Perceived risk and distress related to COVID-19 in healthcare versus non-healthcare workers of Pakistan: a cross-sectional study.

BACKGROUND: Healthcare workers (HCWs) have found themselves and their families more susceptible to contracting COVID-19. This puts them at a higher risk of psychological distress, which may compromise patient care. In this study, we aim to explore the risk perceptions and psychological distress between HCWs and non-healthcare workers (NHCWs) in Pakistan. METHODS: A cross-sectional study was conducted using an online self-administered questionnaire. Psychological distress was assessed through The Hospital Anxiety and Depression Scale (HADS). Comparisons were made between HCWs (front/backend, students/graduates) and NHCWs related to risk perceptions and stress levels related to COVID-19. Following tests for normality (Shapiro-Wilk test), variables that fulfilled the normality assumption were compared using the independent samples t-test, while for other variables Mann-Whitney U-test was employed. Pearson Chi-square test was used to compare categorical data. Multiple logistic regression techniques examined the association of participant age, gender, household income, and the presence of COVID-19 symptoms with depression and anxiety levels. RESULTS: Data from 1406 respondents (507 HCWs and 899 NHCWs) were analyzed. No significant difference was observed between HCWs and NHCWs' perception of susceptibility and severity towards COVID-19. While healthcare graduates perceived themselves (80% graduates vs 66% students, p-value 0.011) and their family (82% graduates vs 67% students, p-value 0.008) to be more susceptible to COVID-19, they were less likely to experience depression than students. Frontline HCWs involved in direct patient care perceived themselves (83% frontline vs. 70% backend, p-value 0.003) and their family (84% frontline vs. 72% backend, p-value 0.006) as more susceptible to COVID-19 than backend healthcare professionals. Over half of the respondents were anxious (54% HCWs and 55% NHCWs). Female gender, younger age, lower income, and having COVID-19 related symptoms had a significant effect on the anxiety levels of both HCWs and NHCWs. CONCLUSION: Frontline HCWs, young people, women, and individuals with lower income were at a higher risk of psychological distress due to the pandemic. Government policies should thus be directed at ensuring the mental well-being of frontline HCWs and improving their satisfaction to strengthen the health care delivery system. The findings suggest the need to provide mental health support for health workers.

Protocol for a cluster randomised controlled trial of secondary distribution of hepatitis C self-testing within the context of a house-to-house hepatitis C micro-elimination programme in Karachi, Pakistan.

BACKGROUND: Globally, just 21% of the estimated 58 million people living with hepatitis C virus (HCV) know their status. Thus, there is considerable need to scale-up HCV testing if the World Health Organization (WHO) 2030 hepatitis elimination goals are to be achieved. HCV self-testing may assist with this; however, there are currently no data on the real-world impact of HCV self-testing. With an estimated 5% of the general population living with HCV, Pakistan has the second highest HCV burden in the world. This study aims to evaluate the acceptability and impact of home delivery of HCV self-testing for secondary distribution in the context of a house-to-house HCV micro-elimination programme in Pakistan. METHODS: This is a parallel group, non-blinded, cluster randomised trial comparing secondary distribution of HCV self-testing with secondary distribution of information pamphlets encouraging individuals to visit a testing facility for HCV screening. The cluster allocation ratio is 1:1. Clusters will be randomised either to HCV self-testing distributed via study staff or control clusters where information on HCV will be given and the participant will be requested to attend their local hospital for HCV screening. In both clusters, only households with a member who has not yet been screened as part of the larger micro-elimination project will be included. The primary outcome is the number and proportion of participants who report completion of testing. Secondary outcomes include the number and proportion of participants who a) receive a positive result and are made aware of their status, b) are referred to and complete HCV RNA confirmatory testing, and c) start treatment. Acceptability, feasibility, attitudes towards HCV testing, and cost will also be evaluated. The target sample size is 2,000 participants. DISCUSSION: This study will provide the first ever evidence regarding secondary distribution of HCV self-testing. By comparing HCV self-testing with facility-based testing, we will assess whether HCV self-testing increases the uptake of HCV testing. The findings will inform micro-elimination programmes and determine whether HCV self-testing can enable individuals to be reached who may otherwise be missed. TRIAL REGISTRATION: This study and was registered on clinicaltrials.gov ( NCT04971538 ) 21 July 2021.

The quality of patient care in oncology departments in Karachi, Pakistan: patients' perceptions.

PURPOSE: This study aims to assess the quality of care among adult oncology patients in tertiary care hospitals in Karachi by using an international standard of quality of care and to identify domains where improvement is needed. DESIGN/METHODOLOGY/APPROACH: This is a cross-sectional study carried out at two tertiary care hospitals of Karachi, Pakistan, belonging to private and public sector, respectively, between February and April 2018. Face-to-face interviews were conducted using a modified questionnaire having five-point Likert scale questions regarding satisfaction of patients with doctors, nursing staff, information provided and the hospital standards. SPSS 20 was used for statistical analysis, and the results were expressed using mean, frequencies, percentages and p-values. FINDINGS: The authors approached 415 patients, out of which 389 patients agreed to participate in the study. For both hospitals, the lowest mean scores were for sections pertaining to satisfaction with psychosocial support and information provided. The mean satisfaction score of patients from the private hospital were found to be significantly higher as compared to patients from the public hospital for all domains of patient care (p-value < 0.01 using t-test for two independent samples). The data showed an increasing trend of "satisfied" responses as the household income increased. RESEARCH LIMITATIONS/IMPLICATIONS: A comparative study should be conducted with the aim of pinpointing the differences in areas in which there is a significant difference in positive satisfaction levels between private and public sectors. Similar research could also be expanded adding other variables that affect quality of care such as doctor's approach to their patients, time given during each consultation and patient's understanding of doctor's knowledge. Further studies can be done to bridge the gaps between what a doctor views as standard care and what the patient knows will help them receive a more holistic approach to care. PRACTICAL IMPLICATIONS: Assessing the quality of care helps determine gaps in care and allocating health resources accordingly. In clinical practice, emphasis needs to be given on increased duration and improved quality of patient counselling to improve the low satisfaction levels of patients regarding the psychosocial support. Addressing patients' concerns should be made part of clinical teaching from an undergraduate level. As far as patient access to doctors of the specific speciality is concerned, hospital managements should adopt systems to ensure continuum of care and come up with mechanisms to bridge the discrepancy between a patient's needs and doctor availability. SOCIAL IMPLICATIONS: After being identified as a major deficiency, training doctors in the sensitivities of the population and demographics, especially with respect to socio-economic statuses, can aid in enhancing patient satisfaction to the treatment. Implementation of patient-centred care leads to greater satisfaction with care, which, in turn, increases a patient's self efficacy in managing important aspects of their care and improves health care-related quality of life. ORIGINALITY/VALUE: Cancer patients have long-term exposure to the hospital environment. A patient's satisfaction with the quality of care is an important determinant in patient compliance to the treatment protocol and required hospital visits. There is a dearth of research on the outpatient quality of care in the oncology departments in Karachi. This study provides an overview of the quality of care available to cancer patients in Karachi both in public and private sectors. The results of our study identify the gaps in the quality of care being provided to the patients in a developing country like Pakistan, which can be used to improve the quality of care, leading to better patient outcomes.

Impact of Gastrointestinal Diseases on Health-Related Quality of Life of Patients in Pakistan.

Objective This study aimed to evaluate the impact of gastrointestinal (GI) diseases on health-related quality of life (HRQoL) in Pakistani patients. Methods A cross-sectional study was conducted from 1st January 2019 to 15th February 2019 at a tertiary care hospital in Pakistan by employing a self-administered questionnaire called Gastrointestinal Quality of Life Index (GIQLI). Questionnaires were distributed among the patients presenting to outpatient gastroenterology clinics to evaluate their HRQoL. Results A total of 199 patients were included in this study, and their mean GIQLI score was 87.8 ± 17.8. Results showed that more severe core symptoms can lead to a poorer QoL. Overall GIQLI scores and most of its domain scores were lower in females as compared to males (p-value: 0.02). Obese patients had an overall lower mean GIQLI score including in the GI, psychological, and social domains while advanced age was associated with a higher disease-specific GIQLI score. Conclusion Based on our findings, GI diseases negatively impact the HRQoL in patients. Physicians need to consider the different domains of QoL as part of a holistic approach to treating these patients.

Evaluation of Hepatitis C Virus Core Antigen Assay in a Resource-Limited Setting in Pakistan.

The diagnosis of Hepatitis C virus (HCV) infection can be challenging due to its cost and a lack of access to centralized testing. There is an urgent need to develop simplified HCV testing algorithms. The aim of this study was to evaluate the performance characteristics of a Hepatitis C core antigen (HCVcAg) assay in a decentralized, resource-limited setting. This is a descriptive cross-sectional study from a highly endemic area of Karachi, Pakistan. Between October 2019 and July 2020, subjects aged 12 years and above who screened positive for HCV antibodies were simultaneously tested for HCV RNA (Xpert HCV Viral Load, GeneXpert® IV, Cepheid, France) and HCVcAg (ARCHITECT HCV Ag assay, Abbott® Diagnostics) to confirm active HCV infection. An Abbott ARCHITECT® i1000SR Immunoassay Analyser was installed at a local district hospital as a point-of-care (POC) facility for HCVcAg testing, while samples for HCV RNA were tested in a central lab. Two hundred individuals (mean age 46.4 ± 14.5 years, 71.5% females), who screened positive for HCV antibody, were included in the study. HCV RNA was detected in 128 (64.0%) while HCVcAg was reactive in 119 (59.5%) cases. Performance of the Immunoassay Analyser was excellent with a higher throughput and quicker readout value compared to the GeneXpert System. The sensitivity and specificity of HCVcAg (≥10 fmol/L) at HCV RNA thresholds of ≥12 was 99.1% (95% CI: 95-100%) and 87.6% (95%CI: 78.4-94%). A strong agreement was observed between the HCVcAg assay and HCV RNA. The ARCHITECT HCV Ag assay showed high sensitivity and specificity compared to HCV RNA in a decentralized, resource-limited setting. It can therefore be used as a confirmatory test in HCV elimination programs, particularly for low-income countries such as Pakistan.

Creating polar antivortex in PbTiO3/SrTiO3 superlattice.

Nontrivial topological structures offer a rich playground in condensed matters and promise alternative device configurations for post-Moore electronics. While recently a number of polar topologies have been discovered in confined ferroelectric PbTiO3 within artificially engineered PbTiO3/SrTiO3 superlattices, little attention was paid to possible topological polar structures in SrTiO3. Here we successfully create previously unrealized polar antivortices within the SrTiO3 of PbTiO3/SrTiO3 superlattices, accomplished by carefully engineering their thicknesses guided by phase-field simulation. Field- and thermal-induced Kosterlitz-Thouless-like topological phase transitions have also been demonstrated, and it was discovered that the driving force for antivortex formation is electrostatic instead of elastic. This work completes an important missing link in polar topologies, expands the reaches of topological structures, and offers insight into searching and manipulating polar textures.

Drug induced liver injury is associated with high mortality-A study from a tertiary care hospital in Pakistan.

BACKGROUND AND AIM: In light of few established drug induced liver injury (DILI) registries, this study aims to evaluate the clinical spectrum and predictors of mortality and morbidity of hospitalized patients with suspected DILI. PATIENTS AND METHODS: DILI cases were identified and categorized on basis of COIMS/RUCAM score and the exclusion of other liver diseases. Clinical and laboratory parameters were analyzed to identify the predictors of morbidity (prolonged hospital stay > 5 days) and mortality. RESULTS: Out of 462 patients, there were 264 (57.6%) males and the mean age of the cohort was 50.83 years (range: 20-94 years). DILI was classified as definite or highly probable in 31.1%, probable in 62.5%, and possible in 7.4% of cases. Pattern of liver injury was hepatocellular in 25.1%, cholestatic in 56.17%, and mixed in 18.72% of patients. Anti-tuberculosis drugs (ATDs) were found to be the most common category of drugs causing DILI, in 295 (63.9%) patients. Clinically, encephalopathy was present in 21.6% patients; other presenting symptoms included abdominal pain (57.1%), vomiting (57.1%), jaundice (54.1%) and pruritus (42.3%). In-hospital mortality was 26.5% and prolonged hospital stay (> 5 days) was observed in 35.93% of patients. Mortality was significantly greater in patients with encephalopathy, male gender, hepatocellular pattern of DILI, increased INR and use of ventilator support. CONCLUSION: In our study, the most frequent cause of DILI in hospitalized patients was ATDs. More than a quarter of patients died during hospital stay. A close control of clinical and biochemical parameters are required to prevent and monitor DILI, especially in patients taking ATDs in our region.

Spectrum and Clinical Outcome of Motility Disorders on High-Resolution Esophageal Manometry: A Study From a Tertiary Center on Patients With Dysphagia in Pakistan.

Objective This study aimed to evaluate the outcome of high-resolution esophageal manometry (HRM) in the diagnosis of esophageal motility disorders in a Pakistani population. It also evaluates the outcomes of management of patients with esophageal dysphagia and no structural abnormality on endoscopy. Methods This is a cross-sectional study. Patients with symptoms of dysphagia with normal endoscopy were subjected to esophageal manometry and to barium swallow as a part of routine workup. Esophageal motility disorders diagnosed by HRM were compared to barium swallow findings. A follow-up of these patients was done after a one-year interval to evaluate improvement in their symptoms. Results A total of 202 patients underwent HRM. There were abnormal findings in 160 patients (79.2%) with achalasia being the most common diagnosis in 35.6% of the total patients. Out of 72 patients diagnosed to have achalasia on HRM, only 46 (32.6%) had similar findings on barium esophagram and this difference is statistically significant, p < 0.001). Among achalasia patients, laparoscopic surgery was performed in 22 (30.5%) patients with 59% patients reporting a good to excellent improvement (>50%) in their symptoms, balloon dilatations were done in 47 (65.27%) patients with a good to excellent improvement in symptoms in 55% patients. Only three patients (5.5%) were given botulinum toxin injections, and two of them had an improvement of >50% in their symptoms. Patients with motility disorders other than achalasia were treated with a combination of proton pump inhibitors (PPIs), calcium channel blockers and selective serotonin reuptake inhibitors (SSRIs). Conclusion Achalasia was the most common esophageal motility disorder in our population. HRM can diagnose significantly more patients with achalasia compared to barium swallow. Likewise, HRM was helpful in detecting other esophageal motility disorders and planning their management.

Minimal Hepatic Encephalopathy: Effect of H. pylori infection and small intestinal bacterial overgrowth treatment on clinical outcomes.

The effect Helicobacter pylori (Hp) infection and small intestinal bacterial over growth (SIBO) in minimal hepatic encephalopathy (MHE) is not well understood. The aim of the study was to determine the effect of eradication of Hp infection and SIBO treatment on MHE in patients with cirrhosis. Patients with cirrhosis were enrolled and MHE was determined by psychometric tests and critical flicker frequency analysis. Hp infection and SIBO were assessed by urea breath and Hydrogen breath tests respectively in patients with cirrhosis and in healthy volunteers. Patients with Hp infection and SIBO were given appropriate treatment. At six weeks follow-up, presence of Hp infection, SIBO and MHE status was reassessed. Ninety patients with cirrhosis and equal number of healthy controls were included. 55 (61.1%) patients in the cirrhotic group were diagnosed to have underlying MHE. Among cirrhotic group, Hp infection was present in 28 with MHE (50.9%) vs. in 15 without MHE (42.8%) (p = 0.45). Similarly, SIBO was present in 17 (30.9%) vs. 11 (31.4%) (p = 0.95) in patients with and without MHE respectively. In comparison with healthy controls, patients with cirrhosis were more frequently harboring Hp and SIBO (47.7% vs. 17.7% (p < 0.001) and 31.1% vs. 4.4% (p < 0.001) respectively. On follow-up, all patients showed evidence of eradication of Hp and SIBO infection. Treatment of SIBO significantly improved the state of MHE in cirrhotics, however eradication of Hp infection did not improve MHE significantly. Additionally, patients with low Model for End-Stage Liver Disease (MELD) score and belonging to Child class B had significantly better improvement in MHE. A large number of patients with cirrhosis had either active Hp infection or SIBO with or without MHE, compared to healthy controls. Treatment of SIBO significantly improved MHE in patients with cirrhosis, whereas eradication of Hp did not affect the outcome of MHE in these patients.

A Dual Protection System for Heterostructured 3D CNT/CoSe2/C as High Areal Capacity Anode for Sodium Storage.

3D electrode design is normally opted for multiple advantages, however, instability/detachment of active material causes the pulverization and degradation of the structure, and ultimately poor cyclic stability. Here, a dually protected, highly compressible, and freestanding anode is presented for sodium-ion batteries, where 3D carbon nanotube (CNT) sponge is decorated with homogeneously dispersed CoSe2 nanoparticles (NPs) which are protected under carbon overcoat (CNT/CoSe2/C). The 3D CNT sponge delivers enough space for high mass loading while providing high mechanical strength and faster conduction pathway among the NPs. The outer amorphous carbon overcoat controls the formation of solid electrolyte interphase film by avoiding direct contact of CoSe2 with electrolyte, accommodates large volume changes, and ultimately enhances the overall conductivity of cell and assists in transmitting electron to an external circuit. Moreover, the hybrid can be densified up to 11-fold without affecting its microstructure that results in ultrahigh areal mass loading of 17.4 mg cm-2 and an areal capacity of 7.03 mAh cm-2 along with a high gravimetric capacity of 531 mAh g-1 at 100 mA g-1. Thus, compact and smart devices can be realized by this new electrode design for heavy-duty commercial applications.

Atomic imaging of mechanically induced topological transition of ferroelectric vortices.

Ferroelectric vortices formed through complex lattice-charge interactions have great potential in applications for future nanoelectronics such as memories. For practical applications, it is crucial to manipulate these topological states under external stimuli. Here, we apply mechanical loads to locally manipulate the vortices in a PbTiO3/SrTiO3 superlattice via atomically resolved in-situ scanning transmission electron microscopy. The vortices undergo a transition to the a-domain with in-plane polarization under external compressive stress and spontaneously recover after removal of the stress. We reveal the detailed transition process at the atomic scale and reproduce this numerically using phase-field simulations. These findings provide new pathways to control the exotic topological ferroelectric structures for future nanoelectronics and also valuable insights into understanding of lattice-charge interactions at nanoscale.

Subunit cell-level measurement of polarization in an individual polar vortex.

Recently, several captivating topological structures of electric dipole moments (e.g., vortex, flux closure) have been reported in ferroelectrics with reduced size/dimensions. However, accurate polarization distribution of these topological ferroelectric structures has never been experimentally obtained. We precisely measure the polarization distribution of an individual ferroelectric vortex in PbTiO3/SrTiO3 superlattices at the subunit cell level by using the atomically resolved integrated differential phase contrast imaging in an aberration-corrected scanning transmission electron microscope. We find, in vortices, that out-of-plane polarization is larger than in-plane polarization, and that downward polarization is larger than upward polarization. The polarization magnitude is closely related to tetragonality. Moreover, the contribution of the Pb─O bond to total polarization is highly inhomogeneous in vortices. Our precise measurement at the subunit cell scale provides a sound foundation for mechanistic understanding of the structure and properties of a ferroelectric vortex and lattice-charge coupling phenomena in these topological ferroelectric structures.