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Introduction People with severe mental illness (SMI) tend to die early due to cardiovascular and respiratory diseases, which may be linked to tobacco use. There is limited information on tobacco use in people with SMI in low- and middle-income countries where most tobacco users reside. We present novel data on tobacco use in people with SMI and their access to tobacco cessation advice in South Asia. Methods We conducted a multi-country survey of adults with SMI attending mental health facilities in Bangladesh, India, and Pakistan. Using data collected with a standardized WHO STEPS survey tool, we estimated the prevalence and distribution of tobacco use and assessed receipt of tobacco cessation advice. Results We recruited 3874 participants with SMI; 46.8% and 15.0% of men and women consumed tobacco, respectively. Smoking prevalence in men varied by country (Bangladesh 42.8%, India 20.1% and Pakistan 31.7%);

Background People with severe mental illness (SMI) die earlier than the general population, primarily because of physical disorders. Aims We estimated the prevalence of physical health conditions, health risk behaviours, access to healthcare and health risk modification advice in people with SMI in Bangladesh, India and Pakistan, and compared results with the general population. Method We conducted a cross-sectional survey in adults with SMI attending mental hospitals in Bangladesh, India and Pakistan. Data were collected on non-communicable diseases, their risk factors, health risk behaviours, treatments, health risk modification advice, common mental disorders, health-related quality of life and infectious diseases. We performed a descriptive analysis and compared our findings with the general population in the World Health Organization (WHO) ‘STEPwise Approach to Surveillance of NCDs’ reports. Results We recruited 3989 participants with SMI, of which 11% had diabetes, 23.3% had hypertension or high blood pressure and 46.3% had overweight or obesity. We found that 70.8% of participants with diabetes, high blood pressure and hypercholesterolemia were previously undiagnosed; of those diagnosed, only around half were receiving treatment. A total of 47% of men and 14% of women used tobacco; 45.6% and 89.1% of participants did not meet WHO recommendations for physical activity and fruit and vegetable intake, respectively. Compared with the general population, people with SMI were more likely to have diabetes, hypercholesterolemia and overweight or obesity, and less likely to receive tobacco cessation and weight management advice. Conclusions We found significant gaps in detection, prevention and treatment of non-communicable diseases and their risk factors in people with SMI.

BackgroundPeople with severe mental illnesses (SMIs) are likely to face disproportionate challenges during a pandemic. They may not receive or be able to respond to public health messages to prevent infection or to limit its spread. Additionally, they may be more severely affected, particularly in low- and middle-income countries.MethodsWe conducted a telephone survey (May–June 2020) in a sample of 1,299 people with SMI who had attended national mental health institutes in Bangladesh and Pakistan before the pandemic. We collected information on top worries, socioeconomic impact of the pandemic, knowledge of COVID-19 (symptoms, prevention), and prevention-related practices (social distancing, hygiene). We explored the predictive value of socio-demographic and health-related variables for relative levels of COVID-19 knowledge and practice using regularized logistic regression models.FindingsMass media were the major source of information about COVID-19. Finances, employment, and physical health were the most frequently mentioned concerns. Overall, participants reported good knowledge and following advice. In Bangladesh, being female and higher levels of health-related quality of life (HRQoL) predicted poor and better knowledge, respectively, while in Pakistan being female predicted better knowledge. Receiving information from television predicted better knowledge in both countries. In Bangladesh, being female, accessing information from multiple media sources, and better HRQoL predicted better practice. In Pakistan, poorer knowledge of COVID-19 prevention measures predicted poorer practice.ConclusionOur paper adds to the literature on people living with SMIs and their knowledge and practices relevant to COVID-19 prevention. Our results emphasize the importance of access to mass and social media for the dissemination of advice and that the likely gendered uptake of both knowledge and practice requires further attention.

Introduction People with severe mental illness (SMI) die on average 10–20 years earlier than the general population. Most of these deaths are due to physical health conditions. The aim of this cross-sectional study is to determine the prevalence of physical health conditions and their associations with health-risk behaviours, health-related quality of life and various demographic, behavioural, cognitive, psychological and social variables in people with SMI attending specialist mental health facilities in South Asia.Methods and analysis We will conduct a survey of patients with SMI attending specialist mental health facilities in Bangladesh, India and Pakistan (n=4500). Diagnosis of SMI will be confirmed using the Mini-international neuropsychiatric interview V.6.0. We will collect information about physical health and related health-risk behaviours (WHO STEPwise approach to Surveillance (STEPS)); severity of common mental disorders (Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder scale (GAD-7)) and health-related quality of life (EQ-5D-5L). We will measure blood pressure, height, weight and waist circumference according to WHO guidelines. We will also measure glycated haemoglobin, lipid profile, thyroid function, liver function, creatinine and haemoglobin. Prevalence rates of physical health conditions and health-risk behaviours will be presented and compared with the WHO STEPS survey findings in the general population. Regression analyses will explore the association between health-risk behaviours, mental and physical health conditions.Ethics and dissemination The study has been approved by the ethics committees of the Department of Health Sciences University of York (UK), Centre for Injury Prevention and Rehabilitation (Bangladesh), Health Ministry Screening Committee and Indian Council of Medical Research (India) and National Bioethics Committee (Pakistan). Findings will be disseminated in peer-reviewed articles, in local and international conferences and as reports for policymakers and stakeholders in the countries involved.Trial registration number ISRCTN88485933; 3 June 2019.

INTRODUCTION People with severe mental illness (SMI) tend to die early due to cardiovascular and respiratory diseases, which may be linked to tobacco use. There is limited information on tobacco use in people with SMI in low- and middle-income countries where most tobacco users reside. We present novel data on tobacco use in people with SMI and their access to tobacco cessation advice in South Asia. METHODS We conducted a multi-country survey of adults with SMI attending mental health facilities in Bangladesh, India, and Pakistan. Using data collected with a standardized WHO STEPS survey tool, we estimated the prevalence and distribution of tobacco use and assessed receipt of tobacco cessation advice. RESULTS We recruited 3874 participants with SMI; 46.8% and 15.0% of men and women consumed tobacco, respectively. Smoking prevalence in men varied by country (Bangladesh 42.8%, India 20.1% and Pakistan 31.7%); <4% of women reported smoking in each country. Smokeless tobacco use in men also varied by country (Bangladesh 16.2%, India 18.2% and Pakistan 40.8%); for women, it was higher in Bangladesh (19.1%), but similar in India (9.9%) and Pakistan (9.1%). Just over a third of tobacco users (38.4%) had received advice to quit tobacco. Among smokers, 29.1% (n=244) made at least one quit attempt in the past year. There was strong evidence for the association between tobacco use and the severity of depression (OR=1.29; 95% CI: 1.12-1.48) and anxiety (OR=1.29; 95% CI: 1.12-1.49). CONCLUSIONS As observed in high-income countries, we found higher tobacco use in people with SMI, particularly in men compared with rates reported for the general population in South Asia. Tobacco cessation support within mental health services offers an opportunity to close the gap in life expectancy between SMI and the general population. [ABSTRACT FROM AUTHOR]

The objective is to assess the impact of knowledge sharing, employee motivation, and employee engagement on overall performance. The quantitative research method is used to collect primary data through an adoptive structured questionnaire based on a 5-Likert scale. The responses are recorded from 322 respondents through the method of sampling in many stages. Using SmartPLS software, recorded responses are examined using statistical tests (such as regression and correlation). The results indicate a positive relationship among knowledge sharing, employee engagement, motivation, and performance. All hypotheses (H1, H2, H3) were accepted with t-values exceeding 1.96. This study elaborates on how knowledge sharing along with the moderating effects of motivation and engagement, improves employee performance, particularly in the academic sector. It also adds to the existing literature on these relationships.

Background: People with severe mental illnesses (SMIs) are likely to face disproportionate challenges during a pandemic. They may not receive or be able to respond to public health messages to prevent infection or to limit its spread. Additionally, they may be more severely affected, particularly in low- and middle-income countries. Methods: We conducted a telephone survey (May–June 2020) in a sample of 1,299 people with SMI who had attended national mental health institutes in Bangladesh and Pakistan before the pandemic. We collected information on top worries, socioeconomic impact of the pandemic, knowledge of COVID-19 (symptoms, prevention), and prevention-related practices (social distancing, hygiene). We explored the predictive value of socio-demographic and health-related variables for relative levels of COVID-19 knowledge and practice using regularized logistic regression models. Findings: Mass media were the major source of information about COVID-19. Finances, employment, and physical health were the most frequently mentioned concerns. Overall, participants reported good knowledge and following advice. In Bangladesh, being female and higher levels of health-related quality of life (HRQoL) predicted poor and better knowledge, respectively, while in Pakistan being female predicted better knowledge. Receiving information from television predicted better knowledge in both countries. In Bangladesh, being female, accessing information from multiple media sources, and better HRQoL predicted better practice. In Pakistan, poorer knowledge of COVID-19 prevention measures predicted poorer practice. Conclusion: Our paper adds to the literature on people living with SMIs and their knowledge and practices relevant to COVID-19 prevention. Our results emphasize the importance of access to mass and social media for the dissemination of advice and that the likely gendered uptake of both knowledge and practice requires further attention. [ABSTRACT FROM AUTHOR]

Abstract Background Self-harm is an important predictor of a suicide death. Culturally appropriate strategies for the prevention of self-harm and suicide are needed but the evidence is very limited from low- and middle-income countries (LMICs). This study aims to investigate the effectiveness of a culturally adapted manual-assisted problem-solving intervention (CMAP) for patients presenting after self-harm. Methods This was a rater-blind, multicenter randomised controlled trial. The study sites were all participating emergency departments, medical wards of general hospitals and primary care centres in Karachi, Lahore, Rawalpindi, Peshawar, and Quetta, Pakistan. Patients presenting after a self-harm episode (n = 901) to participating recruitment sites were assessed and randomised (1:1) to one of the two arms; CMAP with enhanced treatment as usual (E-TAU) or E-TAU. The intervention (CMAP) is a manual-assisted, cognitive behaviour therapy (CBT)-informed problem-focused therapy, comprising six one-to-one sessions delivered over three months. Repetition of self-harm at 12-month post-randomisation was the primary outcome and secondary outcomes included suicidal ideation, hopelessness, depression, health-related quality of life (QoL), coping resources, and level of satisfaction with service received, assessed at baseline, 3-, 6-, 9-, and 12-month post-randomisation. The trial is registered on ClinicalTrials.gov. NCT02742922 (April 2016). Results We screened 3786 patients for eligibility and 901 eligible, consented patients were randomly assigned to the CMAP plus E-TAU arm (n = 440) and E-TAU arm (N = 461). The number of self-harm repetitions for CMAP plus E-TAU was lower (n = 17) compared to the E-TAU arm (n = 23) at 12-month post-randomisation, but the difference was not statistically significant (p = 0.407). There was a statistically and clinically significant reduction in other outcomes including suicidal ideation (− 3.6 (− 4.9, − 2.4)), depression (− 7.1 (− 8.7, − 5.4)), hopelessness (− 2.6 (− 3.4, − 1.8), and improvement in health-related QoL and coping resources after completion of the intervention in the CMAP plus E-TAU arm compared to the E-TAU arm. The effect was sustained at 12-month follow-up for all the outcomes except for suicidal ideation and hopelessness. On suicidal ideation and hopelessness, participants in the intervention arm scored lower compared to the E-TAU arm but the difference was not statistically significant, though the participants in both arms were in low-risk category at 12-month follow-up. The improvement in both arms is explained by the established role of enhanced care in suicide prevention. Conclusions Suicidal ideation is considered an important target for the prevention of suicide, therefore, CMAP intervention should be considered for inclusion in the self-harm and suicide prevention guidelines. Given the improvement in the E-TAU arm, the potential use of brief interventions such as regular contact requires further exploration.

Background: Transcatheter aortic valve replacement (TAVR) are not offered equitably to vulnerable population groups. Adequate levels of insurance may narrow gaps among patients with higher social vulnerability index (SVI). Among a national population of individuals with commercial or Medicare insurance, we sought to determine whether SVI was associated with urgency of receipt of TAVR for aortic stenosis. Methods and results: Using Optum's de-identified Clinformatics Data Mart Database (CDM), we identified admissions for TAVR with aortic stenosis between January 2018 and March 2022. Admission urgency was identified by CDM claims codes. SVI was cross-referenced to patient zip codes and grouped into quintiles. Generalized linear mixed effects models were used to predict the probability of a TAVR admission being urgent based on SVI quintiles, adjusting for patient and hospital-level covariates. Results: Among 6680 admissions for TAVR [median age 80 years (interquartile range 75–85), 43.9 % female], 8.5 % (n = 567) were classified as urgent. After adjusting for patient and hospital-level variables, there were no significant differences in the odds of urgent admission for TAVR according to SVI quintiles [OR 5th (greatest social vulnerability) vs 1st quintile (least social vulnerability): 1.29 (95 % CI: 0.90–1.85)]. Conclusions: Among commercial or Medicare beneficiaries with aortic stenosis, SVI was not associated with admission urgency for TAVR. To clarify whether cardiovascular care delivery is improved across SVI with higher paying beneficiaries, future investigation should identify whether relationships between SVI and TAVR urgency vary for Medicaid beneficiaries compared to commercial beneficiaries.

Objective: to determine the impact of COVID-19 on mental health care service provision and the pattern of morbidity presenting to out-patient child psychiatry services in Pakistan. Study Design: Cross-sectional study. Place and Duration of Study: Child and Adolescent Mental Health Unit, Institute of Psychiatry, Rawalpindi Pakistan, Medical university, from Jan 2019 to Dec 2020. Methodology: Hospital records for the years 2019 and 2020 were used to get data on the total number of Out-Patient Department (OPD) visits in both years, and Departmental OPD records were used to extract data on all new patients. Results: Two thousand two hundred thirty-two OPD visits were recorded in 2019 versus 536 in 2020, a 76% decline. Eight hundred fifty-six new patients were seen in 2019 vs 259 in 2020. The detailed OPD record analysis revealed that the predominant age group reporting was adolescents in both years. 377(44%) patients reported with behavioural problems in 2019 vs 138(53.3%) in 2019. Pharmacological management plans were used in 138(16.1%) in 2019 vs 66(25.5%) in 2019. Common Diagnoses seen in both years were not significantly different, (p=0.087). OPD records were found to have an increase in the “not mentioned category”, thus reflecting declined quality of record keeping. Conclusion: The COVID-19-related lockdown and pandemic led to a sharp decline in out-patient visits and deterioration and record-keeping quality. The number of children and adolescents presenting with behavioural problems increased, but the common diagnoses remained similar. Keywords: COVID-19, Child and adolescent mental health service, Child psychiatry, Pandemic, School closure.

Abstract Background Child and adolescent mental health problems are a global public mental health priority. However, there is a lack of evidence-based scalable psychological interventions for adolescents living in low resource settings. This trial was designed to evaluate the feasibility and acceptability of delivering the World Health Organization’s Early Adolescent Skills for Emotions (EASE) intervention at public schools in a rural sub-district in Rawalpindi, Pakistan. Methods A two arm, single blinded, feasibility cluster randomized controlled trial with mixed-methods evaluation was conducted with 59 adolescents and their caregivers from 8 public schools. In the 4 intervention arm schools, 6 non-specialist facilitators delivered the culturally-adapted EASE group sessions to the adolescents (n = 29) and their caregivers with desired fidelity under the supervision of in-country supervisors. Results The participation rate of adolescents in the intervention sessions was 83%. The intervention strategies were implemented by the adolescents. However, attending biweekly sessions at schools was challenging for caregivers with only 50% caregivers attending the sessions. Conclusions The results of this study support the feasibility and acceptability of delivering this culturally adapted intervention through non-specialist facilitators in school settings in Pakistan and pave the way to conduct a fully powered cluster randomized controlled trial to test the effectiveness of intervention to improve psychological outcomes in adolescents. Trial registration Trial registered with Clinicaltrials.gov prospectively; NCT04254393.

Those who have suffered from traumatic brain injury (TBI) often develop behavioural, affective, and cognitive complications. Some might experience episodes of involuntary and/or exaggerated laughter and crying. This condition is commonly known as ‘pseudobulbar affect’(PBA) and leads to anger, frustration, and social disability. This case report presents the use of low-dose Escitalopram in an individual suffering from agitation and PBA following severe TBI (sTBI). It emphasises the importance of adopting a holistic approach in the treatment of such individuals with appropriate attention paid to factors such as cognitive and behavioural impairment, and caregiver distress. Keywords: Traumatic brain injury, antidepressants, agitation, pseudobulbar affect, involuntary emotional expression disorder.

Abstract Background Nephrolithiasis (NL) affects 1 in 11 individuals worldwide and causes significant morbidity and cost. Common variants in the calcium sensing receptor gene (CaSR) have been associated with NL. Rare inactivating CaSR variants classically cause hyperparathyroidism, hypercalcemia and hypocalciuria. However, NL and familial hypercalciuria have been paradoxically associated with select inactivating CaSR variants in three kindreds from Europe and Australia. Methods To discover novel NL-associated CaSR variants from a geographically distinct cohort, 57 Pakistani families presenting with pediatric onset NL were recruited. The CaSR locus was analyzed by directed or exome sequencing. Results We detected a heterozygous and likely pathogenic splice variant (GRCh37 Chr3:122000958A>G; GRCh38 Chr3:12228211A>G; NM_000388:c.1609-2A>G) in CaSR in one family with recurrent calcium oxalate stones. This variant would be predicted to cause exon skipping and premature termination (p.Val537Metfs*49). Moreover, a splice variant of unknown significance in an alternative CaSR transcript (GRCh37 Chr3:122000929G>C; GRCh38 Chr3:122282082G >C NM_000388:c.1609-31G >C NM_001178065:c.1609-1G >C) was identified in two additional families. Conclusions Sequencing of the CaSR locus in Pakistani stone formers reveals a novel loss-of-function variant, expanding the connection between the CaSR locus and nephrolithiasis.

Background Bipolar disorder is a source of marked disability, morbidity and premature death. There is a paucity of research on personalised psychosocial interventions for bipolar disorder, especially in low-resource settings. A pilot randomised controlled trial (RCT) of a culturally adapted psychoeducation intervention for bipolar disorder (CaPE) in Pakistan reported higher patient satisfaction, enhanced medication adherence, knowledge and attitudes regarding bipolar disorder, and improvement in mood symptom scores and health-related quality of life measures compared with treatment as usual (TAU). Aims The current protocol describes a larger multicentre RCT to confirm the clinical and cost-effectiveness of CaPE in Pakistan. Trial registration: NCT05223959. Method A multicentre individual, parallel-arm RCT of CaPE in 300 Pakistani adults with bipolar disorder. Participants over the age of 18, with a diagnosis of bipolar I or II disorder who are currently euthymic, will be recruited from seven sites: Karachi, Lahore, Multan, Rawalpindi, Peshawar, Hyderabad and Quetta. Time to recurrence will be the primary outcome assessed using the Longitudinal Interval Follow-up Evaluation (LIFE). Secondary measures will include mood symptoms, quality of life and functioning, adherence to psychotropic medications, and knowledge and attitudes regarding bipolar disorder. Results This trial will assess the effectiveness of the CaPE intervention compared with TAU in reducing the time to recurrence for people with bipolar disorder currently in remission in Pakistan and determine the effect on clinical outcomes, quality of life and functioning. Conclusions A successful trial might lead to rapid implementation of CaPE in clinical practice, not only in Pakistan, but also in other low-resource settings, including those in high-income countries, to improve clinical outcomes, social and occupational functioning, and quality of life in South Asian and other minority group patients with bipolar disorder.

Introduction Emotional problems are leading contributors to health burden among adolescents worldwide. There is an urgent need for evidence-based psychological interventions for young people. This study aims to evaluate the effectiveness of a school-based, group psychological intervention, Early Adolescent Skills for Emotions (EASE) developed by the WHO to improve psychosocial distress in Pakistani adolescents.Method and analysis A two-arm, single-blinded, cluster randomised controlled trial, with a wait-list control arm is being conducted in school settings of rural Pakistan. Forty eligible public-school clusters have been randomised (stratified by gender) on a 1:1 allocation ratio into intervention (n=20) and control arm (n=20). Following informed consent, 564 adolescents with psychosocial distress (Youth-reported Paediatric Symptoms Checklist, cut-off ≥28) from 40 schools have been enrolled into the trial (14±3 average cluster size) between 2 November 2021 and 30th November 2021. Participants in the intervention arm will receive EASE in 7-weekly adolescents and 3-biweekly caregivers group sessions in schools. The adolescent sessions involve the components of psychoeducation, stress management, behavioural activation, problem-solving and relapse prevention. Caregivers will receive training to learn and implement active listening; spending quality time and using praise as a strategy to help their children. The primary outcome is reduction in psychosocial distress at 3 months postintervention. Secondary outcomes include symptoms of depression and anxiety, caregiver–adolescent relationship and caregivers’ well-being. Outcomes will be assessed at baseline, immediate 1 week and 3-months postintervention. Qualitative process evaluation will explore barriers and facilitators to programme implementation in low-resource school settings.Ethics Ethics approval has been obtained from Central Ethics Committee of University of Liverpool, UK, Ethics Review Committee of WHO Geneva and from the Institutional Review Board of Human Development Research Foundation (HDRF), Pakistan.Dissemination The findings of the study will be disseminated by WHO and through peer-reviewed publications.Trial registration number ISRCTN17755448.

Background and Objective: With the increasing life expectancy of the populations and rising prevalence of depressive and neurocognitive disorders, there is a need to address the association between the two in terms of magnitude of the neurocognitive disorders and the severity of depression. The current study addresses this issue and aims to observe the association between the two. Methods: This cross-sectional descriptive study was conducted from September 2014 to March 2015 at the Institute of Psychiatry at Benazir Bhutto Hospital, Rawalpindi, Pakistan where consecutive patients aged ≥ 65 years were screened for depression using Geriatric Depression Scale (GDS). Neurocognitive impairment was assessed using Mini Mental State Examination (MMSE). -square test was used to compute the association between depression severity and neurocognitive deficit. Results: There was approximately equal gender distribution with a mean age of 63.6 ± 9.68 years. Eighty six percent of the study population was found to be suffering from clinical depression while seventy percent had neurocognitive deficit. The severity of depression came out to be directly proportional to the magnitude of the neurocognitive disorder (P = 0.000) with 68.8% of the patients with severe depression having moderate to severe neurocognitive deficit. Conclusions: Depression is associated with significant neurocognitive impairment in elderly in the local population; higher the severity of depression more the magnitude of cognitive impairment.

Introduction Suicide is a global health concern. Sociocultural factors have an impact on self-harm and suicide rates. In Pakistan, both self-harm and suicide are considered as criminal offence’s and are condemned on both religious and social grounds. The proposed intervention ‘Youth Culturally Adapted Manual Assisted Problem Solving Training (YCMAP)’ is based on principles of problem-solving and cognitive–behavioural therapy. YCMAP is a brief, culturally relevant, scalable intervention that can be implemented in routine clinical practice if found to be effective.Method and analysis A multicentre rater blind randomised controlled trial to evaluate the clinical and cost-effectiveness of YCMAP including a sample of 652 participants, aged 12–18 years, presenting to general physicians/clinicians, emergency room after self harm or self referrals. We will test the effectiveness of 8–10 individual sessions of YCMAP delivered over 3 months compared with treatment as usual. Primary outcome measure is repetition of self-harm at 12 months. The seconday outcomes include reduction in suicidal ideation, hopelessness and distress and improvement in health related quality of life. Assessments will be completed at baseline, 3, 6, 9 and 12 months postrandomisation. The nested qualitative component will explore perceptions about management of self-harm and suicide prevention among adolescents and investigate participants’ experiences with YCMAP. The study will be guided by the theory of change approach to ensure that the whole trial is centred around needs of the end beneficiaries as key stakeholders in the process.Ethics and dissemination Ethics approval has been obtained from the Ethics Committee of University of Manchester, the National Bioethics Committee in Pakistan. The findings of this study will be disseminated through community workshops, social media, conference presentations and peer-reviewed journals.Trial registration number NCT04131179.

Background and Objective: With the increasing life expectancy of the populations and rising prevalence of depressive and neurocognitive disorders, there is a need to address the association between the two in terms of magnitude of the neurocognitive disorders and the severity of depression. The current study addresses this issue and aims to observe the association between the two. Methods: This cross-sectional descriptive study was conducted from September 2014 to March 2015 at the Institute of Psychiatry at Benazir Bhutto Hospital, Rawalpindi, Pakistan where consecutive patients aged ≥ 65 years were screened for depression using Geriatric Depression Scale (GDS). Neurocognitive impairment was assessed using Mini Mental State Examination (MMSE). -square test was used to compute the association between depression severity and neurocognitive deficit. Results: There was approximately equal gender distribution with a mean age of 63.6 ± 9.68 years. Eighty six percent of the study population was found to be suffering from clinical depression while seventy percent had neurocognitive deficit. The severity of depression came out to be directly proportional to the magnitude of the neurocognitive disorder (P = 0.000) with 68.8% of the patients with severe depression having moderate to severe neurocognitive deficit. Conclusions: Depression is associated with significant neurocognitive impairment in elderly in the local population; higher the severity of depression more the magnitude of cognitive impairment.

Schizophrenia patients demonstrate variations in response to different therapies that are currently being used for the treatment of disorders, such as augmentation therapy (ECT or mood stabilizer) and combination therapy (with antipsychotics). These therapies are also used to treat schizophrenia patients in Pakistan; however, patients show poor overall response. Therefore, this study was conducted to investigate the association between the patients’ response to treatment and the use of antipsychotic agents, with variability in overall response, within different groups of patients. Methods: We conducted a retrospective study that included schizophrenia subjects (N = 200) belonging to different age groups, ethnicities, and regions from different outpatient and inpatient departments in psychiatric institutes located in different cities of Pakistan. These patients were assessed for their response to treatment therapies and categorized into four groups (non-responders (N-R), slow response (S-R), patients with relapse, and completely recovered patients (C-R)) according to their responses. Results: The final analysis included 200 subjects, of which 73.5% were males. Mean age was 34 ± 10 years. Percentage of N-R was 5%, S-R was 42%, patients with relapse were 24%, and C-R was 1.5%. The generalized linear regression model shows a significant association between medication response and age (p = 0.0231), age of onset (p = 0.0086), gender (p = 0.005), and marital status (p = 0.00169). Variability within the medication responses was a result of the treatment regime followed. Antipsychotic agents were significantly associated with the treatment response (p = 0.00258, F = 4.981) of the patients. Significant variation was also observed in the treatment response (p = 0.00128) of the patients that were given augmentation therapy as well as combination therapy. Conclusion: The data suggests proper monitoring of patients’ behavior in response to treatment therapies to implement tailored interventions. Despite several genetic studies supporting the heritability of schizophrenia, an insignificant association between characteristic features and family history might have been due to the limited sample size, suggesting collaborative work with massive sample sizes.

Background and Aims: COVID-19 has infected more than 77 million people worldwide and impacted the lives of many more, with a particularly devastating impact on vulnerable populations, including people with substance use disorders (SUDs). Quarantines, travel bans, regulatory changes, social distancing, and “lockdown” measures have affected drug and alcohol supply chains and subsequently their availability, price, and use patterns, with possible downstream effects on presentations of SUDs and demand for treatment. Given the lack of multicentric epidemiologic studies, we conducted a rapid global survey within the International Society of Addiction Medicine (ISAM) network in order to understand the status of substance-use patterns during the current pandemic.Design: Cross-sectional survey.Setting: Worldwide.Participants: Starting on April 4, 2020 during a 5-week period, the survey received 185 responses from 77 countries.Measurements: To assess addiction medicine professionals' perceived changes in drug and alcohol supply, price, use pattern, and related complications during the COVID-19 pandemic.Findings: Participants reported (among who answered “decreased” or “increased”) a decrease in drug supply (69.0%) and at the same time an increase in price (95.3%) globally. With respect to changes in use patterns, an increase in alcohol (71.7%), cannabis (63.0%), prescription opioids (70.9%), and sedative/hypnotics (84.6%) use was reported, while the use of amphetamines (59.7%), cocaine (67.5%), and opiates (58.2%) was reported to decrease overall.Conclusions: The global report on changes in the availability, use patterns, and complications of alcohol and drugs during the COVID-19 pandemic should be considered in making new policies and in developing mitigating measures and guidelines during the current pandemic (and probable future ones) in order to minimize risks to people with SUD.

BACKGROUND: Assessment of parent/caretaker satisfaction with child and adolescent mental health services in a tertiary care setting METHODS: In this descriptive cross sectional study, 130 parents/caretakers of children aged ≤ 16 years were administered Parent/Caretaker Satisfaction Questionnaire which is a 20-item, 4-point Likert type scale, after their second visit/consultation with Child Psychiatric OPD via non-probability consecutive sampling directly as well as telephonically during six months period. Demographic variables were collected via Proforma. The data was analyzed using SPSS v 16.0. p- value 60), 24.6 %(n=32) were satisfied (satisfaction between 21-60) and only 2.3%(n=3) were unsatisfied (satisfaction ≤20). No significant association was found between demographic variables and level of satisfaction. CONCLUSION: Our study revealed a high level of parent/caretaker satisfaction with Child and Adolescent mental health services in a tertiary care setting. No significant association was found between socio-demographic variables and parent/caretakers’ satisfaction. KEY WORDS: Patient satisfaction, Quality of health care, Child Psychiatry, Mental health services

Background: The coronavirus disease 2019 (COVID-19) pandemic has impacted people with substance use disorders (SUDs) worldwide, and healthcare systems have reorganized their services in response to the pandemic.Methods: One week after the announcement of the COVID-19 as a pandemic, in a global survey, 177 addiction medicine professionals described COVID-19-related health responses in their own 77 countries in terms of SUD treatment and harm reduction services. The health responses were categorized around (1) managerial measures and systems, (2) logistics, (3) service providers, and (4) vulnerable groups.Results: Respondents from over 88% of countries reported that core medical and psychiatric care for SUDs had continued; however, only 56% of countries reported having had any business continuity plan, and 37.5% of countries reported shortages of methadone or buprenorphine supplies. Participants of 41% of countries reported partial discontinuation of harm-reduction services such as needle and syringe programs and condom distribution. Fifty-seven percent of overdose prevention interventions and 81% of outreach services were also negatively impacted.Conclusions: Participants reported that SUD treatment and harm-reduction services had been significantly impacted globally early during the COVID-19 pandemic. Based on our findings, we highlight several issues and complications resulting from the pandemic concerning people with SUDs that should be tackled more efficiently during the future waves or similar pandemics. The issues and potential strategies comprise the following: (1) helping policymakers to generate business continuity plans, (2) maintaining the use of evidence-based interventions for people with SUDs, (3) being prepared for adequate medication supplies, (4) integrating harm reduction programs with other treatment modalities, and (5) having specific considerations for vulnerable groups such as immigrants and refugees.

Objective: Aim of the study was to explore the perceived stress in students at various medical and dental universities across Pakistan during the COVID 19 pandemic, using a validated scale. Materials and Methods: The study took place at the Institute of Psychiatry (IOP) Rawalpindi Medical University (RMU). Results: About 400 medical students participated countrywide. The final analysis was conducted on 333 participants who completed the survey form. Study participants comprised 69.1% female and 30.9% male students. About 74.5% of the participants represented Punjab province, 1.2% were from Sindh, another 1.2% belonged to Baluchistan, 2.4% were from KPK, and 1.5% were from AJK while 19.2% of them resided in Islamabad. The majority of participants were enrolled in MBBS (78.4%) while the rest were from BDS (3%), Allied Health Sciences (12.9%), Clinical Psychology (3.6%), and Pharm D (2.1%). The mean perceived stress score was 21.34, SD=4.90 suggesting high perceived stress levels. Approximately 4.5% of students perceived low levels of stress, 80.2% perceived moderate stress, whereas 15.3% scored high on the perceived stress scale. Male students had statistically significant (p=0.38) lower stress levels (M=19.99, SD=5.91) as compared to females (M= 21.95, SD= 4.26). Conclusions: Perceived stress level in medical students was alarmingly high and requires urgent intervention by the Medical and Dental Universities for immediate action and policy guidance for early identification and effective management. This can be achieved by delivering targeted e-workshops and evidence-based e-trainings for stress management like psychological first aid and mindfulness techniques.

In the Islamic Republic of Pakistan the law relating to people who are mentally ill, until 2001, was set out by the Lunacy Act of 1912, which was inherited from the British colonial occupiers. In 2001 the Mental Health Ordinance 2001 took its place but only for this federal law to be superseded in April 2010 with the 18th constitutional amendment. As part of that amendment, provinces have become responsible for (psychiatric) healthcare, including mental health legislation. Forensic psychiatry is practised in Pakistan but is very much in its infancy; it needs to develop and learn from more experienced countries in Europe and North America. Cultural factors and misconceptions arising from religion can at times contribute to, or create, barriers to the implementation of forensic psychiatric services in Pakistan. This paper reviews the current state of forensic psychiatric services in Pakistan and is intended to open the debate on the challenges ahead.

The anticoagulant effect of the methanol extract of Brassica oleracea var. capitata (MEB) was examined in rabbits. The animals were divided into five groups, each comprising seven animals. Three groups were administered increasing doses of MEB (200, 300, and 500 mg/kg, respectively); one group received warfarin (0.54 mg/kg); animals in the control group received saline (1 ml/day equivalent to the volume of doses applied to the treated and standard animals). Biochemical tests were performed on the 16th and 31st days of dosing. Animals that were administered MEB (500 mg MEB/kg) 30 days displayed increases of 24.07 s, 28.79 s and 4.08 s in activated partial thromboplastin (aPTT), fibrinogen (Fg) and thrombin time (TT). Compared to the control, the increase in aPTT and Fg was highly significant and the increase in TT was significant. The anticoagulant effect exhibited by MEB in rabbits may be due to inactivation or inhibition of factors affecting coagulation.

Large amounts of waste, including dead birds, manure, and poultry litter, are produced by the poultry industry. Poultry waste should be disposed of properly to avoid major pollution and health risks. Composting litter and dead birds could be an option to recycle the waste and use in poultry feed. A study was conducted to investigate the effects of feeding composted poultry waste on the organoleptic qualities and compositional profile of the meat of broiler chickens. A total of 300 day-old broiler chicks (500-Cobb) were randomly allocated to five treatment groups replicated six times with 10 birds each, under a completely randomized design (CRD). Five iso-caloric and iso-nitrogenous diets including composted poultry byproducts at concentrations of 0, 2.5, 5, 7.5, and 10% were fed ad libitum to the birds from day 0 to day 35. The sensory grading and meat composition profile of 500 Cobb broiler chickens were tested at 35 days of age. The findings showed that there were no variations in the sensory profiles of the meat from birds given various diets (P>0.05). Although the results were somewhat lower for the chicks fed compost-containing diets than for the control group, this difference was deemed to be insignificant (P>0.05). Similarly, there were no variations in the compositional profile values of the meat between meat from birds fed various diets (P>0.05). These findings imply that broiler chickens may be raised on diets containing up to 10% poultry byproduct compost without any negative impacts on the meat's sensory quality or composition. Additionally, using compost into broiler diets may help to lower the cost of feed.

The poultry industry generates a lot of waste, including dead birds, manure, and poultry litter. Poultry waste should never be disposed of improperly because it can seriously harm the environment. The waste can be recycled as a feedstock for use in poultry feed by composting the litter and deceased birds. The compositional profile and organoleptic properties of the meat of growing Japanese quail were examined over the course of a 4-week trial to ascertain the effect of adding compost to the diet. In a completely randomized design (CRD), 1200 newly hatched quail chicks (Coturnix coturnix japonica) were divided into five treatment groups (diets with 0, 2.5, 5, 7.5, and 10% compost), each consisting of 40 birds with six replicates. The addition of compost to the diet had no noticeable effects on the organoleptic qualities of appearance, color, aroma, taste, texture, juiciness, tenderness, and acceptability (P>0.05). The compositional profile characteristics for chicks given compost at any level compared to chicks fed the control diet showed no differences (P>0.05). These findings suggest that the sensory characteristics and compositional profile of growing meat quails can be maintained when fed diets including up to 10% compost.

Competing Interests: There are no conflicts of interest.

Background: Vaccines against COVID-19 show high efficacy, yet, infection is still being detected among immunized patients, although with blunted severity. The purpose of this study was to assess the severity of COVID-19 infection among immunized versus non-immunized COVID-19 patients admitted to ICU., Method: A prospective observational cohort study, including all COVID-19 patients admitted to intensive care unit between January 1st, 2021 and June 30th, 2021 were eligible for inclusion. A comparison of severity upon hospitalization of immunized versus non-immunized patients on a 7-level ordinal scale was conducted, using ordinal logistic regression., Results: 592 patients were enrolled, 524 (88.5%) non-immunized, 63 (10.6%) partially immunized, and 5 (0.9%) fully immunized, partially and fully immunized patients were grouped together. Majority of immunized patients (86.7%) were symptomatic before 21 days of immunization. Non-immunized group had fewer patients in the lower severity categories, while more patients in the higher severity categories compared to immunized group. At least one dose of immunization was associated with reduction of odds of moving up severity scale (OR = 0.2 [95% CI: 0.15-0.4]; p < 0.001) in a well fitted ordinal logistic regression model. At least one dose of immunization was associated with lower adjusted odds of 30 day all-cause mortality (OR = 0.45 [95% CI: 0.23-0.89]; p = 0.02). Non-immunized group had higher mortality rate (43.9% versus 29.4% [95% CI: 1.5 to 25.8]; p = 0.02)., Conclusion: Most COVID-19 patients admitted to ICU were non-immunized, most of the partially immunized patients got infected before immunity could develop, and fully immunized patients were likely non-responders. At least one dose of immunization significantly decreases severity of the disease across all ordinal severity categories, and is significantly associated with lower 30 day all-cause mortality. Accordingly, immunization status may have to be considered when deciding on disposition of COVID-19 patients at the point of triage., Competing Interests: All authors declare no conflict of interests., (© 2021 The Authors.)

Objectives: To find the association of serum hyaluronic acid and laminin levels with polymerase chain reaction (PCR) results in hepatitis C sero-positive patients; and the correlation among viral load, serum hyaluronic acid, and serum laminin levels., Study Design: Cross-sectional descriptive study., Place and Duration of Study: Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology (AFIP), Rawalpindi, Pakistan from December 2019 to July 2020., Methodology: One hundred and eighty diagnosed cases of hepatitis C patients were included in this study. To find association, cross tabulation was done after dividing into two groups according to their median by applying Chi-square test. Correlation of viral load, duration of disease, serum hyaluronic acid and laminin levels were calculated using Spearman's correlation., Results: There were 124 (68.9%) males and 56 (31.1%) females. Median (IQR) age was 36 (32.3 - 45.0) years; while median duration of disease was 12 (8 - 18) months. There was a strong association between PCR positive cases with hyaluronic acid (p <0.001) and serum laminin levels (p <0.001). A strong relationship was found between viral load and serum hyaluronic acid (r =0.889, p <0.001), as well as with serum laminin (r =0.889, p <0.001)., Conclusion: Current study established a strong significant association between PCR results and disease duration with levels of serum laminin and hyaluronic acid. The levels of serum laminin and serum hyaluronic acid also correlate well with viral load and duration of disease. Key Words: Hepatitis C, Hepatic fibrosis, Hyaluronic acid, Laminin.

Introduction: People with severe mental illness (SMI) die on average 10-20 years earlier than the general population. Most of these deaths are due to physical health conditions. The aim of this cross-sectional study is to determine the prevalence of physical health conditions and their associations with health-risk behaviours, health-related quality of life and various demographic, behavioural, cognitive, psychological and social variables in people with SMI attending specialist mental health facilities in South Asia., Methods and Analysis: We will conduct a survey of patients with SMI attending specialist mental health facilities in Bangladesh, India and Pakistan (n=4500). Diagnosis of SMI will be confirmed using the Mini-international neuropsychiatric interview V.6.0. We will collect information about physical health and related health-risk behaviours (WHO STEPwise approach to Surveillance (STEPS)); severity of common mental disorders (Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder scale (GAD-7)) and health-related quality of life (EQ-5D-5L). We will measure blood pressure, height, weight and waist circumference according to WHO guidelines. We will also measure glycated haemoglobin, lipid profile, thyroid function, liver function, creatinine and haemoglobin. Prevalence rates of physical health conditions and health-risk behaviours will be presented and compared with the WHO STEPS survey findings in the general population. Regression analyses will explore the association between health-risk behaviours, mental and physical health conditions., Ethics and Dissemination: The study has been approved by the ethics committees of the Department of Health Sciences University of York (UK), Centre for Injury Prevention and Rehabilitation (Bangladesh), Health Ministry Screening Committee and Indian Council of Medical Research (India) and National Bioethics Committee (Pakistan). Findings will be disseminated in peer-reviewed articles, in local and international conferences and as reports for policymakers and stakeholders in the countries involved., Trial Registration Number: ISRCTN88485933; 3 June 2019., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Background: Short-term peripheral venous catheters-related bloodstream infections (PVCR-BSIs) rates have not been systematically studied, and data on their incidence by number of device-days is not available., Methods: Prospective, surveillance study on PVCR-BSI conducted from September 1st, 2013 to 31st Mays, 2019 in 246 intensive care units (ICUs), members of the International Nosocomial Infection Control Consortium (INICC), from 83 hospitals in 52 cities of 14 countries in the Middle East (Bahrain, Egypt, Iran, Jordan, Kingdom of Saudi Arabia, Kuwait, Lebanon, Morocco, Pakistan, Palestine, Sudan, Tunisia, Turkey, and United Arab Emirates). We applied U.S., Results: We followed 31,083 ICU patients for 189,834 bed-days and 202,375 short term peripheral venous catheter (PVC)-days. We identified 470 PVCR-BSIs, amounting to a rate of 2.32/1000 PVC-days. Mortality in patients with PVC but without PVCR-BSI was 10.38%, and 29.36% in patients with PVC and PVCR-BSI. The mean length of stay in patients with PVC but without PVCR-BSI was 5.94 days, and 16.84 days in patients with PVC and PVCR-BSI. The microorganism profile showed 55.2 % of gram-positive bacteria, with Coagulase-negative Staphylococci (31%) and Staphylococcus aureus (14%) being the predominant ones. Gram-negative bacteria accounted for 39% of cases, and included: Escherichia coli (7%), Klebsiella pneumoniae (8%), Pseudomonas aeruginosa (5%), Enterobacter spp. (3%), and others (29.9%), such as Serratia marcescens., Conclusions: PVCR-BSI rates found in our ICUs were much higher than rates published from USA, Australia, and Italy. Infection prevention programs must be implemented to reduce the incidence of PVCR-BSIs., (Copyright © 2020. Published by Elsevier Ltd.)

Background  Escitalopram is widely used for the management of the major depressive disorder and generalized anxiety disorder, but there is no to very limited data available regarding efficacy and safety in Pakistani patients. This study was conducted to evaluate the efficacy and safety of escitalopram oral drops to manage the major depressive disorder and generalized anxiety disorder in a local cluster within Pakistan. Methods This prospective multicenter observational study was conducted in the department of psychiatry from August 2018 - August 2019. Eighty-five patients meeting the selection criteria were included in the study. Adolescent, adult, and geriatric patients of either gender with generalized anxiety disorder having Hamilton Anxiety Rating Scale (HAM-A) rate ≥ 10 and major depressive disorder having Montgomery-Asberg Depression Rating Scale (MADRS) rate ≥ 7 or patients with co-morbid generalized anxiety disorder (GAD), major depressive disorder (MDD) were selected for the study. We are reporting patients' improvement from baseline, response rate, and remission rate. Data analysis is performed by using SPSS version 21 (IBM Inc, Armonk, USA). Results Among enrolled patients, 42 were adolescents, 22 were adults, and 21 were geriatric. The mean age of an adolescent, adult, and geriatric patients was 14.92 ± 2.04, 44.54 ± 12.08, and 64.61 ± 3.16 years, respectively. Among enrolled patients, the mean change in a total score of HAM-A for anxiety and MADRS for depression were -10.04 ± 4.32 and -17.67 ± 14.42, respectively. At the end of the study, the remission rate and response rate for depression were 82 % and 75%, respectively. Similarly, the remission rate and the response for anxiety were 76% and 81%, respectively. Mean HAM-A and MADRS scores were significantly improved for adolescent, adult, and geriatric patients. Adverse events were reported in eight (9.41%) patients with six having gastrointestinal (GI) disturbance and two having to worsen anxiety. All reported adverse events were of mild severity.  Conclusion  Escitalopram oral drops are found effective and tolerable in reducing both anxiety and depression over the duration of study in all age groups, including adolescents, adults, and geriatrics., Competing Interests: The authors have declared financial relationships, which are detailed in the next section., (Copyright © 2020, Afridi et al.)

There is an increasing awareness of the importance of cross-infection control in dental clinics and laboratories. This study evaluates the effects of various disinfecting solutions on the surface hardness of an acrylic resin denture base material. Hardness was measured as resistance to indentation following the method specified by the British Standards Institute. The results demonstrated that immersion of denture base acrylic resin in disinfecting solution for up to 24 hours resulted in no significant effect on hardness values.

This study evaluates the effects of long-term disinfection immersion on the flexural properties of denture base resins; it was conducted against a background of increasing awareness of the importance of cross-infection control in dental clinics and laboratories. The transverse bend testing procedure used followed that specified in the International Standard for denture base polymers. The results demonstrate that alcohol-based disinfectants are not suitable for use with denture base materials of non-cross-linked acrylic resin.