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Background Person-centered care is one of the vital components of a health care system and signifies the concept of health promotion and disease prevention. This study aimed to identify the perceptions of patients and physicians regarding person-centered care in the Eastern Mediterranean Region (EMR). Methods A cross-sectional study was conducted in six countries of EMR during June 2019 to August 2019. In first phase, 190 family physicians (FPs) practicing for atleast six months were recruited. In the next phase, the recruited FPs then approached their patients aged more than 18 years. Multinomial regression analysis was conducted using SPSS version 20. Results Of a total of 300 patients, 25% were aged 40 years or above and the majority 56% were females. Among physicians, 62.8% were between 25 to 35 years and 88% had a postgraduate training in Family Medicine. Thirty six percent of patients and 62.6% of physicians, preferred a person-centered care model of care. Among physicians, field of specialization (ORadj= 0.7; 95% C.I: 0.3-0.9) and regularity in continuing medical education sessions (ORadj= 0.3; 95% C.I: 0.1-0.5) while, among patients, educational status was significantly associated with preference for person-centered care model. Conclusions The transition towards person centered care model has already started and most care providers endorse it. However, there is a need to apply this approach consistently, keeping the cultural aspects in mind. Key messages There is a need for intensive research on the development of integrated primary care models to improve access to person-centered care.

COVID-19 has become a major global public health threat. It started from Wuhan a province of China in December 2019 and has spread in every country of the globe with over 100 million people currently infected and over three million deaths as of May 2021. Nearly a year on, with many town and cities are in lockdown and with all public health measures to minimize transmission of the virus SARS-COV-2 and the scientific achievements with many vaccines developed in record time, the transmission in the second wave is still strong with new variants of the virus emerging. The pandemic has caused a serious impact on the economic, social, political, and cultural dynamics of people, globally. The majority of people with mild and moderate symptoms of COVID-19 seek primary care (PC) service as the entry point for getting medical intervention, reducing flow to hospital care. Currently, primary care settings are facing major challenges including lack of funds, poor infrastructure in some countries, and shortage of health care workers and equipment. Most, if not all primary care centers are not designed to separate people with the virus. The pandemic so far shows that strengthening primary care as the first point of contact with the health system is vital. The health systems of the future cannot be resilient without strong primary care for all, capable of meeting population health needs and aspiration for good health and well-being. [ABSTRACT FROM AUTHOR] Copyright of Middle East Journal of Family Medicine is the property of Medi+WORLD International Pty. Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: The World Health Organisation (WHO) reports that about 314 million people are visually impaired worldwide, and in 153 million of them the impairment is due to uncorrected refractive errors. Hence, uncorrected refractive error is one of the leading causes of blindness around the globe. The aim of this study is to assess the prevalence and patterns of different types of refractive errors among the people attending the eye clinic in Northern Pakistan. Material and methods: A hospital-based retrospective audit was done on patients who presented to the Ophthalmology Outpatients Department of Ayub Medical Complex Abbottabad between 1 st June 2017 and 31 st July 2017. The data of 662 patients were analysed using IBM SPSS Statistics v. 22.0. Results: Refractive errors were found in 487 (73.5%) of the total participants. The crude prevalence of myopia, hyperopia, and astigmatism was found to be 33.5%, 21.9%, and 18.1%, respectively. The refractive error status was found to be independent of gender (p = 0.075), but it varied among different age groups (p = 0.000). Conclusion: Myopia seems to be the most common refractive error in northern Pakistan, followed by hyperopia. The results of our study can be useful for the planning of eye care services in our country so that we can achieve the goal of VISION 2020 with proper care and planning.

With the spread of COVID-19 in Pakistan, Balochistan province with its unique problems of lowest literacy rates in the country, limited resources and a flail health care system is reporting an increasing number of cases of COVID-19. This study discusses the epidemiological and clinical characteristics of COVID-19 patients from the Balochistan province.Situation report Place and Duration of Study: The study was conducted in Balochistan province of Pakistan. The completion date for the study was April 30, 2020.The data was retrieved from the daily situation report from the Health Department, Government of Balochistan. Descriptive statistics (proportions, mean ± SD) were used for data analysis.A total of 1136 patients were confirmed to have COVID-19. The highest rate was found in cases with ages60 years. About 78% of COVID-19 cases were males and majority of the cases (78.56%)were asymptomatic. Out of these, 183 recovered and 16 died. The case fatality rate was 1.3%.COVID-19 cases and case fatality ratio is low in Balochistan. Whether this is due to inability to carry out more tests is still to be ascertained. Males and elderly are more affected and fatalities were higher in cases with co-morbid conditions. Balochistan having a weak healthcare system and with the majority of cases being asymptomatic, needs more stringent actions to practice social distancing to avoid further spread of COVID-19.

Background: Worldwide, some one million people pass the sixty year old threshold every month (Ageing, WHO). Between 2010 and 2050, the number of older people in less developed countries is projected to increase. Methods: Cross-sectional study conducted in Outpatient clinics (OPD) of two hospitals in Karachi from April to May 2013. Elderly (> 60 years of age) visiting the clinics were consecutively recruited. 477 elderly were approached and a pretested, structured questionnaire was used to obtain information. Data was analyzed using SPSS version 19 and Pearson chi-square test was used to identify the factors related to choosing of "Old Age Homes". Results: A total of 400 participants were selected. Fifty-five percent of the elderly were in between 60 to 65 years of age and majority was males 54.8 percent. Elderly were aware of the presence of "Old Age Homes" in Pakistan, however only 7 percent choose to live in there. The main reason was found to be that the elderly did not want to go away from their families and loved ones. Conclusion: In conclusion, majority of the participants felt insecure to live in a home with strangers. However, "Old Age Homes" were preferred choice for those with chronic diseases or those living alone. Media should initiate public education programs to reduce social stigmas in seeking alternate long-term care services outside of the family.

Objective To determine the correlation of functional and nutritional status of elderly patients (equal to and more than 60 years of age) visiting family medicine clinics of tertiary care hospital in Karachi. Study design Cross-sectional, descriptive study. Place and duration of study Family medicine clinics of Aga Khan University Hospital, in Karachi, from August 2014 to February 2015. Methodology A total of 200 participants (60 years and above), Family medicine outpatient clinics, were recruited via non-probability consecutive sampling. Katz scoring and MNA scale were used for the evaluation of functional and nutritional status, respectively. Spearman's rank correlation coefficient was applied to assess the correlation between nutritional status and functional status of elderly. Results Out of 200 participants, 35 % (n=70) were of 60-64 years of age. Most of them (54%, n=109) were males as compared to 46% (n=91) females; 33.5% were at risk of malnutrition and 35.5% were dependent. Spearmen correlation between functional and nutritional status was rho = -0.675, with p-value of p Conclusion There is a negative correlation between nutritional and functional status. As good nutritional status is essential for older persons to become functionally active; hence, this issue needs to be dealt in a developing country like Pakistan.

Objective: Spiritual needs have been of great importance in care giving both religiously and culturally in our society. The aim of this study was to investigate the importance of spiritual needs of care givers and role of spiritual support in care giving. Methods: A cross sectional study was conducted during July to September, 2015 at a tertiary care teaching hospital in Karachi, Pakistan. Participants 18 years old and above, involved in care giving to a family member were consecutively recruited. A pre-tested questionnaire was used to assess information and SPSS was used for data analysis. Results: A total of 400 participants were recruited. About 54% of the participants were males. Most of the participants (80%) feel that care giving gets easy with spiritual support. Conclusion: Spiritual care has favorable impact on psychological and spiritual well being of care givers. Physicians need to be aware of the value held for religious beliefs and spiritual implementation by patients and their care givers.

Cancer is a growing health problem worldwide. Common treatments include surgery, chemotherapy and radiation therapy. Systemic anti-cancer medications often result in an array of physical and psychological side effects. Supportive care assists patients with cancer in managing multidimensional symptoms that result from treatment or the illness itself. This review discusses supportive care and examines patient counselling and mind-diversion activities, which are safe and cost-effective strategies. Improving cancer patients' health and wellbeing should be encouraged in oncology nursing practice and by teaching students the knowledge and skills needed to provide supportive care.

Cognitive testing is an essential component of geriatric assessment. No test of memory currently exists in Pakistan that caters to the socio-demographic needs of its people. With growing numbers of elderly, the need to identify an appropriate screening test of cognition becomes necessary. A literature review was conducted to identify existing tests available for screening of dementia in the community. Two tests (The Mini-Cog and 6- CIT) were selected based on their validity for community screening and low dependence on language and education level. 90 consenting participants age 60 and older visiting the out-patient setting of a tertiary care hospital in Karachi were selected through convenience sampling and given both tests. Analysis was done using SPSS 17. Time and rates of completion were calculated and individual tests items were assessed. Reliability was checked for 6-CIT and Mini-Cog using Cronbach’s alpha. Completion rates of the Mini-cog were almost half that of 6-CIT. Dementia rates were found to be 22 % and 26 % respectively for the Mini-Cog (complete group) and 6-CIT. Almost half i.e.48 % of participants were unable to perform the clock draw test in the Mini-Cog. 6-CIT had a 100 % completion rate and was found to be more reliable in our setting with a Cronbach’s Alpha of 0.7 compared to 0.14 for the Mini-Cog test. The 6-CIT is the most reliable test for community screening of dementia in our setting.

Objective To determine the prevalence of sleep patterns and their relationship with academic performance among adolescents. Methods The analytical cross-sectional study was conducted from March to August 2015 in Gulshan Town of Karachi and comprised students in grades 6 to 8 who were selected from six government and private schools. Data was collected regarding their sleeping time, wake-up time, sleep latency and total sleep duration. Paediatric Daytime Sleepiness Scale was administered to calculate daytime sleepiness. Academic performance of students was taken from school academic records. Data was analysed using SPSS 22. Results Of the 440 subjects, 234 (53.2%) were boys and 206 (46.8%) were girls. The overall age range was 11-16 years. A total of 280 (63.6%) students had abnormal sleep patterns, 182(41.4%) suffered from daytime sleepiness, 41 (9.3%) had abnormal sleep latency and 201 (45.7%) scored below 60% in their exams. Among poor sleepers, 157 (56.1%) scored below 60% in their exams. Conclusions More than half the subjects were found to be sleeping less than required, which eventually affected their academic performance.

A cross-sectional survey was conducted during August 2014 to October 2014, to identify the impact of cable television channels on lives of the people, in Karachi, Pakistan. Three hundred participants were selected through convenience sampling and a pre-tested structured questionnaire was used for data collection. Data was analyzed in SPSS version 19.0. About 15% of participants were more than 40 years. About 62% were females in the study sample. Regression analysis showed that viewing television at night impacts work performance (OR: 1.39; 95% CI: 0.81-2.37), sleep (OR: 1.07; 95% CI: 0.63-1.81), family life (OR: 1.52; 95% CI: 0.89-2.60) and social life (OR: 1.38; 95% CI: 0.78-2.42). To minimize the adverse impact of the cable television it is imperative to monitor and control individual screen time, to avoid its adverse impact work performance, sleep, social life and overall health.

Introduction Diabetes is a global issue. The aim of this study was to identify the high-risk population and factors associated with the future development of type 2 diabetes mellitus (T2DM). Methods A cross-sectional study was conducted in the Family Medicine clinics of a tertiary care hospital in Karachi, Pakistan, from July 2016 to February 2017. Patients or patient care attendants aged 21 to 85 years visiting the clinics were included. Individuals with known diabetes or with serious comorbid conditions were excluded. A total of 600 participants were consecutively approached. QDiabetes (an online diabetes risk calculator) was used to measure the risk of developing T2DM. IBM SPSS Statistics for Windows, Version 19.0 (IBM Corp., Armonk, NY) was used for data analysis. Results Information from a total of 522 participants was included in the final analysis. Roughly 53% of them were between 25 and 44 years of age. There was a predominance of females (63%). Thirty-eight percent of patients were at high-risk. The factors associated with high risk of T2DM were as follows: age 65 years or greater (Relative risk [RR]: 5.81; 95% confidence interval [CI]: 2.01 to 16.76); female (RR: 1.86; 95% CI: 1.05 to 3.28, p = 0.03); a past history of hypertension (RR: 5.11; 95% CI: 2.49 to 10.49); a family history of diabetes (RR: 9.76; 95% CI: 5.49 to 13.35). Conclusion Controlling glucose levels and preventing hyperglycemia is a challenging task due to the increasing trend of a sedentary lifestyle and changes in dietary patterns. Counseling should be provided to caregivers and high-risk patients on the prevention of T2DM including lifestyle modifications.

To determine physical activity level and its correlational factors among secondary school adolescents.This cross-sectional study was conducted in two public and two private schools in Jamshed Town, Karachi, from March 2012 to June 2013, comprising students aged 10-17 years. The subjects, selected by simple random sampling were students of grades VI, VII, VIII. Physical activity was measured using the Physical Activity Questionnaire for older children. Socio-demographic data was also collected. SPSS 19 was used to analyse the data.Of the total 216 students, 131(60.6%) were girls and 85(39.5%) were boys, with an overall mean age of 13±1.4 years. Of the total, 151(70%) subjects had moderate and 65(30%) had low physical activity levels. Boys educated in public schools and those with parental support for sports were more physically active (p0.05).Private school without playgrounds, female gender and lack of parental support for sports were correlates of physical inactivity among the students..

Objective The goal of this study was to determine the frequency and factors associated with adult immunization in patients visiting family medicine clinics at a tertiary care hospital in Karachi. Methods A cross-sectional study was conducted from March 2014 to March 2015 in a tertiary care hospital in Karachi, Pakistan. Participants more than 18 years were invited to participate in the study. A pretested questionnaire was used to collect information. Data were entered and analyzed using IBM SPSS Statistics for Windows, version 19.0 (Armonk, NY: IBM Corp). Results A total of 340 patients were surveyed. The majority of patients were female (69.5%) with a mean age of 35.47 years. The majority were married (61.1%), and 30% of the participants had completed graduation or postgraduate education (20%). Most of the patients believed that vaccines can be used in adults to prevent disease (62.2%). Patients believed that the hepatitis B vaccine, influenza vaccine, and hepatitis A vaccine can be administered to adults (58.1%, 29.9%, 33.8%, respectively). The major sources of their information regarding vaccination in adults were friends or relatives (25%) and media (23.2%). Regarding availability of vaccines, 71.3% thought a hepatitis B vaccine is available, 54.9% thought a tuberculosis vaccine is available, and 49.3% thought a tetanus toxoid vaccine is available. Only 36.4% respondents received any vaccine in adulthood. The majority of patients (62.2%) received the hepatitis B vaccine in adulthood. The major reason given for not receiving vaccines was lack of awareness (62.4%). Conclusion Low adult vaccination coverage rates and awareness, as highlighted by the results of this study, show the dire need to address this major preventive strategy. This information can be utilized to conduct larger community-based surveys, to conduct health awareness sessions in the community, and to educate our doctors regarding the availability and benefits of adult vaccines.

(1) Department of Family Medicine, Aga Khan University, Karachi, Pakistan (2) Director General, Executive Board, Health Ministers’ Council for Cooperation Council States (3) Professor of Public Health, Director, WHO Collaborating Centre, Department of Primary Care and Public Health, School of Public Health, Faculty of Medicine Imperial College London, UK (4) University of Dammam, Saudi Arabia (5) Department of Family & Community Medicine, Arabian Gulf University, Bahrain (6) Vice Dean for Clinical Affairs, Oman Medical College, Sultanate of Oman (7) Family Physician, Bahrain (8) Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia (9) Department of Family Medicine, Cairo University, Egypt (10) Associate Professor of Community and Family Medicine. Senior Consultant Family Physician. Dubai (11) Family Physician, Amman, Jordan (12) Head of the Primary Health Care Faculty at the Kuwait Institution for Medical Specialization. (13) Assistant Program Director in Family Medicine Residency Program, Qatar. (14) Chair Person of Egyptian Family Medicine Association and Faculty of Medicine, Menoufiya University, Shebin El-Kom, Menoufia, Egypt

(1) Department of Family Medicine, Aga Khan University, Karachi, Pakistan (2) Director General, Executive Board, Health Ministers’ Council for Cooperation Council States (3) Professor of Public Health, Director, WHO Collaborating Centre, Department of Primary Care and Public Health, School of Public Health, Faculty of Medicine Imperial College London, UK (4) University of Dammam, Saudi Arabia (5) Department of Family & Community Medicine, Arabian Gulf University, Bahrain (6) Vice Dean for Clinical Affairs, Oman Medical College, Sultanate of Oman (7) Family Physician, Bahrain (8) Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia (9) Department of Family Medicine, Cairo University, Egypt (10) Senior Specialist Family Physician, Baghdad, Iraq (11) Family Physician, Amman, Jordan (12) Head of the Primary Health Care Faculty at the Kuwait Institution for Medical Specialization. (13) Assistant Program Director in Family Medicine Residency Program-Qatar.

Objective This study was designed to assess the impact of caregiving on the lives of the caregivers. Methods A cross-sectional study was conducted between July and September 2015 at a teaching hospital in Karachi, Pakistan. Participants who were more than 18 years old and were involved in caregiving (former or current) of a family member were invited to participate in the study. The participants were recruited through consecutive sampling technique. A total of 400 caregivers were interviewed. Written informed consent was obtained from all the participants. A pretest structured questionnaire was used for data collection and included sections on demographic details and impact of caregiving on various aspects of the lives of caregivers. The data was analyzed using SPSS version 19 (IBM, NY, USA). Results Information about a total of 400 caregivers (215 men and 185 women) was included in the final analysis. The majority (57.0%) of the participants were aged between 18 and 30 years. About three-fifths (60%) of the participants were single and the majority of the participants were students. Approximately 64% of the participants were currently involved in caregiving and about 48% of the participants responded that caregiving has an overall negative impact on various aspects, such as physical (40.8%), psychological (47.8%), and professional aspects (51.8%) of their lives. Conclusion Negative impact of caregiving was observed among caregivers due to extensive demands of caregiving and limited resources. Therefore, it is imperative for health care providers to explore, identify and support caregivers to cope in a better way to the challenging task of caregiving.

Asthma, a major public health issue, is one of the most common diseases affecting millions of population globally. It is a chronic respiratory disease characterized by increased airway inflammation and hyper-responsiveness. Vitamin D is of particular interest in asthma due to its immunomodulatory effects. Serum 25-hydroxyvitamin D is found to be associated with a wide range of pulmonary diseases, including viral and bacterial respiratory infections, asthma, and cancer. Several researches have reported positive associations between vitamin D and asthma. On the other hand, others have reported contrasting effects of vitamin D on asthma. This review provides an examination of current epidemiologic and experimental evidence of a causal association between vitamin D status and asthma or asthma exacerbations, including its probable protective mechanism. Most of the evidence regarding vitamin D and asthma is reported by observational studies. Therefore, results from the experimental trials of vitamin D supplementation are important as they can provide evidence for future recommendations about the significance of vitamin D for asthma. Moreover, the trials can be effective in assessing the correct dosage and safety of vitamin D supplementation when given in diverse age groups such as children, teenagers, and adults for prevention and treatment of asthma.

Background Nocturnal enuresis (NE) is a common symptom in children worldwide. International Children’s Continence Society (ICCS) defines enuresis as either mono-symptomatic, NE with lower urinary tract symptoms and NE with co-morbid conditions. The objectives of this study were to determine the frequencies and types of NE and associated symptoms and conditions in children aged 5 to 16 years based on ICCS criteria. Methods A multi-center cross sectional study was conducted between November 2012 and December 2013 in the primary care clinics of four hospitals in Karachi. Children aged five to fifteen years were included through consecutive sampling. Informed consent was obtained from the parents and a pre-coded semi-structured questionnaire was used to obtain the information. Data was entered on SPSS version 20.0 and multivariable logistic regression analysis was used for data analysis. Results Out of 429 children aged between five and sixteen years, 243(56.9%) were boys and the remaining 186(43.1%) were girls. One hundred and eighty three children (43%) had nocturnal enuresis (NE). Forty four (10.3%), had mono-symptomatic NE, 57(31.1%) had associated lower urinary tract symptoms (NE-LUTS), whereas 30 (16.3%) had NE with a co-morbid condition. Fifty two (28.4%) NE’s had at least one of both LUTS and a co-morbid condition. Out of the 246(57%) non-enuretic’s, 31(12.6%) had a LUTS, 95(38.6%) had a co-morbid condition and 57(23.2%) had at least one of both LUTS and a co-morbid condition. The remaining 63 (25.6%) were symptom free. Increased voiding frequency, urgency, dysuria, suprapubic pain and daytime incontinence were the LUTS significantly associated with NE. Co-morbid conditions significantly associated with NE included constipation, congenital defects, developmental delay, and learning and sleep problems. Conclusion Although NE can be an only symptom, it is often associated with lower urinary tract symptoms like dysuria, urgency, suprapubic pain, and daytime incontinence. Children presenting with NE often have co-morbid conditions like constipation, urinary tract infection, sleep disorders, and developmental delay. Many children presenting with these conditions as the primary complaint may also have NE. It should be addressed as unrecognized and untreated NE can cause additional morbidity and distress.

Background: Family Medicine is growing rapidly across the Eastern Mediterranean Region. However, it needs support in terms of overall health system development. This will require strong leadership in family medicine to implement the change required to improve current conditions. Objective: To collect data that will support the development of a leadership program for the future family physicians in the region. Methods: A cross-sectional study was conducted from July 2016 to September 2016 in eight countries of the Eastern Mediterranean Region, (Bahrain, Egypt, Iraq, Jordan, Kuwait, Qatar, Pakistan, and Saudi Arabia). These countries were selected to obtain perceptions of Family Physicians (FPs) regarding the current leadership model and to explore the need for a new future innovative model in Family Medicine (FM) across the region. Results: The information of 68 family physicians was included in the final analysis. The majority of the FPs was females as compared to males (71% vs. 29%). Forty-four percent of the FPs had 10 to 19 years of experience. Almost all of the FPs (96%) had completed some training in family medicine after graduation. About three fifths of the FPs had completed postgraduate qualifications and out of those, 64% had passed Board or Membership Examinations. Twenty-one percent of them are currently in a leadership role and 45% who were not in any leadership role responded that the current situation of FM in their country is poor. All of the leaders believed that it is important to develop strong leadership in FM to take the specialty forward. Almost similar proportions (67% and 64%) of leaders and non-leaders thought that establishing regional associations would enhance the FM practice model. Approximately two thirds of leaders (67%) responded that the current role of decision makers in the Ministry of Health (MOH) regarding capacity building in FM is not effective. The majority of the FPs (54% and 38%) considers that the existing postgraduate curriculum does not address leadership skill development in FM. Eighty-eight percent of the FPs both from leadership and non-leadership groups agreed that academic institutions and practicing FPs can play an effective leadership role in taking FM forward. Conclusion: The Family Medicine specialty will have to develop leadership capabilities in line with today’s fast-moving changes in healthcare for it to obtain the due recognition in the healthcare delivery system.

Efforts have been made in Pakistan to create ethical guidelines for research and medical practice. This study explored the perceptions of and factors affecting the process of obtaining informed consent to surgery among inpatients and families at a tertiary-care hospital in Karachi. A random sample of 400 post-surgery adult patients answered a pre-tested, structured questionnaire. Overall, 233 patients (58.3%) had signed the surgery consent form themselves, while 167 relatives (41.7%) had signed on behalf of the patient. Perceived factors significantly associated with patients not signing the consent form themselves were: language used (adjusted OR = 4.6), medical terminology used (aOR = 2.7), insufficient time allocation (aOR = 3.8), cultural/traditional reasons (aOR = 1.5) and low education (aOR = 2.4). Inappropriate timing for taking consent and not being informed/asked about consent were not statistically significant factors. Health-care practitioners should encourage patients to sign the consent form themselves.العوامل التي تؤثر على عملية الحصول على موافقة مسبقة على عملية جراحية لدى المرضى وأقاربهم في البلدان النامية: نتائج من باكستانفردوس جهان، روزينا روشان، كشميرة نانجي، عُظْمَى سجواني، شاهين وَرْساني، سلمى جعفرلقد بذلت جهود مؤخراً في باكستان من أجل وضع دلائل إرشادية أخلاقية للبحوث والممارسة الطبية. وقد استكشفت هذه الدراسة التصورات عن عملية الحصول على موافقة مسبقة على عملية جراحية، والعواملَ التي تؤثر على هذه العملية لدى مرضى داخليين وعائلاتهم في مستشفى للرعاية الثالثية في كراتشي. ففي دراسة مستعرضة أجريت عام 2010 أجابت عينة عشوائية مكونة من 400 مريض بالغ بعد الجراحة على استبيان منظَّم تم اختباره مسبقاً. فكان ما إجماليه 233 مريضاً (58.3%) قد وقَّعوا على استمارة الموافقة على الجراحة بأنفسهم، في حين وقَّع 167 من الأقارب (41.7%) نيابة عن المريض. وكانت العوامل المتصوَّرة التي ارتبطت – بشكل ملحوظ – بعدم توقيع المرضى على استمارة الموافقة بأنفسهم: اللغة المستخدمة (OR المعدلة = 4.6)، والمصطلحات الطبية المستخدمة (OR المعدلة=2.7)، وعدم كفاية الوقت المخصص (OR المعدلة = 3.8)، وأسباب ثقافية/تقليدية (OR المعدلة = 1.5)، والتعليم المنخفض (OR المعدلة=2.4). وكان التوقيت غير المناسب لأخذ الموافقة، وعدم الإبلاغ/السؤال عن الموافقة عاملَين غير مهمَّين إحصائياً فينبغي أن يكون ممارسو الرعاية الصحية على علم بالعوامل التي تؤثر في عملية الموافقة المسبقة، وأن يشجعوا المرضى على التوقيع على استمارة الموافقة بأنفسهم.Facteurs influant sur le processus d'obtention d'un consentement éclairé pour une intervention chirurgicale chez des patients et des parents dans un pays en développement : résultats du Pakistan.Des efforts récents ont été réalisés au Pakistan en vue de créer des lignes directrices pour l'éthique en recherche et pratique médicales. La présente étude a évalué les perceptions relatives au processus d'obtention d'un consentement éclairé pour une intervention chirurgicale et les facteurs d’influence chez des patients hospitalisés et leur famille dans un hôpital de soins tertiaires à Karachi. Un échantillon aléatoire de 400 patients adultes postopératoires a répondu à un questionnaire prétesté et structuré. Au total, 233 patients (58,3 %) avaient signé eux-mêmes le formulaire de consentement à une intervention chirurgicale, tandis que 167 parents (41,7 %) avaient signé pour le patient. Les facteurs perçus comme fortement associés aux patients qui n'avaient pas signé eux-mêmes le formulaire de consentement étaient les suivants : la langue utilisée (OR ajusté = 4,6), la terminologie médicale utilisée (OR ajusté = 2,7), l'insuffisance du temps alloué (OR ajusté = 3,8), des raisons culturelles/traditionnelles (OR ajusté = 1,5) et un faible niveau d'études (OR ajusté = 2,4). Un moment inopportun pour demander le consentement et l’absence d’information/d’interrogation à ce sujet n'étaient pas des facteurs statistiquement significatifs. Les professionnels de santé doivent encourager les patients à signer eux-mêmes le formulaire.

Background. Nonverbal behaviors have a significant impact on patients during consultations. This study was undertaken to find out the attitudes and preferences of the patients regarding nonverbal communication during consultations with physicians, in a tertiary care hospital. Methods. A questionnaire based cross-sectional study was carried out at the Aga Khan University Hospital, Karachi, Pakistan, during the months of January to March 2012. All patients (>18 years of age) coming for consultancy in the family medicine clinics were approached; out of 133, 120 agreed to participate. The subjects were asked questions regarding physician’s comforting touch and eye contact and their responses were noted. The data were analyzed using SPSS and chi-square test was used to identify corelations. Results. Overall, 120 patients were enrolled. About 58.3% were men and 41.7% were women with a mean age of 34.9±10.9 years. 95.8% were Muslims and 57.6% had more than 12 years of education. Among females 74% wanted supportive touch from doctors, used to comfort the patient (45%) or to show respect (27.5%) or as healing (30%). 86.1% of the respondents believe that establishing eye contact with the patient shows that the doctor is attentive towards his/her patient. The eye contact should be brief but regular (54.1%) and prolonged staring (36.7%) makes them uncomfortable. Conclusion. Nonverbal communication helps to strengthen the doctor-patient relation as patients do appreciate positive touch and eye contact from their physicians.

Introduction: Public health systems in the Gulf Cooperation Council (GCC) Countries are not well established. The existing systems do not match with the current health challenges and with the use of innovative technology in healthcare (diagnosis, treatment or rehabilitation). This paper is intended to give an overview of the public health situation in these countries. It discusses the need for effective and integrated system of public health laws that plays important role in addressing high priorities in public health. Conclusion: The GCC countries have the infrastructure for establishing a national public health system. However it needs an effective integrated and organized mechanism to shape this system; based on acceptable guidelines and criteria in such a way that they are institutional and capable of meeting the population needs. This system should be cost- effective and investment in health sector should be looked upon as a sustained investment in human and societal development. Despite the great efforts exerted and achievements made, there are great challenges ahead that can be overcome by exhibiting a strong political will and having a united approach of all stakeholders. Keywords: Public health, Public health laws, Public Health Surveillance, GCC countries

Background: It is known that blood group antigens are related to the development of peptic ulcer and gastric carcinoma. Infections due to H. pylori are most widespread among the developing regions due to poor standard of public health. This study sought to determine the association of H. pylori with ABO blood groups, age, gender, and smoking status among inpatients at a public sector hospital in Karachi. Materials and Methods: A cross-sectional study was conducted at endoscopy suite at a public sector hospital in Karachi in the year 2011. All the symptomatic patients coming for upper GIT endoscopy were included in this study. Results: Biopsy for histopathology was taken from 93 patients, with an age range from 15-65 years. Age group of 15 to 20 years was found to be associated with H. pylori infection but without significance (p-value 0.83). In all, 36 (38.7%) turned out to be H. pylori positive with a significant male preponderance (p=0.04). Distribution of ABO blood groups in H. pylori positive group were A=31.4%, B=15.4%, AB=25.0% and O=53.7%, with a statistically significant link for blood group O (p=0.05) . Rhesus factor was also compared but significant relationship was evident (p-value 0.73). Conclusions: This study demonstrated that H. pylori infection can be related to ABO blood group, middle age persons and male gender. People of blood group O are more prone to develop infection related gastritis, ulcers, and even perforations, so they should be more cautious against transmission of the bacterium.

To determine the knowledge regarding calcium contained in food among secondary school-going children.The cross-sectional study was conducted from February to May 2013 in two public and two private schools of Jamshed Town, Karachi. Stratified random sampling was used to raise the study sample. A pre-coded, piloted questionnaire was used for data collection. Data was analysed using SPSS 19.Of the 153 participants, 27(18.3%) had adequate knowledge while 126(81.7%) had inadequate knowledge about calcium contained in food. The mean age of the participants was 13.52±1.725 years. Statistically significant association was present between knowledge regarding calcium and mother's and father's educational level (p=0.039 and p=0.012, respectively), mother's and father's working status (p=0.002 and p=0.015, respectively) and acquisition of knowledge from parents (p=0.020), teachers (p=0.039) and via television (p=0.034).Most adolescents did not have knowledge about calcium contained in food.

Background. Metabolic Syndrome (MetS) is a major public health concern. Objective. The aim of this study was to estimate the frequency of MetS, its components, and factors associated with MetS amongst apparently healthy individuals in Pakistan. Methods. A retrospective cross-sectional study was conducted at the executive Clinics of Aga Khan Hospital, Pakistan. Medical records of patients aged ≥18 years visiting the clinics from July 2011 to December 2011 were consecutively reviewed. Records in which either MetS components data or 10% of overall data was missing were excluded. A total of 1329 participants’ records was included in final analysis. Data was analyzed using SPSS version 19 and multivariable logistic regression was used to identify the factors associated with MetS. Results. A total of 847 (63.7%) participants had MetS; mean age of the participants were 47.6 ± 11.6 years. About 70.4% were males and 29.6% were females. Approximately 70% of participants had BMI ≥25 kg/m2. MetS was associated with male gender (AOR = 2.1; 95% C.I: 1.6–3.2) and history of diabetes among parents (AOR = 3.0; 95% C.I: 1.6–6.0). Conclusion. This study shows that a large proportion of population has MetS and is overweight or obese. This requires urgent interventions on part of health care providers’ especially family physicians. Educating masses about life style factors can make a difference. Further researches on this issue are warranted.

Background: Medical colleges invest considerable effort in developing assessment programs to effectively evaluate students across attributes of knowledge, skills, and behavior. While assessment by direct observation is designed to be objective, “soft characteristics” such as personality, demeanor of student, and assessor may make assessment more subjective. The effect of such attributes in medical education remains unclear and needs exploration. The objective of this study was to explore non-cognitive traits of assessor and learner to understand their roles in student assessment. Methods: A mixed-method study was conducted during March to June 2015. All clinical faculty members at the Aga Khan University were invited to participate in this study. A questionnaire was designed and completed by the study participants. Two focus group discussions (FGDs) with faculty members explored teacher and learner traits influencing student assessment. A documentary analysis of the yearly student feedback report with a focus on the section on assessment was also utilized. Data triangulation was achieved by combining three sets of data. Results: Fifty-four (28%) clinical faculty members completed the questionnaire and 11 participated in the FGDs. About 68% reported rating students leniently. More than 50% reported their personality as a factor influencing assessment and 76% reported student appearance influencing assessment. The documentary analysis identified faculty personality and rating styles as key issues affecting the validity of student assessment during ongoing observation. In the FGDs, traits such as eagerness, intuition in students, and body language were reported to influence faculty members during the assessment. Discussion: Softer attributes of trainer and trainee increase the subjectivity of student assessment. Ongoing faculty training and rater feedback are required for a robust and objective assessment.

Background and Aim: Cancer is a daunting illness affecting a vast number of people globally. During the illness trajectory, cancer patients suffer from physical and/or psychosocial issues. These physical and psychosocial issues demand conscious actions by patients to maintain their well-being. Hence, the objective of the pilot study was to evaluate the level of self-care behaviors and satisfaction in women suffering from cancer after exposure to supportive care (education and mind diversion activities) delivered via a patient help group program. Methods: The study was conducted at the chemotherapy day care unit of one of the tertiary care hospitals located in Karachi, Pakistan. In this study, supportive care interventions were offered via the patient help group program over a 5-week period, and in the 6th week, data were collected. The total sample size of this pilot study was n = 17. Female cancer patients receiving weekly chemotherapy regimen and diagnosed with breast or gynecological cancers were a part of the study. Outcome variables, self-care behavior and satisfaction, were assessed via a self-developed questionnaire. Content validity index of the questionnaire was calculated on the basis of expert review and was found to be 96% for relevancy and 94% for clarity. Frequencies were calculated to evaluate outcome variables. Outcome variable satisfaction was also assessed via few open-ended questions. Results: Participants reported moderate-to-high self-care behaviors and satisfaction after exposure to supportive care interventions delivered via the patient help group program. Conclusion: Counseling and mind diversion activities are effective in producing a positive change in chemotherapy patients' self-care behaviors and satisfaction. Therefore, oncology nurses must utilize them in chemotherapy patient care. Future studies should evaluate the effectiveness of these interventions with larger sample size and comparative analysis.

Objective: To determine psychosocial risk factors for acute myocardial infarction at a teaching hospital in Karachi. Methods: One hundred and fifty three cases were recruited from cardiology clinics and 153 controls from internal medicine and family medicine clinics of Aga Khan University Hospital, Karachi, through non-probability sampling using a structured questionnaire. Cases were those who were diagnosed with acute myocardial infarction for the first time in past month. Controls were selected from family medicine and internal medicine clinics of the same hospital and included patients above the age of 40 years without acute myocardial infarction. Associations between psychosocial risk factors and acute myocardial infarction were investigated using multiple logistic regressions. Results: The psychosocial risk factors associated with acute myocardial infarction were irritability at home (OR: 4.86, 95% CI: 3.24-7.53), self-illness (OR: 3.33, 95% CI: 2.86-5.23), illness in family (OR: 8.44, 95% CI: 6.21-10.1), loss of job (OR: 3.71, 95% CI: 1.16-8.86) and death in family (OR: 7.42, 95% CI: 3.98-10.12) in fully adjusted models. Conclusions: Psychosocial risk factors are associated with acute myocardial infarction. Therefore, regular screening for these risk factors should be undertaken by physicians to identify high risk patients.

Background: Use of smoke-less tobacco (SLT) is very common in South and South-East Asian countries. It is significantly associated with various types of cancers. The objectives of this study were to assess the proportion of hospital staff that use SLT, and to identify the factors associated with its use and their practices. Methods: In a cross-sectional study, 560 staff of two tertiary care hospitals were interviewed in the year 2009. Nurses, ward boys and technicians were counted as a paramedic staff while drivers, peons, security guards and housekeeping staff were labeled as non-paramedic staff. SLT use was considered as usage of any of the following: betel quid (paan) with or without tobacco, betel nuts with or without tobacco (gutkha) and snuff (naswar). Results: About half (48.6%) of the hospital staff were using at least one type of SLT. Factors found to be statistically significant with SLT were being a male (OR=2.5; 95% CI=1.8-3.7); having no/fewer years of education (OR=1.7; 95% CI=1.2-2.4) and working as non-paramedic staff (OR=2.6; 95% CI=1.8-3.8). Majority of SLT users were using it on regular basis, for > 5 years and keeping the tobacco products in the oral cavity for >30 minutes. About half of the users started due to peer pressure and had tried to quit this habit but failed. Conclusion: In this study, about half of the study participants were using SLT in different forms. We suggest educational and behavioral interventions for control of SLT usage.

Background: The use of simulated patients in student assessment is supported by the Best Evidence Medical Education and U.S. Agency for Healthcare Research and Quality, and it provides a safe and effective alternative to real patients in many situations. To assess the validity and feasibility of moulage technique–where a cosmetically constructed rash is used on simulated patients–two dermatologic rashes were developed using moulage simulation on standardized patients at Aga Khan University Hospital for 3rd year medical summative Objective Structured Clinical Examination (OSCE). Methods: Checklists for cases that focused on history taking of a skin rash were developed. These also included a description and identification of lesions, differential diagnosis, and basic management. Cases were first reviewed and approved by the Educational Committee and a dermatologist content expert. Stations were piloted to assess validity and feasibility. Simple nontoxic materials were used to develop the rash by faculty familiar with moulage simulation. Results: Sixty-four students were assessed on a Herpes Zoster case and 32 students on a Herpes Simplex case in morning and afternoon sessions. The total mean score obtained at all OSCE stations was 64.82 ± 10.22. Mean scores on the morning and afternoon dermatology stations were 62.72 ± 9.74 and 69.03 ± 9.98, respectively. Face validity for both stations was established through input of content experts. The internal reliability as measured by Cronbach's alpha between the checklist items on the morning and afternoon stations was acceptable at 0.60 (20 items) and 0.65 (18 items), respectively. Discussion: The use of moulage technique to develop dermatologic lesions on simulated patients may be utilized for student assessment.

OBJECTIVES. To assess the proportion of women subjected to intimate partner violence and the associated factors, and to identify the attitudes of women towards the use of violence by their husbands. DESIGN. Cross-sectional study. SETTING. Family practice clinics at a teaching hospital in Karachi, Pakistan. PARTICIPANTS. A total of 520 women aged between 16 and 60 years were consecutively approached to participate in the study and interviewed by trained data collectors. Overall, 401 completed questionnaires were available for analysis. Multivariate logistic regression analysis was used to identify the association of various factors of interest. RESULTS. In all, 35% of the women reported being physically abused by their husbands in the last 12 months. Multivariate analysis showed that experiences of violence were independently associated with women's illiteracy (adjusted odds ratio=5.9; 95% confidence interval, 1.8-19.6), husband's illiteracy (3.9; 1.4-10.7), smoking habit of husbands (3.3; 1.9-5.8), and substance use (3.1; 1.7-5.7). CONCLUSION. It is imperative that intimate partner violence be considered a major public health concern. It can be prevented through comprehensive, multifaceted, and integrated approaches. The role of education is greatly emphasised in changing the perspectives of individuals and societies against intimate partner violence. Language: en

This special issue focuses on the role of complementary and alternative medicine (CAM) in controlling dyslipidemia. Complementary and alternative medicine (CAM), also known as nonconventional medicine, includes a wide and heterogeneous array of health care practices (such as herbal medicine, acupuncture, yoga, meditation, and homeopathic medicine) that are not part of a health care system. The popularity of CAM has dramatically increased in many developed countries since the 1990s. This could be attributed to the aging of population, prevalence of chronic diseases, and concern about the adverse reaction of chemical drugs. All these aspects have contributed greatly to the worldwide popularity of CAM. In the United States, consumers spend over $34 billion per year on CAM therapies spent outside the conventional health care financing system. This out-of-pocket expenditure is evidence of the belief that CAM therapies have benefits that outweigh their costs. CAM is generally more popular in most developed countries, especially in North America, Europe, and Australia. According to the 2007 National Health Interview Survey on more than 32,800 Americans, 38.2% of adults and 12% of children used some form of CAM within the previous 12 months. Dyslipidemia is an independent preventable risk factor of coronary heart disease and has been shown to increase the risk of cardiovascular mortality manyfold. Therefore, the study on various indicators and risk factors of dyslipidemia appears to be significant for future health outcomes. It is critically important to recognize the need for treatment of dyslipidemia and to institute necessary therapies to reduce the long-term risks of disease recurrence or modify the metabolic derangements that promote atherosclerosis. Drugs used in dyslipidemia may cause adverse effects if used for longer duration. Therefore patients use CAM to reduce lipids without any major side effect. The exact reasons for the popularity of CAM are complex; as they change with time and space, they vary from individual to individual and from therapy to therapy. In general, there are a broad range of positive motivations to the present popularity of CAM. Although the use and expenditure of CAM have been increased radically, the potential role of CAM in modern clinical practice and health care system seems to be limited. As the efficacy and safety have been the major concerns in the recognition of CAM and integrating it into the conventional medicine, hence, there is an urgent need to provide evidence regarding the merits of the numerous techniques of CAM. The best way to achieve this is through rigorous research. Since then, in CAM, simple answers or broad generalizations are not possible. Each of the numerous techniques has to be evaluated separately. It is necessary to bring the practice of CAM in line with evidence. The wide dissemination of its findings is also important to include CAM into the modern clinical practice. Studies have reported that CAM can be ineffective for a specific condition, but still they could be used as they do not harm the patients. Some argue that CAM should be used regardless of the results of placebo-controlled clinical trials, particularly when its use is not associated with serious risks. The main purpose of this issue is to illustrate the inevitability of researches in the field of CAM to integrate it into the modern clinical practice. Altogether, 14 manuscripts were submitted for publication, out of which 11 manuscripts got accepted. The articles in this issue represent a wide range of therapeutic approaches of CAM in preventing dyslipidemia. This special issue includes a review that discusses the progress and perspective of studies on dyslipidemia with single Chinese herb and its monomers or effective extracts during the past 10 years. The review concludes that traditional Chinese medicine (TCM) has some beneficial effects on the treatment of patients with dyslipidemia and has less adverse effects as compared to chemical agents. However, future clinical trials are needed to be confirmed about the effects of TCM. This edition also includes a randomized, double-blind, placebo-controlled clinical trial on 50 hyperlipidemic patients. The results of this trial show that daily consumption of the fruit extract of Vaccinium arctostaphylos significantly reduces the serum levels of total cholesterol, LDL-C, and triglyceride (TG) and oxidative stress in hyperlipidemic patients. Therefore, this extract could be considered as a potential agent for treatment of dyslipidemia. Another study in this issue is on Chaihu-Shugan-San (CSS), an ancient classical formula composed of seven Chinese herbs, which found that integrated recipe might work as a significant anti-inflammatory effect in Kupffer cells. In addition, another study conducted by Han et al. on the molecular docking of echinocystic acid (EA) (isolated from G. sinensis fruits) and the effects of it on the possible targets in in vitro rat liver microsomes has been added. This review also includes a research paper which concluded that preventive acupuncture and moxibustion can significantly decrease the plasma TG and LDL, increase the plasma HDL, and prevent fat accumulation during climacteric period in rats. Moreover, a paper included is on intestinal transportations of main chemical compositions of Polygoni Multiflori Radix (PMR, originated from the root of Polygonum multiflorum Thunb.). This has been used in the treatment of hyperlipidemia in some countries for centuries. Another paper using the same herb PMR has been added to this special issue which discusses the mechanisms of the water extracts of Polygoni Multiflori Radix (PMR) and its processed products (PMRP) on liver lipid metabolism. Moreover, another paper was included in this review on propolis, which is a brownish resinous material collected by worker bees from the leaf buds of numerous plants that have strong pharmacological and biological properties. Another study analyzed the effects of acupuncture on interleukin, IL-17expression in fat excess liver on adult mice, and provided some basic evidences that the inflammatory damage of hyperlipidemic fatty liver could be restricted through acupuncture. A study in this review investigates the beneficial effects of ethanol extract of Gastrodia elata Blume (EGB) on lipid metabolism and endothelial dysfunction in a high-fructose (HF) diet animal model.

BACKGROUND This aim of this study was to assess the degree to which the doctors of a public sector hospital in Karachi adhere to medical ethics during their consultations. MATERIAL AND METHODS A cross-sectional study was conducted in Civil Hospital, Karachi, Pakistan, during April-June 2010. 337 patients from Out Patients Departments (OPDs) and wards were recruited through consecutive sampling. A pre-tested structured questionnaire was administered to the participants and they were asked about their demographic profile, and their doctor's practices regarding obtaining informed consent, respecting privacy and confidentiality, and treatment modalities. Written informed consent was taken from all the participants. Data was analysed using SPSS version 16.0, and a p-value of < 0.05 was considered as statistically significant. RESULTS The mean age of the study population was 38.4 ± 15.0 years. There was an equal ratio of males and females. Our study showed that informed consent was obtained from 66.4% of patients. 56.9% of patients responded that they were not informed about the side effects of the prescribed medicines. 74% females were satisfied with the privacy maintained during the consultation. 64.8% were assured of the confidentiality of their information. Regarding advertisement by doctors, 46.5% of patients said it should be done. CONCLUSION There has been a marked improvement as compared with the previous practices of biomedical ethics by the doctors of this public sector hospital. However, awareness sessions should be conducted to update / improve the knowledge of ethics among doctors to help them translate their knowledge into practice.

Patient evaluation of family practice care is the most direct assessment of quality of healthcare services provided. This study aimed to evaluate family practice care and to assess patient views on the attributes of a good family physician.A multicentre cross-sectional study was conducted at 18 family practice clinics of Aga Khan Hospital, Karachi, Pakistan. A total of 600 adult patients (aged over 18 years and visiting the clinic for more than a year) were approached consecutively to take part in this study. A pre-tested structured questionnaire including the EUROPEP was used by trained medical graduates to collect patient information. Data were analysed using SPSS v. 19; the internal consistency and reliability of the EUROPEP were tested. Means and proportions were reported for individual items of the questionnaire and a P-value of0.05 was considered statistically significant.Of 600 patients, 502 (83.67%) agreed to participate and were interviewed. About one-third (72.3%) were females and 38% were within the age group 35-50 years. The overall mean scale score on EUROPEP was 82.8 (± 18.0), the score was higher for females at 83.7 (± 17.4) points. The three statements that were most highly rated for assessing family practice care were listening to the patient (mean = 4.54, SD = 0.92), thoroughness (mean score = 4.46, SD = 0.04) and proper physical examination (mean score = 4.44, SD = 1.07). The poorly rated statements were waiting time (excellent 9.8% vs poor 45.6%) and physician not accessible on telephone (36.5% excellent vs 35.5% poor).The results of this study identified some areas of improvement in family practice, such as accessibility of family practice on telephone and reduction in waiting times. Strategies should be devised regarding these issues at continuous medical education platform so that these attributes can be adapted to improve the overall quality of care.

Fibromyalgia Syndrome (FMS) is a chronic condition causing pain, stiffness, and tenderness of the muscles, tendons, and joints. It is also characterized by restless sleep, tiredness, fatigue, anxiety, depression, and disturbances in bowel functions. The etiology of fibromyalgia remains unknown, but recent advances and discoveries have helped to unravel some of the mysteries of this disease. Research highlights some of the biochemical, metabolic, and immunoregulatory abnormalities associated with fibromyalgia. Management of FMS at the present time is very difficult as it has multiple etiological factors and psychological predispositions; however, a patient centered approach is essential to handle this problem.

Background: Adverse drug reactions (ADRs) present a challenging and expensive public health problem. Polypharmacy is defined according to the WHO criteria as the, ‘‘concurrent use of five or more different prescription medication’’. Elderly are more prone to adverse reactions due to comorbid conditions, longer lists of medications and sensitivity to drug effects. The aim of the study is to estimate the incidence and strength of association of ADRs due to polypharmacy among the geriatric cohort attending outpatient clinics at a tertiary care center. Methods: A hospital based prospective cohort study was conducted at ambulatory care clinics of Aga Khan University Hospital April 2012 to March 2013. One thousand geriatrics patients (age $65 years) visiting ambulatory clinics were identified. They were divided on the basis of exposure (polypharmacy vs. no polypharmacy). We followed them from the time of their enrollment (day zero) to six weeks, checking up on them once a week. Incidence was calculated and Cox Proportional Hazard Model estimates were used. Results: The final analysis was performed on 1000 elderly patients. The occurrence of polypharmacy was 70% and the incidence of ADRs was 10.5% among the study cohort. The majority (30%) of patients were unable to read or write. The use of herbal medicine was reported by 3.2% of the patients and homeopathic by 3%. Our Cox adjusted model shows that polypharmacy was 2.3 times more associated with ADRs, con-current complementary and alternative medicine (CAM) was 7.4 times and those who cannot read and write were 1.5 times more associated with ADRs. Conclusion: The incidence of ADRs due to poly pharmacy is alarmingly high. The factors associated with ADRs are modifiable. Policies are needed to design and strengthen the prescription pattern. Citation: Ahmed B, Nanji K, Mujeeb R, Patel MJ (2014) Effects of Polypharmacy on Adverse Drug Reactions among Geriatric Outpatients at a Tertiary Care Hospital in Karachi: A Prospective Cohort Study. PLoS ONE 9(11): e112133. doi:10.1371/journal.pone.0112133 Editor: Robin Dore, David Geffen School of Medicine, United States of America Received July 14, 2014; Accepted October 12, 2014; Published November 17, 2014 Copyright: 2014 Ahmed et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: The authors confirm that all data underlying the findings are fully available without restriction. All relevant data are within the paper and its Supporting Information files. Funding: This work was supported by the University Research Council, Aga Khan University URC ID 102013MED. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. * Email: junaiddrpatel@gmail.com . These authors contributed equally to this work.

Background: Doctor-Patient consultation models have evolved over time, but there is a need for a paradigm shift from a directive consultation style towards a non-directive, person-centered consultation style. The aim of this study was to identify patients’ attitudes and perceptions to a person-centered model of care. Methods: A pilot cross-sectional study was conducted at a general outpatients department of a tertiary care hospital in Karachi, Pakistan, from September to November 2011. A total of 460 adult patients (>18 years and visiting the same doctor for more than one year) were consecutively approached. A pre-tested structured questionnaire was used to collect patient information. Data were analyzed using SPSS version 19 and multivariable logistic regression analysis. Results: In total 424 participants were included in the final analysis. The majority of the patients were males (57.3%). Females preferred the person-centered care (PCC) model more (52.7 vs. 42.7%). The regression analysis showed that those participants who had 6 to 12 years of education preferred the PCC model more as compared to those with low educational status (AOR:0.08, 95% C.I: 0.06-3.0, p=

Introduction. This special issue focuses on the role of complementary and alternative medicine (CAM) in cardiovascular diseases (CVD). The role of CAM in healthcare specifically in cardiovascular diseases (CVDs) has been a contentious issue for centuries. With demographic shifts, urbanization, and changing lifestyles, disease burden of cardiovascular diseases (CVDs) has increased dramatically and can further increase in the future. Despite the growing popularity of CAM therapies, limited information is available regarding patterns of use of CAM therapies in cardiovascular diseases. The definition of CAM has continued to evolve. As defined by the National Center of complementary and alternative medicine (NCCAM), “it is a group of diverse medical and healthcare systems, practices, and products that are not generally considered part of conventional medicine.” The 5 domains of CAM as classified by the NCCAM are whole medical systems (e.g., homeopathy, and ayurvedic medicine), mind-body interventions (e.g., yoga, meditation, and hypnotherapy), biologically based therapies (e.g., herbal treatments, mega-dose vitamins), manipulative and body-based methods (e.g., chiropractic therapy), and energy therapies (e.g., Reiki, and magnetic therapy). Over the last several decades, the use of CAM has become increasingly popular in both developed and the developing countries. A high proportion of patients using CAM believe CAM has remedial benefits and are safe compared to their prescribed treatments; this serves as a strong motivational factor for both present and future use of CAM. In addition, patients with CVD might be more likely to seek CAM treatments to decrease the psychological stress associated with this condition. Misconceptions regarding their efficacy have largely driven the popularity of these products whereas the adverse effects have been underreported. In disadvantaged societies where access to biomedical services is poor, the reliance on traditional/herbal medicines is more. In affluent population CAM is more used for disease prevention and health promotion. Data from the National Health Interview Surveys (NHIS) reported that 38% of adults in the USA were using CAM therapy in 2007 and among those 36% had CVD. CVD patients are often unwilling to inform their medical practitioners of CAM use and the majority of attending physicians do not discuss CAM use with their patients. Since many commonly used CAM products have the potential to interfere with the intended action of concomitant prescription medications, this could lead to serious drug interactions. In addition, the use of CAM may have negative impact on the compliance with prescription medications. A number of CAM therapies have purported cardiovascular effects; but most research on these products is either inconclusive, conflicting, or shows no benefit for their use. Several systematic reviews and meta-analysis on the effectiveness and possible side effects of CAM interventions suggest that some approaches may be beneficial as adjuncts to conventional management of cardiovascular disease, but no evidence exists to support their role as primary treatment. Dietary supplements (fish oil, coenzyme Q10, garlic, etc.) are among the most commonly used treatment modalities in patients with CVD. Fish oil supplements are accepted as a part of the treatment regimen for elevated serum triglycerides and the maintenance of vascular wall health. However, the efficacy of vitamin E has been questionable. Another intervention of CAM, that is, mind-body therapies (relaxation, stress management, meditation, etc.) have minimal side effects. However, in some countries unavailability of trained professionals in the field poses hindrance in its usage. Several styles of meditation have been tested and found to reduce blood pressure, improve heart rate, and even provide survival benefit. Evidence-based trials have been supportive of the conclusion that yoga can lower blood pressure and improve physical fitness. This one issue cannot answer all the questions regarding the safety, quality, and effectiveness of CAM therapies in CVDs. However, the main purpose of this issue is to open the communication line between patients and physicians on CAM use. It also illustrates the necessity of more rigorous researches to determine the precise pharmacological effects and long-term benefits on cardiovascular morbidity and mortality with CAM usage. Altogether, 27 papers were submitted for publication, out of which 19 papers were accepted. The articles in this issue represent a wide range of therapeutic approaches of CAM in preventing cardiovascular diseases. There are papers on extracts of herbal plants such as Nigella sativa, extract of black chokeberry, Salvia miltiorrhiza, polyphenol and Pueraria lobata, and their cardioprotective role in treating hypertension. Ethanolic extract of black chokeberry fruits has a potential role as prophylactic agent but can also function as a nutritional supplement in the management of arterial hypertension. In addition, a study on the use of repeatedly heated oil (a common practice in Asian countries) concluded that it has the predisposing factor of atherosclerosis leading to cardiovascular diseases. Therefore, it is advisable to avoid the consumption of repeatedly heated palm oil. This special issue also has a number of reviews on the role of CAM in preventing CVD. There is a review on the role of garlic in cardiovascular diseases: treatment and prevention which concluded that garlic can be used as an adjuvant with lipid lowering drugs for control of lipids. Moreover, another evidence-based review discusses CAM and CVDs; this review recommends that more rigorous researches are needed to determine the precise physiologic effects and long-term benefits on cardiovascular morbidity and mortality with CAM usage. In addition, there is a review on Chinese herbal medications (CHM) for hypertension. This review on 10 systematic reviews found that the majority of the RCTs (randomised controlled trials) do not include primary endpoints and therefore their conclusions remain uncertain. Another review on a traditional Chinese herbal formula, Zhen Gan Xi Feng Decoction, appears to be effective in improving blood pressure and symptoms in patients with essential hypertension. The edition also includes a paper on protein kinase II signal transduction pathway that inhibits cardiac arrhythmias in rats with myocardial infarction. Another study on palm tocotrienol-rich fraction found that it was comparable to folate in reducing high-methionine diet-induced plasma hyperhomocysteinemia, aortic oxidative stress, and inflammatory changes in rats. Conclusion. The articles presented in this issue represent the recognition of CAM's role in CVD patients. Nevertheless, better education of patients and medical practitioners is needed to improve the understanding of the risks and benefits of CAM use in CVD patients. Further pieces of evidence are required to determine the impacts of CAM use in CVD patients, particularly its clinical and prognostic impact when used in conjunction with prescription medicines. An open dialogue between healthcare professionals and patients regarding intended or present CAM use is also warranted. Acknowledgments. We hope that this special issue informs and stimulates thinking about the rationale use of CAM in CVD patients. We also hope that readers will find the papers included in this issue a valuable contribution to the field and it reflects the recent trends. We would like to thank the contributors to this special issue for their insightful papers. We would also like to acknowledge the many reviewers for their detailed comments and constructive suggestions. I wish to express my gratitude to all the Guest Editors for encouraging this project throughout, and meticulously carrying out the numerous and often arduous tasks involved with this project. Waris Qidwai Peng Nam Yeoh Victor Inem Kashmira Nanji Tabinda Ashfaq

Background Adverse drug reactions (ADRs) present a challenging and expensive public health problem. Polypharmacy is defined according to the WHO criteria as the, “concurrent use of five or more different prescription medication”. Elderly are more prone to adverse reactions due to comorbid conditions, longer lists of medications and sensitivity to drug effects. The aim of the study is to estimate the incidence and strength of association of ADRs due to polypharmacy among the geriatric cohort attending outpatient clinics at a tertiary care center. Methods A hospital based prospective cohort study was conducted at ambulatory care clinics of Aga Khan University Hospital April 2012 to March 2013. One thousand geriatrics patients (age ≥65 years) visiting ambulatory clinics were identified. They were divided on the basis of exposure (polypharmacy vs. no polypharmacy). We followed them from the time of their enrollment (day zero) to six weeks, checking up on them once a week. Incidence was calculated and Cox Proportional Hazard Model estimates were used. Results The final analysis was performed on 1000 elderly patients. The occurrence of polypharmacy was 70% and the incidence of ADRs was 10.5% among the study cohort. The majority (30%) of patients were unable to read or write. The use of herbal medicine was reported by 3.2% of the patients and homeopathic by 3%. Our Cox adjusted model shows that polypharmacy was 2.3 times more associated with ADRs, con-current complementary and alternative medicine (CAM) was 7.4 times and those who cannot read and write were 1.5 times more associated with ADRs. Conclusion The incidence of ADRs due to poly pharmacy is alarmingly high. The factors associated with ADRs are modifiable. Policies are needed to design and strengthen the prescription pattern.

Background: Person-centered care has long been identified as a key component of health systems and one of the six domains of quality. This study aimed to identify the perceptions of patients and physicians regarding person-centered care in the Eastern Mediterranean Region (EMR).Methods: A multicountry, cross-sectional study was conducted in 6 countries of EMR during July 2012 to September 2012. From each country, an expert Family Physician (FP) was identified and invited for the study. During the first phase, 190 FPs practicing for at least 6 months were recruited. In the second phase, the recruited FPs approached 300 patients aged > 18 years with 1 or more recurring problems. Data analysis was conducted using SPSS version 19.Results: Of a total of 360 patients, 53% were between 25-40 years of age and the majority 55.7% were females. Among physicians, 66.8% were females and 72.1% had undergone specialization in Family Medicine from EMR. About 36% of the patients, while 62.6% of the physicians, preferred a person-centered care model of care. Among physicians, field of specialization (AOR= 0.7; 95% C.I: 0.3-0.9) and regularity in continuing medical education sessions (AOR= 0.3; 95% C.I: 0.1-0.5) were significant factors for preferring a person-centered care model. Educational status (AOR= 3.0; 95% C.I: 1.1-7.9) was associated with a preference for person-centered care among patients.Conclusion: The results of the study highlight that a majority of physicians prefer person-centered care, while patients prefer a mix of both patient- and physician-centered care. Strategies should be developed that will help physicians and patients to embrace person-centered care practices.

Background: Increasing modernization and mechanization have turned the life into fast pace and it has devastating effects on the health of the people.Objective:To identify the perceptions of patients regarding fast pace of life and its impact on health.Methods: A cross-sectional study was conducted at out-patients department of two tertiary care hospitals in Karachi, Pakistan; from January to March 2013. A total of 401 participants aged > 18 years were recruited through consecutive sampling. Data analysis was done using SPSS 19.0 and multivariable logistic regression was applied to identify impact of fast life.Results: Out of total 401 participants, 55% of the patients were between 21-35 years of age and majority was females (75%). Majority of the participants was suffering from fast pace life (82%) and main reasons for fast pace life were competition and the increasing needs of the family. Those who were suffering from fast pace life were at risk of affecting their physical health (AOR: 2.6; 95% C.I:1.3-5.2), social life (AOR: 2.1 95% C.I:1.0-4.5), psychological wellbeing (AOR: 2.4; 95% C.I:1.2-4.5) and are more susceptible to stress and depression (AOR: 4.6; 95% C.I:2.3-9.3).Conclusion: This study found that majority of urban population is suffering from fast pace of life with severe consequences on its physical, social and mental health. The society seems to be speeding up and becoming less empathic and increasingly stressful. This will have delirious effects on physical and mental health of people in the decades to come. Therefore, it is important for people to take time out for themselves and their families to keep themselves fit for survival in this fast moving world.