Heated tobacco products- well known or well understood? A national cross-sectional study on knowledge, attitudes and usage in Pakistan.

BACKGROUND: Heated tobacco products (HTPs) are reshaping the tobacco industry and just recently, a plan was sought to regularize HTPs in Pakistan. Pakistan provides an intriguing case study in this context, as tobacco use is deeply ingrained in public use. To ensure that future evidence-based policy recommendations are grounded in the public's knowledge, attitudes, and usage of HTPs, a nationwide survey must be conducted. METHODS: A cross-sectional study was conducted using an online-based questionnaire nationwide in Pakistan. The questionnaire was validated and distributed through convenience sampling. The questionnaire assessed participants' knowledge, attitudes, and usage of HTPs. Descriptive statistics was used to describe participants' response and linear regression was performed at a p-value of < 0.05 using SPSS version 26. RESULTS: In our sample of 1195 respondents (mean age of 33 years, 41.8% males and 58.2% females), 54.7% had previously heard about HTPs and 16.9% reported using HTPs at least once. Additionally, 38.24% were unsure of the legality of HTP use. Those with monthly household incomes of PKR 100,000 to 500,000, were more likely to have higher knowledge scores (OR:1.80[1.07-3.04]). On the other hand, males (OR:0.70 [0.55-0.89]) and respondents from Balochistan (OR:0.40 [0.22-0.71]) were more likely to have lower knowledge scores. The strongest motivators were the enjoyability of HTPs (55.73%) and usage as a cigarette alternative (54.64%), while the strongest deterrents were the negative health effects (82.68%) and potential for addiction (81.01%). CONCLUSION: Our study underscores the need for awareness campaigns and interventions concerning HTPs, given prevalent preconceived notions and mixed attitudes among respondents. It was found that women and households with higher incomes scored higher on knowledge. Subjective enjoyment and a substitute for cigarettes were important motivators, but the most mentioned deterrents were the possibility of addiction and the detrimental effects on health. These insights form the basis for informed policy making for non-cigarette tobacco products.

Integrated AI-driven optimization of Fenton process for the treatment of antibiotic sulfamethoxazole: Insights into mechanistic approach.

Antibiotics, as a class of environmental pollutants, pose a significant challenge due to their persistent nature and resistance to easy degradation. This study delves into modeling and optimizing conventional Fenton degradation of antibiotic sulfamethoxazole (SMX) and total organic carbon (TOC) under varying levels of H2O2, Fe2+ concentration, pH, and temperature using statistical and artificial intelligence techniques including Multiple Regression Analysis (MRA), Support Vector Regression (SVR) and Artificial Neural Network (ANN). In statistical metrics, the ANN model demonstrated superior predictive accuracy compared to its counterparts, with lowest RMSE values of 0.986 and 1.173 for SMX and TOC removal, respectively. Sensitivity showcased H2O2/Fe2+ ratio, time and pH as pivotal for SMX degradation, while in simultaneous SMX and TOC reduction, fine tuning the time, pH, and temperature was essential. Leveraging a Hybrid Genetic Algorithm-Desirability Optimization approach, the trained ANN model revealed an optimal desirability of 0.941 out of 1000 solutions which yielded a 91.18% SMX degradation and 87.90% TOC removal under following specific conditions: treatment time of 48.5 min, Fe2+: 7.05 mg L-1, H2O2: 128.82 mg L-1, pH: 5.1, initial SMX: 97.6 mg L-1, and a temperature: 29.8 °C. LC/MS analysis reveals multiple intermediates with higher m/z (242, 270 and 288) and lower m/z (98, 108, 156 and 173) values identified, however no aliphatic hydrocarbon was isolated, because of the low mineralization performance of Fenton process. Furthermore, some inorganic fragments like NH4+ and NO3- were also determined in solution. This comprehensive research enriches AI modeling for intricate Fenton-based contaminant degradation, advancing sustainable antibiotic removal strategies.

Decomposing acute malnutrition by educational inequality of mother's among under five children in Jammu and Kashmir.

Health outcomes in the state of Jammu and Kashmir have shown improvement in recent decades. However, nutritional achievements, particularly among children under the age of five, have not seen similar progress. Various factors influence the nutritional status of this age group, with the socio-cultural and biological attributes of mothers being considered significant determinants. While some studies have examined these attributes, there is a scarcity of research exploring the causal link between socio-culturally determined factors, such as maternal education, and child nutritional achievements, especially in Indian states located in North India. This paper aims to address this gap by analysing the prevalence of acute malnutrition (stunting) among children under five in Jammu and Kashmir in relation to educational inequality among mothers. The latest round of the National Family Health Survey (NFHS-5) is used to assess the levels of stunting (low height for age) among children, considering the literacy status of mothers and other control variables. Bivariate and multivariable methods are employed to study the association and identify risk factors. Additionally, the Oaxaca decomposition method is used to analyse the educational gap in factors associated with child stunting. The results indicate a higher prevalence of stunting among children of uneducated mothers (29%) compared to those of educated mothers (25%). The findings demonstrate a lower risk of stunting among children whose mothers are literate (OR 0.89). The Oaxaca decomposition analysis reveals a statistically significant difference in stunting between children based on their mother's education. These results highlight the wide disparities in acute malnutrition among children due to variations in maternal education. It is therefore crucial for policymakers to prioritize efforts to reduce educational disparities in order to alleviate the nutritional burden faced by children.

Novel modeling and optimization framework for Navy Blue adsorption onto eco-friendly magnetic geopolymer composite.

The disproportionate potency of dyes in textile wastewater is a global concern that needs to be contended. The present study comprehensively investigates the adsorption of Navy-Blue dye (NB) onto bentonite clay based geopolymer/Fe3O4 nanocomposite (GFC) using novel statistical and machine learning frameworks in the following steps; (1) synthesis and characterization of GFC, (2) experimental testing and modelling of NB adsorption onto GFC following Box-Behnken design and three response surface prediction models namely stepwise regression analysis (SRA), Support vector regression (SVR) and Kriging (KR), (3) parametric, sensitivity, thermodynamic and kinetic analysis of pH, GFC dose and contact time on adsorption performance, and (4) finding global parametric solution of the process using Latin Hypercube, Sobol and Taguchi orthogonal array sampling and combining SRA-SVR-KR predictions with novel hybrid simulated annealing (SA)-desirability function (DF) approach. Under the given testing range, parametric/sensitivity analysis revealed the critical role of pH over others accounting ∼37% relative effect and primarily derived the NB adsorption. The statistical evaluation of models revealed that all models could be utilized for elucidating and predicting the NB removal using GFC, however, SVR accuracy was better among others for this particular work, as the overall computed root mean squared error was only 0.55 while the error frequency counts remained <1 for 90% predictions. GFC showed 86.29% NB removal for the given experimental matrix which can be elevated to 96.25% under optimum conditions. The NB adsorption was found to be physical, spontaneous, favorable and obeyed pseudo-2nd order kinetics. The results demonstrate the suitability of GFC as the promising cost-effective and efficient alternative for the decolourization of urban and drinking water streams and elucidate the potential of machine learning models for accurate prediction & elevation of adsorption processes with less experimentation in water purification applications.

Post-COVID-19 sequelae of the respiratory system. A single-centre experience reporting the compromise of the airway, alveolar and vascular components.

The long-term sequelae of COVID-19 have now become more common and appreciable. The SARS-CoV-2 virus can cause a variety of infectious and non-infectious pulmonary complications. The purpose of this study is to raise awareness about post-COVID-19 pulmonary sequelae, both infectious and non-infectious, in this geographical area. A retrospective study was conducted from July 1st 2020 to December 20th 2020. A total of 1200 patients were evaluated, with 83 suffering from post-COVID-19 pulmonary complications. The patients' mean age was 62 years (IQR 55-69), with 63 (75.9%) being male. The most common co-morbid illnesses were hypertension (49, 59%) and diabetes (45, 54.2%). The majority of them (37, 44.6%) had severe COVID-19, followed by critical COVID-19 (33, 39.8%). There was no statistically significant difference in recurrence of respiratory symptoms or duration of current illness between non-severe, severe, and critical COVID-19 patients. Non-infectious complications were observed in the majority of patients (n=76, 91.5%), including organizing pneumonia/ground glass opacities in 71 (88%) patients, fibrosis in 44 (55%), pulmonary embolism in 10 (12.5%), pneumomediastinum in 6 (7.4%) and pneumothorax in 7 (8.6%). Infective complications (25, 30.1%) included aspergillus infection in 10 (12.0%) and bacterial infection in 5 (8.47%), with more gram-negative infections and one patient developing Mycobacterium tuberculosis. Post COVID-19 mortality was 11 (13.3%). The long-term pulmonary sequelae of COVID-19 are not rare. Cryptogenic organizing pneumonia, ground glass opacities, and fibrosis were common post-COVID-19 sequelae in our patients. This necessitates frequent close monitoring of these patients in order to initiate early appropriate management and prevent further morbidity and eventual mortality.

Behavioural support and nicotine replacement therapy for smokeless tobacco cessation: protocol for a pilot randomised-controlled multi-country trial.

BACKGROUND: Smokeless tobacco (ST) is consumed globally by more than 350 million people, with approximately 85% of all users based in South and Southeast Asia. In this region, ST products are cheap and easily accessible. Evidence-based interventions to people quit ST use are lacking. This study aims to test the feasibility of conducting a future definitive trial of ST cessation, using a culturally adapted behavioural intervention, and/or nicotine replacement therapy (NRT) in three South Asian countries. METHODS: We will conduct a factorial design, randomised-controlled pilot trial in Bangladesh, India and Pakistan. Daily ST users will be recruited from primary health care settings in Dhaka, Noida and Karachi. Participants will be individually randomised to receive intervention A (4 or 6 mg NRT chewing gum for 8-weeks), intervention B (BISCA: face-to-face behavioural support for ST cessation), a combination of interventions A and B or usual care (Very Brief Advice - VBA). The participants will provide demographic and ST use related data at baseline, and at 6, 12 and 26 weeks of follow-up. Salivary cotinine samples will be collected at baseline and 26 weeks. The analyses will undertake an assessment of the feasibility of recruitment, randomisation, data collection and participant retention, as well as the feasibility of intervention delivery. We will also identify potential cessation outcomes to inform the main trial, understand the implementation, context and mechanisms of impact through a process evaluation and, thirdly, establish health resource use and impact on the quality of life through health economic data. DISCUSSION: The widespread and continued use of ST products in South Asia is consistent with a high rate of associated diseases and negative impact on the quality of life. The identification of feasible, effective and cost-effective interventions for ST is necessary to inform national and regional efforts to reduce ST use at the population level. The findings of this pilot trial will inform the development of larger trials for ST cessation among South Asian users, with relevance to wider regions and populations having high rates of ST use. TRIAL REGISTRATION: ISRCTN identifier 65109397.

Residual symptoms and the quality of life in individuals recovered from COVID-19 infection: A survey from Pakistan.

BACKGROUND: There remains scarcity of literature regarding the patient's health status post-COVID-19 infection. This study analyzes the prevalence of residual symptoms and quality of life (QoL) after COVID-19. METHODS: An anonymous online survey was administrated in Pakistan from November 2020 to April 2021 in COVID-19 survivors. The questionnaire used the 12-Item Short Form Health Survey (SF-12) to assess mental and physical QoL. Multivariate linear regression was used to explore factors associated with mental and physical QoL scores. RESULTS: A total of 331 COVID-19 survivors participated in our survey. Around 42.0% of the cohort reported within 1-3 months of diagnosis of COVID-19. The common residual symptoms were body aches (39.9%), low mood (32.6%), and cough (30.2%). Better physical QoL was associated with being male (adjusted beta: 3.328) and having no residual symptoms (6.955). However, suffering from nausea/vomiting during initial COVID-19 infection (-4.026), being admitted to the ICU during COVID-19 infection (-9.164), and suffering from residual body aches (-5.209) and low mood (-2.959) was associated with poorer QoL. Better mental QoL was associated with being asymptomatic during initial COVID-19 infection (6.149) and post-COVID (6.685), while experiencing low mood post-COVID was associated with poorer mental QoL (-8.253 [-10.914, -5.592]). CONCLUSION: Despite presumed "recovery" from COVID-19, patients still face a wide range of residual symptoms months after initial infection, which contributes towards poorer QoL. Healthcare professionals must remain alert to the long-lasting effects of COVID-19 infection and aim to address them appropriately to improve patients' QoL.

The effect of ivermectin on non-severe and severe COVID-19 disease and gender-based difference of its effectiveness.

The COVID-19 pandemic has led to mortality and morbidity since December 2019. Many possible treatment options have been advised till date. The role of ivermectin in the treatment of COVID-19 disease remains controversial. The aim of our study was to evaluate the effect of ivermectin in hospitalized patients with non-severe and severe COVID-19 disease. We conducted a retrospective cohort study that compared outcomes in 2 groups of COVID-19 patients hospitalized at the largest tertiary care center of Pakistan. The study group was given ivermectin along with standard treatment of covid-19 disease; the comparison group was not. Data on mortality, inflammatory markers such as C-reactive protein (CRP) and ferritin, length of hospital stay and baseline characteristics were collected from Aga Khan University's database from October 2020 till February 2021. Statistical analysis was done to determine the effectiveness of ivermectin in non-severe and severe COVID-19. Comparison of effectiveness of Ivermectin in both the genders was also conducted. The cohort included 188 patients out of which 90 were treated with ivermectin. Mortality and length of hospitalization was not found to be significantly different in the study group compared with the control group (5.6% vs 5.1%; p=0.87 and 5 days vs 4 days; p=0.27). Analysis of secondary outcomes did not yield statistically significant results, apart from ferritin levels which were significantly less in patients treated with ivermectin (547.1 vs 756.7; p=0.03). The ferritin and CRP levels in affected males were higher than in females on admission and discharge. Our findings suggest ivermectin does not significantly affect all-cause mortality, length of hospitalization and CRP levels in hospitalized COVID-19 patients. Large scale randomized controlled trials (RCTs) are required to further evaluate the role of ivermectin in covid-19 disease.

The environmental impact of inhaled therapy: making informed treatment choices.

When selecting the best inhaler and drug combination for a patient with respiratory disease, a number of factors should be considered. While efficacy and safety of medical treatments are always a priority, in recent years the environmental impacts of all aspects of life have become an increasingly necessary consideration and inhaled therapies are no exception. The carbon footprint of an item, individual or organisation is one of the most important and quantifiable environmental impacts, assessed by the amount of greenhouse gases (often expressed in terms of carbon dioxide equivalents) generated throughout the life cycle. The two most commonly prescribed and manufactured inhaler types worldwide are pressurised metered-dose inhalers (pMDIs) containing hydrofluorocarbon (HFC) propellants and dry powder inhalers (DPIs). Most of the carbon footprint of current pMDIs is a result of the propellants that they contain (HFC-134a and HFC-227ea, which are potent greenhouse gases). In comparison, the powder in DPIs is dispersed by the patient's own inhalation, meaning DPIs do not contain a propellant and have a lower carbon footprint than most pMDIs currently available. Soft mist inhalers are another propellant-free option: the device contains a spring, which provides the energy to disperse the aqueous medication. In this review, we examine the published data on carbon footprint data for inhalers, providing an analysis of potential implications for treatment decision making and industry initiatives.

Acceptance of COVID-19 Vaccine in Pakistan: A Nationwide Cross-Sectional Study.

Introduction The coronavirus disease 2019 (COVID-19) vaccine is available across various countries worldwide, with public-private partnerships ensuring all individuals are vaccinated through a phased approach. Irrespective of the geographical spread, several myths pertaining to the COVID-19 vaccine have stemmed, ultimately limiting the national administration of vaccines and rollouts. This study assessed the acceptance of the COVID-19 vaccine among the general public in Pakistan. Methods A pre-validated questionnaire was administered from January 2021 to February 2021 to assess the public attitude and acceptance of the COVID-19 vaccine. Logistic regression analyses were run to identify factors associated with the acceptance among the population. Results A total of 936 responses were elicited, where 15% perceived their risk of being infected at 20-30% with an overall 70% agreeing to be vaccinated if recommended. Multivariate analysis identified higher acceptance in the male gender, healthcare workers, and students. Of all, 66% respondents chose healthcare workers and public officials, whereas 15.6% chose scientific literature, and 12.9% chose social media as the most reliable source of COVID-19 information. Conclusion Given the relatively greater trust in healthcare providers for information regarding COVID-19, healthcare workers ought to be on the frontline for vaccine campaigns and public outreach efforts, with governmental efforts in addition to the promotion of scientific materials for population-level understanding.

Factors motivating smoking cessation: a cross-sectional study in a lower-middle-income country.

INTRODUCTION: Only one-quarter of smokers in Pakistan attempt to quit smoking, and less than 3% are successful. In the absence of any literature from the country, this study aimed to explore factors motivating and strategies employed in successful smoking cessation attempts in Pakistan, a lower-middle-income country. METHODS: A survey was carried out in Karachi, Pakistan, amongst adult (≥ 18 years) former smokers (individuals who had smoked ≥100 cigarettes in their lifetime but who had successfully quit smoking for > 1 month at the time of survey). Multivariable logistic regression, with number of quit attempts (single vs. multiple) as the dependent variable, was performed while adjusting for age, sex, monthly family income, years smoked, cigarettes/day before quitting, and having suffered from a smoking-related health problem. RESULTS: Out of 330 former smokers, 50.3% quit successfully on their first attempt with 62.1% quitting "cold turkey". Only 10.9% used a cessation aid (most commonly nicotine replacement therapy: 8.2%). Motivations for quitting included self-health (74.5%), promptings by one's family (43%), and family's health (14.8%). Other social pressures included peer-pressure to quit smoking (31.2%) and social avoidance by non-smokers (22.7%). Successful smoking cessation on one's first attempt was associated with being married (OR: 4.47 [95% CI: 2.32-8.61]), employing an abrupt cessation mode of quitting (4.12 [2.48-6.84]), and telling oneself that one has the willpower to quit (1.68 [1.04-2.71]). CONCLUSION: In Pakistan, smoking cessation is motivated by concern for self-health and family's health, family's support, and social pressures. Our results lay a comprehensive foundation for the development of smoking-cessation interventions tailored to the population of the country. IMPLICATIONS: Little is known about the patterns and strategies employed by smokers who are attempting to quit smoking, especially in lower-middle-income countries like Pakistan. Likewise, there are very few smoking cessation programs designed to assist in quitting. Our study will allow for a better understanding of the culture-specific motivating factors and strategies that most contributed to successful quit attempts. Based on these results, evidence based smoking cessation interventions can be developed tailored to the socioeconomic demographic of our country and region, including smoking cessation clinics and public outreach and media campaigns highlighting key elements of successful smoking cessation.

Violence against Healthcare Workers during the COVID-19 Pandemic: A Review of Incidents from a Lower-Middle-Income Country.

Background: Healthcare workers (HCWs) across the globe have met tremendous challenges during the COVID-19 (coronavirus disease 2019) pandemic, such as shortages of personal protective equipment, extensive work hours, and constant fear of catching the virus or transmitting it to loved ones. Adding on to the already existing burnout, an increase in incidents of violence and aggression against HCWs was seen in Pakistan and globally. Objectives: Primarily to review cases of violence against HCWs in Pakistan, highlighting and comparing the instigating factors seen within the country and globally. Secondly, to enlist possible interventions to counter workplace violence in healthcare during a pandemic and in general. Methods: Incidents of violence towards HCWs in Pakistan during the COVID-19 pandemic occurring between April 7, 2020, and August 7, 2020, were included. The incidents reported from local newspapers were reviewed. Findings and Conclusion: A total of 29 incidents were identified, with perpetrators of violence most commonly being relatives of COVID-19 patients. Most frequent reasons included mistrust in HCWs, belief in conspiracy theories, hospitals' refusal to admit COVID-19 patients due to limited space, COVID-19 hospital policies, and the death of the COVID-19 patients. Protests by doctors and other HCWs for provision of adequate PPE, better quarantine conditions for doctors with suspected COVID-19, and better compensation for doctors on COVID-19 patient duty resulted in police violence towards HCWs. To avoid such incidents in the future, institutions, healthcare policymakers, media organisations, and law enforcement agencies must work together for widespread public awareness to counter misconceptions and to exhibit responsible journalism. In hospitals, measures such as de-escalation training and increased security must be implemented. Furthermore, law enforcement agencies must be trained in non-violent methods of crowd dispersal and control to manage peaceful protests by HCWs over legitimate issues.

Knowledge, attitude and perception of Pakistanis towards COVID-19; a large cross-sectional survey.

BACKGROUND: The Novel Coronavirus Disease (COVID-19) has created havoc globally as countries worldwide struggle to combat this pandemic. Since prevention and social isolation are known to be the only ways to prevent the spread of COVID-19, this has created challenges among the lower-middle income countries (LMIC) including Pakistan, as it battles between an under-resourced healthcare, an economic shutdown, and widespread myths and misconceptions. Therefore, a study was conducted to evaluate the knowledge, attitude and perceptions regarding COVID-19 as public understanding is vital to help facilitate the control of this outbreak. METHODS: A pre-validated online questionnaire was distributed among the general population of Pakistan from 1st to 12th June 2020. Descriptive statistics were analyzed using SPSS v25. Adequate knowledge was assigned as a score of > 4 (range: 0-8) and good perception as a score of > 3 (range: 0-5). Chi-square test was used to determine the significance of difference in knowledge and perception of COVID-19 with socio-demographic characteristics. Logistic regression analysis was run to identify factors associated with adequate knowledge and perception. P < 0.05 was considered as significant. RESULTS: A total of 1200 respondents participated in this study with a wide range of age groups and education. Majority of the respondents had adequate knowledge (93.3%) with a mean score of 6.59 ± 1.35, and good perception (85.6%) with a mean score of 4.29 ± 0.82. Significant differences in knowledge and perception were observed among genders, age groups, education and between students and employees in the healthcare and non-healthcare department. A multivariate analysis revealed a higher educational status and female gender to be significant predictors of adequate knowledge and perception. CONCLUSIONS: Albeit the surge of COVID-19 cases in Pakistan, the participants demonstrated an overall adequate knowledge and good perception towards COVID-19. There is a need to follow the preventive protocols and dissemination of correct information through conducting educational interventions that target safe health practices and provide appropriate information on this infection.

Idiopathic pulmonary hemosiderosis - A rare cause of chronic anemia.

Idiopathic pulmonary hemosiderosis (IPH) is a rare disease marked by alveolar bleeding and accumulation of hemosiderin in the lungs. Here we present three cases of IPH. The first case is of a 26-year-old male with anemia, hemoptysis and dyspnea. Bronchoscopy confirmed diffuse alveolar hemorrhage (DAH). A diagnosis of IPH was made after ruling out other causes of DAH and observing good response to steroids. The patient's condition improved with prednisolone and azathioprine. The second case is of 26-year-old female with severe anemia. Imaging suggested IPH and lung biopsy confirmed it. She died shortly afterwards. The third case is of a 7-year-old male with chronic anemia. CT was suggestive of IPH and lung biopsy confirmed the diagnosis. Later, patient developed posterior reversible encephalopathy syndrome (PRES). This patient is stable on azathioprine and prednisolone. We aim to emphasize the importance of considering IPH as a differential in patients with DAH or chronic anemia.

Compliance of smokeless tobacco supply chain actors and products with tobacco control laws in Bangladesh, India and Pakistan: protocol for a multicentre sequential mixed-methods study.

INTRODUCTION: South Asia is home to more than 300 million smokeless tobacco (ST) users. Bangladesh, India and Pakistan as signatories to the Framework Convention for Tobacco Control (FCTC) have developed policies aimed at curbing the use of tobacco. The objective of this study is to assess the compliance of ST point-of-sale (POS) vendors and the supply chain with the articles of the FCTC and specifically with national tobacco control laws. We also aim to assess disparities in compliance with tobacco control laws between ST and smoked tobacco products. METHODS AND ANALYSIS: The study will be carried out at two sites each in Bangladesh, India and Pakistan. We will conduct a sequential mixed-methods study with five components: (1) mapping of ST POS, (2) analyses of ST samples packaging, (3) observation, (4) survey interviews of POS and (5) in-depth interviews with wholesale dealers/suppliers/manufacturers of ST. We aim to conduct at least 300 POS survey interviews and observations, and 6-10 in-depth interviews in each of the three countries. Data collection will be done by trained data collectors. The main statistical analysis will report the frequencies and proportions of shops that comply with the FCTC and local tobacco control policies, and provide a 95% CI of these estimates. The qualitative in-depth interview data will be analysed using the framework approach. The findings will be connected, each component informing the focus and/or design of the next component. ETHICS AND DISSEMINATION: Ethical approvals for the study have been received from the Health Sciences Research Governance Committee at the University of York, UK. In-country approvals were taken from the National Bioethics Committee in Pakistan, the Bangladesh Medical Research Council and the Indian Medical Research Council. Our results will be disseminated via scientific conferences, peer-reviewed research publications and press releases.

Cystic echinococcosis: a 10-year experience from a middle-income country.

Cystic echinococcosis (CE), or hydatid disease, is a neglected tropical disease (NTD) afflicting one million people globally. This study aims to elucidate the presentation, treatment and outcomes of the disease in Pakistan. A review of charts of 225 patients (median age = 42.3 years) with CE admitted at Aga Khan Hospital, Karachi during 2007-2017, was carried out. Abdominal pain was present in 34.7% followed by fever in 26.2%. There were 142 (63.1%) cases of hepatic cysts and 55 (24.4%) of pulmonary hydatid cysts. Combined surgical and medical therapy was given to 130 (57.8%) patients. Surgery only was performed in 23 (10.2%) patients, medical therapy only was given to 35 (15.6%) patients, and puncture, aspiration, injection and reaspiration (PAIR) with medical therapy was given to 15 (6.7%) patients. Recurrence occurred in 14 (6.2%) patients and mortality in 7 (3.1%) patients. Owing to its non-specific presentation, a high index of suspicion is required to diagnose and treat CE in a timely manner.

Identification of Policy Priorities to Address the Burden of Smokeless Tobacco in Pakistan: A Multimethod Analysis.

INTRODUCTION: We assessed the magnitude of smokeless tobacco (ST) use in Pakistan and identified policy gaps to help ascertain short-, medium-, and long-term priorities. We then elicited stakeholders' views as to which of these identified priorities are most important. METHODS: In a multimethod study, we: analyzed Global Tobacco Surveillance System data sets to estimate ST consumption and disease burden; conducted a documentary review to identify gaps in policies to control ST in comparison with smoking; elicited stakeholders' views in an interactive workshop to identify a set of policy options available to address ST burden in Pakistan; and ranked policy priorities using a postevent survey. RESULTS: Among all tobacco users in Pakistan (n = 24 million), one-third of men and two-thirds of women consume ST. In 2017, its use led to an estimated 18 711 deaths due to cancer and ischemic heart disease. Compared to smoking, policies to control ST lag behind significantly. Priority areas for ST policies included: banning ST sale to and by minors, advocacy campaigns, introduction of licensing, levying taxes on ST, and standardizing ST packaging. A clear commitment to close cooperation between state actors and stakeholder groups is needed to create a climate of support and information for effective policy making. CONCLUSIONS: Smokeless tobacco control in Pakistan should focus on four key policy instruments: legislation, education, fiscal policies, and quit support. More research into the effectiveness of such policies is also needed. IMPLICATIONS: A number of opportunities to improve ST regulation in Pakistan were identified. Among these, immediate priorities include banning ST sale to and by minors, mobilizing advocacy campaign, introduction of licensing through the 1958 Tobacco Vendors Act, levying taxes on ST, and standardizing ST packaging.

The Maverick Disease: Cystic Echinococcosis in Unusual Locations: A Ten Year Experience from an Endemic Region.

Background Cystic echinococcosis (CE) is a neglected tropical disease which affects more than 1 million people globally, causing a loss of 1-3 million disability-adjusted life years (DALYs) and a financial burden of US$ 3 billion annually.The two most commonly involved organs are the liver and the lungs with involvement in 75% and 5 -15% of cases respectively. The rest of the body can be involved in up to 10% of cases. In this study, we aim to explore the presentation, treatment and outcomes of CE in unusual locations. Methods Retrospective review of charts of 225 patients of CE admitted at Aga Khan Hospital, Karachi from 2007-2017 was done. Demographic information, date of admission, clinical presentation, laboratory and radiological findings, histopathology reports (where applicable), treatment course and outcomes were noted. Results CE occurred in the liver in 146 (64.9%) patients, in the lungs in 55 (24.4%) patients and in unusual locations in 24 (10.7%) patients. Primary involvement of unusual locations was seen in 22 (91.7%) cases. Amongst the 24 patients with disease in unusual locations, 13 (54.2%) were males and 11 (45.8%) were females and the median age of these patients was 43 years. Fever and dyspnea were the most common presenting complains, occurring in 5 (20.8%) patients each followed by epigastric abdominal pain and weight loss occurring in 3(12.5%) patients each. Spleen was the most common unusual location for CE with four cases (16.7%) of splenic involvement occurring, followed by cardiac, spinal and mediastinal involvement occurring in three (12.5%) patients each. Other unusual locations included the abdominal cavity, bones, breast, kidney, seminal vesicle, brain, adrenal glands and the inguinal region. The treatment courses employed were a) medical, consisting of oral albendazole use(400 mg twice daily), b) surgical c) combined (medical plus surgical) therapy. Combined surgical and medical therapy, was the most common modality employed, with it being given to 14 (58.3%) patients. Surgery only was performed in 5 (20.8%) patients while medical therapy only to 3 (12.5%) patients. Resolution of the disease was seen in 19 (79.2%) patients on follow up imaging. Recurrence occurred in 4 (16.7%) and mortality in 1 patient. Two patients (8.3%) were lost to follow up. Conclusions CE can be challenging to diagnose especially when it occurs in unusual locations. CE must be included in the differential diagnosis of a cystic lesion in any organ of the body, especially in endemic areas, to ensure timely diagnosis and treatment, to prevent morbidity and mortality associated with chronicity of the disease.

Solitary Endobronchial Papilloma: A Rare Entity.

Solitary papillomas of the lower airways are uncommon clinical entities that present a diagnostic challenge because they are not usually considered among the differential diagnoses. Reliable clinical data about their presentation and treatment remain scarce. We describe a case of an elderly male who presented to us with cough and hemoptysis. He had been a smoker for 50 years. Chest radiograph revealed hyperinflated lungs and slight hilar enlargement on the right side. Bronchoscopy revealed a polypoid mass at the origin of the right upper lobe bronchus. Biopsy showed it to be a papillomatous growth composed of squamous epithelial cells. No malignant cells were detected microscopically. Patient declined surgical removal of this papilloma. He was fine on followup visits during the subsequent months. In patients with hemoptysis, solitary endobronchial papilloma should also be considered in the differential diagnosis.

Granulomatosis With Polyangiitis: A 17 Year Experience From A Tertiary Care Hospital In Pakistan.

Granulomatosis with Polyangitis (GPA) is an uncommon immunologically mediated necrotizing vasculitis affecting the small and medium sized systemic blood vessels. We previously reported our experience with this condition and herein, we document our study findings and compare them to the clinical and radiological findings of various studies from around the world. By doing so we hope to further create awareness of this condition afflicting not only our part of the population but is part of a larger global phenomenon.