Dietary habits and physical activity patterns in relation to nutritional status among school-aged children in Pakistan: A cross-sectional study.

Background: Childhood malnutrition remains a significant public health problem impacting the physical and mental growth if school aged children, particularly in limited-resource countries. Objective: The study objective was to assess levels of physical activity, patterns of screen time (S.T.), the relationship between physical activity and screen time patterns, and how these factors affect growth status (adjusting for socioeconomic status). Methodology: A cross-sectional study included 3,834 children between 6-14 years attending pre-selected schools. Teachers, students, and parents were invited to fill out a standardized questionnaire, and Body Mass Index (BMI) was calculated using Center for disease control (CDC) centile charts. A Chi-square was performed to see the possible association between any height and weight abnormalities and all possible risk factors. Multivariate logistic regression was applied to see the effect of variables significantly associated with univariate analysis. Results: Approximately 2,447 (63.8%) children were between 11-14 years old and 1,387 (36.2%) were between 4-10 years old. The mean height was 143.71 ± 16.51 centimetres, the mean weight was 36.5 ± 12.9 kilogram, and the mean BMI was 17.16 ± 3.52. Multivariate logistic regression status and junk food combined affected stunting socioeconomic status was significantly associated with being underweight p = 0.001. Conclusion: Childhood obesity and stunting remain significant problems in Pakistani school-going children. These are significantly associated with poverty, a lack of physical activity opportunities, and available food quality.

Amoxicillin-clavulanate induced DRESS syndrome masquerading as red man syndrome.

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe drug-induced hypersensitivity reaction carrying a mortality rate of up to 10%. We present a rare case of DRESS syndrome induced by amoxicillin-clavulanate, initially masquerading as red man syndrome. A 32-year-old male was admitted with flu-like symptoms and a maculopapular rash on the trunk and face that was exacerbated with vancomycin infusion, concerning for red man syndrome. He was receiving systemic antibiotics (vancomycin, ceftriaxone, and metronidazole) for infective endocarditis and previously took amoxicillin-clavulanate for a dental abscess. Despite the discontinuation of vancomycin, the exanthem continued to worsen, extending to involve >50% of his body surface area. Eosinophilia, hepatosplenomegaly, and acute kidney and liver injuries prompted consideration of DRESS syndrome. All antibiotics were discontinued, and systemic glucocorticoids were initiated. Punch biopsy revealed interface dermatitis with eosinophilic infiltrates; a high RegiSCAR score confirmed the diagnosis of DRESS. Amoxicillin-clavulanate was flagged as a severe allergy and deemed the culprit owing to the timing of exposure and personal/family history of hypersensitivity.

Diagnosis, Management And Prevention Of Hepatitis C In Pakistan 2017.

AIMS AND OBJECTIVES: Since the advent of direct acting antiviral agents, there is a revolutionary change in the management of HCV infection. Newer drugs with different mechanism of action are being introduced and are expected to be available in coming few months in Pakistan as well. The main purpose of the guideline is to review and induct the latest research in field of HCV infection in Pakistani perspective so that our healthcare professionals can apply the new recommendations in timely and judicial manner. Target groups of guidelines are general physicians treating hepatitis C, hepatologists and gastroenterologists. Other beneficiaries of these guidelines are public health institutions of Pakistan, which provide free treatment to deserving patients under National Hepatitis Prevention and Control Program and Pakistan Bait-ul- Mal Program. METHODOLOGY: These guidelines are based on the review of National consensus practice guidelines: Diagnosis, Management and Prevention of Hepatitis C Pakistan 2009. Published data in National and International Journals searched with the help of Google search and pub med, and 2015-16 guidelines of HCV by AASLD, EASL, APASL and WHO. Local studies are preferably added with references to enhance the Pakistani perspective. Evidence was also taken from published studies. Recommendations have been based upon evidence from national publications on the subject and scientific presentations at national liver meeting as well from experts' personal experience and opinion.

Clinical experience with insulin detemir in patients with type 2 diabetes from the near East countries.

INTRODUCTION: This study aimed at determining the clinical safety and efficacy of insulin detemir (IDet) in combination with oral anti-diabetic drugs (OADs) in type 2 diabetes (T2D) patients from four Near East Countries (Israel, Jordan, Pakistan and Lebanon). METHODS: This prospective observational study included T2D patients previously on OADs and newly diagnosed patients initiating IDet with or without OADs, at the discretion of physicians. Safety objectives included evaluation of hypoglycemia and adverse drug reactions (ADRs) from baseline to Week 24. Efficacy outcomes included baseline to Week 24 changes in glucose control parameters (glycated hemoglobin [HbA1c], fasting plasma glucose [FPG] and post-breakfast post-prandial plasma glucose [PPPG]). Change in body weight during this period was also assessed. RESULTS: A total of 2,155 patients (mean ± SD: age 57.1 ± 11.0 years, BMI 29.4 ± 5.1 kg/m(2), average diabetes duration 9.2 ± 5.4 years) were included. IDet dose at baseline was 0.20 ± 0.09 U/kg titrated up to 0.34 ± 0.14 U/kg by Week 24. From baseline to Week 24, the total number of hypoglycemic episodes increased from 1.30 to 1.37 events/patient-year, while major hypoglycemic episodes decreased from 0.15 to 0.02 events/patient-year. A total of 9 ADRs were reported, of which one event was a serious ADR. Statistically significant improvements in glucose control were reported from baseline to Week 24 (HbA1c: 9.6 ± 1.6% vs. 7.6 ± 1.1%; FPG: 201.5 ± 59.5 mg/dL vs. 124.9 ± 31.6 mg/dL; PPPG: 264.2 ± 65.7 mg/dL vs. 167.2 ± 36.8 mg/dL; all p < 0.0001). Body weight did not change significantly after 24 weeks of IDet therapy. CONCLUSION: IDet therapy in combination with OADs improved glycemic control without increasing the risk of hypoglycemia or weight gain.

Integrating care coordination home telehealth and home based primary care in rural Oklahoma: a pilot study.

The purpose of this program was to evaluate the benefits of integrating VA Care Coordination Home Telehealth and Telemental health within HBPC. A case study design was used to determine quality assurance and quality improvement of incorporating additional home telehealth equipment within Home Based Primary Care (HBPC). Veterans with complex medical conditions and their caregivers living in rural Oklahoma were enrolled. Veterans received the same care other HBPC patients received with the addition of home telehealth equipment. Members from the interdisciplinary treatment team were certified to use the telehealth equipment. Veterans and their caregivers were trained on use of the equipment in their homes. Standard HBPC program measures were used to assess the program success. Assessments from all disciplines on the HBPC team were at baseline, 3, and 6 months, and participants provided satisfaction and interview data to assess the benefits of integrating technology into standard care delivery within an HBPC program. Six veterans were enrolled (mean age = 72 yrs) with a range of physical health conditions including: chronic obstructive pulmonary disease, cerebrovascular accident, spinal cord injury, diabetes, hypertension, and syncope. Primary mental health conditions included depression, dementia, anxiety, and PTSD. Scores on the Mini-Mental State Examination ranged from 18 to 30. Over a 6-month period, case studies indicated improvements in strength, social functioning, decreased caregiver burden, and compliance with treatment plan. This integration of CCHT and HBPC served previously underserved rural veterans having complex medical conditions and appears both feasible and clinically beneficial to veterans and their caregivers.

Study of the effect of antiviral therapy on homocysteinemia in hepatitis C virus- infected patients.

BACKGROUND: Hepatitis C virus (HCV) infection is one of the leading causes of chronic liver disease (CLD). About 80% of those exposed to the virus develop a chronic infection. Hyperhomocysteinemia, which is an independent risk factor for atherosclerotic vascular disease and thromboembolism, may develop in HCV-infected patients although altered alanine amino transferase (ALT) enzyme levels are generally associated with damage to liver cells. The gold standard therapy for chronic hepatitis C patients is pegylated interferon combined with an anti-viral drug (ribavirin). The current study aimed to investigate the effect of antiviral therapy on plasma homocysteine (Hcy) levels in HCV patients in addition to other parameters. METHODS: 532 HCV-infected patients and 70 healthy controls were recruited for the study. All patients were subjected to laboratory investigations including HCV-RNA levels, complete blood cell counts, serum levels of homocysteine, ALT, alkaline phosphatase (ALP), lipid profile and liver ultrasonographic examination. The outcome of treatment with pegylated interferon α plus ribavirin treatment and sustained virologic response (SVR) was determined 6-9 months post-therapy. RESULTS: Hyperhomocysteinemia was found in 91.35% of HCV-infected patients. The difference in plasma Hcy concentrations reached statistical significance between the patient and control groups. ALT, cholesterol and triglycerides (TGs) levels were found higher than normal in the patients group. After receiving a combined therapy for 24 weeks, 43.66% patients showed an SVR (responders); 30.98% patients were non-responders while 25.35% patients initially responded to therapy but again retrieved positive status of HCV infection six months post-therapy (relapse-cirrhotic patients). The mean levels of plasma Hcy, ALT and ALP were significantly reduced in responders within 10 weeks of therapy when compared with non-responders and relapse-cirrhotic patients. CONCLUSION: Elevated homocysteine levels in serum due to HCV infection can be reduced to normal range with the standard interferon α plus ribavirin treatment. This study highlights the significance of the measurement of serum homocysteine levels in the diagnosis and monitoring of HCV infection treatment in addition to other laboratory parameters.

Occult HCV or delayed viral clearance from lymphocytes of Chronic HCV genotype 3 patients after interferon therapy.

BACKGROUND: A recently discovered occult HCV entity reported by various investigators seems to be highly controversial. Especially, the clinical significance of these findings remains uncertain. For optimal outcome of antiviral therapy, investigation of occult HCV needs a broad-based probe in order to investigate the results of viral therapy and its host/viral interaction. The current study was aimed at determining the prevalence of occult HCV in peripheral blood lymphocytes of predominantly genotype 3 HCV-infected patients after completion of antiviral therapy and to investigate long term outcomes in the presence or absence of PBMC positivity. METHOD: A total of 151 chronic, antiHCV and serum RNA-positive patients were enrolled in the study. Patients with a complete virological response at the end of treatment were screened for the presence of viral RNA in their PBMCs and were followed for up to one year for the presence of serum and PBMC viral genomic RNA. RESULTS: Out of 151 patients, 104 (70%) responded to the prescribed interferon treatment and showed viral-clearance from serum. These were screened for the presence of genomic RNA in their PBMCs. Sixteen samples were PBMC-positive for viral RNA at the end of treatment (EOT). All these patients had also cleared the virus from peripheral blood cells after the 6-12 month follow-up study. CONCLUSION: True occult hepatitis C virus does not exist in our cohort. Residual viremia at the EOT stage merely reflects a difference in viral kinetics in various compartments that remains a target of immune response even after the end of antiviral therapy and is eventually cleared out at the sustained viral response (SVR).

Pre-treatment predictors of response for assessing outcomes to standard treatment in infection with HCV genotype 3.

OBJECTIVE: To determine the role of pre-treatment predictors of response in assessing outcomes to standard treatment in HCV genotype 3. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Department of Medicine, KRL General Hospital, Islamabad, from December 2004 to December 2006. METHODOLOGY: All patients with positive anti-HCV and PCR genotype 3a were recruited and written and informed consent was taken. Patients were treated with standard Interferon plus Ribavirin therapy (IFN alpha-2a, 3MU t.i.w 24 weeks plus Ribavirin 1000-1200 mg/day) for 6 months. The effect of pre-treatment factors influencing outcome i.e. age, gender, weight, baseline ALT, necroinflammatory grade, fibrosis and steatosis on the final outcome were further analyzed by univariate logistic regression analysis. RESULTS: Response rates to standard Interferon plus Ribazole therapy were studied in 190 patients. The end-of-treatment complete response (EOTCR) was seen in 81% (n=155) of the patients, whereas 17% (n=33) were non-responders (NR). Sustained viral response (SVR) was seen in 58% (n=112) patients and 24% (n=45) were relapsers. SVR was higher in patients without steatosis (OR=2.52, 95% CI=1.356- 4.71, p=0.04). Higher SVR was seen in patients weighing less than 65 kg, as compared with weight>65 kg (OR=2.277, 95% CI=1.246-4.161, p=0.007). The other variables were not found to be significantly associated with improved SVRs. CONCLUSION: Out of the studied predictors, body weight and presence of steatosis, were statistically related to treatment outcome. Pre-treatment host factors can predict response to treatment that can help in individualizing treatment and patient selection and optimize treatment outcomes.

Response rates to standard interferon treatment in HCV genotype 3a.

BACKGROUND: Chronic Hepatitis C infection infects almost 130 to 170 million or approximately 2.2-3% of world's population. HCV is one of the main causes of chronic liver disease leading to progressive liver injury, fibrosis, cirrhosis and liver cancer. It is also one of the leading indications for liver transplantation worldwide. The objective of the study was to determine the response of treatment with standard Interferon and Ribazole in treatment naïve Hepatitis C infected patients. METHODS: This quasi-experimental study was carried out at the Department of Medicine, KRL General Hospital Islamabad, from January 2003 to January 2005. A total of 250 patients were enrolled in this descriptive study. All patients were anti HCV positive, PCR positive for HCV RNA and had 3a genotype. A non-probability purposive sampling technique was applied to collect data. After taking a written and informed consent; specially designed performa containing the patient profile, family transmission, and baseline laboratory values was filled. Patients were treated with a set protocol of Interferon plus Ribavarin therapy (IFN alpha 2a, 3 mIU thrice weekly for 24 weeks plus Ribavarin 1,000 to 1,200 mg/day) for six months. Chi-Square tests were used to analyse the data. Primary end point was a sustained virological response (SVR) that is response assessed after six months of completion of treatment. RESULTS: Response rates to standard Interferon plus Ribazole therapy were studied over two years period. Out of the total of 250 patients, 60 patients were excluded; as 30 patients did not meet inclusion criteria, 23 patients were lost to follow. Seven patients declined treatment. Out of the 190 patients, 155 (81.6%) achieved End of Treatment Complete Response (EOTCR) whereas 35 (18.4%) were nonresponders (NR). These 155 patients, who showed complete response were followed for six months after the treatment to assess sustained viral response, which was seen in 112 (72.25%) patients whereas 43 (27.7%) were relapsers. Response rates were co-related with gender, baseline ALT and necro-inflammatory stage assessed by liver biopsy, probable risk factors and family history. CONCLUSION: Management of Hepatitis C with genotype 3a, with standard Interferon and Ribazole for six months showed lower SVR compared to that reported in previous international and local data.

Declining sustained virological response in hepatitis C.

OBJECTIVE: To determine the response of treatment with standard interferon and Ribazole in treatment naïve hepatitis C infected patients, with different grades of activity. DESIGN: A quasi-experimental study. PLACE AND DURATION OF STUDY: This study was carried out at the Department of Medicine, KRL General Hospital, Islamabad, from January 2001 to September 2004. PATIENTS AND METHODS: A total of 300 patients were enrolled. All patients were anti-HCV positive confirmed by device method, PCR positive and had 3a genotype. A specially-designed proforma containing the patient profile, family transmission, and baseline laboratory values was filled. All patients were treated according to a set protocol of Interferon plus ribavirin therapy (IFN alpha 2a, 3MU t.i.w 24 weeks plus ribavirin 1000 to 1200 mg/day) for six months. Chi-square tests were used to analyze the data. Primary end point was a sustained virological response (SVR) that is response assessed after six months of completion of treatment. RESULTS: Over a period of four years response rates to standard Interferon plus Ribazole therapy were studied. Out of the total 300 patients data was available for 161 patients as 60 patients were excluded and 79 patients are currently under treatment. Treatment was stopped in 3 patients due to serious side effects. In the 161 patients, 135 (83.8%), achieved response at the end of treatment at six months; End of Treatment Complete Response (EOTCR); and 26 (16.14%) were non-responders (NR). Out of the complete responders, 68 patients had been followed completely upto six months after the treatment to asses Sustained Viral Response (SVR) defined as undetectable HCV RNA in serum at the end of six months posttreatment follow-up. Sustained viral response was seen in 46 patients i.e. 68% ( CI: 57-79%) and 22(32.3%) were relapsers (those who developed recurrence of viremia after having achieved eradication at the end of six months treatment). Response rates are co-related with gender, baseline ALT and necroinflammatory stage assessed by liver biopsy, probable risk factors and positive family history. CONCLUSION: Management of hepatitis C with genotype 3a, with standard Interferon and Ribazole for six months appear to show declining SVR compared to that reported in previous international and local data.