Genomic characterization of Puccinia triticina using molecular marker technology

Abstract Leaf rust, caused by Puccinia triticina, is the most common rust disease of wheat. The fungus is an obligate parasite capable of producing infectious urediniospores. To study the genetic structure of the leaf rust population 20 RAPD primers were evaluated on 15 isolates samples collected in Pakistan. A total of 105 RAPD fragments were amplified with an average of 7 fragments per primer. The number of amplified fragments varied from 1 to 12. GL Decamer L-07 and GL Decamer L-01 amplified the highest number of bands (twelve) and primer GL Decamer A-03 amplified the lowest number of bands i.e one. Results showed that almost all investigated isolates were genetically different that confirms high genetic diversity within the leaf rust population. Rust spores can follow the migration pattern in short and long distances to neighbor areas. Results indicated that the greatest variability was revealed by 74.9% of genetic differentiation within leaf rust populations. These results suggested that each population was not completely identical and high gene flow has occurred among the leaf rust population of different areas. The highest differentiation and genetic distance among the Pakistani leaf rust populations were detected between the leaf rust population in NARC isolate (NARC-4) and AARI-11and the highest similarity was observed between NARC isolates (NARC-4) and (NARC-5). The present study showed the leaf rust population in Pakistan is highly dynamic and variable.

Treatment Outcomes of Severe Acute Malnutrition and Its Determinants Among Paediatric Patients in Quetta City, Pakistan

Purpose

Severe acute malnutrition (SAM) is the most prevalent reason for admission to a paediatric unit, and it is a leading cause of mortality in many countries, including Pakistan. This study aimed to assess treatment outcomes and associated factors among children aged 6-59 months with severe acute malnutrition.

Patients and Methods

A retrospective cohort study was conducted at the Outpatient Therapeutic Feeding Program Centre established at the Sheikh Khalifa bin Zayed Al Nahyan Medical Complex Quetta. Out of 225 patients' records, data from 182 (80.8%) records were analysed based on the inclusion criteria. The SAM logbook was used as a source of data. Predictors of treatment outcomes were identified by applying a regression model with p<0.05 taken as significant.

Results

One hundred and twenty (65.9%) of the children were diagnosed with SAM, while the remaining 34.1% had Moderate Acute Malnutrition. Ninety-five (52.2%) children were included in the marasmus, while 47.8% were included in the Kwashiorkor cohort. The recovery rate was 68.6%; 22.5% were non-responsive, 11% defaulted on the program, and 3.5% died during management. The multivariate logistic regression identified the presence of diarrhea and the use of amoxicillin as significant prognosticators of treatment outcomes. Consequently, the odds of recovery on SAM among children with diarrhea [AOR = 0.60, 95% CI: (0.35-0.75)] were lower than those without diarrhea. Likewise, children on PO amoxicillin had higher chances of recovery [AOR = 2.45, 95% CI: (2.21-4.68)].

Conclusion

This study found that the recovery rate among children treated for SAM was poor based on the established Sphere Standard recommendation. In addition to community-based educational campaigns, capacity enhancement of OTP and frequent monitoring of services as well as program evaluation based on the management protocol is recommended to reduce the frequency of SAM among children.

Hospital Pharmacists' Viewpoint on Quality Use of Antibiotics and Resistance: A Qualitative Exploration from a Tertiary Care Hospital of Quetta City, Pakistan

Suboptimal antibiotics use and the development of antibiotic resistance is a universal calamity. The theoretical model of therapeutic efficacy correlates quality use of antibiotics with healthcare practitioners' understanding of antibiotic use and resistance. Keeping this phenomenon in mind, we aimed to evaluate hospital pharmacists' understanding of antibiotic use and resistance at a public healthcare institute in Quetta city, Pakistan. This was a qualitative study that employed a semi-structured interview guide for data extraction. The phenomenology-based approach commissioned in-depth, face-to-face interviews with hospital pharmacists stationed at the surgical unit of Sandeman Provincial Hospital, Quetta. The interviews were audio taped followed by transcribed verbatim and were then analyzed for thematic contents by the standard content analysis framework. Although the saturation was reached after the 10th interview, we conducted two additional interviews for definite validation. Content analysis revealed five major themes: (1) Defining antibiotics, quality use of antibiotics and resistance, (2) antibiotic use: awareness and concern, (3) antimicrobial resistance: awareness and concern, (4) responding to antibiotic use and resistance, and (5) barriers to quality use of antibiotics and prevention of antibiotic resistance. The knowledge of quality use of antibiotics and resistance was promising, and the respondents were eager to address the drastic situation. The respondents were aware of the critical situation and provided valuable insights that can offer valued input while promoting the quality use of antibiotics in a developing country. The current study managed to identify an adequate understanding of antibiotic use and resistance among hospital pharmacists. Additionally, prospective concerns and possible predictors of antibiotic resistance were also highlighted. The current findings must be disseminated to the policymakers and prescribers to take prompt restorative actions to address antibiotic use and the development of antibiotic resistance in a developing country like Pakistan.

Nurses’ Perceptions, Involvement, Confidence and Perceived Barriers Towards Antimicrobial Stewardship Program in Pakistan: Findings from a Multi-Center, Cross-Sectional Study

Purpose

Antimicrobial resistance (AMR) is leading to greater therapeutic cost, length of hospital stays, adverse events, morbidity and mortality. Hospital-based antimicrobial stewardship programs (ASPs) engaging physicians, pharmacists, microbiologists and nurses are considered as effective way to ensure appropriate use of antimicrobial agents. The aims of our study were to assess nurses’ perception, involvement, confidence and barriers towards hospital-based ASPs, and use the findings to provide future guidance.

Methods

A web-based, cross-sectional study was conducted among the nurses serving at eleven hospitals of Punjab province of Pakistan during a period of two months (December 2021-January 2022). Data were collected using a validated self-administered questionnaire. All data were analyzed using SPSS version 22.

Results

A total of 583 nurses participated in the study (response rate = 77.7%). All the participants were female staff nurses and 86% had a minimum of 3 years of working experience. The overall median score on the perception towards ASPs among the nurses was 18 (IQR: 16, 19) on a 0 to 20 scale whereas median score on the involvement in ASPs was 18 (IQR: 15, 37) on a 0 to 64 scale. Median perception and involvement score were statistically significantly differed by age (p < 0.001) and years of experience (p < 0.001). The overall median score on the confidence to perform ASP activities was 22 (IQR: 14, 24) on a 0 to 28 scale. Lack of knowledge, insufficient support from administration, and heavy workload were found to be the common barriers to perform ASP.

Conclusion

Our study concluded that Pakistani nurses have positive perception but limited involvement in ASPs. Moreover, they are confident to perform ASP besides many barriers.

Cost of Illness Analysis of Type 2 Diabetes Mellitus: The Findings from a Lower-Middle Income Country

BACKGROUND

Diabetes is a major chronic illness that negatively influences individuals and society. Therefore, this research aimed to analyze and evaluate the cost associated with diabetes management, specific to the Pakistani Type 2 diabetes population. Research scheme and methods: A survey randomly collected information and data from diabetes patients throughout Pakistan out-patient clinics. Direct and indirect costs were evaluated, and data were analyzed with descriptive and inferential statistics.

RESULTS

An overall of 1839 diabetes patients participated in the study. The results have shown that direct and indirect costs are positively associated with the participants' socio-demographic characteristics, except for household income and educational status. The annual total cost of diabetes care was USD 740.1, amongst which the share of the direct cost was USD 646.7, and the indirect cost was USD 93.65. Most direct costs comprised medicine (USD 274.5) and hospitalization (USD 319.7). In contrast, the productivity loss of the patients had the highest contribution to the indirect cost (USD 81.36).

CONCLUSION

This study showed that direct costs significantly contributed to diabetes's overall cost in Pakistan and overall diabetes management estimated to be 1.67% (USD 24.42 billion) of the country's total gross domestic product. The expense of medications and hospitalization mostly drove the direct cost. Additionally, patients' loss of productivity contributed significantly to the indirect cost. It is high time for healthcare policymakers to address this huge healthcare burden. It is time to develop a thorough diabetes management plan to be implemented nationwide.

Comparative effectiveness of individualized longer and standardized shorter regimens in the treatment of multidrug resistant tuberculosis in a high burden country

Objective: To compare the effectiveness of second line injectables containing shorter (duration 9–12 months) and longer treatment regimens (LTR, duration ≥ 20 months) among multidrug-resistant tuberculosis (MDR-TB) patients with no documented resistance and history of treatment with any second-line anti-TB drug (SLD) for ≥ 1 month.

Methods: This was an observational cohort study of MDR-TB patients treated at eight PMDT units in Pakistan. Patients’ data from baseline until treatment outcomes were collected from Electronic Nominal Recording and Reporting System. The treatment outcomes of “cured” and “treatment completed” were grouped together as successful, whereas “death,” “treatment failure,” and “lost to follow-up” were collectively grouped as unsuccessful outcomes. Time to sputum culture conversion (SCC) was analyzed using the Kaplan–Meier method and the differences between groups were compared through the log-rank test. Multivariate Cox proportional hazards and binary logistic regression analyses were used to find predictors of time to SCC and unsuccessful treatment outcomes. A p-value < 0.05 was considered statistically significant.

Results: A total 701 eligible MDR-TB patients [313 treated with shorter treatment regimen (STR) and 388 treated with LTR at eight centres in Pakistan were evaluated]. Time to achieve SCC was significantly shorter in STR group [mean: 2.03 months, 95% confidence interval (CI):1.79–2.26] than in LTR group (mean: 2.69 months, 95% CI: 2.35–3.03) (p-value<0.001, Log-rank test). Treatment success was higher in STR (83.7%) than in LTR (73.2%) group (p-value <0.001) due to high cure (79.9% vs. 70.9%, p-value = 0.006) and low death (9.9% vs. 18.3%, p-value = 0.002) rates with STR. Treatment with STR emerged the only predictor of early SCC [adjusted Hazards ratio (aHR) = 0.815, p-value = 0.014], whereas, patient’s age of 41–60 (OR = 2.62, p-value<0.001) and >60 years (OR = 5.84, p-value<0.001), baseline body weight of 31–60 (OR = 0.36, p-value = 0.001) and >60 kg (OR = 0.23, p-value <0.001), and treatment with LTR (OR = 1.88, p-value = 0.001) had statistically significant association with unsuccessful treatment outcomes.

Conclusion: STR exhibited superior anti-microbial activity against MDR-TB. When compared LTR, treatment with STR resulted in significantly early SCC, high cure, and lower death rates among MDR-TB patients who had no documented resistance and history of treatment with any SLD ≥ 1 month.

Physicians' Response and Preparedness of Terrorism-Related Disaster Events in Quetta City, Pakistan: A Qualitative Inquiry

Background

Besides catastrophes, infrastructural damages, and psychosocial distress, terrorism also imposes an unexpected burden on healthcare services. Considerably, adequately-prepared and responsive healthcare professionals affirms effective management of terrorism-related incidences. Accordingly, the present study aimed to evaluate physicians' preparedness and response toward terrorism-related disaster events in Quetta city, Pakistan.

Methods

A qualitative design was adopted. Physicians practicing at the Trauma Center of Sandeman Provincial Hospital (SPH), Quetta, were approached for the study. We conducted in-depth interviews; all interviews were audio-taped, transcribed verbatim, and analyzed for thematic contents by a standard content analysis framework.

Results

Fifteen physicians were interviewed. The saturation was achieved at the 13th interview however we conducted another two to validate the saturation. The thematic content analysis revealed five themes and 11 subthemes. All physicians have experienced, responded to, and managed terrorism-related disaster events. They were prepared professionally and psychologically in dealing with a terrorism-related disaster. Physicians identified lack of disaster-related curricula and training, absence of a standardized protocol, recurrence of the disaster, and hostile behavior of victim's attendants during an emergency as critical barriers to effective terrorism-related disaster management. Among limitations, all respondents mentioned workspace, and resources as a foremost constraint while managing a terrorism-related disaster event.

Conclusion

Although physicians understood the abilities and had the required competencies to mitigate a terrorism-related disaster, lack of workspace and resources were identified as a potential barrier to effective disaster management. Based on the results, we propose reconsideration and integration of the medical curriculum, particularly for terrorism-related disaster management, collaboration, and communication among various stakeholders to manage terrorism-related disaster events competently.

Alternanthera yellow vein virus (AYVV); a betasatellite independent begomovirus infecting Sonchus palustris in Pakistan

Satellites associated begomoviruses are the most diverse group of plant viruses in tropical and subtropical regions. In Pakistan, during field surveys in 2019-2020, Sonchus palustris (a weed plant) was observed showing begomovirus symptoms i.e., vein yellowing and mosaic patterns on leaves. Rolling circle amplification from total isolated DNA of symptomatic leaves was performed to amplify circular viral genomes. Subsequent cloning and sequencing showed that a new strain of Alternanthera yellow vein virus (AlYVV) is associated with vein yellowing disease of S. palustris. The identity percentage analysis through BLAST search and SDT analysis showed that the new strain is 94-98% identical to AlYVV isolates reported from Pakistan, India and China. In phylogenetic tree, it clustered with AlYVV-[PK:E prostrata:15-KX710155], AlYVV-[PK:E prostrata:13]-KX906697] and AlYVV-[PK:E prostrata:11]-KX906694] previously reported from Pakistan. There was no detectable level of betasatellite or any other satellite molecule in the samples studied here. Phylogenetic analysis of Rep and CP genes of AlYVV with corresponding genes of closely related viruses circulating in Southeast Asia showed intra-specific recombination involving both complementary and virion sense region of virus. Relaxed clock and Bayesian Skyline Plot analysis based on CP gene sequences indicated slight higher substitution rates (4.75 x 10-3 substitutions/nucleotide/year). In the Indian subcontinent satellite-associated monopartite begomoviruses predominately infect crops and non-crop plants. But AlYVV is found infecting mostly non-crop plants independent of satellite molecules. We hypothesize here that AlYVV evolved as a true monopartite begomovirus in the Indian sub-continent and could be a great threat to introduced crops under suitable conditions. Such studies are crucial to understand probable future epidemics of begomoviruses in the region.

Impact of diabetes-related knowledge and medication adherence on quality of life among type 2 diabetes patients in a tertiary health facility in Multan, Pakistan

Purpose: To assess the impact of drug adherence and diabetes-related knowledge on the quality of life (QoL) of type 2 diabetes patients in a hospital in Pakistan.Methods: A cross-sectional study was conducted in City Hospital, Multan, Pakistan between March and September 2020. A total of 151 patients diagnosed with type 2 diabetes mellitus (T2DM) were recruited. Medication adherence, diabetes-related knowledge, and QoL were assessed by Drug attitude inventory-10 (DAI-10), the Michigan Diabetes Knowledge Test (MDKT), and EQ-5D-3L tools, respectively. The association between sociodemographic data and study variables was assessed by independent t-test and one-way ANOVA.Results: Among the 151 patients, 53 % were males. The mean MDKT score was 0.33 ± 0.18, indicating poor knowledge of diabetes. An overall moderate level of adherence was observed among the participants (mean adherence score, 6.14 ± 1.39). Mean QoL score was 1.31 ± 0.28, and the Visual Analog Scale score (VAS) was 59.6 ± 12.21, indicating a good to moderate QoL among the study participants. Study participants with a longer duration of diabetes and poor adherence to their medications showed poor QoL (p = 0.01, p = 0.004 respectively).Conclusion: Overall, the patients reported poor knowledge, moderate adherence, and good to moderate QoL. Moreover, patients with poor adherence to medication, longer duration of diabetes, and poorly controlled HbA1c showed poor QoL.

Screen to Intervene; establishing a dedicated metabolic clinic for patients with chronic mental illness in an Irish Metal Health Service

Introduction

People with serious mental illness exhibit higher morbidity and mortality rates of chronic diseases than the general population.

Objectives

The aim of this study was to establish a dedicated clinic for patients with chronic mental illness to monitor physical health in accordance with best practice guidelines.

Methods

Patients were invited to attend the metabolic clinic. The following areas were examined: Personal and family history of cardiovascular disease, diet, exercise, smoking. Mental state examination, waist circumference, BP, pulse, ECG and BMI. Laboratory tests including U+E, LFTs, HbA1c, Lipid profile and other tests as appropriate such as serum lithium. AIMS scale, HoNOS and WHOQOL-BREF scales as additional indicators of global health.

Results

A total of 80 patients attended during 3.5 years of clinic. Mean age was 54.9 years (SD:13.81) at first contact and 45% were females. Mean years in the service was 19.66 (SD:11.54) and mean number of previous hospital admissions was 4.4 (SD:5.63). Metabolic syndrome was present in 42% at first assessment and 20% had at least one new physical abnormality identified during the clinic. A statistically significant difference was found for the psychological domain of the WHOQOL-BREF and the HoNOs particularly at third assessment. (β=4.64, Wald x²=7.38, df:1, p=0.007, CI:1.3-8.1, β =-.889, Wald x²=4.08, df:1, p=0.043, CI: -1.752 to-.026) respectively.

Conclusions

The results show a high prevalence of physical health conditions in this cohort, some of which represent a new diagnosis. This implicates better allocation of existing resources for screening and early detection, and potential to run joint clinics with primary care.

Disclosure

No significant relationships.

Disposal practices of unused and expired pharmaceuticals among the general public in Quetta city, Pakistan

Objective

Although community practices towards disposal of expired and unused medications vary globally, the phenomenon is neglected specifically in developing countries. We, therefore, aimed to assess the disposal practices of unused and expired pharmaceuticals among the general public in Quetta city, Pakistan.

Methods

A questionnaire-based, cross-sectional survey was conducted among 830 respondents in Quetta city, Pakistan. A pre-validated, structured questionnaire was used for data collection. Data were coded and analyzed by Statistical Package for Social Science (SPSS) version 26. Both descriptive and inferential statistics were sued and p<0.05 was taken as significant.

Results

Almost 87% of the respondents had unused medicines at their homes and reusing the medications was the purpose of medicine storage (50%). Medicines were mostly kept in refrigerators (36.0%) followed by bedrooms (28.8%). Fifty percent of the respondents never checked the expiry date before using the medications. The procedure to dispose of nearly expired or expired medicines was unknown to 88% of the respondents and for those reasons, medicines were disposed either in household trash or flushed in the toilet or sink. Interestingly, medicines were kept at home even after being expired by 27% of the respondents. Income was associated with reason of storing medicines (p = 0.004; φc = 0.402) while educational status had significant associations with storage of medications (p = 0.002; φc = 0.399), reading about storage instructions (p = 0.008; φc = 0.452) and checking expiry date before purchasing and using the medicines (p = 0.007; φc = 0.114 and p = 0.001; φc = 0.100) respectively.

Conclusion

Improper storage and disposal of unused and expired medications is a common practice among study respondents and raised serious concerns. Findings of the current study call upon immediate development and implementation of the strategies to promote awareness and strengthen the pharmaceutical waste management program at the societal level.

Comparative Analysis of Strength and Deformation Behavior of Cemented Tailings Backfill under Curing Temperature Effect

Mineral resources are increasingly being developed in cold and permafrost regions. However, the mechanical and physical properties of cemented tailings backfill (CTB) cured at normal temperature are no longer applicable. To clarify the reasons for this variability, a series of tests were performed. The mechanical properties of CTB with different cement-tailings ratios (CTR, 1:4, 1:8, 1:12, 1:16, and 1:20) were tested at different curing ages (3, 7 and 28 days) and curing temperatures (20 °C, 5 °C, -5 °C, and -20 °C). The differences of CTB in mechanical and physical properties under positive- and negative-temperature curing conditions were analyzed, and the microscopic failure process of CTB under negative-temperature curing conditions was discussed. The results revealed that the mechanical properties and deformation behavior of CTB under positive- and negative-temperature curing conditions were different. The frozen CTB had higher early strength than the standard-temperature curing condition (20 °C), and the lower the temperature, the higher the early strength. The low-temperature curing condition, on the other hand, was not beneficial to CTB's long-term strength. The low-temperature curing condition was not conducive to the long-term strength of CTB. After yielding, strain hardening and strain softening appeared in the deformation behavior of frozen backfill, indicating ductility. In contrast to the typical-temperature curing condition, the frozen CTB showed a new failure pattern that has little relation to curing time or CTR. Furthermore, the failure process of frozen backfill was reviewed and studied, which was separated into four stages, and altered as the curing time increased. The results of this study can act as a guide for filling mines in permafrost and cold climates.

Medication Errors and Type 2 Diabetes Management: A Qualitative Exploration of Physicians' Perceptions, Experiences and Expectations From Quetta City, Pakistan

Background

Type 2 Diabetes-related medication errors are frequently reported from the hospitals and consequently are of major concern. However, such reports are insufficient when developing healthcare settings are pursued in literature. Keeping this inadequacy in mind, we therefore aimed to explore physicians' perceptions, experiences and expectations of medication errors when managing patients with Type 2 Diabetes Mellitus.

Methods

A qualitative design was adopted. By using a semi-structured interview guide through the phenomenology-based approach, in-depth, face-to-face interviews were conducted. Physicians practicing at the medicine ward of Sandeman Provincial Hospital, Quetta, were purposively approached for the study. All interviews were audio-taped, transcribed verbatim, and were then analyzed for thematic contents by the standard content analysis framework.

Results

Although the saturation was reached at the 13th interview, we conducted additional two interviews to ensure the saturation. Fifteen physicians were interviewed, and thematic content analysis revealed six themes and nine subthemes. Mixed conceptualization and characterization of medication errors were identified. Medication errors were encountered by all physicians however poor understanding of the system, deficiency of logistics and materials were rated as barriers in reporting medication errors. Among contributors of medication errors, physicians themselves as well as dispensing and patient-related factors were identified. Physicians suggested targeted training sessions on medication error-related guidelines and reporting system. Parallel, establishment of an independent unit, involving the pharmacists, and strict supervision of paramedics to minimize medication errors was also acknowledged during data analysis.

Conclusion

With a longer life expectancy and a trend of growing population, the incidences of medication errors are also expected to increase. Our study highlighted prescribing, dispensing and administration phases as contributing factors of medication errors. Although, physicians had poor understanding of medication errors and reporting system, they believed getting insights on guidelines and reporting system is essential. A review of admission and discharge reconciliation must be prioritized and a culture of teamwork, communication and learning from mistakes is needed.

Prognostic accuracy of time to sputum culture conversion in predicting cure in extensively drug-resistant tuberculosis patients: a multicentre retrospective observational study

Background

There was a lack of information about prognostic accuracy of time to sputum culture conversion (SCC) in forecasting cure among extensively drug-resistant tuberculosis (XDR-TB) patients. Therefore, this study evaluated the prognostic accuracy of SCC at various time points in forecasting cure among XDR-TB patients.

Methods

This retrospective observational study included 355 eligible pulmonary XDR-TB patients treated at 27 centers in Pakistan between 01-05-2010 and 30-06-2017. The baseline and follow-up information of patients from treatment initiation until the end of treatment were retrieved from electronic nominal recording and reporting system. Time to SCC was analyzed by Kaplan–Meier method, and differences between groups were compared through log-rank test. Predictors of time to SCC and cure were respectively evaluated by multivariate Cox proportional hazards and binary logistic regression analyses. A p-value < 0.05 was considered statistically significant.

Results

A total of 226 (63.6%) and 146 (41.1%) patients respectively achieved SCC and cure. Median time to SCC was significantly shorter in patients who achieved cure, 3 months (95% confidence interval [CI]: 2.47–3.53), than those who did not (median: 10 months, 95% CI: 5.24–14.76) (p-value < 0.001, Log-rank test). Patient’s age > 40 years (hazards ratio [HR] = 0.632, p-value = 0.004), baseline sputum grading of scanty, + 1 (HR = 0.511, p-value = 0.002), + 2, + 3 (HR = 0.523, p-value = 0.001) and use of high dose isoniazid (HR = 0.463, p-value = 0.004) were significantly associated with early SCC. Only SCC at 6 month of treatment had statistically significant association with cure (odds ratio = 15.603, p-value < 0.001). In predicting cure, the sensitivities of SCC at 2, 4 and 6 months were respectively 41.8% (95%CI: 33.7–50.2), 69.9% (95%CI: 61.7–77.2) and 84.9% (95%CI: 78.1–90.3), specificities were respectively, 82.8% (95%CI: 76.9–87.6), 74.6% (95%CI: 68.2–80.4) and 69.4% (95%CI: 62.6–75.5) and prognostic accuracies were respectively 65.9% (95%CI: 60.7–70.8), 72.7% (95%CI: 67.7–77.2) and 75.8% (95%CI: 71.0–80.1).

Conclusion

In forecasting cure, SCC at month 6 of treatment performed better than SCC at 2 and 4 months. However, it would be too long for clinicians to wait for 6 months to decide about the regimen efficacy. Therefore, with somewhat comparable prognostic accuracy to that SCC at 6 month, using SCC at 4 month of treatment as a prognostic marker in predicting cure among XDR-TB patients can decrease the clinicians waiting time to decide about the regimen efficacy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07202-y.

A national survey to assess breast cancer awareness among the female university students of Pakistan

The incidence of breast cancer is increasing in Pakistan as well as globally. Awareness of women about breast cancer plays a cornerstone role in its early detection, better management, and prevention. Keeping this in mind, a cross-sectional study was carried out to assess the awareness of female university students about breast cancer’s risk factors, signs and symptoms, and breast cancer examination. The data was collected from female university students studying in Pakistan. A total of 774 participants completed the survey and recorded their responses on an online pre-tested self-administered questionnaire. Only 29.8% of the participants have identified breast cancer history in their first-degree relatives as a risk factor. Moreover, 14.1% of the participant considered that the use of oral contraceptives for more than 5 years can increase the risk of developing breast cancer. In addition, inward pulled nipple, wounds around the nipple, and abrupt changes in the breast size were considered as the sign and symptoms of breast cancer by 25.2%, 25.7%, and 31.7% of the participants, respectively. Moreover, only 20.9% of the participants identified the correct year for starting breast cancer examination and 44.4% of the respondents marked that mammography should be initiated after 40 years. Overall, the university female students of Pakistan were poorly aware of breast cancer’s risk factors, signs and symptoms, and breast examination. This study has highlighted the need for initiation of aggressive strategies regarding breast cancer awareness in both the literate and illiterate female population of Pakistan.

Profile and Predictors of Maternal Quality of Life During Physiological Pregnancy: A Cross-Sectional Analysis

Background

Quality of Life (QoL) and its determinants are significant in all stages of life, including pregnancy. The physical and emotional changes during pregnancy affect the QoL of pregnant women, affecting both maternal and infant health. Hence, assessing the QoL of pregnant women is gaining interest in literature. We, therefore, aimed to describe the QoL of pregnant women during physiological pregnancy and to identify its associated predictors in women attending a public healthcare institute of Quetta city, Pakistan.

Methods

A cross-sectional study was conducted at the Obstetrics and Gynecology Department of Sandeman Provincial Hospital Quetta city, Pakistan. The respondents were asked to answer the Urdu (lingua franca of Pakistan) version of the Quality of Life Questionnaire for Physiological Pregnancy. Data were coded and analyzed by SPPS v 21. The Kolmogorov–Smirnov test was used to establish normality of the data and non-parametric tests were used accordingly. Quality of Life was assessed as proposed by the developers. The Chi-square test was used to identify significant associations and linear regression was used to identify the predictors of QoL. For all analyses, p < 0.05 was taken significantly.

Results

Four hundred and three pregnant women participated in the study with a response rate of 98%. The mean QoL score was 19.85 ± 4.89 indicating very good QoL in the current cohort. The Chi-Square analysis reported a significant association between age, education, occupation, income, marital status, and trimester. Education was reported as a positive predictor for QoL (p = 0.006, β = 2.157). On the other hand, trimester was reported as a negative predictor of QoL (p = 0.013, β = −1.123).

Conclusion

Improving the QoL among pregnant women requires better identification of their difficulties and guidance. The current study highlighted educational status and trimester as the predictors of QoL in pregnant women. Health care professionals and policymakers should consider the identified factors while designing therapeutic plans and interventions for pregnant women.

Prescribing Patterns for Upper Respiratory Tract Infections: A Prescription-Review of Primary Care Practice in Quetta, Pakistan and the Implications

Background: To identify and address the potential overuse of antibiotics, it is important to ascertain the prescribing practices of physicians. We, therefore, conducted this prescription analysis to document URTI-specific antibiotic prescription frequency in a public primary healthcare setting of Quetta city, Pakistan.

Methods: A retrospective record review was conducted of all prescriptions for URTIs in Combined Military Hospital, Quetta from 1 March to 31st May 2021. The Mann-Whitney U and Jonckheere–Terpstra test was used to evaluate the association between the tendencies of a different group of prescribers. p-value of <0.05 was of statistical significance.

Results: Over the 3 months, 50,705 prescriptions were screened and analyzed according to the established inclusion and exclusion criteria. A total of 4,126 (8.13%) URTI prescriptions met the inclusion criteria, of which 2,880 (69.80%) prescriptions contained antibiotics. Among all antibiotics, penicillins (Amoxicillin + Clavulanate) were the most prescribed antibiotic, constituting 1,323 (45.9%) of total antibiotics prescribed for all cases, followed by the Macrolide group 527 (18.2%). The Jonckheere–Terpstra test revealed a statistically significant association between the status of the prescriber and the diagnosis (p = 0.002). Furthermore, a moderate positive trend was reported with specialists being more competent in antibiotic prescribing based on their diagnosis, followed by postgraduates and house officers (τ = 0.322).

Conclusion: The prescribing patterns for the management of URTIs in the hospital were inconsistent with current guidelines. Strict adherence to guidelines must be ensured and antibiotic prescribing for URTIs should be discouraged.

Depression, Anxiety, and Stress Among Nurses During the COVID-19 Wave III: Results of a Cross-Sectional Assessment

Purpose

The current study was aimed to evaluate depression, anxiety, and stress among nurses during the COVID-19 (wave III) at a public hospital in Quetta city, Pakistan.

Participants and Methods

By using the validated Depression, Anxiety and Stress Scale - 21, three hundred and twenty-five nurses practicing at the Sandeman Provincial Hospital, Quetta were approached for data collection. Through SPSS, both descriptive and inferential statistics were used during data analysis. Chi-square test was used to assess the goodness-of-fit between observed values and demographic variables. The factors that were significantly associated with depression, anxiety, and stress were further assessed by binary logistic regression analysis. The statistical significance was set at 0.05.

Results

Out of the 325 nurses, 297 participated in the study with a response rate of 91.3%. Mild depression and stress were reported in the current cohort of nurses (6.00 ± 5.30 and 8.01 ± 4.47), respectively. The mean anxiety score was 6.68 ± 4.86 indicating moderate anxiety among the study respondents. Marital status, working department, and job experience were significantly associated with depression, anxiety, and stress with moderate effect size (>0.3). The logistic regression reported department in which nurses were stationed (adjusted OR = 2.54, 95% CI = 1.118–1.415, p < 0.001) and job experience (adjusted OR = 1.004, 95% CI = 1.001–1.215, p = 0.002) as significant predictors of depression, anxiety and stress. Nurses working in the corona ward were more likely to develop depression, anxiety and stress by a factor of 2.54 and married nurses with a factor of 1.004 provided controlling other confounding factors.

Conclusion

Moderate depression, anxiety, and stress were observed among nurses and it calls for hospital management to consider interventions for all nurses irrespective of their present working departments. Facilitating continuous and comprehensive support mechanisms aimed at protecting nurses’ mental health is of great importance during pandemics. The findings of the study have some clear suggestions for mental health advocacy among nurses that are essential for improving the quality of services and patients’ safety.

Translation and validation study of Quality of Life Questionnaire for Physiological Pregnancy at Sandeman Provincial Hospital, Quetta, Pakistan

OBJECTIVE

To examine the psychometric properties of the Urdu version of Quality of Life Questionnaire for Physiological Pregnancy.

METHODS

The cross-sectional study was conducted from August 1 to October 31, 2020, at the Obstetrics and Gynaecology department of Sandeman Provincial Hospital, Quetta, Pakistan. The Quality of Life Questionnaire for Physiological Pregnancy was translated into Urdu by using a forward-backward procedure. The test-retest reliability was assessed through Cronbach's alpha reliability analysis. The validity of the translated questionnaire was constructed by using exploratory factor analysis through principal axis factoring extraction and Oblique rotation with Kaiser Normalisation. The constructs were retained based on extracted communalities. Data was analysed using SPSS v 21.

RESULTS

The Urdu version of the questionnaire exhibited acceptable test-retest alpha values of 0.780 and 0.812 at two-time points, with an overall value of 0.790. All items showed good stability with intraclass correlation coefficient values of >0.80. The Kaiser-Meyer-Olkin measure for factor analysis was 0.812. Barlett's Test of Sphericity was significant (p<0.05). Three factors explaining the variance were extracted and the loading values for all nine constructs were acceptable (>0.40). All items of the translated version were retained, proving the validity of the Urdu version of the questionnaire.

CONCLUSIONS

The translated version of Quality of Life Questionnaire for Physiological Pregnancy was found to be a valid and reliable instrument for the assessment of quality of life for pregnant women in regions where Urdu is the prime language of communication.

Exploring Nurses' Perception of Antibiotic Use and Resistance: A Qualitative Inquiry

Purpose

Quality use of antibiotics and the development of antibiotic resistance is a global catastrophe. In the conceptual context, the phenomenon is correlated with the healthcare practitioners’ understanding of antibiotic use and resistance. Therefore, the study aimed to highlight nurses’ perception of antibiotic use and resistance at a public healthcare institute in Quetta City, Pakistan.

Respondents and Methods

By using a semi-structured interview guide through the phenomenology-based approach, in-depth, face-to-face interviews were conducted. Nurses practicing at the surgical and medical units of Sandeman Provincial Hospital (SPH), Quetta, were approached for the study. All interviews were audio-taped, transcribed verbatim, and were then analyzed for thematic contents by the standard content analysis framework.

Results

Although the saturation was reached after the 13th interview, an additional two were interviewed for absolute validation. Content analysis revealed five major themes: (1) defining antibiotics and antibiotic resistance, (2) antibiotic use: awareness and concern, (3) antimicrobial resistance: awareness and concern, (4) responding to antibiotic use and resistance, and (5) barriers to quality use of antibiotics and prevention of antibiotic resistance. Even though the understanding of nurses regarding antibiotic use and resistance was promising, certain apprehensions were also observed. The respondents were aware of the critical situation and provided valuable insights that can offer significant input while promoting the quality use of antibiotics in a developing country.

Conclusion

While the perception towards antibiotics appeared positive, potential areas of concern and contributing factors regarding antibiotic resistance were also identified. Importantly, nurses too highlighted possible solutions to address the issue of irrational antibiotic use and the development of antibiotic resistance.

Prediabetes in adolescents - an emerging epidemic - a cross-sectional survey of medical students at a public university, Quetta, Pakistan

OBJECTIVE

To determine the prevalence and determinants of prediabetes among adolescents.

METHODS

The cross-sectional study was conducted at a public-sector medical university in Quetta, Pakistan, from December 2019 to February 2020, and comprised students aged 16-19 years. A self-administered questionnaire was used to gather socio-demographic data. Fasting blood sample was taken to measure the fasting plasma glucose level, lipid profile and glycated haemoglobin levels. Height, weight, neck circumference and waist circumference were also measured. Data was analysed using SPSS 21.

RESULTS

Of the 351 subjects, 158(45%) were males and 193(55%) were females. The overall mean age was 18.81±0.41 years. Of the total, 81(23.1%) participants were found to have prediabetes. Neck circumference was identified as the strongest predictor for prediabetes, followed by high level of triglycerides, high systolic blood pressure, low levels of high-density lipoproteins, high levels of low-density lipoproteins, high diastolic blood pressure, waist circumference and body mass index (p<0.05). There was no significant difference in the prevalence of prediabetes among male and female students (p>0.05).

CONCLUSIONS

There was no significant difference in the prevalence of prediabetes among male and female medical students. Neck circumference, Waist circumference, Body mass index, systolic blood pressure, Diastolic blood pressure, Triglyceride and High density Lipoprotein were strong predictors of prediabetes in adolescent population.

Diabetes-related Knowledge, Medication Adherence, and Health-related Quality of Life: A Correlation Analysis

CONTEXT

Even though positive treatment outcomes for type 2 diabetes mellitus (T2DM) are linked to disease knowledge and adherence to medications, inadequate knowledge, poor adherence, and resistance to lifestyle modifications are still common among patients. This situation has been a continuing dilemma for patients and healthcare providers, and these factors negatively affect the health-related quality of life (HRQoL) of patients.

OBJECTIVE

The current study intended to evaluate the correlations between diabetes-related knowledge, medication adherence, and HRQoL among T2DM patients in Pakistan.

DESIGN

The study was designed as a questionnaire-based, cross-sectional descriptive analysis, with participants being selected using a prevalence-based sampling method.

SETTING

The study was conducted at four different healthcare institutes namely Sandeman Provincial Hospital, Bolan Medical Complex Hospital, Al-Khair Hospital and Sajid Hospital, Quetta city, Pakistan.

PARTICIPANTS

Participants were 300 patients with T2DM who were receiving treatment at public and private healthcare institutes in Quetta, Pakistan.

OUTCOME MEASURES

In addition to collection of demographics, the Urdu version of Michigan Diabetes Knowledge Test (MDKT-U), the Drug Attitude Inventory (DAI-10), and the EuroQol EQ-5D were used to assess diabetes-related knowledge, medication adherence and HRQoL, respectively. The relationships among the 3 variables were determined using the Spearmen rho correlation coefficient, and the results were interpreted using Cohen' criteria. SPSS v.20 was used for data analysis, and P < .05 was considered significant for all analysis.

RESULTS

The mean diabetes-related knowledge score was 5.83 ± 1.92, indicating participants' lack of knowledge of T2DM. Moderate adherence was reported, with a mean adherence score of 4.94 ± 2.72. Additionally, the mean EQ-5D score was 0.48±0.36, and the mean Visual Analogue Score (VAS) was 54.58 ± 20.28, highlighting poor HRQoL. The Spearman's rho correlation coefficient indicated significant, moderate correlations among all variables (P < .05; r = 0.053-0.231).

CONCLUSIONS

The study found limited diabetes-related knowledge, moderate medication adherence, and poor HRQoL among patients with T2DM in Pakistan. Nevertheless, a positive significant correlation revealed that a directly proportional change in one study variable can improve the others.

"Expecting the Unexpected:" Nurses' Response and Preparedness of Terrorism-Related Disaster Events in Quetta City, Pakistan

Background: In addition to the psychiatric and societal misery, terrorism places an exceptional burden while delivering healthcare services. Accordingly, a responsive and well-prepared healthcare system ensures effective management of terrorism-related events. Within this context, with a strong historic grounding in addressing situations of societal crisis nurses are well-placed in contributing to the global arena of humanitarian policy and social research. Therefore, assessing their response and preparedness is vital in effective management of a terrorism-related disaster. For that very reason, we aimed to evaluate nurses' preparedness and response toward terrorism-related disaster events in Quetta city, Pakistan. Methods: A qualitative design was adopted to explore nurses' response and preparedness of terrorism-related disaster events. By using a semi-structured interview guide through the phenomenology-based approach, in-depth, face-to-face interviews were conducted. Nurses practicing at the Trauma Center of Sandeman Provincial Hospital (SPH), Quetta, were approached for the study. All interviews were audio-taped, transcribed verbatim, and were then analyzed for thematic contents by the standard content analysis framework. Results: Fifteen nurses were interviewed and thematic content analysis revealed five themes. All nurses have experienced, responded to, and managed terrorism-related disaster events. They were prepared both professionally and psychologically in dealing with a terrorism-related disaster. Among limitations, space and workforce were highlighted by almost all the respondents. Lack of disaster-related curricula, absence of a protocol, recurrence of the disaster, and hostile behavior of victim's attendants during an emergency were highlighted as a key barrier toward terrorism-related disaster management. Conclusion: The skills and expertise needed to address a terrorism-related disaster are well-understood by the nurses but are lacking for various reasons. In addition to the review and adaption of the nursing curriculum specifically for terrorism-related disaster management, collaboration and dialogue between various stakeholders is required to efficiently manage terrorism-related disaster events.

Perceptions, Expectations, and Experience of Physicians About Pharmacists and Pharmaceutical Care Services in Pakistan: Findings and Implications

Background: Optimal collaboration between pharmacists and other healthcare professionals such as physicians is integral in implementing pharmaceutical care. However, there are concerns regarding the role of pharmacists, especially among low- and middle-income countries. This study explored the perceptions, expectations, and experience of physicians working in various hospital settings of Punjab, Pakistan, about pharmacists and their roles.

Methods: A self-administered questionnaire consisting of four sections was administered from October to December 2020. Descriptive and inferential statistics such as Kruskal-Wallis and Mann-Whitney tests were used for data analysis using SPSS.

Results: Six hundred and seventy-eight physicians participated in this study with a response rate of 77.9%. Most of the physicians reported minimal to no interaction with pharmacists (n = 521, 76.8%). However, more than three-quarters of physicians (n = 660, 97.3%) accepted pharmacists as evidence-based sources of drug information. In addition, many physicians (n = 574, 84.7%) strongly agreed that pharmacists should attend patient care rounds to respond promptly to questions related to patient medication. A limited number of physicians (n = 124, 18.3%) assumed that pharmacists were advising their patients regarding the judicial use of their drugs. Median expectation and experience score had a significant association with age, experience, and education of physicians (P < 0.05).

Conclusions: The perception of physicians was positive toward certain roles of pharmacists, coupled with high expectations. However, their experience was low, with most of the activities of pharmacists due to inadequate interprofessional coordination.

Effectiveness of Shorter Treatment Regimen in Multidrug-Resistant Tuberculosis Patients in Pakistan: A Multicenter Retrospective Record Review

In Pakistan, the treatment of multidrug-resistant tuberculosis (MDR-TB) with a shorter treatment regimen (STR), that is, 4-6 months of amikacin, moxifloxacin (Mfx), ethionamide, clofazimine (Cfz), pyrazinamide (Z), ethambutol (E), and high-dose isoniazid, followed by 5 months of Mfx, Cfz, Z, and E, was initiated in 2018. However, there is a lack of information about its effectiveness in Pakistani healthcare settings. Therefore, this retrospective record review of MDR-TB patients treated with STR at eight treatment sites in Pakistan aimed to fill this gap. Data were analyzed using SPSS 23. Multivariate binary logistic regression (MVBLR) analysis was conducted to find factors associated with death and treatment failure, and lost to follow-up (LTFU). A P-value < 0.05 was considered statistically significant. Of 912 MDR-TB patients enrolled at the study sites, only 313 (34.3%) eligible patients were treated with STR and included in the current study. Of them, a total of 250 (79.9%) were cured, 12 (3.8%) completed treated, 31 (9.9%) died, 16 (5.1%) were LTFU, and four (1.3%) were declared as treatment failures. The overall treatment success rate was 83.7%. In MVBLR analysis, patients' age of 41-60 (odds ratio [OR] = 4.9, P-value = 0.020) and > 60 years (OR = 3.6, P-value = 0.035), being underweight (OR = 2.7, P-value = 0.042), and previous TB treatment (OR = 0.4, P-value = 0.042) had statistically significant association with death and treatment failure, whereas patients' age of > 60 years (OR = 5.4, P-value = 0.040) and previous TB treatment (OR = 0.2, P-value = 0.008) had statistically significant association with LTFU. The treatment success rate of STR was encouraging. However, to further improve the treatment outcomes, special attention should be paid to the patients with identified risk factors.

Preparedness and impact of COVID 19 infection at tertiary care neurology centers in Pakistan

Objective

We aimed to assess the response and impact of covid 19 pandemic at tertiary care centers in Pakistan especially pertaining to neurological care, facilities and training.

Methods

A pre-tested survey form was sent to 40 neurology tertiary care centers in all the provinces in the country in the first week of July 2020. 33 filled forms were received, out of which 18 were public (government) and 15 were private hospitals.

Results

Estimated 1300 HCW (faculty, medical officers, trainees and nurses) work at these 33 participating centers. There were 17 deaths among HCW (1.3%) at ten centers. Sufficient personal protective equipment (PPE) were provided to 158 HCW (12%). 129 (10%)HCW tested positive for COVID 19 at 31 centers including trainees/medical officers (39), consultants (29) and nursing and other staff (61). Due to low neurology admissions, 23/33 hospitals (70%) posted neurology trainees in COVID 19 units to contribute to covid care. Less than 50% hospitals did covid screening PCR before admission to neurology wards. Only 10% hospitals provide training and regular update to HCW. Neurology tele-health services were started for clinically stable patients at 15 (45%) centers. Only 60% neurology training programs were able to start online training. Ongoing research studies and trials focusing neurological manifestations of COVID-19 were done at 10 (30%) centers. Modification of facilities for COVID patients showed that 24(72%) hospitals strictly reduced the number of attendants accompanying patients. Only 10 (30%) centers had neurophysiological tests being conducted on COVID-19 patients. Mental health support services to HCW were provided at 12 (36%) centers.

Conclusions

Among HCW 10% tested positive for covid and 1.3% died. Mental health support services offered for HCW were available in 36% institutions. Neurology training was substantially affected due to low admissions, limited ward rounds and limited availability of online training.

Knowledge and perception about bioethics: A comparative study of private and government medical college students of Karachi Pakistan

Introduction:

Ethics plays an elementary role in current medical practice. Recent advancement in medical technology and its implications have raised many ethical issues and dilemmas in clinical practice, requiring dire needs for incorporation of bioethics into medical curriculum.

Aim:

The objective of this study is to assess the base line knowledge and perception of medical students regarding bioethical issues in clinical practice based on exposure to formal bioethics teaching in their medical curriculum.

Setting and design:

This cross sectional study was conducted among medical students of a private and government medical college who were currently enrolled into third to fifth year MBBS.

Methods and Material:

A pretested questionnaire was used to collect data. A structured questionnaire consisting of 27 questions was used for this study. An Ethics Review Committee approval was taken.

Analysis:

Data analysis was done under SPSS version 17 and frequencies were calculated.

Results:

A total of 285 medical students, 145 from private and 140 from government medical college participated in this study. Private college medical students (57%) had slightly better knowledge of bioethics as compared to the government students 43%.

Conclusion:

The study clearly signifies the need of teaching bioethics in the both the medical colleges. Our findings provide strong evidence for major educational initiatives related to bioethics education in medical curriculum.

Treatment Outcomes of Extensively Drug-Resistant Tuberculosis in Pakistan: A Countrywide Retrospective Record Review

Background: The current study is conducted with the aim to the fill the gap of information regarding treatment outcomes and variables associated with unsuccessful outcome among XDR-TB patients from Pakistan. Methods: A total of 404 culture confirmed XDR-TB patients who received treatment between 1^st May 2010 and June 30, 2017 at 27 treatment centers all over Pakistan were retrospectively followed until their treatment outcomes were reported. A p-value <0.05 reflected a statistical significant association. Results: The patients had a mean age 32.9 ± 14.1 years. The overall treatment success rate was 40.6% (95% confidence interval [CI]:35.80-45.60%). A total of 155 (38.4%) patients were declared cured, 9 (2.2%) completed treatment, 149 (36.9%) died, 60 (14.9%) failed treatment and 31 (7.7%) were lost to follow up (LTFU). The results of the multivariate binary logistic regression analysis revealed that the patients' age of >60 years (OR = 4.69, 95%CI:1.57-15.57) and receiving high dose isoniazid (OR = 2.36, 95%CI:1.14-4.85) had statistically significant positive association with death, whereas baseline body weight >40 kg (OR = 0.43, 95%CI:0.25-0.73) and sputum culture conversion in the initial two months of treatment (OR = 0.33, 95%CI:0.19-0.58) had statistically significant negative association with death. Moreover, male gender had statistically significant positive association (OR = 1.92, 95%CI:1.04-3.54) with LTFU. Conclusion: The treatment success rate (40.6%) of XDR-TB patients in Pakistan was poor. Providing special attention and enhanced clinical management to patients with identified risk factors for death and LTFU in the current cohort may improve the treatment outcomes.

Perspectives of community pharmacists in Pakistan about practice change and implementation of extended pharmacy services: a mixed method study

Background Community pharmacists' role in the primary health care, patient-centered services, beyond traditional dispensing services is well established in the developed world. However, this role is not fully established in low-middle-income countries including Pakistan. Objective To explore community pharmacists' perspectives and preparedness about practice change and associated facilitators and barriers to extended services. Setting A study was conducted involving community pharmacists of Lahore, Pakistan. Method Two phased studies were conducted using mixed-method sequential design. The first phase involved qualitative semi-structured face-to-face interviews with the community pharmacists, while the second phase constituted a questionnaire-based cross-sectional study. Main outcome measure Pharmacists' perspectives about extended pharmacy services, facilitators, barriers and preparedness for the practice change. Results For the first phase, pharmacists were purposively sampled and the saturation yielded a final sample size of fifteen pharmacists (N = 15). The thematic content analysis yielded four distinct themes; (1) current practices and familiarity with extended pharmacy services (2) practice gap between Pakistan and the developed countries (3) facilitators and the preparedness, and (4) barriers towards its implementation and provision. The second part was a questionnaire-based cross-sectional phase, where a total of 348 community pharmacists were approached, while only 242 responded, yielding a response rate of 69.5%. The triangulation of qualitative and quantitative data identified several barriers such as; shortage of pharmacists, lack of knowledge and skills, poor collaboration with general practitioners, failure of customers to pay for extended services. Facilitators and preparedness for the provision of extended pharmacy services were; access to patient notes, follow-up, separate counselling areas, accreditation of specific services and sufficient resources. Conclusion This study's findings call for the implementation and enforcement of Punjab Drug Sale Rules 2007 to facilitate the practice change and provision of comprehensive pharmacy services in Punjab, Pakistan. There is a need for additional laws to define community pharmacists' roles, uniform job description, training, new funding model, separate area, and accreditation of extended pharmacy services in Pakistan.

Religious Cliché and Stigma: A Brief Response to Overlooked Barriers in COVID-19 Management

For decades, religion has provided explanations and answers to existential questions and queries that can emerge during a pandemic. This characteristic of religion has helped communities in finding answers and meanings to their confusions. During a pandemic, healthcare professionals are often unprepared in answering the patients' religious beliefs regarding the diseases. Moreover, patients are faced with religious clichés and stigma that results because of religious beliefs and practices. To overcome the religious stigma, a deeper understanding of religious beliefs and values is required so that a perception or practice change can take place. Therefore, the inclusion and collaboration of spiritual leaders with healthcare professionals are needed to ensure a holistic understanding and overcome the stigma that can shape as a barrier for reaching an optimal therapeutic outcome.

Knowledge, Attitude, and Practices of Healthcare Professionals on COVID-19 and Risk Assessment to Prevent the Epidemic Spread: A Multicenter Cross-Sectional Study from Punjab, Pakistan

In the current outbreak of novel coronavirus (COVID-19), healthcare professionals (HCPs) have a primary role in combating the epidemic threat. HCPs are at high risk of not only contracting the infection but also spreading it unknowingly. It is of utmost importance to evaluate their knowledge, attitudes, and practices (KAP) and the ability to assess the risks associated with the outbreak. A cross-sectional online survey involving physicians, pharmacists, and nurses was conducted. A 39-itemed questionnaire based on the World Health Organization (WHO)COVID-19 risk assessment tool was shared with healthcare professionals in three purposively selected key divisions of Punjab province. Out of 500 healthcare professionals, 385 responded to the survey. The majority (70%) were aged 22–29 years; 144 (37.4%) physicians, 113 (29.4%) nurses, and 128 (33.2%) pharmacists completed the survey. Overall, 94.8% of healthcare professionals scored adequately (>14) for COVID-19-related knowledge; 97.9% displayed an optimistic attitude (>42) and 94.5% had an adequate practice score (>28). Kruskal–Wallis and Jonckheere–Terpstra tests showed significant differences (p < 0.05) in KAP and risk assessment scores among groups; physicians and nurses scored higher as compared to pharmacists. Further research and follow-up investigations on disaster management and risk assessment can help policy-makers better tackle future epidemics.

Patterns of physicians' knowledge, attitude and prescribing trends against upper respiratory tract infections in Lahore, Pakistan

Although viruses cause most of upper respiratory tract infections but still antibiotics are irrationally prescribed in mild infections, especially in upper respiratory tract infections. To identify gaps among prescribers, due to lack of standard guidelines and antimicrobial stewardship programs, it is needed to check knowledge, attitude, perception and current prescribing pattern of antibiotics. Based on the data recommendations can be specified to overcome the prescribing deficiencies and increasing rates of antimicrobial resistance. It is inevitable to educate patients about ineffectiveness of antibiotics in viral infections, and to develop guidelines for prescribing antibiotics, running continuing medical education and establishing antibiotic stewardship programs. We conducted a cross-sectional survey-based study by engaging physicians of public and private sector hospitals in Lahore, Pakistan. About 66% agreed for semi-structured interview and met the inclusion criteria. Fifty percent of physicians have an understanding that antibiotics should be prescribed in URTIs, otherwise symptoms may get worsen. The only encouraging thing is that 78.8% believe that antibiotics are being misused and are major cause of increasing rate of resistance. Most of prescribers have an understanding that antibiotics should be prescribed in upper respiratory tract infections. They are prescribing antibiotics ignoring Center for Disease Control guidelines for the treatment or prophylaxis of upper respiratory infections.

Medication Management Program: Adherence, Disease-related Knowledge, Health-related Quality of Life, and Glycemic Control for Type 2 Diabetes Mellitus

CONTEXT

Escalation in rates of diabetes in Pakistan is posing threats to the economy and to the people's quality of life due to poor glycemic control and very high rates of complications. Cost of care is very high, and many barriers to quality care exist. Most often patients are unable to afford the high cost of treatment. Patients' knowledge about diabetes is associated with better medication adherence and better glycemic control.

OBJECTIVE

The current study intended to evaluate the effects of an educational intervention in a pharmacist led, medication management program (MTM) tailored for patients with type 2 diabetes (T2DM).

DESIGN

The research team conducted a nonclinical, randomized controlled trial.

SETTING

The study took place at District Headquarters and Teaching Hospital, a public-sector hospital (Sargodha, Pakistan).

PARTICIPANTS

Participants were 392 individuals with T2DM.

INTERVENTION

Participants were randomly assigned to one of 2 groups-intervention and control-with 196 patients in each. The intervention group, instead of receiving standard care, received pharmaceutical care through the Medication Therapy Management program, whereas the control group received standard care.

OUTCOME MEASURES

At baseline and 3 mo post ntervention, the study assessed participants' diabetes-related knowledge, medication adherence, and health-related quality of life (HRQoL) using the 14-item Michigan Diabetes Knowledge Test, the 8-item Morisky Medication Adherence Scale, and the European Quality of Life scales, respectively. To determine glycemic control, participants' baseline HbA1c levels were taken from their medical records, and the final HbA1c result was obtained postintervention.

RESULTS

For the intervention and control groups at baseline, diabetes-related knowledge was average, at 7.99 ± 2.65 and 8.03 ± 2.49, respectively; medication adherence was low, at 4.54 ± 1.69 and 4.41 ± 1.84, respectively; and glycemic control was poor, at 9.47 ± 1.57 and 9.41 ± 1.57, respectively. After the educational intervention, the intervention group had increased its diabetes-related knowledge, medication adherence, and HRQoL scores, with the results being 10.55 ± 2.56, 5.24 ± 1.48, and 0.6115 ± 0.286, respectively. The group's glycemic control has also improved to 8.97 ± 1.362. A statistically significant difference between the groups had occurred, with P < .001. The control group's scores had remained approximately the same for medication adherence, HRQoL, and glycemic control, and little difference had occurred as compared with the group's baseline analysis.

CONCLUSION

The study found that the educational program increased the intervention group's level of diabetes-related knowledge, and improved its adherence to medication and its glycemic control, all due to its improved HRQoL. Patients' beliefs about the effects of long-term use of medicines were also addressed by the MTM program. The program was successful because it decreased participants' HbA1c values, which is a positive indicator of successful T2DM therapy.

Point prevalence surveys of antimicrobial use: a systematic review and the implications

Introduction: In view of increasing concerns with antimicrobial resistance (AMR), the World Health Organization (WHO) instituted a Global Action Plan (GAP) to address this. Area covered: One of the strategies to achieve the goals of GAP is to conduct regular surveillance of antimicrobial use through point prevalence surveys (PPS). In this review, PubMed, EBSCO, Proquest, Cinahl, and Scopus were searched for PPS of antimicrobial use published in English between January 2000 and December 2019. After systematic database screening of 2,893 articles, 60 PPS met the inclusion criteria and consequently were incorporated in this systematic review. Expert opinion: This review highlighted that most of the PPS were conducted in upper-middle and high-income countries. Prevalence of antimicrobial use was significantly higher in non-European hospitals compared with European hospitals. The domination of third-generation cephalosporin and fluoroquinolones use across all the regions suggests substantial use of broad-spectrum antimicrobials across countries. Among all identified regions around the world, India was the region where the highest use of antimicrobials was observed. Although PPS is a useful tool to assess the pattern of antimicrobial use and provides a robust baseline; however, a standardized surveillance method is needed. In order to optimize antimicrobial use, more efforts are required to improve antimicrobial use.

Knowledge and practice of adolescent females about menstruation and menstruation hygiene visiting a public healthcare institute of Quetta, Pakistan

BACKGROUND

The current study is aimed to assess menstruation-related knowledge and practices of adolescent females visiting a public health care institute of Quetta city, Pakistan.

METHODS

A questionnaire-based cross-sectional survey was conducted. Nine hundred and twenty three female adolescents attending general out-patient departments of Mohtarma Shaheed Benazir Bhutto Hospital Quetta, Balochistan, was approached for data collection. Based on the objectives of the study, descriptive analysis was conducted and SPSS v. 21.0 was used for the data analysis.

RESULTS

Demographic characteristics revealed that the mean age of the respondents was 15 years. Mothers' (67%) were the main source of menstruation-related information. Majority (77.7%) of our respondents never had a class or session regarding menstruation-related education in their schools. About (44%) knew that menstruation is a physiological phenomenon while 60.2% knew that menstrual blood comes from the vagina. Nearly 40% of our study respondents missed their schools because of menarche. The use of absorbent material was frequent (90%) among the adolescent females and (68.7%) used commercially available sanitary napkins/pads. Although majority of the respondents (58.2%) were not taking baths during menstruation, 80.5% do cleaned their genitalia with water during menstruation.

CONCLUSION

Female adolescents of our study had certain misconception regarding menstruation because of poor access to health-related education. Education can be provided at healthcare facilities, residential area as well as religious centers. Adolescent reproductive health should be included in the school curriculum; this will influence general reproductive health of females.

Low-income community knowledge, attitudes and perceptions regarding antibiotics and antibiotic resistance in Jelutong District, Penang, Malaysia: a qualitative study

BACKGROUND

Understanding community perspectives on antibiotics and antibiotic resistance (ABR) is a key component in designing educational interventions to combat ABR at the community level in Malaysia. Therefore, this study aimed to explore community residents' knowledge, attitudes and perceptions regarding antibiotics and ABR in Jelutong District, Penang, Malaysia. Moreover, it intended to identify areas of focus to be addressed when designing an educational intervention to increase residents' knowledge and change their attitudes and perceptions.

METHODS

A qualitative approach was adopted to gain a deeper understanding of community residents' knowledge, attitudes and perceptions regarding antibiotics and ABR. A purposive sampling was employed. Twenty-two residents (aged ≥18 years) were interviewed with the aid of a semi-structured interview guide. All interviews were audio recorded, transcribed verbatim and thematically analysed.

RESULTS

The majority of the participants asserted that antibiotics could be effective against viral infections. Moreover, many participants were unaware that antibiotics have adverse effects. Some acquired antibiotics from a community pharmacy without a prescription, took antibiotics given to them by their family or friends, or took leftover antibiotics prescribed for a previous illness. A few indicated that they would request antibiotics from their physician when they had viral infections. More than half of the participants discontinued taking antibiotics when their symptoms improved. The majority stated that ABR occurs when the body becomes used to antibiotics. Most participants were unaware of the causes, consequences and prevention of ABR. In fact, they were not concerned about it. As a result, only a few perceived themselves as having responsibility for preventing this problem.

CONCLUSIONS

The community residents had misconceptions about antibiotics and ABR, negative attitudes towards antibiotics and negative perceptions of ABR. The areas of focus that need to be addressed when designing an educational intervention to increase the general public knowledge and change their attitudes and perceptions are the appropriate use of antibiotics and their adverse effects; the importance of adhering to antibiotic therapy; and the definition, causes, consequences and prevention of ABR.

Antimicrobial dispensing practices and determinants of antimicrobial resistance: a qualitative study among community pharmacists in Pakistan

Background

There are concerns with the extent of dispensing of antibiotics among community pharmacists in Pakistan often without a prescription adding to antimicrobial resistance (AMR) rates.

Objective

To explore the determinants of AMR and the pattern of antimicrobial dispensing among community pharmacists.

Design

In this qualitative study design, a semistructured interview guide was developed based on an in-depth review of published papers. Audio-recorded interviews with transcripts were analysed by thematic content analysis.

Setting

Interviews were conducted among community pharmacists in Lahore, Pakistan.

Participants

In order to obtain individual points of view, in-depth face-to-face interviews with purposively selected pharmacists were conducted.

Results

A total of 12 pharmacists were interviewed for the study. After analysis, four major themes emerged: (1) knowledge and perception of community pharmacists about antimicrobials, (2) antimicrobial dispensing practices of community pharmacists, (3) determinants of AMR, (4) potential interventions to control AMR. Most of the pharmacists have limited knowledge about AMR, antimicrobial stewardship programmes and related guidelines. However, all the pharmacists strongly agreed that different appropriate actions should be taken in order to rationalise future antimicrobial use.

Conclusion

The results indicated that irrational antimicrobial dispensing and use is common among community pharmacists in Pakistan owing to lack of knowledge. The community pharmacists perceived that behaviour of patients and the societal environment contributed to irrational antimicrobial use and subsequent development of AMR. They suggested a need for a multidisciplinary framework in order to improve future antimicrobial use and reduce AMR in Pakistan.

Antimicrobial prescribing and determinants of antimicrobial resistance: a qualitative study among physicians in Pakistan

Background Understanding physicians' perception about antimicrobial use and resistance is essential to ensure that the objectives of the Pakistan national action plan on antimicrobial resistance are met. Little is currently known about physicians' perceptions in Pakistan. Objective Assess physicians' perception surrounding antibiotic use and resistance, factors influencing antibiotic prescribing and potential interventions to improve future antibiotic prescribing. Settings The study was conducted in Lahore, the capital of the province of Punjab, which is the second largest and most populous city of Pakistan. Method Qualitative study was conducted with a semi-structured interview guide involving in-depth face-to-face interviews with purposively selected physicians. Audiorecorded interviews were transcribed verbatim and transcripts analyzed by thematic content analysis. Main outcome measures Themes surrounding the perspectives of physicians on issues of antimicrobial use and resistance. Results Five major themes emerged: (1) knowledge and perception of physicians about antimicrobials, (2) antimicrobial prescribing behaviors of physicians, (3) factors influencing prescribing, (4) determinants of antimicrobial resistance, (5) and potential interventions to reduce antimicrobial resistance. The main challenges and issues associated with antibiotic prescribing were the improvement of knowledge, implementation of hygienic measures, access to and clarity of treatment recommendations and minimizing external factors influencing prescribing including pharmaceutical company activities. Suggestions for the future included stricter regulations for prescribing, improved diagnosis, availability of local guidelines and monitoring of prescribing and resistance patterns. Conclusion Identification of concerns regarding inappropriate antimicrobial prescribing will enable specific initiatives and approaches to improve future antimicrobial use and reduce antimicrobial resistance in Pakistan.

A multicenter point prevalence survey of antibiotic use in Punjab, Pakistan: findings and implications

OBJECTIVES

In line with the recent global action plan for antimicrobial resistance, this is the first time such a comprehensive antimicrobial point prevalence survey has been undertaken in Pakistan, the sixth most populous country.

METHODS

This point prevalence survey (PPS) was conducted in 13 hospitals among 7 different cities of Pakistan. The survey included all inpatients receiving an antibiotic on the day of PPS. A web-based application was used for data entry, validation, and reporting as designed by the University of Antwerp (www.global-pps.com).

RESULTS

Out of 1954 patients, 1516 (77.6%) were treated with antibiotics. The top three most reported indications for antibiotic use were prophylaxis for obstetrics or gynaecological indications (16.5%), gastrointestinal indications (12.6%) and lower respiratory tract infections (12.0%). The top three most commonly prescribed antibiotics were ceftriaxone (35.0%), metronidazole (16.0%) and ciprofloxacin (6.0%). Out of the total indications, 34.2% of antibiotics were prescribed for community-acquired infections (CAI), 5.9% for healthcare-associated infections (HAI), and 57.4% for either surgical or medical prophylaxis. Of the total use for surgical prophylaxis, 97.4% of antibiotics were given for more than one day.

CONCLUSIONS

Unnecessary prophylactic antibiotic use is extremely high, and broad-spectrum prescribing is common among hospitals in Pakistan. There is an urgent need to work on the  national action plan of Pakistan on antibiotic resistance to address this.

Parents' self-directed practices towards the use of antibiotics for upper respiratory tract infections in Makkah, Saudi Arabia

Background

Excessive and inappropriate antimicrobial use in the community is one risk factor that can result in the spread of antimicrobial resistance. Upper respiratory tract infections are most frequently reported among children and mainly of viral origin and do not require antibiotics.

We have conducted Knowledge, Attitude and Perception (KAP) survey of parents to explore the parent’s knowledge, attitude & perception of Saudi parents.

Methods

A knowledge attitude perception questioner was adopted from a previous study conducted in Greece by Panagakou et al. Raosoft online sample size calculator calculated the sample size by adding the total estimated Makkah population of 5,979,719 with a response rate of 30%, 5% margin of error and 99% confidence interval. Based on the described criteria five hundred & fifty-eight was the required sample size of the study. Incomplete questioners were excluded from the statistical analysis. SPSS version 21 was used to analyse data and to produce descriptive statistics.

Results

Most of the mothers (95%) responded among parents. 67% had no health insurance to cover medications costs. Most of them (74%) were related to medium income level. Seventy per cent of the parents believed physicians as a source of information for judicious antibiotics use. Interestingly, only 8% were agreed that most of the upper respiratory tract infections are caused by viral reasons.

Majority of Saudi parents (53%) expect pediatricians to prescribe antimicrobials for their children for symptoms like a cough, nose discharge, sore throat and fever.

Moreover, most the parents had the poor knowledge to differentiate commonly used OTC medications for URTI and antibiotics like Augmentin (Co-amoxiclav), Ceclor (cefaclor) and Erythrocin (Erythromycin). While comparing males and female’s knowledge level, few males have identified Amoxil (Amoxicillin). Similarly, parents of age 20–30 years have good knowledge about the antibiotics.

Conclusions

Majority of Saudi parents believe in pediatricians and use antibiotics on physician’s advice. Most of them expect antibiotics from their physicians as a primary treatment for upper respiratory tract infections. There is need for more educational activities to parents by the pharmacists to prevent antibiotics overuse among children.

Complementary and alternative medicine (CAM) disclosure to health care providers: A qualitative insight from Malaysian thalassemia patients

BACKGROUND AND PURPOSE

This study investigated the disclosure of complementary and alternative medicine (CAM) use to health care providers by Malaysian thalassemia patients.

METHODS

The semi-structured interviews were audio taped, transcribed verbatim, and translated into English.

RESULTS

Thematic analysis identified four themes: 1) reason for CAM disclosure, 2) attempt to disclose CAM, 3) withdrawal from CAM disclosure, and 4) non-disclosure of CAM use. The reason for patients' disclosure of CAM use to healthcare providers is because they wanted to find information about CAM and were afraid of the interaction between the conventional medicine and CAM. Patients also disclosed the use of CAM because they were not satisfied with the conventional medicine that had caused them harm.

CONCLUSION

Effective communication between patients and health care providers is important, especially for patients who are undergoing conventional thalassemia treatment, for fear that there is an interaction between conventional treatment and CAM use.