Pakistan Postgraduate Medical Journal

THE BURGEONING BURDEN OF PERINATAL MENTAL HEALTH IN LOWER MIDDLE-INCOME COUNTRIES

Waqqas Khokhar, ADEKIITE TANIMOWO, DISHA PANDURANGI — Sat, 30 Mar 2024 00:00:00 +0000

Perinatal mental health broadly refers to mental health during the six months before conception, through pregnancy, and up to a year after delivery.¹Perinatal mental health problems (PMHPs) affect women all over the world and include conditions such as anxiety, depression, psychosis, tocophobia and obsessive-compulsive disorder amongst others. Teenagers and young women under 25 are at particularly high risk of having perinatal mental disorders. PMHPs can also affect men although in much lesser proportions.

Per recent global mental health literature, up to one in five women worldwide will experience a perinatal mental health condition but the prevalence increases to more than one in three for women in low and middle-income countries.² In particular, the prevalence of perinatal depression ranges between 7 per cent and 15 per cent in some high-income countries (HICs) while it increases to between 10 per cent to 39 per cent in low and middle-income countries (LMICs).³

PMHPs do not only contribute significantly to maternal morbidity and mortality but they also create potential long-term adverse impacts on the physical, emotional, and neurological development of newborns and children. For instance, a systematic review of middle-income countries showed that women with perinatal mental health conditions are 60% more likely to have babies with low birth weight and more than twice as likely to give birth prematurely.⁷ In Pakistan, low birth weight, growth retardation, and delayed cognitive and motor development are outcomes that have been identified as associated with children of depressed mothers.

PMHPs may also put women at risk of additional mental health issues including eating disorders, substance-use-related issues, post-traumatic stress disorder, and personality disorders. Literature has shown a correlation between serious perinatal mental disorders and an increase in maternal deaths by suicide, a significant cause of maternal mortality in the past two decades with a higher burden in LMICs.⁸

Despite this higher burden of PMHPs in LMICs requiring greater investment, Perinatal Mental Health Services remains under resourced in LMICs. For instance, while the UK spends 8.1 per cent of its National Health Service budget on mental health, Bangladesh only spends about 0.5% of its health budget on mental health, thereby severely limiting service provision.^5,6

Beyond financial resources, there are multiple barriers to service provision in LMICs extending from the individual level (e.g., stigma, poor awareness, poverty), to the interpersonal/community level (e.g., intimate partner violence, preference for male child, cultural barriers), to the institutional, or organisational level (e.g., resource inadequacies, service fragmentation) and the structural level (e.g., weak policies). A few of these barriers demand further expatiation.

Stigma and shame associated with PMHPs prevents women from accessing care due to entrenched notion that mental health conditions are not serious conditions and should stay within the family when they occur. This is even more applicable in South Asian cultures which are collectivist in that social controls such as family, culture, religion, and community often dominate decision-making and strongly shape the attitudes that individuals hold. Another significant barrier involves the shortage of manpower. A severe discrepancy exists between the burden of mental health conditions and the availability of health workers in LMICs. There are less than 15 mental health workers per 100,000 population on average across low- and middle-income countries and less than 1 per 100,000 in low-income countries.⁹

In finding lasting solutions to service provision, several care models have been trialled. One is the ‘integrated care model’ which involves the provision of screening for perinatal mental health problems and low-intensity treatments by midwives and health visitors in collaboration with primary mental health services. Another is the ‘task-sharing’ model in which non-specialist health practitioners are trained to deliver specific interventions with support from interlinked specialists sharing responsibility for care; or collaborative care, which encourages self-management by the patient using community resources and digital innovations.

A further variation is the stepped care model that involves ‘task-shifting’ to non-specialist health practitioners who provide less resource-intensive evidence-based interventions while more complex cases are referred to specialist services. An example is the WHO’s Thinking Healthy Programme. This model was adopted in Pakistan where social peers were trained and used to deliver psychosocial intervention on maternal depression. A review of this intervention during the 3-year postnatal period showed reduced severity of maternal depression symptoms and high remission rates.¹⁰ However, this multi-year, psychosocial intervention task-shifted via peers was also discovered to be susceptible to reductions in fidelity and dosage over time. It was posited that early intervention efforts might need to rely on multiple models, be of greater intensity, and potentially target higher-risk mothers.¹⁰ Ultimately, what these findings reveal is that whatever model an LMIC country chooses to adopt would require longitudinal evaluations of efficacy and effectiveness to determine the best fit. It is also important that the model of care caters to users’ partners and families. Furthermore, consideration for and provision of perinatal mental health care for childbearing-age women within generic adult psychiatric care should be fostered.

Overall, it is clear that perinatal mental health care is a key global health concern in LMICs that requires urgent attention. Stakeholders must address the complex cultural, social, and structural determinants from the individual to the structural level. Established (and new) economically effective models need to be piloted in different settings and evaluated to determine needed modifications for effectiveness, efficacy, and sustainability. Of course, without adequate funding and thorough commitment from relevant stakeholders to manage this burgeoning burden, making a lasting change would remain an elusive ideal.

CORRELATION BETWEEN TOTAL SERUM BILIRUBIN LEVELS AND TRANSCUTANEOUS BILIRUBINOMETER VALUES IN NEONATAL JAUNDICE

Sat, 30 Mar 2024 00:00:00 +0000

Background: Jaundice in newborns is a prevalent postnatal complication, typically benign in nature. To assess neonatal jaundice, the development of non-invasive techniques, such as the transcutaneous bilirubinometer, has proven instrumental. This study focuses on evaluating neonatal bilirubin levels using transcutaneous bilirubin (TcB) meters, which employ a non-invasive approach by measuring light transmission through the skin.

Objective: The objective of this research is to conduct a comparative analysis between transcutaneous bilirubin levels in neonates and their corresponding total blood bilirubin levels.

Method: A cross- sectional study was conducted over the course of six months in the neonatal unit at Bahria International Hospital in Lahore. Systematic random sampling was used to recruit a total of 100 instances of newborn jaundice. Babies' demographic information was collected after they were born. The transcutaneous bilirubinometer (TCB) JM-105 was used to measure their bilirubin levels. Bilirubin levels in the serum were measured and documented simultaneously. The results of the two tests were compared to determine the degree of correlation between them.

Results: Out of 100 neonates, 61(61%) were male. For all weight ranges mean TCB values significantly correlated with mean serum bilirubin level (p<0.001) with correlation coefficient 0.778.

Conclusion: In newborns, total serum bilirubin (TSB) levels are highly associated with transcutaneous bilirubin (TcB) levels. Therefore, TcB can be utilized to direct care for these infants.

SKIN, SOFT TISSUE INFECTIONS AND THEIR MICROBIOLOGICAL PROFILE FROM A TERTIARY CARE HOSPITAL

Sat, 30 Mar 2024 00:00:00 +0000

Background: Skin and soft tissue infections (SSTIs) are considered as diverse group of infections which may vary in microbial etiology and clinical presentation and ranges from simple, uncomplicated infections to severe, complicated picture. Causative organisms with antimicrobial resistance may worsen the situation.

Objectives: The aim of present study was to check the frequency and antibiotic sensitivity pattern of bacterial isolates causing SSTIs.

Methods: A retrospective study performed over a period of 3 years. Pus and wound samples were collected and were processed by using standard microbiological procedures. Confirmation of bacterial species was done by different biochemical tests. Antimicrobial susceptibility pattern (AST) was checked on Mueller-Hinton (MH) agar by disc-diffusion method according to CLSI guidelines.

Results: Among 2345 total samples, 63.1% were cultured positive. Percentage of gram-negative bacteria was 51.3% while 48.7& were gram positive. E. coli (33.7%) was most common organism among gram-negative and S. aureus (34.5%) was more prevalent among gram positive organisms. Linezolid and glycopeptides showed excellent susceptibility against gram-positive organism, while maximum resistance was observed against Co-trimoxazole and Fluoroquinolones among gram-negative isolates.

Conclusion: Changing trend of bacterial spectrum causing SSTIs along with increasing antimicrobial resistance becomes a serious health problem which limits the treatment options for such infections.

ASSESSMENT OF REFRACTIVE ERRORS IN SCHOOL GIRLS IN A RURAL SETTING

Sat, 30 Mar 2024 00:00:00 +0000

Background: Among children, undiagnosed refractive error is the second most common cause of curable blindness and the major cause of visual disability these days. Children often do not complain of visual problems and may not even be aware of their symptoms. Ophthalmic screening programs in school children are not only essential but are also valuable School screening programs assist in early detection of amblyopia and its risk factors such as strabismus, refractive errors and media opacities

Methods: A total of 155 schoolgirls between ages 5 to 18 years were included in the screening process at a Government Higher Secondary School in April 2019. The students were asked to fill in a self-devised questionnaire for a superficial ocular assessment. Next, visual acuity was measured with Snellen distant vision chart. Data was analyzed using IBM SPSS Version 23. Data was checked for normality of distribution by Shapiro-Wilk test. Frequency and percentages of refractive errors were determined. A p-value ≤ 0.05 was considered statistically significant.

Results: The frequency of girls having right eye error was more than those having it in left eye and the percentage of girls having failed visual acuity in either eye i.e VA<6/12 was 17.4%. Pearson Chi Squared test was applied to determine any relationship between categorical variables and it showed significance between reading from books, threading the needle 0.000 and parents wearing glasses. (p-value<0.05).

Conclusion: Awareness about causes of refractive errors must be prioritized. Annual screening should be made mandatory in schools of both urban as well as rural setting, health education programs, walks, seminars should be conducted in order to create awareness amongst the general masses, and last but not the least smartphone usage hours should be restricted in children in order to prevent them from the deleterious effects of this gadget.

CLINICAL COURSE AND OUTCOME OF PATIENTS WITH DENGUE FEVER, DENGUE HEMORRHAGIC FEVER AND DENGUE SHOCK SYNDROME IN A TERTIARY CARE HOSPITAL IN RECENT ENDEMIC 2022

Mirza Muhammad Ilyas Baiz, Hafiz Abdul Rauf, Awais Ahmed, Arzinda Fatima — Sat, 30 Mar 2024 00:00:00 +0000

Background: Dengue fever cases have been increased almost 30-fold over last 50 years and now reaches an estimated 100 million clinically apparent infections annually. This rapid increase in the incidence of dengue fever cases has become a threat not only to public health globally but also economic burden to developing countries like Pakistan and also other countries of South- Asia.

Objective: To assess clinical course and outcome in patients with dengue fever, dengue hemorrhagic fever and dengue shock syndrome in patients in a tertiary care hospital.

Methods: This cross-sectional study was conducted in the department of Medicine, Fatima Memorial Hospital, Lahore from September to November 2022. Data of all those patients who had dengue fever, dengue hemorrhagic fever and dengue shock syndrome was collected carefully. Laboratory tests were evaluated for the positivity of dengue fever by either NS1 or IgM. All patients who had positive of any of these tests were included in our study. Other laboratory tests (CBC-ESR, serum electrolytes, LFTs, RFTs, Urine analysis, chest x-ray and ultrasound abdomen and chest) were also included to assess the severity of dengue infection. These laboratory tests were repeated at least three times, one day apart to see any improvement or worsening of condition. We divided these patients in three groups according to severity of disease. Data were analyzed by SPSS- version 23. ANOVA was applied for continuous variable and chi-square was applied for categorical variables.

Results: The study comprised a total of 207 dengue patients. Distribution of gender, with 58% of the patients were men and 42% were women. The patients were divided into three groups based on their dengue infection severity type: dengue fever, dengue hemorrhagic fever, or dengue shock syndrome. There was no significant difference in blood pressure of dengue fever and dengue hemorrhagic fever, but significant fall of Blood pressure was found in dengue shock syndrome. Similarly respiratory rate change was found in DSS. Temperature changes in these patients were not significant in all types of dengue virus infection. There were significant differences in the oxygen saturation values in dengue fever, dengue hemorrhagic fever and dengue shock syndrome and across the several dengue strains DNV1-4 (p 0.001). The analysis of laboratory data showed that the levels of hemoglobin, hematocrit, platelet count, white blood cell count, alanine transaminase (ALT), and aspartate transaminase (AST) varied considerably across the various dengue severity levels.

Conclusion: In our study it was shown that patients had variable level of severity at the time of presentation, and most of patients can be treated but patients who presented late, developed complications and even death in few patients, patients who presented with shock, most of them expired and female to male ratio was different, as most of females expired. There was also significant different oxygen saturation level according to severity of dengue infection. Platelets count was significant but not of predictive value for severity of dengue infection, as patients with very low platelets count recovered.

IMPACT OF SURGERY ON QUALITY OF LIFE (QoL) IN PATIENTS WITH STRUCTURAL HEART DISEASE

Kiran Sheikh, ABDUL MALIK SHEIKH, Touqeer Akbar, Hina Sattar, Asma Kanwal — Sat, 30 Mar 2024 00:00:00 +0000

Background: Structural heart disease is one of the most commonly occurring congenital disorders with about 0.8% - 1.2% of live births worldwide Despite the tremendous progress in field of cardiology, majority of this growing population with CHD even after the surgery continue to face life-long challenges and are at risk for having a poor (QoL).

Objectives: To evaluate the impact of surgery on QoL in patients with structural heart disease.

Materials: This Quasi experimental study was conducted in Rawalpindi Institute of Cardiology Rawalpindi. From July 2019 to June 2020. We included 76 children and adolescents of both genders with one of their parents after consent. Demographic and clinical data was recorded on the preset Performa. The QoL was accessed by using Urdu version of World Health Organization Quality of Life Brief Version (WHOQOL-BREF) before and one month after surgery. Data was analyzed on SPSS 20 and p value of<0.05 was taken as significant.

Results: The mean age of participant (n=76) children and adolescents is 14.5 (14.5 ± 3.3) years. Out of total, 52.6% were females while 47.4% were males. Most of the patients had VSD, 26(34 .2%) followed by TOF 12(15 .7%) and ASD 9(11 .2%). Valvular heart disease (Mitral, Aortic) was found in 8 (10. 5%) and 5(6 .5%) cases respectively the individual parameters of WHO QoL scale were compared in pre- and post-surgical period. Further the parameters of WHO QOL scale were divided into sub categories of physical health, psychological wellbeing, social interaction and environmental health for analysis. Results revealed that physical health, psychological wellbeing, social interaction and environmental health all considerably improved in the post intervention period (p value 0.008, <0.001, <0.001 and 0.001 respectively). The overall QoL of patients also improved significantly (p value 0 .001).

Conclusion: There was significant improvement in physical health, psychological wellbeing, social interaction and environmental health in the post intervention period. Overall QoL in the postoperative period was also improved.

ANTI-NOCICEPTIVE OUTCOMES OF ANTICONVULSANT/ANTIDEPRESSANT MEDICINES IN THE MANAGEMENT OF FORMALIN INDUCED PAIN IN GROUP OF MICE

Sidra Shah, Ayesha Shaukat — Sat, 30 Mar 2024 00:00:00 +0000

Background: Anti-depressant are used to treat various disorders like neuropathic pain, migraine etc. Anticonvulsant drugs may have a role in the modulation of changes include inhibition of voltage gated ion channels at sites of spinal, supraspinal and peripheral.

Objectives: An experimental observational study was carried out to find the role of anti-nociceptive outcomes of anticonvulsant/antidepressant medicines in the management of formalin induced pain in group of mice.

Methods: A total of 20 albino mice weighed 20-30 gm. were taken from animal dwelling of The University of Lahore. Formalin induced pain was judged by observing the lifting of paw and behavior. Animals were divided in 4 groups (five mice in each group) group no 1: Control, group no 2: Paracetamol, group no 3: Fluvoxamine, group no 4: Lamotrigine. After given the doses of drugs, 5.0 % formalin solution was injected. Number of counts of licking paw and paw-lifting of mice during first phase and second phase was noted. Percentage effectiveness was calculated by the formula.

The palliative action of the medicine was evaluated by calculating the latency moment in reaction to stimulus of heat. The animals were positioned on hot plate at time interval zero min, 30 min, 60 min and 90 min subsequent the administration of medicine. The Latency time until animal began either jumping or licking was noted. Percentage of maximum possible effects (MPE) is calculated by formula.

Conclusion: Our study shows the anti-nociceptive outcomes of fluvoxamine & lamotrigine in the management of formalin induced pain in group of mice

FREQUENCY AND SEVERITY OF IRON DEFICIENCY ANEMIA IN FEMALES OF CHILDBEARING AGE

Sat, 30 Mar 2024 00:00:00 +0000

Background: Anemia is a condition which develops either due to decrease in the number of red blood cells or low hemoglobin concentration. Hemoglobin is oxygen transport protein in red blood cells. Young children, anorexic teenagers, females of reproductive age group, pregnant females and malnourished females are at greater risk of developing anemia.

Objectives: The objective of this study was to find out the frequency and severity of anemias in child bearing females.

Methods: This descriptive retrospective study was conducted in Ghurki Trust Teaching hospital Lahore from January 2022 to December 2023. Total of 2000 females of child bearing age, who ranged between 20-40 years were included. First group had ranged of age between 21 to 30 years whereas the second had ranged of age between 31 to 40 years. Data were entered and analysis by using SPSS version 22.

Results: Out of a total of 2000 cases, 713 (35.6%) had a normal hemoglobin level, whereas 1,287 (64.35%) had a decreased hemoglobin level. In present study, we found 41.05% females with mild, 18.6% cases of moderate anemia, whereas only 4.75% cases presented with severe degree of anemia.

Conclusion: Females presenting with symptoms of fatigue, tiredness and palpitations, anemia should be considered as one of the causes of this presentation of anemia.

ARTIFICIAL INTELLIGENCE AND MENTAL HEALTH SERVICES: A SYSTEMATIC REVIEW

Saima Majeed, Altaf Qadir Khan — Sat, 30 Mar 2024 00:00:00 +0000

Artificial Intelligence (AI) is increasingly being applied in mental health services to provide improved diagnosis, treatment, and support. This systematic review article aims to explore the current literature on the use of AI in mental health services, focusing on the effectiveness of AI-based interventions and the ethical considerations surrounding their use. The databases PsycINFO, PubMed, and Web of Science were explored for articles published between 2015 and 2022 using the following search terms: “Artificial Intelligence”, “Mental Health”, “Intervention”, and “Ethics”. A search based on inclusion and exclusion criteria ended up with 50 articles highlighting the potential of AI to enhance the efficiency and accessibility of mental health services. Further deliberation excluded 30 articles and the present systematic review has been carried out with twenty articles. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines resulted in stating the results of this systematic review. The results suggest that AI-based interventions have promising outcomes for improving the diagnosis and treatment of disorders related to mental health, early detection and prevention of mental disorders, improved quality of care as well as reduced cost of mental health services. However, ethical considerations, such as privacy and transparency, must be considered in the implementation of AI in mental health services, and issues related to empathy and reflective practices were also highlighted. Implications and future directions for the research were also discussed.

HEPATIC ENCEPHALOPATHY MIMICKING STROKE IN A PATIENT WITH CHRONIC LIVER DISEASE

Sat, 30 Mar 2024 00:00:00 +0000

Hepatic Encephalopathy is a potentially reversible life-threatening neuro-psychiatric complication of liver cirrhosis. It generally presents with sleep disturbances, drowsiness and personality changes. Focal neurological loss in form of hemiplegia is a very rare presentation of hepatic encephalopathy. A 55-year old gentleman presented with irritability, drowsiness, right sided body weakness and constipation for last 3 days. He was a diagnosed patient of Hepatitis C positive Chronic liver disease for 3 years having completed a 24-week course of oral sofosbuvir 400mg and daclatasvir 60mg. On examination, the patient was drowsy but arousable having a GCS of 12/15 (E3, V4, M5). Power of grade 4/5 was noted in both left upper and lower limb with an extensor left plantar reflex. Flapping tremors were preset and bilateral mild pitting pedal edema was noted. Abdomen was soft, non-tender, mildly distended with positive shifting dullness. A CT scan (Brain) was done to rule out intracranial bleeding and the patient was admitted on lines of ischemic stroke and hepatic encephalopathy. He had thrombocytopenia, deranged LFTs and serum ammonia level. MRI Scan (Brain) showed foci of diffusion restriction in the left periventricular region and basal ganglia and T2WI/FLAIR hyperintense signals in the periventricular region, basal ganglia and deep white matter, however MR angiography demonstrated normal cerebral vessels. He was diagnosed as having hepatic encephalopathy mimicking stroke and underlying liver cirrhosis. After initiating lactulose and Rifaximin, the patient passed stools which resulted in resolution of his symptoms. His repeat serum ammonia was within normal limits and the patient was discharged.