Dementia: need for studies in the new era

Current insights into the structure and function of the human brain has brought about revolutionary changes in concepts about normal and abnormal conditions affecting it. An age-old issue is that of Dementia, previously ignored as an inevitable consequence of aging or mental disorder, that can now be studied in greater depth and perhaps manged more efficiently in light of new research.

Stress, anxiety and depression levels among nurses working at Hayatabad Medical Complex, Peshawar, Pakistan

Introduction: Though mental disorders have remained global issues, their relationship with stressful life styles and occupations are a modern phenomenon. Anxiety and depression can become permanent components of personality, thereby affecting productivity and social activities. Objective: To determine the stress, anxiety and depression levels among nurses working at Hayatabad Medical Complex, Medical Teaching Institution, Peshawar, Khyber Pakhtunkhwa, Pakistan. Materials & Methods: A cross-sectional descriptive study was conducted on 100 nurses by using convenient sampling technique at Hayatabad Medical Complex, Medical Teaching Institution, Peshawar, Khyber Pakhtunkhwa, Pakistan, over 6 months duration from March 2020 to August 2020. A valid, reliable and adopted DASS-21 Scale was used for data collection. The data were analyzed for descriptive statistics by SPSS version 22.0. Results: Among all participants, 76% were female and 26% were male and have experience from 6 months to 20 years. More than half of the participants were highly affected by stress, anxiety and depression, and significant associations have been found between demographic variables, stress, anxiety and depression. The mean score of Stress, Anxiety and Depression was 16.74, 14.12 and 16.44 respectively. Conclusion: In conclusion, health care settings should provide their employees a respectful, culture sensitive and supportive environment to single female staff where they feel safe and happy. Lastly, cross-sectional surveys should be conducted on these psychological problems to find out the key factors behind them. Keywords: Stress, Anxiety, Depression, Nurses, Tertiary Care Hospital

Assessment of quality of life in patients with aphasia

Introduction: Personal satisfaction (Quality of Life; QoL) is the person's impression of their own prosperity. Aphasia is the most significant likely result of stroke and profoundly affects a patient's life, causing enthusiastic pain, sadness, and social separation, because of loss of language capacities. Objective: To document personal satisfaction in patients with aphasia. Materials & Methods: A cross sectional study was conducted at a Speech Clinic from October 2018 to March 2019 on 57 patients of aphasia to assess their quality of life. Informed consent was taken from respondents. Patients having aphasia due to any neurological cause or traumatic brain injury were included in study, while patients having childhood aphasia were excluded. Standardized questionnaire “Measuring changes in Quality of life in persons with aphasia: Is Communication Confidence a good measure?” was used to obtain information from participants through purposive sampling. Data were collected by face to face interviews with patients and their caregivers. Descriptive data analysis was done through SPSS. Results: Majority (68.42%) of respondents did not feel confident about their ability to convey meaning via speech with people. Difficulties in social communication were also a reason of concern for 45.61% participants, whereas 50.87% participants stated that they could not make their decisions. Conclusion: Patients suffering from aphasia had low quality of life, mainly due to their communication disabilities and dependence on other people for understanding, as well as the fact that their caretakers had to take decisions for them.

Association of upper crossed syndrome and posture among general population having neck pain in Islamabad

Introduction: Upper crossed syndrome is a common postural dysfunctional pattern that describes the dysfunctional tone of the musculature of the shoulder girdle/ cervicothoracic region of the body. Objective: To determine association of Upper Crossed Syndrome and Neck pain among general population in Islamabad. Materials & Methods: A cross sectional survey was conducted from December 2017 to February 2018 in Rawal General and Dental Hospital Islamabad, and National Institute of Rehabilitation Sciences Islamabad after approval of synopsis from Advanced Studies and Research Board. Convenience sampling was used to collect data from male and female participants having neck pain after obtaining informed consent. The questionnaires provided for a subjective assessment from the patient and an objective measure for the clinician. REEDCO scale was used to analyze the proper alignment of head, neck and shoulder, while wall push test was used to assess the abnormal protrusion of scapula. Data were analyzed for descriptive and inferential statistics by SPSS 20; continuous variables were expressed as mean ± SD, and categorical variables as frequency and percentage. A p≤0.05 denoted significance. Results: The occurrence of upper crossed syndrome was 24.1%. Out of 340 respondents, 143 (42.06%) had poor posture whereas 197 respondent (57.94%) had good posture. There was strong association between posture and upper crossed syndrome (p˂0.05). Conclusion: Most patients with neck pain are exposed to the risk of adopting poor posture which can lead to Upper Crossed Syndrome in future; hence the importance of postural awareness among general population of Islamabad.

Depression in females: comparison of patients visiting urban and rural teaching hospitals of Peshawar, Khyber Pakhtunkhwa

Introduction: Even though frequency of depression is documented globally, the spectrum of depression and its inciting factors in Pakistan are unique to the local cultural and social beliefs. Objective: To compare the status of depression and its provoking socio-cultural factors among urban and rural females attending selected hospitals of Peshawar. Materials & Methods: A cross-sectional comparative study was conducted from March to May 2017 on 93 female patients attending two selected urban and rural teaching hospitals of Peshawar. Data were collected on Beck Depression Inventory through convenience sampling, and were analyzed for descriptive statistics by SPSS version 20. Comparisons were done by the Chi Square test and the Student’s T test keeping p≤0.05 as significant. Results: Out of 93 female patients, a final 89 females (53 urban and 36 rural) were included due to incomplete data entries. More urban females were in the normal, mild or borderline clinically depressed categories (38/53, 71.7%), compared to rural females (15/36, 41.7%), more of whom were in moderate, severe and extremely depressed categories (21/36, 58.3%); the difference was significant (p=0.025). Among the many factors leading to depression, there were significant differences in poor socio-economic status (p=0.011), illiteracy (p=0.003) and hostile in-laws (p=0.016), all of which were mainly due to females of rural area rather than urban females. Conclusion: Rural females suffered significantly greater depression compared to their urban counterparts related to poor socio-economic status, illiteracy, and hostile in-laws. Keywords: Depression; Anxiety; Stress; Female; Marriage; Domestic Violence.

Diabetic Foot: its grades and mode of presentation at a tertiary care hospital of Peshawar, Khyber Pakhtunkhwa, Pakistan

Introduction: Diabetic foot is defined as the foot of diabetic patients with ulceration, infection, and/or destruction of the deep tissues, associated with neurological abnormalities and various degrees of peripheral vascular disease in the lower limb. Foot ulcers are the principal cause of severe complications and hospitalization among patients with diabetes, substantially increasing the costs of this disease. Objectives: To describe the presentation, distribute the diabetic foot lesions according to Wagner’s classification, and determine the outcome of diabetic foot ulceration in a tertiary care hospital of Peshawar, Pakistan. Materials & Methods: This study was conducted in the Surgery department of Rehman Medical Institute Peshawar. Thirty nine (39) patients with diabetic foot disease presenting from Jan 2018 to Dec 2019 were included in the study. The patients were evaluated and managed by classifying their disease according to Wagner’s classification for diabetic foot disease. Statistical analysis was done by using SPSS version 26 for descriptive statistics. Results: The most common age of presentation with diabetic foot lesion was between 41-70 years; out of 39 patients, 28 (71.8%) were males and 11 (28.2%) were females. Their mode of presentation was as follows- 22 cases (56.4%) with Ulcer, 9 cases (23.1%) with Cellulitis, 7 cases (17.9%) with Gangrene, and 1 case (2.6%) with Abscess. The most common grade of presentation were grades 3 and 4 Wagner’s lesion followed by Grade 1, and Grade 2. Debridement was the most common treatment modality (56.2%), followed by Amputation (41%). Conclusion: Foot ulceration in diabetic patients is a resource-consuming, disabling morbidity that often is the first step towards lower extremity amputation. Diabetic foot lesions can be easily graded according to the Wagner classification and helps in correlating appropriate treatment to the grade of the lesion for a better outcome.

Correlation of serum alpha fetoprotein (AFP) and tumor size of hepatocellular carcinoma (HCC) in a tertiary care hospital of Peshawar

Introduction: Early diagnosis of Hepatocellular Carcinoma (HCC) by imaging and biochemical tests would be valuable in controlling morbidity and mortality associated with this most common primary hepatic malignancy which is the third leading cause of global cancer-related deaths. Objective: To determine an association between the level of serum Alpha Fetoprotein (AFP) and the size of the tumor in Hepatocellular Carcinoma (HCC).Materials & Methods: This cross-sectional descriptive study was conducted in Rehman Medical Institute, Peshawar, Pakistan from January 2018 till December 2019. Data were gathered from the medical records of Endoscopy Unit of Rehman Medical Institute. Patients were separated into three groups on the basis of serum AFP levels: Group I had standard levels of AFP (<20 IU/ml), Group II had moderately raised AFP (20-399 IU/ml), and Group III had significantly raised AFP (>400 IU/ml). Patients were also separated into three groups on the basis of tumor; in Group A tumor size was less than 3 cm, in Group B it was between 3 and 5 cm, and in Group C the size was greater than 5 cm. For categorical variables, the Chi-square and Z test for proportions were applied; the Wilcoxon Rank-Sum (Mann-Whitney) test was used to evaluate the variation in the two categories, and the Kruskal-Wallis Rank test was used to evaluate the difference between categories. A p value ≤0.05 was taken as significant. Descriptive statistics were obtained by SPSS 24. Result: A total of 136 patients were evaluated according to AFP levels. The male to female ratio was 2.31:1. The mean presenting age was 59.36 ± 9.85 years while the mean tumor size was 6.93 ± 4.39 cm. Regarding AFP groups, there were 50(36.76%), in Group I, 31(22.79%) in Group II and 38(27.94%) in Group III. As per the Child Pugh classification, Class A, B and C were 69.85%, 16.18% and 0% respectively.Conclusion: Serum alpha fetoprotein was significantly associated with HCC tumor size. Alpha fetoprotein level can be a helpful marker to detect HCC and to differentiate between its initial and late stages. Monitoring AFP levels could be useful to diagnose recurring disease for patients with tumors that produce AFP.Keywords: Serum Alpha Fetoprotein; Hepatocellular Carcinoma; Tumor size.

Risk factors for ventricular tachycardia in acute ST-elevated myocardial infarction patients of a tertiary care hospital of Peshawar

Introduction: Ventricular arrhythmias are the most common cause of death in various ST-Elevated Myocardial Infarction (STEMI) patients and can be prevented if diagnosed and managed in time. Objectives: To document the occurrence of ventricular tachycardia in patients with acute ST-segment elevated myocardial infarction (STEMI) admitted to a tertiary care hospital of Peshawar and to identify associated risk factors. Materials & Methods: A descriptive cross-sectional study consisting of 252 MI patients of 51-60 years of age, were observed for the presence of ventricular tachycardia at Lady Reading Hospital, Peshawar from September 2017 to January 2018. Results: Hypertension was found to be the most common risk factor for ventricular tachycardia observed in 180 patients. Diabetes mellitus was the 2nd most common risk factor present in 104 patients while smoking was found in 56 patients. The most common location of ST-Elevation MI was anterior wall myocardial infarction (30.2%) occurring in 76 patients. Conclusion: Ventricular tachycardia occurred in a quarter of the patients presenting with acute ST-elevated myocardial infarction, and was more common in anterior wall MI followed by extensive anterior wall MI.

Pakistan specific COVID-19 overview and recommendations

Soon after its emergence in Wuhan, China in late December, the novel coronavirus (SARS-CoV-2) spread rapidly to the other parts of the world and acquired a pandemic status. Pakistan reported its first case of SARS-CoV-2 on February 26, 2020, in Karachi. Since then, a higher prevalence of COVID-19 was reported from almost all major cities of Pakistan. Owing to the high rate of COVID-19, Pakistan enforced a lockdown across the whole country on March 24, 2020. This lockdown controlled the SARS-CoV-2 successfully; however, severe economic losses were observed in the lockdown Standard Operating Procedure (SOP) guidelines. We, therefore, proposed an alternative plan termed as “regulated reverse lockdown” which will help decrease the burden of COVID-19 without having a negative effect on the economy. The present editorial will address the potential flaws in the already imposed lockdown and will propose an alternative plan to make the lockdown more effective in terms of COVID-19 prevalence and economic growth of Pakistan.

Outcome of tonsillectomy in children without the use of postoperative antibiotics at two tertiary care hospitals of Peshawar

Introduction: Overuse of antibiotics can lead to antimicrobial resistance and unnecessary costs. Although early studies reported improved outcomes following use of perioperative antibiotics for tonsillectomy, more recent studies have not been able to demonstrate a significant benefit on post tonsillectomy morbidity. Objective: To determine the need for postoperative antibiotics in children undergoing tonsillectomy under aseptic conditions at two tertiary care hospitals of Peshawar. Materials & Methods: Children aged 5-14 years admitted to the departments of Otorhinolaryngology-A unit of Hayatabad Medical Complex and Rehman Medical Institute, Peshawar from March 01, 2018 to September 30, 2018 for recurrent sore throat and recurrent quinsy were included in this quasi-experimental study based on prospective data collection and convenience sampling. Children with blood dyscrasias, upper and lower respiratory tract infections, and cardiopulmonary diseases were excluded. Routine preoperative investigations were done, and all were given postoperative analgesics. The patients were divided into two consecutive groups of 60 each; Group-A was given Co-amoxiclav 20mg/5mg/kg/day for 10 days and Group-B was not given any antibiotic. During their stay in the hospital and on follow up they were asked about pain via Visual Analogue Scale, and presence of fever and/or bleeding were documented. Results: Of 120 children, 50 (41.6%) were males and 70 (58.4%) were females, of ages 05-14 years; 01(1.6%) from Group-A and 01(1.6%) from Group-B presented with reactionary hemorrhage. However, 01(1.6%) from Group-A and 25(40%) from Group-B presented with secondary hemorrhage for which they were readmitted and put on injectable antibiotics. Similarly, 05(8.3%) from Group-A and 14(23.3%) from Group-B presented with pain for which pain killers were prescribed. Conclusion: Post tonsillectomy antibiotics may have a role in reducing the morbidities associated with the procedure in our setup. Keywords: Tonsillectomy; Postoperative Infections; Antibiotic Resistance; Hemorrhage.