Screening of C. auris among Candida isolates from various tertiary care institutions in Lahore by VITEK 2 and real time PCR based molecular technique.

Candida auris is a multidrug-resistant pathogen, that is a well-known cause of nosocomial infections. This pathogen is being identified using advanced diagnostic approaches and epidemiological typing procedures. In underdeveloped nations, several researchers developed and validated a low-cost approach for reliably identifying Candida auris. The goal of this study was to assess the burden of Candida auris in different teaching hospitals of Lahore and to limit its spread to minimize hospital-related illnesses. Candida isolates were obtained from various tertiary care institutions in Lahore in the form of culture on various culture plates. Sabouraud agar culture plates were used to culture the Candida spp. Fluconazole-resistant Candida species were chosen for further identification using VITEK 2 Compact ID and molecular identification using species-specific PCR assay. The current study obtained 636 Candida samples from several tertiary care institutions in Lahore. Fluconazole resistance was found in 248 (38.9%) of 636 Candida samples. No isolate was identified as Candida auris by VITEK 2 Compact ID and real-time PCR-based molecular identification. Thus with limited resources, these two methods may serve as useful screens for Candida auris. However, it should be screened all over the country to limit its spread to break the chain of nosocomial infections.

Association of Vitamin D with Moderate to Severe Acne Vulgaris.

OBJECTIVE: To determine the association of vitamin D deficiency in moderate to severe acne. STUDY DESIGN: A comparative study. Place and Duration of the Study: Dermatology OPD at Dow University of Health Sciences, Karachi, Pakistan, from December 2021 to May 2022. METHODOLOGY: Fifty patients with moderate acne, 50 patients with severe acne, and 50 healthy controls were inducted. Information regarding age, gender, and medical and medication history were taken. The severity of acne was rated according to the GAGS (global acne grading system) score. Levels of 25(OH) D were classified as sufficient (>20 ng/mL), insufficient (12-20 ng/mL), or deficient (<12 ng/mL). Significance was taken at p-value <0.05. RESULTS: The median concentration of vitamin D levels was 7.09 ng/ml in severe acne vulgaris, 13.7 ng/ml in moderate acne vulgaris and 21.6ng/ml in the control group. Serum vitamin D levels were significantly lower (p<0.001) in individuals with acne vulgaris as compared to the healthy controls. However, the decrease in level of vitamin D did not correspond with the severity of acne vulgaris. CONCLUSION: Vitamin D deficiency is additionally pronounced in acne vulgaris individuals, but vitamin D levels are not proportional to the severity of acne vulgaris. KEY WORDS: Acne vulgaris, Vitamin D deficiency, Pilosebaceous unit, GAGS score.

Molecular Characterization of Extensively Drug Resistant Salmonella Enterica Serovar Typhi Clinical Isolates from Lahore, Pakistan.

Background: The emergence of extensively drug-resistant (XDR) typhoid in Pakistan has endangered the treatment options available to manage this infection. Third generation cephalosporin were the empiric choice to treat typhoid fever in Pakistan, but acquisition of ESBLs have knocked them out of the arsenal. The current empiric choice is azithromycin which is vulnerable to resistance too. This study aimed to assess the burden of XDR typhoid and the frequency of resistance determinants in blood culture samples collected from different hospitals in Lahore, Pakistan. Methods: A total of 835 blood cultures were collected from different tertiary care hospitals in Lahore during January 2019 to December 2021. Among 835 blood cultures, 389 Salmonella Typhi were identified, and 150 were XDR S. Typhi (resistant to all recommended antibiotics). Antibiotics resistance genes of the first-line drugs (blaTEM-1, catA1, sul1, and dhfR7) and second line drugs (gyrB, gyrA, qnrS, ParC and ParE) were investigated among XDR S. Typhi. There were different CTX-M genes isolated using the specific primers, blaCTX-M-U, blaCTX-M-1, blaCTX-M-15, blaCTX-M-2, blaCTX-M-8 and blaCTX-M-9. Results: Antibiotic resistant genes of the first-line drugs were isolated with different frequency, blaTEM-1 (72.6%), catA1 (86.6%), sul1 (70%), and dhfR7 (56%). Antibiotics resistance genes of second-line drugs were isolated as: gyrB (60%), gyrA (49.3%), qnrS (32.6%), parC (44%) and parE (28%). Among CTX-M genes, blaCTX-M-U (63.3%) was the most frequent followed by blaCTX-M-15 (39.3%) and blaCTX-M-1 (26%). Conclusion: Our study concluded that XDR isolates circulating in Pakistan have acquired first-line and second-line antibiotic resistant genes quite successfully along with CTX-M genes (ESBLs) rendering them resistant to the third generation cephalosporins as well. Emergence of azithromycin resistance in XDR S. Typhi which is currently used as an empiric treatment option is worrisome and needs to be monitored carefully in endemic countries like Pakistan.

Timi Risk Index, A Simple Tool In Emergency Percutaneous Revascularization For The Prediction Of Contrast Induced Nephropathy.

BACKGROUND: Contrast induced nephropathy (CIN) is a common complication seen after primary percutaneous coronary intervention (PCI) which can contribute to increased morbidity and mortality in patients of acute ST elevation myocardial infarction (STEMI). Aim of this study was to validate the TIMI Risk Index (TRI) for the risk stratification of CIN in patients undergone primary PCI. METHODS: Consecutive patients of STEMI undergone primary PCI at a tertiary care cardiac center were included for this study. Patients in Killip class IV at presentation, patients with history of any PCI and chronic kidney diseases were excluded from this study. TRI was calculated using the formula " " and post-procedure serum creatinine level increase of either 25% or 0.5 mg/dL was taken as CIN. RESULTS: A total of 507 patients were included in this study out of which 82.2% were males and 17.8% were females. In total 8.7% (44) patients developed CIN. In the receiver operating characteristic (ROC) curve analysis, area under the curve (AUC) for TRI was found to be 0.717, [0.649-0.758] for the prediction of CIN. Sensitive, specificity, positive predictive value and negative predictive value of TRI >22.8 to predict the development of CIN were 59.09%, 76.69%, 19.55% and 95.19% respectively. CONCLUSIONS: TIMI risk index is and easy to calculate and readily accessible score which has good predictive value to evaluate the risk of CIN in primary PCI setting.

Neurotoxic effects of environmental contaminants-measurements, mechanistic insight, and environmental relevance.

Pollution is a significant and growing concern for any population regardless of age because these environmental contaminants exhibit different neurodegenerative effects on persons of different ages. These environmental contaminants are the products of human welfare projects like industry, automobile exhaust, clinical and research laboratory extrudes, and agricultural chemicals. These contaminants are found in various forms in environmental matrices like nanoparticles, particulate matter, lipophilic vaporized toxicants, and ultrafine particulate matter. Because of their small size, they can easily cross blood-brain barriers or use different cellular mechanisms for assistance. Other than this, these contaminants cause an innate immune response in different cells of the central nervous system and cause neurotoxicity. Considering the above critiques and current needs, this review summarizes different protective strategies based on bioactive compounds present in plants. Various bioactive compounds from medicinal plants with neuroprotective capacities are discussed with relevant examples. Many in vitro studies on clinical trials have shown promising outcomes using plant-based bioactive compounds against neurological disorders.

Technology-assisted task-sharing to bridge the treatment gap for childhood developmental disorders in rural Pakistan: an implementation science case study.

BACKGROUND: As in many low-income countries, the treatment gap for developmental disorders in Pakistan is nearly 100%. The World Health Organization (WHO) has developed the mental Health Gap Intervention guide (mhGAP-IG) to train non-specialists in the delivery of evidence-based mental health interventions in low-resource settings. However, a key challenge to scale-up of non-specialist-delivered interventions is designing training programs that promote fidelity at scale in low-resource settings. In this case study, we report the experience of using a tablet device-based application to train non-specialist, female family volunteers in leading a group parent skills training program, culturally adapted from the mhGAP-IG, with fidelity at scale in rural community settings of Pakistan. METHODS: The implementation evaluation was conducted as a part of the mhGAP-IG implementation in the pilot sub-district of Gujar Khan. Family volunteers used a technology-assisted approach to deliver the parent skills training in 15 rural Union Councils (UCs). We used the Proctor and RE-AIM frameworks in a mixed-methods design to evaluate the volunteers' competency and fidelity to the intervention. The outcome was measured with the ENhancing Assessment of Common Therapeutic factors (ENACT), during training and program implementation. Data on other implementation outcomes including intervention dosage, acceptability, feasibility, appropriateness, and reach was collected from program trainers, family volunteers, and caregivers of children 6 months post-program implementation. Qualitative and quantitative data were analyzed using the framework and descriptive analysis, respectively. RESULTS: We trained 36 volunteers in delivering the program using technology. All volunteers were female with a mean age of 39 (± 4.38) years. The volunteers delivered the program to 270 caregivers in group sessions with good fidelity (scored 2.5 out of 4 on each domain of the fidelity measure). More than 85% of the caregivers attended 6 or more of 9 sessions. Quantitative analysis showed high levels of acceptability, feasibility, appropriateness, and reach of the program. Qualitative results indicated that the use of tablet device-based applications, and the cultural appropriateness of the adapted intervention content, contributed to the successful implementation of the program. However, barriers faced by family volunteers like community norms and family commitments potentially limited their mobility to deliver the program and impacted the program' reach. CONCLUSIONS: Technology can be used to train non-specialist family volunteers in delivering evidence-based intervention at scale with fidelity in low-resource settings of Pakistan. However, cultural and gender norms should be considered while involving females as volunteer lay health workers for the implementation of mental health programs in low-resource settings.

Improving psychosocial distress for young adolescents in rural schools of Pakistan: study protocol of a cluster randomised controlled trial.

INTRODUCTION: Emotional problems are leading contributors to health burden among adolescents worldwide. There is an urgent need for evidence-based psychological interventions for young people. This study aims to evaluate the effectiveness of a school-based, group psychological intervention, Early Adolescent Skills for Emotions (EASE) developed by the WHO to improve psychosocial distress in Pakistani adolescents. METHOD AND ANALYSIS: A two-arm, single-blinded, cluster randomised controlled trial, with a wait-list control arm is being conducted in school settings of rural Pakistan. Forty eligible public-school clusters have been randomised (stratified by gender) on a 1:1 allocation ratio into intervention (n=20) and control arm (n=20). Following informed consent, 564 adolescents with psychosocial distress (Youth-reported Paediatric Symptoms Checklist, cut-off ≥28) from 40 schools have been enrolled into the trial (14±3 average cluster size) between 2 November 2021 and 30th November 2021. Participants in the intervention arm will receive EASE in 7-weekly adolescents and 3-biweekly caregivers group sessions in schools. The adolescent sessions involve the components of psychoeducation, stress management, behavioural activation, problem-solving and relapse prevention. Caregivers will receive training to learn and implement active listening; spending quality time and using praise as a strategy to help their children. The primary outcome is reduction in psychosocial distress at 3 months postintervention. Secondary outcomes include symptoms of depression and anxiety, caregiver-adolescent relationship and caregivers' well-being. Outcomes will be assessed at baseline, immediate 1 week and 3-months postintervention. Qualitative process evaluation will explore barriers and facilitators to programme implementation in low-resource school settings. ETHICS: Ethics approval has been obtained from Central Ethics Committee of University of Liverpool, UK, Ethics Review Committee of WHO Geneva and from the Institutional Review Board of Human Development Research Foundation (HDRF), Pakistan. DISSEMINATION: The findings of the study will be disseminated by WHO and through peer-reviewed publications. TRIAL REGISTRATION NUMBER: ISRCTN17755448.

Staphylococcal Cassette Chromosome mec Typing and Multilocus Variable Number Tandem Repeat Analysis of Methicillin Resistant Staphylococcus aureus Clinical Isolates with Vancomycin Creep Phenomenon.

Background: The association of treatment failure and mortality with vancomycin minimum inhibitory concentration creep (MIC) is a matter of serious concern in patients with severe methicillin resistant Staphylococcus aureus (MRSA) infections. The purpose of the study was to identify and characterize staphylococcal cassette chromosome mec (SCCmec) and clonal types of MRSA strains, exhibiting the vancomycin MIC creep phenomenon. Methods: A total of 3305 S. aureus strains were isolated from various clinical samples of Lahore General Hospital, Lahore, Pakistan. MRSA strains were identified by cefoxitin resistant (≤21mm) followed by mecA and mecC gene genotyping. Vancomycin MIC creep was determined by E-test. Isolates having MIC values >1.5 µg/mL were further subjected for SCCmec typing (I-V and XI) and multiple-locus variable number tandem repeat analysis (MLVA) by amplification of spa, sspA, clfA, clfB, and sdrCDE genes. A dendrogram was created based on the similarity index using bioneumerics software. Results: About 13.3% (440/3305) isolates were MRSA with 99.3% (437/440) and 0.7% (3/440) carried mecA and mecC genes, respectively. In 120 MRSA isolates, the MIC of vancomycin was >1.5µg/mL. In MRSA isolates with high vancomycin MIC (>1.5µg/mL), the most common SCCmec type was SCCmec III (38.3%), followed by SCCmec IVa (15.8%), SCCmec IIIa (13.3%,), SCCmec IVc (7.5%), SCCmec IVe (5.8%), SCCmec IVd (5.8%), SCCmec IVb (4.2%), SCCmec II (2.5%), SCCmec V (1.7%), SCCmec I (1.7%) and SCCmec XI (1.7%). MLVA revealed 60 genotypic groups of MRSA isolates having a 92% similarity index. Conclusion: SCCmec III was the most common type in genetically related MRSA isolates showing vancomycin MIC creep. The presence of SCCmec XI may further add burden to infection control measures.

Feasibility and acceptability of a multicomponent, group psychological intervention for adolescents with psychosocial distress in public schools of Pakistan: a feasibility cluster randomized controlled trial (cRCT).

BACKGROUND: Child and adolescent mental health problems are a global public mental health priority. However, there is a lack of evidence-based scalable psychological interventions for adolescents living in low resource settings. This trial was designed to evaluate the feasibility and acceptability of delivering the World Health Organization's Early Adolescent Skills for Emotions (EASE) intervention at public schools in a rural sub-district in Rawalpindi, Pakistan. METHODS: A two arm, single blinded, feasibility cluster randomized controlled trial with mixed-methods evaluation was conducted with 59 adolescents and their caregivers from 8 public schools. In the 4 intervention arm schools, 6 non-specialist facilitators delivered the culturally-adapted EASE group sessions to the adolescents (n = 29) and their caregivers with desired fidelity under the supervision of in-country supervisors. RESULTS: The participation rate of adolescents in the intervention sessions was 83%. The intervention strategies were implemented by the adolescents. However, attending biweekly sessions at schools was challenging for caregivers with only 50% caregivers attending the sessions. CONCLUSIONS: The results of this study support the feasibility and acceptability of delivering this culturally adapted intervention through non-specialist facilitators in school settings in Pakistan and pave the way to conduct a fully powered cluster randomized controlled trial to test the effectiveness of intervention to improve psychological outcomes in adolescents. Trial registration Trial registered with Clinicaltrials.gov prospectively; NCT04254393.

Comparative analysis of four established risk scores for prediction of in-hospital mortality in patients undergoing primary percutaneous coronary intervention.

OBJECTIVE: This study was conducted to compare the predictive power of Shock Index (SI), TIMI Risk Index (TRI), LASH Score, and ACEF Score for the prediction of in-hospital mortality in a contemporary cohort of ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) at a tertiary care cardiac center of a developing country. METHODS: Consecutive patients diagnosed with STEMI and undergoing primary PCI were included in this study. SI, TRI, LASH, and ACEF were computed and their predictive power was assessed as the area under the curve (AUC) on the receiver operating characteristics (ROC) curve analysis for in-hospital mortality. RESULTS: We included 977 patients, 780 (79.8%) of which were male, and the mean age was 55.6 ± 11.5 years. The in-hospital mortality rate was 4.3% (42). AUC for TRI was 0.669 (optimal cutoff: ≥17.5, sensitivity: 76.2%, specificity: 45.6%). AUC for SI was 0.595 (optimal cutoff: ≥0.9, sensitivity: 21.4%, specificity: 89.8%). AUC for LASH score was 0.745 (optimal cutoff: ≥0, sensitivity: 76.2%, specificity: 66.9%). AUC for the ACEF score was 0.786 (optimal cutoff: ≥1.66, sensitivity: 71.4%, specificity: 73.5%). CONCLUSION: In conclusion, ACEF showed sufficiently high predictive power with good sensitivity and specificity compared to other three scores. These simplified indices based on readily available hemodynamic parameters can be reliable alternatives to the computational complex scoring systems for the risk stratification of STEMI patients.

Preparing for parenthood: developing a life-skills and socioemotional health program for young married couples in rural Pakistan.

BACKGROUND: Socioemotional life-skills to negotiate important life-transitions such as marriage and parenthood are critical for the wellbeing of young couples and their offspring, but programs addressing this issue are lacking in Low and Middle-Income Countries (LMICs). OBJECTIVE: This study describes the development of a 'life-skills' program for young married women, their husbands and families, living in rural settings in Pakistan. METHODS: Our methods included: a) a targeted review of relevant literature on life-skills and mental health in young people, b) a qualitative study and, c) intervention development workshops with experts and stakeholders. The review showed that common life-skills employed as part of psychosocial interventions in LMICs were communication skills, problem-solving, assessing relations, stress management, emotional regulation, identifying/eliciting affect, and self-awareness. RESULTS: The qualitative study indicated that areas of particular need included interpersonal communication skills with significant others, coping with the pressures of parenthood, and mental well-being. Existing helpful practices included social support by family members and elders. Lack of empowerment in young married women and poor engagement of husbands were identified as a barrier to accessing a potential intervention. Our proposed intervention called 'Preparing for Parenthood' consisted of 10 core sessions and 10 follow-up sessions designed to be delivered by lay health workers. It synergistically combined evidence-based socioemotional life-skills (awareness, communication skills, assertiveness, decision-making skills, goal-setting, critical thinking, problem-solving, and coping with stress), with cognitive behavioural strategies (gently challenging existing thoughts and attitudes, behaviour activation and problem solving). The intervention focuses on engagement of the entire family, including husbands. CONCLUSIONS: The intervention can supplement existing sexual and reproductive health programs by providing skills to prospective parents to effectively negotiate stressful life-transitions and life-events. We envisage the intervention would improve mental as well as sexual and reproductive health of young couples and plan to test this in future randomised trials.

Evaluating the impact of a common elements-based intervention to improve maternal psychological well-being and mother-infant interaction in rural Pakistan: study protocol for a randomised controlled trial.

INTRODUCTION: Millions of children in low resource settings are at high risk of poor development due to factors such as under nutrition, inadequate stimulation and maternal depression. Evidence-based interventions to address these risk factors exist, but often as a separate and overlapping package. The current study aims to evaluate the effectiveness of a common elements-based intervention to improve mother-infant interaction at 12 months post-partum. METHOD AND ANALYSIS: A two-arm, single-blinded, individual randomised controlled trial is being carried out in the community settings of the rural subdistrict of Gujar Khan in Rawalpindi, Pakistan. 250 pregnant women in third trimester with distress (Self-Reporting Questionnaire, cut-off score >9) have been randomised on 1:1 allocation ratio into intervention (n=125) and treatment-as-usual arms (n=125). The participants in the intervention arm will receive 15 individual sessions of intervention on a monthly basis by non-specialist facilitators. The intervention involves components of early stimulation, learning through play, responsive feeding, guided discovery using pictures, behavioural activation and problem solving. The primary outcome is caregiver-infant interaction at 12 months postpartum. The secondary outcomes include maternal psychological well-being, quality of life, social support and empowerment. Infant secondary outcomes include growth, nutrition and development. The data will be collected at baseline, 6 and 12 months postpartum. A qualitative process evaluation will be conducted to inform the feasibility of intervention delivery. ETHICS: Ethics approval for the present study was obtained from the Human Development Research Foundation Institutional Review Board, Islamabad Pakistan. DISSEMINATION: If proven effective, the study will contribute to scale-up care for maternal and child mental health in low resource settings, globally. The findings of the present study will be published in peer-reviewed journals and presented at conferences and community forums. TRIAL REGISTRATION NUMBER: NCT04252807.

Evaluation of the Hypoglycemic Activity of Morchella conica by Targeting Protein Tyrosine Phosphatase 1B.

Morchella conica (M. conica) Pers. is one of six wild edible mushrooms that are widely used by Asian and European countries for their nutritional value. The present study assessed the anti-diabetic potential of M. conica methanolic extract (100 mg/kg body weight) on streptozotocin (STZ)-induced diabetic mice. STZ was used in a single dose of 65 mg/kg to establish diabetic models. Body weights, water/food intake and fasting blood glucose levels were measured. Histopathological analysis of the pancreas and liver were performed to evaluate STZ-induced tissue injuries. In addition, in vitro assays such as α-amylase and protein tyrosine phosphatase 1B (PTP1B) inhibitory, antiglycation, antioxidant and cytotoxicity were performed. The in vitro study indicated potent PTP1B inhibitory potential of M. conica with an IC50 value of 26.5 µg/ml as compared to the positive control, oleanolic acid (IC50 36.2 µg/ml). In vivo investigation showed a gradual decrease in blood sugar level in M. conica-treated mice (132 mg/dl) at a concentration of 100 mg/kg as compared to diabetic mice (346 mg/dl). The extract positively improved liver and kidney damages as were shown by their serum glutamic pyruvic transaminase, serum glutamic oxaloacetate, alkaline phosphatase, serum creatinine and urea levels. Histopathological analysis revealed slight liver and pancreas improvement of mice treated with extract. Cytotoxicity assays displayed lower IC50 values. Based on the present results of the study, it may be inferred that M. conica are rich in bioactive compounds responsible for antidiabetic activity and this mushroom may be a potential source of antidiabetic drug. However, further studies are required in terms of isolation of bioactive compounds to validate the observed results.

Effectiveness of a technology-assisted, family volunteers delivered, brief, multicomponent parents' skills training intervention for children with developmental disorders in rural Pakistan: a cluster randomized controlled trial.

BACKGROUND: Globally, there is a large documented gap between needs of families and children with developmental disorders and available services. We adapted the World Health Organization's mental health Gap-Intervention Guidelines (mhGAP-IG) developmental disorders module into a tablet-based android application to train caregivers of children with developmental disorders. We aimed to evaluate the effectiveness of this technology-assisted, family volunteers delivered, parents' skills training intervention to improve functioning in children with developmental disorders in a rural community of Rawalpindi, Pakistan. METHODS: In a single-blinded, cluster randomized controlled trial, 30 clusters were randomised (1:1 ratio) to intervention (n = 15) or enhanced treatment as usual (ETAU) arm (n = 15). After screening, 540 children (18 participants per cluster) aged 2-12 years, with developmental disorders and their primary caregivers were recruited into the trial. Primary outcome was child's functioning, measured by Childhood Disability Assessment Schedule for Developmental Disorders (DD-CDAS) at 6-months post-intervention. Secondary outcomes were parents' health related quality of life, caregiver-child joint engagement, socio-emotional well-being of children, family empowerment and stigmatizing experiences. Intention-to-treat analyses were done using mixed-models adjusted for covariates and clusters. RESULTS: At 6-months post-intervention, no statistically significant mean difference was observed on DD-CDAS between intervention and ETAU (mean [SD], 47.65 [26.94] vs. 48.72 [28.37], Adjusted Mean Difference (AMD), - 2.63; 95% CI - 6.50 to 1.24). However, parents in the intervention arm, compared to ETAU reported improved health related quality of life (mean [SD] 65.56 [23.25] vs. 62.17 [22.63], AMD 5.28; 95% CI 0.44 to 10.11). The results were non-significant for other secondary outcomes. CONCLUSIONS: In the relatively short intervention period of 6 months, no improvement in child functioning was observed; but, there were significant improvements in caregivers' health related quality of life. Further trials with a longer follow-up are recommended to evaluate the impact of intervention. Trial registration Clinicaltrials.gov, NCT02792894. Registered April 4, 2016, https://clinicaltrials.gov/ct2/show/NCT02792894.

Prepregnancy Counseling Among U.S. Women With Diabetes and Hypertension, 2016-2018.

INTRODUCTION: Individuals who have diabetes or hypertension established before pregnancy are at increased risk for maternal and infant health complications. Guidelines recommend that providers deliver prepregnancy counseling, but little is known about the receipt of those services among patients with chronic conditions. METHODS: Data from the 2016-2018 Pregnancy Risk Assessment Monitoring System, a population-based survey among women with recent live births, were used. Self-reported receipt of prepregnancy counseling on folic acid supplementation, pregnancy desire, contraceptive use, and improving health before pregnancy was examined overall and by diabetes and hypertension status. Multivariable logistic regression examined the association between diabetes and hypertension status and the 4 prepregnancy counseling outcomes. Analyses were conducted in 2020. RESULTS: Overall, 2.1% of women reported having both diabetes and hypertension, 1.3% reported having diabetes alone, and 3.1% reported having hypertension alone. Less than half of the sample reported receiving each prepregnancy counseling outcome. In adjusted models, women with hypertension alone were more likely to report each counseling outcome than women without diabetes or hypertension. Women with diabetes alone were only more likely to report receiving counseling about improving health, and women with both conditions were not more likely to report the receipt of any counseling outcome under study. CONCLUSIONS: Women with prepregnancy diabetes, hypertension, or both reported low levels of the recommended prepregnancy counseling, suggesting an evidence-practice gap that should be addressed to optimize maternal and infant health outcomes. There is a need for evidence-based and patient-centered models of prepregnancy counseling for those with diabetes and hypertension.

Transfer of metal element in soil plant chicken food chain: health risk assessment.

This investigation was done for the assurance of potassium amassing in four assortments of maize (grains, shoot and root), soil, and water and in seven tissues of chickens (kidney, liver, heart, bone, gizzard, breast meat). The analysis of variance showed significant differences for potassium concentration in water in all sources of water; however, the season and variety significantly influenced the quantity of potassium in cereals. The corn varieties MMRI, Sadaf, and Pearl behaved differently when treated with water from various sources. Water taken from sewage had a higher concentration of potassium compared to canal and groundwater that is why the maize plants irrigated with this water had a higher grouping. Data regarding potassium concentration in different body parts of chicken showed that season and treatment have a significant effect on the potassium concentration in chicken organs. The variety was non-significant for the potassium concentration only in the bone. Season × Variety interaction was only significant in blood, meat heart, and gizzard. Season × Treatment and Variety × Treatment interactions were significant in the heart, kidney, and gizzard. The potassium contents were higher in the chicken body parts that were reared on grains irrigated with sewage water as compared to other groups. The potassium contents were higher in the chicken meat (96.23 ± 0.00) reared on grains of the Pearl variety raised with the sewage water. In a nutshell, the irrigation of grains with sewage water led to accumulation of nutrients greater than those irrigated with ground or canal water.

Debate: Child and adolescent mental health services in Pakistan; Do we need in-patient mental health facilities for children and young people?

Depression and anxiety are leading causes of morbidity in children and adolescents worldwide. In Pakistan, young people are exposed to many chronic adversities including violence, social and economic inequalities, and are at greater risk of developing mental health problems. Yet there is a lack of trained human resources, in-patient child and adolescent mental healthcare facilities, and training opportunities in child and adolescent psychiatry and mental health in Pakistan. Given the poor economic condition of the country, which has been made even worse by the COVID-19 pandemic, it is very unlikely that dedicated resources will be made available in near future to develop specialist child and adolescent mental health services in Pakistan. To bridge this treatment gap, we propose a multitiered, transdiagnostic, task-shifting strategy-based model for child and adolescent mental health services in Pakistan.

Scaling-up school mental health services in low resource public schools of rural Pakistan: the Theory of Change (ToC) approach.

BACKGROUND: Ninety percent of children with mental health problems live in low or middle-income countries (LMICs). School-based programs offer opportunities for early identification and intervention, however implementation requires cross-sector collaboration to assure sustainable delivery of quality training, ongoing supervision, and outcomes monitoring at scale. In Pakistan, 35% of school-aged children are reported to have emotional and behavioral problems. As in many other LMICs, the government agencies who must work together to mount school-based programs have limited resources and a limited history of collaboration. The "Theory of Change" (ToC) process offers a way for new partners to efficiently develop mutual goals and long-term prospects for sustainable collaboration. OBJECTIVE: Develop a model for scale-up of school based mental health services in public schools of Pakistan. METHODS: We used ToC workshops to develop an empirically supported, 'hypothesized pathway' for the implementation of WHO's School Mental Health Program in the public schools of rural Pakistan. Three workshops included 90 stakeholders such as policy makers from education and health departments, mental health specialists, researchers, head teachers, teachers and other community stakeholders including non-governmental organizations. RESULTS: The ToC process linked implementers, organizations, providers and consumers of school mental health services to develop common goals and relate them (improved child socioemotional wellbeing, grades and participation in activities) to interventions (training, monitoring and supervision of teachers; collaboration with parents, teachers and primary health care facilities and schools). Key testable assumptions developed in the process included buy-in from health care providers, education officials and professionals, community-based organizations and families. For example, teachers needed skills for managing children's problems, but their motivation might come from seeking improved school performance and working conditions. Poverty, stigma and lack of child mental health literacy among teachers, administration, and parents were identified as key hypothesized barriers. Children and their families were identified as key stakeholders to make such a program successful. DISCUSSION: ToC workshops assisted in team building and served as a stakeholders' engagement tool. They helped to develop and support testable hypotheses about the structures, collaborations, and knowledge most important to scaling-up school based mental health services in Pakistan.

Effect of adding a psychological intervention to routine care of common mental disorders in a specialized mental healthcare facility in Pakistan: a randomized controlled trial.

BACKGROUND: In many low resource settings, the provision of government mental health care services is limited to specialized psychiatry units in urban hospital care facilities, where the most common treatment for common mental disorders (CMDs) is pharmacotherapy, occasionally with adjunct nonspecific psychological support. We aimed to evaluate the effectiveness of adding a low intensity, psychological intervention, Problem Management Plus (PM+) for CMDs into routine care in a specialized mental health care facility in Pakistan. METHODS: A two arm, single-blind individual randomized controlled trial (RCT) was carried out with adults (N = 192), referred for psychological support by psychiatrists. The study participants were randomized (1:1) to PM + plus Treatment as Usual (TAU) (n = 96) or TAU only (n = 96). The primary outcomes were symptoms of anxiety and depression, measured by the Hospital Anxiety and Depression Scale (HADS) and functional impairment as measured by WHO Disability Assessment Schedule (WHODAS 2.0) at 20 weeks after baseline. RESULTS: The analysis was done on intention-to-treat principle. The linear mixed model analysis showed that at 20 weeks after baseline, there was a significant reduction in symptoms of anxiety and depression (mean [SD], 16.23 [8.81] vs 19.79 [7.77]; AMD, - 3.10; 95% CI, - 0.26 to - 5.76); p = 0.03 and improvement in functioning (mean [SD], 22.94 [9.37] vs 27.37 [8.36]; AMD, - 4.35; 95% CI, - 1.45 to - 7.24); p = 0.004 in PM + plus TAU versus TAU arm. The follow-up rate was 67% at primary end-point. CONCLUSIONS: Specialized care facilities in LMICs may consider adding brief, evidence-based psychological treatments for CMDs to their routine care. Trial Registration Australian New Zealand Clinical Trials Registry, ACTRN12616000381482. Registered March 23, 2016. Retrospectively registered, https://www.anzctr.org.au/Default.aspx/ ACTRN12616000381482.