A comparison of treatments offered to patients with nonalcoholic steatohepatitis

OBJECTIVE: To compare various treatment options provided to patients with Nonalcoholic Steatohepatitis (NASH) and assess improvement in liver status via reduction in serum Alanine Aminotransferase (ALT) levels. STUDY DESIGN: Retrospective cohort study. PLACE AND DURATION OF STUDY: The Aga Khan University Hospital, Karachi, from April 2000 to April 2007. METHODOLOGY: All available records of patients aged between 20-70 years, fatty liver on ultrasound, elevated serum ALT and having at least one follow-up, after a baseline visit were included. The patients had variable number of follow-ups and a maximum of 3 follow-ups were considered. Information was collected on demographic and clinical characteristics of the subjects. The treatment options were categorized as weight reduction alone, with statins, and with other medications. Serum ALT level was the main outcome measured in IU/l. Repeated-measures ANOVA, using a mixed model approach was performed with treatment options as between subject factor, and follow-up as within subject factor and p-value \u3c 0.05 was considered significant. RESULTS: Sixty-nine records of subjects, consisting of 50 males and 19 females were selected. The mean (+/- SD) age was 40+/-12 years. Thirty-one subjects (45%) were advised weight reduction only, and experienced a 72% reduction in serum ALT levels, over the mean follow-up time of 9+/-3 months. Twelve subjects (17%) received statins along with weight reducing advice, and experienced a 56% reduction in mean ALT over the mean follow-up of 11+/-7 months. Twenty-six subjects (38%) received other medications along with advice for weight reduction and experienced a 73% reduction in serum ALT levels over the mean time of 10+/-4 months. The mean ALT declined at follow-up times, irrespective of the prescribed treatment, and that the decline with time was different for males and females. CONCLUSION: Serum ALT levels among patients with NASH decreased with time, regardless of the provided treatment, and the decrease was different for males and females

Post-traumatic stress disorder and its predictors in emergency medical service personnel: A cross-sectional study from Karachi, Pakistan

Background: Emergency medical service (EMS) personnel who work to provide emergency medical care at the scene and during transportation are exposed to various kinds of stressors and are particularly susceptible to developing stress-reactions. This study assesses symptoms of post-traumatic stress disorder and its predictors among the personnel of a selected EMS in Karachi, Pakistan.Methods: Data were gathered from 518 personnel working in an EMS setting from February to May 2014. Participants were screened for post-traumatic stress symptoms using the Impact of Event Scale-Revised (IES-R). Demographic and work-related characteristics, coping styles and the social support systems of the participants were assessed. Linear regression was used on the IES-R to identify predictors of post-traumatic stress symptoms.Results: The mean score of the IES-R was 23.9 ± 12.1. EMS personnel with a dysfunctional coping style (β = 0.67 CI 0.39 – 0.95), anxiety, and depression (β = 0.64 CI 0.52 – 0.75) were more likely to have increased severity of post-traumatic stress symptoms. Age was found to have an inverse relationship with stress symptoms (β = −0.17 CI 0.33 – -0.023), indicating the susceptibility of younger EMS personnel to stress.Conclusion: The EMS personnel in this setting were found to have a moderate level of post-traumatic stress symptoms. The significant predictors of post-traumatic stress symptoms in this EMS population were age, coping style, and levels of anxiety and depression. These predicting factors can be a potential avenue for interventions to improve the mental health of these frontline workers

Association of depression and life satisfaction with low resilience among married women of Karachi, Pakistan

Background: The concept of resilience is very crucial in promoting positive psychological well-being. However, this construct was never looked among married women of Karachi, Pakistan. Therefore, this study aimed to assess the prevalence and the associated risk factors of resilience in Pakistan. Methods: It was a cross-sectional survey, using the Wagnild Resilience Scale (RS) to assess resilience, Beck Depression Inventory II (BDI-II) for measuring depression and Trait Wellbeing Inventory for determining Life Satisfaction. Systematic sampling was employed to enroll 636 participants of aged 20 to 40 years living in two urban squatter settlements of Karachi, Pakistan. Prevalence ratio was computed with their 95% confidence interval. Results: A total of 636 married women participated in the study. The average age of females with low resilience was 29.8 (5.7) whereas the mean age of females with high resilience was 31.1 (5.7). Around 90% of all the participants could speak in Urdu. The prevalence of low resilience among women was 21.9%. Moreover, the prevalence of depression among low resilience group was 43.9% whereas the mean life satisfaction score among females with low resilience was lower than females with high resilience. The females who had low resilience were younger and had no formal/informal education as compared to their counterparts. After controlling for other variables, the prevalence of low resilience was 1.78 times more among depressed females as compared to the non-depressed with a 95% CI: (1.27-2.51). Moreover with every one unit increase in the life satisfaction scores, the prevalence of low resilience decreased 9%. Furthermore, age and informal schooling were also found to be significantly associated with resilience. Conclusion: Depression and life satisfaction are the potential modifiable risk factors for resilience and hence we can improve resilience through interventions that may focus on reducing depression and improving satisfaction towards life. Our study also recommends that health care professionals should be educated about these modifiable risk factors to bring about a change in the society and reduce the mental health illness by promoting constructive adaptation

Factors affecting depression among married women living in urban squatter settlements of Karachi, Pakistan

Background: Depression is one of the growing public health concerns among women worldwide. This is one of the most under-recognized and under-treated mental illnesses worldwide. Women of developing countries are inexplicably affecting with depression. Purpose: The purpose of study is to assess the prevalence and associative factors of depression among women of aged 20 to 40 years living in urban squatter settlements of Karachi, Pakistan. The identification of all the potential determinants will potentially help in formulating preventive strategies in order to decline the prevalence of depression among women and improve the well being of women.Methods: An analytical cross-sectional survey was employed among women living in Reta Plot and Kala Board communities of Karachi, Pakistan. Beck Depression Inventory II (BDI-II) was used to measure depression. Systematic sampling was used to recruit 636 married women. Cox proportional hazard was run to compute prevalence ratios and their 95% confidence interval.Results: Our study estimated 33.3% of depression among study participants. The current study showed that age, possession of own vehicle, years of schooling and recent deaths in family were significantly associated with depression.Conclusion: This research was a bold step to address the issue of increasing rate of depression among Pakistani population. Our study results can convince policy makers to extend mental health support to women by improving accessibility of services. Recommendation: Our study recommends that the women of our society should be encouraged for attaining education. This study also recommends that at primary health care setting, every health professional should be trained to screen the depression. Moreover, the results of our study can also encourage policy makers to expand mental health support services for women

Pregnancy Outcomes among Women with an Unintended Pregnancy: Findings from a Prospective Registry in Rural Pakistan

Background: Unintended pregnancies are an important public health issue in both developed and developing countries. An unintended pregnancy may affect maternal health seeking behavior during the antenatal and postpartum periods, which can adversely affect perinatal outcomes. Aim: The specific aim of our study was to measure antepartum, intrapartum, and postpartum pregnancy outcomes among women with unintended pregnancies in a rural Pakistani population.Methods: Using a prospective maternal and newborn health registry in Thatta Pakistan, we evaluated temporal associations between unintended pregnancy and several dimensions of health seeking behavior including: antenatal care, preference for private versus government facility for antenatal care, and use of tetanus toxoid (TT) vaccine during the current pregnancy. We performed logistic regressions to analyze the data.Results: In a multivariable model, we found that women who claimed their pregnancies as unintended were 1.27 times more likely to not utilize any facility for antenatal care as compared to women with intended pregnancies [OR = 1.27; 95% CI (1.11 - 1.46)]. Likewise, women with unintended pregnancies were 1.23 times more likely to not receive tetanus toxoid vaccine during the antenatal period [OR = 1.23; 95% CI (1.06 - 1.41)] and were 1.20 times more likely to utilize a government facility compared to private facilities for the antenatal care as compared to their counterparts with intended pregnancies [OR = 1.20; 95% CI (1.04 - 1.38)].Conclusions: Women with unintended pregnancies were less likely to seek antenatal care and preferred government facilities when they did enroll; these facilities are known for providing subsidized but suboptimal care. Our results show that women who decide to carry unintended pregnancies should be considered a high-risk group that requires focused counseling on adherence to antenatal care and delivery planning. Prevention of unintended and unplanned pregnancies in rural areas through provision of family planning services should be encouraged

Geographic access to working family planning centers and unintended pregnancies among married women: a community based nested case control study.

Background: Unintended pregnancies pose substantial risk to mothers and children. In Pakistan, unintended pregnancies account for 46% of all pregnancies. Lack of geographic access to open and well-supplied family planning (FP) centers may be related to the occurrence of such pregnancies, particularly in rural areas. Objective: The objective of this analysis is to determine if geographic access to family planning centers in the Thatta district of Pakistan is related to unintended pregnancy rates among married women. Methods: We conducted a community-based, nested case-control study of 800 pregnant women identified from the database of an active surveillance system, which registers and follows all pregnant women in the catchment area of Thatta district. Women were enrolled during the first trimester; those that reported their pregnancy to be unintended were selected as cases (n = 200), and those whose pregnancies were intended served as controls (n = 600). We defined geographic access as including both the distance of a family planning center from the woman’s home, and availability of personal transportation. Logistic regression was used for analysis. Results: In the multivariate model, neither distance [OR = 1.0; 95% CI (0.95 - 1.05)] nor availability of transportation [OR = 1.14; 95% CI (0.78 - 1.67)] were significantly associated with unintended pregnancy. In fact, women with unintended pregnancies were more likely to be aware of family planning [OR = 2.21; 95% CI (1.23 - 3.97)] and more likely to have been using a contraceptive method before conceiving their index pregnancy [OR = 3.59; 95% CI (1.83 - 7.06)]. Other factors related to unintended pregnancy were older maternal age [OR = 1.13; 95% CI (1.08 - 1.17)], having already had at least one son [OR = 3.13; 95% CI (1.93 - 5.07)]; spousal opposition to contraceptive use, [OR = 3.24; 95% CI (1.89 - 5.56)] and low spousal education level [OR = 1.85; 95% CI (1.08 - 3.18)] as compared to women with intended pregnancy. Conclusion: Lack of geographic access to FP centers is not a risk factor for unintended pregnancy in women from the Thatta district. However, in this population, unintended pregnancies are more common among older women, women having at least one son, and those who have a spouse who does not approve of contraceptive use, and is less educated. Of note, women who reported unintended pregnancy did have knowledge about FP and were more often using contraceptives before they conceived

Prevalence of anxiety, depression and associated factors among pregnant women of Hyderabad, Pakistan.

Background: Few studies have examined the relationship between antenatal depression, anxiety and domestic violence in pregnant women in developing countries, despite the World Health Organization\u27s estimates that depressive disorders will be the second leading cause of the global disease burden by 2020. There is a paucity of research on mood disorders, their predictors and sequelae among pregnant women in Pakistan. Aims: To determine the prevalence of anxiety and depression and evaluate associated factors, including domestic violence, among pregnant women in an urban community in Pakistan. Methods: All pregnant women living in identified areas of Hyderabad, Pakistan were screened by government health workers for an observational study on maternal characteristics and pregnancy outcomes. Of these, 1,368 (76%) of eligible women were administered the validated Aga Khan University Anxiety Depression Scale at 20-26 weeks of gestation. Results: Eighteen per cent of the women were anxious and/or depressed. Psychological distress was associated with husband unemployment (p = 0.032), lower household wealth (p = 0.027), having 10 or more years of formal education ( p = 0.002), a first (p = 0.002) and an unwanted pregnancy ( p \u3c 0.001). The strongest factors associated with depression/anxiety were physical/sexual and verbal abuse, 42% of women who were physically and/or sexually abused and 23% of those with verbal abuse had depression/anxiety compared to 8% of those who were not abused. Conclusions: Anxiety and depression commonly occur during pregnancy in Pakistani women, rates are highest in women experiencing sexual/physical as well as verbal abuse, but they are also increased among women with unemployed spouses and those with lower household wealth. These results suggest that developing a screening and treatment programme for domestic violence and depression/anxiety during pregnancy may improve the mental health status of pregnant Pakistani women

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 \u3c13 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\u3c0.0001), 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

A combined community and facility-based approach to improve pregnancy outcomes in low-resource settings: A global network cluster randomized trial

Background: Fetal and neonatal mortality rates in low-income countries are at least 10-fold greater than in high-income countries. These differences have been related to poor access to and poor quality of obstetric and neonatal care.Methods: This trial tested the hypothesis that teams of health care providers, administrators and local residents can address the problem of limited access to quality obstetric and neonatal care and lead to a reduction in perinatal mortality in intervention compared to control locations. In seven geographic areas in five low-income and one middle-income country, most with high perinatal mortality rates and substantial numbers of home deliveries, we performed a cluster randomized non-masked trial of a package of interventions that included community mobilization focusing on birth planning and hospital transport, community birth attendant training in problem recognition, and facility staff training in the management of obstetric and neonatal emergencies. The primary outcome was perinatal mortality at ≥28 weeks gestation or birth weight ≥1000 g.Results: Despite extensive effort in all sites in each of the three intervention areas, no differences emerged in the primary or any secondary outcome between the intervention and control clusters. In both groups, the mean perinatal mortality was 40.1/1,000 births (P = 0.9996). Neither were there differences between the two groups in outcomes in the last six months of the project, in the year following intervention cessation, nor in the clusters that best implemented the intervention.Conclusions: This cluster randomized comprehensive, large-scale, multi-sector intervention did not result in detectable impact on the proposed outcomes. While this does not negate the importance of these interventions, we expect that achieving improvement in pregnancy outcomes in these settings will require substantially more obstetric and neonatal care infrastructure than was available at the sites during this trial, and without them provider training and community mobilization will not be sufficient. Our results highlight the critical importance of evaluating outcomes in randomized trials, as interventions that should be effective may not be.Trial Registration: ClinicalTrials.gov NCT01073488

Study Protocol: Validation and Adaptation of community-worker-administered stroke symptom questionnaire in a periurban Pakistani community to determine disease burden.

Background : Stroke is the second leading cause of mortality and the leading cause of disability in the world today. The disease burden is on the rise in developing nations, but there is scarcity of data from these regions to inform policy decisions. Stroke burden can be determined by clinical diagnosis alone in the public health context and is a far more feasible way to assess disease status in low- to middle-income countries like Pakistan. We aim to translate and adapt a validated stroke symptom questionnaire, train community health workers in its administration, and verify it against assessment by two trained neurologists. Methods/Design : This is a prospective study, which we aim to carry out in Ibrahim Hyderi, a periurban slum of Karachi. We translated into Urdu the questionnaire for verifying stroke free status (QVSFS), which is an internationally validated tool to assess the same. Two community health workers (CHW) will be identified and will receive training by neurologists, which will include teaching regarding stroke pathophysiology, symptomatology, and detection. They will be familiarized with the QVSFS, and their questionnaire administration will be assessed through roleplay. We intend to recruit 322 subjects from the same community and the CHWs will gather data on them. The same subjects will later be assessed by two trained neurologists, and the findings collaborated to validate those obtained by the CHWs. Sensitivity, specificity, positive and negative predictive values, and Cohen’s kappa will be determined for the CHW-administered ques tionnaire tested against assessment by two neurologists together and separately for the two CHWs. Data analysis will be done using SPSS version 19.0. Discussion ; The results of this study will determine if and how well CHW-administered questionnaires are at assessing stroke status in a community. This will facilitate use of the same as a practical alternative for stroke surveillance in the countr