Pakistan Medical Association

The predictability of triglyceride glucose index (TyG index) as a biomarker for identification of insulin resistance (IR) is being extensively studied in various ethnic populations. TyG index could be a beneficial tool for identification of IR and populations at high risk for developing diabetes in future. However, more studies are required to standardize optimal cut-off values in different ethnicities and populations. The present review describes existing literature, and identifies merits and demerits of TyG index as a surrogate marker for IR.

The world has experienced pandemics worse than the coronavirus disease (COVID-19) which resulted in great loss of life and economy. However, the global effect of this pandemic has been devastating. Billions of people are in lockdown and isolation on six continents around the world. Most have easy access to information due to internet connectivity and electronic media, which has helped share information about the pandemic. However, information overload during the current COVID-19 pandemic has posed a set of challenges not encountered before. There is an "infodemic" in which false news, conspiracy theories, magical cures and racist news are being shared at an alarming rate, with the potential to increase anxiety and stress and even lead to loss of life. This review highlights some of these challenges and suggests general measures to avoid information overload and infodemic in the connected world of 21st century.

Reliability and validity are among the most important and fundamental domains in the assessment of any measuring methodology for data-collection in a good research. Validity is about what an instrument measures and how well it does so, whereas reliability concerns the truthfulness in the data obtained and the degree to which any measuring tool controls random error. The current narrative review was planned to discuss the importance of reliability and validity of data-collection or measurement techniques used in research. It describes and explores comprehensively the reliability and validity of research instruments and also discusses different forms of reliability and validity with concise examples. An attempt has been taken to give a brief literature review regarding the significance of reliability and validity in medical sciences.

Objectives: To study the demographic details of diabetes patients and their knowledge, attitude and practices (KAP) regarding diabetes in Nepal. Methods: The KAP of the diabetes patients visiting the Manipal Teaching hospital (MTH) during the period from 22nd August to 7th December 2006 were studied by using the KAP questionnaire developed by the researchers. Results: Altogether 182 patients were enrolled in the study. There were 103 (56.59%) males and 79 (43.41%) females. The greatest number of patients were in the age group of 51-60 years. A total of 685 drugs were prescribed to these patients. Antidiabetics were the commonest class of drugs prescribed accounting for 314 (45.84%) of the total drugs. The overall mean ( SD) scores of the patients was 7.78  3.8. Knowledge score was 4.90  3.34; attitude 2.03  0.95 and practice 0.840.76, with maximum possible scores for knowledge, attitude and practice patient being 18, 4 and 3 respectively. Conclusion: The KAP scores of the patients were low. This suggests the need for educational interventions to improve the knowledge, attitude and practices of the diabetes patients. (Rawal Med J 2008;33:8-11).

With the ongoing pandemic of COVID-19 having caught the world almost unaware millions of people across the globe are presently grappling to deal with its acute effects . Our previous experience with members of the same corona virus family (SARS and MERS) which have caused two major epidemics in the past albeit of much lower magnitude , has taught us that the harmful effect of such outbreaks are not limited to acute complications alone .Long term cardiopulmonary, glucometabolic and neuropsychiatric complications have been documented following these infections .In the given circumstance it is therefore imperative to keep in mind the possible complications that may occur after the acute phase of the disease subsides and to prepare the healthcare system for such challenges.

COVID-19 is a highly contagious disease, which has human-to-human transmission through droplet and contact. It is commonly manifested as fever, dry cough, myalgia, and dyspnoea; the severity of this disease may range from mild, severe to a critical-illness. Currently, there is no definitive treatment or vaccine for COVID-19. The only proven form of management is isolation and supportive care. Therefore, nurses have a pivotal role to play in its management. This evidence-based comprehensive literature review provides the role of nurses in the management of patients with COVID-19, which starts from the initial assessment and triaging, sample collection, care of patients with mild-to-moderate symptoms, care of the critically-ill patient, and care of the dead body.

OBJECTIVE: To study the phenomenon of cyberchondria and related worries about health among individuals without any diagnosed medical condition. . METHODS: The survey-based, cross-sectional study was conducted from January to July 2018 in the twin cities of Rawalpindi and Islamabad, Pakistan, and comprised graduates of either gender aged at least 35 years with access to internet and means of use, and with no current diagnosed medical condition. The self-reporting Cyberchondria Severity Scale was used data-collection along with a demographic sheet. SPSS 21 was used for data analysis. RESULTS: Of the 150 subjects, 90(60%) were men and 60(40%) were women. A total of 40(26.6%) subjects had low level of cyberchondria, while 35(23.3%) experienced a higher level of it. Mean scores of men on total CSS were slightly higher than those of women (p>0.05). Men also scored higher on compulsion, distress, excessiveness and reassurance subsclaes (p>0.05 each), whereas women scored slightly higherthan men on 'mistrust of medical profession' subscale (p>0.05). No significant gender differences werefound on cyberchondria and its subscales (p>0.05 each). CONCLUSIONS: Doctors / health professionals may benefit from the findings by focussing on their patients who use internet as a major source of medical information.

Recent advances in the field of endodontics have greatly improved the outcome and success rate of dental materials. For last three decades, there has been great interest in the development of bioactive dental material with the ability to interact and induce surrounding dental tissues to promote regeneration of pulpal and periradicular tissues. As these bioactive materials are mainly based on calcium silicates, they are also referred to as Calcium Silicate materials. The first material introduced was Mineral Tri-oxide Aggregate, which, due to its favourable biological properties, gained importance initially. However, later, due to its drawbacks, liked is colouration, long setting time and difficult manipulation, several modifications were done and newer bioactive materials, such as Biodentine, BioAggregate, Endosequence, Calcium-Enriched Mixture etc., were developed. The main applications of these materials are for pulp capping (direc t/indirec t), pulpotomy, perforation repair, resorption defects, apexogenesis and as retrograde filling materials, apexification and endodontic sealers. This review discusses the various types of bioactive materials, their composition, setting mechanism, and literature evidence for current applications.

Objective: To examine the level of satisfaction with specific dimensions of nursing care in an effort to provide quality improvement knowledge that will lead to understand and identify the principle drivers to patient satisfaction. Methods: This cross-sectional study was conducted at District Headquarter Hospital Dera Ismail Khan, from July 1, 2006 to August 31, 2006. In the description of nursing care, we have used a Questionnaire regarding satisfaction which was administered by the investigator in line with Henderson’s basic nursing care model.. Six dimensions of care were selected for examination. Results: Total 153 eligible patients were identified and invited for interview through questionnaire. Out of these, 122 patients agreed to participate. Overall, patients had a variable experience of nursing care; 45 % patients were satisfied with care provided, while 55 % were partially dissatisfied. Among 6 dimensions of care, 94 % liked nursing practice of keeping privacy of patients. When asked about behavior, 90 % patients were not feeling comfortable talking to nurses. Only 10 % felts nurses were excellent. 84 % patients had negative experiences as they observed nurses were not attentive to their needs, particularly at night. The same percentage also had negative perception with respect to physical care. Overall, the data showed that patients’ expectations were not sufficiently met Conclusion: Nursing care is a key determinant of overall patient satisfaction during hospital admission. Patients’ comments suggest that number of concerns must be addressed. The nurses need to know what factors influence patient satisfaction, if we must improve the quality of health care. (Rawal Med J 2007;32:28-30)

Immature necrotic permanent tooth presents a distinctive challenge for the endodontist. Various treatment modalities have been employed to create hard tissue barrier at the apex, which includes non-vital pulp therapy with calcium hydroxide, apexification with mineral trioxide aggregate, pulp revascularisation and regeneration. Regenerative endodontics is a novel modality which involves physiological replacement of the damaged structures of tooth like dentin, root and cells of the pulp-dentin complex. Numerous published case reports have revealed increased dentinal wall thickness, continued root development and apical closure, but there is still lack of sound scientific evidence regarding histological nature of the type of tissue. The current literature review was planned to summarise the evidence regarding the treatment of immature necrotic permanent teeth by regenerative endodontic procedures.

Patellar metastasis is an exceptionally rare manifestation of skeletal metastasis, attributed to the patella's limited red marrowcontent and sparse vascularity. Patellar metastases have been most frequently reported in lung and renal carcinomas,whereas patellar involvement from prostate adenocarcinoma is exceedingly uncommon. Recognition of such unusual sitesis important, as delayed diagnosis may result in pain, restricted mobility, and pathologic fracture. This case adds to thelimited literature on patellar metastasis from prostate adenocarcinoma and highlights the value of whole-body Ga-68 PSMAPET/CT in detecting rare sites of skeletal metastasis that may influence staging, prognosis, and clinical management.Keywords: prostate adenocarcinoma, patellar metastasis, Gallium-68 PSMA PET/CT.

Chronic pain syndromes, such as fibromyalgia (FM) and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), represent a significant global health burden. Their etiology is complex and multifactorial, encompassing central sensitization, autonomic dysfunction, immune dysregulation, and mitochondrial abnormalities. Lifestyle medicine emphasizes predominantly plant-based nutrition, physical activity, nocturnal restorative sleep, stress regulation, and social connectedness. It offers a structured evidence-based strategy for managing fibromyalgia and ME/CFS. First, anti-inflammatory, nutrientdense diets modulate systemic inflammation, mitochondrial function, and neuroimmune activity. Then, graded exercise and mind–body practices alleviate widespread pain, persistent fatigue, and impaired functional capacity. Next, sleep optimization combined with cognitive-behavioural strategies effectively targets non-restorative sleep; and finally, peer support enhances social connectedness. Integrating these elements into individualized, multidisciplinary programmes, offers a holistic framework to address the core mechanisms of FM and ME/CFS while empowering patients to improve function and quality of life. This mini-review synthesizes contemporary evidence and identifies research and clinical opportunities, focusing on anti-inflammatory and antioxidant diets, neuro-nutritional approaches, nutraceuticals, the gut–brain axis, graded exercise therapy, mind–body practices, and cognitive-behavioural interventions. Keywords: Fibromyalgia, ME/CFS, chronic fatigue syndrome, lifestyle medicine, plant-based diet, gut-brain axis.

Objective: To identify socioeconomic and clinical factors associated with chronic otitis media and hearing loss. Method: The cross-sectional study was conducted at PNS Shifa Hospital, Karachi, from January 1 to June 30, 2024, and comprised patients of either gender aged 10-75 years having chronic otitis media in one ear. A detailed past medical and surgical history was obtained along with demographic data and history of bilateral chronic otitis media disease. Evaluation of chronic otitis media was done using high-resolution computed tomography of temporal bone pneumatisation. Data was analysed using SPSS 27. Results: Of the 46 patients with mean age 40.96±15.613 years (range: 12-72 years), 32(69.6%) were male 14(30.4%) were female. Chronic otitis media was found more prevalent in male and Punjabi population. Hypo-pneumatisation and hearing loss were more common and significantly associated with chronic otitis media. Majority of the patients belonged to rural areas, and were uneducated. Hearing loss was associated with low socioeconomic status. Hearing loss was not associated with age and gender. Conclusion: Chronic otitis media was found to be a leading cause of avoidable deafness. Key Words: Hearing loss, Ethnicity, Middle ear infection, Otitis media, Temporal bone, social class, Low socioeconomic status, Urban population, Rural population, Hearing loss.

This brief communication defines, describes and delineates the field of obstetric obesity. It lists the various challenges that a woman living with obesity may face during her obstetric career, in a solution-oriented manner. The authors call for greater awareness, and for teamwork, while managing obstetric obesity in a person-centred manner. Keywords: Antenatal care, diabetes, obesity, overweight, pregnancy, PIH, person centred care, VTE.

Neglected tropical diseases (NTDs) are an umbrella term that represents 20 major diseases, as classified by the World Health Organisation (WHO), that disproportionately affect the marginalised communities of tropical and subtropical areas.1 These are also referred to as ancient diseases of poverty. They impose an immense human, social, and economic burden on over one and a half billion people worldwide. This article underscores the successes and challenges of the WHO 2021-2030 roadmap, and the latest epidemiological data, offering a comprehensive overview of the global elimination efforts to combat NTDs. The key focuses of the World Health Organisation’s (WHO) NTDs 2021-2030 roadmap are to achieve a 90% reduction in the percentage of people requiring interventions, eliminate at least 1 NTD in 100 countries, and eradicate 2 NTDs by 2030.1 There has been remarkable progress in the fight against NTDs that demonstrates the efficacy of current interventions. By December 2023, 50 countries had successfully eliminated at least one NTD, marking the halfway point toward the WHO 2030 target of 100 countries.2 The number of people requiring interventions for NTDs also decreased by 80 million from 2020 to 2021. Still, the speed of decline falls short of the 2030 targets. The most recent epidemiological data presents a picture of the suffering that NTDs continue to inflict. Examining specific NTDs further emphasizes the urgency of the situation as concluded in Table 1. The control and elimination of NTDs are hindered by a complex interplay of obstacles and challenges. Weak health systems in endemic regions hinder efficacy due to poor data recording, inadequate drug logistics, and insufficient monitoring.3 Many initiatives depend on international donors, making them vulnerable to changing global priorities and economic crises. In conflict zones, healthcare disruption, lack of government ownership, population displacement, and insecurity obstruct intervention implementation.4 Several countries struggle to adopt WHO's multisectoral approaches due to limited coordination and resources.5 Community perceptions can affect participation in mass drug administration. Additionally, climate change alters transmission patterns and expands affected areas. NTD control demands urgent targeted action. Prioritizing high-burden countries, strengthening surveillance, integrating programs into national health systems, and ensuring sustainable funding are critical. Addressing social determinants like water and sanitation remains essential. National ownership must align efforts with local needs. Enhancing research capacity and fostering international collaboration will accelerate innovations. A unified global response is imperative—not just ethically, but to achieve true health equity.

Objective: To examine the efficacy of Stephen Brooks’ strategy of hypnotherapy for smoking cessation among male young adults. Method: The quasi-experimental study was conducted from March to May 2024 at Lahore School of Behavioural Sciences, UOL, Lahore, and comprised males aged 18-26 years from private universities of Lahore, Pakistan, who were smoking 'Capstan' cigarettes, and had a relative who had died from smoking-related illness. Smoking Cessation Motivation Questionnaire was used to check the motivation among the participants to quit smoking, whereas the Cigarette Dependence Scale was used to record the cigarette dependence scores before and after the intervention. Uptime-downtime induction and staircase induction techniques were used for inducing trance, which was followed by the intervention for smoking cessation. The intervention comprised three sessions based on the Stephen Brooks model. Data was analysed using SPSS V 29.0.1. Results: There were 8 males with mean age 22.54+/-2.87 years. The intervention had a significant impact in favour of smoking cessation (p<0.001). Motivation to quit smoking had a significant negative correlation with scores of cigarette dependence scale (p<0.05). Conclusion: Evidence confirmed the efficacy of Stephen Brooks’ hypnotherapy strategy for smoking cessation among male young adults. Key Words: Effectiveness, Stop smoking, Hypnosis, Trance, Hypnotic induction.

Thyrotoxic Periodic Paralysis (TPP) is a rare condition associated with hyperthyroidism, particularly in young males. This report presents the case of a 20-year-old male with TPP complicated by decreased bone mineral density (BMD). While TPP is primarily a neuromuscular disorder characterised by hypokalaemia-induced periodic paralysis, this case highlights the less-recognised impact of prolonged hyperthyroidism on bone metabolism, resulting in significant bone loss. The patient was treated with potassium supplementation, antithyroid therapy, and alendronate sodium to address bone metabolism. This case underscores the importance of comprehensive management in TPP, emphasising early diagnosis and incorporation of bone health monitoring to mitigate long-term complications such as osteoporosis. Keywords: Thyrotoxic Periodic Paralysis; Graves' disease; Hypokalaemia; Bone metabolism disorder.

Objective: To assess the prevalence and severity of stress level and burnout among trainee anaesthesiologists at two different stages of training. Method: The prospective, cross-sectional study was conducted at the Anaesthesia Department of the Aga Khan University Hospital, Karachi, from December 2020 to June 2021, and comprised individuals of either gender receiving training for the Fellowship of the College of Physicians and Surgeons Pakistan. They were divided into two groups based on their length of training period. Group J included trainees before the IMM exam but only with 6-18 months of training, and Group S included trainees after the IMM exam with 30t-42 months of training. The Perceived Stress Scale and Maslach Burnout Inventory were used to measure stress and burnout. Data was analysed using SPSS 25. Results: Of the 99 subjects with mean age 27.81±2.50 years, 58(58.6%) were female and 41(41.4%) were male. There were 58(58.6%) subjects in Group J compared to 41(41.4%) in Group S. Of the total, 50(50.5%) subjects were associated with private-sector hospitals, while 49(49.5%) were working in the public sector. Overall stress was moderate 19.74±6.66 and burnout was in the low range 17.02±9.36. In Group J, 12(20.7%) subjects had high stress compared to 5(12.2%) in Group S. There was a significantly higher level of stress and burnout in those working in the private sector than those in the public sector (p=0.001). Conclusion: Stress and burnout were found to be highly-prevalent among anaesthesia trainees, particularly in the earlier stages of training. Key Words: Stress, Burnout, Anaesthesia trainee, FCPS.

Objectives: Supratentorial intraventricular tumours (SIVTs) represent rare and surgically demanding subset of intracranial neoplasms, characterized by heterogeneous pathology, deep anatomical location, and significant perioperative risk. Due to their low prevalence, robust outcome-data and evidence-based surgical guidelines remain scarce. This study evaluated clinical characteristics, surgical outcomes, and predictors of adverse events in a large single-center cohort. Method: A retrospective study was conducted on patients operated for SIVTs between April 2010 - April 2025. The data was collected between November 2025 - January 2026. Presenting complaints, radiological and surgical details, and postoperative complications were analyzed. Functional outcomes were assessed using the modified Rankin Scale (mRS). Multivariate logistic regression identified predictors of gross total resection (GTR) and postoperative ventriculoperitoneal shunt (VPS) dependence. Survival analysis was performed using Kaplan-Meier methods. RESULTS: A total of 170 patients were included (mean age of 32.4 ± 15.7 years; 31(18.2%) were children). Headache 129(75.9%), nausea 68(40.0%), and vomiting 65(38.2%) were the most common presenting symptoms. Favourable preoperative mRS of 0-1 was noted in 133(79.6%) patients. Lateral ventricular tumours comprised 95(56%) of cases. GTR was achieved in 87/147(59.2%) patients. Postoperative complications occurred in 52/145(35.9%), including meningitis 9(6.2%), hydrocephalus 9(6.2%), and seizures 6(4.1%). No statistically significant predictors were identified for these complications. Multivariate logistic regression demonstrated that temporal transcortical- transventricular approach (OR 9.04; p=0.041) and low-grade tumours (OR 9.48; p=0.006) were independent predictors of GTR. Hydrocephalus at presentation showed a strong trend toward need of postoperative VPS (OR 7.68; p=0.054). During median follow-up of 13.8 months, recurrence was observed in 22.7% with a thirty-day mortality of 4.2%, both significantly worse in children and high-grade tumours. CONCLUSIONS: Surgery for SIVTs carries meaningful risk but achieves favourable outcomes in most patients. Tumour grade and surgical approach are the strongest determinants of GTR, while preoperative hydrocephalus may guide anticipatory VP shunt planning. These findings can inform surgical decision-making and preoperative counselling in this rare tumour subset.

Medicine, today, grapples with newer challenges, newer concerns, and newer contests. One such condition is obesity. Emerging as a major pandemic, obesity impacts not only individuals, but societal health as well. Considered a chronic endocrine disease, with significant lifestyle determinants, it needs sustained endocrine and lifestyle modification for control. This requires a lifelong, or infinite attitude and approach towards weight maintenance.1 In this editorial, we take academic inspiration from Simon Sinek’s book ‘The Infinite game’, and glean actionable insights from his treatise.2 These aim to assist persons living with obesity, as well as their care givers and health care professionals, navigate the complexity and confusion that obesity often creates. We reflect upon two rubrics shared by Sinek, to prepare meaningful models that can help manage obesity. CONTINUE...