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BackgroundCoronavirus disease (COVID-19) pandemic has spread to 198 countries, with approximately 2.4 million confirmed cases and 150,000 deaths globally as of April 18. Frontline healthcare workers (HCWs) face a substantially higher risk of infection and death due to excessive COVID-19 exposure. This review aimed at summarizing the evidence of the physical and mental health impacts of COVID-19 pandemic on health-care workers (HCWs).MethodsWe used the Arksey O’Malley framework to conduct a scoping review. A systematic literature search was conducted using two databases: PubMed and Google Scholar. We found 154 studies, and out of which 10 met our criteria. We collected information on the date of publication, first author’s country, the title of the article, study design, study population, intervention and outcome, and key findings, and divided all research articles into two domains: physical and mental health impact.ResultsWe reviewed a total of 154 articles from PubMed (126) and Google Scholar (28), of which 58 were found to be duplicate articles and were excluded. Of the remaining 96 articles, 82 were excluded after screening for eligibility, and 4 articles did not have available full texts. Ten full-text articles were reviewed and included in this study.Our findings identified the following risk factors for COVID-19-related health impact: working in a high-risk department, diagnosed family member, inadequate hand hygiene, suboptimal hand hygiene before and after contact with patients, improper PPE use, close contact with patients (≥ 12 times/day), long daily contact hours (≥ 15 h), and unprotected exposure. The most common symptoms identified amongst HCWs were fever (85%), cough (70%), and weakness (70%). Prolonged PPE usage led to cutaneous manifestations and skin damage (97%), with the nasal bridge (83%) most commonly affected site. HCWs experienced high levels of depression, anxiety, insomnia, and distress. Female HCWs and nurses were disproportionately affected.ConclusionThe frontline healthcare workers are at risk of physical and mental consequences directly as the result of providing care to patients with COVID-19. Even though there are few intervention studies, early data suggest implementation strategies to reduce the chances of infections, shorter shift lengths, and mechanisms for mental health support could reduce the morbidity and mortality amongst HCWs.

This study aims to assess the impact of six evidence-based Waterpipe (WP)-specific pictorial health warnings (HWs) placed on the WP device on puffing behavior, toxicant exposure, subjective smoking experiences, harm perception, motivation and intention to quit among young WP smokers in Florida. In a crossover experiment, a total of 100 WP smokers completed two 45-minute ad-libitum WP smoking sessions (without HW vs. with HW on the device) after a 12-hour abstinence. Exhaled Carbon Monoxide (eCO) was measured before and after each session, while puff topography was recorded throughout the smoking session. Additionally, participants completed survey questionnaires before and after the WP smoking sessions to assess subjective smoking experiences, harm perception, motivation to quit, and intention to quit. Study participants had a mean age of 22.5 years (SD = 3.4), and most (56.6%) were male.The mean e-CO boost (34.16 vs. 26.58) (p = 0.006) was higher in the no-HW condition compared to the HW condition. Differences were also observed between the two conditions for puff topography. For example, median smoking time (46.4 min vs 45.3 min; p < 0.001), median puffing time (4.35 min vs. 4.22 min; 0.004), average puff duration (3.13 sec vs. 2.90 sec; 0.029), and the total number of puffs (95.0 vs. 84.0; 0.039) were lower in the HW compared to no-HW conditions. Subjective measures also demonstrated differences between the two conditions, including greater suppression of the urge to smoke (14.98 vs. 7.51; p < 0.001), reduced puff liking (4.01 vs. 3.63; p = 0.010), and reduced puff satisfaction (4.11 vs. 3.65; p = 0.009) following exposure to HW compared to no-HW conditions. Motivation to quit (p = 0.058), intention to quit (p = 0.659), and harm perception (p = 0.301) increased after smoking the WP with HW; however these were not statistically significant. Using an evidence-based approach, a large sample size for clinical studies, and an efficient and sensitive within-subject design, this study demonstrates that pictorial HWs on WP devices effectively reduce smoking behavior, toxicant exposure, and subjective experiences while increasing harm perception, intention, and motivation to quit WP smoking.

Diabetic retinopathy (DR) is a major reason of blindness around the world. The ophthalmologist manually analyzes the morphological alterations in veins of retina, and lesions in fundus images that is a time-taking, costly, and challenging procedure. It can be made easier with the assistance of computer aided diagnostic system (CADs) that are utilized for the diagnosis of DR lesions. Artificial intelligence (AI) based machine/deep learning methods performs vital role to increase the performance of the detection process, especially in the context of analyzing medical fundus images. In this paper, several current approaches of preprocessing, segmentation, feature extraction/selection, and classification are discussed for the detection of DR lesions. This survey paper also includes a detailed description of DR datasets that are accessible by the researcher for the identification of DR lesions. The existing methods limitations and challenges are also addressed, which will assist invoice researchers to start their work in this domain.

IntroductionChildhood mortality in the emergency setting is disproportionately high in low-income and middle-income countries (LMIC), with limited research dedicated to improving timely interventions, especially for critically ill children during transport. To perform essential prehospital paediatric research, there is a need for a tailored consent process, which reflects the specific needs and concerns of participants in this challenging research context.ObjectiveThe objective is to prospectively investigate stakeholder perceptions and preferences regarding consent processes for a specific paediatric ambulance-based telemedicine trial.MethodsExploratory qualitative study design using face-to-face semistructured interviews and focus group discussions. Data were analysed using thematic analysis. Participants included healthcare providers (paediatric telemedicine physicians and emergency medical technicians) and parents of children who required emergency transportation in Karachi, Pakistan.Results47 participants, ranging from 19 to 47 years old, were involved in in-depth interviews or focus group discussions. The participants comprised 29 healthcare workers and 18 parents. Among them, 9 were women and 38 were men. Expressing diverse attitudes towards different consent methods, the majority recommended a prospective written informed consent approach to build trust and provide legal protection. Participants understood the situational incapacity that occurs in emergency settings, emphasised the importance of keeping the consent brief and recommended a subsequent contact in 2–3 days after the emergency transport to reconfirm consent and answer any questions.ConclusionOur interpretation of the findings revealed that participants preferred a staged consent process for telemedicine trials in LMIC paediatric emergency settings.

Background Traditional, instructor led, in-person training of CPR skills has become more challenging due to COVID-19 pandemic. We compared the learning outcomes of standard in-person CPR training (ST) with alternative methods of training such as hybrid or online-only training (AT) on CPR performance, quality, and knowledge among laypersons with no previous CPR training. Methods We searched PubMed and Google Scholar for relevant articles from January 1995 to May 2020. Covidence was used to review articles by two independent researchers. Effective Public Health Practice Project (EPHPP) Quality Assessment Tool was used to assess quality of the manuscripts. Results Of the 978 articles screened, twenty met the final inclusion criteria. All included studies had an experimental design and moderate to strong global quality rating. The trainees in ST group performed better on calling 911, time to initiate chest compressions, hand placement and chest compression depth. Trainees in AT group performed better in assessing scene safety, calling for help, response time including initiating first rescue breathing, adequate ventilation volume, compression rates, shorter hands-off time, confidence, willingness to perform CPR, ability to follow CPR algorithm, and equivalent or better knowledge retention than standard teaching methodology. Conclusion AT methods of CPR training provide an effective alternative to the standard in-person CPR for large scale public training.

Introduction: This study aimed to analyze exhaled breath condensate (EBC) for 8-oxoguanine (8-oxoGua), an oxidative stress biomarker among waterpipe (WP) smokers. Methods: In a within-subject pre-post exposure design, thirty waterpipe smokers completed two 45 min laboratory sessions. EBC was analyzed for 8-oxoGua before and after WP smoking. Median differences between time points (pre vs. post) were assessed using the Wilcoxon sign rank test, with significance defined as p < 0.05. Results: The analysis included 59 WP smoking sessions. Participants had a median age of 24 years (IQR: 21–25), with 62.1% being female. Most had a bachelor’s degree or less (62.1%), and over half were students (55.2%), while 34.5% were employed. The average age for first WP use was 18.6 years, with participants reporting a median of three WP smoking sessions per month. Results indicate a median increase in 8-oxoGua among participants from 5.4 ng/mL (IQR: 8.8) before the smoking session to 7.6 ng/mL after (IQR: 15.7; p < 0.001). Conclusions: This study is the first to examine 8-oxoGua in EBC. Findings provide strong evidence of WP smoking’s contribution to oxidative stress in the airways. It justifies the use of EBC to study the exposure to markers of oxidative stress with emerging tobacco use methods such as the waterpipe.

Objective The objective of this study is to explore the perception of teachers, parents and students’ regarding implementation of a school-based lifesaving skills program and help predict potential barriers and solutions. Methods This qualitative exploratory study was conducted in Karachi, Pakistan, from December 2020- to October 2021. We included students, teachers, and parents of secondary (grades VIII, IX, and X) and higher secondary level students (grades XI and XII) in Karachi, Pakistan's public and private schools and colleges. We selected one public, two semi-private, and two private schools. We recruited students, teachers, and parents through convenience sampling. We conducted fifteen focus group discussions (FGDs) with the students, six FGDs with the teachers, and eighteen in-depth interviews (IDIs) with parents. We transcribed the data from audio recordings and translated it into the English language. Finally, we manually analyzed the data using thematic analyses. Results This study found that bystanders' main barriers to performing lifesaving skills are lack of knowledge, fear of legal involvement, fear of hurting the patient by incorrect technique, lack of empathy among community stakeholders, and gender bias. However, the participants had a positive and supportive attitude toward implementing lifesaving skills training in schools. They suggested starting student training in the early teenage years, preferred medical staff as trainers, and suggested frequent small sessions in English/Urdu both or Urdu language and training via theory and practical hands-on drills. Furthermore, the training was proposed to be integrated into the school curriculum to make it sustainable. Finally, the government needs to support the program and make the legal environment more conducive for bystanders. Conclusion This study identified the significant barriers to performing lifesaving skills in an emergency in a low- and middle-income country (LMIC). The participants supported implementing a national lifesaving skills program in schools and colleges. However, the participants expressed that support is needed by the government for sustainability, integrating lifesaving skills into the school curriculum, providing legal support to the bystanders, and creating awareness among the general public.

Background This study aimed to document the evolution of perceptions of frontline healthcare workers (FHCW) regarding their well-being and the quality of health systems' response to the COVID-19 pandemic over four months in Pakistan. Methods We conducted this prospective longitudinal qualitative study during the four months (June–September 2020) coinciding with the peak and trough of the first wave of Pakistan's COVID-19 pandemic. We approached frontline healthcare workers (physicians and nurses) working in emergency departments (ED) in two hospitals using the WhatsApp group of the Pakistan Society of Emergency Physicians (PSEM). Participants were asked to self-record their perception of their wellness and their level of satisfaction with the quality of their hospitals' response to the pandemic. We transcribed, translated, and analysed manually using MAXQDA 2020 software and conducted the thematic analysis to identify themes and sub-themes. Results We invited approximately 200 FHCWs associated with PSEM to participate in the study. Of the 61 who agreed to participate, 27 completed the study. A total of 149 audio recordings were received and transcribed. Three themes and eight sub-themes have emerged from the data. The themes were individual-level challenges, health system-level challenges, and hope for the future. Sub-themes for individual-level challenges were: fear of getting or transmitting infection, feeling demotivated and unappreciated, disappointment due to people’s lack of compliance with COVID-19 protocols, physical exhaustion, and fatigue. For the healthcare system, sub-themes were: Infrastructure, logistics, management, and communications response of the hospital/healthcare system and financial stressors. For sub-themes under hope for the future were the improved disease knowledge and vaccine development. The overall perceptions and experiences of FHCWs evolved from fear, grief, and negativity to hope and positivity as the curve of COVID-19 went down. Conclusion This study shows that the individuals and systems were not prepared to deal with the challenges of the COVID-19 pandemic. The findings highlight the challenges faced by individuals and health systems during the wake of the Covid-19 pandemic. The healthcare workers were emotionally and physically taxed, while the health systems were overwhelmed by COVID-19. The overall perceptions of FHCWs evolved with time and became negative to positive as the curve of COVID-19 went down during the first wave of COVID-19 in Pakistan.

Objectives Trauma registries are essential tools for improving trauma care quality and efficiency, but many fail to capture long-term patient-reported outcome measures (PROMs). Focusing on these outcomes is crucial for understanding the extent of disability patients experience and identifying potential post-discharge interventions to optimize recovery. Studies reflecting the experience from low- and middle-income countries in this area are limited. Therefore, we aim to develop a digital trauma registry in Pakistan to prospectively capture patient-reported outcome measures at one, three, six, and twelve months post-injury. Methods We will develop and implement a digital trauma registry at two tertiary care facilities in Karachi, Pakistan: Aga Khan University Hospital and Jinnah Postgraduate Medical Center. The registry will include all admitted adult trauma patients (≥ 18 years). Data collection will be conducted digitally using tablets, with mortality, level of disability, functional status, and quality of life as primary outcomes. Follow-up data will be collected through telephone interviews with patients and caregivers. We will employ descriptive statistics to summarize participant’s socio-demographic and clinical characteristics. Additionally, we will perform survival analysis using Kaplan-Meier curves and Cox proportional hazard models and utilize mixed-effects linear regression to adjust for potential confounders for primary outcomes. Discussion The trauma registry will fill the current gap in knowledge regarding long-term outcomes among trauma patients in low- and middle-income countries (LMICs). This study will delineate future direction for capturing post-discharge data, enhancing our understanding of recovery, and informing the design of interventions aimed at improving long-term outcomes.

ObjectivesA diverse set of trauma scoring systems are used globally to predict outcomes and benchmark trauma systems. There is a significant potential benefit of using these scores in low and middle-income countries (LMICs); however, its standardized use based on type of injury is still limited. Our objective is to compare trauma scoring systems between neurotrauma and polytrauma patients to identify the better predictor of mortality in low-resource settings.MethodsData were extracted from a digital, multicenter trauma registry implemented in South Asia for a secondary analysis. Adult patients (≥18 years) presenting with a traumatic injury from December 2021 to December 2022 were included in this study. Injury Severity Score (ISS), Trauma and Injury Severity Score (TRISS), Revised Trauma Score (RTS), Mechanism/GCS/Age/Pressure score and GCS/Age/Pressure score were calculated for each patient to predict in-hospital mortality. We used receiver operating characteristic curves to derive sensitivity, specificity and area under the curve (AUC) for each score, including Glasgow Coma Scale (GCS).ResultsThe mean age of 2007 patients included in this study was 41.2±17.8 years, with 49.1% patients presenting with neurotrauma. The overall in-hospital mortality rate was 17.2%. GCS and RTS proved to be the best predictors of in-hospital mortality for neurotrauma (AUC: 0.885 and 0.874, respectively), while TRISS and ISS were better predictors for polytrauma patients (AUC: 0.729 and 0.722, respectively).ConclusionTrauma scoring systems show differing predictability for in-hospital mortality depending on the type of trauma. Therefore, it is vital to take into account the region of body injury for provision of quality trauma care. Furthermore, context-specific and injury-specific use of these scores in LMICs can enable strengthening of their trauma systems.Level of evidenceLevel III.