Covid Prognostic Score (CoPs) to predict prognostic outcome in Patients with Severe Covid-19 Pneumonia

Objectives: To assess the degree of medical intervention needed for treatment and its application in areas with low resources and testing facilities. Methodology: A Retrospective Cohort study was conducted on 141 patients from June 2020 to May 2021. All PCR positive covid patients were included; excluding those who died or left within 24 hours of admission. Data was obtained from hospital record. (HIMS), incorporating sociodemographic details, history of co-morbids and presenting complaints. A Covid-Prognostic Score was developed to predict hospital outcome and severity of covid disease. It comprised of age, comorbidity (diabetes and ischemic heart disease), chest-x ray score, neutrophil- lymphocyte ratio (NLR) and ferritin score. Using SPSS version 23, descriptive means were analyzed; Chi-square test was applied along with Mann- Whitney U and linear regression. P-value less than 0.05 was considered significant. Results: A significant association was found between health status (i.e., alive or dead) and diabetes (p=0.045) and ischemic heart disease (p=0.004), which reinforced their importance in the CoPS score. Association between CoPS and gender health status was highly significant; (p=0.003) (p=0.000) respectively. A positive correlation was found between CoPS and duration of hospital stay (R = 0.495) (p=0.216). Conclusion: The continuous surge of Covid-19 is causing hospital resource and facility burn out. The CoPS score aims to pave way for triage therapy from the point of admission. A multi-center approach and scoring of “severity strata” of disease would further corroborate the relevance of the CoPS scoring system

The Changing Landscape for Stroke\ua0Prevention in AF: Findings From the GLORIA-AF Registry Phase 2

Background GLORIA-AF (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation) is a prospective, global registry program describing antithrombotic treatment patterns in patients with newly diagnosed nonvalvular atrial fibrillation at risk of stroke. Phase 2 began when dabigatran, the first non\u2013vitamin K antagonist oral anticoagulant (NOAC), became available. Objectives This study sought to describe phase 2 baseline data and compare these with the pre-NOAC era collected during phase 1. Methods During phase 2, 15,641 consenting patients were enrolled (November 2011 to December 2014); 15,092 were eligible. This pre-specified cross-sectional analysis describes eligible patients\u2019 baseline characteristics. Atrial fibrillation disease characteristics, medical outcomes, and concomitant diseases and medications were collected. Data were analyzed using descriptive statistics. Results Of the total patients, 45.5% were female; median age was 71 (interquartile range: 64, 78) years. Patients were from Europe (47.1%), North America (22.5%), Asia (20.3%), Latin America (6.0%), and the Middle East/Africa (4.0%). Most had high stroke risk (CHA2DS2-VASc [Congestive heart failure, Hypertension, Age  6575 years, Diabetes mellitus, previous Stroke, Vascular disease, Age 65 to 74 years, Sex category] score  652; 86.1%); 13.9% had moderate risk (CHA2DS2-VASc = 1). Overall, 79.9% received oral anticoagulants, of whom 47.6% received NOAC and 32.3% vitamin K antagonists (VKA); 12.1% received antiplatelet agents; 7.8% received no antithrombotic treatment. For comparison, the proportion of phase 1 patients (of N = 1,063 all eligible) prescribed VKA was 32.8%, acetylsalicylic acid 41.7%, and no therapy 20.2%. In Europe in phase 2, treatment with NOAC was more common than VKA (52.3% and 37.8%, respectively); 6.0% of patients received antiplatelet treatment; and 3.8% received no antithrombotic treatment. In North America, 52.1%, 26.2%, and 14.0% of patients received NOAC, VKA, and antiplatelet drugs, respectively; 7.5% received no antithrombotic treatment. NOAC use was less common in Asia (27.7%), where 27.5% of patients received VKA, 25.0% antiplatelet drugs, and 19.8% no antithrombotic treatment. Conclusions The baseline data from GLORIA-AF phase 2 demonstrate that in newly diagnosed nonvalvular atrial fibrillation patients, NOAC have been highly adopted into practice, becoming more frequently prescribed than VKA in Europe and North America. Worldwide, however, a large proportion of patients remain undertreated, particularly in Asia and North America. (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients With Atrial Fibrillation [GLORIA-AF]; NCT01468701

Global age-sex-specific mortality, life expectancy, and population estimates in 204 countries and territories and 811 subnational locations, 1950–2021, and the impact of the COVID-19 pandemic: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

Background Estimates of demographic metrics are crucial to assess levels and trends of population health outcomes. The profound impact of the COVID-19 pandemic on populations worldwide has underscored the need for timely estimates to understand this unprecedented event within the context of long-term population health trends. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 provides new demographic estimates for 204 countries and territories and 811 additional subnational locations from 1950 to 2021, with a particular emphasis on changes in mortality and life expectancy that occurred during the 2020–21 COVID-19 pandemic period. Methods 22 223 data sources from vital registration, sample registration, surveys, censuses, and other sources were used to estimate mortality, with a subset of these sources used exclusively to estimate excess mortality due to the COVID-19 pandemic. 2026 data sources were used for population estimation. Additional sources were used to estimate migration; the effects of the HIV epidemic; and demographic discontinuities due to conflicts, famines, natural disasters, and pandemics, which are used as inputs for estimating mortality and population. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate under-5 mortality rates, which synthesised 30 763 location-years of vital registration and sample registration data, 1365 surveys and censuses, and 80 other sources. ST-GPR was also used to estimate adult mortality (between ages 15 and 59 years) based on information from 31 642 location-years of vital registration and sample registration data, 355 surveys and censuses, and 24 other sources. Estimates of child and adult mortality rates were then used to generate life tables with a relational model life table system. For countries with large HIV epidemics, life tables were adjusted using independent estimates of HIV-specific mortality generated via an epidemiological analysis of HIV prevalence surveys, antenatal clinic serosurveillance, and other data sources. Excess mortality due to the COVID-19 pandemic in 2020 and 2021 was determined by subtracting observed all-cause mortality (adjusted for late registration and mortality anomalies) from the mortality expected in the absence of the pandemic. Expected mortality was calculated based on historical trends using an ensemble of models. In location-years where all-cause mortality data were unavailable, we estimated excess mortality rates using a regression model with covariates pertaining to the pandemic. Population size was computed using a Bayesian hierarchical cohort component model. Life expectancy was calculated using age-specific mortality rates and standard demographic methods. Uncertainty intervals (UIs) were calculated for every metric using the 25th and 975th ordered values from a 1000-draw posterior distribution. Findings Global all-cause mortality followed two distinct patterns over the study period: age-standardised mortality rates declined between 1950 and 2019 (a 62·8% [95% UI 60·5–65·1] decline), and increased during the COVID-19 pandemic period (2020–21; 5·1% [0·9–9·6] increase). In contrast with the overall reverse in mortality trends during the pandemic period, child mortality continued to decline, with 4·66 million (3·98–5·50) global deaths in children younger than 5 years in 2021 compared with 5·21 million (4·50–6·01) in 2019. An estimated 131 million (126–137) people died globally from all causes in 2020 and 2021 combined, of which 15·9 million (14·7–17·2) were due to the COVID-19 pandemic (measured by excess mortality, which includes deaths directly due to SARS-CoV-2 infection and those indirectly due to other social, economic, or behavioural changes associated with the pandemic). Excess mortality rates exceeded 150 deaths per 100 000 population during at least one year of the pandemic in 80 countries and territories, whereas 20 nations had a negative excess mortality rate in 2020 or 2021, indicating that all-cause mortality in these countries was lower during the pandemic than expected based on historical trends. Between 1950 and 2021, global life expectancy at birth increased by 22·7 years (20·8–24·8), from 49·0 years (46·7–51·3) to 71·7 years (70·9–72·5). Global life expectancy at birth declined by 1·6 years (1·0–2·2) between 2019 and 2021, reversing historical trends. An increase in life expectancy was only observed in 32 (15·7%) of 204 countries and territories between 2019 and 2021. The global population reached 7·89 billion (7·67–8·13) people in 2021, by which time 56 of 204 countries and territories had peaked and subsequently populations have declined. The largest proportion of population growth between 2020 and 2021 was in sub-Saharan Africa (39·5% [28·4–52·7]) and south Asia (26·3% [9·0–44·7]). From 2000 to 2021, the ratio of the population aged 65 years and older to the population aged younger than 15 years increased in 188 (92·2%) of 204 nations. Interpretation Global adult mortality rates markedly increased during the COVID-19 pandemic in 2020 and 2021, reversing past decreasing trends, while child mortality rates continued to decline, albeit more slowly than in earlier years. Although COVID-19 had a substantial impact on many demographic indicators during the first 2 years of the pandemic, overall global health progress over the 72 years evaluated has been profound, with considerable improvements in mortality and life expectancy. Additionally, we observed a deceleration of global population growth since 2017, despite steady or increasing growth in lower-income countries, combined with a continued global shift of population age structures towards older ages. These demographic changes will likely present future challenges to health systems, economies, and societies. The comprehensive demographic estimates reported here will enable researchers, policy makers, health practitioners, and other key stakeholders to better understand and address the profound changes that have occurred in the global health landscape following the first 2 years of the COVID-19 pandemic, and longer-term trends beyond the pandemic

Pyknodysostosis: A Challenging Diagnosis

We report a case of a 7-year-old boy presented to us with short stature, born at full term by SVD with an immediate cry and a birth weight of 03 kg, breast-fed for 2 years. There are no apparent signs of development delay. By the age of two, the mother was concerned about physical and developmental delays. The patient had a male sibling with a history of repeated fractures and sensorineural hearing loss, labelled osteopetrosis. EXAMINATION: An active male child of 95cm and 12 kg falls below the 3rd centile. He had frontal bossing, mildly hypoplastic maxillae, a wide open fontanelle, and sutural diastasis. INVESTIGATIONS: Complete Blood Count, Thyroid profile, Serum Calcium, Phosphorus and Alkaline Phosphatase. All normal. A skeletal survey showed an increase in bone density. Sutural diastasis, multiple Wormian bones, thickening of the Calvaria, thickening of long bones with medullary sparing, and spool deformity of vertebral bodies. DIFFERENTIAL DIAGNOSIS Pyknodysostosis Hypothyroidism Osteopetrosis CONCLUSION: Additional X-rays, including the mandible, showed an obtuse angle, the clavicle was laterally deficient, and the hand showed acro osteolysis. The patient was diagnosed with a rare case of pyknodysostosis

Fostering the need of HPV Vaccination Programmes in Pakistan

Madam, In Pakistan's female population of 112 million (1) , Human Papillomavirus (HPV) has caused devastating results of cervical cancer in females aged fifteen years and older. Being the second most common cancer in females aged fifteen to forty-four years and third most common cancer amongst females, current statistics estimate 5000 victims and 3000 deaths annually due to HPV. (2)(3). This is becoming a huge burden and needs to be acknowledged. HPV, a circular double-stranded DNA virus, is a common infection of the reproductive tract. Worldwide accepted strategies to reduce the burden of this deadly virus is through vaccines and screening. Due to the uneven distribution of this lethal virus. there are currently three vaccines available that were approved by Food and Drug Administration (FDA) back in 2006, 2009 and 2014, namely Gardasil, Cervarix, and Gardasil-9, respectively(4). CDC has endorsed the need for two doses of the vaccine. At the age of 11-12, The first dose can also be given at 9 years followed by a second dose with an interval of 6-12 months (5). However, in a developing country like Pakistan, HPV vaccination programmes are still a challenge due to lack of awareness amongst the population and inconsistent efforts by the healthcare system in providing the screening and vaccination strategies. Many other factors are related with this gross burden:  the availability of the vaccines, insufficient funds and various collateral factors associated with the spread of rumours through social media. A study recently proved the strength of vaccination at a young age.  It concluded that females’ inoculation at the age of 12 to 13 years significantly reduced the risk of grade 3 cervical intraepithelial neoplasia (CIN) (6). Centres for disease and control and prevention (CDC) has stated that the majority of the people who are unvaccinated and sexually active will get HPV during their lives. Therefore, there is an essential need to vaccinate children below the age of fifteen years so that 33,000 of these cancers can be prevented that are caused by this infection. Since, cervical cancer is a public health problem, a global strategy for its elimination was inaugurated in 2020 by WHO. Despite the worldwide challenges, WHO did not take a step back and continued its challenging efforts. However, situation in Pakistan did not improve. ---Continu

Global Paediatric Hepatitis Outbreak

Madam, WHO is investigating a global outbreak of severe acute hepatitis of questionable aetiology among children. Since this is not linked to Hepatitis types A-E, there are still ongoing investigations to explore the causative agent for this worldwide outbreak. At least 228 cases of acute hepatitis of unknown origin had been recorded from 20 countries since May 1, 2022, in Europe, America and other countries, with the highest number of cases recorded in the United Kingdom, 145 since January (1). Adenovirus was found in 74 individuals, suggesting that there may be a possible association. However, this hypothesis needs further investigation. The United Kingdom has recently witnessed an increase in adenovirus infections; however, this might be due to increased testing rather than this epidemic. (2) As a result, affected countries have increased their surveillance efforts and are receiving additional support from WHO. Although the cases ranged in age from one month to sixteen years, the majority of the children who were affected were under the age of five and had gastrointestinal symptoms such as abdominal pain, nausea, and diarrhoea, as well as jaundice and elevated liver enzymes (AST and ALT greater than 500 IU/L). Infectious hepatitis (Types A, B, C, D, E), is the most common cause of hepatitis, was not found. Around 10% of these children have needed a liver transplant, and at least one has died. WHO's working probable case definition has been an individual presenting with acute hepatitis (non-hepatitis A-E) with serum transaminase >500 IU/L (AST or ALT), who is 16 years or younger, since 1 October 2021 (1,2). Hepatitis is a liver inflammation caused by viral infections, primarily the Hepatitis A, B, and C viruses, as well as a variety of other factors such as alcohol consumption, drugs, medicines, and other medical disorders. Fever, exhaustion, lack of appetite, nausea, vomiting, stomach discomfort, dark urine, light-coloured stools, joint pain, and jaundice are all signs and symptoms of hepatitis. The underlying cause determines the hepatitis treatment. (3). Parents and doctors are advised to look out for these signs and symptoms. Adenovirus, a double-stranded DNA virus distributed by close contact, respiratory droplets, and fomites, is most commonly associated with respiratory illness. ---Continu

Twindemic - An emerging concern in Pakistan

Dear Madam, As winter approaches, people succumb to a myriad of winter illnesses. Seasonal Influenza (Flu) is predominantly prevalent in the USA and Pakistan. CDC reported 20,000 deaths and 380,000 hospitalizations from flu in 2019 till 2020(1). According to Dr Ebell, we are likely less immune, since we are not exposed to flu for twenty months or even more. There is uncertainty regarding flu strains since it can undergo antigenic shifts and antigenic drift that can cause the evolution of new strains (2). Therefore, CDC estimates that approximately seven hundred thousand people would   get hospitalized in the upcoming flu-season (3). Flu season paired with covid-19 classically presents as “Twindemic”. Although influenza (Flu) and Covid share similar clinical symptoms, both can have severe, mild or moderate effects, mode of transmission and preventive strategies, but they still differ in their treatment modalities and vaccines. Therefore, during the covid era it has become challenging to report influenza cases as both diseases present with similar symptoms making clinical diagnosis difficult. However, some studies suggest that preventive measures used for Covid were also effective against the prevention of flu. Hence, the number of flu cases were reported to be lower than expected for the year 2020-2021. People infected with Covid and Influenza at the same time, are more prone to develop severe illness. To keep the pressure off healthcare systems, vaccination programmes are imperative. CDC has issued new guidelines for this potential twindemic this winter, stating that flu vaccines must protect against all 4 influenza virus strains that were noy t the recommendation in prior years. However, in Pakistan Flu shots are not prioritized. Even though CDC recommends a flu shot annually, there is no national influenza vaccination policy in Pakistan. Low levels of vaccination are due to little knowledge regarding the importance of influenza prevention, misinformation about its side effects and lack of public awareness (4), due to which the death toll of influenza was reported to be 42.03 per 100,000 of population as per 2018 data (5). Despite the serious health and economic consequences faced due to influenza, vaccination rates remain low. Pakistan Government must play a pivotal role to include influenza vaccination in its EPI schedule in order to make it available for the citizens at low costs. The risk of co-infection is estimated to be higher as the season changes. ---Continu

Application of Machine Learning Techniques to Delineate Homogeneous Climate Zones in River Basins of Pakistan for Hydro-Climatic Change Impact Studies

Climatic data archives, including grid-based remote-sensing and general circulation model (GCM) data, are used to identify future climate change trends. The performances of climate models vary in regions with spatio-temporal climatic heterogeneities because of uncertainties in model equations, anthropogenic forcing or climate variability. Hence, GCMs should be selected from climatically homogeneous zones. This study presents a framework for selecting GCMs and detecting future climate change trends after regionalizing the Indus river sub-basins in three basic steps: (1) regionalization of large river basins, based on spatial climate homogeneities, for four seasons using different machine learning algorithms and daily gridded precipitation data for 1975–2004; (2) selection of GCMs in each homogeneous climate region based on performance to simulate past climate and its temporal distribution pattern; (3) detecting future precipitation change trends using projected data (2006–2099) from the selected model for two future scenarios. The comprehensive framework, subject to some limitations and assumptions, provides divisional boundaries for the climatic zones in the study area, suitable GCMs for climate change impact projections for adaptation studies and spatially mapped precipitation change trend projections for four seasons. Thus, the importance of machine learning techniques for different types of analyses and managing long-term data is highlighted

Plausible Precipitation Trends over the Large River Basins of Pakistan in Twenty First Century

Inter alia, inter-annual and spatial variability of climate, particularly rainfall, shall trigger frequent floods and droughts in Pakistan. Subsequently, a higher proportion of the country’s population will be exposed to water-related challenges. This study analyzes and projects the long-term spatio-temporal changes in precipitation using the data from 2005 to 2099 across two large river basins of Pakistan. The plausible precipitation data to detect the projected trends seems inevitable to study the future water resources in the region. For, policy decisions taken in the wake of such studies can be instrumental in mitigating climate change impacts and shape water management strategies. Outputs of the Coupled Model Intercomparison Project 5 (CMIP5) climate models for the two forcing scenarios of RCP 4.5 and RCP 8.5 have been used for the synthesis of projected precipitation data. The projected precipitation data have been synthesized in three steps (1) dividing the area in different climate zones based on the similar precipitation statistics (2) selection of climate models in each climate zone in a way to shrink the ensemble to a few representative members, conserving the model spread and accounting for model similarity in a baseline period of 1971–2004 and the projected period of 2005–2099 and (3) combining the selected model’s data in mean and median combinations. The future precipitation trends were detected and quantified, for the set of four scenarios. The spatial distribution of the precipitation trends was mapped for better understanding. All the scenarios produced consistent increasing or decreasing trends. Significant declining trends were projected in the warm wet season at 0.05% significance level and the increasing trends were projected in cold dry, cold wet and warm dry seasons. Framework developed to project climate change trends during the study can be replicated for any other area. The study therefore can be of interest for researchers working on climate impact modeling