Oral mucositis & oral health related quality of life in women undergoing chemotherapy for breast cancer in Karachi, Pakistan: A multicenter hospital based cross-sectional study.

BACKGROUND: Oral mucositis is an inflammatory condition of oral cavity which is a common and serious side effect of cancer treatment. Severe oral mucositis compromises basic functions like eating and swallowing causing malnutrition also affecting overall patient's oral health related quality of life. The aim of the study was to find the frequency of oral mucositis in patients with breast cancer during their chemotherapy, the factors associated with oral mucositis & the overall patient's oral health related quality of life. METHODS: A cross-sectional study was conducted and a total of 160 women diagnosed with breast cancer, receiving chemotherapy and who had undergone at least one cycle of chemotherapy were recruited from two hospital settings. In-person interviews were done, patients were asked questions about their sociodemographic history, personal habits, oral history and oral findings, breast cancer stage, chemotherapy history and Oral Health Related Quality of Life. Their oral examination was done at the end of the interview to assess presence or absence of oral mucositis, using World Health Organization oral mucositis tool. Oral Health Related Quality of Life was assessed using Oral Health Impact Profile-14 questionnaire. RESULTS: Our results showed that out of 160 patients 88 (55%) of the breast cancer cases developed oral mucositis during chemotherapy. The mean Oral Health Impact Profile -14 scores in patients with oral mucositis was high 18.36±0.96 showing poor Oral Health Related Quality of Life. Occasional frequency of brushing was significantly associated with oral mucositis (Prevalence ratio:2.26, 95%_CI 1.06-4.84) compared to those patients who brushed once and twice daily. Low level of education showed negative association with oral mucositis (Prevalence ratio:0.52, 95%_CI 0.31-0.88). CONCLUSION: Our study showed significant positive association of occasional brushing with OM and protective association of low level of education with the development of OM. Emphasis should be given to oral hygiene instructions and dental education to cancer patients in oncology clinics with the prescription of mouth washes, gels and toothpaste to patients to decrease OM during chemotherapy.

Oral health related quality of life in head and neck cancer survivors within the first year following treatment: a cross-sectional study in Karachi, Pakistan.

After completing treatment for head and neck cancer (HNC), patients often face oral complications like oral pain, limited mouth opening and dry mouth which significantly reduce their oral health related quality of life (OHRQoL). These issues impact their overall well-being, social activities and long-term survival. The primary objective of this study was to evaluate OHRQoL and its association with sociodemographic characteristics, oral hygiene practices and oral clinical parameters such as oral hygiene status and oral mucositis grade in patients who have completed treatment for head and neck cancer. This cross-sectional study involved 79 HNC-treated patients within first year after completion of cancer treatment attending ENT and dental clinics at outpatient department (OPD) setting in Karachi. Data was collected electronically using structured questionnaire comprising of EORTC QLQ H&N - 35 to measure OHRQoL, patients were also examined for oral hygiene status using oral hygiene index- simplified (OHI-s) and oral mucositis grade using WHO oral mucositis scale. Multiple linear regression was used to test OHRQoL associations with the sociodemographic and different clinical factors. The result showed an overall mean score for oral health related quality of life (OHRQoL) of 25.02 ± 15.86 (95% CI 21.46-28.57), with difficulty in mouth opening 53.16 ± 18.88 and dry mouth 45.14 ± 24.48 being predominant concerns for decline in the OHRQoL in the population. Male predilection was observed among participants n = 60 (75.9%), majority of the participants n = 41 (51.9%) were below 52 years of age. n = 63 (80%) participants received radiotherapy alongside surgery and chemotherapy. Most of participants n = 66 (83.5%) experienced moderate to severe oral mucositis with poor oral hygiene status n = 56 (71%). Significant associations were found between OHRQoL and BMI, OH status, marital status, monthly income, gender and fluoride toothpaste (p < 0.05). These findings suggest that Quality of Life (QoL) among HNC treated patients is negatively impacted by their poor oral health, post cancer treatment. Therefore, it is important to evaluate and modify the current treatment modalities and involve multidisciplinary teams, to improve their OHRQoL thereby enhancing overall QoL.

Factors associated with continuation of hormonal contraceptives among married women of reproductive age in Gilgit, Pakistan: a community-based case-control study.

OBJECTIVE: This study aimed to determine the factors associated with continuation of hormonal contraceptive methods among married women of Gilgit, Pakistan at least 6 months after their initiation. DESIGN: Unmatched case-control study. SETTING: Community settings of Gilgit, Pakistan from 1 April 2021 to 30 July 2021. PARTICIPANTS: The cases were married women of reproductive age who, at the time of interview, were using a hormonal method of contraception for at least 6 months continuously, and controls were married women of reproductive age who had used a hormonal method in the past and currently were using a non-hormonal method for at least 6 months. PRIMARY AND SECONDARY OUTCOME MEASURES: OR for continuation of hormonal contraceptive. RESULTS: The factors significantly associated with continuous use of hormonal contraceptive methods for our sample from Gilgit were the family planning centre's distance from home (adjusted OR (AOR) 6.33, 95% CI 3.74 to 10.71), satisfaction with current method used (AOR 3.64, 95% CI 2.06 to 6.44), visits to the family planning centre to avail services (AOR 1.86, 95% CI 1.07 to 3.45) and relatively older age of women (AOR 1.07, 95% CI 1.02 to 1.12). In addition, women with formal education (AOR 0.27, 95% CI 0.12 to 0.6) were less likely to use a modern contraceptive method. CONCLUSION: Continuation of using a hormonal method was associated with easy access to family planning centres, satisfaction with the current method and frequent visits to the family planning centres. Continuation of using a hormonal method was also seen in women with low education status. The importance of the presence of family planning centres near residential areas cannot be emphasised more. This does not only provide easy access to family planning methods, but also reassure women of continuation of modern methods when they face any unpleasant effects while using these.

Association of depressive symptoms and quality of life in Pakistani youth (15-24 years) with polycystic ovarian syndrome: a web-based analytical cross-sectional study.

Introduction: Polycystic ovarian syndrome (PCOS) is associated with impaired quality of life (QOL) of individuals, predominantly in youth, who are most vulnerable to its impact. Psychological morbidity could be one of the factors influencing QOL. The study investigated the association between depressive symptoms and QOL in Pakistani youth (15-24 years) with PCOS and determined other factors associated with QOL. Methods: We conducted an analytical-cross-sectional survey on 213 single Pakistani females aged 15-24 years recruited via a web-based approach. Depression and QOL were assessed through Center-of-Epidemiological-Studies-Depression tool and Polycystic-ovarian-syndrome-quality-of-life-scale. Multiple-linear-regression was used to determine factors associated with QOL, and adjusted regression-coefficients along with a 95% confidence interval were reported. Results: The mean QOL score: 2.9 ± 1.1. The domain of obesity had the lowest mean score (2.5 ± 1.6) whereas domain of hirsutism had the highest (3.2 ± 1.9). 172/213 (80%) participants were screened positive for depressive symptoms. Participants with depressive symptoms reported reduced mean QOL scores than respondents with no such symptoms (2.8 ± 1.0 vs. 3.4 ± 1.3, p < 0.001). No differences were found in overall QOL and individual domains between participants 15-19 years (n = 36, 17%) and participants >19-24 years (n = 177, 83%) (2.9 ± 1.1 vs. 2.9 ± 1.1) (p > 0.05). We found a significant interaction between depressive symptoms and PCOS duration, indicating that the estimated mean overall QOL score decreases by 25.1 (-36.6, -13.6) for every year increase in PCOS duration among participants screened positive for depressive symptoms. Furthermore, for those respondents who had family history of PCOS and were not satisfied with their healthcare provider treating PCOS, the estimated mean QOL score was 17.47 (-26.1, -8.8) lower than participants who had no family history of PCOS and were satisfied with their healthcare provider. Other factors associated with reduced quality of life included societal pressure to improve appearance affected by PCOS, parental criticism related to PCOS, education, socioeconomic status, working status and BMI. Conclusion: Depressive symptoms with increasing duration of PCOS were significantly associated with reduced QOL. Therefore, to improve the overall QOL of PCOS youth, screening and timely addressing of psychological morbidities should be considered.

Factors associated with Diabetes Empowerment among patients with type 2 diabetes, at OPD setting, Karachi, Pakistan.

Diabetes Empowerment is important for diabetic control as it postpones the onset of complications. This study aimed to investigate the association of medication adherence, self-care behaviors, and diabetes knowledge with Diabetes Empowerment among patients with type II diabetes. A cross-sectional study was conducted on 451 type II diabetes patients attending Endocrinology clinics at OPD setting in Karachi. Data was collected electronically using a structured questionnaire comprising of tools to measure Diabetes Empowerment, medication adherence, self-care behaviors, diabetes knowledge, and socioeconomic scale. It also included health-related information from patients' medical record. As outcome variable was continuous, so multiple linear regression analysis was used to assess the independent effect of Diabetes Empowerment on medication adherence, self-care behaviors and diabetes knowledge with other co-variates. The mean Diabetes Empowerment score was 3.62 (SD = 0.31). The mean age of the participants was 56.68 (SD = 11.76). 53.88% were females, 80.71% were married, 77.56% were obese, and 66.30% were upper-middle class with average diabetes duration of 11.7 years (SD = 7.89). HbA1c values were ≥ 7 in 63.41% of study participants. Diabetes Empowerment was significantly associated with medication adherence (P = 0.001), general diet (P < 0.001), special diet (P = 0.011), smoking status (P = 0.001), and socioeconomic status (upper lower, P = 0.085). A comprehensive strategy for the treatment of type II diabetes is essential to enhance clinical results, improve patient quality of life, and prevent diabetes-related comorbidities. People with type II diabetes should be encouraged to embrace an empowerment-based approach by healthcare providers. It is critical to do research that promotes empowerment.

Detection of typhoid carriers by duodenal fluid culture in a tertiary care hospital, Karachi: A cross-sectional study.

We aimed to detect typhoid carriers by performing duodenal fluid culture in patients in a tertiary care hospital in Pakistan. A cross-sectional study was conducted during 2017 at the Aga Khan University Hospital, Karachi. Patients who underwent upper gastrointestinal endoscopy were included. Participants were interviewed, and duodenal fluid samples were taken for culture to detect Salmonella typhi (S. typhi) and paratyphi. A polymerase chain reaction on 100 randomly selected sub-samples was also conducted. A total of 477 participants were enrolled. The mean age was 42.4±15.5 years. History of typhoid fever was present in 73 (15.3%) participants. Out of the 477 duodenal fluid cultures tested for various micro-organisms, 250 (52.4%) were positive. Neither S. typhi nor paratyphi were isolated. S. typhi was also not detected by PCR. To better detect S. typhi carriage in general population, future studies should target people with gall bladder diseases and screen them using culture and PCR based methods.

Cardiovascular Dysfunction in Children Exposed to Preeclampsia During Fetal Life.

BACKGROUND: Keeping in view the developmental origin of health and disease hypothesis, the aim of this study was to assess differences in cardiac and vascular structure and function in children exposed to preeclampsia in utero compared with those of normotensive mothers. The hypothesis under investigation was that children exposed to preeclampsia would have altered cardiac and vascular structure and function compared with the unexposed group. METHODS: This was a retrospective cohort study that included children 2 to 10 years of age born to mothers with and without exposure to preeclampsia in utero (n = 80 in each group). Myocardial morphology and function using echocardiography and carotid intima-media thickness and pulse-wave velocity were determined. Multivariate linear regression was used to compare preeclampsia-exposed and nonexposed groups. Subgroup analysis to assess differences between early- and late-onset preeclampsia was also performed. RESULTS: Forty-one percent of mothers (n = 33) had early-onset preeclampsia. Children in the exposed group had a significantly higher prevalence of stage 1 systolic and diastolic hypertension (22% [n = 18] and 35% [n = 18], respectively) compared with the unexposed group (9% [n = 7] and 19% [n = 15], respectively; P = .01). Children in the exposed group also had higher pulse-wave velocity compared with those in the unexposed group (0.42 ± 0.1 vs 0.39 ± 0.1, P = .03). Subgroup analysis revealed that changes in blood pressure and pulse-wave velocity were determined primarily by early-onset preeclampsia. There was no significant difference in cardiac morphology or systolic and diastolic function between the exposed and unexposed groups. CONCLUSION: In utero exposure to preeclampsia has an effect on vascular function in children aged 2 to 10 years, related primarily to early-onset disease. Routine blood pressure screening should be recommended for such children.

Effect of parent-child relationship on physical aggression among adolescents: Global school-based student health survey.

Data from the Global School-based Student Health Survey (GSHS) conducted in 2009 consisting of 5192 Pakistani school-going adolescents was used to assess the association between parent-child-relationship and physical-aggression. A multilevel-weighted-cox-proportional-algorithm was performed. The overall prevalence of physical-aggression was 41% of which 27% had a poor parent-child relationship. Male adolescents who have a poor bond with their parents had two times the prevalence of physical-aggression (95% CI: 1.82, 3.00) than those female adolescents with the strong parent-child-bonding. The findings of this study implicated that the poor parental bond and the role of gender as potential factors in physically aggressive adolescents.

Are Rural Hospitals in Pakistan Responding to the Global Surgery Movement? An Analysis of the Gaps, Challenges and Opportunities.

BACKGROUND: Access to essential surgical care is vital for reduction in mortality and morbidity as a result of surgical conditions. These account for 28-32% of the overall global burden of disease, yet billions of people lack access to safe, affordable surgical and anesthesia care when needed. The purpose of this study was to assess the capacity for surgical care in rural hospitals across four provinces of Pakistan. METHODS: This was a cross-sectional study undertaken in 10 rural hospitals across four provinces of the country. Of these, six were district and four sub-district hospitals that were purposively selected in consultation with the government. Data were gathered using the WHO-PGSSC Surgical Assessment Tool. RESULTS: This study estimated 3 of the 6 indicators proposed by the Lancet Commission on Global Surgery. While most hospitals had basic provisions of infrastructure and equipment, severe shortage of specialists was observed with 0.56 specialists (surgeons, gynecologists and anesthetists) present per 100,000 population. Two-hour access was possible for the catchment population of 7 out of the 10 hospitals. Of the 43 essential surgical procedures assessed, 13 or 30% procedures were available per hospital. The three Bellwether procedures were provided by only 1 hospital. Mean number of surgeries performed was 753 ± 979 per 100,000 population. CONCLUSIONS: Our study has demonstrated major gaps in the provision of surgical care in rural hospitals in Pakistan. While developing a strategy and national action plan is necessary, implementation can immediately begin at the local level to address the gaps that need urgent attention.

Factors associated with the discontinuation of modern methods of contraception in the low income areas of Sukh Initiative Karachi: A community-based case control study.

INTRODUCTION: Discontinuation of a contraceptive method soon after its initiation is becoming a public health problem in Low middle income countries and may result in unintended pregnancy and related unwanted consequences. A better understanding of factors behind discontinuation of a modern method would help in designing interventions to continue its use till desired spacing goals are achieved. OBJECTIVE: To determine factors associated with the discontinuation of modern contraceptive methods within six months of its use compared to continued use of modern method for at least six months in low-income areas of Karachi, Pakistan. METHODS: A community-based case-control study was conducted in low-income areas of Karachi. Cases were 137 users who discontinued a modern contraceptive method within 6 months of initiation and were not using any method at the time of interview, while controls were 276 continuous users of modern method for at least last six months from the time of interview. Information was collected by using a structured questionnaire. Applied logistic regression was used to identify the associated factors for discontinuation. RESULTS: The mean ages of discontinued and continued users were 29.3±5.3 years and 29.2±5.4 years respectively. A larger proportion of the discontinued users had no formal education (43.8%) as compared to the continued users (27.9%). The factors associated with discontinuation of a modern method of contraception were belonging to Sindhi ethnicity [OR: 2.54, 95%CI 1.16-5.57], experiencing side effects [OR: 15.12; 95% CI 7.50-30.51], difficulty in accessing contraceptives by themselves [OR: 0.40, 95%CI 0.19-0.83] and difficulty in reaching clinics for management of the side effects [OR: 4.10, 95%CI 2.38-7.05]. Moreover, women having support from the husband for contraceptive use were less likely to discontinue the method [OR: 0.58, 95% CI 0.34-0.98]. CONCLUSIONS: Sindhi ethnicity and side effects of modern methods of contraception were identified as major factors for discontinuation in low-income populations. Similarly, women who had difficulty in travelling to reach clinics for treatment also contributed to discontinuation. Furthermore, women using long acting methods and those supported by their husbands were less likely to discontinue the contraceptive methods. Findings emphasize a need to focus on Sindhi ethnicity and trainings of service providers on management of side effects and provision of high quality of services.

Effectiveness of a School Based Smokeless Tobacco Intervention: A Cluster Randomized Trial.

To assess the effectiveness of intervention in improving knowledge, attitude and perception regarding smokeless tobacco (SLT) use and its harmful effects and intention to quit SLT among school going adolescents. A school-based cluster randomized control trial was carried out in 18 secondary schools targeting male and female students from grades 6 to 10 in Karachi. Primary outcome was knowledge about hazards of smokeless tobacco (SLT) and secondary outcomes were attitude and Perception about hazards of SLT, and intention to quit SLT. We enrolled 738 participants in intervention group and 589 in the control group. Mean score of knowledge significantly improved in intervention as compared to control group (P value < 0.01). Intention to quit was found to be proportionately higher (33%) in the intervention group as compared to control group. Generalized estimating equations were used to assess the association of factors with knowledge regarding harmful effects of SLT use. Significant predictors of increase in knowledge score were found in children: who had seen any anti SLT messages on social media in the past 30 days, who were getting information regarding harmful effects of SLT use in school or textbooks and who had friends using SLT. A school-based intervention was effective in increasing knowledge regarding the harmful effects of SLT use and intention to quit SLT use among school adolescents. Introduction of such educational programmes on a regular basis in schools or as part of school curriculum can have an impact on reducing prevalence of SLT use.Trial Registration NCT03418506. https://register.clinicaltrials.gov/NCT03418506 .

Quality of life after stroke in Pakistan.

BACKGROUND: There is very little information about the quality of life (QOL) of stroke survivors in LMIC countries with underdeveloped non communicable health infrastructures, who bear two thirds of the global stroke burden. METHODOLOGY: We used a sequential mix methods approach. First, a quantitative analytical cross-sectional study was conducted on 700 participants, who constituted 350 stroke survivor and their caregiver dyads. QOL of stroke survivor was assessed via Stroke Specific Quality of Life Scale (SSQOLS) whereas QOL of caregivers was assessed through RAND-36. In addition; we assessed complications, psychosocial and functional disability of stroke survivors. Following this quantitative survey, caregivers were qualitatively interviewed to uncover contextually relevant themes that would evade quantitative surveys. Multiple linear regression technique was applied to report adjusted ß-coefficients with 95% C.I. RESULTS: The QOL study was conducted from January 2014 till June 2014, in two large private and public centers. At each center, 175 dyads were interviewed to ensure representativeness. Median age of stroke survivors was 59(17) years, 68% were male, 60% reported depression and 70% suffered post-stroke complications. The mean SSQOLS score was 164.18 ± 32.30. In the final model severe functional disability [adjß -33.77(-52.44, -15.22)], depression [adjß-23.74(-30.61,-16.82)], hospital admissions [adjß-5.51(-9.23,-1.92)] and severe neurologic pain [adjß -12.41(-20.10,-4.77)] negatively impacted QOL of stroke survivors (P < 0.01). For caregivers, mean age was 39.18 ± 13.44 years, 51% were female and 34% reported high stress levels. Complementary qualitative study revealed that primary caregivers were depressed, frustrated, isolated and also disappointed by health services. CONCLUSION: The QOL of Stroke survivors as reported by SSQOLS score was better than compared to those reported from other LMIC settings. However, Qualitative triangulation revealed that younger caregivers felt isolated, depressed, overwhelmed and were providing care at great personal cost. There is a need to develop cost effective holistic home support interventions to improve lives of the survivor dyad as a unit. TRIAL REGISTRATION: NCT02351778 (Registered as Observational Study).

Association of tobacco use and other determinants with pregnancy outcomes: a multicentre hospital-based case-control study in Karachi, Pakistan.

OBJECTIVES: The study aimed to identify the effects of maternal tobacco consumption during pregnancy and other factors on birth outcomes and obstetric complications in Karachi, Pakistan. DESIGN: A multicentre hospital-based case-control study. SETTING: Four leading maternity hospitals of Karachi. PARTICIPANTS: A random sample of 1275 women coming to the gynaecology and obstetric department of selected hospitals for delivery was interviewed within 48 hours of delivery from wards. Cases were women with adverse birth outcomes and obstetric complications, while controls were women who had normal uncomplicated delivery. PRIMARY AND SECONDARY OUTCOME MEASURES: Adverse birth outcomes (preterm delivery, low birth weight, stillbirth, low Apgar score) and obstetric complications (antepartum haemorrhage, caesarean section, etc). RESULTS: Final multiple logistic regression analysis revealed that with every 1 year increase in age the odds of being a case was 1.03 times as compared with being a control. Tobacco use (adjusted OR (aOR): 2.24; 95% CI 1.56 to 3.23), having no slits in the kitchen (proxy indicator for indoor air pollution) (aOR=1.90; 95% CI 1.05 to 3.43), gravidity (aOR=0.83; 95% CI 0.73 to 0.93), non-booked hospital cases (aOR=1.87; 95% CI 1.38 to 2.74), history of stillbirth (aOR=4.06; 95% CI 2.36 to 6.97), miscarriages (aOR=1.91; 95% CI 1.27 to 2.85) and preterm delivery (aOR=6.04; 95% CI 2.52 to 14.48) were significantly associated with being a case as compared with control. CONCLUSIONS: This study suggests that women who had adverse pregnancy outcomes were more likely to have exposure to tobacco, previous history of adverse birth outcomes and were non-booked cases. Engagement of stakeholders in tobacco control for providing health education, incorporating tobacco use in women in the tobacco control policy and designing interventions for tobacco use cessation is warranted. Prenatal care and health education might help in preventing such adverse events.

The effect of individualized patient education, along with emotional support, on the quality of life of breast cancer patients - A pilot study.

PURPOSE: This study aimed to determine the effect of individualized patient education along with emotional support on the quality of life (QoL) of breast cancer patients undergoing chemotherapy. It also aimed to determine the intervention's feasibility in the Pakistani context. METHODS: A quasi-experimental design, with pre- and post-test, in two groups, via time block, was used. The study was conducted at a public hospital in Karachi with a sample of 50 patients; 25 patients each in the intervention and control group. The intervention was delivered over a period of six weeks. It comprised verbal and written patient education, availability of a nurse during patients' chemotherapy administration and over the telephone, and a telephone follow-up of the patients by the nurse. patients' QoL was assessed at baseline and at the sixth week of receiving chemotherapy. RESULTS: Tests indicated a significant improvement in the overall QoL, breast cancer subscale scores, and the physical and emotional well-being of the intervention group, as compared to the control group. The intervention effect size was moderate (0.655) for the QoL. CONCLUSION: The intervention was found to be effective in improving patients' QoL. However, a larger study, in a multi-center setting, is recommended to ascertain the findings of this pilot study.

Barriers and Facilitators of Compliance with Universal Precautions at First Level Health Facilities in Northern Rural Pakistan.

AIM: We assessed the compliance at first level care facilities (FLCF) with universal precautions (UP) and its behavioral predictors using Health Belief Model (HBM). METHODS: A sample of FLCF from public clinic (PC), privately owned licensed practitioners' clinic (LPC) and non-licensed practitioners' clinic (NLPC) was obtained. Health Care Workers (HCW) who diagnose and prescribe medication was termed as Prescriber and that carries out prescriber's order was defined Assistant. Compliance to UP was measured on 11 items Likert scale. HCW responded "always" or "often" to all items of UP were added to compute a binary variable of overall compliance. We used linear regression to assess association between HBM and UP score. RESULTS: We interviewed 485 HCW (75% prescribers) from 365 clinics; mean age 38±10.4 years. Overall, compliance to UP was 6.6%; 11.6% LPC, 5.3% PC, and 4.4% NLPC. Prescribers were less compliant than Assistants. Compliance with not recapping contaminated needle was poor (PC=32%, LPC=33%, NLPC=15%). Compliance with wearing gloves during blood or body fluid exposure was lowest (30%) at PC. Modes of transmission knowledge, self-efficacy and perceived benefits of safe practice, and susceptibility to blood borne infections were positively associated with UP score. CONCLUSION: Higher perception of barriers and severity of blood borne infection result in lower compliance.

High HIV incidence among persons who inject drugs in Pakistan: greater risk with needle sharing and injecting frequently among the homeless.

BACKGROUND: The incidence of HIV among persons who inject drugs (PWIDU) has fallen in many nations, likely due to successes of clean needle/syringe exchange and substance abuse treatment and service programs. However in Pakistan, prevalence rates for PWID have risen dramatically. In several cities, prevalence exceeded 20% by 2009 compared to a 2003 baseline of just 0.5%. However, no cohort study of PWID has ever been conducted. METHODS: We enrolled a cohort of 636 HIV seronegative PWID registered with three drop-in centers that focus on risk reduction and basic social services in Karachi. Recruitment began in 2009 (March to June) and PWID were followed for two years. We measured incidence rates and risk factors associated with HIV seroconversion. RESULTS: Incidence of HIV was 12.4 per 100 person-years (95% exact Poisson confidence interval [CI]: 10.3-14.9). We followed 474 of 636 HIV seronegative persons (74.5%) for two years, an annual loss to follow-up of <13 per 100 person years. In multivariable Cox regression analysis, HIV seroconversion was associated with non-Muslim religion (Adjusted risk ratio [ARR] = 1.7, 95%CI:1.4, 2.7, p = 0.03), sharing of syringes (AR  = 2.3, 95%CI:1.5, 3.3, p<0.0001), being homeless (ARR = 1.7, 95%CI:1.1, 2.5, p = 0.009), and daily injection of drugs (ARR = 1.1, 95%CI:1.0, 1.3, p = 0.04). CONCLUSIONS: Even though all members of the cohort of PWID were attending risk reduction programs, the HIV incidence rate was very high in Karachi from 2009-2011. The project budget was low, yet we were able to retain three-quarters of the population over two years. Absence of opiate substitution therapy and incomplete needle/syringe exchange coverage undermines success in HIV risk reduction.

Does admission hyperglycemia predict intracranial and extracranial vasculopathy?

OBJECTIVE: To study the association between admission hyperglycaemia and the presence and pattern of intracranial and extracranial vascular disease. METHODS: This retrospective study was conducted at a major tertiary care hospital in Karachi, Pakistan. Patients who had presented with acute stroke and had undergone a carotid ultrasound Doppler of the carotids and/or Magnetic Resonance Angiography (MRA) of the brain were included in the study. A multiple logistic regression analysis of variables was done for an abnormal finding on each investigation. RESULTS: Out of the total of 216 patients, the age of majority of the patients (83.3%) was > 50 years and 134 (62%) were male. One hundred and fourteen patients (52.8%) had admission hyperglyaemia. Multiple logistic regression analysis revealed that increasing age and admission hyperglycaemia (P = 0.045, Odds ratio = 1.9 [95% CI: 1.0-3.6]) were independent predictors of an abnormal finding on a carotid Doppler investigation. Admission hyperglycaemia did not predict the presence of general intracranial vasculopathy but it was significantly associated with focal stenosis as visualized on a MRA. CONCLUSION: Admission hyperglycaemia is associated with large vessel disease manifesting itself in the carotids as plaques and in the intracranial circulation as focal stenosis. Acute stroke patients presenting with admission hyperglycemia would require a more careful investigation for large artery disease especially in the extracranial vessels.

An autoregressive integrated moving average model for short-term prediction of hepatitis C virus seropositivity among male volunteer blood donors in Karachi, Pakistan.

AIM: To identify the stochastic autoregressive integrated moving average (ARIMA) model for short term forecasting of hepatitis C virus (HCV) seropositivity among volunteer blood donors in Karachi, Pakistan. METHODS: Ninety-six months (1998-2005) data on HCV seropositive cases (1000(-1) x month(-1)) among male volunteer blood donors tested at four major blood banks in Karachi, Pakistan were subjected to ARIMA modeling. Subsequently, a fitted ARIMA model was used to forecast HCV seropositive donors for 91-96 mo to contrast with observed series of the same months. To assess the forecast accuracy, the mean absolute error rate (%) between the observed and predicted HCV seroprevalence was calculated. Finally, a fitted ARIMA model was used for short-term forecasts beyond the observed series. RESULTS: The goodness-of-fit test of the optimum ARIMA (2,1,7) model showed non-significant autocorrelations in the residuals of the model. The forecasts by ARIMA for 91-96 mo closely followed the pattern of observed series for the same months, with mean monthly absolute forecast errors (%) over 6 mo of 6.5%. The short-term forecasts beyond the observed series adequately captured the pattern in the data and showed increasing tendency of HCV seropositivity with a mean +/- SD HCV seroprevalence (1000(-1) x month(-1)) of 24.3 +/- 1.4 over the forecast interval. CONCLUSION: To curtail HCV spread, public health authorities need to educate communities and health care providers about HCV transmission routes based on known HCV epidemiology in Pakistan and its neighboring countries. Future research may focus on factors associated with hyperendemic levels of HCV infection.

Prevalence and predictors of depression among an elderly population of Pakistan.

OBJECTIVE: To assess the magnitude and risk factors of the problem of depression in an elderly population of Pakistan. METHOD: A cross-sectional study was conducted using a sample of 402 people aged 65 and above visiting the Community Health Center of the Aga Khan University, Karachi. Questionnaire based interviews were conducted for data collection and the 15-Item Geriatric Depression Scale was used to screen for depression. Univariate and multivariate logistic regression analyses were performed to identify factors associated with depression. RESULTS: Of the 402 participants; 69.7% (95% CI=+/-4.5%) were men, 76.4% (95% CI=+/-4.2%) were currently married, 36.8% (95% CI=+/-5%) had received 11 or more years of education and 24.4% (95% CI=+/-4.2%) were employed. The mean age was 70.57 years (SD=+/-5.414 years). The prevalence of depression was found to be 22.9% (95% CI=+/-4.1%) and multiple logistic regression analysis indicated that higher number of daily medications (p-value=0.03), total number of health problems (p-value=0.002), financial problems (p-value<0.001), urinary incontinence (p-value=0.08) and inadequately fulfilled spiritual needs (p-value = 0.067) were significantly associated with depressive symptoms. CONCLUSION: We have identified several risk factors for depression in the elderly which need to be taken into account by practicing family physicians and health care workers.