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The global population is ageing rapidly, with low- and middle-income countries (LMICs) undergoing a fast demographic transition. As the number of older adults in LMICs increases, services able to effectively address their physical and mental health needs will be increasingly important.We review the health and socioeconomic resources currently available for older people in South Asian countries, Bangladesh, India, Nepal, Pakistan and Sri Lanka, to identify gaps in available resources and assess areas for improvement.We conducted a search of grey and published literature via Google Search, Compendex, EBSCO, JSTOR, Medline, Ovid, ProQuest databases, Scopus and Web of Science. Data on population demographics, human resources, health funding and social protection for older people were extracted. Local informants were consulted to supplement and verify the data.In the study countries, the number of health professionals with expertise in elderly care was largely unknown, with minimal postgraduate training programmes available in elderly medicine or psychiatry. Older adults are therefore cared for by general physicians, nurses and community health workers, all of whom are present in insufficient numbers per capita. Total average healthcare expenditure was 2.5-5.5% of GDP, with 48.1-72.0% of healthcare costs covered by out-of-pocket payments. Pakistan did not have a social pension; only India and Nepal offered financial assistance to people with dementia; and all countries had disproportionately low numbers of care elderly homes.Inadequate healthcare funding, a shortage of healthcare professionals and insufficient government pension and social security schemes are significant barriers to achieving universal health coverage in LMICs. Governing bodies must expand training programmes for healthcare providers for older adults, alongside increasing social protection to improve access to those in need and to prevent catastrophic health expenditure.

Objectives: Polymorphism in cytochrome P450 3A4 (CYP3A4) and its regulatory gene peroxisome proliferator activated receptor (PPARA) may significantly affect the metabolism of tacrolimus. This study aims to explore the effect of the single nucleotide polymorphisms (SNP) of cytochrome P450 3A4 and PPARA on the pharmacological variables of adverse effects and the concentration-to-dose ratio (CDR) of the immune suppressant drug tacrolimus in Pakistani liver transplant recipients. Methods: Eighty-one liver transplant patients were included and their demographic and clinical data were recorded. Dosages and trough levels of tacrolimus measured by electrochemiluminescence (ECLIA) were recorded daily. Genotyping for transplant recipients was performed for CYP3A4 rs35599367, PPARA rs4253728 and rs4823613. Incidence of sepsis, acute cellular rejection (ACR) and other adverse effects were recorded. Results: Liver transplant recipients with CYP3A4 rs35599367 CT and TT genotype reported higher tacrolimus CDR compared to the CC genotype during week-1 (p

Background and objective Gabapentinoids are the first-line drugs for neuropathic pain. These drugs are the substrate of organic cation transporter (OCTN1) for renal excretion and absorption across the intestinal epithelium. Gabapentinoids exhibit wide interindividual variability in daily dosage and therapeutic efficacy which makes titration regimens prolonged for optimal efficacy. The present study aimed to investigate the possible influence of the single nucleotide polymorphism (SNP) of OCTN1 on therapeutic efficacy and safety of gabapentinoids in neuropathic pain patients of the Pakistani population. Methods Four hundred and twenty-six patients were enrolled in the study. All participants were genotyped for OCTN1 rs1050152 and rs3792876 by PCR-RFLP method and followed up for eight weeks. The therapeutic outcomes of gabapentinoids, reduction in pain score, inadequate or complete lack of response, adverse events (AEs) in responders and discontinuation of treatment on account of AEs were recorded for all patients. Results There was no significant association of genotypes and alleles of both SNPs on the clinical response of gabapentinoids (P ˃ 0.05). Similarly, significant differences were not found in the reduction of pain scores and AEs among different genotypes in the responders. The present study has reported the association of OCTN1 rs1050152 and rs3792876 polymorphisms with clinical outcomes of gabapentinoids for the first time in the real-world clinical setting. Conclusion Our results suggest a lack of influence of OCTN1 genetic variants in the determination of clinical response to gabapentinoids in patients with neuropathic pain in the Pakistani population. These findings signify the role of renal functions in predicting the interindividual variability to therapeutic responsiveness of gabapentinoids.

Background: Self-Harm (SH) is a major global public health problem which is under-researched in Pakistan. A prior act of self-harm is one of the strongest predictors of future suicide.Method: This retrospective descriptive study describes the characteristics of SH cases (n=350) that presented to a tertiary care teaching hospital in Karachi, Pakistan, from January 2013 to December 2017. Details related to demography, history, associated factors, access to methods used, and intent to die were collected on a structured proforma and analysed using STATA version 14. Results: It was found that self-harm acts were twice as more common in females than in males. More than half of the reported cases were in the age group 20-39 years. Drug overdose and use of insecticides were the two most common methods used in both genders. Depression was identified in nearly half of the reported SH cases. Intention to die was found to be 3 times greater among patients with psychiatric illness as compared to those with no history of psychiatric illness. Conclusion: This study suggests that limiting access to lethal means, regulating over-the-counter sale of medications, and safe storage of pesticides can possibly serve as effective measures to minimize self-harm incidences. Moreover, integration of suicide assessment and prevention programmes for the general population is also suggested.

Background Self-Harm (SH) is a major global public health problem under-researched in Pakistan due to religious and legal implications. This study aims to identify the characteristics and patterns among patients with SH and factors associated with the intent to die. Method This retrospective descriptive study where SH cases presented to private tertiary care teaching hospital in Karachi, Pakistan, from January 2013 to December 2017 were extracted from HIMS records. Details related to demography, history, associated factors, access to methods used, and intent to die were collected on a structured proforma and analysed using STATA version 14. Results A total of 350 cases were analysed. More than half of the reported cases were in the age group 20–39 years. Though only one-fourth of the SH cases had a past psychiatric history, it was found to be significantly (P-value Conclusion This paper provides recent data on the characteristics and patterns associated with the intent to die of individuals who have self-harmed. In most cases of SH, past psychiatric history was not evident. Current psychiatric diagnosis and young adults were favoured in this study. The data from this study has limited representation for all demographic representation of SH cases from Pakistan as being from a single private hospital. There is a need for further research on SH in Pakistan.

Objective: To evaluate the possible association of ABCB1 single nucleotide polymorphism (SNPs) of the ABCB1 gene with tacrolimus dosages, concentration-to-dose ratios (CDR) and adverse effects in Pakistani liver transplant recipients. Methods: This observational study was conducted at Shifa International Hospital, Shifa Tameer-e-Millat University, Islamabad and Basic Medical Sciences Institute, Karachi from September 2016 to July 2020. Eighty-one liver transplant recipients were included. Demographics, clinical data, tacrolimus trough levels and doses were monitored. Electrochemiluminescence immunoassay (ECLIA) was used to measure tacrolimus trough levels. Transplant recipients were genotyped for three ABCB1 SNPs (rs1045642, rs2032582 and rs1128503). Acute cellular rejection (ACR), sepsis and other adverse events were monitored. Results: ABCB1 rs1045642 CC genotype showed lower tacrolimus CDR as compared to CT and TT genotype in the first week of the post-transplantation period (p=0.02). There was a significant association of polymorphisms in rs1045642, rs2032582 and rs1128503 with psychosis, sepsis and ACR respectively. Conclusion: Identification of ABCB1 rs1045642 polymorphism may shorten the time to achieve optimum levels of tacrolimus during dose titration. ABCB1 polymorphism rs1045642, rs2032582 and rs1128503 may predict adverse effects in liver transplant recipients receiving tacrolimus. doi: https://doi.org/10.12669/pjms.37.3.3898 How to cite this:Azam F, Khan M, Khaliq T, Bhatti ABH. Influence of ABCB1 gene polymorphism on concentration to dose ratio and adverse effects of tacrolimus in Pakistani liver transplant recipients. Pak J Med Sci. 2021;37(3):689-694. doi: https://doi.org/10.12669/pjms.37.3.3898 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 Exercise tolerance test (ETT) and angiographic evaluation are important tools to evaluate patients presenting with ischemic cardiac pathologies. Angiographic evaluation is regarded as the gold standard diagnostic modality to diagnose coronary artery disease (CAD). Our study aims to evaluate the positive predictive value (PPV) of ETT to diagnose CAD using coronary angiography. Methods We conducted a cross-sectional study that analyzed 94 patients with a positive ETT test after the application of strict inclusion and exclusion criteria. All 94 patients were referred for angiography after a positive ETT test. Data collection was performed using a structured proforma, and analysis was carried out on Statistical Package for Social Sciences (SPSS) version 23 (IBM Corp., Armonk, NY). PPV for various demographic characteristics was calculated. Results Out of 94 patients, 76 were males and 18 were females with a mean age of 52.28 ± 7.55 years. A total of 35.1% of the patients had type-2 diabetes, and 31.9% were hypertensive. On coronary angiography, only 25 patients had normal findings, and 69 patients had a significant occlusion in at least one of the major coronary arteries. The overall PPV of the ETT against angiographic evaluation was 73.40%. The PPV for females, hypertensives, non-smokers, and non-diabetics was lower than the PPV of males, smokers, non-hypertensives, and diabetics. Conclusion Angiographic evaluation of patients with positive ETT findings has a high likelihood of false positivity especially among females, non-smokers, hypertensives, and non-diabetics. The results of ETT must be interpreted with caution in these subsets of the population. Invasive radiological modalities can be used for diagnosis; however, such modalities do not elucidate the functioning of myocardium under stress.

BackgroundThe global population is ageing rapidly, with low- and middle-income countries (LMICs) undergoing a fast demographic transition. This necessitates effective services to address the increasing physical and mental health needs of multimorbid and frail older people in LMICs. We review the current provision of health and socioeconomic resources for older people in South Asian countries: Bangladesh, India, Nepal, Pakistan and Sri Lanka, to identify gaps in available resources and assess areas for improvement. MethodsWe conducted a search of grey and published literature via Google Search and Compendex, EBSCO, JSTOR, Medline, Ovid, ProQuest databases, Scopus and Web of Science to extract data on population demographics, human resources, health funding and social security provision for older people. Local informants were consulted to supplement and verify the data. ResultsIn most study countries, care of the elderly is provided by general physicians or primary care doctors, nurses and community health workers, though in very low numbers per capita. The number of geriatricians and specialist allied health professionals were largely unknown, with minimal postgraduate programmes available for specific training in geriatric medicine or psychiatry. Total average healthcare expenditure as a percentage of GDP was between 2.5-5.5%, markedly below the global average of 10.0%, with between 48.1-72.0% of healthcare costs covered by out-of-pocket payments. All countries, except Pakistan, had a social pension offering a minimum level of protection against financial constraints, but with varying coverage of those eligible. Financial provision for people with dementia was only available in India and Nepal. A modest number of state and charity-run care homes were established in all countries, though numbers were disproportionate to the growing number of older adults requiring long term care.ConclusionsInadequate health funding, a lack of specific healthcare and training and insufficient government pension and social security schemes are a current threat to achieving universal health coverage in LMICs. Governing bodies must establish geriatrics and geriatric psychiatry as specialities and scale up training programmes for specific healthcare providers for the elderly. This needs to occur alongside increased social protection provision to improve access to those in need and prevent catastrophic health expenditure.

We re-examine the risk-return tradeoff in the U.S. equity market by allowing for time variation in the tradeoff and estimating conditional variance by the new mixed data sampling method. The main finding is that the risk-return tradeoff is strongly time-varying with the state of the market and the average of the time-varying tradeoff estimates is 1.43. The lagged market return is found to be the best indicator of market states. The empirical finding holds true for a battery of robustness checks during the post-Compustat sample period. The evidence from the international markets is similar to the U.S. one.

Objective: To investigate the current dosing regimens of gabapentinoids in Pakistani patients with neuropathic pain and to compare their clinical efficacy and tolerability in terms of pain relief and adverse effects using difference in pain score as a treatment outcome. Methods: This observational, prospective study was conducted in 320 patients with neuropathic pain from August 2016 to March 2018 at Basic Medical Sciences Institute (BMSI), Karachi in collaboration with Shifa International Hospital and Benazir Bhutto Hospital, Islamabad. Demographic data, treatment-related adverse effects and pain intensity was documented at recruitment and follow up visits at two, four and eight weeks. Discontinuation due to adverse effects and lack of efficacy were also recorded. Data was entered and analyzed using SPSS version 22. Results: Mean age of patients was 52.57±12.47 and the most common ethnicity were Punjabi speaking population (66%). Diabetic neuropathy (51%) was the most common etiology followed by radicular pain (25%). Mean dosages of pregabalin and gabapentin were 114mg and 470mg respectively. Mean pain score was significantly reduced by gabapentinoids (

Objectives There are many different ways to measure body composition and bioelectric impedance is one of the most popular methods to measure body ratios. The navy-seal formula is another simple way of measuring body fat ratio which takes into account simple variables such as gender, weight, height, waist, hip and neck circumference. The objective of our study was to compare the results of body fat composition by these two methods. Materials and methods Height and weight were measured in 85 study participants using a wall-mounted stadiometer and digital scale. Body composition measurements were recorded using a simple measuring tape. Participants were then asked to stand on the electrical impedance machine to determine the body fat and muscle mass. Data were analyzed on IBM's statistical package for the social sciences (SPSS) version 23 (IBM, Armonk, NY). Results The Navy-seal formula had slightly higher values for both muscle mass and body fat ratio in both genders and across all body mass index (BMI) categories. Body fat ratio and muscle mass of both genders were similar in underweight, normal, over weight and obese participants. In males, the results on two instruments showed more similarity with the increase in BMI, whereas, in females, the results of the two methods were more similar in the normal weight category. Conclusion Navy-seal formula and bioelectrical impedance are both simple and reliable instruments to measure body composition in adults. The navy-seal formula can be used to screen individuals with high-fat body fat ratio whereas bioelectric impedance can be used to measure the body composition for personal monitoring.

Objective To evaluate the association between tacrolimus trough levels and dosage in Pakistani patients undergoing live donor liver transplantation (LDLT), and the efficacy and adverse effects at different tacrolimus trough levels and dosages. Study design An observational study. Place and duration of study Shifa International Hospital, Shifa Tameer-e-Millat University, Islamabad and Basic Medical Sciences Institute, Karachi, from September 2016 to October 2018. Methodology Sixty liver transplant recipients were included. Demographics, clinical data, tacrolimus trough levels and doses were monitored as per routine protocol. Electrochemiluminescence immunoassay (ECLIA) was used to measure tacrolimus trough levels. Acute cellular rejection (ACR), sepsis and other adverse events were monitored at different tacrolimus trough levels in early post-transplantation period. Results Mean age of transplant recipients was 49.1 ± 10.6 years. Mean tacrolimus trough levels were 6.1 ± 2.2 ng/ml and mean dose was 0.94 ± 0.3 mg. Sepsis (27%) psychosis (20%), seizures (10%), and renal insufficiency (13%) were the most common adverse effects. Acute cellular rejection (ACR) was observed in 15% patients. Patients with sepsis had significantly high mean tacrolimus levels of 7.7 ± 2.5 ng/ml versus 5.5 ± 1.9 ng/ml (p=0.001). Mean tacrolimus trough levels in patients with ACR were significantly lower (4.05 ± 1.6 ng/ml vs. 6.43 ± 2.2ng/ml, p=0.003). None of the patients with a single tacrolimus trough level >10 ng/ml experienced ACR. Conclusion A tacrolimus trough level between 5 to 7.5 ng/ml appears to be safe in Pakistani liver transplant recipients significantly minimising the risk of ACR and other adverse events.

Objectives To evaluate the effect of Atorvastatin as an adjuvant with betamethasone valerate on disease severity and cardiovascular risks in chronic plaque type psoriatic patients. Methods It is an interventional study conducted in Pharmacology Department of BMSI, JPMC with the collaboration of Dermatology Department of JPMC, Karachi. The duration of study was from June 2013 to June 2016. Seventy five psoriatic patients were prescribed Tablet Atorvastatin 40-20 mg/day (40mg for first three months twice daily followed by 20mg once daily for the next three month) plus topical Betamethasone Valerate 0.1% once daily for 6 months (three week apply than one week interval). The efficacy and safety profile of drugs was measured by PASI, DLQI, hsCRP, LFTS and Lipid profile. Results The percentage change of PASI is 86.749±0.547, DLQI is 82.697±.2.61 and hsCRP is 40.371±8.505, which showed highly significant improvement in patient at the end of last follow up. LFTs and CPK for safety profile of therapy showed non-significant results. Conclusion Atorvastatin used as an adjuvant therapy with currently existing standard therapy (topical betamethasone) in patients having mild to moderate plaque type psoriasis reduces disease severity and cardiovascular risks.

This paper examines whether long-run integration between the United States and many international stock markets has strengthened over time, with special attention paid to the impact of the abolition of capital control in these markets and the 1987 international stock market crash. The results show that during most of the thirty-two-year sample period (January 1970-December 2001), there exists no long-run relationship between most of these markets and the United States. However, there is evidence of recent increasing integration between many smaller markets and the United States while no such pattern emerges for larger markets including Japan, the United Kingdom, and Germany, which suggests long-run benefits to U.S. investors of diversifying into these larger markets. Moreover, there is no marked change in the degree of integration between any of these stock markets and the United States that can be apparently associated with the abolition of capital control or the 1987 international stock market crash.

In Pakistan, an increasing proportion of psychiatric patients present to community health services as crisis admissions, with their relatives as the main decision makers. Patients are bound to perceive this process as coercive. Farnham & James (2000) report that elements of coercion are found even in voluntary hospital admission, in the form of verbal persuasion, physical force and threats of commitment. Few patients consider hospitalisation justified and most view the process of admission negatively (Swartz et al, 2003; Katsakou & Priebe, 2006; Priebe et al, 2009).

Respiratory dyskinesia is an under-recognized side effect of neuroleptic administration. There are only few studies that have addressed the prevalence of respiratory dyskinesia in patients with tardive dyskinesia. Our case report highlights the need to regularly examine patients on antipsychotics for any evidence of dyskinetic movements including respiratory musculature. Since RD is underrecognized and misdiagnosed, early detection can improve long term prognosis as treatment options are few and usually of only limited effect. A 62-year-old Asian male, retired civil engineer, had more than 20 years history of depressive illness, developed antidepressant induced hypomania, and was given risperidone upto 1 mg per day. He developed extrapyrmidal side effects as tremors, rigidity and later dyskinetic movements of lips with shortness of breathing, dyspnoea, grunting or gasping. He was referred to the pulmonologist who got the neccessary medical work up done, which was normal. A diagnosis of respiratory dyskinesia was made. Respiratory dyskinesia is an under-recognised and distressing condition that clinicians need to be aware of when treating patients with anti-psychotic medications. And also there is a need to regularly examine patients on antipsychotics for any evidence of dyskinetic movements including respiratory musculature for early diagnosis and better outcome. This case report also is worth reading for professionals of other specialties also because of the presentation of this patient, it can be easily misdiagnosed and result in poor outcome.

Major depressive disorder is a serious and disabling illness in the world and is common chronic and recurrent disorder. It is the fourth most important cause of worldwide loss in disability.This was prospective and open-label study, study conducted in JPMC. Karachi, to evaluate the efficacy and adverse effects in major depressive disorder individuals. A total of 40 patients irrespective of the gender, aged 18 years up to 65 years were enrolled from OPD of Psychiatry Department. Follow-up visits were carried out fortnightly after making evaluation of symptoms at baseline visit (day 0), follow-up continued till 90 days when the results were compiled.Statistically significant (p0.05) results were observed in all the parameters at the end of study, i.e., day 90.Among all the symptoms of major depressive disorder, trazodone proved to be more effective in controlling insomnia.

The precise relationship of Hyperuricemia found in hypertensive patients is still obscure; this study is a urinary uric acid lowering intervention with Losartan in hypertensive patients induced by Thiazide diuretics. A number of pharmacological agents like loop diuretics, similarly low doses of aspirin (3g daily) aggravate Hyperuricemia. The effect of Losartan on urinary uric acid excretion In Hypertensive patients with Thiazide induced Hyperuricemia were investigated in the Department of pharmacology and therapeutics, Basic Medical Sciences Institute Jinnah Postgraduate Medical Centre Karachi. It was randomized, open label, prospective, comparative study. Total 60 hypertensive Hyperuricemic patients were enrolled one by one in this study, selected from medical OPD and wards of Jinnah Postgraduate Medical Centre, Karachi. Patients were divided in three groups. Group-1 patients were treated with Thiazide 50 mg/day, Group-2 with Losartan + Thiazide 50 mg/day, and Group-3 with Losartan 50 mg/day. The effect on urinary uric acid level was measured, after every fortnightly. Treatment with Thiazide + Losartan group and Losartan group showed significantly increase in urinary uric acid excretion. Whereas, Thiazide group decrease in urinary uric acid level. In contrast to Thiazide and Losartan alone Thiazide + Losartan led to a greater increased in urinary uric acid excretion. The average percentage increase in urinary uric acid excretion in Thiazide + Losartan group was -13.27% and the average percentage increased in urinary uric acid excretion was 6.7% in Losartan group. Thus it can be concluded from the present study that urinary uric acid excretion was more increased in combination therapies. Ultimately Losartan decrease serum uric acid level and uricosuric effect of Losartan might be particularly useful in Hyperuricemic patients those on Thiazide diuretic (for hypertension and heart failure).

To observe the safety and efficacy of topical Lodoxamide eye drops in patients with diagnosed vernal keratoconjunctivitis (VKC).This study was conducted at Department of Pharmacology and Therapeutics, BMSI, JPMC, Karachi in collaboration with Department of Ophthalmology, JPMC, Karachi, from April to October, 2009. A total of forty patients with diagnosed vernal keratoconjunctivitis were selected and enrolled consecutively from the out patient department (OPD) of Ophthalmology. Each patient received two drops of Lodoxamide eye drops topically in each eye four times daily. Patients were examined with a torch and slit lamp at baseline and follow-up visits.Out of 40 patients included, 39 completed the study and there was a significant effect of the drug on symptoms and signs of the disease. At the end of the study, 38 (97.4%) were cured, with few side effects. The cure criteria was based on patient's history of becoming symptom-free and resolution of ocular signs.Topical lodoxamide eye drops, when used for treatment of VKC, are effective with fewer adverse effects.

The correlations between combined body fat parameters and risk factors of obesity explained a portion of the variation in the weight, BMI and waist circumference, the average number of categorical metabolic risk factors increases progressively with increasing total body fat content. There is currently no data available in which influence of drugs can be assessed on total body fat content. This was a non-randomized, prospective, open-label, parallel group study was conducted to compare the effectiveness of sibutramine, orlistat and ispahgula in reducing body weight and percentage of total body fat content in obese individuals.A nonrandomized, open label, prospective, intention to treat clinical trial was conducted from July 2008 to March 2009 in JPMC, Karachi, Pakistan. The study was based on three arms A (ispahgula), B (orlistat) and C (sibutramine) comprising 40 patients in each. The selection criteria has included patients from either sex with age 18 years or more with BMIor =30 as obese with or without associated risk factors and BMIor = 2730 as over weight only if any significant risk factor is present. Compliance on diet chart and instruction for life style modification were assessed monthly.The comparison of mean difference in percentage of total body fat content between the groups and within the groups at day 150 is (p-value) 0.029 and difference in body weight is (p-value) 0.042 which is statistically significant.Sibutramine is more effective than ispahgula and orlistat in reducing body weight and percentage of total body fat content in obese patients.

To assess the frequency of depression among hospitalized patients, the socio-demographic variables associated with depression and the number of cases referred by physicians to Psychiatry.A cross-sectional study was carried out at the Aga Khan University Hospital Karachi. An anonymous Urdu version of the WHO-developed self-reporting questionnaire (SRQ) was administered to inpatients meeting the inclusion criteria. Data was analyzed by SPSS version 13.0.Of the 225 patients approached, 178 completed the questionnaire (men= 45.2%, women = 54.8%). The mean age of the sample was 45.2 years. Out of the total 30.5% of patients were identified as having probable depression, among which housewives were more likely to be depressed compared to others (p=0.031). Among variable comparison, there with secondary school education or below and those with psychiatric co-morbidities, showed significantly greater prevalence of depression (p=0.003) and (p=0.005) respectively. Attending physicians correctly diagnosed 7 (13%) patients and referred only 3 patients to Psychiatry over the previous month.The prevalence of depression among inpatients is comparable to that in the general population. Being a housewife, level at or below secondary school education and having a past psychiatric history are significant factors associated with depression in medical inpatients. A very small number of depressed cases were referred to a psychiatrist.

The presentation of depression in primary care is in many ways different from that seen in psychiatric settings. The process of detection and treatment is also different. This is particularly so in developing countries like Pakistan, which has high prevalence rates of depression but poorly organized primary health care services and primary care physicians (PCPs) who have little psychiatric training, either at undergraduate or postgraduate levels. There is a need to review difficulties faced by primary care physicians in detection and management of depression. It is hoped this would lead to better and more effective management of depression at primary health care level.

To evaluate the gender differences in age at onset of schizophrenia.Prospective case control study.Department of Psychiatry, Aga Khan University Hospital, Karachi between January to December 2002.Sixty patients admitted consecutively to psychiatry ward and meeting the inclusion criteria were enrolled for the study. Age at onset of illness was defined as age at onset of gross psychotic symptoms, age at first contact with psychiatrist and age at index admission. Statistical method included two independent samples t-test. Data was dichotomized into those with family history of schizophrenia versus those without family history of illness and then Chi-square test of association was applied.The mean age of onset of illness was 23.96 years in females and 24.13 years in males. In all other measures used to assess the onset of illness, females were overrepresented at the younger age group. 56.7% patients had a family history of psychotic disorder. Among them the mean ages at onset of illness were 20.59 years in females and 21.85 years in males ( c 0.04 df =58). The illness occurred at a younger age in those with positive family history of schizophrenia (21.22 years) than those without it (25.14 years) with dissipation of gender difference in the former.There was no significant gender difference in age at onset of disorder in this study. Family history of schizophrenia appears to be the most significant factor that eliminates the gender differences in age at onset of schizophrenia.