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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.

Gabapentinoids are substrate of L-type amino acid transporter 1 (LAT1) for distribution across the blood-brain barrier. The present study aimed to evaluate the effect of LAT1 rs4240803 genetic polymorphism on the clinical efficacy and tolerability of gabapentinoids in Pakistani patients with neuropathic pain. Three-hundred and ninety-two patients were recruited, genotyped for SNP rs4240803, and followed up for eight weeks to evaluate the clinical response to gabapentinoids in terms of pain relief, inadequate response, and the emergence of adverse events. LAT1 rs4240803 GG, GA, and AA genotype frequency were 33.42%, 47.96% and 18.62%, respectively. Out of 392 patients, 323 responded to the treatment and 17.6% discontinued either due to insufficient response or intolerable adverse events (AEs). GA genotype was more frequent in non-responder group (P ˂ 0.001). Maximum pain responders (≥50%) in combination with the lowest incidence of AEs were observed in the GG group, whereas partial responders belonged to GA genotype and with the highest frequency of somnolence (83.6%) and dizziness (69.9%). Overall, 72.5% patients with GA genotype experienced AEs (P ˂ 0.001). In conclusion, clinical outcomes of gabapentinoids are influenced by LAT1 rs4240803 polymorphism and population pharmacogenetics should be considered to evaluate the maximum potential of gabapentinoids in the management of neuropathic pain.

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 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 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.

The economic consequences of mental illnesses are much more than health consequences. In Low and Middle Income Countries (LMIC) the economic impact of mental illnesses is rarely analyzed. This paper attempts to fill the gap in research on economics of mental health in LMIC. We provide economic burden of mental illness in Pakistan that can serve as an argument for reorienting health policy, resource allocation and priority settings.To estimate economic burden of mental illnesses in Pakistan.The study used prevalence based cost of illnesses approach using bottom-up costing methodology. We used Aga Khan University Hospital, Psychiatry department data set (N = 1882) on admission and ambulatory care for the year 2005-06. Healthcare cost data was obtained from finance department of the hospital. Productivity losses, caregiver and travel cost were estimated using socio-economic features of patients in the data set and data of national household survey. We used stratified random sampling and methods of ordinary least square multiple linear regressions to estimate cost on medicines for ambulatory care. All estimates of cost are based on 1000 bootstrap samples by ICD-10 disease classification. Prevalence data on mental illnesses from Pakistan and regional countries was used to estimate economic burden.The economic burden of mental illnesses in Pakistan was Pakistan Rupees (PKR) 250,483 million (USD 4264.27 million) in 2006. Medical care costs and productivity losses contributed 37% and 58.97% of the economic burden respectively. Tertiary care admissions costs were 70% of total medical care costs. The average length of stay (LOS) for admissions care was around 8 days. Daily average medical care cost of admitted patients was PKR 3273 (USD 55.72). For ambulatory care, on average a patient visited the clinic twice a year. The estimated average yearly cost for all mental illnesses was PKR 81,922 (USD 1394.65) and PKR 19,592 (USD 333.54) for admissions and ambulatory care respectively. In the sensitivity analysis productivity losses showed high variability (from USD 1022.17 million to USD 4007.01 million). Assuming a gate keeping role of primary healthcare (PHC) demonstrated a saving of USD 1577.19 million in total economic burden.This study set out to generate evidence using a low cost innovative approach relevant to many LMICs. In Pakistan, like many LMICs, patients access tertiary care directly, even for illness that can be efficiently managed at PHC level. In economic terms the non-medical consequences of mental illnesses are far greater than medical consequences. Based on these finding we recommend, firstly, that mental illnesses should be prioritized equally as other illnesses in health policy and secondly there needs to be integration of mental health in primary health care in Pakistan.

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.