Early Intervention in Psychosis and Management of First Episode Psychosis in Low- and Lower-Middle-Income Countries: A Systematic Review

BACKGROUND AND HYPOTHESIS

People with first-episode psychosis (FEP) in low- and lower-middle-income countries (LMIC) experience delays in receiving treatment, resulting in poorer outcomes and higher mortality. There is robust evidence for effective and cost-effective early intervention in psychosis (EIP) services for FEP, but the evidence for EIP in LMIC has not been reviewed. We aim to review the evidence on early intervention for the management of FEP in LMIC.

STUDY DESIGN

We searched 4 electronic databases (Medline, Embase, PsycINFO, and CINAHL) to identify studies describing EIP services and interventions to treat FEP in LMIC published from 1980 onward. The bibliography of relevant articles was hand-searched. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.

STUDY RESULTS

The search strategy produced 5074 records; we included 18 studies with 2294 participants from 6 LMIC countries. Thirteen studies (1553 participants) described different approaches for EIP. Pharmacological intervention studies (n = 4; 433 participants) found a high prevalence of metabolic syndrome among FEP receiving antipsychotics (P ≤ .005). One study found a better quality of life in patients using injectables compared to oral antipsychotics (P = .023). Among the non-pharmacological interventions (n = 3; 308 participants), SMS reminders improved treatment engagement (OR = 1.80, CI = 1.02-3.19). The methodological quality of studies evidence was relatively low.

CONCLUSIONS

The limited evidence showed that EIP can be provided in LMIC with adaptations for cultural factors and limited resources. Adaptations included collaboration with traditional healers, involving nonspecialist healthcare professionals, using mobile technology, considering the optimum use of long-acting antipsychotics, and monitoring antipsychotic side effects.

The relationship between pain and depression and anxiety in patients with inflammatory arthritis: a systematic review protocol

Pain is a major challenge for patients with inflammatory arthritis (IA). Depression and anxiety are common comorbidities in IA, associating with worse outcomes. How they relate to pain is uncertain, with existing systematic reviews (a) mainly considering cross-sectional studies, (b) focusing on the relationship between pain and mental health in the context of disease activity/quality of life, and (c) not specifically considering the impact of treating depression/anxiety on pain. This PROSPERO-registered (CRD42023411823) systematic review will address this knowledge-gap by synthesizing evidence to summarise the associations (and potential mediators) between pain and depression/anxiety and evaluate the impact of treating co-morbid depression/anxiety on pain in IA. Relevant databases will be searched, articles screened and their quality appraised (using Joanna Briggs Institute critical appraisal tools) by two reviewers. Eligible studies will include adults with rheumatoid arthritis or spondyloarthritis, be a clinical trial or observational study, and either (a) report the relationship between pain and depression/anxiety (observational studies/baseline trials), or (b) randomise participants to a pharmacological or psychological treatment to manage depression/anxiety with a pain outcome as an endpoint (trials). To synthesise data on the association between pain and depression/anxiety, where available adjusted coefficients from regression models will be pooled in a random-effects meta-analysis. A synthesis without meta-analysis will summarise mediators. To evaluate the impact of treating depression/anxiety on pain, endpoint mean differences between treatment arms will be combined in a random-effects meta-analysis. Through understanding how depression/anxiety contribute to pain in IA, our review has the potential to help optimise approaches to IA pain.

Human-black bear conflict: crop raiding by Asiatic black bear (Ursus thibetanus) in Azad Jammu and Kashmir, Pakistan

Abstract Asiatic black bear has long been in conflict with human beings crop raiding is a major cause of this conflict frequently noted in South Asia. Crops raided by black bears affected by temporal, spatial and anthropogenic attributes. Insight in this conflict and its mitigation is vital for the conservation of this threatened species. Present study aimed to evaluate crop raiding by black bears in the mountainous region of Azad Jammu and Kashmir. Field surveys were carried out to observe spatial and temporal crop raiding features between 2015-2020 and data gathered using designed questionnaires randomly tailored in villages nearby the forests. Results revealed that maize was the sole crop raided by black bears. A total of 28-acre area was raided by black bear in the fall season (Aug-November) resulting in a damage of 51 metric tons, whole raiding was carried out at night. Each respondent received crop damage on 0.09 acre with a loss of 0.17 metric ton yield. Crop quantity and area were significantly correlated to each other. District Neelum shared 49% of the total crop loss, while 47% of the maize was raided at the altitudinal range of 2100-2500 m. crop raiding was highly significantly ( χ 2 = 1174.64 ; d f = 308 ; p < 0.01) dependent upon distance to the forest. Linear regression revealed that maize quantity was determined by area, time and the total field area. Farmers faced 3.8 million PKRs loss due to crop damage by black bears. Despite the huge loss, the majority (23%) of the respondents did not respond to the query on mitigation measures indicating a poor adaptation of preventive measures. Preferred strategy to avoid crop damage was making noise (27.8%) when bears attacked their crops. A start of compensation scheme to the farmers is recommended that will have turned their negative attitude into a positive one toward the wildlife and black bear particularly. Study provides a new insight in human-bear conflict, particularly in spatial and temporal context of crop raiding in AJ&K.

The acceptability of the Fire and Rescue Service working with primary care to improve identification of mental health problems in older adults. A mixed-method qualitative study

BACKGROUND

Mental ill-health in older adults (aged 60 years and over) is often underdiagnosed and undertreated. Older adults are less likely to access mental health services owing to perceived stigma and fear of being a burden. Non-traditional providers of health care, such as the Fire and Rescue Services (FRS), provide a possible solution to facilitate early detection of problems and help-seeking among older adults, especially in the context of pressured statutory services.

AIM

To examine whether and how FRS Home Fire Safety Visits (HFSV) could be optimised to include detection and signposting for mental health problems - particularly anxiety and depression - in older adults.

DESIGN & SETTING

This mixed-method qualitative study took place in the West Midlands, UK in 2022.

METHOD

This study involved focus groups (n = 24) and interviews with FRS staff (n = 4) to develop an in-depth contextual understanding of he acceptability and feasibility of expanding HFSV to include identification of anxiety and depression.

RESULTS

FRS staff were open to expanding their HFSVs to include mental health, provided they had sufficient training and support from partner agencies in primary and social care settings to accept referrals for service users presenting with symptoms of anxiety and/or depression.

CONCLUSION

The positive reputation of FRS staff and engagement with older adults suggests that HFSV could support the detection of anxiety and depression in older adults, and appropriate signposting to other services including primary care.

Peristaltic motion of Jeffrey fluid with nonlinear mixed convection

Since previous few decays the consideration of non-Newtonian liquids motion due to its immense usages in medicine, biology, industrial procedures, chemistry of catalysts and in environment. Various studies examine the significance of bio-materials flow in physiological procedures to explore the cure of diagnosed symptoms of disease appearing during movement in a human physiological system. To illustrate the characteristics of physiological liquids various non-Newtonian models have been proposed, but yet no such single liquid model is exploited which describes all the properties of nonlinear behaving liquids. Among these several non-Newtonian models, Jeffery liquid model should be reduced to its base fluid case (i.e. viscous liquid) by choosing λ₁ = λ₂ = 0. Various physiological materials which represents both linear and nonlinear characteristics respectively blood is one of these. Jeffery fluid and peristaltic motion have some common properties such as radii, relaxation time and retardation time. Moreover heat and mass transfer is also an important phenomenon which is suitable for various physiological processes such as hemodialysis and oxygenation etc. Thus due to such motivating facts this research is conducted to investigate the peristaltic motion of electrically conducting Jeffery liquid. The peristaltic propagating channel walls are asymmetric and inclined. Joule heating and magnetic field effects are considered by applying magnetic field in transverse direction to the flow. Further conservation laws modelled the flow situation via considering quadric mix convection, thermos diffusion and diffusion-thermos, heat generation and absorption, chemical reaction with activation energy features. Moreover, creeping flow and long wavelength assumptions are used to simplify the mathematical modelling. The reduced system of equation is solved numerically through built-in technique in Mathematica software. This built-in technique is working through ND Solve command and shooting and RK-Felburg numerical schemes are behind this technique. These numerical results are used to discuss the flow quantities i.e., velocity, temperature and concentration against the sundry dimensionless quantities. Examining the results it comes to know that both thermal and concentration nonlinear mix convection have oppositely affecting the axial velocity. Both heat and mass transfer are escalating function of thermo-diffusion/diffusion-thermo aspects.

Comparison Of Hemodynamic Effect Caused By Intrathecal Low Dose Administration Of 0.5% Against 0.75% Hyperbaric Bupivacaine In Patients Undergoing Lower Limb Surgery Under Unilateral Spinal Anaesthesia

BACKGROUND

Spinal anaesthesia has its unique place in modern anaesthetic practice. In past, most of the surgeries, irrespective of the site of surgery, were performed in general anaesthesia but now in the modern anaesthetic field, spinal anaesthesia has markedly replaced general anaesthesia, specifically in obstetrics, lower limbs, and abdominal surgeries.

METHODS

A total of 100 patients fit to undergo lower limb surgery between the ages of 20 to 70 years were included in the study. 50 patients were in 0.5% hyperbaric bupivacaine (Group A) while 50 patients were in the 0.75% hyperbaric bupivacaine group (Group B). Patients with a history of allergies to local anaesthetics, ischemic heart disease and contraindications to spinal anaesthesia were excluded. At the end of the injection, the patient was immediately laid down and tilted to 30 degrees lateral on the operative side for unilateral anaesthesia. Mean arterial pressure at baseline, 15, 30, 45 and 60 minutes was recorded by trainee anaesthesia. A baseline was taken of mean arterial pressure measured 15 minutes before induction of spinal anaesthesia in a lying position.

RESULTS

The mean baseline arterial pressure of patients in group A was 88.72±1.71 mmHg and in group B was 88.94±1.95 mmHg. Mean arterial pressure MAP at 15, 30, 45 and 60 minutes in both groups was as follows; 86.22±2.55 vs 81.78±1.52 mmHg, 83.72±3.36 vs 75.84±1.34 mmHg, 80.02±3.40 vs 70.90±0.97 mmHg and 77.14±4.24 vs 66.06±1.62 mmHg respectively (p-value <0.05).

CONCLUSIONS

This study concluded that the hemodynamic parameters in terms of mean arterial pressure remained more stable by deviating less from the baseline value with the use of a low dose of 0.5% hyperbaric bupivacaine instead of 0.75% hyperbaric bupivacaine in patients undergoing lower limb surgery under unilateral spinal anaesthesia.

Evidence of novel Treponema phylotypes implicated in contagious ovine digital dermatitis and association of treponemes with major lameness causing foot pathogens

In this study 269 swabs collected from 254 ovine foot lesions and 15 apparently healthy ovine feet were screened by PCR for the presence of major lameness causing foot pathogens viz. Treponema species, D. nodosus, F. necrophorum and T. pyogenes with the presumption that ovine foot lesion positive for Treponema species alone or in association with other three pathogens were categorized as contagious ovine digital dermatitis (CODD). While samples positive for D. nodosus alone or its combination with F. necrophorum and T. pyogenes were considered as footrot (FR) and samples in which F. necrophorum or T. pyogenes was found either alone or in combination were considered as interdigital dermatitis (ID). The overall occurrence of Treponema sp. in ovine foot lesions was 48.0%, and ranged from 33 to 58%. In Treponema positive samples D. nodosus, F. necrophorum and T. pyogenes were present in 34 (27.4%), 66 (54.4%) and 84 (68.5%) in contrast to Treponema negative samples in which these were present in 15 (11.1%), 20 (14.12%) and 17 (12.6%) samples, respectively. The data signifies that Treponema sp. are significantly associated with these foot pathogens and their different combinations with Treponema sp. influence the severity of CODD lesion. The identification of Treponema phylotypes was done by sequencing the 16S rRNA gene fragment of ten representative samples. Out of ten sequences, four (Trep-2, Trep-4, Trep-7 and Trep-10) were identical to Treponema sp. phylotype 1 (PT1) that belongs to phylogroup T. refringens-like, one sequence (Trep-1) was genetically close (90% sequence homology) to Treponema brennaborense while five sequences (Trep-3, Trep-5, Trep-6, Trep-8 and Trep-9) matched with uncultured bacterium clones of treponemes forming separate monophyletic group in phylogenetic tree and could represent new digital dermatitis phylogroup presently containing five ovine specific phylotypes. This is the first report on the presence of Treponema phylotypes other than three digital dermatitis (DD) Treponema phylogroups viz. T. phagedenis-like, T. medium/T. vincentii-like, and T. pedis-like that are frequently detected in CODD lesions. Metagenomic analysis of two representative samples revealed the abundance of genus Treponema in CODD lesion while this genus was absent in swab collected from clinically healthy foot suggesting that it might play primary role in producing CODD. These findings may further aid in understanding the etiopathogenesis of CODD and could help to develop appropriate treatment and mitigation strategies to combat the disease.

Traditional healers working with primary care and mental health for early intervention in psychosis in young persons: protocol for the feasibility cluster randomised controlled trial

OBJECTIVES

In low/middle-income countries (LMICs), more than half of patients with first-episode psychosis initially seek treatment from traditional and religious healers as their first care. This contributes to an excessively long duration of untreated psychosis (DUP). There is a need for culturally appropriate interventions to involve traditional and spiritual healers to work collaboratively with primary care practitioners and psychiatrists through task-shifting for early detection, referral and treatment of first episode of psychosis.

METHODS

To prevent the consequences of long DUP in adolescents in LMICs, we aim to develop and pilot test a culturally appropriate and context-bespoke intervention. Traditional HEalers working with primary care and mental Health for early interventiOn in Psychosis in young pErsons (THE HOPE) will be developed using ethnographic and qualitative methods with traditional healers and caregivers. We will conduct a randomised controlled cluster feasibility trial with a nested qualitative study to assess study recruitment and acceptability of the intervention. Ninety-three union councils in district Peshawar, Pakistan will be randomised and allocated using a 1:1 ratio to either intervention arm (THE HOPE) or enhanced treatment as usual and stratified by urban/rural setting. Data on feasibility outcomes will be collected at baseline and follow-up. Patients, carers, clinicians and policymakers will be interviewed to ascertain their views about the intervention. The decision to proceed to the phase III trial will be based on prespecified stop-go criteria.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from Keele University Ethical Review Panel (ref: MH210177), Khyber Medical University Ethical Review Board (ref: DIR/KMU-EB/IG/001005) and National Bioethics Committee Pakistan (ref no. 4-87/NBC-840/22/621). The results of THE HOPE feasibility trial will be reported in peer-reviewed journals and academic conferences and disseminated to local stakeholders and policymakers.

TRIAL REGISTRATION NUMBER

ISRCTN75347421.

Effect Of Perineural Administration Of Dexmedetomidine With Bupivacaine Versus Bupivacaine Alone In Ultrasound Guided Supraclavicular Block For Upper Extremity Orthopaedic Operations

BACKGROUND

During procedures on the upper limbs, the brachial plexus block is usually advised. To increase the length of the block, many medicines have been utilized as adjuvants. The purpose of this study was to compare the effects of dexmedetomidine plus bupivacaine against bupivacaine alone on the onset and duration of the sensory and motor block and the duration of analgesia in the supraclavicular block during upper extremity orthopaedic surgery.

METHODS

Sixty individuals qualified for orthopaedic operations on the upper extremities, ranging in age from 20 to 60 years, participated in this prospective, randomized investigation. The modified Bromage scale and the pinprick method were used to assess the sensory and motor block. Using a visual analogue pain scale, the postoperative pain was evaluated at 0, 6, 12 and 24 hours after surgery.

RESULTS

In patients receiving only bupivacaine, the mean onset time of sensory and motor block was 32.84 minutes and 26.67 minutes respectively; while in those receiving bupivacaine along with dexmedetomidine, it was 23.38 minutes and 14.81 minutes (p<0.005). In the intervention group (bupivacaine and dexmedetomidine), the period between the first request for analgesia and the duration period of sensory and motor block were both longer (p<0.005). The intervention group experienced less postoperative discomfort for 24 hours (p<0.05).

CONCLUSIONS

Dexmedetomidine added to bupivacaine perineurally prolonged both numbness and immobility while shortening the time it took for sensory and motor blocks to begin. Moreover, dexmedetomidine considerably decreased postoperative pain when combined with bupivacaine for supraclavicular blocks.

Role of Primary Care Physicians in management of Schizophrenia in Low and Middle Income Countries (LMIC): A systematic review

Many people with Schizophrenia lack the resources and access to mental health services especially in low and middle income countries. Integration of mental health into primary care services can be a cost effective way of reducing the disability associated with Schizophrenia. Our aim was to review the studies conducted on role of Primary care physicians in management of Schizophrenia in low and middle income countries. PRISMA guidelines were followed and we registered the study protocol at PROSPERO. Four Electronic Databases (Medline, Psycinfo, CINAHL and Embase) were searched in May 2022. Relevant articles after search were 504 of which 61 full text were examined. A total of 20 studies were included in the final review comprising of observational, experimental and qualitative studies. Most studies reported on abilities of Primary care physicians including their knowledge, perceptions, skills and competencies in identifying and management of Schizophrenia and related Psychosis. Findings suggest that there is considerable amount of stigma, lack of awareness and social support about people diagnosed with Schizophrenia. Significant improvement was observed in diagnosis and management of schizophrenia by Primary care physicians who received appropriate training by experts in the field. This review suggests that appropriate training of General practitioners in diagnosing and treating schizophrenia can help in reduction of huge Treatment Gap in Schizophrenia. They can also be utilised in delivering psycho social interventions to improve overall quality of patient care.

Study protocol of DIVERGE, the first genetic epidemiological study of major depressive disorder in Pakistan

INTRODUCTION

Globally, 80% of the burdenof major depressive disorder (MDD) pertains to low- and middle-income countries. Research into genetic and environmental risk factors has the potential to uncover disease mechanisms that may contribute to better diagnosis and treatment of mental illness, yet has so far been largely limited to participants with European ancestry from high-income countries. The DIVERGE study was established to help overcome this gap and investigate genetic and environmental risk factors for MDD in Pakistan.

METHODS

DIVERGE aims to enrol 9000 cases and 4000 controls in hospitals across the country. Here, we provide the rationale for DIVERGE, describe the study protocol and characterise the sample using data from the first 500 cases. Exploratory data analysis is performed to describe demographics, socioeconomic status, environmental risk factors, family history of mental illness and psychopathology.

RESULTS AND DISCUSSION

Many participants had severe depression with 74% of patients who experienced multiple depressive episodes. It was a common practice to seek help for mental health struggles from faith healers and religious leaders. Socioeconomic variables reflected the local context with a large proportion of women not having access to any education and the majority of participants reporting no savings.

CONCLUSION

DIVERGE is a carefully designed case-control study of MDD in Pakistan that captures diverse risk factors. As the largest genetic study in Pakistan, DIVERGE helps address the severe underrepresentation of people from South Asian countries in genetic as well as psychiatric research.

Impacts of entropy generation in radiative peristaltic flow of variable viscosity nanomaterial

Current analysis highlights the aspects of different nanoparticles in peristalsis with entropy generation. Mathematical equations of considered problem are modelled via conservation laws for mass, momentum and energy. Such equations contain variable viscosity, nonlinear thermal radiation, viscous dissipation, heat generation/absorption and mixed convection aspects. Boundary conditions comprise the second order velocity and first order thermal slip effects. Entropy expression is obtained by utilization thermodynamics. Simplified and dimensionless forms of the considered conservative laws are obtained through lubrication technique. Resulting system of equations subject to the considered boundary conditions is solved numerically via built-in shooting procedure in Mathematica. Such numerical procedure is very suitable to obtain numerical results directly and fastly in the form of graphs. Further all the considered flow quantities are discussed graphically for the significant parameters of interest in detail. Both velocity and temperature are decreasing against large volume fraction parameter. Increasing temperature dependent viscosity effects decrease the entropy and enhance the Bejan number.

Patients’ and healthcare professionals’ perspectives on a community-based intervention for schizophrenia in Pakistan: A focus group study

Objective

To explore the perceptions and experiences of schizophrenia from patients, their care givers, health care providers, spiritual and traditional healers to develop a community-based intervention for improving treatment adherence for people with schizophrenia in Pakistan.

Methods

This qualitative study involved four focus group discussions (FGD) with a total of 26 participants: patients and carers (n = 5), primary care staff (n = 7), medical technicians (n = 8) and traditional and spiritual healers (n = 6). The participants were selected using purposive sampling method. FGDs were audio-recorded and transcribed. A thematic analysis was applied to the data set.

Results

The themes identified were (i) Schizophrenia is not merely a biomedical problem: participants believed that poverty and an inferiority complex resulting from social disparity caused schizophrenia and contributed to non-adherence to medications; (ii) Spiritual healing goes hand in hand with the medical treatment: participants regarded spiritual and traditional treatment methods as an inherent part of schizophrenia patients’ well-being and rehabilitation; (iii) Services for mental illness: mental health is not covered under primary health in a basic health unit: participants believed that the lack of services, training and necessary medication in primary care are major issues for treating schizophrenia in community; (iv) Barriers to community-based interventions: primary care staff believed that multiple pressures on staff, lack of incentives, non-availability of medication and lack of formal referral pathways resulted in disintegration of dealing with schizophrenia patients in primary care facilities.

Conclusion

The study has identified a number of barriers and facilitators to developing and delivering a psychosocial intervention to support people living with schizophrenia in Pakistan. In particular, the importance of involving spiritual and traditional healers was highlighted by our diverse group of stakeholders.

Implementing 3HP vs. IPT as TB preventive treatment in Pakistan

BACKGROUND: We assessed treatment uptake and completion for 6 months of isoniazid (6H) and 3 months of isoniazid plus rifapentine weekly (3HP) in a programmatic setting in Pakistan.METHODS: All household contacts were clinically evaluated to rule out TB disease. 6H was used for TB preventive treatment (TPT) from October 2016 to April 2017; from May to September 2017, 3HP was used for contacts aged ≥2 years. We compared clinical evaluation, TPT uptake and completion rates between contacts aged ≥2 years in the 6H period and in the 3HP period.RESULTS: We identified 3,442 contacts for the 6H regimen. After clinical evaluation, 744/1,036 (72%) started treatment, while 46% completed treatment. In contrast, 3,722 contacts were identified for 3HP. After clinical evaluation, 990/1,366 (72%) started treatment, while 67% completed treatment. Uptake of TPT did not differ significantly between the 6H and 3HP groups (OR 1.03, 95%CI 0.86-1.24). However, people who initiated 3HP had 2.3 times greater odds (95% CI 1.9-2.8) of completing treatment than those who initiated 6H after adjusting for age and sex.CONCLUSION: In programmatic settings in a high-burden country, household contacts of all ages were more likely to complete TPT with shorter weekly regimens, although treatment uptake rate for the two regimens was similar.

HISTOPATHOLOGICAL PROFILE OF GASTROINTESTINAL NEUROENDOCRINE TUMORS IN A TERTIARY CARE HOSPITAL

Background. Recently there has been a lot of discussion about the terminology and classification of neuroendocrine tumours of the gastrointestinal tract. The WHO has recommended a change of terminology and classification of these tumours. In 2019 a significant update was done in the WHO classification of neuroendocrine tumours of GIT in which neuroendocrine carcinomas (NECs) are all considered high-grade tumours. Previously, grade 1 and 2 tumours were regarded as neuroendocrine tumours (NETs) and grade 3 neoplasms as NECs. The new classification avoids confusion between these two clinically and molecularly distinct notions. Objective. The aim of the research was to study GI neuroendocrine neoplasms and classify them as per location and Histopathological classification of GI neuroendocrine neoplasms according to the recent WHO classification. To use IHC whenever and wherever required for categorization of GI NET’s. Methods. Over a period of 15 years, a total of 85 cases of neuroendocrine neoplasms of GIT were studied. The histopathological material of patients was reviewed and histopathological diagnosis confirmed. Paraffin embedded tissue blocks were used to study and review the material. Sections from tissue blocks were stained. Five-micron sections were cut and stained. The sections were stained using DAKO LSAB-2® system HRP glass slides coated with 0.5% poly-lysine. Results. Out of 85 cases 40 involved male and 45 female patients. The mean age was 46.4 years; age range 9-85 years. In our study, appendix 24 (28.23%) and stomach 11 (12.95%) were the commonest sites of primary involvement followed by colon (10), ileum (10), duodenum (5), GE junction (5), jejunum (3), oesophagus (2), rectum (2) and gall bladder (1). Metastasis to the liver were observed in 12 patients with known and unknown primary diagnosis. Based on the latest WHO classification 5 patients were classified under NECs and the rest under NETs. Conclusions. Neuroendocrine tumours (NETs) are uncommon malignancies of GIT. Appendix followed by stomach was the most common anatomical site. NET Grade 1 was the most common histological type. IHC markers NSE, Synaptophysin and Chromogranin can be used in diagnosis of NETs.

Study protocol for the development and internal validation of Schizophrenia Prediction of Resistance to Treatment (SPIRIT): a clinical tool for predicting risk of treatment resistance to antipsychotics in first-episode schizophrenia

INTRODUCTION

Treatment-resistant schizophrenia (TRS) is associated with significant impairment of functioning and high treatment costs. Identification of patients at high risk of TRS at the time of their initial diagnosis may significantly improve clinical outcomes and minimise social and functional disability. We aim to develop a prognostic model for predicting the risk of developing TRS in patients with first-episode schizophrenia and to examine its potential utility and acceptability as a clinical decision tool.

METHODS AND ANALYSIS

We will use two well-characterised longitudinal UK-based first-episode psychosis cohorts: Aetiology and Ethnicity in Schizophrenia and Other Psychoses and Genetics and Psychosis for which data have been collected on sociodemographic and clinical characteristics. We will identify candidate predictors for the model based on current literature and stakeholder consultation. Model development will use all data, with the number of candidate predictors restricted according to available sample size and event rate. A model for predicting risk of TRS will be developed based on penalised regression, with missing data handled using multiple imputation. Internal validation will be undertaken via bootstrapping, obtaining optimism-adjusted estimates of the model's performance. The clinical utility of the model in terms of clinically relevant risk thresholds will be evaluated using net benefit and decision curves (comparative to competing strategies). Consultation with patients and clinical stakeholders will determine potential thresholds of risk for treatment decision-making. The acceptability of embedding the model as a clinical tool will be explored using qualitative focus groups with up to 20 clinicians in total from early intervention services. Clinicians will be recruited from services in Stafford and London with the focus groups being held via an online platform.

ETHICS AND DISSEMINATION

The development of the prognostic model will be based on anonymised data from existing cohorts, for which ethical approval is in place. Ethical approval has been obtained from Keele University for the qualitative focus groups within early intervention in psychosis services (ref: MH-210174). Suitable processes are in place to obtain informed consent for National Health Service staff taking part in interviews or focus groups. A study information sheet with cover letter and consent form have been prepared and approved by the local Research Ethics Committee. Findings will be shared through peer-reviewed publications, conference presentations and social media. A lay summary will be published on collaborator websites.

Impact of COVID-19 on mental health research: is this the breaking point?

There are many structural problems facing the UK at present, from a weakened National Health Service to deeply ingrained inequality. These challenges extend through society to clinical practice and have an impact on current mental health research, which was in a perilous state even before the coronavirus pandemic hit. In this editorial, a group of psychiatric researchers who currently sit on the Academic Faculty of the Royal College of Psychiatrists and represent the breadth of research in mental health from across the UK discuss the challenges faced in academic mental health research. They reflect on the need for additional investment in the specialty and ask whether this is a turning point for the future of mental health research.

An International Adult Guideline for Making Clozapine Titration Safer by Using Six Ancestry-Based Personalized Dosing Titrations, CRP, and Clozapine Levels

This international guideline proposes improving clozapine package inserts worldwide by using ancestry-based dosing and titration. Adverse drug reaction (ADR) databases suggest that clozapine is the third most toxic drug in the United States (US), and it produces four times higher worldwide pneumonia mortality than that by agranulocytosis or myocarditis. For trough steady-state clozapine serum concentrations, the therapeutic reference range is narrow, from 350 to 600 ng/mL with the potential for toxicity and ADRs as concentrations increase. Clozapine is mainly metabolized by CYP1A2 (female non-smokers, the lowest dose; male smokers, the highest dose). Poor metabolizer status through phenotypic conversion is associated with co-prescription of inhibitors (including oral contraceptives and valproate), obesity, or inflammation with C-reactive protein (CRP) elevations. The Asian population (Pakistan to Japan) or the Americas' original inhabitants have lower CYP1A2 activity and require lower clozapine doses to reach concentrations of 350 ng/mL. In the US, daily doses of 300-600 mg/day are recommended. Slow personalized titration may prevent early ADRs (including syncope, myocarditis, and pneumonia). This guideline defines six personalized titration schedules for inpatients: 1) ancestry from Asia or the original people from the Americas with lower metabolism (obesity or valproate) needing minimum therapeutic dosages of 75-150 mg/day, 2) ancestry from Asia or the original people from the Americas with average metabolism needing 175-300 mg/day, 3) European/Western Asian ancestry with lower metabolism (obesity or valproate) needing 100-200 mg/day, 4) European/Western Asian ancestry with average metabolism needing 250-400 mg/day, 5) in the US with ancestries other than from Asia or the original people from the Americas with lower clozapine metabolism (obesity or valproate) needing 150-300 mg/day, and 6) in the US with ancestries other than from Asia or the original people from the Americas with average clozapine metabolism needing 300-600 mg/day. Baseline and weekly CRP monitoring for at least four weeks is required to identify any inflammation, including inflammation secondary to clozapine rapid titration.

Suicide, self-harm and suicidal ideation during COVID-19: A systematic review

We aimed to do a systematic review and meta-analysis of studies describing suicidal ideation, suicide attempts and suicide and associated risk factors during COVID-19 pandemic. We searched following electronic databases using relevant search terms: Medline, Embase, PsycInfo and CINAHL and systematically reviewed the evidence following PRISMA guidelines. The meta-analysis of prevalence of suicidal ideation was done using random effect model. The search returned 972 records, we examined 106 in full text and included 38 studies describing 120,076 participants. Nineteen studies described suicide or attempted self-harm, mostly in case reports. Out of 19 studies describing suicidal ideations, 12 provided appropriate data for meta-analysis. The pooled prevalence of suicidal ideation in these studies was 12.1% (CI 9.3-15.2). Main risk factors for suicidal ideations were: low social support, high physical and mental exhaustion and poorer self-reported physical health in frontline medical workers, sleep disturbances, quarantine and exhaustion, loneliness, and mental health difficulties. We provide first meta-analytic estimate of suicidal ideation based on large sample from different countries and populations. The rate of suicidal ideations during COVID pandemic is higher than that reported in studies on general population prior to pandemic and may result in higher suicide rates in future.

1588 A Rare Case of Arteriovenous Malformation Following TMJ Arthroscopy: A Case Report and Review of The Literature

Patients undergo temporo-mandibular joint (TMJ) arthroscopy as part of the diagnosis and management of chronic pain in the TMJ. Known complications of the procedure include bleeding within the joint spaces, lacerations of the external auditory canal and local nerve damage. We present the case of a 25-year-old woman who developed an arteriovenous fistula in the right pre-auricular region secondary to TMJ arthroscopic examination. She had presented with ongoing TMJ pain necessitating further investigation with arthroscopy. Following her procedure her TMJ symptoms improved, however she developed right pre-auricular swelling of gradual onset, right-sided headaches, and pulsatile tinnitus. Due to her pregnancy of around 16 weeks this was originally linked to expansion in plasma volume and hyperdynamic circulation; however, this was later diagnosed as an extremely rare, post-operative complication of TMJ arthroscopy. Her examination revealed a pre-auricular pulsatile swelling measuring approximately 1.5 cm. Blood tests including ESR and CRP were within normal limits excluding temporal arteritis. An ultrasound scan revealed an AV fistula of the right superficial temporal artery; Her MRI confirmed single vessel supply. Following discussion in the vascular anomalies MDT, she underwent embolisation with PHIL and surgical excision via a preauricular approach. The procedure was successful, and the patient made a full recovery. The literature reports very few cases of iatrogenic arterio-venous fistulas resulting from TMJ arthroscopic surgery. Our case emphasises the importance of a multidisciplinary approach in combining embolisation with surgical excision resulting in the successful management of a rare post-operative complication.

Automated chest radiography and mass systematic screening for tuberculosis

BACKGROUND: Systematic screening for TB using automated chest radiography (ACR) with computer-aided detection software (CAD4TB) has been implemented at scale in Karachi, Pakistan. Despite evidence supporting the use of ACR as a pre-screen prior to Xpert^® MTB/RIF diagnostic testing in presumptive TB patients, there has been no data published on its use in mass screening in real-world settings.METHOD: Screening was undertaken using mobile digital X-ray vehicles at hospital facilities and community camps. Chest X-rays were offered to individuals aged ≥15 years, regardless of symptoms. Those with a CAD4TB score of ≥70 were offered Xpert testing. The association between Xpert positivity and CAD4TB scores was examined using data collected between 1 January and 30 June 2018 using a custom-built data collection tool.RESULTS: Of the 127 062 individuals screened, 97.2% had a valid CAD4TB score; 11 184 (9.1%) individuals had a CAD4TB score ≥70. Prevalence of Xpert positivity rose from 0.7% in the <50 category to 23.5% in the >90 category. The strong linear association between CAD4TB score and Xpert positivity was found in both community and hospital settings.CONCLUSION: The strong association between CAD4TB scores and Xpert positivity provide evidence that an ACR-based pre-screening performs well when implemented at scale in a high-burden setting.

Pharmacological or non-pharmacological interventions for treatment of common mental disorders associated with Tuberculosis: A systematic review

We aimed to review the literature on interventions for treating Common Mental Disorders (CMD) in people with Tuberculosis (TB). We followed PRISMA guidelines and the protocol was registered at PROSPERO. The electronic databases (PsycInfo, CINAHL, Medline, Google Scholar, Embase) were searched from 1982 to 2020. 349 relevant records were screened, with 26 examined at full text. 13 studies were included totalling 4326 participants. A meta-analysis was not possible due to nature of data, thus descriptive synthesis was conducted. Eleven studies evaluated psychosocial interventions, which significantly improved adherence or cure rates from TB, anxiety and depression. The elements of effective psychosocial interventions included; combating stigma, socioeconomic disadvantage, managing associated guilt and fear of contagion, and explanatory models of illness in local population. Two articles evaluated pharmacological interventions (antidepressants and Vitamin D). This is the first systematic review of interventions to treat CMD in TB. The studies were mostly low quality and mental health outcomes were not adequately described. However, this review suggests that it is feasible to develop and test interventions for improving mental health outcomes and enhancing treatment adherence in TB.

Contribution of advanced fluorescence nano microscopy towards revealing mitotic chromosome structure

The organization of chromatin into higher-order structures and its condensation process represent one of the key challenges in structural biology. This is important for elucidating several disease states. To address this long-standing problem, development of advanced imaging methods has played an essential role in providing understanding into mitotic chromosome structure and compaction. Amongst these are two fast evolving fluorescence imaging technologies, specifically fluorescence lifetime imaging (FLIM) and super-resolution microscopy (SRM). FLIM in particular has been lacking in the application of chromosome research while SRM has been successfully applied although not widely. Both these techniques are capable of providing fluorescence imaging with nanometer information. SRM or "nanoscopy" is capable of generating images of DNA with less than 50 nm resolution while FLIM when coupled with energy transfer may provide less than 20 nm information. Here, we discuss the advantages and limitations of both methods followed by their contribution to mitotic chromosome studies. Furthermore, we highlight the future prospects of how advancements in new technologies can contribute in the field of chromosome science.

Switching antipsychotics to support the physical health of people with severe mental illness: a qualitative study of healthcare professionals' perspectives

OBJECTIVES

The side effects of antipsychotic medications (APs) can increase the risk of developing physical health conditions. Some APs pose a higher risk than others. Evidence suggests switching to lower risk APs can support physical health outcomes. We sought to explore the views of healthcare professionals about switching antipsychotics to support physical health in people with severe mental illness (SMI).

DESIGN

A qualitative study with semi-structured interviews conducted with general practitioners (GPs), psychiatrists and mental health nurses. The main focus was to explore participants' views on the physical health of people with SMI, the impact of APs and decision-making about switching medication to support physical health. Data were analysed thematically using principles of constant comparison.

SETTINGS

Participants recruited through primary care and one mental health trust in the West Midlands.

PARTICIPANTS

Interviews were conducted with 9 GPs, 10 psychiatrists and 4 mental health nurses.

RESULTS

Awareness and knowledge of AP side-effects and risk profiles varied considerably between primary and secondary care clinicians. GPs reported limited awareness, while psychiatrists and nurses demonstrated a comprehensive understanding of AP risk profiles and side-effects. Mental health and control of symptoms were prioritised. Switching to promote physical health was considered as a reactive intervention, once side-effects or complications developed. There were a range of views over where responsibility lay for monitoring physical health and consideration of switching. Collaboration between primary and secondary care was identified as a way to address this.

CONCLUSIONS

This study presents multidisciplinary perspectives on awareness, decision making, perceived responsibility and barriers to switching APs to support physical health. Collaborative approaches that involve liaison between primary and secondary care, but tailored to the individual patient, may support switching, and present an opportunity to intervene to address the physical health inequalities experienced by individuals with SMI.

Scarlett Letter: A study based on experience of stigma by COVID-19 patients in quarantine

Background and Objectives

Stigma around COVID-19 is a major barrier in global efforts to control the COVID 19 pandemic. Limited data is available regarding stigma faced by COVID-19 patients in low- and middle-income countries (LMIC). The aim of the current study was to explore the stigma experienced by hospitalized patients with COVID-19 illness in Lahore, Pakistan.

Methods

Following Institutional Review Board approval and informed consent, patients were assessed using modified HIV short form stigma scale and open-ended questions. Questions focused on experiences, feelings, and opinions as to how patients feel and how they were treated prior to and during the hospitalization. Data analysis for quantitative data was performed using SPSS-20, while qualitative responses were interpreted by content analysis method.

Results

One hundred and fourteen patients were interviewed (Mean age 38.8 years + 15.3) with 53.5% being males. Widespread experience of stigma was reported by patients particularly for concerns about public attitudes (7.43 + 1.43) & disclosure (6.89 + 1.45). Main themes which emerged from the qualitative responses were social stigma and rejection, humiliating behaviour of others, breach of confidentiality, loss of trust/ respect, and impact of COVID-19 diagnosis on their business.

Conclusions

Existence of significant stigma among COVID-19 patients isolated in a tertiary care hospital in a LMIC highlights the need for culturally sensitive strategies to address it.

Acute myocardial infarction in several mental illness: a nationwide analysis of prevalence, management strategies and outcomes

Background

Severe mental illness (SMI) is associated with an increased risk of cardiovascular disease and mortality. However, it is unclear whether SMI patients are just as likely to receive guideline-recommended therapy for AMI as those without mental illness.

Purpose

To examine national-level estimates of the prevalence, management strategies and in-hospital clinical outcomes of SMI patients presenting with AMI.

Methods

All AMI hospitalisations from the United States National Inpatient Sample were included, stratified by mental health status in to 5 groups: no-SMI, Schizophrenia, “Other non-organic psychoses” (ONOP), Bipolar Disorder and Major Depression. Multivariable logistic regression modelling was performed to examine the association between SMI subtypes and receipt of invasive management and subsequent in-hospital clinical outcomes, expressed as adjusted odds ratios (aOR) and 95% confidence intervals (CI).

Results

Out of 6,968,777 AMI hospitalisations between 2004 and 2014, a total of 439,544 (6.5%) had an SMI diagnosis. The prevalence of SMI amongst the ACS population doubled over the study period (from 4.5% in 2004 to 9.5% in 2014), primarily due to an increase in Major Depression and Bipolar Disorder diagnoses. All SMI subtypes were less likely to receive coronary angiography and PCI, with the Schizophrenia group being at least odds of either procedure (aOR 0.46 95% CI 0.45, 0.48 and aOR 0.57 95% CI 0.55, 0.59, respectively). Although patients with Schizophrenia and ONOP experienced higher crude rates of in-hospital mortality and stroke compared to those without SMI, only Schizophrenia patients were associated with increased odds of mortality (aOR 1.10 95% CI 1.04, 1.16), while ONOP were the only group at increased odds of stroke (aOR 1.53 95% CI 1.42,1.65) following multivariate adjustment. Patients with ONOP were the only group associated with increased odds of in-hospital bleeding compared to those without SMI (aOR 1.11 95% CI 1.04,1.17).

Conclusion

Patients with SMI are less likely to receive invasive management for AMI, with women and schizophrenia diagnosis being the strongest predictors of conservative management. Schizophrenia and “other non-organic psychoses” are the only SMI subtypes associated with adverse clinical outcomes after AMI. A multidisciplinary approach between psychiatrists and cardiologists could improve outcomes of this high-risk population.

Odds of management and clinical outcomes

Funding Acknowledgement

Type of funding source: None

Cost-effectiveness of WHO Problem Management Plus for adults with mood and anxiety disorders in a post-conflict area of Pakistan: randomised controlled trial

BACKGROUND

With the development of evidence-based interventions for treatment of priority mental health conditions in humanitarian settings, it is important to establish the cost-effectiveness of such interventions to enable their scale-up.

AIMS

To evaluate the cost-effectiveness of the Problem Management Plus (PM+) intervention compared with enhanced usual care (EUC) for common mental disorders in primary healthcare in Peshawar, Pakistan. Trial registration ACTRN12614001235695 (anzctr.org.au).

METHOD

We randomly allocated 346 participants to either PM+ (n = 172) or EUC (n = 174). Effectiveness was measured using the Hospital Anxiety and Depression Scale (HADS) at 3 months post-intervention. Cost-effectiveness analysis was performed as incremental costs (measured in Pakistani rupees, PKR) per unit change in anxiety, depression and functioning scores.

RESULTS

The total cost of delivering PM+ per participant was estimated at PKR 16 967 (US$163.14) using an international trainer and supervisor, and PKR 3645 (US$35.04) employing a local trainer. The mean cost per unit score improvement in anxiety and depression symptoms on the HADS was PKR 2957 (95% CI 2262-4029) (US$28) with an international trainer/supervisor and PKR 588 (95% CI 434-820) (US$6) with a local trainer/supervisor. The mean incremental cost-effectiveness ratio (ICER) to successfully treat a case of depression (PHQ-9 ≥ 10) using an international supervisor was PKR 53 770 (95% CI 39 394-77 399) (US$517), compared with PKR 10 705 (95% CI 7731-15 627) (US$102.93) using a local supervisor.

CONCLUSIONS

The PM+ intervention was more effective but also more costly than EUC in reducing symptoms of anxiety, depression and improving functioning in adults impaired by psychological distress in a post-conflict setting of Pakistan.

Genotyping and antibiotic resistance patterns of Campylobacter fetus subsp.venerealis from cattle farms in India

Bovine genital campylobacteriosis caused by Campylobacter fetus subsp. venerealis (Cfv) is of considerable economic importance to the cattle industry worldwide. Cfv causes syndrome of temporary infertility in female cattle, early embryonic mortality, aberrant oestrus cycles, delayed conception, abortions and poor calving rates. In the present study, a total of 200 samples obtained from vaginal swabs, cervicovaginal mucous (CVM), preputial washes and semen straws were investigated that were obtained from organized cattle farm of MLRI, Manasbal and unorganized sectors. Out of a total of 200 samples, 49 (47·57%) vaginal swabs, 1 (3·33%) preputial wash and 8 (25%) carried out CVM samples were positive for Cfv, whereas none of the semen straws were positive for Cfv. A total of eleven isolates of Cfv were recovered. PFGE (Pulse field gel electrophoresis) analysis revealed four different pulsotypes (I-IV) circulating in the screened farms. A common pulsotype circulating among farms could not be established. Insertion element (ISCfe1), a 233 bp amplicon of Cfv, was sequenced and the sequence was deposited in GenBank (accession no: MK475662).

Variable characteristics of viscosity and thermal conductivity in peristalsis of magneto-Carreau nanoliquid with heat transfer irreversibilities

BACKGROUND

Peristaltic is a basic way of fluid transportation in physiology, engineering and nuclear industry. Importance of peristalsis is due to its contraction and compulsion property of symmetric and asymmetric type channel walls. Another beauty of this mechanism is that the channel walls propagates and push the material along the tube/conduit channel walls. This mechanism shows its presence in physiology while food particles are transferred through esophagus and stomach, urine through intestines, spermatoza transportation in reproductive tract. In industry it is found in roller and finger pumps, drug delivery and various nuclear materials e.g. toxic, corrosive, noxious etc. Magnetic field in peristalsis is found helpful in treatment of various treatments using magnets. Actually earth and human body as a whole comprises of magnetic and electric fields. The medical specialists found that unbalances of electromagnetic field in human body is the reason for emotional and physical disturbance. In addition it has significant and potential utilizations in modification of medical, industrial and chemical, procedures for example MRI, evaporation, convection, thermoregulation, MHD throttles, and in various types of tumor treatments. Entropy production work out irreversibility in complex systems which are frequently encountered in industrial mechanisms. In view of that, this methodology is effectually implemented in distinct technological applications covering porous media, propulsion ducts, electronic cooling, turbo-machinery and combustion.

METHOD

Modelled flow mechanism is nonlinear and coupled due to considered assumptions (i.e. nanofluid, nonlinear porous channel, mixed convection, variable viscosity and thermal conductivity, activation energy and chemical reaction). Such nonlinear and coupled system is difficult to tackle analytically. Thus to obtain the solution we employed RK algorithm for numerical simulations.

RESULTS

Stronger magnetic parameter shows resistive characteristics to the flow field. Nonlinear Darcy medium assists the fluid motion at channel center and resits at walls vicinity. Variable characteristics of thermal conductivity moderate the soak or disperse up heat ability which corresponds to temperature reduction. Thermal slip quantity increase the temperature whereas concentration slip deduct the concentration of Carreau nanomaterial. Entropy and Bejan number shows maximum response for higher dissipation estimations. Brownian and thermopherotic motions aspects has reverse impact on nanomaterial concentration.

CONCLUSION

Entropy and Bejan number deduces for higher variable thermal conductivity values. Carreau material variable enhance the entropy of the system as a whole.

Corrigendum to "Transport of hybrid type nanomaterials in peristaltic activity of viscous fluid considering nonlinear radiation, entropy optimization and slip effects" [Computer methods and programs in biomedicine 184 (2020) 105,086]

In this published paper, a mathematical modeling has been conducted for the peristaltic transport in flow of hybrid nanofluid between rotating channel in the presence of nonlinear thermal radiation, slip effects and entropy generation. This corrigendum correct the flow geometry, figures captions and plots "Transport of hybrid type nanomaterials in peristaltic activity of viscous fluid considering nonlinear radiation, entropy optimization and slip effects" [Computer Methods and Programs in Biomedicine 184 (2020) 105,086] where these mistake are occurred during production process and therefore, some captions are shuffled. The difference in the captions and plots however does not affect the authenticity and mathematical validity of the problem in purpose of this published research article is to investigate the peristaltic transport in flow of hybrid nanofluid between rotating channel subject to nonlinear thermal radiation, slip effects and entropy generation. However, the flow geometry and the captions and plots should be arranged.

Supervised treatment in outpatients for schizophrenia plus (STOPS+): protocol for a cluster randomised trial of a community-based intervention to improve treatment adherence and reduce the treatment gap for schizophrenia in Pakistan

INTRODUCTION

There is a significant treatment gap, with only a few community-based services for people with schizophrenia in low-income and middle-income countries. Poor treatment adherence in schizophrenia is associated with poorer health outcomes, suicide attempts and death. We previously reported the effectiveness of supervised treatment in outpatients for schizophrenia (STOPS) for improving treatment adherence in patients with schizophrenia. However, STOPS was evaluated in a tertiary care setting with no primary care involvement, limiting its generalisability to the wider at-risk population. We aim to evaluate the effectiveness of STOPS+ in scaling up the primary care treatment of schizophrenia to a real-world setting.

METHODS AND ANALYSIS

The effectiveness of the STOPS+ intervention in improving the level of functioning and medication adherence in patients with schizophrenia in Pakistan will be evaluated using a cluster randomised controlled trial design. We aim to recruit 526 participants from 24 primary healthcare centres randomly allocated in 1:1 ratio to STOPS+ intervention and enhanced treatment as usual arms. Participants will be followed-up for 12 months postrecruitment. The sample size is estimated for two outcomes (1) the primary clinical outcome is level of functioning, measured using the Global Assessment of Functioning scale and (2) the primary process outcome is adherence to treatment regimen measured using a validated measure. An intention-to-treat approach will be used for the primary analysis.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from Keele University Ethical Review Panel (ref: MH-190017) and Khyber Medical University Ethical Review Board (ref: DIR-KMU-EB/ST/000648). The results of the STOPS+ trial will be reported in peer-reviewed journals and academic conferences and disseminated to local stakeholders and policymakers.

TRIAL REGISTRATION NUMBER

ISRCTN93243890.

Outcome of slip features on the peristaltic flow of a Rabinowitsch nanofluid in an asymmetric flexible channel

Purpose

Naturally, all the materials are not viscous (i.e. milk, mayonnaise, blood, vaccines, syrups, cosmetics, oil reservoirs, paints, etc.). Here present analysis focuses on the usage of non-Newtonian fluid rheological properties enhancing, damping tools, protection apparatus individuals and in various distinct mechanical procedures. Industrial applications of non-Newtonian liquids include minimum friction, reduction in oil-pipeline friction, scale-up, flow tracers and in several others. The peristaltic mechanism is used as a non-Newtonian material carrier here. This mechanism occurs because of continuous symmetrical and asymmetrical propulsion of smooth channel walls. Peristalsis is a very significant mechanism for carrying drugs and other materials during sensitive diseases treatments.

Design/methodology/approach

Keeping in mind the considered problem assumptions (Rabinowitsch fluid model, thermal Grashof number, Prandtl number, density Grashof number, wall properties, etc.), it is found that the modeled equations are coupled and nonlinear. Thus here, analytical results are quite challenging to acquire and very limited to extremely venerated circumstances unsettled to their nonlinearity. Hence various developments found in computing proficiencies, numerical procedures that provides accurate, stable and satisfying solutions for non-Newtonian material flows exclusively in complex dimensions play a significant role. Here BVP4C numerical technique is developed to evaluate the nonlinear coupled system of equations with appropriate boundary constraints.

Findings

Due to convectively heated surface fluid between the walls having a small temperature. Sherwood and Nusselt numbers both deduce for fixed radiation values and different Rabinowitsch fluid quantity. Skin friction is maximum in the case of Newtonian, while minimum in case of dilatant model and pseudoplastic models. The influence of numerous parameters associated with flow problems such as thermal Grashof number, density Grashof number, Hartman number, Brownian motion, thermophoresis motion factor and slip parameters are also explored in detail and plotted for concentration profile, temperature distribution and velocity. From this analysis, it is concluded that velocity escalates for larger

Originality/value

The work reported in this manuscript has not been investigated so far by any researcher.

Hospital preparedness for disaster and mass casualty management in Pakistan: A cross-sectional evaluation study

BACKGROUND

World Health Organization has advocated preemptive readiness of health systems to manage disas-trous events. Pakistan is known to be highly susceptible to disasters on the one hand and significantly lacking in coping ability on the other. Preparedness of health facilities in such locales is especially important, despite which there is little published evidence regarding hospitals' response capacity in Pakistan.

METHODS

From 12 most disaster prone districts of the country, a purposive sample of 20 hospitals was assessed us-ing 51 indicators, scored as fully (2), partially (1), or not prepared (0). Two domains, disaster preparedness and mass casualty management, and five subdomains, networking, planning, staff-readiness, materials, and safety, were evalu-ated. Proportions of maximum possible scores achieved by an entity were categorized as acceptable (≥66 percent), par-tial (35-65 percent), or inadequate (<35 percent).

RESULTS

Out of the 20 hospitals, 14 (70 percent) were secondary and 3 tertiary level facilities (30 percent). Overall, hospitals were partially prepared with a score of 54.0 percent, 95 percent confidence interval [52.3 percent, 54.7 percent]. Disaster preparedness, 55.2 percent [54.0, 57.0], was significantly better prepared than mass casualty management, 49.2 percent [46.8, 51.6], p < 0.001. Overall, facility safety was the least prepared among the subdomains, 38.3 per-cent [31.8, 44.8], while materials were the best, 75.9 percent [72.6, 79.3]. The least prepared subdomains were staff-readiness in Punjab, 52.1 percent [47.5, 56.8], and facility safety in KP, 29.2 percent [22.1, 36.4].

CONCLUSIONS

Hospitals' preparedness for disaster and mass casualty management is deficient in these most vulner-able districts of Pakistan. Improvement initiatives commensurate with locale vulnerabilities should be instituted.

Pharmacological interventions for prevention of depression in high risk conditions: Systematic review and meta-analysis

BACKGROUND

Background Depressive disorders account for almost half of all Disability Adjusted Life Years caused by psychiatric disorders but efficacy of pharmacological interventions to prevent depressive disorders is not known. We aimed to assess efficacy of pharmacological treatments in prevention of depression.

METHODS

We searched PubMed, Psych Info, EMBASE, and CINHAL from 1980 to January 2020 and bibliographies of relevant systematic reviews. We selected randomised controlled trials (RCTs) that used a pharmacological intervention to prevent the onset of the new depressive episode in adult population. Study selection, data extraction and reporting was done following PRISMA guidelines. Data were pooled using random-effects meta-analysis.

RESULTS

28 trials (2745 participants) were included in meta-analysis. Antidepressants (22 studies), Selenium, Hormone Replacement Therapy Omega-3 fatty acids and Melatonin were used to prevent depression, mostly in physical conditions associated with high risk of depression. All pharmacological interventions [pooled Odds Ratios (OR) 0.37 CI (0.25-0.54)], and antidepressants (OR 0.29, 95% CI: 0.18, 0.46) were significantly more effective than placebo in preventing depression. Antidepressants were significantly better than placebo in trials that had low risk of bias (n = 16; OR 0.43 [0.30, 0.60]), in preventing post stroke depression (OR = 0.16, 95% CI: 0.05, 0.55) and depression associated with Hepatitis C (OR = 0.56, 95% CI: 0.31, 1.02). Limitations include small number of studies focussed only on high risk conditions and short follow up in most studies.

CONCLUSIONS

Prevention of depression may be possible in patients who have high-risk conditions such as stroke but the strategy requires complete risk and benefits analysis before it can be considered for clinical practice.

Entropy generation minimization (EGM) in magneto peristalsis with variable properties

OBJECTIVE AND BACKGROUND

This article featuring the peristaltic transport of viscous material with variable properties (i.e. temperature dependent viscosity and thermal conductivity) through curved configuration. Fluid saturating through porous channel walls of uniform space. Entropy generation consideration here is to analyze irreversibility aspects. Channel boundaries retain the velocity and thermal slip conditions.

METHOD

Wave frame of reference is attained with the utilization of long wavelength and small Reynolds number approach. Solution of the simplified coupled system of dimensionless constraints is obtained numerically. Detailed analysis of important quantities of interest has been presented in discussion portion.

RESULTS

Entropy generation variation near center is very small whereas in the vicinity of the channel wall is larger. Bejan number has reverse variation as observed for entropy generation.

CONCLUSION

Variable characteristics of viscosity has opposite impact on velocity and temperature is observed. It is also noticed small irreversibility effects are obtained for higher varying viscosity and thermal conductivity near the vicinity of the channel walls.

Pharmacoepidemiology research: delivering evidence about drug safety and effectiveness in mental health

Research that provides an evidence base for the pharmacotherapy of people with mental disorders is needed. The abundance of digital data has facilitated pharmacoepidemiology and, in particular, observational research on the effectiveness of real-world medication. Advantages of pharmacoepidemiological research are the availability of large patient samples, and coverage of under-researched subpopulations in their naturalistic conditions. Such research is also cheaper and quicker to do than randomised controlled trials, meaning that issues regarding generic medication, stopping medication (deprescribing), and long-term outcomes are more likely to be addressed. Pharmacoepidemiological methods can also be extended to pharmacovigilance and to aid the development of new purposes for existing drugs. Drawbacks of observational pharmacoepidemiological studies come from the non-randomised nature of treatment selection, leading to confounding by indication. Potential methods for managing this drawback include active comparison groups, within-individual designs, and propensity scoring. Many of the more rigorous pharmacoepidemiology studies have been strengthened through multiple analytical approaches triangulated to improve confidence in inferred causal relationships. With developments in data resources and analytical techniques, it is encouraging that guidelines are beginning to include evidence from robust observational pharmacoepidemiological studies alongside randomised controlled trials. Collaboration between guideline writers and researchers involved in pharmacoepidemiology could help researchers to answer the questions that are important to policy makers and ensure that results are integrated into the evidence base. Further development of statistical and data science techniques, alongside public engagement and capacity building (data resources and researcher base), will be necessary to take full advantage of future opportunities.

Using a person-generated mental health outcome measure in large clinical trials in Kenya and Pakistan: Self-perceived problem responses in diverse communities

Health care should be informed by the physical, socioeconomic, mental, and emotional well-being of the person, and account for social circumstances and culture. Patient-generated outcome measures can contribute positively to mental health research in culturally diverse populations. In this study, we analysed qualitative responses to the Psychological Outcome Profiles (PSYCHLOPS) Questionnaire-a patient-generated outcome measure based on open-ended questions, and compared the qualitative responses gathered to conventional, nomothetic measures used alongside the PSYCHLOPS in two studies. Data were collected as part of outcome research on a psychological intervention in Pakistan (N = 346) and Kenya (N = 521). Two researchers coded the qualitative responses to the PSYCHLOPS and identified overarching themes. We compared the overarching themes identified to the items in the conventional, nomothetic outcome measures to investigate conceptual equivalence. Using the PSYCHLOPS, the most frequently reported problems in Kenya were financial constraints, poor health, and unemployment. In Pakistan, the most frequent problems were poor health and emotional problems. Most of the person-generated problem concepts were covered also in nomothetic measures that were part of the same study. However, there was no item equivalence in the nomothetic measures for the most frequent PSYCHLOPS problem cited in both countries. Response bias and measurement bias may not be excluded. More research on the use of PSYCHLOPS alongside conventional outcome measures is needed to further explore the extent to which it may bring added value. Use of a PSYCHLOPS semistructured interview schedule and efforts to minimise response biases should be considered.

Transport of hybrid type nanomaterials in peristaltic activity of viscous fluid considering nonlinear radiation, entropy optimization and slip effects

BACKGROUND

In last few decades, a new class of working materials which comprises from two solid materials dispersed in a continuous phase liquid was established and deeply scrutinized. These materials are called hybrid nanomaterials. This research article aims to investigate entropy optimization in hybrid nanomaterial flow through a rotating peristaltic channel walls. Flow behavior is analyzed between the channels which is caused by propagation of sinusoidal waves. Viscosity of fluid is considered variable instead of constant characteristics. Fluid saturates through porous attributes of channel walls. Nonliear radiative flux and convective condition are considered. Slip conditions are imposed at the boundary of walls.

METHODS

Built-in-Shooting technique is employed to obtain the numerical outcomes for the considered flow problem.

RESULTS

Impacts of sundry variables on the entropy, temperature and velocity are scrutinized through different graphs. Numerical result presents that the axial velocity escalates with the inclusion of hybrid nanomaterial. The temperature of fluid enhances through higher estimations of hybrid nanoparticles.

CONCLUSIONS

Here the flow behavior is discussed between the channels which are caused by propagation of sinusoidal waves with speed c. Entropy generation rate is minimum for variable viscosity and maximum for hybrid nanoparticles. Hybrid nanoparticles increase the temperature of fluid. Bejan number presents the similar impact for variable viscosity and thermal slip parameters. Temperature field decays through higher values of Brinkman number.

Do Asian Patients Require Only Half of the Clozapine Dose Prescribed for Caucasians? A Critical Overview

Since 1997, studies have found that Asians need lower clozapine doses than Caucasians. Caucasians with average clozapine metabolism may need from 300 to 600 mg/day to reach the therapeutic range (350 ng/ml). Thus, serum clozapine concentration-to-dose (C/D) ratios typically range between 0.60 (male smokers) and 1.20 (female non-smokers). A 2019 systematic review of clozapine levels demonstrated weighted mean C/D ratios of 1.57 in 876 East Asians and 1.07 in 1147 Caucasians (P < .001). In Asian countries, average clozapine doses are lower than 300 mg/day. After sex and smoking stratification in 5 Asian samples with clozapine concentrations, the clozapine dose required to reach 350 ng/ml in female non-smokers ranged from 145 to 189 mg/day and in male smokers, from 259 to 294 mg/day. Thus, in Asian patients with average metabolism (with no inducers other than smoking, with no inhibitors, and in the absence of extreme obesity), the dose needed for clinical response may range between 150 mg/day for female non-smokers to 300 mg/day for male smokers. Clozapine levels may help personalize dosing in clozapine poor metabolizers (PMs) and ultrarapid metabolizers (UMs). Asian PMs may need very low doses (50-150 mg/day) to obtain therapeutic concentrations. About 10% (range 2-13%) of Asians are genetic PM cases. Other PMs are patients taking CYP1A2 inhibitors such as fluvoxamine, oral contraceptives, and valproate. Temporary clozapine PM status may occur during severe systemic infections/inflammations with fever and C-reactive protein (CRP) elevations. Asian UMs include patients taking potent inducers such as phenytoin, and rarely, valproate.