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Aug 14, 2024, was the day the World Health Organization (WHO) announced, mpox (previously known as monkeypox) as a Public Health Emergency of International Concern (PHEIC-2024).1 While mpox undoubtedly remains a global public health problem, neglected tropical diseases (NTDs) such as dengue, chikungunya, rabies, snake bite, and leishmaniasis, listed among the 20 NTDs by WHO, predominate in Pakistan. The fragile health system of Pakistan, overwhelmed for the past decades by infectious diseases such as tuberculosis and malaria, further worsened due to the COVID-19 pandemic. The synchronal rise of mpox, dengue, and chikungunya infections is posing increasing concerns for the population and healthcare system further straining the economy's capacity to respond effectively. Mpox is a zoonotic infection caused by the monkeypox virus (MPVX), an orthopoxvirus in the same genus as the variola virus, which is the causative agent of smallpox and, vaccinia virus (the virus used in the smallpox vaccine).1 Mpox has two clades, Clade I (Central Africa) and Clade II (West Africa). Clade I, which was recently reported from Sweden, is more contagious and has a higher fatality rate (10%), raising global health concerns. The figures show that the global mpox count in 2024 surpassed last year's with 15,600 cases and 537 deaths.1 Integrated Disease Surveillance & Response (IDSR), NIH, Islamabad, Pakistan has recorded a total of 14 travel related cases including one death (co-infection of HIV). All confirmed cases in Pakistan have been identified as the Clade IIb strain, and no evidence of local transmission has been documented. A worrying aspect of mpox is that no antiviral treatment is currently available for mpox and the initial clinical trials of the antiviral 'Tecovirimat' are not very promising against Clade Ib.1 Moreover, controlling mpox infections in the younger age groups is particularly challenging as vaccination is not recommended for individuals that are 15 and under. This poses a grace concern as mpox infection is known to cause higher mortality in children younger than 15 as was reported in the Democratic Republic of Congo. Pakistan currently doesn't have the availability of the mpox vaccine, making it inaccessible for those in need. Another endemic NTD that accounts for a huge burden of disease in Pakistan is rabies. Human infections are mostly due to dog bites and cases are diagnosed on clinical grounds only. Pakistan ranks in the top five countries globally in rabies-related mortality, with an estimated 2700-5000 deaths attributed to rabies in Pakistan. Dengue fever is yet another daunting health threat in Pakistan. About half of the world's population is at risk of dengue with an estimated 100–400 million infections annually.2 In 2024, dengue cases surged globally, with the WHO reporting over 7.6 million cases by April, including 3.4 million confirmed cases, 16,000 severe cases, and more than 3,000 deaths. Re-infection with a different dengue serotype increases the risk of severe illness, adding to the complexity of the outbreak.2 Pakistan faces a critical public health emergency, with 2,800 new dengue cases reported in September 2024, mostly in Baluchistan. Since May 2024, Karachi has experienced a surge in mosquito-borne infections, including dengue and chikungunya. The situation is being exacerbated by inadequate sanitation, optimal monsoon weather for mosquito breeding, prolonged heat waves, inadequate vector control measures, as well as contributing factors such as climate change, increased vector abundance (primarily Aedes aegypti and Aedes albopictus mosquitoes), and population movements.2,3 Both diseases are transmitted by Aedes mosquitoes, also vectors for Zika and yellow fever. Thankfully, despite the presence of the vector, Pakistan remains free of yellow fever and Zika cases. Strengthening surveillance systems and training healthcare workers to ensure timely identification and management of mpox and other NTDs are crucial. The interconnected efforts for healthy ecosystems and communities are essential for resilience in the face of environmental challenges. By actively addressing climate change, we can enhance planetary health and ensure a sustainable future for all. Collaborative initiatives that involve governments, communities, and individuals will be crucial in achieving these goals. Strong advocacy and resource mobilization at national and global levels are essential to secure funding for outbreak preparedness, support the stockpiling of medical supplies, and reinforce public health measures. A multisectoral approach is required to tackle the rise in mpox and NTDs which remains a persistent challenge not only for Pakistan but also for planetary health. Despite the grim circumstances, there are positive breakthroughs, such as the recent success in eliminating trachoma, a long-standing NTD in Pakistan. This is a promising development for Pakistan, the 19th country to reach this milestone. The trachoma elimination reflects the government's commitment, WHO's support, and the contributions of partners and communities. Eliminating one disease is an achievement that reinforces our optimism in working towards controlling NTDs in the future for the well-being of our planet and all its inhabitants. Editor-in-Chief How to cite this: Alamgir W, Shan H. Mpox and Neglected Tropical Diseases in Pakistan: A Growing Planetary Health Concern. Life and Science. 2024; 5(4): 431-432. doi: http://doi.org/10.37185/LnS.1.1.835

Objective: To study electroencephalography patterns in COVID-19 patients admitted to intensive care unit and find the association of these patterns with outcome. Study Design: Comparative cross-sectional study. Place and Duration of Study: Intensive Care Unit, Pak Emirates Military Hospital, Rawalpindi Pakistan, from Nov 2020 to Mar 2021. Methodology: Eighteen electroencephalograms in COVID-19 patients with Encephalopathy were recorded using a 10-20 electrode system. The duration of each recording was 30 minutes. Traces were analysed by a neurologist for delta slowing, epileptiform discharges, and posterior dominant rhythm. Generalised slowing was classified as mild (background slowing), moderate (intermittent slowing) and severe (continuous slowing). Results: A total of 18 COVID-19 patients, with a mean age of 63±16.02 years, underwent electroencephalography recording of 30 min duration. Diabetes mellitus and ischemic heart disease were the most common co-morbidity (7, 38.9%), followed by CKD. Non-specific generalised slowing was observed in all EEGs. No epileptiform discharges or focality were seen. Posterior Dominant Rhythm has been related to a good outcome. At the same time, severe Encephalopathy (Richmond Agitation-Sedation Scale of -3 to -5) was associated with poor outcomes (p-value

The COVID-19 pandemic has highlighted substantial inequities in access to vaccines. A primary reason behind this inequity was the concentration of manufacturing capacity in developed regions of the world. The lack of a distributed spread of local facilities has meant that many countries are reliant on global suppliers and manufacturers, making the low- and middle-income countries (LMICs) vulnerable to pandemics.1 Addressing this imbalance in terms of accessibility to life-saving vaccines is crucial for health security and vaccine equity. Gavi’s new five-year strategy (Gavi 6.0’ for 2026–2030) aims to address these issues with a vision “leaving no one behind with immunisation”. GAVI mission was revised for Gavi 5.0 and puts ‘equity’ at the heart of the Alliance’s strategy to increase equitable and sustainable use of vaccines. GAVI 6.0 incorporates a new principle on the climate change while equity will remain at the core of Gavi’s next strategy, as a key contribution to the Immunisation Agenda 2030 (IA 2030) and the Sustainable Development Goals. At the heart of the Gavi model is also a unique approach to programmatic and financial sustainability.2 Grounded in Gavi’s eligibility, transition and co-financing (ELTRACO) policy, the model has been highly successful so far in bolstering country ownership of vaccine programmes and in driving domestic public resource allocation towards immunisation. From 2011 to 2023, countries increased their resources for Gavi-supported vaccines from US$ 36 million to US$ 630 million, representing 41% of the combined investment by Gavi and countries into routine, Gavi-supported vaccines. At the end of 2023, 19 countries had fully transitioned out of Gavi support. In line with Gavi’s vaccine policy, based on the country’s Gross National Income (GNI); Pakistan will eventually graduate from GAVI support which would result in added economic capitals to sustain the vaccine accessibility which are acquired as country co-financing share. Despite progress, immunisation coverage in Pakistan remains low, and the country has not met its 2015 health, nutrition, and population (HNP) Millennium Development Goals targets.4 Establishing a local vaccine manufacturing facility is imperative to reduce reliance on contract manufacturing and streamline the supply chain for the Expanded Programme on Immunisation (EPI) and health security. The BioNTech mRNA Vaccine Manufacturing Facility in Rwanda serves as a model for sustainable vaccine production in LMICs. With a $150 million investment and local personnel training, the facility aims to produce mRNA-based vaccines by 2025, promoting vaccine production and supply in African Union member states. Similar initiatives can be replicated regionally to enhance vaccine self-sufficiency.5 Currently, over 60% of BCG and over 80% of measles vaccines are produced in India and Indonesia, underscoring the need for Pakistan to develop its vaccine production capabilities. The domestic market’s annual vaccine intake is Rs 17.6 billion, indicating substantial demand and potential for local manufacturing.6 Developing the capacity for essential immunisation in the country requires more than market-driven solutions. Achieving global vaccine equity demands transparency, active government oversight, favourable intellectual property policies, proactive technology transfers, and building regional technical, manufacturing, and regulatory capacities. Public-private partnerships (PPP) can expedite the establishment of Bioequivalence and Bioavailability centres, ensuring sustainable vaccine technology aligned with international standards (FDA, WHO, EU). By addressing these challenges, we can create a resilient and equitable global health security system, ensuring vaccine equity and sustainability in the fight against infectious diseases. Editor-in-Chief How to cite this: Alamgir W, Sajjad W. Strengthening Health Security through Sustainable Vaccine Economics and Equity. Life and Science. 2024; 5(3): . doi: http://doi.org/10.37185/LnS.1.1.768

Antimicrobial Resistance (AMR), is one of the biggest emerging threats to human health and healthcare systems. Experts are suggesting that the post-antibiotic era, in which microbial infections and minor injuries will again become fatal, is near. A report published by the Antibiotics Resistance Collaborators, in the Lancet, reported that 1.27 million people died due to antibiotic-resistant bacterial infections in 2019.1 Deaths could reach 10 million by 2050 if the problem is not addressed. Antimicrobial resistance arises as a natural adaptation of microorganisms to environmental challenges. One typical self-defense mechanism is by producing enzymes that inactivate antimicrobial agents. Bacteria can also become resistant to β-lactams by producing β-lactamase, and by altering binding sites for antimicrobials agents (resistance to glycopeptide antibiotic agents), expressing multidrug efflux pumps such as tigecycline resistance to Acinetobacter baumannii, and limiting cell permeability for antibiotics such as Acinetobacter baumannii and pseudomonas aeruginosa.2,3 th In the early 20 century, infectious diseases were the major cause of death. The advent of antibiotics led to a significant decrease in mortality.4 However, antibiotics resistance has now reached a threshold that is invalidating commonly used antibiotic agents. Currently the attempts to manage microbial resistance to antibiotics include the development of novel antimicrobial agents. However, there is no guarantee that the introduced new antimicrobial agents would be able to cope with the microbial resistance effectively and efficiently.5 Apart from developing new antibiotics, the chemical modification of existing antimicrobial agents is emerging as an upcoming strategy to combat antimicrobial resistance.4-6 Research on the effect of antibiotic associated nanoparticles on bacterial function is being conducted with the hope that advances in nanotechnology will lead to strategies for reconfiguration of presently available antibiotic molecules. Several nanomaterials have been identified as alternates for combating antimicrobial resistant strains. Each metallic and ceramic nanomaterials and more specifically their nanoparticles have their own peculiar antimicrobial properties. Studies have reported that these nanoparticles can be surface-functionalized with antimicrobial agents or molecules to further enhance their antimicrobial efficacy.6 Engineering antibiotics into nanoscale or functionalizing nanoparticles with antibiotic agents allows them to penetrate microbial cells and reach their target sites with precision and accuracy. Studies have shown that in contrast to free antibiotics, tailored functionalized nanoparticles and small antibiotic molecules have improved binding affinities and target specificity.6 Currently, these nanotechnology-based solutions have reported some problems like cytotoxicity, targeted selectivity, and bulk production. However, with concrete planning and a cohesive approach from academia, industry, and government, the development of nanoantibiotics drugs of unique shapes and sizes, high surface areas, ability to carry antibiotic drugs to target sites, and protein disruption will help overcome antimicrobial resistance. Editor-in-Chief How to cite this: Alamgir W, Adnan H. Nanoantibiotics: A Tool Against Antimicrobial Resistance. Life and Science. 2024; 5(2): 130-131. doi: http://doi.org/10.37185/LnS.1.1.657

Air pollution in Pakistan, and the region at large, has become one of the greatest environmental risks to health. Three major cities of Pakistan, Lahore, Karachi, and Peshawar, have been declared the worst in the world for their Air Quality Index and PM air pollution. The population residing in these cities is facing adverse health 2.5 effects. Children, with developing lungs and geriatric patients with chronic diseases are the worst affected. The impact of short-term and long-term exposure to air pollution includes premature mortality, exacerbated chronic heart and lung disease, lung cancer, decreased lung function in children as well as school absenteeism and restricted activity days.1 Hospitals and healthcare facilities are facing the increasing burden of a growing number of hospitalizations and emergency department visits. Alarmingly, a recent global analysis from 116 countries has described an association between PM2.5 and clinical antibiotic resistance.2 The profound impact of air pollution has been seen recently in Lahore, where school and business closures have hindered the normal functioning of society's education system and economic activities. Air pollution ranks among Africa and Asia's top ten risk factors for disability-adjusted life-years (DALYs). The combined effect of exposure to fine particles in ambient (outdoor) and household air pollution is associated with 7 million premature deaths annually.1 Globally, air pollution is the leading cause of death, killing 600,000 children under the age of 15 every year. Ambient air pollution is estimated to have caused 4.2 million premature deaths worldwide; 89% of those deaths occurred in low- and middle-income countries, notably in Asia and Western Pacific Regions.2 In Pakistan, it has been estimated that the average lifespan is reduced by 3.9 years due to air pollution, whereas in Lahore, life expectancy is reduced by seven years. The main sources of air pollution are industrial emissions, traffic-related pollutants, coal power plants, smoke from brick kilns, crop burning, dust from construction sites, household biomass combustion, and indoor pollutants from chemicals and tobacco. The toxic contaminants in the air include particulate matter (PM), ozone (O3 ), nitrogen dioxide (NO2 ), carbon monoxide (CO), and carbon dioxide (CO2 ). PM includes inhalable particles measuring 10 microns or less in size. PM10 & PM2.5 are proxy indicators for air pollution with the level of risk and adverse health effects varying with the size of the particles. Fine particulate matter of 2.5 microns or less, including diesel-derived PM, is among the most dangerous airborne pollutants because of its small size and ability to stay airborne longer. Burning fossil fuels, such as gasoline and coal, significantly contributes to air pollution, releasing pollutants like nitrogen oxides and volatile organic compounds into the atmosphere. The interaction of sunlight with nitrogen oxides and volatile organic compounds in the atmosphere creates ground-level ozone, a greenhouse gas and a principal constituent of smog. Exposure to PM, lead, and the gaseous pollutants CO and SO2 have reported pro-arrhythmic effects resulting in heart failure, ischemia, and atrial and ventricular arrhythmias.3 It is now widely recognized that PM is 2.5 associated with enhanced atherosclerosis development, premature aging of blood vessels, build-up of calcium in the coronary artery, and blood coagulability.3 At ground level, ozone causes breathing difficulties, coughing, throat irritation, asthma, and COPD. Ultra-fine PM can penetrate the bronchial epithelial barrier and enter the bloodstream, causing systemic inflammatory changes and oxidative stress, leading to metabolic disorders, dysbiosis, neurodegeneration, and dementia. Research has found links between air pollution exposure and genetic and epigenetic changes that can be inherited across generations. Poor air quality is linked to immune dysregulation, allergic rhinitis, allergic conjunctivitis, and other stronger allergic reactions. Socially and economically marginalized vulnerable populations, outdoor workers, and professionals like construction workers, athletes, and traffic wardens are more likely to be adversely affected by toxic air. Increased air pollution during outdoor activities has brought into question the public health perspective advocating outdoor exercise as a preventative measure for various health issues, from heart problems to mental well-being. The focus of COP28 held in December 2023 revolved around critical objectives such as reducing greenhouse gas emissions. "Beginning of the end" of the fossil fuel era, the United Nations Climate Change Conference (COP 28) signalled the need to move away from fossil fuels for the first time. However, a significant challenge arises for a country like Pakistan, where the swift implementation of green technology is hindered by the substantial costs associated with its adoption. The urgency of addressing climate change is apparent; however, the economic constraints faced by Pakistan make the immediate achievement of fossil fuel reduction targets a complex and formidable task. Healthcare providers, public health workers, and academia should promote planetary health and advocate for embracing individual responsibility in mitigating the impact of greenhouse gas emissions. A pressing need exists for prioritizing public policies to safeguard individuals from air pollutant exposure, enforce stringent regulations and penalties for polluters, promote sustainable practices, and invest in low-cost carbon sinks like the urban green and blue spaces. Concerted efforts to address this crisis are paramount for our children's future survival. Editor-in-Chief How to cite this: Alamgir W, Shan H. Air Pollution: A Challenge to Public Health and Healthcare Systems. Life and Science. 2024; 5(1): 1-2. doi: http://doi.org/10.37185/LnS.1.1.594

Biomaterials are substances that can be introduced into the body or tissue for a wide array of therapeutic or diagnostic purposes. Biomaterials can be of both natural or synthetic origin. The first examples describing the use of biomaterials includes the Neanderthals use of wood as dental implanting materials, and from 7th BC to the 4th AD, the ancient civilizations of Greece and Rome used various other naturally occurring substances and metals for treatment of wounds and other medical complications. In 16th century in Europe, silver and gold materials were used for dental repair and iron threads were used for bone repairs and various immobilization procedures.1 Significant advancement has been made in the field of biomaterials in the recent decades, and both natural and synthetic biomaterials have been effectively used to replace various human tissues such as teeth, ligaments, tendons, bones, and load-bearing implants. The biocompatibility, bioactivity, and mechanical properties of biomaterials plays a pivotal role in meeting the need for long-term implants and bone replacement. Biomaterials in use include but are not limited to metal-based biomaterials (titanium alloys, alumina, stainless steel, zirconia, cobalt-chromium alloys) and polymer-based biomaterials (polymethyl methacrylate and ultra-high molecular weight polyethylene). These are usually selected because they meet the required criteria of mechanical strength, biocompatibility, and desired physical and chemical properties. Considerable progress has been made in improving the effectiveness of artificial joints, reducing wear, and extending the life of implants or prostheses inserted into the human body.2,3 Until recently, the focus had been on biomaterials as replacement materials. However, the main issue is immune rejection of the introduced material. Therefore, the focus has changed to using biomaterials for tissue regeneration. A viable cellular construct in a controlled laboratory environment for the purpose of transplantation can be achieved by using bioactive scaffolds that provide a structured environment to support cell growth and their function. Another strategy has been to trigger tissue regeneration within the body itself by using porous meshes or degradable bioactive materials which can facilitate the process.2 These techniques pose a risk of infection. Extensive research is currently underway to address these problems. In a recent study, scientists have successfully fabricated a composite scaffold of cellulose and silver nanoparticles.4 This innovative scaffold showed promising properties in preventing microbial infections and has the potential to prevent infections at wound sites. However, while it is important to acknowledge the above-mentioned beneficial properties of biomaterials; there is still a long way to go to achieve the desired goals. Immunomodulating biomaterials have been developed with the potential to effectively overcome common chronic diseases such as type 1 diabetes in non-obese diabetic mice. Supramolecular biomaterials, formed by non-covalent interactions between molecular components are being fabricated which can be activated or deactivated in response to physiological signals or which can mimic the signaling mechanisms seen in real biological systems. In addition, injectable biomaterials for delivering therapeutic drugs, proteins and genetic material are being developed, for treating a wide range of diseases via targeted delivery by bypassing immune system recognition. The use of synthetic and naturally produced injectable biomaterials in ongoing research has the potential for future applications in the treatment of bone deformities, detection and treatment of cancer, and heart related diseases. In Pakistan, researchers have diverted their attention towards biomaterials sciences and its potential role in biomedical devices since last two decade, evident from the increasing number of publications and patents. However, there is still a scarcity of good quality applied research in the field. In addition, the lack of capacity for conducting clinical trials of biomedical devices developed in Pakistan is also a hindrance to the commercialization of these products. For these products to reach the market, high quality clinical trials according to international best practices have to be conducted. It is imperative for Pakistan to develop centers where phase I and II clinical trials can be conducted that comply with the required international methodological, ethical and regulatory guidelines. This will only be possible where the triple helix model of Government-Academia-Industry collaboration is implemented in its true spirit. Editor-in-Chief How to cite this: Alamgir W, Haider A. The Past, Present and Future of Biomaterials. Life and Science. 2023; 4(4): 363-364 . doi: http://doi.org/10.37185/LnS.1.1.500

Objective: To compare NEDOCS with ICMED in predicting clinicians' concerns regarding crowding in the Emergency Department of a tertiary care hospital in Pakistan. Study Design: Prospective comparative study. Place and Duration of Study: Accident & Emergency Department, Pak Emirates Military Hospital, Rawalpindi Pakistan, from Dec 2021 to Jan 2022. Methodology: This study was conducted at the Accident and Emergency Department over 14 different days, 30 data sets of 3-hour intervals each were collected using the NEDOCS and ICMED proforma. NEDOCS Scores and ICMED scores were calculated. In addition, perceptions of the staff regarding crowding and danger to the patient's status were recorded on Visual Analogue scales. Results: The mean recorded NEDOCS score was 577.94±251.57, with 29 'extremely overcrowded' and 1 'overcrowded' data set.The mean ICMED score was 2.86±0.83. Twenty-four (80%) sets did not have crowding, with only six (20%) sets being categorized as 'crowded'. The NEDOCS score had a moderately positive correlation with the crowding perception of the staff (Correlation coefficient (r)=0.593). Conclusion: NEDOCS was a more suitable measure for recording ED crowding in Pakistan, as it recorded the quantitative component of waiting time. ICMED, on the other hand, only recorded waiting time on a binary scale, with the waiting time impact not translated fully on the total score.

Objective: To identify demographic patterns and etiologies of CNS infections and to identify the clinical presentations, diagnostic accuracy, and clinical outcomes of various CNS infections in hospitalized patients in a tertiary care hospital. Study Design: Cross sectional study. Place and Duration of Study: Pak Emirates Military Hospital, Rawalpindi Pakistan, from Oct 2019 to Jun 2020. Methodology: A total of 97 adult patients presenting with clinical features of Central Nervous System (CNS) infection were enrolled for this in-hospital study. Cerebrospinal fluid (CSF) was collected for a routine examination, bacterial culture, and viral Polymerase Chain Reaction (PCR) test. Human Immunodeficiency Virus (HIV) serology and neuroimaging were done in all cases. The diagnosis was established based on World Health Organization guidelines for infectious diseases. Infections were classified into four major categories for analysis purposes. Results: Of 97 enrolled patients, the mean age was 38.8±18.5 years. CNS tuberculosis was the most common infection seen in 46(47.4%) cases, 25(25.7%) patients had viral encephalitis, and 17(17.5%) had bacterial meningitis. The rest of the patients (n=9) had fungal (3%) or parasitic infections (4%). In contrast, two patients were found to have focal cerebritis, one due to Brucella and the other due to Salmonella typhi. Conclusion: Tuberculosis is the most common (CNS infection in this region. First, patients with CNS infections, especially chronic ones, present very late in our setting, leading to increased morbidity and mortality. Secondly, Molecular diagnosis is obtainable in only a small percentage of cases for various reasons.

Objective: To determine the association of body mass index with the severity of COVID-19 pneumonia in hospitalized patients. Study Design: Cross-sectional study. Place and Duration of Study: Pak Emirates Military Hospital, Rawalpindi Pakistan, form May to Jun 2021. Methodology: Patients diagnosed with COVID-19 pneumonia on PCR and chest imaging and admitted to our hospital were included in the study. Body mass index was calculated on the first day of hospital admission, and they were followed up for two weeks during the disease. Increased oxygen demand, duration of admission, CT severity score and use of non-invasive ventilation were compared in patients with normal and increased body mass index. Results: A total of 800 COVID-19 patients admitted to the hospital were included in the final analysis. The mean age of the study participants was 41.36±4.55 years. Out of 800 patients, 337(42.1%) had normal BMI, 420(52.5%) were classed in the category of overweight and 43(5.4%) were obese. Furthermore, it was seen that increased demand for oxygen, high CT severity score and longer duration of hospital admission had a statistically significant relationship (p-value

Objective: To compare the yield of interictal epileptiform discharges on prolonged (1-2 hours) electroencephalogram (EEG) as compared to standard routine (30 minutes) electroencephalogram (EEG). Study Design: Comparative observational study. Place and Duration of Study: Pak Emirates Military Hospital, Rawalpindi from Oct 2019 to Sep 2020. Methodology: A total of 364 outdoor patients with suspected epilepsy were recruited for the study. Out of these 55 electroencephalograms were excluded after applying exclusion criteria and 309 were included for final analysis. Electro-encephalograms were recorded using a 10-20 international system of electrode placement. The duration of each standard electroencephalogram was 30 minutes. It was followed by recording for an extended period of 60 minutes at least. The time to the appearance of the first abnormal interictal epileptiform discharge was noted. For analytical purposes, epileptiform discharges were classified as “early” if they appeared within the first 30 minutes and as “late” if appeared afterward. All electro-encephalograms were evaluated independently by two neurologists. Results: A total of 309 electroencephalograms were included for final analysis. Interictal epileptiform discharges were seen in 48 (15.6%) recordings. The mean time to appearance of first interictal epileptiform discharge was 14.6 ± 19.09 minutes. In 36 (11.7%) cases, discharges appeared early (within the first 30 minutes) whereas in the remaining 12 (3.9%) cases, discharges appeared late. This translates into a 33% increase in the diagnostic yield of electroencephalogram with an extended period of recording. Conclusion: Extending the electroencephalogram recording time results in a significantly better diagnostic yield of outdoor electroencephalogram.

The accelerating global concern of climate change and its link with human health requires sustainability to be a crucial part of healthcare quality. The protection of planetary health in the context of ecological and social determinants of health require the integration of all aspects of health services including the professionals, management, and administration. Clinical health professionals particularly hold a critical position in this scenario, as they are mandated to protect individuals and communities from diseases caused or accelerated by environmental factors. Therefore, to combat the negative impacts of climate change on human health, the trusted voice of clinicians needs to be raised for communicating climate risks and solutions to patients, the public, and policymakers. Medical colleges’ curricula and continuing education programs require an alignment of climate and health education. This will equip future and current health professionals with skills for planetary health, regardless of their area of health focus. Clinical teaching and training with an updated medical education curriculum focusing on prevention; self-care; patient empowerment; lean service delivery such as community-based interventions; minimizing waste of medications and consumables, and low carbon emission alternatives is imperative to health service’s contribution in enhancing the quality of ecological sustainability. It has been documented that if the healthcare sector is ranked as a country, it would be the 5th largest CO2 emitter in the world with 4.4% global net emissions of greenhouse gases.1 The WHO has recently reported that 60% of healthcare facilities in the global south are ill equipped to handle existing waste loads. The healthcare community, clinicians, and hospital management are well-placed to play a vital role as change agents with Health in All Policies approach by protecting health during the current climate crises. An eco-friendly, equitable, interprofessional, and transdisciplinary approach is required to create a resilient healthcare sector that works harmoniously with nature while coping with increasing disease burdens and challenges to healthcare infrastructure. The triple bottom line is a holistic framework that helps organizations consider the environmental, social, and economic costs of their actions.2 In a healthcare setting, triple bottom line incorporates environmental and social impacts with patient-based outcomes and financial costs to measure the sustainability of healthcare interventions and services.2 It is an approach to reduce the adverse effects of healthcare delivery on the environment by incorporating improved sustainable quality and resource stewardship. The overall sustainable value is measured when the patient-based outcomes comprising utilization of a system, service, or process in healthcare are weighed against the “planet, people, and profit”. In conclusion, embedding sustainability principles, core knowledge, and practice in health professional expertise; the voice of clinicians in advocacy and policy to minimize healthcare sector greenhouse gases and ecologic footprint; and cross-sectoral solutions to the climate crisis are the only way forward for sustainable healthcare and the planet. Editor-in-Chief

Background and Purpose: Coronavirus disease 2019 (CO­VID-19) has an increased propensity for systemic hypercoagulability and thromboembolism. An association with cerebrovascular diseases, especially cerebral venous thrombosis (CVT), has been reported among these patients. The objective of the present study was to identify risk factors for CVT as well as its presentation and outcome in COVID-19 patients. Methods: This is a multicenter and multinational observational study. Ten centers in 4 countries (Pakistan, Egypt, Singapore, and the United Arab Emirates) participated in this study. The study included patients (aged >18 years) with symptomatic CVT and recent COVID-19 infection. Results: Twenty patients (70% men) were included. Their mean age was 42.4 years, with a male-to-female ratio of 2.3:1. Headache (85%) and seizures (65%) were the common presenting symptoms, with a mean admission Glasgow Coma Scale (GCS) score of 13. CVT was the presenting feature in 13 cases (65%), while 7 patients (35%) developed CVT while being treated for COVID-19 infection. Respiratory symptoms were absent in 45% of the patients. The most common imaging finding was infarction (65%), followed by hemorrhage (20%). The superior sagittal sinus (65%) was the most common site of thrombosis. Acute inflammatory markers were raised, including elevated serum D-dimer (87.5%), erythrocyte sedimentation rate (69%), and C-reactive protein (47%) levels. Homocysteine was elevated in half of the tested cases. The mortality rate was 20% (4 patients). A good functional outcome was seen in the surviving patients, with a mean modified Rankin Scale score at discharge of 1.3. Nine patients (45%) had a modified Rankin Scale score of 0–1 at discharge. Conclusion: COVID-19-related CVT is more common among males at older ages when compared to previously reported non-COVID-19-related CVT cases. CVT should be suspected in COVID-19 patients presenting with headache or seizures. Mortality is high, but functional neurological outcome is good among survivors.

Nanomaterials (NMs) have gained importance in technological advancement due to their changeable chemical, biological, and physical properties with improved efficacy compared to their bulk form. NMs are categorized according to their composition, size, shape, and origin with sizes ranging from 1 to 100 nm.1 NMs are being widely investigated for their potential use in Nanomedicine, a multifaceted field where biological sciences intersect with nanoscience, nanoengineering and nanotechnology. Due to its adaptable platform and design, nanomedicine can be useful in many fields, either by employing a multimodal therapeutic strategy or by developing highly specialized multifunctional nanodevices for the clinical purpose at hand. Nanomedicine research covers a wide range of areas, including the development of vaccines, antibacterial agents, drugs, wearable devices, diagnostic and imaging tools, high-throughput screening platforms, implants, etc., using biological, hybrid, biomimetic, or non-biological materials. Nanomedicine has enabled many significant developments in both basic and translational research, particularly in cellular, preclinical, and clinical research. However, most of these developments have been in the area of cancer treatment and detection. Many of these developments are beginning to be translated into viable, commercially available clinical products. For example, in August 2020, a rapid optical sensor-based test for the detection of COVID-19 was developed by a group of researchers at the University of Georgia. Their test kit was based on an optical nanosensor based on silver nanotriangle arrays functionalized with the human angiotensin-converting enzyme 2 (ACE2) protein.2 Studies on functionalized (ligand) nanoparticles that interact with the epitopes of the virus, were shown to rendering it inactive and preventing it from entering cells.3 The lipid nanoparticle-based vaccine developed by Pfizer and BioNTech using COVID -19 mRNA was approved by the UK authorities for emergency use in 2020, followed by Moderna's vaccines. Later, both Pfizer and Moderna were fully approved by the FDA. In addition, researchers involved in nanodevice manufacturing have turned their research interests to other ideas such as artificial organs and antibiotic resistance. Given its enormous potential, we believe that nanomedicine will eventually play a central role in all areas of medicine and enter clinics to become part of conventional clinical practice, provided that all aspects of implementation, including safety, regulatory, and ethical criteria, are met. Once this is the case, Nanomedicine should pave the way for the development of improved drugs and tools that can be used for the early detection and treatment of a wide range of diseases with high efficacy and specificity. This will ultimately improve the quality of life of patients. Although Nanomedicine offers exciting potential and opportunities to solve many medical problems, there are also certain scientific hurdles, mainly because we do not fully understand how nanomedicines behave in a biological system. A deep understanding of nanomedicine and the biological system can, therefore, pave the way for nanomedicine revolution. Editor-in-Chief How to cite this: Alamgir W, Haider A. The Nanomedicine Revolution. Life and Science. 2022; 4(2): 86-87. doi: http://doi.org/10.37185/LnS.1.1.389

Objective: To determine the prevalence of cognitive decline among the patients of stroke and analyze the associated socio demographic factors. Study Design: Cross sectional study. Place and Duration of Study: Tertiary care hospital of Rawalpindi, from May 2018 to Aug 2018. Methodology: The sample population comprised of n=180 patients of hemorrhagic or ischemic stroke presenting at a tertiary care hospital in Rawalpindi, Pakistan. Cognitive decline was assessed by using the British Columbia Cognitive Complaints Inventory (BC-CCI) four weeks after the acute stroke. Relationship of age, gender, marital status, education, type of stroke, presence of physical impairment and tobacco smoking was assessed with the presence of cognitive decline among the patients of stroke. Results: Out of 180 patients of stroke screened through British Columbia Cognitive Complaints Inventory, 129 (71.7%) showed the presence of cognitive decline while 51 (28.3%) had no cognitive decline. After applying the logistic regression we found that female gender and presence of physical impairment had significant association with the presence of cognitive decline among the patients of stroke. Conclusion: This study showed a high prevalence of cognitive decline among the patients of stroke in Pakistan. Routine screening for cognitive decline should be done at the stroke follow up clinic and special attention should be paid to the female patients of stroke and those with physical impairment.

Objective: To determine the frequency of neurological manifestations and complications of SARS-COV-2. We were especially concerned with the cases where the primary presentation was neurological indicating the neuro-invasive potential of the virus. Study Design: Prospective observational study. Place and Duration of Study: Pak Emirates Military Hospital, Rawalpindi, from Apr to May 2020. Methodology: A total of 405 confirmed COVID patients were enrolled for the study. Demographic features and initial clinical manifestations were noted and patients were followed during the hospital stay for the development of any new neurological signs and symptoms. For analytical purposes, neurological presentations were grouped into the central nervous system, peripheral nervous system, and musculoskeletal system manifestations. Appropriate laboratory testing was employed as required on case to case basis. Results: In this study, the mean age was 46.6 ± 15.5 years. Two hundred and seventy one (66.9%) patients were male while one hundred and thirty four (33.1%) were female. The neurological illness was a primary manifest-tation in twenty four (6%) cases. These included encephalopathy (n=15), ischemic stroke in young (n=2), Guillain-Barre syndrome, (n=1), facial nerve palsy (n=2), and encephalitis (n=1). The most common neurological symp-toms were headache 142 (35%), and hyposmia 39 (9.6%) followed by encephalopathy 34 (8.3%). More serious complications like seizures 7 (0.7%) and stroke 9 (2.2%) were also seen. Conclusion: Severe Acute Respiratory Syndrome-Coronavirus 2 can present with a neurological illness like its predecessors. We should remain vigilant to the possibility of neurological presentation of COVID-19 that can be thromboembolic, inflammatory or immune-mediated.

Objective: To determine the prevalence of headache among the patients of epilepsy and improvement in it after the treatment at a tertiary care hospital of Pakistan. Study Design: Interventional study. Place and Duration of Study: Department of Neurology, Pak Emirates Military Hospital Rawalpindi, from May 2018 to Aug 2018. Methodology: A total of 110 cases were included in the study, which were diagnosed as epilepsy in neurology outpatient department (OPD) by a consultant neurologist. Visual Analogue Scale (VAS) and Migraine Disability Assessment Questionnaire (MIDAS) were administered to these patients at the presentation and then 2 weeks after the appropriate medical treatment for epilepsy to assess the difference between the severity scores of the headache before and after the appropriate antiepileptic treatment. Results: A total of 125 patients were included, eighty patients were males and 30 were females. Most common type of seizures were generalized followed by partial. Sodium valproate was the most commonly prescribed antiepileptic drug followed by Levetiracetam and carbamezapine. 68 (61.8%) of our patients had headache at the time of presentation and diagnosis of epilepsy. Mean MIDAS score of the patients before the anti-epileptic treatment was 17.69 ± 3.85 and two weeks after the treatment was 7.29 ± 4.968 (p-value

Electroencephalogram (EEG) is widely used for the diagnosis of neurological conditions like epilepsy, neurodegenerative illnesses and sleep related disorders. Proper interpretation of EEG recordings requires the expertise of trained neurologists, a resource which is scarce in the developing world. Neurologists spend a significant portion of their time sifting through EEG recordings looking for abnormalities. Most recordings turn out to be completely normal, owing to the low yield of EEG tests. To minimize such wastage of time and effort, automatic algorithms could be used to provide pre-diagnostic screening to separate normal from abnormal EEG. Data driven machine learning offers a way forward however, design and verification of modern machine learning algorithms require properly curated labeled datasets. To avoid bias, deep learning based methods must be trained on large datasets from diverse sources. This work presents a new open-source dataset, named the NMT Scalp EEG Dataset, consisting of 2,417 recordings from unique participants spanning almost 625 h. Each recording is labeled as normal or abnormal by a team of qualified neurologists. Demographic information such as gender and age of the patient are also included. Our dataset focuses on the South Asian population. Several existing state-of-the-art deep learning architectures developed for pre-diagnostic screening of EEG are implemented and evaluated on the NMT, and referenced against baseline performance on the well-known Temple University Hospital EEG Abnormal Corpus. Generalization of deep learning based architectures across the NMT and the reference datasets is also investigated. The NMT dataset is being released to increase the diversity of EEG datasets and to overcome the scarcity of accurately annotated publicly available datasets for EEG research.

Human health, worldwide, is in great peril due to pollution and climate change. The sheer scale and expanse of climate change manifested as extreme weather conditions, changes in air quality, natural calamities, and vector ecology are negatively impacting human health. Frequent floods, wildfires, erratic rainfall, sea-level rise, and cyclones were documented across the globe in countries including Australia, Algeria, Brazil, China, Italy, Greece, Malaysia, Nigeria, Pakistan, South Africa, Spain, Türkiye and USA.1 The growing number of adverse health outcomes due to climate hazards is increasing the burden in the health services already impacted by the COVID-19 pandemic, co-epidemics (e.g., human immunodeficiency virus and tuberculosis) and double burden of disease (communicable and non-communicable diseases). Anthropogenic activities have drastically increased atmospheric greenhouse gas levels leading to a significant increase in the global mean surface temperature by 1.1° Celsius, warmer than the pre-industrial levels. The past seven years were declared the warmest, the 1.5-degree climate target agreed upon at the Conference of the Parties (COP21 )in Paris seems far out of reach as the global mean surface temperature is projected to rise to a dangerous level of between 1.5o Celsius and 3.5 Celsius by the end of this century.1 The ongoing climate stressors affect the populations that are most vulnerable and marginalised, like older people, pregnant women, new-born babies, people who are socially deprived and people working outdoors. Human exposure to intense heat is associated with heatstroke, adverse pregnancy outcomes (including premature birth), acute kidney injury, disturbed sleep patterns, mental health problems, cancers and worsening of underlying respiratory and cardiac disease. Annually, three million deaths are attributable to infections caused by outdoor PM2-5 air pollution.1 Asthma, the most common respiratory illness among adolescents, is influenced by higher and longer pollen seasons and poor air quality, increasing the risk of acute asthma episodes. Vector-borne diseases like malaria and dengue have increased in Africa and Asia. Rare severe infectious diseases caused by Naegleria fowleri, Nipah virus, and Coccidiodes spp have also increased. Extreme climate events also disrupt the food supply; leading to malnutrition and disease susceptibility. Human contact with environmentally mediated pathogens through food, water, animals, or insect vectors, causes substantial morbidity and mortality globally. Waterborne diseases are rising globally, especially in LMICs, with outbreaks of diarrhoea, hepatitis, cholera, malaria, dengue, salmonellosis, typhoid, dysentery, schistosomiasis, and giardiasis.2 Moreover, Vibrio pathogens are more transmissible due to rising coastal water temperatures. In Pakistan, waterborne diseases are becoming more frequent due to climate-based increased variations in temperatures and rainfall patterns, which have led to the challenges of water unavailability and exposure to unsafe water. In 2017, an epidemic of drug-resistance typhoid resulted in an untreatable and prolonged infection in Pakistani citizens resulting in many deaths in children below 15 years of age. The footprint of climate change is becoming more extreme in South Asia; India, Pakistan and the Philippines are in the “high” bracket” of the vulnerability assessment that has been most severely impacted by extreme weather events, according to the latest report by Intergovernmental Panel on Climate Change (IPCC). Pakistan, a negligible contributor to the overall carbon footprint, is still among the top ten countries vulnerable to climate change by Global Climate Risk Index 2021.1 The recent heavy rainfall and floods in Pakistan have resulted in the loss of life and livelihood. Human suffering, socioeconomic constraints, involuntary migration and displacement in climate emergency are massive. The response to the needs of the disaster-affected population remains a key challenge in terms of resource constraints, afflicted health systems, changing disease burden, the provision of shelter and emergency relief items, delivering lifesaving and livelihood assistance, water, sanitation and hygiene (WASH) needs, prevention of disease outbreaks, addressing malnutrition, Gender-based violence (GBV), Psychosocial Support (PSS), dignified protection, and family tracing. The recent 2022 United Nations Climate Change Conference (COP27) concluded with a cover decision known as the Sharm el-Sheikh Implementation Plan. COP27 concluded to provide “loss and damage” funding for vulnerable countries hit hard by climate disasters. The other decisions included cutting greenhouse gas emissions and adapting to the inevitable impacts of climate change, boosting finance and technology support, and widening the capacity building needed by LMICs. The planet's warming is jeopardising human health, demanding immediate climate action for mitigation and adaptation, fossil fuel reduction, building resilient communities, investing in emerging green technology, and integrating climate education into medical and school curricula.1-3 In our efforts towards a sustainable planet, it is critical to accelerate climate action by strengthening multisectoral engagement.

Avoiding a mosquito bite can prevent a number of viral as well as parasitic diseases like Chikungunya, Dengue, Japanese encephalitis, Rift valley fever, Yellow fever, Zika, Malaria and Lymphatic Filariasis. Of all these infections, malaria has been our nemesis right from the dawn of history. However, it is Dengue which has established itself as the most successful arthropod-borne viral infection not only in Pakistan but globally.1 The first case of Dengue in Pakistan was reported in 1994 from Karachi, after which it went quiet for almost twelve years to return in the form of an epidemic in 2006, which again remained limited to Karachi. However, it spread to many other parts of the country in the next few years on endemic scales. A person can get infected four times as the Dengue virus has four serotypes (DEN1, DEN2, DEN3 and DEN4) eachof which confers monotypic immunity. It is now a recognized acute febrile illness of the monsoon season (July-September), when a drop temperature and increased humidity provide optimal conditions for this urban dwelling, dawn and dusk, vector mosquito, Aedes aegypti. This vector now seems to be defying these climatic conditions as patients continue to report to hospitals in the winter months as well. The textbook diagnosis of Dengue looks simple; by detecting the virus either (by viral culture), its nucleic acid (by PCR), its components like the non-structural protein (NS-1), or the evidence of infection (IgM), or if none of these is available, then the surrogate markers like the typical bicytopenia showing reduced neutrophils and platelets are indicators of the disease. Similarly, the clinical diagnosis is not very difficult once the epidemic is established, due to its peculiar symptoms like retro-orbital pain and body aches , so severe as if the bones will break, hence the name 'Break Bone' fever. Dengue is temporarily incapacitating but rarely fatal, and in Pakistan it has a case fatality rate around 0.4 per cent.2 This low fatality rate should not lead to complacency as every life is precious. A few fundamentals, however, need emphasis especially for the young doctors and the medical staff attending the patients of Dengue. Like many other infectious diseases, Dengue follows the principle of the “tip of the iceberg”. Majority of those infected with the virus, remain either asymptomatic or present with minimum symptoms including low grade fever. However, a small percentage of patients may proceed to the critical stage called the Dengue Haemmorhagic Fever (DHF)/Dengue Shock Syndrome (DSS) and warrant special attention. These are basically the manifestations of underlying plasma leakage and it is this cohort of patients that are at an increased risk of an adverse outcome. The parameter which helps in this situation is the packed cell volume (haematocrit), an increase of about 15% of which is a reliable indicator of internal dehydration. DHF/DSS occur as a result of a second exposure by a different serotype, and a still not completely understood phenomenon, known as the Antibody Dependent Enhancement (ADE). Pakistan has barely recovered from the COVID19 pandemic, hit by the economic crisis and now unprecedented floods in Sindh and Baluchistan, where most parts are still inundated and are likely to be so for another several weeks, we are indeed in a very difficult situation. An estimated 6.4 million people require immediate assistance as around 1.96 million houses, 22,000 schools and 12,716 km of roads have been either destroyed or damaged in 81 districts.3 Ironically these two provinces have bulk of the country's falciparum malaria cases, which is the most lethal form with severe complications like heavy parasitaemia, cerebral malaria, black water fever and chloroquine resistance. Stagnant water all around the stranded people is a perfect mosquito breeding haven. It is difficult to comprehend the plight of people now living along the roadside under a tent in hot and humid conditions, as they are exposed twenty-four seven, either to the Dengue mosquito at dawn and dusk or, malaria causing anopheles mosquito at night. The magnitude of this problem is much bigger than the resources of any medical community and the government. Spraying insecticides over this volume is logistically not feasible. The only practical solution is the use of personal protective measures. Deaths from these two diseases along with gastroenteritis have already started to occur. The exact toll of these mosquito bites will be written by the medical historians or the statisticians sometime in the future. It is the youth of Pakistan which has once again risen to the occasion and is working relentlessly on volunteer basis, to reach out to these people not only providing them with mosquito nets and repellants but explaining their proper use. This altruistic effort will definitely save many lives. Editor-in-Chief How to cite this: Alamgir W, Usman J. Mosquito Bite and the Deadly Duo. Life and Science. 2022; 3(4): 149-150. doi: http://doi.org/10.37185/LnS.1.1.288

Objective: To determine the frequency of raised levels of homocysteine and associated socio-demographic factors among the young patients presenting with stroke at the neurology department of a tertiary care hospital of Pakistan. Study Design: Cross-sectional analytical study. Place and Duration of Study: Pak Emirates Military Hospital Rawalpindi, from May 2017 to May 2018. Methodology: The sample population comprised of young patients (18-44 years) presenting with the stroke at the emergency department of Military Hospital Rawalpindi. CT-scan brain was done and a consultant neurologist was consulted to confirm the stroke and its type. Fasting homocysteine level was done with in twenty four hours of the acute presentation at the hospital. Age, gender, body mass index, type of stroke, smoking, family history of stroke and hyperlipidemeia were correlated with the presence of raised homocysteine levels among these patients of stroke in young. Results: Out of 102 young patients confirmed with acute stroke on CT scan at the neurology department, 57 had presence of hyperhomocysteinemia while 45 patients had normal homocysteine levels. Mean age of the study participants was 30.66 ± 3.445. High body mass index and tobacco smoking had a significant relationship with the presence of raised homocysteine levels among these patients of stroke in young when binary logistic regression was applied. Conclusion: Raised homocysteine levels should be considered a possibility while evaluating the patients of stroke especially those who are young.

Objective: To determine the frequency and causes related to the precipitation of breakthrough seizures among adult patients with epilepsy despite antiepileptic treatment. Study Design: Cross sectional analytical study. Place and Duration of Study: Pak Emirates Military Hospital Rawalpindi, from May 2018 to Oct 2018. Methodology: The sample population comprised of 161 adult patients of epilepsy reporting to Military Hospital Rawalpindi with the epilepsy using the antiepileptic drugs (AEDs) at least for the past six months. Detailed history and physical examination was carried out for all the patients. Frequency of breakthrough seizures among this population was calculated and relationship were assessed with the precipitation of the breakthrough seizure. Results: Out of 161 patients of epileptic included in the study, 78 were male and 83 were female. Out of these 80.1% patients had breakthrough seizures. After applying the logistic regression we found that increasing age, marital status, sleep deprivation, total duration of treatment, missing one or two doses of antiepileptic drugs and watching television for long hours were strongly related to the precipitation of breakthrough seizures in our study patients. Conclusion: There was showed high frequency of breakthrough seizures in our population despite the use of AEDs. Special attention should be paid to the patients with increasing age and living alone. Education of patients regarding proper sleep, stress management, restricting TV hours and strict compliance should be done in order to prevent the phenomenon of breakthrough seizures and achieve a good control over this potentially life threatening condition.

Objective: To determine the frequency of different neurological features in Hashimoto's encephalopathy and to evaluate association with underling disease. Study Design: Cross sectional study. Place and Duration of Study: A Three-year study from Jul 2015 to Jul 2018. Conducted in Pak Emirates Military Hospital (PEMH) Rawalpindi. Methodology: This study is comprised of diagnosed patients of Hashimoto's encephalopathy. These patients fulfilled the diagnostic criteria. Any case with metabolic, toxic, vascular or malignant etiology of encephalopathy was excluded. Data regarding clinical symptoms particularly neurological and neuropsychiatric features, of diagnosed cases with Hashimoto’s encephalopathy was obtained from hospital record. Moreover, data about antithyroid antibody type, cerebrospinal fluid analysis, and MRI findings was gathered. Gender and age of the patients were also mentioned. Data was gathered on proforma by a resident doctor. The analysis was carried out using SPSS 20. Results were mentioned in the form of the mean for variables like age and percentage and frequencies for categorical variables. Results: Out of 13 patients, 5 (38.5%) were male and 8 (61.5%) were females. Majority of the patients 8 (61.5%) were euthyroid. Neuropsychiatric symptoms were present in all 13 patients with depression present in 8 (61.5%) cases, while 5 (38.4%) had hallucinations. Most cases were cognitively normal 8 (61.5%), while rest had mild impairment. No neurological manifestation was found significantly more common in any of the thyroid disease. Migraine-like headaches was present in 4 (30.7%) cases while epileptic seizures were present in 8 (61.5%) patients with GTCS the most common seizures type in 3 (23%) patients. Only three patient had MRI changes including temporal and hippocampal T2WI hyperintensities. Conclusion: If etiological factors for encephalopathy has been ruled out in the presence of underlying thyroid disease with a short history of symptoms, one should have a low threshold for treatment with the steroid to observe for the response.

Objective: To assess the clinical profile of the premonitory phase of migraine among the patients presenting with acute attack of migraine at a neurology unit of a tertiary care teaching hospital of Pakistan. Study Design: Cross sectional study. Place and Duration of Study: Neurology department, Pak Emirates Military Hospital Rawalpindi. One year, from 1st May 2017 to 30th April 2018. Methodology: The sample population comprised of 201 patients of new or previously diagnosed migraine presenting with acute attack at neurology department of PEMH Rawalpindi. Migraine was diagnosed by the consultant neurologist on the basis of International Classification of Headache Disorders diagnostic criteria for migraine. Symptoms of the premonitory phase were classed as Fatigue and musculoskeletal problems, cognitive and affective problems, homeostatic alterations, perceptual abnormalities, affective symptoms and others. Results: Out of 201 patients of migraine reporting in neurology OPD, 90.1% patients reported at least one symptom of premonitory phase. Male to female ratio of the patients was 1:3. Affective symptoms including low mood was the commonest symptoms reported among the target population followed by fatigue. Mean age of patients included in the study was 33.43 ± 3.845 years. Sleep disturbance was the least reported premonitory phase symptom among the patients of migraine in our study. Conclusion: There was high frequency of premonitory phase symptoms among the patients of migraine headaches in Pakistan. Sensitivity and severity of these symptoms need to be assessed routinely among the target population in order to effectively treat this headache syndrome with holistic approach.

Objective: To study the patterns of resistance to anti tuberculosis drugs in patients of drug resistant pulmonary tuberculosis. Study Design: Cross sectional analytical study. Place and Duration of Study: Department of Pulmonology, PEMH Rawalpindi from Jul 2016 to Dec 2017. Methodology: Four hundred and eighty eight (n=488) adult patients with suspected pulmonary tuberculosis based on clinical history or Chest X-ray findings suggestive of pulmonary TB were included in the study after full informed consent and using consecutive sampling. Patients were evaluated with examination of sputum or/and endobronchial washings for AFB smear, MTB GeneXpert/RIF assay and Culture for mycobacterium tuberculosis with drug susceptibility testing for first and second line anti TB drugs. Patients with resistance to any anti TB drug were classified as drug resistant tuberculosis cases and pattern of drug resistance documented. Results: Overall 74 patients were found to have drug resistant tuberculosis. Treatment naïve patients made up 48.6% of the drug resistant cases while 51.4% of the patients of drug resistant cases were previously treated cases. Among the drug resistant TB patients, 29 Patients (39.2% of the DR TB cases) were found to have MDR TB while 28 patients (37.8%) were found to have mono resistance tuberculosis. Resistance to INH was the commonest being present in 57 (77% of DR TB cases) patients which included 25 patients with mono INH resistance (89.3% of mono drug resistant cases). Fourteen patients (18.9% of DR TB) were found to have rifampicin resistance (RR-TB) on GeneXpert/RIF assay alone. Fluoroquinolone resistance was present in 22 patients (29.7% of the DR TB cases) while resistance to second line injectables was detected in three patients (4.1% of DR TB cases) including two patients diagnosed a XDR TB. Conclusion: Drug resistant pulmonary tuberculosis was frequent in previously treated as well as new patients of pulmonary tuberculosis. Drug susceptibility testing including molecular methods for detection of resistance to first line and second line drugs are essential for optimum management of these cases.

Objective: To determine the frequency of cerebral venous sinus thrombosis (CVST) among the patient with headache presenting from high altitude (HA). Study Design: Cross-sectional study. Place and Duration of Study: Pak Emirates Military Hospital, Rawalpindi, from 24th Apr 2018 to 24th Jan 2019. Methodology: The sample population comprised of patients presenting with the headache, living at a height of 3000-8200 meter above sea level. CT-scan brain, MRI brain and MRV brain was performed on all the cases. Carotid Doppler, d-dimers, thrombophillic screen, autoimmune profile, EEG and other relevant investigations were performed of all the cases diagnosed with CVST. Age, altitude, total time spent at HA and acclimatization were correlated with the presence of CVST among the patients of headache at HA. Results: Out of 60 patients reporting with headache from HA, 9 had presence of CVST on the relevant neuroimaging. Among these cases of CVST 2 had secondary polycythemia, 1 had protein C deficiency and 1 had protein S deficiency. Poor acclimatization had a significant relationship with the presence of CVST when logistic regression was applied. Conclusion: Cerebral venous sinus thrombosis should be considered a possibility while evaluating the causes of headache among the patients reporting from high altitude. Special attention should be given on acclimatization process for the people who are ascending to high altitude.

Objective: To determine the frequency and pattern of neurological features in patients diagnosed with gluten related disorder (GRD). Study Design: Cross sectional analytical study. Place and Duration of Study: Pak Emirates Military Hospital Rawalpindi, from Jan 2016 to Jun 2018. Patients and Methods: This study included cases who presented initially with neurological manifestations and later diagnosed having GRD, including coeliac disease (CD) or non-coeliac gluten sensitivity (NCGS). Cases fulfilling inclusion and exclusion criteria were selected. Record of patients was obtained from the hospital stats office. Cases were analyzed for clinical symptomatology, laboratory and neuro-radiological findings. Data was collected using performa and analysis was done using SPSS version 20. Results: Out of 31 patients, 18 (58.1%) were male and 13 (49.9%) were females. Mean age was 28.8 ± 10.4 years. Nineteen (61.3%) were diagnosed with CD while 12 (38.7%) had NCGS. Anti-TTG antibodies were detected in 17 out of 19 patients with CD, while anti Gliadin antibodies were positive in 11 out of 12 patients with NCGS. These results were statistically significant with p-value

Objective: To determine the burden of carotid artery disease among the patients of ischemic stroke and to analyze the relationship of associated socio demographic factors including the diabetes mellitus (DM). Study Design: Cross sectional analytical study. Place and Duration of Study: Pak Emirates Military Hospital Rawalpindi, from 10th May 2017 to 10th Nov 2017. Material and Methods: The sample population comprised of 190 patients of ischemic stroke presenting at a tertiary care hospital in Rawalpindi, Pakistan. CT-scan brain was performed to confirm the presence of acute ischemic stroke. Ultrasound Doppler was done by a consultant radiologist to assess the presence of clinically significant carotid artery stenosis. Relationship of age, gender, diabetes mellitus and duration of disease, education status, dyslipidemias and tobacco smoking was assessed with the presence of carotid artery stenosis among the patients of ischemic stroke. Results: Out of 190 patients of stroke assessed through ultrasound doppler, 53.7% showed the presence of significant carotid artery stenosis while 46.3% had no clinically significant stenosis. Hundred patients were nsuffering from DM. After applying the logistic regression we found that presence of DM and long duration of DM had significant association with the presence of carotid artery stenosis among the patients of ischemic stroke. Conclusion: This study showed a high frequency of carotid artery stenosis among the patients of ischemic stroke in Pakistan. Special attention should be paid to the patients who have been suffering from a metabolic disorder like DM. Long duration of DM also emerged as independent risk factor for carotid artery stenosis in our study population.

Present day decision making in healthcare has become a data-intensive process leading to the rise of healthcare analytics. These analytics involve the integration and analysis of data collected from multiple heterogenous sources including biomedical data (electronic health records), experimental (R&D) data, patient lifestyle and behavior data (store records, social media, wearable electronic devices etc) and financial data. Healthcare analytics is further being transformed by the application of current - omics technologies (genomics, epigenomics, transcriptomics, proteomics, metabolomics, pharmacogenomics etc), shifting healthcare to a system that is “predictive, preventive, participatory, and personalized”, referred to as the P4 medicine paradigm. The omics revolution is generating a huge amount of data that needs to be collected, stored, transformed, analyzed and ultimately delivered in a format that is understandable to the clinicians. Properly applied, healthcare analytics provide actionable insights that can lead to improvement in healthcare management and delivery, clinical outcomes, health policies and allocation of health resources to communities in need. Medical institutions worldwide are facing many challenges. There is a shortage of trained human resource, patients are more demanding and regulators are becoming more stringent. The healthcare systems are under pressure to provide better and safer healthcare that is also more cost-effective. This is leading to the development of a whole new healthcare analytics industry to capture, store and analyze big data for healthcare providers, health system leaders, and those in government health and human services to improve healthcare delivery and outcomes. A report by McKinsey Global Institute published in 2011 estimated that if US healthcare were to use big data creatively and effectively, the sector could create more than $300 billion in value every year.1 While innovative new technologies and platforms are making it possible to capture vast amounts of information of individual patient over a large timescale, a large amount of data remains underutilized and wasted. It is estimated that healthcare providers discard around 90% of the data that they produce.1 One of the greatest challenges in healthcare analytics is harvesting the data from multiple complex and heterogenous sources spread across different healthcare systems, health insurers, scientists, government bodies etc. and transforming it to generate meaningful information. Moreover, the personal and financial data and medical records of patients required to contribute to effective analytical platforms may be confidential and private and therefore inaccessible. Hospitals are also reluctant to share their financial and clinical audits. There is the issue also of ownership of the data and in many countries patient data is legally possessed by the patient. Even so the healthcare industry, slow to transition towards data mining and IT solutions, has now begun to adapt to the digital data age. Algorithms for collecting, compressing, anonymizing and sharing medical data are being developed by different groups in addition to various platforms specific to healthcare analytics. The implementation of healthcare analytics, particularly in developing countries like Pakistan where most healthcare facilities lack even the most basic form of EHRs is a formidable challenge. Pakistan has a robust IT community with a special interest and investment by the government sector in IT and Artificial Intelligence platforms. Pakistan government last year announced seed money of Rs 1.1 billion, to carry out a three-year project on AI, through the Higher Education Commission to be conducted by six universities. One of these projects, related to medical imaging and diagnostics, is a step in the right direction. However, we still have a long way to go if we are to reap the benefits of healthcare analytics in Pakistan. There is a need for the involvement and commitment of all stakeholders including healthcare facilities, academicians, researchers and industry etc to contribute to this endeavor. There is no shortage of qualified human resource in the country. All that is required is the will of the health sector to invest in this golden opportunity for healthcare analytics to play a role in improving the delivery of cost-effective care, save lives and define health policies in Pakistan. Editor-in-Chief How to cite this: Alamgir W, Mohyuddin A . Healthcare Analytics: Applications and Challenges. Life and Science. 2022; 3(3): 97-98. doi: http://doi.org/10.37185/LnS.1.1.263

BackgroundCytokine release syndrome (CRS) plays a pivotal role in the pathophysiology and progression of Coronavirus disease-2019 (COVID-19). Therapeutic plasma exchange (TPE) by removing the pathogenic cytokines is hypothesized to dampen CRS.ObjectiveTo evaluate the outcomes of the patients with COVID-19 having CRS being treated with TPE compared to controls on the standard of care.MethodologyRetrospective propensity score-matched analysis in a single centre from 1st April to 31st July 2020. We retrospectively analyzed data of 280 hospitalized patients developing CRS initially. PSM was used to minimize bias from non-randomized treatment assignment. Using PSM 1:1, 90 patients were selected and assigned to 2 equal groups. Forced matching was done for disease severity, routine standard care and advanced supportive care. Many other Co-variates were matched. Primary outcome was 28 days overall survival. Secondary outcomes were duration of hospitalization, CRS resolution time and timing of viral clearance on Polymerase chain reaction testing.ResultsAfter PS-matching, the selected cohort had a median age of 60 years (range 32-73 in TPE, 37-75 in controls), p = 0.325 and all were males. Median symptoms duration was 7 days (range 3-22 days' TPE and 3-20 days controls), p = 0.266. Disease severity in both groups was 6 (6.6%) moderate, 40 (44.4%) severe and 44 (49%) critical. Overall, 28-day survival was significantly superior in the TPE group (91.1%), 95% CI 78.33-97.76; as compared to PS-matched controls (61.5%), 95% CI 51.29-78.76 (log rank 0.002), pConclusionAn earlier use of TPE was associated with improved overall survival, early CRS resolution and time to discharge compared to SOC for COVID-19 triggered CRS in this selected cohort of PS-matched male patients from one major hospital in Pakistan.

The world as we know has changed. While a global pandemic has been an ominous risk for decades, COVID-19 came as a jolt, characterized by the functional interdependencies of the social, economic and public health systems. The initial shock and systemic failures from policy unpreparedness, not only bared open the fault lines of social injustice and inequity, but also led to xenophobic orientation and conspiratorial thinking. Social isolation, mental health illness, redundancies, financial difficulties and permanent closure of many businesses were the fall out of this crisis. The world adapted and moved from physical to digital. Financial systems, education, industry and entertainment were restructured and decentralized. The pandemic also had significant effect on the sociopolitical trends including sense of human solidarity, rebuilding of national pride, work-home balance, reducing human impact on climate and the selfless dedication of health professionals. The pandemic’s chaos presented an opportunity to reevaluate priorities and develop new strategic solutions to the disruptions caused by tactical difficulties consequent to this plague. The interdependencies of our society, use of information technology and exceptional computational sciences, are the so-called new normal, the most appropriate way to do governance in an era of hyper connectedness. The pandemic has shown that economic and social determinants of ill-health are strong predictors of health outcome. There is a need to work for universal health coverage as it is in everyone’s interest that people who feel unwell should not check their pocket before they seek help. It is also imperative to integrate community-led services into public systems so as to enable universal access, Free healthcare is not only vital for tackling pandemics but it also prevents millions of people from falling into extreme poverty by the cost of healthcare every year. One also needs to strengthen social safety nets to enhance resilience, given the interrelation between health and livelihoods. Lastly, developing a common culture that emphasizes personal responsibility in the public interest, is essential. It is important to underscore that the biggest steps forward in health have usually happened in response to a major crisis as raising of post-Second World War health systems across Europe or establishment of NHS in United Kingdom. Thus, coronavirus crisis, first and foremost a health crisis, has complex and long-term consequences. Policy preparedness, financing our health, and business leadership are key to resilience against such large systemic shocks. It can therefore be seen as an important opportunity for largescale, deep-seated structural change, far beyond the obvious, in scale and scope. Editor-in-Chief How to cite this: Alamgir W, Gilani RA. Normalization after Covid-19 Pandemic: Way Forward Towards Healthy Recovery. Life and Science. 2022; 3(2): 64-64 . doi: http://doi.org/10.37185/LnS.1.1.250 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited

Objective: To find out frequency of different causes of thrombophilia in young patients of cerebrovascular accidents. Study Design: Cross sectional descriptive study. Place and Duration of Study: This study was carried out at department of haematology, Army Medical College, Military Hospital and Armed Forces Institute of Pathology Rawalpindi, from Nov 2016 to Nov 2017. Material and Methods: Young patients aged 18 to 45 years were included in this study. Relevant history was obtained and general physical examination was done. Base line investigations included, complete blood count, prothrombin time, activated partial thromboplastin time and lipid profile. Tests for inherited thrombophilia (protein C, protein S, antithrombin, factor V leiden and prothrombin gene mutation) were carried out along with anticardiolipin, antiphospholipid antibodies and plasma homocysteine levels were measured to rule out, thrombophilia as a cause of CVA in young patients. The frequencies, of various causes of thrombophilia in CVA patients were analyzed. Results: Out of 30 patients there were 26 (86.7%) males and 04 (13.3%) females. The mean age was 36.6 years. The results of protein C, protein S, prothrombin gene mutation, antiphospholipid anticardiolipin antibodies, antithrombin and factor V leiden mutation were normal in all 30 patients. However, plasma homocysteine levels were raised in 20 patients with mean of 22.90. A statistical significance between the homocysteine levels and male genders was observed in this study. Conclusion: Raised plasma homocysteine levels were most common finding in young patients of CVA. All other laboratory parameters of thrombophilia were negative in young patients of CVA in our study.

Methanol is a frequently used organic solvent. However toxic doses of methanol may lead to serious metabolic acidosis and neurologic side effects including subarachnoid hemorrhage and sometimes even death. The case described suffered from such poisoning. Diagnosis was made on MRI brain that demonstrated bilateral putamen necrosis a neuro-radiological hallmark of methanol toxicity.