Reflections of an earliest established screening and testing facility for COVID-19 in the largest Metropolis, Pakistan

As the world struggles to deal with the COVID-19 pandemic, this article talks about the experience and findings of the first COVID-19 screening facility in a tertiary care hospital in Karachi, Pakistan. Department of Family Medicine at Aga Khan University (AKU) took initiative where COVID-19 screening of stable patients first began in a dedicated area. Since testing kits were limited and community spread had not started, nurses would screen every walk-in patient based on the presence of fever, cough, travel history and exposure to COVID-19 positive patient in the last 14 days, and advise swab testing if indicated. Out of 742-screened patients, approximately 66% were males and 34% were females. 38% of patients reported fever and 54% of patients reported cough. 8% (65) patients checked all three screening criteria of cough, fever and international travel exposure whereas 35% were asymptomatic. The majority had clinical exposure (38.3%) followed by public exposure (33.4%) and international travel exposure (19.8%)

Implementation and evaluation of employee health and wellness program using RE-AIM framework

Purpose: To describe the design, implementation, and evaluation of an employer-sponsored health screening program [Employee Health and Wellness Program (EHWP)] in an academic healthcare system in Pakistan.Design/methodology/approach: One-year after implementation, we use the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation and Maintenance) to evaluate and report participant- and organizational-level indicators of success.Findings: Of 5286 invited employees, 4523 (86%) completed blood work and 1809 (34%) completed health risk assessment (Reach). Of the 915 (51%) who required referrals, 3% were referred for new diagnoses of diabetes, hepatitis C or severe anemia; 63% for elevated 10- year risk of cardiometabolic diseases (cardiovascular disease and diabetes); and 25% for counseling for depression, obesity or smoking cessation (Effectiveness). Employees’ barriers to enrollment were explored (Adoption). While institutional costs were considered nominal (US $ 20/employee), organizational barriers were identified (Implementation). Finally, 97% of users reported interest in enrollment if EHWP was offered again (Maintenance).Originality/ value: In a country with minimal focus on adult preventive care, we report the impact of an employer-offered wellness program that identified new risk factors and offered referral for ongoing care. Employees reported a positive experience and were willing to reenroll. Using the RE-AIM framework, we have defined indicators in the real-world setting, that can be used effectively by other institutions to start such a program

Patterns of suicide and self-harm in Pakistan: a retrospective descriptive study protocol

Introduction Suicide is a major global public health problem. Low-income and middle-income countries contribute 78% of all suicidal deaths. Pakistan, a South Asian country, lacks official statistics on suicides at national level. Statistics on suicide are neither collected nationally nor published in the annual national morbidity and mortality surveys. Medicolegal reports on suicides and self-harm are extremely rich and important source of information but greatly underused in Pakistan. We aim to examine the patterns of suicides and self-harm retrospectively in patients who were registered with medicolegal centres (MLCs) in Karachi, during the period January 2017 to December 2021. Methods and analysis Using retrospective descriptive design, the data will be collected from the medical records maintained at the main office of the Karachi police surgeon. Data from all nine MLCs of Karachi are collated and stored at the main office of Police surgeon. Information on suicide and self-harm cases will be extracted from records of all MLCs. The data will be collected using structured proforma and it will be analysed using descriptive and inferential analysis. Ethics and dissemination The study was approved for exemption from Aga Khan University, Ethical Review Committee. The findings of the study will be disseminated by conducting seminars for healthcare professionals and stakeholders including psychiatrists, psychologists, counsellors, medicolegal officers, police surgeons, mental health nurses, general and public health physicians and policy makers. Findings will be published in local and international peer-reviewed scientific journals

Off-label prescribing of antipsychoric drugs in depressive disordrs in general pratitioner\u27s settings from Karachi, Pakistan; a pilot study

Pharmacological treatment is a critical part of much of psychiatric practice round the globe; in patients from a wide age range and across many diagnostic groups. Despite the availability of varying psychotropic drug groups, an eloquent proportion of patients will remained troubled by distressing and disabling symptoms even after succession of licensed pharmacological treatment/s. The situation will aid an ascending weightage to the existing state of mental health with special emphasis on developing regions of the world which are accountable with more than half of the total global burden of common mental health disorders. In terms of drug regulation and control FDA has a limited role in monitoring the practice of a medicine, although new indications are timely revised in drug monographs. In countries like Pakistan; where almost 70% of the total health care is provided by the general practitioners\u27 there, is an awful requisite to study their psychopharmacological practices systemically. Aims: We designed this survey to analyze the proportion of off-label prescribed Antipsychotics drugs in depression among patients\u27 with common mental health disorders at general practice. We also ascertained for associated factors. Methods: An analytical cross sectional study was designed on pilot scale to determine the extent of off-label prescribing at general practice. The study followed a multi-stage cluster sampling technique. Out of the total 18 towns 4 of the towns of Karachi city were taken as PSU (primary sampling units). From each town, 1-2 union councils were taken as SSU (secondary sampling units). General practitioners\u27 clinics were mapped from SSU\u27s as per eligibility criteria. A short interview was conducted from the physician at first stage whose clinic was selected as study site to ascertain about their competencies in terms of clinical management of common mental health disorders. Within each of the respective clinics adult patients (18-65) years of age who sought medical care for CMD\u27s (common mental health disorders) were then approached toaccess them for depression screening by SRQ-20 scale and prescription record review on a pre-designed questionnaire by the trained research staff. GEE (Generalized estimating equation) technique through binary logistic regression analysis was used to determine the co-relation between general physician\u27s clinical expertise and his / her prescribing practices. Results: The study estimated an overall proportion of off-label prescribing of Antipsychotic drugs in depression as 19% among clinic attendees. The factors independently associated with off-label prescribing among clinic attendees at general practice were gender (OR adj -7 2.908, 95% Cl= 1.027- 8.2377) and SRQ-20 scoring for Depression (OR adj= 0.1266, 95% C1= 0.0309- 0.5184). Furthermore we have received 37.5% response rate from the mapped general practitioners\u27 clinics located in selective towns of Karachi. Among these almost 96% (n= 24) were practicing as private clinicians, 80% (n=20) reported a proportion of almost 10% cases of common mental health disorders in their clinical practice, 68% (n=17) of them were unaware for diagnosing depression as per DSM-1V criteria, 44% (n=11) were familiar with the concept of off-label use of a drug in clinical practice. In addition to it 76% (n=19) of them were agreed with the notion of experiencing difficulties in clinical management of psychiatric patients in their clinical practice. Concerning about preferred choice of drug in depression the utmost response was for SSRI\u27s (selective serotonin re-uptake inhibitors) by the physicians. Conclusion: The study was designed and conducted as a first baseline pilot scale survey in our regional settings. The results of this study will be guiding us in designing and planning a larger scale epidemiological study to explore the novel concept of off-label prescribing of drugs systematically at each health care level of our country. Besides the findings of this small scale survey will be speculated as obligatory for all those stake holders (Drug Regulatory Authority‘of Pakistan and Health Care Professionals) who are linked with Drug monitoring and regulation at national level

Development of palliative care services at a tertiary care teaching hospital in Pakistan: Retrospective analysis of existing palliative care program

Context: Palliative care (PC) is an important aspect of providing holistic care to patients and their families who are dealing with a serious or life limiting illness. Medical community and public poorly understand the implications and benefits of these services. Unfortunately, because of this, PC remains a neglected area of healthcare in the most institutions of Pakistan. Objectives: We sought to review the current structure, barriers in context of growing need for PC, possible means to overcome these challenges and future perspectives at tertiary care hospital. Methods: Retrospective longitudinal cross-sectional study was done using data from 2017 to 2019 in the section of PC at Aga Khan University Hospital (AKUH). Results: PC program has been self-sustainable and serving 3747 patients in 2017-2019. The results show that palliative care services (PCS) are well integrated for oncology with all three models of PCS delivery. Most of the patients opted for comfort code during hospital stay and preferred end-of-life-care at home. We received less referral from outside the hospital and other specialties but received more self-referrals surprisingly. Home-based-palliative-care was also a key aspect of the program. PCS providing quality of care and nearly reaching target goal of quality indicators. Conclusion: The enormous burden of life-threatening illnesses is associated with physical and psychosocial sufferings, which explains the illustrious need for PC in developing countries such as Pakistan. PCS at AKUH initiated in 2017. Nevertheless, there are challenges to service expansion and progress, which are being addressed

Evaluation of postgraduate family medicine trainee\u27s knowledge and attitude following an online educational module in palliative care: A descriptive study

Objectives: To identify improvement in knowledge and attitude of Family Medicine (FM) postgraduate trainees (PGT) towards Palliative care (PC) in order to provide effective care to the patients with advanced disease.Methods: A cross-sectional study was conducted over eight weeks from 1st July till 3rd September 2021 at Family Medicine Department, Aga Khan University Hospital (AKUH). PGT who willingly signed the written informed consent were enrolled in the study. Descriptive analysis, frequencies, proportions and thematic approach were used for data analysis. Data was analyzed using SPSS version 23.Results: FM-PGT were included in the study. Improvement in knowledge was observed in posttest scores along with positive change in their attitude and improved perception of level of confidence for managing PC patients. Overall assessment of PCM was positive.Conclusion: This PCM seems to be a useful tool for PC training in postgraduate medical education (PGME). This highlights some useful aspects for future applications in PC education and training

Needs assessment survey regarding effectiveness of chronic care in Diabetes in a hospital setting

Objectives: To assess the current knowledge level about diabetes and acceptance of nurse-led educational programmes among diabetic patients. Method: The cross-sectional study was conducted at a community health centre in Karachi from August, 2018 to December, 2019 and comprised adult patients of ether gender with diabetes. Data was collected using a predesigned questionnaire to record demographic information, participants’ DM knowledge, self-management aspects and their opinions along with preferences for a DM educational support group. Data was analysed using STATA/SE 15.1. Results: Of the 215 participants, 80(37%) were males and 135(63%) were females. The overall mean age was 55.814.5 yrs. Most participants had diabetes for 5 years 127(59%) and 141(66%) did not know their type of diabetes. Most participants were prescribed anti-diabetic medications 201(94%), and 45(2%) had forgotten to take their medication recently. Insulin was being used by 65(30%) participants, and, among them, 27(42%) reused syringes. Most patients struggled to make lifestyle modifications 133(62%), and 144 (67%) were willing to attend nurse-led diabetic education sessions. Conclusion: There was found to be a need of diabetes education support programme to address knowledge deficiencies, and a nurse-led programme was found to be acceptable to the majority of study subjects. Key Words: Diabetes mellitus, Diabetes complications, Tertiary prevention, Health educators

Inhibition and Disruption of Amyloid Formation by the Antibiotic Levofloxacin: A New Direction for Antibiotics in an Era of Multi-drug Resistance

Neurodegenerative diseases are a group of debilitating maladies involving protein aggregation. To this day, all advances in neurodegenerative disease therapeutics have helped symptomatically but have not prevented the root cause of the disease, i.e., the aggregation of involved proteins. Antibiotics are becoming increasingly obsolete due to the rising multidrug resistance strains of bacteria. Thus, antibiotics, if put to different use as therapeutics against other diseases, could pave a new direction to the world of antibiotics. Hence, we studied the antibiotic levofloxacin for its potential anti-amyloidogenic behavior using human lysozyme, a protein involved in non-systemic amyloidosis, as a model system. At the sub-stoichiometric level, levofloxacin was able to inhibit amyloid formation in human lysozyme as observed by various spectroscopic and microscopic methods, with IC50 values as low as 8.8 ± 0.1 μM. Levofloxacin also displayed a retarding effect on seeding phenomena by elongating the lag-phase (from 0 to 88 h) at lower concentration, and arresting lysozyme fibrillation at the lag stage in sub-stoichiometric concentrations. Structural and computational analyses provided mechanistic insight showing that levofloxacin stabilizes the lysozyme in the native state by binding to the aggregation-prone residues, and thereby inhibiting amyloid fibrillation. Levofloxacin also showed the property of disrupting amyloid fibrils into a smaller polymeric form of proteins which were less cytotoxic as confirmed by hemolytic assay. Therefore, we throw new light on levofloxacin as an amyloid inhibitor and disruptor which could pave way to utilization of levofloxacin as a potential therapeutic against non-systemic amyloidosis and neurodegenerative diseases

Integrating a Community-Based Health Information System with a Patient-Centered Medical Home to improve care of patients with hypertension: A longitudinal observational study protocol

Background: The primary healthcare system in Pakistan focuses on providing episodic, disease-based care. Health care for low-middle income communities is largely through a fee-for-service model that ignores preventive and health-promotive services. The growing burden of cardiovascular illnesses requires restructuring of the primary health care system allowing a community-to-clinic model of care to improve patient- and community-level health indicators.Methods: We propose a model that integrates a Patient-Centered Medical Home (PCMH) with a Community-Based Health Information System (CBHIS) using hypertension (HTN) as an example. This protocol describes the integration and evaluation of the PCMH-CBHIS infrastructure through a population-based, observational, longitudinal study in a low-middle income, urban community in Pakistan. Participants are being enrolled in CBHIS and will be followed longitudinally over two years for HTN outcomes. A mixed-methods approach is adopted to evaluate the process of integrating PCMH with CBHIS. This involves building partnerships with the community through formal and informal meetings, focus group discussions, and a household health assessment survey (HAS). Community members identified with HTN are linked to PCMH for disease management. A customized electronic medical record system links community-level data with patient-level data to track changes in disease burden. The RE-AIM evaluation framework will be used to monitor community and individual-level metrics to guide implementation assessment, the potential for generalization, and the effectiveness of the PCMH in improving HTN-related health outcomes. Ethical clearance has been obtained from the Ethics Review Committee at Aga Khan University (2022-6723-20985).Discussion: This study will evaluate the value of restructuring the primary care health system by ensuring systematic community engagement and measurement of health indicators at the patient- and community-level. While HTN is being used as a prototype to generate evidence for the effectiveness of this model, findings from this initiative will be leveraged towards strengthening the management of other acute and chronic conditions in primary care settings. If effective, the model can be used in Pakistan and other LMICs and resource-limited settings

Patterns of suicide and self-harm in Pakistan: A retrospective descriptive study protocol

Introduction: Suicide is a major global public health problem. Low-income and middle-income countries contribute 78% of all suicidal deaths. Pakistan, a South Asian country, lacks official statistics on suicides at national level. Statistics on suicide are neither collected nationally nor published in the annual national morbidity and mortality surveys. Medicolegal reports on suicides and self-harm are extremely rich and important source of information but greatly underused in Pakistan. We aim to examine the patterns of suicides and self-harm retrospectively in patients who were registered with medicolegal centres (MLCs) in Karachi, during the period January 2017 to December 2021.Methods and analysis: Using retrospective descriptive design, the data will be collected from the medical records maintained at the main office of the Karachi police surgeon. Data from all nine MLCs of Karachi are collated and stored at the main office of Police surgeon. Information on suicide and self-harm cases will be extracted from records of all MLCs. The data will be collected using structured proforma and it will be analysed using descriptive and inferential analysis.Ethics and dissemination: The study was approved for exemption from Aga Khan University, Ethical Review Committee. The findings of the study will be disseminated by conducting seminars for healthcare professionals and stakeholders including psychiatrists, psychologists, counsellors, medicolegal officers, police surgeons, mental health nurses, general and public health physicians and policy makers. Findings will be published in local and international peer-reviewed scientific journals