Exploring Esketamine's Therapeutic Outcomes as an FDA-Designated Breakthrough for Treatment-Resistant Depression and Major Depressive Disorder With Suicidal Intent: A Narrative Review.

The expansive spectrum of major depressive disorder (MDD) continues to pose challenges for psychiatrists to treat effectively. Oral antidepressant (OAD) medications that alter monoamine neurotransmitters, mainly selective serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs), have been the mainstay of therapy for decades. Although these drugs have been largely beneficial, a considerable subset of patients do not respond adequately to multiple conventional therapies administered for an appropriate length of time, leading to a diagnosis of treatment-resistant depression (TRD). Ketamine, a non-monoaminergic drug, has long been known for its beneficial effects on TRD when given intravenously (IV). Between 2019 and 2020, an intranasal formulation of the S (+) enantiomer of racemic ketamine, esketamine (ESK), was granted "breakthrough designation" by the FDA and approved for the indications of TRD and MDD patients exhibiting acute suicidal intent. The objective of this narrative review was to review the academic literature and collect clinical evidence that may corroborate intranasal ESK's effectiveness for its approved indications while addressing its safety and tolerability profile, adverse effects, and impact on cognition. An overview of the drug's origins, pharmacology, and standard treatment regimen are provided. The outcomes from double-blinded randomized control trials (DB-RCTs) of ESK are outlined to demonstrate the efficacy and safety data leading to its FDA approval, along with its long-term post-market safety outcomes. Comparative trials between ESK and ketamine are then evaluated to highlight ESK's consideration as a more practical alternative to ketamine in common clinical practice. The authors further discuss currently approved and developing therapies for TRD, propose future research directions, and identify the inherent limitations of the review and further research. To conduct the research required, three digital databases (PubMed, Medline, and ClinicalTrials.gov) were queried to search for key terms, including ketamine, esketamine, treatment-resistant depression, and biomarkers, using automation tools along with selective search engine results. After streamlining the results by title and abstract and removing duplicates, a total of 37 results were chosen, of which 18 are clinical trials. A reduction in the Montgomery-Asberg Depression Rating Scale (MADRS) score was the primary efficacy endpoint for most of these clinical trials. In conclusion, intranasal ESK, when used as an adjunct to market OADs, shows greater efficacy in treating TRD and MDD with suicidal intent compared to OADs and placebo alone and provides a more suitable alternative to IV ketamine. It is important to note that further research is required to fully understand the novel mechanism of action of ESK, as well as the establishment of a consensus definition of TRD, which may facilitate better detection and treatment protocols. More focused quantitative and qualitative ESK studies are needed, as well as those pertaining to its use in patients with co-existing mental illnesses.

Neck Health Metrics and Quality of Life: A Comparative Study in Bike Drivers with and without Neck Pain.

Purpose: Neck pain is a prevalent musculoskeletal issue among bike drivers, often resulting from extended static postures, repetitive head movements, and exposure to vibrations. This study aims to assess the connection between cervical ROM, neck proprioception, CVA, and QOL in bike drivers with neck pain compared to those without neck pain so that the targeted interventions can be developed to enhance their well-being. Methods: A cross-sectional study involving 100 bike drivers aged 20-50 years was conducted, split into two groups: those with neck pain (n=50) and those without neck pain (n=50). Cervical ROM was measured using a smartphone, neck proprioception was assessed through a head repositioning test, and CVA was determined using lateral-view photographs with a plumb line. The Short Form-36 (SF-36) questionnaire was employed to evaluate QOL. Data analysis was conducted using independent t-tests and Pearson's correlation coefficient. Results: Bike drivers with neck pain exhibited significantly reduced cervical ROM (p-value=<0.001), impaired neck proprioception (p-value=<0.001), and decreased CVA (p-value=<0.001) compared to their counterparts without neck pain. A strong negative correlation was found between neck pain and QOL, with lower scores in all eight domains of the SF-36. Cervical ROM, neck proprioception, and CVA showed moderate correlations with various QOL domains (p-value=<0.05). Conclusion: Neck pain in bike drivers is linked to decrease cervical ROM, compromised neck proprioception, and reduced CVA. These factors correlate with a lower quality of life, both physical and mental domains. Interventions addressing these aspects may enhance the quality of life for bike drivers experiencing neck pain.

Hybrid Ensemble Model for Predicting the Strength of FRP Laminates Bonded to the Concrete.

The goal of this work was to use a hybrid ensemble machine learning approach to estimate the interfacial bond strength (IFB) of fibre-reinforced polymer laminates (FRPL) bonded to the concrete using the results of a single shear-lap test. A database comprising 136 data was used to train and validate six standalone machine learning models, namely, artificial neural network (ANN), extreme machine learning (ELM), the group method of data handling (GMDH), multivariate adaptive regression splines (MARS), least square-support vector machine (LSSVM), and Gaussian process regression (GPR). The hybrid ensemble (HENS) model was subsequently built, employing the combined and trained predicted outputs of the ANN, ELM, GMDH, MARS, LSSVM, and GPR models. In comparison with the standalone models employed in the current investigation, it was observed that the suggested HENS model generated superior predicted accuracy with R2 (training = 0.9783, testing = 0.9287), VAF (training = 97.83, testing = 92.87), RMSE (training = 0.0300, testing = 0.0613), and MAE (training = 0.0212, testing = 0.0443). Using the training and testing dataset to assess the predictive performance of all models for IFB prediction, it was discovered that the HENS model had the greatest predictive accuracy throughout both stages with an R2 of 0.9663. According to the findings of the experiments, the newly developed HENS model has a great deal of promise to be a fresh approach to deal with the overfitting problems of CML models and thus may be utilised to forecast the IFB of FRPL.

Characteristics of Calls to a COVID-19 Mental Health Hotline in the First Wave of the Pandemic in New York.

This report describes the development, implementation and outcomes of a "COVID-19 Anxiety Hotline," designed to address the community's mental health crisis provoked by the coronavirus pandemic. The service was specifically designed using survey data regarding the effects of the COVID-19 pandemic on its staff and community members. Callers had around-the-clock direct access to mental healthcare providers at no cost. Quantitative analysis showed that nearly three out of four callers experienced new onset anxiety and insomnia driven by fear of exposure, and had difficulty accessing mental health care. In addition to immediate support, referral to tele-mental health care was provided to 86% of callers. Qualitative analysis indicates the effectiveness of immediate support and appropriate referrals using a tele-health platform. Our report indicates that the service was utilized by the general population, by health care workers, and rapidly provided referrals to individuals with limited access to mental health care during the pandemic.

Comparison of cultured cell attachment on a temperature-responsive polymer, poly-L-lysine, and collagen using modeling curves and a thermal-controlled quartz crystal microbalance.

The characteristics of cultured cell attachment onto poly-L-lysine (PLL), collagen, and the thermoresponsive polymer poly(N-isopropylacrylamide) (PNIPAM) were studied using a quartz crystal microbalance (QCM). A QCM with microscope cameras enclosed in a Peltier chamber was developed to enable QCM measurements and microphotographic imaging to be conducted in a temperature-controlled CO2 incubator. Human hepatoma cell line HepG2 cells were cultured on the quartz crystals coated with PLL, collagen, and PNIPAM. Response curves of the resonant frequency of the quartz crystals during the cell attachment process were analyzed on the basis of the parameters of modeling curves fit to the experimentally obtained curves. Analysis of the fitting curves showed that the time constants of the first-lag response were 11 h for PLL, 16 h for collagen, and 38 h for PNIPAM and that the frequency change for the PNIPAM films was six times smaller than those for the PLL and collagen films. These findings were supported by photographic images showing wider cell spread on PLL and collagen than on PNIPAM. The response of cells on PNIPAM was measured during a thermal cycle from 37 to 20 °C to 37 °C. In the resonance frequency-resonance resistance (F-R) diagram, the slopes of ΔR/ΔF corresponding to the cell attachment process and those corresponding to the thermal cycling process differed; the positions in the F-R diagram also shifted to higher resonant frequencies after the thermal cycle. These results suggested that the mass effect decreased as a result of the weakening of the cell attachment strength by the thermal cycle because the molecular brushes of PNIPAM were disarranged.

Anomalies in industrial wastewater quality data in Kuwait.

Data was collected on the quality and quantity of wastewater discharged from different petroleum and nonpetroleum industrial sources in Kuwait over a period of one year. A field survey included 75 factories distributed in three industrial areas (Sabhan, Kuwait City, and Shuaiba). Among the industries contacted only 41 agreed to participate in field measurements and wastewater sampling campaign. The questionnaire feedback obtained indicated that the activities of these industries can be categorized into 20 categories including 4 and 37 petroleum and nonpetroleum industries, respectively. The mean quality of wastewater generated in Sabhan industrial area were found to be higher than those of Kuwait City and Shuaiba areas. The inorganic results indicated that high values of total suspended solids (TSS), total dissolved solids (TDS), sulfide, free chlorine, and fluoride were observed in the wastewater of petroleum factories of Shuaiba, while high values of total phosphate, ammonia, total Kjeldahl nitrogen, total nitrogen, and floatables were observed in the wastewater of nonpetroleum factories of Kuwait City. Additionally, organic results indicated that high values of chemical oxygen demand (COD), biochemical oxygen demand (BOD), oil and grease, and total petroleum hydrocarbons (TPHs) were observed in the wastewater of petroleum factories of Shuaiba area. GIS maps were generated for 25 wastewater parameters for the participating 41 factories using ArcView GIS software.

Comorbidity in Schizophrenia: Conceptual Issues and Clinical Management.

Schizophrenia is a complex psychiatric disorder that affects cognitive, perceptual, and emotional functioning. The currently available evidence suggests heterogenous intertwining of biological and psychosocial etio-pathogeneses. Clinical and research interests in the comorbidity issues of schizophrenia were borne out of the real-world clinical challenges that patients often present with multiple coexisting psychopathologies as well as comorbid medical conditions. The recent DSM-5 shift toward a symptom dimensional-based perspective, the NIMH Research Domain Criteria (RDoC) initiative to examine biopsychosocial pathogeneses in mental illness, and the FDA's emphasis on real world-based clinical trial criterion all have promoted a shift in clinical research that has facilitated understanding and treatment of comorbidity in schizophrenia. This emerging conceptual shift as well as pharmacological developments that address the multidimensional pathogeneses in schizophrenia may pave the way for a better understanding and treatment.

Monitoring and Modeling of Living Cell Responses in the Attachment Process and Reaction to the Antitumor Reagent Cisplatin Studied by a Quartz Crystal Microbalance Combined with a Microscope.

The attachment process and response to an antitumor reagent for cultured cells were monitored with a quartz crystal microbalance (QCM) combined with a microscope. To fit the experimentally obtained curves of the resonant frequency, model equations of resonant frequency curves were built, and parameters of time constants and scale coefficients were determined. For the cell attachment process, a first-order lag response curve well fit the experimental curves. For the response to cisplatin, two response steps were observed in both QCM data and microscopic images, where the cells loosened in the first step and shrank in the second step. Resonant frequency responses for both processes were well fit by two logarithmic normal distribution functions. In addition, the dependence of the resonant frequency change on the cell number was also studied, and a cell-cell interaction model for attached cells was proposed to explain the saturation of the resonant frequency change in high density cell seeding.

Prevalence and Outcomes of Sudden Cardiac Arrest in a University Hospital in the Western Region, Saudi Arabia.

BACKGROUND: Sudden cardiac arrest (SCA) is a major cause of mortality, yet its epidemiological and outcome data in hospitals from Saudi Arabia are limited. OBJECTIVES: This study aimed to evaluate the prevalence, risk factors and outcomes of SCA in a teaching hospital in Jeddah, Saudi Arabia. METHODS: This retrospective study included all patients aged ≥18 years with SCA who were resuscitated at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, between January 1 and December 31, 2016. Data were retrieved from the hospital medical records as flow sheets designed in accordance with the Utstein-style recommendations. Factors relating to mortality were analyzed using descriptive analyses and chi-square test. RESULTS: A total of 429 cases of SCA met the inclusion criteria, and its prevalence was 7.76 cases/1000 adult hospital admission. Of these, 61.3% were male, and the mean age was 58.4 years, with 36.6% aged >65 years. Only 3.5% were outside-hospital cardiac arrests. The most common initial rhythm was pulseless electrical activity/asystole (93.2%), while ventricular tachycardia/ventricular fibrillation was documented in only 29 cases (6.8%). The overall rate of return to spontaneous circulation (ROSC) was 56.2%, and 56.8% in cases of in-hospital cardiac arrest (IHCA). Patients with SCA due to sepsis had significantly increased mortality (P < 0.000; odds ratio [OR] = 0.24 [0.12-0.47 95% confidence interval [CI]]), while those with SCA due to respiratory causes had significantly better survival outcomes (P = 0.001; OR = 2.3 [1.5-3.8 95% CI]). No significant differences in outcomes were found between other risk factors, including cardiac causes. CONCLUSION: In this population, the prevalence of SCA in adults was higher than reported in many similar studies. Further, sepsis was found to affect the survival rate. Although the rate of ROSC for IHCA patients was favorable compared with other studies, it is relatively poor. This finding signifies the need to identify and control risk factors for SCA to improve survival.

The efficacy of cervical spine phantoms for improving resident proficiency in performing ultrasound-guided cervical medial branch block: A prospective, randomized, comparative study.

BACKGROUND: Few studies have been conducted on the utility of cervical spine phantoms for practicing cervical procedures. Here, we describe a simple method for creating a cervical spine phantom and investigate whether the use of a gelatin-based phantom is associated with improved proficiency in performing ultrasound-guided cervical medial branch block. METHODS: A cervical spine phantom was prepared using a cervical spine model immersed in a mixture of gelatin and psyllium husk. In total, 27 participants, inexperienced in spinal ultrasonography, were enrolled and allocated to 1 of 2 groups (training group, n = 18; control group, n = 9). All participants were tested (test-1) following an introductory course of basic ultrasonography. Participants in the control group were tested again after 1 week (test-2). Those in the training group received a further individual 3-hour training session, and were tested again after 1 week (test-2). RESULTS: The mean performance score in test-1 was 62.5 ±â€Š10.1 points in the training group and 62.3 ±â€Š4.1 points in the control group [95% confidence interval (95% CI) -5.5 to 5.8; P = .954]. In test-2, the mean score was 86.8 ±â€Š6.5 points and 59.9 ±â€Š4.4 points in the training and control groups, respectively (95% CI 21.9-31.8; P < .001). The mean time required to complete test-1 was 84.6 ±â€Š26.6 seconds in training group and 90.7 ±â€Š43.9 seconds in the control group (95% CI -34.0 to 21.7; P = .653); in test-2, the time required was 56.6 ±â€Š27.9 and 91.2 ±â€Š43.8 seconds (95% CI -63.0 to -6.2; P = .019), respectively. Interobserver reliability showed excellent agreement based on the intraclass correlation coefficient, and moderate to almost perfect agreement by kappa statistics. CONCLUSION: Training using a gelatin-based cervical spine phantom helps novices acquire the skills necessary to perform ultrasound-guided cervical medial branch blocks.

Risk factors and classification of stillbirth in a Middle Eastern population: a retrospective study.

OBJECTIVE: To estimate the incidence of stillbirth, explore the associated maternal and fetal factors and to evaluate the most appropriate classification of stillbirth for a multiethnic population. METHODS: This is a retrospective population-based study of stillbirth in a large tertiary unit. Data of each stillbirth with a gestational age >/=24 weeks in the year 2015 were collected from electronic medical records and analyzed. RESULTS: The stillbirth rate for our multiethnic population is 7.81 per 1000 births. Maternal medical factors comprised 52.4% in which the rates of hypertensive disorders, diabetes and other medical disorders were 22.5%, 20.8% and 8.3%, respectively. The most common fetal factor was intrauterine growth restriction (IUGR) (22.5%) followed by congenital anomalies (21.6%). All cases were categorized using the Wigglesworth, Aberdeen, Tulip, ReCoDe and International Classification of Diseases-perinatal mortality (ICD-PM) classifications and the rates of unclassified stillbirths were 59.2%, 46.6%, 16.6%, 11.6% and 7.5%, respectively. An autopsy was performed in 9.1% of cases reflecting local religious and cultural sensitivities. CONCLUSION: This study highlighted the modifiable risk factors among the Middle Eastern population. The most appropriate classification was the ICD-PM. The low rates of autopsy prevented a detailed evaluation of stillbirths, therefore it is suggested that a minimally invasive autopsy [postmortem magnetic resonance imaging (MRI)] may improve the quality of care.

Opinions Regarding Benzodiazepine Teaching and Prescribing Among Trainees in Psychiatry.

OBJECTIVES: Benzodiazepines are widely prescribed for a variety of symptoms and illnesses. There has been limited investigation on the training psychiatry residents receive regarding benzodiazepine prescribing. This study surveyed US psychiatric trainees about their didactic and clinical experience with benzodiazepines, investigating how experience with benzodiazepines may shape trainees' opinions and likelihood to prescribe. METHODS: The 14-question online survey was distributed to residents and fellows at US training programs through an invitation from their training directors. RESULTS: Of 466 programs contacted, with an estimated 1345 trainees, a total of 97 programs (20.8%) and 424 trainees (31.5%) responded. The analyses focused only on the 342 general psychiatry trainees who responded. Most trainees reported having formal didactics on benzodiazepines, and earlier training was correlated with higher trainee quality of instruction assessments (p < 0.01). Most trainees rated their instructors as Above or Well Above Average. Trainees cited the observation and opinion of supervisors as the two most important factors affecting likelihood of future benzodiazepine prescribing. Trainees commonly reported pressure from patients to prescribe benzodiazepines but were split on perceived pressure from supervisors about prescribing and whether a bias exists against prescribing at their program or in general. CONCLUSION: The survey indicated that psychiatry trainees generally feel adequately trained through didactic and clinical experience with benzodiazepines. Trainees perceived pressure by patients to prescribe benzodiazepines, but generally felt comfortable in managing benzodiazepine usage. Psychiatry attendings' opinions on benzodiazepines most impacted trainees. Influences on trainees' prescribing patterns are important variables that can impact future benzodiazepine prescribing.

Deep Venous Thrombosis among hypertensive patients in King Abdulaziz University (KAU) Hospital, Jeddah, Kingdom of Saudi Arabia.

BACKGROUND: Deep venous thrombosis (DVT) is a frequent cardiovascular disorder. It is among the main causes of morbidity and mortality among hospitalized patients and, at the same time, can be easily avoided. Studies clarified that there are a variety of factors which can be significantly associated with the development of DVT in hospitalized patients. OBJECTIVE: to identify frequency and factors associated with occurrence of DVT among hypertensive patients referred to KAU hospital, Jeddah, Kingdom of Saudi Arabia. METHODS: A cross-sectional hospital-based study was conducted from October 2016 to March, 2017. All hypertensive patients referred to or admitted to the hospital departments and who were suspected to have DVT and subjected to Doppler examination were included in the study. A questionnaire was designed to obtain data about DVT frequency among participants and factors associated with the development of DVT among them. Data was collected through face to face interviews of patients included in the study. RESULTS: DVT was detected in 13.5 % of the studied hypertensive patients. Increased age and gender had no significant association with the development of DVT among the studied patients. In addition, other studied factors and comorbidities had no significant role in DVT development among the study participants. CONCLUSION: Knowing the most common risk factors and their significance in developing DVT is essential for early detection of DVT to prevent it, especially for hypertensive patients. Awareness campaigns should be held more often in different neighborhoods of the city.

Epidemiology of senile prostatic enlargement among elderly men in Arar, Kingdom of Saudi Arabia.

BACKGROUND AND AIM: Senile prostatic enlargement due to benign prostatic hyperplasia (BPH) is a common problem among older men, and is responsible for considerable disability. This study was conducted to determine the prevalence and determinants of the clinically diagnosed prostatic enlargement among elderly men in Arar, Northern Saudi Arabia. METHODS: This cross-sectional study was carried out on all consented elderly males attending the outpatient clinic of the urology department of Arar Central Hospital from February 2017 to July 30, 2017. Each participant underwent a general examination and digital per rectal to detect general chronic diseases, obesity and prostatic enlargement. Data were analyzed by SPSS version 16, using descriptive statistics and Chi-squared test. RESULTS: Among 81 elderly male participants in the study, 19.8% had clinically diagnosed senile prostatic enlargement (SPE) and 3.7% had prostatic tumors. There was significant relation between SPE and age as 6.2% of cases were 60-69 years, 43.8% were 70-79 years and 44.0% were 80 years or more (p<0.05). There was also significant relation between SPE and obesity as 62.5% of cases were obese and 37.5% were non obese (p<0.05). There was no significant relation with marital status, smoking or diabetes mellitus (p<0.05). CONCLUSION: Senile prostatic enlargement is one of the significant important issues in public health in Arar city, Northern Saudi Arabia. The prevalence of this condition reaches 19.3%, thereby placing even greater burden on the quality of life of the elderly and on the health system in the region.

Height, weight and BMI percentiles and nutritional status relative to the international growth references among Pakistani school-aged children.

BACKGROUND: Child growth is internationally recognized as an important indicator of nutritional status and health in populations. This study was aimed to compare age- and gender-specific height, weight and BMI percentiles and nutritional status relative to the international growth references among Pakistani school-aged children. METHODS: A population-based study was conducted with a multistage cluster sample of 1860 children aged five to twelve years in Lahore, Pakistan. Smoothed height, weight and BMI percentile curves were obtained and comparison was made with the World Health Organization 2007 (WHO) and United States' Centers for Disease Control and Prevention 2000 (USCDC) references. Over- and under-nutrition were defined according to the WHO and USCDC references, and the International Obesity Task Force (IOTF) cut-offs. Simple descriptive statistics were used and statistical significance was considered at P < 0.05. RESULTS: Height, weight and BMI percentiles increased with age among both boys and girls, and both had approximately the same height and a lower weight and BMI as compared to the WHO and USCDC references. Mean differences from zero for height-, weight- and BMI-for-age z score values relative to the WHO and USCDC references were significant (P < 0.001). Means of height-for-age (present study: 0.00, WHO: -0.19, USCDC: -0.24), weight-for-age (present study: 0.00, WHO: -0.22, USCDC: -0.48) and BMI-for-age (present study: 0.00, WHO: -0.32, USCDC: -0.53) z score values relative to the WHO reference were closer to zero and the present study as compared to the USCDC reference. Mean differences between weight-for-age (0.19, 95% CI 0.10-0.30) and BMI-for-age (0.21, 95% CI 0.11-0.30) z scores relative to the WHO and USCDC references were significant. Over-nutrition estimates were higher (P < 0.001) by the WHO reference as compared to the USCDC reference (17% vs. 15% overweight and 7.5% vs. 4% obesity) while underweight and thinness/wasting were lower (P < 0.001) by the WHO reference as compared to the USCDC reference (7% vs. 12% underweight and 10% vs. 13% thinness). Significantly lower overweight (8%) and obesity (5%) prevalence and higher thinness grade one prevalence (19%) was seen with use of the IOTF cut-offs as compared to the WHO and USCDC references. Mean difference between height-for-age z scores and difference in stunting prevalence relative to the WHO and USCDC references was not significant. CONCLUSION: Pakistani school-aged children significantly differed from the WHO and USCDC references. However, z score means relative to the WHO reference were closer to zero and the present study as compared to the USCDC reference. Overweight and obesity were significantly higher while underweight and thinness/wasting were significantly lower relative to the WHO reference as compared to the USCDC reference and the IOTF cut-offs. New growth charts for Pakistani children based on a nationally representative sample should be developed. Nevertheless, shifting to use of the 2007 WHO child growth reference might have important implications for child health programs and primary care pediatric clinics.

Family-based factors associated with overweight and obesity among Pakistani primary school children.

BACKGROUND: Childhood obesity epidemic is now penetrating the developing countries including Pakistan, especially in the affluent urban population. There is no data on association of family-based factors with overweight and obesity among school-aged children in Pakistan. The study aimed to explore the family-based factors associated with overweight and obesity among Pakistani primary school children. METHODS: A population-based cross-sectional study was conducted with a representative multistage cluster sample of 1860 children aged five to twelve years in Lahore, Pakistan. Overweight (> +1SD BMI-for-age z-score) and obesity (> +2SD BMI-for-age z-score) were defined using the World Health Organization reference 2007. Chi-square test was used as the test of trend. Linear regression was used to examine the predictive power of independent variables in relation to BMI. Logistic regression was used to quantify the independent predictors of overweight and adjusted odds ratios (aOR) with 95% confidence intervals (CI) were obtained. All regression analyses were controlled for age and gender and statistical significance was considered at P < 0.05. RESULTS: Significant family-based correlates of overweight and obesity included higher parental education (P < 0.001), both parents working (P = 0.002), fewer siblings (P < 0.001), fewer persons in child's living room (P < 0.001) and residence in high-income neighborhoods (P < 0.001). Smoking in living place was not associated with overweight and obesity. Higher parental education (P < 0.001) and living in high-income neighborhoods (P < 0.001) showed a significant independent positive association with BMI while greater number of siblings (P = 0.001) and persons in child's living room (P = 0.022) showed a significant independent inverse association. College-level or higher parental education as compared to high school-level or lower parental education (aOR 2.54, 95% CI 1.76-3.67), living in high-income neighborhoods as compared to low-income neighborhoods (aOR 2.13, 95% CI 1.31-3.46) and three or less siblings as compared to more than three siblings (aOR 1.75, 95% CI 1.26-2.42) were significant independent predictors of overweight. CONCLUSION: Family-based factors were significantly associated with overweight and obesity among school-aged children in Pakistan. Higher parental education, living in high-income neighborhoods and fewer siblings were independent predictors of overweight. These findings support the need to design evidence-based child health policy and implement targeted interventions, considering the impact of family-based factors and involving communities.

Waist circumference, waist-hip ratio and waist-height ratio percentiles and central obesity among Pakistani children aged five to twelve years.

BACKGROUND: Central obesity has been associated with the risk of cardiovascular and metabolic disease in children and anthropometric indices predictive of central obesity include waist circumference (WC), waist-hip ratio (WHR) and waist-height ratio (WHtR). South Asian children have higher body fat distribution in the trunk region but the literature regarding WC and related indices is scarce in this region. The study was aimed to provide age- and gender-specific WC, WHR and WHtR smoothed percentiles, and to explore prevalence and correlates of central obesity, among Pakistani children aged five to twelve years. METHODS: A population-based cross-sectional study was conducted with a representative multistage random cluster sample of 1860 primary school children aged five to twelve years in Lahore, Pakistan. Smoothed percentile curves were constructed for WC, WHR and WHtR by the LMS method. Central obesity was defined as having both age- and gender-specific WC percentile ≥90th and WHtR ≥0.5. Chi-square test was used as the test of trend. Multivariate logistic regression was used to quantify the independent predictors of central obesity and adjusted odds ratios (aOR) with 95% CI were obtained. Linear regression was used to explore the independent determinants of WC and WHtR. Statistical significance was considered at P < 0.05. RESULTS: First ever age- and gender-specific smoothed WC, WHR and WHtR reference curves for Pakistani children aged five to twelve years are presented. WC increased with age among both boys and girls. Fiftieth WC percentile curves for Pakistani children were higher as compared to those for Hong Kong and British children, and were lower as compared to those for Iranian, German and Swiss children. WHR showed a plateau pattern among boys while plateau among girls until nine years of age and decreased afterwards. WHtR was age-independent among both boys and girls, and WHtR cut-off of ≥0.5 for defining central obesity corresponded to 85th WHtR percentile irrespective of age and gender. Twelve percent children (95% CI 10.1-13.0) had a WC ≥90th percentile and 16.5% children (95% CI 14.7-18.1) had a WHtR ≥0.5 while 11% children (95% CI 8.9-11.6) had both WC ≥90th percentile and WHtR ≥0.5. Significant predictors of central obesity included higher grade, urban area with high socioeconomic status (SES), high-income neighborhood and higher parental education. Children studying in higher grade (aOR 5.11, 95% CI 1.76-14.85) and those living in urban area with high SES (aOR 82.34, 95% CI 15.76-430.31) showed a significant independent association. Urban area with high SES and higher parental education showed a significant independent association with higher WC and higher WHtR while higher grade showed a significant independent association with higher WC. CONCLUSIONS: Comprehensive worldwide reference values are needed to define central obesity and the present study is the first one to report anthropometric indices predictive of central obesity for Pakistani school-aged children. Eleven percent children were centrally obese and strong predictors included higher grade, urban area with high SES and higher parental education. These findings support the need for developing a National strategy for childhood obesity and implementing targeted interventions, prioritizing the higher social class and involving communities.

Prevalence and socioeconomic correlates of overweight and obesity among Pakistani primary school children.

BACKGROUND: Childhood obesity is becoming an equally challenging, yet under-recognized, problem in developing countries including Pakistan. Children and adolescents are worst affected with an estimated 10% of the world's school-going children being overweight and one quarter of these being obese. The study aimed to assess prevalence and socioeconomic correlates of overweight and obesity, and trend in prevalence statistics, among Pakistani primary school children. METHODS: A population-based cross-sectional study was conducted with a representative multistage cluster sample of 1860 children aged 5-12 years in Lahore, Pakistan. Overweight (> + 1SD) and obesity (> + 2SD) were defined using the World Health Organization child growth reference 2007. Chi-square test was used as the test of trend. Linear regression was used to examine the predictive power of independent variables in relation to BMI. Logistic regression was used to quantify the independent predictors for overweight and adjusted odds ratios (aOR) with 95% confidence intervals (CI) were obtained. All regression analyses were controlled for age and gender and statistical significance was considered at P < 0.05. RESULTS: Seventeen percent (95% CI 15.4-18.8) children were overweight and 7.5% (95% CI 6.5-8.7) were obese. Higher prevalence of obesity was observed among boys than girls (P = 0.028), however, there was no gender disparity in overweight prevalence. Prevalence of overweight showed a significantly increasing trend with grade (P < 0.001). Children living in the urban area with high socioeconomic status (SES) were significantly at risk for being overweight and obese (both P < 0.001) as compared to children living in the urban area with lower SES and rural children. Being in higher grade (aOR 2.39, 95% CI 1.17-4.90) and living in the urban area with higher SES (aOR 18.10, 95% CI 10.24-32.00) independently predicted the risk of being overweight. CONCLUSION: Alarmingly rapid rise in overweight and obesity among Pakistani primary school children was observed, especially among the affluent urban population. The findings support the urgent need for National preventive strategy for childhood obesity and targeted interventions tailored to local circumstances with meaningful involvement of communities.

Urban-rural inequities in knowledge, attitudes and practices regarding tuberculosis in two districts of Pakistan's Punjab province.

OBJECTIVE: The aim of this study was to explore inequities in knowledge, attitudes and practices regarding tuberculosis (TB) among the urban and rural populations. DESIGN: A cross-sectional study was conducted in two districts of Pakistan's Punjab province. The 1080 subjects aged 20 years and above, including 432 urban and 648 rural respondents, were randomly selected using multistage cluster sampling and interviewed after taking verbal informed consent. Logistic regression was used to calculate the crude odds ratio (OR) with 95% confidence interval (CI) for the urban area. The differences in knowledge, attitudes, practices and information sources between the urban and rural respondents were highlighted using Pearson chi-square test and Fisher's exact test. RESULTS: The study revealed poor knowledge regarding TB. The deficit was greater in the rural areas in all aspects. The knowledge regarding symptoms (OR 2.03, 95% CI 1.59-2.61), transmission (OR 1.93, 95% CI 1.44-2.59), prevention (OR 2.24, 95% CI 1.70-2.96), duration of standard treatment (OR 1.88, 95% 1.41-2.49) and DOTS (OR 1.84, 95% CI 1.43-2.38) was significantly higher in the urban areas (all P < 0.001). Although a majority of the subjects (urban 83.8%, rural 81.2%) were aware of the correct treatment for TB, less than half (urban 48.1%, rural 49.2%) were aware of the availability of the diagnostic facility and treatment free of cost. The practice of seeking treatment at a health facility (P = 0.030; OR 2.01, 95% CI 1.06-3.82), as soon as they realized that they had TB symptoms (P < 0.001; OR 1.72, 95% CI 1.26-2.35), was significantly higher in the urban areas. People in the urban areas were more likely to feel ashamed and embarrassed being a TB patient (P < 0.001; OR 2.03, 95% CI 1.50-2.76); however, they seem to be supportive in case their family member suffered from TB (P = 0.005; OR 1.53, 95% CI 1.13-2.06). Nearly half of the respondents, irrespective of the area of residence, believed that the community rejects the TB patient (urban 49.8%, rural 46.4%). Television (urban 80.1%, rural 68.1%) and health workers (urban 30.6%, rural 41.4%) were the main sources for people to acquire the TB related information. CONCLUSION: Respondents' knowledge regarding TB was deficient in all aspects, particularly in the rural areas. Intended health seeking behavior was better in the urban areas. Television and health workers were the main sources for TB related information in both the urban as well as the rural areas. Therefore, the area of residence should be considered in tailoring communication strategies and designing future interventions for TB prevention and control.