cells. Using IR spectroscopy, we can identify various types of cancer such as basal cell carcinoma, malignant melanoma, nevus and metastatic potential by alternations in hydration level and molecular changes. We examined biopsy of different types of cancer cells to diagnose skin cancer at early stages by using FTIR spectroscopy. To differentiate metastases we examined two human melanoma cells of same patient but at different metastatic potential and two murine melanoma cells with common genetic background but different metastatic potential. Our findings revealed that melanoma changes the permeability of cell membrane and higher metastatic potential is related to the hydration level of cell membrane. Thus, ATR-FTIR spectroscopy is a potential technique to help in early diagnosing of skin cancer and to differentiate different metastatic potentials.

A comparative study of RapidArc and intensity-modulated radiotherapy plan quality for cervical cancer treatment.

BACKGROUND: RapidArc therapy, a complex form of intensity-modulated radiotherapy (IMRT), is now widely used to treat cancer patients. AIMS: This study aimed to investigate and compare the plan quality of IMRT and RapidArc techniques using various dosimetric indices to find the better treatment modality for treating patients with cervix cancer. MATERIALS AND METHODS: Thirteen cervical cancer patients treated with IMRT were selected for analysis and original plans were subsequently re-optimized using the RapidArc technique. Plans were generated such that dose of 5000 cGy was delivered in 25 equal fractions. Inverse planning was done by Eclipse (Varian Medical Systems, Palo Alto, CA) treatment planning system for 15 MV photon beams from computed tomographic data. Double arcs were used for RapidArc plans. Quality of treatment plans was evaluated by calculating conformity index (CI), homogeneity index (HI), gradient index (GI), coverage, and unified dosimetry index (UDI) for each plan. RESULTS AND CONCLUSION: RapidArc resulted in better planning target volume (PTV) coverage as is evident from its superior conformation number, coverage, CI, HI, GI, and UDI. Regarding organs at risk (OARs), RapidArc plans exhibit superior organ sparing as is evident from integral dose comparison. Difference between both techniques was determined by statistical analysis. For all cases under study, modest differences between IMRT and RapidArc treatment were observed. RapidArc-based treatment planning is safer with similar planning goals compared to the standard fixed IMRT technique. This study clearly demonstrated that favorable dose distribution in PTV and OARs was achieved using RapidArc technique, and hence, the risk of damage to normal tissues is reduced.