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Objective: This study aims to develop and assess the content validity along with the reliability of a Professionalism Assessment Tool (PAT) with an intention to measure professionalism among undergraduate medical students. Methods: This psychometric analytical study validation study was carried out at Rawalpindi Medical University from 1st February to 1st June, 2021 after establishing feasibility and obtaining ethical approval. The non-probability convince sampling was employed to collect data. Using Nunnally’s, the ratio of e subjects per item was selected, as our preliminary tool has 48 items so 384 sample size was estimated for scale validation. The preliminary 48-item tool with five subscales(cSS) developed through mutual consensus by the Delphi technique namely Communication skill(cSS1),-7 item, Accountability(cSS2)-8 item, Altruism(cSS3)-13 item, Self-Directed Learning (cSS4)-10 item and Ethics(cSS5),-10 item was labelled as Professionalism Assessment Tool (PAT). The tool was administered to 4th year MBBS students, the data obtained was analyzed by calculating Cronbach’s alpha to estimate the reliability. The SPSS version 26 was used for data analysis. Results: The 48-item PAT had an overall reliability (Cronbach’s alpha) of 0.783. The Reliability of the new Subscales were communication skills (0.405), self-directed learning (0.527), Accountability (0.378), Altruism (0.486) and Ethics (0.715). Conclusion: The final tool developed for assessment of professionalism had 48 items on a seven point Likert like scale, across five Subscales. Results showed that it was determined as a useful tool in assessing professionalism in undergraduate medical students to generate reliable results for valid decision-making. doi: https://doi.org/10.12669/pjms.39.2.6608 How to cite this: Noreen K, Zuberi RW, Aftab K, Fatima S. Assessment of Medical Professionalism: Development and psychometric analysis of Professionalism Assessment Tool (PAT) in Pakistani context using Delphi Techniques. Pak J Med Sci. 2023;39(2):---------. doi: https://doi.org/10.12669/pjms.39.2.6608 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

A 72-year-old asthmatic gentleman with a history of recurrent sinusitis and chronic bronchitis presented with shortness of breath and progressively worsening hypoxemic respiratory failure. His CT chest demonstrated airspace disease bilaterally with ground-glass opacifications. He had peripheral eosinophilia with raised inflammatory markers but negative work up of infection. On further investigation, ANA was positive, titer 1:160, speckled pattern and both pANCA and cANCA were present. The patient was diagnosed with Eosinophilic Granulomatosis with Polyangiitis (EGPA) and started on intravenous steroids and cyclophosphamide. A rare multi-organ vasculitis, EGPA is hallmarked by asthma, sinusitis and eosinophilia. In initial stages vasculitic involvement is not usually seen thereby making EGPA a diagnostic challenge. doi: https://doi.org/10.12669/pjms.39.1.6436 How to cite this: Mahmood K, Butt NI, Ashfaq F, Aftab S. Eosinophilic Granulomatosis with Polyangiitis (EGPA): A case report with atypical presentation. Pak J Med Sci. 2023;39(1):---------. doi: https://doi.org/10.12669/pjms.39.1.6436 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective: This study aimed to improve the mechanical properties of denture base material using various concentrations of natural biopolymer, i.e., Gum Arabic (GA). Methods: This experimental study was conducted at the Dental Health Department of the College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia from May 2022 to July 2022. After obtaining exemption from the institutional review board, the powdered GA was added in ratios of weight 5, 10, and 20% to PMMA heat-cured acrylic powder to produce bar-shaped samples (65 × 10 × 30 mm3 in dimensions). While the control group was prepared as such. Micro hardness (n=10/group) and fracture toughness (n=10/group) were evaluated. One-way analysis of variance method was used to statistically analyze the results (p

Background & Objective: Child & adolescent mental health needs to be considered as an integral component of overall health, however significant gaps exist in service provision especially inpatient services in Pakistan. The paper presents the characteristics of admitted youths and response to treatment in Pakistan’s first dedicated child & adolescent psychiatry inpatient unit in Lahore over a period of first seven years. The aim of this study was to better understand the various characteristics of children and youth admitted to this inpatient unit and response to treatment over a seven years’ period since the inception of the unit. Methods: Inpatient medical records of children & adolescents admitted to dedicated Child & Adolescent Inpatient Unit at King Edward Medical University, Lahore were reviewed. Data was extracted regarding referral patterns, sociodemographic factors and diagnosis for the first seven years, from 2012 to 2019. Patients’ scores on Strengths and Difficulties Questionnaire and Clinical Global Impressions Scales administered during intake were also reviewed. Results: Six hundred and thirty-four (634) patients, 56% (355) being females were admitted to the unit during seven years with mean age of 12.3±2.3. Mean duration of admission was 15.60±6.3 days. Most predominant ICD-10 Axis-I psychiatric diagnosis were neurotic, stress related and somatoform disorders (262); mood disorders (78); schizophrenia, schizotypal & delusional disorders (77) and behavioral and emotional disorders with onset usually occurring in childhood and adolescence (44). One hundred and fifty-nine (25%) children had comorbid diagnosis of intellectual disability on Axis-III. Strengths and difficulties questionnaire scores were in abnormal range for significant proportion (>50 %) of patients. CGI mean scores showed marked improvement at discharge. Conclusion: Neurotic, stress related and somatoform disorders are the most common diagnosis in youth needing inpatient treatment in Pakistani setup. Study results indicate that there is a clear need for specialized inpatient child and adolescent services such as ours in low- & middle-income countries. doi: https://doi.org/10.12669/pjms.37.2.2611 How to cite this:Imran N, Bodla ZH, Asif A, Shoukat R, Azeem MW. Pakistan’s First Child & Adolescent Psychiatry Inpatient Unit: Characteristics of admitted patients and response to treatment over a 7-year period. Pak J Med Sci. 2021;37(2):305-311. doi: https://doi.org/10.12669/pjms.37.2.2611 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective: To determine the effectiveness of Fragility Fracture Integrated Rehabilitation Management (FIRM) on mobility, activity of daily living and cognitive functioning in elderly with hip fracture. Methods: A randomized control trial was conducted at Seoul National University Bundang Hospital, South Korea from August 2017 to January 2018. Patients of both genders with the age 65-95 years, diagnosed cases of hip fracture specifically fractures neck of femur, intertrochanteric, subtrochantric, patients who got bipolar hemiarthroplasty, total hip replacement arthroplasty, reduction and internal fixation were included in this study. A total of n=39 sample was collected through non probability convenience sampling technique and randomly divided into Fragility Integrated Rehabilitation Management (FIRM) group (n=20) and Conventional Physical therapy (CPT) group (n=19). The data was collected through KOVAL for walking ability, modified barthal index (MBI) for behaviors related to activities of daily living (ADLS) and mini mental status examination (MMSE) for cognitive functions at baseline on 2nd postoperative day and after 10th FIRM session on 15th postoperative day. Results: The mean age of study participants was 82.07±6.00 years. The post intervention comparison did not show any significant difference (p>0.05) in walking ability, overall ADLs and cognitive functioning. But FIRM group showed significant improvement in stair climbing {0(5) ver. 2(7.5), p=0.049} and ambulation or walker use {8(5) ver. 2(4), p=0.037}, as compared to CPT group. Conclusion: Both groups improved in indoor mobility with walker and crutches as well as activities of daily living. But FIRM showed more improving ambulation with walker and stair climbing. While cognitive functioning was observed only in FIRM group. ClinicalTrials.gov Identifier: NCT03430193. https://clinicaltrials.gov/ct2/show/NCT03430193. doi: https://doi.org/10.12669/pjms.36.5.2412 How to cite this:Aftab A, Awan WA, Habibullah S, Lim JY. Effects of fragility fracture integrated rehabilitation management on mobility, activity of daily living and cognitive functioning in elderly with hip fracture. Pak J Med Sci. 2020;36(5):965-970. doi: https://doi.org/10.12669/pjms.36.5.2412 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Corrosive ingestion in children is a common problem in low income countries. These agents cause injuries and later strictures of esophagus and stomach. Gastric outlet obstruction is known complication of acids and surgery is the mainstay of treatment. There are multitude of surgical options for these strictures depending on the involved segment of the stomach and experience of the surgeon. Here we present three cases of children who accidentally ingested acid stored in soda bottles and subsequently developed isolated pyloric strictures. These cases presented between August 2018 and April 2019 to our facility, a tertiary care hospital in Karachi, Pakistan. All three patients had an initial latent period of one to two weeks following corrosive ingestion, after which symptoms of gastric outlet obstruction appeared. Intraoperatively, all three had normal esophagus and antrum but scarred and strictured pylorus. Heineke-Mikulicz pyloroplasty was done in these cases without complications and the outcomes were satisfactory. doi: https://doi.org/10.12669/pjms.36.ICON-Suppl.1714 How to cite this:Soomro MA, Aftab M, Hasan M, Arbab H. Heineke-Mikulicz pyloroplasty for isolated pyloric stricture caused by corrosive ingestion in children. Pak J Med Sci. Special Supplement ICON 2020. 2020;36(1):S87-S90. doi: https://doi.org/10.12669/pjms.36.ICON-Suppl.1714 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background & Objectives: Retinoblastoma is a malignant intraocular tumor and its treatment requires a multidisciplinary approach. Chemotherapy is an important modality in treatment of retinoblastoma. The purpose of this study was to assess the histopathological changes in retinoblastomas treated with chemotherapy along with correlation of comorbid conditions with high risk histopathological factors (HRF). Methods: All post-chemotherapy enucleated eye specimens received in the pathology department between 2017 to 2021 were included in the study. Slides were retrieved and reviewed for chemotherapeutic effects, tumor regression, and for assessment of HRF. Patient demographic data, information regarding chemotherapy and co-morbid conditions were retrieved through the hospital database. Chi-square was used to analyze the relation between comorbid conditions and HRF. Results: Chemotherapeutic effects were seen in all eyes with varying degrees of responses. Necrosis, calcification, and gliosis were the most common findings. The majority of eyes showed tumor occupying less than 50% of the eye whereas complete regression was noted in one eye only. Retinal detachment, glaucoma, and buphthalmos were the most common comorbid conditions at the time of diagnosis. Patients with glaucoma were more likely to have ciliary body invasion. Kaplan Meier analysis showed that patients with more than two HRF had decreased survival rates in comparison to those with one or no HRF. Conclusion: Histopathological evaluation of chemotherapy-treated eyes shows varying degrees of response to chemotherapy. Post enucleation histopathological evaluation of the globe plays an important role in assessing disease activity and guiding further treatment to prevent metastasis. doi: https://doi.org/10.12669/pjms.38.ICON-2022.5786 How to cite this:Yaqoob N, Mansoor S, Zia N, Aftab K, Kaleem B, Jamal S. Chemotherapy induced histopathological changes in retinoblastoma, assessment of high risk predictive factors & its correlation with comorbid conditions. Pak J Med Sci. 2022;38(2):362-368. doi: https://doi.org/10.12669/pjms.38.ICON-2022.5786 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background & Objectives: The assessment of histopathological risk factors (HRFs) in retinoblastoma in upfront enucleated eyes is important in deciding treatment protocols. Limited data is available from the developing countries as very few studies were conducted on retinoblastoma. The study aims to report this data from Pakistan. Methods: This cross-sectional study included treatment naïve retinoblastoma patients who underwent upfront enucleation between 2017 to 2021. Various tumor characteristics i.e. laterality, size, histologic grade, anaplasia grade, growth pattern, extent and length of optic nerve invasion, pathologic staging, tumor involvement of ocular structures were assessed. High-risk factors such as involvement of anterior chamber, choroidal, scleral, extrascleral, and optic nerve were also noted. Results: A total number of 54 patients were enrolled, out of which 53.7% were females while remaining were males. Median age at presentation was 24 months. Unilateral tumor was seen in 92.6% cases. Most frequent histologic grade was G2 (64.7%) and moderate anaplasia was observed in 59.2% cases. Vitreous involvement was seen in (86.5%). Pathologic staging of most of the tumors was pT1 (39.2%). Assessment of high-risk factors revealed that optic nerve involvement (35.1%) was the most common finding with retrolaminar tumor invasion seen in 75% cases. Choroidal invasion (≤3mm) was seen in 55.6% of patients. Limited involvement of anterior chamber (3.8%), sclera (7.4%), and extrascleral (3.8%) tissue was also observed. Conclusion: The presence of high risk histopathological factors in enucleated eyes diagnosed with retinoblastoma are known to have a profound impact on the risk stratification as well as decision of future treatment plan. doi: https://doi.org/10.12669/pjms.38.ICON-2022.5787 How to cite this:Yaqoob N, Mansoor S, Aftab K, Kaleem B, Hamid A, Jamal S. High risk histopathological factors in retinoblastoma in upfront enucleated eyes: An experience from a tertiary care centre of Pakistan. Pak J Med Sci. 2022;38(2):369-374. doi: https://doi.org/10.12669/pjms.38.ICON-2022.5787 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective: Serum Vitamin-D plays pivotal role in inflammatory and infectious diseases; among them liver infections are more distinct. This study was aimed to determine Vitamin-D status in HCV-infected patients and healthy controls in Faisalabad, Pakistan. Methods: We performed randomized cross-sectional study of 74 individuals from 20th August, 2017 to 20th February 2018 at The University of Faisalabad and Dar us Shifa Clinic, Faisalabad. Fifty-one patients were hepatitis C RNA-PCR positive (22 compensated cirrhotic and 29 decompensated cirrhotic patients). In addition, 23 subjects without liver disease were recruited as healthy control. HCV RNA–PCR was performed by ARTUS ® HCV QS-RGQ V1. Vitamin-D levels were measured by chemiluminescence. SPSS version 20 was used for statistical analysis. Results: The mean level of Vitamin-D was significantly lower in HCV patients in compensated and decompensated cirrhotic patients (26.85 ng/mL & 20.65 ng/mL respectively) as compared to healthy controls (30.41 ng/mL). This study showed sub optimal level of Vitamin-D in 76.5% of HCV patients. Vitamin-D insufficiency (21-29 ng/mL) as prevalent among healthy individuals (47.8%) as well as in HCV patients (39.2%) (P < 0.001). In addition, Vitamin-D levels showed inverse relationship with more severe conditions of liver disease as 55.2% of decompensated cirrhosis patients were sufferer of Vitamin-D deficiency as compared to 13.6% deficiency of Vitamin-D in compensated cirrhotic group (P

Objective: Serum Vitamin-D plays pivotal role in inflammatory and infectious diseases; among them liver infections are more distinct. This study was aimed to determine Vitamin-D status in HCV-infected patients and healthy controls in Faisalabad, Pakistan. Methods: We performed randomized cross-sectional study of 74 individuals from 20th August, 2017 to 20th February 2018 at The University of Faisalabad and Dar us Shifa Clinic, Faisalabad. Fifty-one patients were hepatitis C RNA-PCR positive (22 compensated cirrhotic and 29 decompensated cirrhotic patients). In addition, 23 subjects without liver disease were recruited as healthy control. HCV RNA–PCR was performed by ARTUS ® HCV QS-RGQ V1. Vitamin-D levels were measured by chemiluminescence. SPSS version 20 was used for statistical analysis. Results: The mean level of Vitamin-D was significantly lower in HCV patients in compensated and decompensated cirrhotic patients (26.85 ng/mL & 20.65 ng/mL respectively) as compared to healthy controls (30.41 ng/mL). This study showed sub optimal level of Vitamin-D in 76.5% of HCV patients. Vitamin-D insufficiency (21-29 ng/mL) as prevalent among healthy individuals (47.8%) as well as in HCV patients (39.2%) (P < 0.001). In addition, Vitamin-D levels showed inverse relationship with more severe conditions of liver disease as 55.2% of decompensated cirrhosis patients were sufferer of Vitamin-D deficiency as compared to 13.6% deficiency of Vitamin-D in compensated cirrhotic group (P

Objectives: To determine the clinical spectrum and underlying etiologies of children presented with precocious puberty at The Children’s Hospital &The Institute of Child health, Lahore. Methods: It is a retrospective review of all the children presented with precocious puberty over one year, from January 2015 to December 2015; at the department of Paediatric Endocrinology & Diabetes, The Children’s Hospital & The Institute of Child Health, Lahore. Results: Total 43 cases of precocious puberty (PP), with 26 females were reported in one year. Central precocious puberty (CPP) constituted 55.8% (24/43) and was found to be more prevalent in female (22/24). In 20/24 cases (83.3%) of central precocious puberty underlying etiology was idiopathic. Peripheral precocious puberty was found in 19/43 cases (44.1%) with male predominance (15/19). Congenital adrenal hyperplasia was the most frequent (12/19) underlying cause of peripheral precocious puberty in our cohort. Conclusion: Precocious puberty could be a manifestation of underlying serious medical condition. It should be thoroughly evaluated with the aim to diagnose the underlying pathology and to treat them promptly. doi: https://doi.org/10.12669/pjms.38.4.4816 How to cite this:Aftab S, Manzoor J, Mahmood Q, Shaheen T. Precocious puberty: The clinical profile and the etiological classification of children presented at a tertiary care children’s hospital. Pak J Med Sci. 2022;38(4):---------. doi: https://doi.org/10.12669/pjms.38.4.4816 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objectives: The current study aimed to determine the Spontaneous Bacterial Peritonitis (SBP) risk due to increased use of Proton Pump Inhibitors (PPIs) among cirrhotic patients with ascites. Methods: This retrospective case-control study was conducted at Chandka Medical College & Hospital, Larkana from March 2013 to February 2014, involving 215 cirrhotic patients with ascites. Paracentesis was performed to distinguish cirrhotic patients with SBP and Polymorphonuclear Neutrophil (PMN) count ≥ 250 neutrophils/mm3 (cases) and non-SBP with PMN count < 250 neutrophils/mm3 (controls). The demographic details, history of PPIs use before admission and duration of Chronic Liver Disease (CLD) were inquired and statistical analysis was carried through SPSS Version 23.0. Results: Increased pre-hospital PPI intake was observed among cirrhotic patients with SBP (69.8%) as compared to those without SBP (48.8%; p = 0.014). The mean duration of PPI use was 19.16 ± 4.772 days, and it was more significant among older cirrhotic patients (p < 0.05). Increased duration of CLD was observed among PPI users, i.e. 20.47 ± 6.305 months vs. 18.95 ± 5.527 months among non-PPI users (p < 0.05). Conclusions: Our results show that cirrhotic patients with ascites consuming PPIs are more likely to develop SBP as compared to non-PPI users. doi: https://doi.org/10.12669/pjms.37.4.3476 How to cite this:Shaikh BA, Shaikh ZA, Shah AH, Kumar A. Determining the Risk of Spontaneous Bacterial Peritonitis due to increase use of Proton Pump Inhibitors among cirrhotic patients with ascites. Pak J Med Sci. 2021;37(4):1075-1079. doi: https://doi.org/10.12669/pjms.37.4.3476 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective: To find out the prevalence of human immunodeficiency virus (HIV) and Hepatitis (B & C) among the drug users in a tertiary care public hospital. Methods: The study was conducted at addiction ward of Mayo Hospital Lahore. A total of 453 drug users were admitted in drug addiction ward from 1st of August 2016 to 31st of July 2017. Their history was taken using self-constructed case history form and they were screened for HIV and hepatitis (B & C). Additionally three types of screening tests including Unigold, Determine and Bioline were used for HIV screening. Results: Of 402 (100%) drug users, 394 (98%) were male and 8 (2%) were female. Their mean age was 32.2 (8.8) years. Overall prevalence of HIV virus was 21.1%, Hepatitis C 34.3% and Hepatitis B 3.2% in drug users. Among HIV positive drug users, 84.7% drug users took drugs through injections as compared to 15.3% who took drugs orally. Among HCV positive drug users, 68.9% drug users took drugs through injections as compared to 31.1% oral drug users. Relapse rate of drug use among all drug users was also very high as 83.3%. Of these drug users, 47.2% had previously sought treatment while other 52.8% never sought any treatment. Family history of drug abuse indicated that 32.2% drug users had family members who were also drug users. Moreover, about 11.4% drug users had previous history of blood transfusion. Conclusion: HIV and hepatitis B & C were prevalent among drug users specially those who took drugs through injections. Relapse rate was significantly high and history of drug use in family may also predispose an individual towards becoming a drug addict.

Objective: To determine the classification and etiological diagnosis of children presented with ambiguous genitalia/atypical genitalia according to the newer classification system of Disorder of Sex Development (DSD). Methods: This observational, cross-sectional study was conducted at the Department of Pediatric Endocrinology and Diabetes at The Children’s Hospital &Institute of Child Health, Lahore from January, 2007 to December; 2014. Files of all the children with ambiguous genitalia were retrospectively analyzed and relevant data was retrieved. All the information was recorded on predesigned proforma and analyzed accordingly. Results: A total of 300 cases of ambiguous genitalia classified according to the new DSD classification. 46, XX DSD were 54.3% (n=163), 46, XY DSD were 43.7% (n=131), sex chromosome DSD were 2% (n=6). Among 46, XX DSD cases, the most common cause was congenital adrenal hyperplasia (97%, n=158). However, in 46, XY DSD partial androgen insensitivity/5α-reductase deficiency (62%. n=81) constituted the most commonest disorder. Other causes of 46XY DSD include testosterone synthesis defect(23%), congenital adrenal hyperplasia (CAH,12%), testis regression syndrome (1.5%) and persistent mullerian duct syndrome (PMDS,1.5%). Sex chromosome disorder constituted one case of iso-chromosome X turner syndrome, mixed gonadal dysgenesis (n=3), ovotesticular DSD/chimerism (n=2). Conclusion: Ambiguous genitalia have varied etiologies, 46; XXDSD found being the commonest of all, showing predominance of CAH especially salt loosing type. The early detection and prompt treatment of cases of ambiguous genitalia plays a pivotal role in the management of acute life threatening condition and gender assignment.

Objectives: To determine the factors affecting the outcome of hospitalization in patients suffering liver cirrhosis hospitalized to tertiary care hospital, Gujranwala, Pakistan. Methods: After informed consent, the data of liver cirrhosis patients with age >12 years hospitalized from June 2016 to May 2017 was collected by purposive sampling. The outcome of the hospitalization in term of ‘death’ and ‘no death’ was noted. Statistical analysis was done using SPSS version 25. Bivariate analysis as well binary logistic regression was performed to ascertain the effect of different predictors like gender, age, history of diabetes mellitus, etiology of cirrhosis, presence of hepatic encephalopathy at presentation, presence of upper GI bleed, and tracheobronchial aspiration on the likelihood that death would be the outcome in liver cirrhosis patients. Results: Amongst total of 1304 patients, 15.7% died during hospitalization. The mean age of those who died was 58.08 + 14.49 years. Bivariate analysis suggested that mortality was significantly higher in group of patients who had hepatic encephalopathy at presentation (p

Background and Objective: Mental health problems not only affect the common person but also medical health practitioners (MHPs) dealing with health care issues of patients. The current study aimed to explore the triadic (three dimensional) comorbidity of mental health problems and its association with three forms of psychological burnout (person, client and work related). Methods: This correlational study was conducted at three hospitals of Islamabad/ Rawalpindi (Holy Family Hospital=57, District Headquarter Hospital=60, and Benazir Bhutto Hospital=40) from June 2018 to September 2018. The sample comprised of 157 medical health practitioners (medical doctors) serving in general ward (n=64), emergency (n=60) and OPD (n=33) sections. The participants were administered self-report measures of DASS-21 and Copenhagen Burnout Inventory. Results: Triadic comorbidity of depression, anxiety and stress ranged from 9% to 26% for excessive severe and normal levels respectively. Comorbidity of work related and personal related burnout at severe level was found 8%. Further, depression, anxiety and stress symptoms were strongly associated with psychological burnout at .0001 significance level. Conclusion: MHPs demonstrated excessive severe comorbidity of depression, anxiety and stress simultaneously. Along with this triadic comorbidity, the presence of severe psychological burnout is alarming and affecting overall efficiency and mental health of doctors which need to be identified, screened out and managed timely and managed properly.

Background and Objectives: Stigma around COVID-19 is a major barrier in global efforts to control the COVID 19 pandemic. Limited data is available regarding stigma faced by COVID-19 patients in low- and middle-income countries (LMIC). The aim of the current study was to explore the stigma experienced by hospitalized patients with COVID-19 illness in Lahore, Pakistan. Methods: Following Institutional Review Board approval and informed consent, patients were assessed using modified HIV short form stigma scale and open-ended questions. Questions focused on experiences, feelings, and opinions as to how patients feel and how they were treated prior to and during the hospitalization. Data analysis for quantitative data was performed using SPSS-20, while qualitative responses were interpreted by content analysis method. Results: One hundred and fourteen patients were interviewed (Mean age 38.8 years + 15.3) with 53.5% being males. Widespread experience of stigma was reported by patients particularly for concerns about public attitudes (7.43 + 1.43) & disclosure (6.89 + 1.45). Main themes which emerged from the qualitative responses were social stigma and rejection, humiliating behaviour of others, breach of confidentiality, loss of trust/ respect, and impact of COVID-19 diagnosis on their business. Conclusions: Existence of significant stigma among COVID-19 patients isolated in a tertiary care hospital in a LMIC highlights the need for culturally sensitive strategies to address it. doi: https://doi.org/10.12669/pjms.36.7.3606 How to cite this:Imran N, Afzal H, Aamer I, Hashmi A, Shabbir B, Asif A, et al. Scarlett Letter: A study based on experience of stigma by COVID-19 patients in quarantine. Pak J Med Sci. 2020;36(7):1471-1477. doi: https://doi.org/10.12669/pjms.36.7.3606 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective: This study aims to establish the 99th percentile upper reference limits of high sensitive cardiac troponin I in a healthy Pakistani population. Methods: It was an Observational cohort study carried out in Department of Chemical Pathology and Endocrinology Rehman Medical Institute Peshawar, over the period of one year (January 2019- December 2019). Total 299 cardio-healthy males and females were interviewed and taken past medical history. Based on history, clinical examination, echocardiogram and laboratory data including results of estimated glomerular filtration rate (eGFR) and N-terminal pro-B-type natriureteric peptide (NT-proBNP), subjects with possible subclinical diseases were excluded. High Sensitive Cardiac Troponin I (hs-cTtrop I) was analysed on Abbot ARCHITECT STAT ci8200 using chemiluminescent immunoassay technique. The 99th percentile upper reference limit (URL) of hs-cTtrop I was determined using a non-parametric statistic, while gender specific results were compared. Results: In this study, 178 males (59.5%) and 121 females (40.5%) were included. The median Interquartile ranges (IQR) of age was 57 (11.6) for males and 56 (13) for females. The 99th percentile URL hs-cTtrop I was found to be 33.9 ng/L, while gender specific values were 38.41ng/L and 15.73ng/L for males and females, respectively (p= 0.0045). Conclusion: High sensitivity cardiac troponin I 99th percentile URL in our study population was found to be 33.9 ng/L with gender specific values being 38.41 ng/L and 15.73ng/L for males and females respectively. Troponin I in males was substantially high in comparison with females. doi: https://doi.org/10.12669/pjms.36.6.2328 How to cite this:Bahadur K, Ijaz A, Salahuddin M, Alam A. Determination of high sensitive cardiac troponin I 99th percentile upper reference limits in a healthy Pakistani population. Pak J Med Sci. 2020;36(6):1303-1307. doi: https://doi.org/10.12669/pjms.36.6.2328 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background and Objective: Mental health problems not only affect the common person but also medical health practitioners (MHPs) dealing with health care issues of patients. The current study aimed to explore the triadic (three dimensional) comorbidity of mental health problems and its association with three forms of psychological burnout (person, client and work related). Methods: This correlational study was conducted at three hospitals of Islamabad/ Rawalpindi (Holy Family Hospital=57, District Headquarter Hospital=60, and Benazir Bhutto Hospital=40) from June 2018 to September 2018. The sample comprised of 157 medical health practitioners (medical doctors) serving in general ward (n=64), emergency (n=60) and OPD (n=33) sections. The participants were administered self-report measures of DASS-21 and Copenhagen Burnout Inventory. Results: Triadic comorbidity of depression, anxiety and stress ranged from 9% to 26% for excessive severe and normal levels respectively. Comorbidity of work related and personal related burnout at severe level was found 8%. Further, depression, anxiety and stress symptoms were strongly associated with psychological burnout at .0001 significance level. Conclusion: MHPs demonstrated excessive severe comorbidity of depression, anxiety and stress simultaneously. Along with this triadic comorbidity, the presence of severe psychological burnout is alarming and affecting overall efficiency and mental health of doctors which need to be identified, screened out and managed timely and managed properly. doi: https://doi.org/10.12669/pjms.35.6.444 How to cite this:Ashraf F, Ahmad H, Shakeel M, Aftab S, Masood A. Mental health problems and psychological burnout in Medical Health Practitioners: A study of associations and triadic comorbidity. Pak J Med Sci. 2019;35(6):1558-1564. doi: https://doi.org/10.12669/pjms.35.6.444 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background & Objective: Dengue infection is an arthropod borne disease caused by Dengue virus in humans. Dengue virus infection has more potential to produce severe form of the disease with more severe symptoms. Proper diagnosis of dengue fever is very important for its safe management. The objective of this study was to evaluate the non structural protein-1 (NS1) positive parameter for identification of dengue fever by using ELISA from 2013 dengue outbreak in Khyber Pakhtunkhwa. Methods: It was a cross sectional study conducted among 384 patients tested for dengue admitted to different hospitals of Khyber Pakhtunkhwa April to December 2013 with symptoms related to classical dengue fever. Written informed consent was taken from 100 NS1 positive diagnosed patients, and 3 to 5 ml blood sample was collected for confirmation through ELISA testing. ELISA test for dengue IgG and IgM was performed two time in order to confirm the dengue cases. Data was entered and analyzed by using SPSS version 16. Result: The study performed on 100 NS1 positive samples of patients, admitted to hospitals with symptoms related to classical dengue fever, indicated that after performing the IgM and IgG capture ELISA test only 76 samples were actually found positive for dengue. The rest of the 24 samples were found negative for both IgM and IgG capture ELISAs. The study also revealed that 90.8 % patients had primary dengue infection and 35.5% patients had secondary dengue infection. Most patients were between the age of 10-20 years (26%), among them19.7% were having primary dengue infection. Among 10-20 years of age 50% female patients were false dengue patients. Conclusion: About 24 % NSI protein positive samples were found negative for both IgM and IgG capture ELISAs showed that NS1protein positivity does not confirm actual dengue infection.

Objectives: To determine the factors affecting the outcome of hospitalization in patients suffering liver cirrhosis hospitalized to tertiary care hospital, Gujranwala, Pakistan. Methods: After informed consent, the data of liver cirrhosis patients with age >12 years hospitalized from June 2016 to May 2017 was collected by purposive sampling. The outcome of the hospitalization in term of ‘death’ and ‘no death’ was noted. Statistical analysis was done using SPSS version 25. Bivariate analysis as well binary logistic regression was performed to ascertain the effect of different predictors like gender, age, history of diabetes mellitus, etiology of cirrhosis, presence of hepatic encephalopathy at presentation, presence of upper GI bleed, and tracheobronchial aspiration on the likelihood that death would be the outcome in liver cirrhosis patients. Results: Amongst total of 1304 patients, 15.7% died during hospitalization. The mean age of those who died was 58.08 + 14.49 years. Bivariate analysis suggested that mortality was significantly higher in group of patients who had hepatic encephalopathy at presentation (p

Objective: To find out the prevalence of human immunodeficiency virus (HIV) and Hepatitis (B & C) among the drug users in a tertiary care public hospital. Methods: The study was conducted at addiction ward of Mayo Hospital Lahore. A total of 453 drug users were admitted in drug addiction ward from 1st of August 2016 to 31st of July 2017. Their history was taken using self-constructed case history form and they were screened for HIV and hepatitis (B & C). Additionally three types of screening tests including Unigold, Determine and Bioline were used for HIV screening. Results: Of 402 (100%) drug users, 394 (98%) were male and 8 (2%) were female. Their mean age was 32.2 (8.8) years. Overall prevalence of HIV virus was 21.1%, Hepatitis C 34.3% and Hepatitis B 3.2% in drug users. Among HIV positive drug users, 84.7% drug users took drugs through injections as compared to 15.3% who took drugs orally. Among HCV positive drug users, 68.9% drug users took drugs through injections as compared to 31.1% oral drug users. Relapse rate of drug use among all drug users was also very high as 83.3%. Of these drug users, 47.2% had previously sought treatment while other 52.8% never sought any treatment. Family history of drug abuse indicated that 32.2% drug users had family members who were also drug users. Moreover, about 11.4% drug users had previous history of blood transfusion. Conclusion: HIV and hepatitis B & C were prevalent among drug users specially those who took drugs through injections. Relapse rate was significantly high and history of drug use in family may also predispose an individual towards becoming a drug addict. How to cite this:Asif A, Ayub S, Komal A, Noor S, Jalal U. Prevalence of human immunodeficiency virus and Hepatitis (B & C) among drug users in a tertiary care public hospital. Pak J Med Sci. 2019;35(2):459-463. doi: https://doi.org/10.12669/pjms.35.2.500 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective: To determine the classification and etiological diagnosis of children presented with ambiguous genitalia/atypical genitalia according to the newer classification system of Disorder of Sex Development (DSD). Methods: This observational, cross-sectional study was conducted at the Department of Pediatric Endocrinology and Diabetes at The Children’s Hospital &Institute of Child Health, Lahore from January, 2007 to December; 2014. Files of all the children with ambiguous genitalia were retrospectively analyzed and relevant data was retrieved. All the information was recorded on predesigned proforma and analyzed accordingly. Results: A total of 300 cases of ambiguous genitalia classified according to the new DSD classification. 46, XX DSD were 54.3% (n=163), 46, XY DSD were 43.7% (n=131), sex chromosome DSD were 2% (n=6). Among 46, XX DSD cases, the most common cause was congenital adrenal hyperplasia (97%, n=158). However, in 46, XY DSD partial androgen insensitivity/5α-reductase deficiency (62%. n=81) constituted the most commonest disorder. Other causes of 46XY DSD include testosterone synthesis defect(23%), congenital adrenal hyperplasia (CAH,12%), testis regression syndrome (1.5%) and persistent mullerian duct syndrome (PMDS,1.5%). Sex chromosome disorder constituted one case of iso-chromosome X turner syndrome, mixed gonadal dysgenesis (n=3), ovotesticular DSD/chimerism (n=2). Conclusion: Ambiguous genitalia have varied etiologies, 46; XXDSD found being the commonest of all, showing predominance of CAH especially salt loosing type. The early detection and prompt treatment of cases of ambiguous genitalia plays a pivotal role in the management of acute life threatening condition and gender assignment. How to cite this:Manzoor J, Aftab S, Yaqoob M. Ambiguous genitalia: An overview of 7 years experience at the Children’s Hospital & Institute of Child Health, Lahore, Pakistan. Pak J Med Sci. 2019;35(1):151-155. doi: https://doi.org/10.12669/pjms.35.1.289 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective: This study aimed to investigate influence of multiple sociodemographic characteristics on the patient satisfaction levels in outpatient public and private dental practices of Riyadh, Saudi Arabia. Methods: Questionnaire-based survey data were collected from 500 patients, 250 each from the public and private dental clinics of Riyadh, Saudi Arabia from September to December, 2017. Questions related to demographic factors and service attributes were included. A Likert scale of 5-points was used to measure satisfaction levels. Data was analyzed to calculate the descriptive and inferential statistics (analysis of variance and multiple regression analysis) to find the statistical difference (p < 0.01). Results: Satisfaction level differed significantly by education level (P< 0.001) and the type of clinic (P

Background & objectives Terrorist attack in Army Public School Peshawar, Pakistan left behind more than hundred children dead. It was the highest death toll of children in the world in a single terrorists attack. The attack dominated national and international news, high level security measures have been adopted in all school throughout Pakistan, which created fear and stress in children. The objective of the study was to determine post-traumatic stress disorder among children after six month of terrorist attack inspite of rigorous psychosocial support and rehabilitation. Methods We wanted to determine Post Traumatic Stress Disorder (PTSD) among children of Army Public School of age range 10 to 18 years after 5 months of intervention and rehabilitation following terrorists attack. For this a self-report questionnaire, Child PTSD Symptom Scale (CPSS), which assess and identify symptoms matching DSM (Diagnostic and Statistical Manual of Mental Disorders) IV criteria for post-traumatic stress disorder of children, was filled. Informed consent was taken from school Principal and responders. Results A total 205 students of age range 10 to 18 years participated in the study. The most frequent age group of the study were 16 years and 14 years students with frequency 58 (28.3%) and 46 (22.4%) respectively. Among 205 participated school children PTSD were found in 154 (75.2%) children while only 24.8% students had no PTSD symptoms. In more than 50% PTSD positive school children had functional impairment for each category of fun and hobbies, friendship, school work, family relation, doing chores, general happiness and saying prayers. Conclusion Study found a very high prevalence of PTSD among 10 to 18 years age group students of Army Public School inspite of five months continuous intervention and rehabilitation services. Study showed that this age group needs long term psychosocial treatment in case of trauma.

Background & objective Low back pain (LBP) is the foremost cause to hamper an individual's functional activities in Pakistan. Its impact on the quality of life and work routine makes it a major reason for therapeutic consultations. About 90% of the cases with LBP are non-specific. Various options are available for the treatment of LBP. Posterior-anterior vertebral mobilization, a manual therapy technique; and thermotherapy are used in clinical practice, however evidence to gauge their relative efficacy is yet to be synthesised. This study aimed to compare the effectiveness of posterior-anterior vertebral mobilization versus thermotherapy in the management of non-specific low back pain along with general stretching exercises. Methods A randomised controlled trial with two-group pretest-posttest design was conducted at IPM&R, Dow University of Health Sciences (DUHS). A total of 60 Non-specific low back pain (NSLBP) patients with ages from 18 to 35 years were inducted through non-probability and purposive sampling technique. Baseline screening was done using an assessment form (Appendix-I). Subjects were allocated into two groups through systematic random sampling. Group-A (experimental group) received posterior-anterior vertebral mobilization with general stretching exercises while group B (control group) received thermotherapy with general stretching exercises. Pain and functional disability were assessed using NPRS and RMDQ respectively. Pre & post treatment scores were documented. A maximum drop-out rate of 20% was assumed. Recorded data were entered into SPSS V-19. Frequency and percentages were calculated for categorical variables. Intragroup and intergroup analyses were done using Wilcoxon signed ranked test and Mann-Whitney Test respectively. A P-value of 0.05 was considered statistically significant. Results Pre and post treatment analysis revealed that P-values for both pain and disability were less than 0.05, suggesting significant difference in NPRS and RMDQ scores. Whereas, median scores for both pain and disability were decreased by 75% in experimental group and 50% in control group. For inter group analysis p-values for both pain and disability were found to be less than 0.05. Conclusion Both physiotherapeutic interventions, the PAVMs and thermotherapy, have significant effects on NSLBP in terms of relieving pain and improving functional disability. However PAVMs appeared to be more effective than thermotherapy.

Objective: This cross-sectional study aimed to examine the impact of learning management system and WhatsApp application as educational tools on students’ academic achievement and attitude. Methods: The sample population was the students of six medical colleges of Riyadh, Saudi Arabia attending Medical Pharmacology’s semester course in Bachelor of Medicine, Bachelor of Surgery (MBBS) program from September 2016 to January 2017. An exploratory approach was adopted based on a comparison between students exposed to only in-class lectures (Group-N), in-class lectures together with WhatsApp platform to disseminate the lecture slides (Group-W) and students group with in-class lectures facility blended with Learning Management System (LMS) and WhatsApp platform (Group-WL). The students’ grades were assessed using unified multiple choice questions at the end of the semester. Data were analyzed using descriptive statistics and Pearson correlation (p

Objective: The aim of this research was to assess the effect of mouth rinses with and without alcohol on the hardness of dental nano-filled composite. Methods: The micro-hardness of fifty circular disk shaped specimens of 7 mm x 2 mm were measured after 14 days. Specimens were immersed into alcohol containing (Listerine and Colgate Perioguard) and alcohol-free (Prodent and Sensodyne Oral antiseptic) mouth rinse solutions. Artificial saliva served as the control. Vickers Micro-hardness was measured with a 30gram load for 30 seconds dwell time by using a diamond indenter. Significant differences were represented by p0.05). Control specimens depicted highest value of micro-hardness(60.5746 ± 3.2703) compared to the lowest value seen in specimens immersed in Listerine solvent(54.4687 ± 1.0937). Conclusion: Alcohol containing mouth rinsing solutions have more deleterious effect on hardness of nano composites as compared to alcohol-free mouth rinses.

Background and Objective: Patient’s perception of their illness influences their healthcare decisions. The objectives of this study were to explore patient’s own beliefs about their illness (Schizophrenia) and perceived social support, and its impact on their attitudes toward pharmacological treatment in Lahore, Pakistan. Methods: This study was conducted at Mayo Hospital Lahore from March to September 2016. Hundred individuals suffering from Schizophrenia completed four questionnaires; a socio-demographic questionnaire, the Illness Perception Questionnaire for Schizophrenia(IPQ-S), Drug attitude Inventory-10 (DAI) and Multidimensional Scale of Perceived Social Support (PSS). Results: Stress, family problems, lack of friends & financial worries were endorsed strongly by patients as cause of their mental illness. Ambiguity regarding their mental illness duration and personal control was observed. Patients’ perceived significant negative consequences, negative emotional response, as well as had poor understanding of their mental illness and treatment effectiveness. Statistically significant gender differences in treatment control and illness coherence subscales of IPQS were observed. Drug attitude inventory was positively correlated with Treatment control subscale (p < .01) and negatively correlated with Illness coherence subscale of IPQS (p < .05). The negative consequences subscale and perceived social support was negatively correlated (p < .01). Conclusion: Patient’s perception about their own illness is predictor of their drug taking attitude and perceived social support. Study results should help to develop new interventions to correct inaccurate beliefs in patients with schizophrenia to improve illness outcome.