PAKistan Study of prEmature coronary atHerosclerosis in young AdulTs (PAK-SEHAT): A prospective longitudinal study protocol investigating the prevalence, severity and determinants of atherosclerotic cardiovascular disease in the young adult Pakistani population

Introduction: Atherosclerotic cardiovascular disease (ASCVD) is a major cause of morbidity, mortality and health expenditures worldwide. Despite having higher ASCVD in the Pakistani population, data on subclinical coronary atherosclerosis in young Pakistanis remain scarce. The PAKistan Study of prEmature coronary atHerosclerosis in young AdulTs (PAK-SEHAT) aims to assess the prevalence, severity and determinants of subclinical coronary atherosclerosis among Pakistani men (35-60 years) and women (35-65 years) free of clinically symptomatic ASCVD and will assess 5-year rates of ASCVD events.Methods and analysis: PAK-SEHAT is an ongoing prospective cohort study with 2000 participants from all provinces of Pakistan who will be interviewed at the baseline along with phlebotomy, measurement of carotid intima-media thickness (CIMT) and coronary CT angiography (CCTA). Phlebotomy will be repeated at 2.5 years, whereas CIMT and CCTA will be repeated at 5 years. We will report the frequency of maximal coronary stenosis ≥50% and ≥70%, number of coronary vessels with plaque and the number of coronary segments affected per participant on CCTA. We will use Cox proportional hazards regression models to evaluate the association between baseline characteristics and incident ASCVD events during follow-up. These associations will be presented as HRs with 95% CIs.Ethics and dissemination: The study protocol was approved by the Tabba Heart Institute Institutional Review Board (THI/IRB/FQ/22-09-2021/016). All study procedures are consistent with the principles of the Declaration of Helsinki. Findings of the study will be disseminated via peer-reviewed publications and conference presentations.Trial registration number: NCT05156736

Longitudinal association between parental-to-child-maltreatment and self-reported generalized anxiety disorder symptoms in Pakistani adolescents

Background: Parent-to-child maltreatment is considered one of the risk factors for Generalized Anxiety Disorder (GAD) symptoms, but this hypothesis has not been adequately tested in Pakistani settings.Aim: This study aimed to examine the association between parent-to-child maltreatment and the risk of developing GAD symptoms among adolescents.Methods: The association of none to rare, occasionally, and frequently parent-to-child maltreatment with the incidence of GAD symptoms was investigated in a sample of 800 adolescents aged 11-17 years who were followed for two years. Parent-to-child maltreatment was assessed using ICAST-C (International child abuse screening tool). GAD Symptoms were determined by SCARED (Screen for children anxiety-related disorders). Cox Proportional Algorithm was used to estimate risk ratios.Results: Among children with both uneducated parents, frequently maltreatment was associated with 7.31 (2.20-24.04) times the risk of GAD symptoms compared to none to rare maltreatment. In contrast, the risk of GAD symptoms in frequently maltreated children was 5.58 times (1.40-21.97) than negligibly maltreated children with either educated parent.Conclusion: The frequency of parent-to-child maltreatment is significantly associated with an increased risk of developing GAD symptoms in which parental education plays a crucial role. Parents should be imparted with the awareness of the consequences of child maltreatment. In Pakistani settings the need to have this awareness is even more necessary due to the culturally acceptable disciplinary measures used by parents

Association between depression and quality of lift among Pakistani adolescents and youth (15-24 years) with self-reported polycystic ovarian syndrome- A web-based analytical cross-sectional survey

Clinical-stigmata inherent in Polycystic ovarian syndrome (PCOS), including hormonal and aesthetic changes, can impair the quality of life of individuals, predominantly adolescents and youth who are most vulnerable to its impact. Depression could be one of the factors influencing the quality of life as there exists a possibility that depression might modulate how an individual perceives her symptoms, eventually affecting the quality of life. It is essential to determine the quality of life and its associated factors as it is a critical step towards identifying the adequate measures and interventions required to ensure the overall psychological, physical, and social well-being of patients with PCOS. Objectives: The study investigated the association between depression and quality of life in Pakistani adolescents and youth (15-24 years) with PCOS and also determined other factors influencing the quality of life. Methods: We conducted a web-based analytical-cross-sectional survey on 213 single Pakistani females aged 15-24 years who had self-reported PCOS. The study questionnaire was broadcasted on the internet via Google forms. The Google form link was made available to the target population via various social media platforms (Facebook, Twitter, Instagram), WhatsApp messages, and SMS. Individuals with internet availability were able to access the questionnaire by clicking on the link. Depression and quality of life were assessed through the Center of Epidemiological Studies Depression tool and polycystic ovarian syndrome quality of life scale. Multiple linear regression was the choice of analysis, and adjusted regression coefficients along with a 95% confidence interval were reported. Results: The mean age of participants in this study was 21.4+1.89 years. Majority of the participants were residents of Sindh(64.3%), belonged to middle-class backgrounds(72.7%), and had graduation/post-graduation as their highest level of education(69.0%). The mean overall quality of life score was 2.9+0.3. The most affected domains of quality of life were obesity/weight gain (2.5+0.1) and emotional health(2.9+0.4). The least distressing domain was hirsutism(3.2+0.1). 172 out of 213 (80.0%) participants were screened positive for depressive. symptoms. Depressed participants reported reduced mean overall quality of life scores compared to nondepressed counterparts (2.8+0.3 vs. 3.5+0.5,

Clinical characteristics, management, and 5-year survival compared between no standard modifiable risk factor (SMuRFless) and ≥ 1 SMuRF ACS cases: an analysis of 15,051 cases from Pakistan

Abstract Background There has been an increase in Acute Coronary Syndrome (ACS) patients without standard modifiable risk factors i.e. hypertension, diabetes, dyslipidemia, and tobacco use (SMuRFless) compared to the patients with ≥ 1 SMuRF but this has not been studied in South Asia despite them being a high-risk population. We conducted a comparative analysis of first episodes of ACS cases admitted to a tertiary cardiac center in Pakistan between SMuRFless and ≥ 1 SMuRF patients for clinical presentation, management, in-hospital, and 5-year mortality. Methods We undertook a retrospective study and data of 15,051 patients admitted at Tabba Heart Institute (THI) with the first episode of ACS was extracted from Chest Pain-MI™, and the CathPCI Registry® registry affiliated with the National Cardiovascular Data Registry (NCDR®), USA. Logistic regression and Cox proportional algorithm yielded odds ratio (OR) and hazard ratios (HR) with 95% confidence interval (CI) for associated factors of in-patient and 5-year mortality. Results There were 15% SMuRFless cases and in-hospital mortality was 4.1% in SMuRFless vs. 3.9% in the ≥ 1 SMuRF group (p-0.59), the difference remained insignificant after adjusting for age, gender, Killip class, multivessel disease, type of ACS, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) (Adjusted OR:1.1 [0.8, 1.3]. Unadjusted 5-year mortality was 40% lower in the SMuRFless group but the difference was insignificant after adjusting for age, gender, disease at presentation, its severity, and management (Adjusted HR 0.7 95% CI[0.5, 1.0]). STEMI, NSTEMI, Killip class, and multivessel disease increased the risk of overall 5-year mortality. Conclusion In-hospital and 5-year mortality was not different between the SMuRFless and ≥ 1 SMuRF group, there is a need to understand mediators of immediate and long-term mortality risk in SMuRFless patients

PRESENTATION, MANAGEMENT, AND EARLY OUTCOMES OF YOUNG ACUTE CORONARY SYNDROME PATIENTS- ANALYSIS OF 23,560 SOUTH ASIAN PATIENTS FROM 2012-2021

Therapeutic Area: ASCVD/CVD Risk Factors Background: There is a scarcity of literature exploring early outcomes of young acute-coronary-syndrome patients, predominantly in South Asians, who are considered to be at most risk of developing premature coronary artery disease. Therefore, we compared presentation, management, and early outcomes of young vs. old ACS patients and explored predictors of in-hospital mortality. Methods: We extracted data of 23,560 ACS patients presented at Tabba Heart Institute, Karachi, Pakistan, from July 2012-June 2020, from the Chest pain-MI Registry™. Young patients: ≤45 years. Chi-sq/Fischer exact tests assessed the difference between variables in younger vs. older patients. Logistic regression was used to determine predictors of early mortality, and odds ratios along with 95% confidence intervals were reported. Results: The mean age was 59.0±11.4 years, women: 23.5%, and younger patients: 12.3%. Dyslipidemia (34.5% vs. 22.4%), diabetes (52.1% vs. 27.4%) and hypertension (68.3% vs. 42.9%) were higher in older adults. In contrast, Family history of premature coronary artery disease (32.7% vs. 18.1%) and smokeless-tobacco (8.4% vs. 6.5%) was higher in young adults. Younger adults were more likely to present with STEMI (45% vs. 33.2%) and be asymptomatic on presentation (40.8% vs. 36.1%). Median symptom-to-door-time was higher in younger patients (760(192, 3140) vs. 635(186,2735) minutes). Coronary angiography and CABG were higher in older patients; however, PCI was higher in young adults. The use of all medications in first 24 hours except IV anticoagulant and angiotensin receptor blockers was higher in younger adults. In-hospital mortality (4.3% vs. 1.7%) and complications including cardiac arrest (1.9% vs. 0.7%), cardiogenic shock (1.9% vs. 0.9%) and heart failure (1% vs. 0.6%) were more common in older patients. After adjusting for risk factors, older age (2.4, 1.5-3.7) was a significant predictor of early mortality. Other predictors included: STEMI (OR:3.2, 95% CI:1.9-5.5), women (1.4, 1,1-1.8), Killip III/IV (3, 2.4-3.8), cardiac arrest (3.2, 2.2-4.5) and heart failure (1.8, 1.4-2.3) at presentation, Left ventricular ejection fraction (0.9, 0.93-0.95) and PCI (1.3, 1.1-1.7) and CABG (3, 2.3-3.9) at index hospitalization. Conclusion: Younger patients presented differently from their older counterparts as they were likely to be asymptomatic and have STEMI. They had favorable clinical outcomes, which might be explained by the aggressive treatment

Predictors of non-obstructive coronary artery disease in patients undergoing elective coronary angiography

Background: Appropriate patient selection for coronary angiography (CAG) is essential to minimize the unnecessary risk of morbidities and exposure to radiation and iodinated contrast. This becomes even more relevant in low-to-middle-income settings where most health expenditures are out-of-pocket due to lack of medical insurance. We determined predictors of non-obstructive coronaries (NOC) in patients undergoing elective CAG. Methods: CathPCI Registry®, single-center data was extracted for 25,472 patients who had CAG over an eight year period. After excluding patients for compelling conditions or known CAD, 2,984 (11.7%) patients were included in this study. Non-Obstructive Coronaries was defined as \u3c50% left main coronary artery and major epicardial vessel stenosis. Multiple Cox proportional algorithm was employed to report prevalence ratios (PR) of predictors of NOC along with 95% confidence interval. Results: Mean age of patients was 57.9 ± 9.7 years, 23.5% were women. Preprocedural non-invasive testing (NIT) was performed in 46% of the patients; of which 95.5% reported to be positive but only 67.3% were stratified as high risk. Of 2,984 patients undergoing elective CAG, 711 (24%) had NOC. Predictors of NOC included younger age \u3c50 years (PR: 1.3, CI: 1.0-1.5), Women (1.8, 1.5-2.1), low (1.9, 1.5-2.5) and intermediate risk stratification (1.3, 1.0-1.6) on Modified Framingham Risk Score and inappropriate (2.7, 1.6-4.3) and uncertain (1.3, 1.1-1.6) classification of CAG on Appropriate Use Criteria. Patients with heart failure as an indication of CAG (1.7, 1.4-2.0) and No NIT or positive low risk NIT (1.8, 1.5-2.2) were more likely to have NOC. Conclusion: Approximately one out of four patients undergoing elective CAG had NOC. Yield of diagnostic catheterization can be improved by adjudicating NIT especially in younger patients, women, patients with heart failure as an indication of CAG, patients classified as inappropriate on Appropriate Use Criteria and patients categorized as low or intermediate risk on MFR

Factors associated with parenting stress among mothers of children with developmental disabilities: A cross-sectional study

Introduction: Parents of children with developmental disabilities, particularly mothers, are likely to suffer from stress. Nevertheless, the association between parenting stress and the type and extent of disability is far from evident.Methods: To examine the relationship between parenting stress, and type and extent of disability, we collected demographic details and the Parenting Stress Scale from 250 mothers of children with a developmental disability attending special-education schools in Karachi. Type and extent of disability were diagnosed by the school’s psychologist based on DSM criteria. Adjusted beta-coefficients along with a 95% confidence interval were reported using multiple linear regression.Results: The overall mean parenting stress score among mothers was found to be 43.2 (95% CI: 42.3–44.1). A total of 80 mothers (32%) had a child with Intellectual disability (ID), 60 (24%) with Attention deficit hyperactivity disorder (ADHD), 41 (16%) with Autism, and 69 (28%) with Down syndrome. A large proportion of these children (41%) had mild symptoms and around 26% had severe disability. Multivariable analysis showed that the estimated mean parenting stress score was higher for mothers of children with severe autism (β: 8.09, 95% CI: 3.07, 13.11), severe ID (β: 7.45, 95% CI: 3.71, 11.19) and severe ADHD (β: 7.03, 95% CI: 2.62, 11.44) compared to mothers of children with mild autism, ID, and ADHD.Conclusion: Nurturing a child with special care needs is challenging for mothers. Appropriate clinical services aiming to support parents of children with various disabilities should offer resources to educate and enable mothers to manage their child’s disabilities and needs. Tailored parenting interventions must also be introduced to reduce the levels of stress among mothers

Gender differences in clinical outcomes after percutaneous coronary intervention-analysis of 15,106 patients from the Cardiac Registry of Pakistan database

There is a scarcity of data on gender differences in outcomes during and after percutaneous coronary intervention (PCI) in the South Asian population. We assessed the gender differences in in-hospital mortality and complications in patients who underwent PCI. We conducted a cross-sectional study of 15,106 patients from the CROP (Cardiac Registry of Pakistan) CathPCI database. Logistic regression was used to determine factors associated with in-hospital mortality (primary outcome), access site hematoma, and bleeding complications. Approximately 19.6% were women. Women were older (mean age = 57.3 vs 54.4 years) and had a higher prevalence of diabetes (49.3% vs 32.6%), hypertension (72.8% vs 56.4%), peripheral arterial disease (1.5% vs 1%), and cerebrovascular accident (1.2% vs 0.8%) than men (

Demographic psychosocial factors associated with internet addiction among the Pakistani population during COVID-19: A web-based survey

This study aims to determine the burden of COVID19-induced internet addiction and related psychosocial factors among the Pakistani sample. A web-based cross-sectional survey was conducted from January to March 2021. An analytical crosssectional survey was broadcast on the internet via a Google form completed by 1145 Pakistanis. Individuals aged 13 years and above with competency to comprehend English or Urdu language, currently residing in any province of Pakistan, having access to the questionnaire, and willing to participate were eligible to participate. Overseas Pakistanis were excluded from the study. The outcome is COVID19-induced internet addiction was measured using the validated tool Young’s Internet Addiction Test (IAT). In addition, symptoms of depression, anxiety, stress, and other psychosocial factors were assessed using the validated tool Depression, Anxiety, and Stress Scale-21 (DASS-21). Adjusted odds ratios with a 95% confidence interval were reported using multinomial logistic regression. Most participants were females and youth (between 20 and 24 years). The prevalence of problematic internet users (PIU) and addictive internet users (AIU) was 27.3% and 11.3%, respectively. The odds of extremely severe anxiety among AIU were approximately three times (Adj OR: 2.6 (1.1-7.1), followed by the odds of having extremely severe stress being about five times higher among AIU (Adj OR: 5.4 (1.6-17.6)) as compared to normal internet users (NIU). Amid COVID-19, the burden of internet addiction has surged among the Pakistani populace. This study identified that gender, marital status, depression, stress, anxiety, work situation, and mood changes during the COVID-19 pandemic are significantly correlated with problematic and addictive internet use. Preventative measures against the addictive use of the internet are needed to avoid or mitigate any serious mental health problem