Mental Health Care in Pakistan
Shahid Kamal
Pakistan faces multiple challenges in the health sector, including the status of mental health care. This issue is further compounded by socio-cultural, religious, economic factors, and a weak inadequate mental health care infrastructure [1]. The health budget allocated for Pakistan in 2023 is PKR 24.25 billion, constituting 2.8% of the total development budget and a mere 0.05% of the GDP. Of this, the allocation for mental health care is a mere 0.4%. Moreover, despite a population exceeding 220 million, the country has fewer than 500 qualified psychiatrists [2]. The mental health of our populace has further deteriorated due to longstanding political disputes, violence, terrorism, epidemics, droughts, earthquakes, economic challenges, and unemployment issues [3].
doi.org/10.21089/njhs.101.0001
Prevalence of Red Blood Cell Alloimmunization among Children with Sickle Cell Disease in Southern Region of Saudi Arabia: A Single-Center Experience
Badriah Gharamah Al Asmari, Mohammed Alpakra, Ali Mujtaba Tahir, Ali Abdullah Hawan, Nagwan Nabil Mohamed Hossameldin, Mahnoor Saeed, Abdulaziz Mohammed Alsharaef, Jamilah Hadi Eissa Al Ali
Abstract: Background: Sickle cell disease (SCD), carrying a varied worldwide prevalence, is a commonly encountered entity in Kingdom of Saudi Arabia and Mediterranean. It is characterized by a range of complications. Blood transfusion is essentially required for both episodic and chronic indications. These blood transfusions inherently imply various risks including alloimmunization.
Objective: To ascertain the incidence of red blood cell alloimmunization in children having sickle cell disease (SCD).
Materials and Methods: Retrospective cross-sectional study was conducted at the Department of Pediatric Medicine, Armed Forces Hospital Southern Region, Khamis Mushait, Saudi Arabia, after obtaining permission from Research Ethics Committee (REC certificate number AFHS-RMREC/2024/Pediatrics/745). The data was collected for last three years 1st July 2021 to 30th June 2024, regarding pediatric patients having sickle cell disease while aged one to fourteen years.
Results: 188 patients of sickle cell disease – all with Saudi ethnicity – were selected with 81 (43%) patients being female and 107 (57%) male. The mean age was 6 years 2 months. Each patient had an average of 2.3 admissions during the course of the disease. Out of these 188 patients, 14 (7.4%) patients were found to have alloimmunization. Mean age at which they developed alloimmunization was 6 years 8 months. 12 patients were on hydroxyurea and 7 patients (50%) underwent splenectomy. On average these cases received 13 transfusions. In contrast, only three (21.4%) patients had undergone exchange transfusion. The most commonly identified single alloantibody was anti-E as seen in 3 patients (21.4%), followed by anti-M in two cases (14.3%). In 4 cases (28.6%), there was an indeterminate antibody (with no specific pattern). Two (14.3%) children were having combination of alloantibodies.
Conclusion: Among the children from southern region of Kingdom of Saudi Arabia, the incidence of alloimmunization in SCD was 7.4%.
Received: December 09, 2024
Revised: February 17, 2025
Accepted: February 20, 2025
doi.org/10.21089/njhs.101.0003
Association of Xmn-1 Polymorphism with HbF Levels in Patients Presenting with Sickle Cell Disease at Tertiary Care Hospital, Karachi.
Almas Khan, Saima Siddiqui, Haya ul Batool Abbasi, Danish Zahid, Arpna Nihal, Sumaira Sharif
Abstract: Background: Sickle cell anemia is a common hereditary disease in Pakistan, which still maintains significant inter patient variation in disease manifestations and the reasons behind such variations remain uncertain. Among other genetic modifiers the XmnI polymorphism has been noted to influence HbF levels, response to HbF augmenting drugs and milder phenotype of disease as observed in studies conducted in various parts of world and subcontinent. XmnI polymorphism frequency and its association with HbF levels have not been investigated in Pakistani patients of sickle cell disorder. This study aims to determine different genotypes of XmnI polymorphism, and association with high HbF levels in patients of homozygous sickle and sickle/β thalassemia.
Objective: To ascertain the incidence of red blood cell alloimmunization in children having sickle cell disease (SCD).
Materials and Methods: Retrospective cross-sectional study was conducted at the Department of Pediatric Medicine, Armed Forces Hospital Southern Region, Khamis Mushait, Saudi Arabia, after obtaining permission from Research Ethics Committee (REC certificate number AFHSRMREC/2024/Pediatrics/745). The data was collected for last three years 1st July 2021 to 30th June 2024, regarding pediatric patients having sickle cell disease while aged one to fourteen years.
Results: 188 patients of sickle cell disease – all with Saudi ethnicity – were selected with 81 (43%) patients being female and 107 (57%) male. The mean age was 6 years 2 months. Each patient had an average of 2.3 admissions during the course of the disease. Out of these 188 patients, 14 (7.4%) patients were found to have alloimmunization. Mean age at which they developed alloimmunization was 6 years 8 months. 12 patients were on hydroxyurea and 7 patients (50%) underwent splenectomy. On average these cases received 13 transfusions. In contrast, only three (21.4%) patients had undergone exchange transfusion. The most commonly identified single alloantibody was anti-E as seen in 3 patients (21.4%), followed by anti-M in two cases (14.3%). In 4 cases (28.6%), there was an indeterminate antibody (with no specific pattern). Two (14.3%) children were having combination of alloantibodies.
Conclusion: Among the children from southern region of Kingdom of Saudi Arabia, the incidence of alloimmunization in SCD was 7.4%.
Received: June 30, 2024
Revised: February 04, 2025
Accepted: February 04, 2025
doi.org/10.21089/njhs.101.0008
Patient Satisfaction after Basal Cell Carcinoma (BCC) Excision in Head and Neck Region Followed By Reconstruction with Loco Regional Flaps and Full Thickness Skin Graft
Seema, Waqas Sami, Faisal Akhlaq Ali Khan, Sana Shoukat, Maryam Noor, Mujtaba Pervez Khan
Abstract: Background: Basal cell carcinoma (BCC) is one of the most frequent malignancies and constitutes nearly 80% of the non-melanoma skin malignancies. There is scarcity of local data regarding the patient satisfaction level in the BCC treatment.
Objective: To assess patient satisfaction after BCC excision in head & neck region followed by reconstruction with loco regional flaps & full thickness skin grafts (FTSG).
Materials and Methods: The present prospective cohort study was performed in Department of Plastic & Reconstructive Surgery Department at Dr. Ruth KM, Pfau, Civil Hospital Karachi, Pakistan during 1st November 2023 to 1st November 2024 after obtaining approval from ethical committee (IRB-3096/DUHS/Approval/2023/420). Post-operatively, patient satisfaction was assessed using four key aspects: skin color, tissue coordination, scar appearance, and skin texture. Each aspect is scored on a scale of 1 to 5, with 1 indicating “Extremely Dissatisfied” and 5 indicating “Extremely Satisfied. Total satisfaction score was calculated by summing four categories and total score of ≥14 was considered as greater patient satisfaction.
Results: Total 215 patients were enrolled into the study with mean age of 50.4 ± 10.0 years. More than half of the patients were males (68.4%) and having lesion of nose (51.6%). Mean lesion size was 1.6 ± 0.6 cm. Half of the patients underwent FTSG reconstruction (50.2%). Satisfaction related to skin color (4.2±0.8 vs 3.2±0.8, p < 0.001), skin tissue (3.5±0.9 vs 3.3±0.8, p=0.009) and scarring (3.9±0.7 vs 3.6±0.6, p < 0.001) were higher in patients underwent local flap reconstruction than FTSG.
Conclusion: The present study demonstrated that post-BCC excisional defects reconstruction in head and neck region using local-regional flap brings out higher satisfaction level among patients in comparison to full thickness skin graft.
Received: November 09, 2024
Revised: February 26, 2025
Accepted: February 28, 2025
doi.org/10.21089/njhs.101.0015
Evaluating the Predictors of Mortality in Extremely and very Preterm Neonates in a Developing Country
Durre Shahwar Khan, Haider Abbas, Kashif Abbas
Abstract: Background: : Various comorbidities affect preterm infants throughout their hospitalization. Death among children under the age of five years occurs mainly due to complications developed after preterm births accounting for almost a million fatalities annually. Infants with extremely preterm births are at great risk of complications, which frequently cause death.
Objective: To identify the rate of survival and deaths in extremely and very preterm neonates in our center and to identify the commonest predictors of mortality in our preterm population.
Materials and Methods: This prospective observational longitudinal study was conducted at the Department of pediatric medicine, Liaquat National Hospital, Karachi, Pakistan, after obtaining the permission from Ethics Committee of the hospital (Ref. App # 0889 -2023-LNH-ERC), over a period of 9 months from 10th April 2023 to 10th January 2024. 169 Neonates in total were managed uniformly and followed up till discharge or death. Chi-square test was used to compare categorical variables. P-value ≤ 0.05 was taken as statistically significant.
Results: There were 53.3% male and 46.7% female patients. The majority of patients (89.3%) had very low birth weights. Most of the births were very preterm births (67.5%) followed by preterm births (20.1%), and extremely preterm births (12.4%). Death was recorded in 11 (6.5%) patients and among these patients sepsis was the most observed cause with 45.5%. Extremely preterm births and very preterm births were significantly associated with gender and birth weight, but not with survival status and predictors of mortality.
Conclusion: Very preterm was the most common birth status. Mortality was reported 6.5% cases. The most common predictor of mortality was Sepsis.
Received: August 04, 2024
Revised: February 08, 2025
Accepted: February 10, 2025
doi.org/10.21089/njhs.101.0020
Dental Age Estimation on Digital Panoramic Radiographs: A Comparison among Final Year Students, Graduates, and Postgraduate Trainees
Nayab Raza, Syed Yawar Ali Abidi, Samira Adnan, Maham Muneeb Lone
Abstract: Background: Panoramic radiographs aid in holistic treatment planning and dental age estimation based on tooth development stages and eruption sequence. Evaluating dental professionals’ proficiency to precisely estimate patient age using orthopantomograms (OPGs) is crucial for identifying existing skill gaps.
Objective: This study aimed to evaluate and compare the knowledge of dental age estimation using digital panoramic radiographs among final-year dental students, recent graduates, and postgraduate trainees.
Materials and Methods: This cross-sectional study was conducted at Sindh Institute of Oral Health Sciences (SIOHS), Jinnah Sindh Medical University (JSMU), over a two-month period from 1st October till 30th November 2022, at the Department of Oral Radiology. Ethical approval was obtained bearing number JSMU/IRB/2022/-639. The calculated sample size was 402, and non-probability convenience sampling was used. An online questionnaire was designed with eight digital OPGs (6–16 years), analyzed by dental specialists using the American Dental Association (ADA) eruption sequence guideline. Each OPG was accompanied by options related to the most likely age to be selected by the study participants. The Google Form link was shared with all potential participants via Facebook and WhatsApp Messenger. Frequency of correct responses was calculated, and chi-square test was applied to determine any significant differences between participants based on their responses (p- value ≤ 0.05).
Results: The response rate was 78.7%, with 493 completed forms analyzed. Most participants were aged 18-23 years (53.3%), and 71.2% were female. Participants comprised final-year students (32.7%), graduates (41%), and postgraduate trainees (26.4%). Postgraduate trainees had the highest percentage (60.4%) of correct responses, followed by graduates (54.7%) and final-year students (48.4%). Radiographic image 8 had the highest correct responses (74.2%), while image 7 had the lowest (25.6%). No statistically significant relationship was found between participants’ qualifications and their ability to identify the correct age range on OPGs (p > 0.05).
Conclusion: The ability to correctly identify the age range of OPGs seems to improve with progression in clinical training, since more postgraduate dental trainees were able to accurately identify the age range of patients compared to other participants.
Received: June 29, 2024
Revised: February 12, 2025
Accepted: February 12, 2025
doi.org/10.21089/njhs.101.0026
Addressing Soft Tissue Defects of Hand and Forearm Using Posterior Interosseous Artery Flap: An Observational Study
Shiza Mehak Sohail, Faisal Akhlaq Ali Khan, Waqas Sami, Sumaira Sattar, Erum Naz
Abstract: Background: Covering large wounds in a stable, long-lasting, and aesthetically pleasing manner is the primary task for a hand surgeon. Because the posterior interosseous artery (PIA) flap produces thin, malleable skin, it is an excellent tissue for covering hand deformities.
Objective: To determine frequency of successful flap survival based on PIA flap in patients with soft tissue injuries of the dorsum of the forearm and hand.
Materials and Methods: The prospective observational study was conducted at Plastic & Reconstructive Surgery Department of Dr. KM Ruth Pfau Civil Hospital in Karachi, Pakistan. After obtaining approval from the institutional review board’s official, (IRB-3378/DUHS/clearance/2024/24), the study took place from 1st May to 30th October of 2024.The follow-up was done two weeks after their surgery. Clinical examination was used to monitor the flaps including assessment of flap color, skin turgor and absence of venous congestion. If patients were found normal and recovering during the follow-up, the flaps were marked as successful.
Results: A total of 32 patients were studied with average age of 31.4 ± 9.9 years. Age range of patients was 18-50 years. Three-fourth of study participants were males (75%).Average duration of injury was 15.8 ± 4.6 days. More than three-fourth were accident cases (84.4%) and had injury in hand (78.1%).Out of 32 patients, flap was successful in 31 patients. Only one flap was unsuccessful while complications were observed in 2 patients only. One had complication of wound infection and other had complication of marginal flap necrosis.
Conclusion: This study concludes that PIA flap is a safe and reliable technique in reconstruction of soft tissue defects of hand and forearm. However, patients should be closely monitored post-operatively to detect any complications for timely surgical intervention.
Received: January 28, 2025
Revised: March 11, 2025
Accepted: March 11, 2025
doi.org/10.21089/njhs.101.0032
Breastfeeding Practices and Morbidity among Infants Born to Covid-19 Mothers at a Tertiary Care Hospital Karachi, Pakistan: A Prospective Cohort Study
Khushboo Qaim Ali, Sameera Ali Rizvi, Saleema Khowaja, Syeda Tabeena Ali, Uswa Jiwani, Shabina Ariff
Abstract: Background: The novel coronavirus disease 2019 has affected general population including pregnancy due to physiological changes that can causes partial immune compression in women and increases risk of acquiring severe infections. It has also shown an impact on infants born to Covid-19 mothers. The aim of the study was to compare breastfeeding and Morbidity among infants born to Covid positive and negative mothers at the age of six months.
Objective: The study aimed to evaluate the long-term impact of breastfeeding and morbidity of infants among Covid 19 mothers.
Materials and Methods: : This is a prospective cohort study which was conducted at the Aga Khan University Hospital (AKUH) from 20th November 2020 to 2nd July 2021, after obtaining the permission from the Research Ethics Board at Shaheed Zulfiqar Ali Bhutto Institute of Science and Technology (SZABIST) (IERB(7)/SZABIST-KHI(LIFE)/19104121/200118) and the AKUH Ethical Review Committee (ERC#:-Ped-ERC- 2020-5576-14891). Mothers were identified from hospital medical records and were followed-up at the age of six months. Participants were recruited via a non-probability purposive sampling method. Antenatal, perinatal, postnatal outcomes and neonatal data was collected via structured questionnaire.
Results: Altogether 208 neonates were enrolled in the study, (n=104) in each group. Early initiation of breastfeeding within first hour of life was observed in 69 (33.3%) neonates (p value=0.049). Altogether, 120 (58.5%) neonates were exclusively breastfed during hospital stay. It was observed that exclusive breastfeeding was higher (68.9%) in non-exposed group immediately after birth. There was no significant difference in breastfeeding practices (RR; 1.0, 95% CI: 0.76-1.32; p value= 0.99) and morbidity status (RR; 1.07, 95% CI: 0.82-1.41; p value= 0.579) of infants at the age of six months among both groups.
Conclusion: COVID-19 has impacted maternal and early neonatal outcomes, necessitating prompt interventions to reduce complications. Encouraging timely breastfeeding initiation can enhance benefits, lower infant morbidity, and support sustained exclusive breastfeeding.
Received: September 11, 2024
Revised: March 11, 2025
Accepted: March 13, 2025
doi.org/10.21089/njhs.101.0037
Diagnostic Accuracy of Orthopantogram in Identifying the Proximity of Inferior Alveolar Nerve Canal to the Roots of Mandibular Third Molar as Compared to Cone Beam Computed Tomography
Iqra Naeem, Muhammad Usman Khalid, Malik Muhammad Usama, Muhammad Shafique Ashraf
Abstract: Background: Third molar extraction is the most frequent surgical treatment performed in a dental office. For initial risk evaluation of IAN damage, traditional radiographic examinations like orthopantomography (OPG) are indicated. To gather local evidence, we did this research.
Objective: The aim of this research is to compare orthopantomography with cone beam computed tomography in identifying whether an impacted mandibular third molar (IM3M) is near the inferior alveolar nerve canal.
Materials and Methods: This cross sectional (validation) study was conducted at the Department of Oral & Maxillofacial Surgery, Faisalabad Medical University, Faisalabad from 30-5-2022 to 30-11-2022 after obtaining the permission from ethical review committee (F.No.48-ERC/2020-21/PHRC/FMU/103). 280 candidates fulfilled selection criteria were selected from the OPD. Patients then underwent OPG and findings were recorded and patient was labeled as positive or negative. Later on, patients underwent CBCT and findings were recorded. All the data was recorded on proforma while analyzed in SPSS ver 20.0.
Results: The mean age of patients was 34.76±9.27 years. Out of 280 patients, there were 131 (46.8%) males and 149 (53.2%) females. Out of 280 patients, 135 (48.2%) had left side IM3M extraction while 145 (51.8%) had right side IM3M extraction. On OPG, 65 (23.2%) had superimposition, 71 (25.4%) had interruption, 64 (22.9%) had darkening of roots and 80 (28.6%) had narrowing. The sensitivity of OPG was calculated as 79.8%, specificity was 97.2%, while PPV and NPV were calculated as 97.9% and 74.8% and diagnostic accuracy of OPG was 86.4%, taking CBCT as gold standard.
Conclusion: Thus, OPG can be somewhat reliable method for IAN position before Im3M extraction.
Received: December 25, 2024
Revised: February 24, 2025
Accepted: February 25, 2025
doi.org/10.21089/njhs.101.0046
Modernizing Thalassemia Detection: Insights from Third Generation Sequencing
Shahzad Ali Jiskani, Asma Mustafa, Maryam Zulfiqar, Bushra Anam Ali, Aliena Sohail, Asfa Zawar
Abstract: Thalassemia, an inherited hematologic disorder, places a considerable societal and economic burden. Efficient prevention and management of this ailment necessitates the implementation of comprehensive screening strategies. Third–generation sequencing (TGS), an innovating technology, shows significant potential for applications in screening and diagnosis across numerous disorders. Although its utilization in the detection of thalassemia is in early phases, the current review explore recent and extensive applications, benefits of TGS, and associated problems and resolutions in incorporating it into routing screening and diagnostic procedures of thalassemia. In essence, TGS has displayed heightened degrees of progressive detection analysis and diagnostic precision in comparison to traditional methodologies and NGS. This observation suggests that technologies of TGS stands as a reasonable choice for diagnostic laboratories conducing the testing of thalassemia. The integration of TGS in diagnosis of thalassemia is anticipated to simplify the formulation of operational prevention and therapeutic approaches, ultimately mitigating impact of thalassemia on individuals and community.
Received: July 04, 2024
Revised: December 25, 2024
Accepted: January 15, 2025
doi.org/10.21089/njhs.101.0051
Superior Vena Cava Syndrome in a Child with Steroid Resistant Nephrotic Syndrome; A Case Report and Review of Literature
Saima Kashif, Khemchand N. Moorani
Abstract: Nephrotic syndrome (NS) is one of the risk factors for thromboembolism (TE). We report here a rare case of a 6.5-year-old boy who presented with superior vena cava syndrome (SVCS) secondary to thrombosis during relapse of NS. He was diagnosed with primary steroid resistant nephrotic syndrome (SRNS) and was maintaining partial remission with triple regime immunosuppressive treatment for the last one year. He presented in the emergency department with generalized body swelling, more marked on face and neck for last one week. Initially managed as relapse of nephrotic syndrome but it was observed that his face and neck edema instead of disappearing, increased despite his pedal edema improving. This raised suspicion of neck vein thrombosis. Ultrasound doppler revealed sluggish flow in the internal jugular vein (IJV) and superior vena cava (SVC). CT angiogram further confirmed thrombosis in IJV extending to SVC. The patient was successfully treated with low molecular weight (LMW) heparin followed by maintenance anticoagulant therapy with rivaroxaban, a factor X inhibitor. Early consideration and intervention may prevent morbidity and mortality.
Received: July 30, 2024
Revised: January 06, 2025
Accepted: January 23, 2025
doi.org/10.21089/njhs.101.0059
