Low and middle-income countries (LMICs) hold the majority of disease burden attributed to major depressive disorder (MDD). Despite this, there remains a substantial gap for access to evidence-based treatments for MDD in LMICs like Pakistan. Measurement-based care (MBC) incorporates systematic administration of validated outcome measures to guide treatment decision making and is considered a low-cost approach to optimise better clinical outcomes for individuals with MDD but there is a paucity of evidence on the efficacy of MBC in LMICs.

This protocol highlights a randomized trial which will include Pakistani outpatients with moderate to severe major depression.

Participants will be randomised to either MBC (guided by schedule), or standard treatment (guided by clinicians’ judgement), and will be prescribed with paroxetine (10–60mg/day) or mirtazapine (7.5–45mg/day) for 24 weeks. Outcomes will be evaluated by raters blind to study protocol and treatment.

National Bioethics Committee (NBC) of Pakistan has given full ethics approval. The trial is being conducted and reported as per recommendation of the CONSORT statement for RCTs.

With increasing evidence from high-income settings supporting the effectiveness of MBC for MDD, it is now necessary to explore its feasibility, utility. and efficacy in low-resource settings. The results of the proposed trial could inform the development of a low-cost and scalable approach to efficiently optimise outcomes for individuals with MDD in Pakistan.

None Declared

Bipolar disorder (BD) is a source of marked disability, morbidity, and premature death. There is a paucity of research on personalized psychosocial interventions for BD, especially in lowresource settings. A previously published pilot randomized controlled trial (RCT) of a Culturally adapted PsychoEducation (CaPE) intervention for BD in Pakistan reported higher patient satisfaction, enhanced medication adherence, knowledge and attitudes towards BD, and improvement in mood symptom scores and health-related quality of life measures compared to treatment-as-usual (TAU).

This protocol describes a larger multicentre RCT to confirm the clinical and cost-effectiveness of CaPE in Pakistan.

A multicentre individual, parallel arm, RCT of CaPE in 300Pakistani adults with BD. Participants over the age of 18, with adiagnosis of bipolar I and II and who are currently euthymic, will berecruited from seven sites including Karachi, Lahore, Multan, Rawalpindi,Peshawar, Hyderabad and Quetta. Time to recurrence will be the primaryoutcome assessed using Longitudinal Interval Follow-up Evaluation(LIFE). Secondary measures will include mood symptomatology, qualityof life and functioning, adherence to psychotropic medications, andknowledge and attitudes towards BD.

Full ethics approval has been received from National Bioethics Committee (NBC) of Pakistan and Centre for Addiction and Mental Health (CAMH), Toronto, Canada. The study has completed sixty-five screening across the seven centres, of which forty-eight participants have been randomised.

A successful trial will lead to rapid implementation of CaPE in clinical practice, not only in Pakistan, but also in other low-resource settings including those in high-income countries, to improve clinical outcomes, social and occupational functioning, and quality of life in South Asian and other minority patients with BD.

None Declared

Depression is a global public health problem with highest rates in women in low income countries including Pakistan. Paediatricians may be a resource to help with maternal depression. Little is known in low income countries about the prevalence of depression and its social correlates in mothers of children attending paediatric clinics.

Using cross-sectional design consecutive women attending the paediatric clinic were screened using the Edinburgh Postnatal Depression Scale (n=185). Women scoring 12 or more (n=70) and a random sample of low scorers (n=16) were interviewed using the Clinical Interview Schedule Revised (CIS-R) to confirm the diagnosis of depression, the Oslo scale was used to measure social stress and EQ-5D for health related quality of life.

The prevalence of maternal depression was 51%. The mean age of the sample was 26 years. Depressed mothers were more likely to be living in a joint family household, they were less educated and they and their husbands were less likely to be employed. The depressed mothers had more financial difficulties and they were more likely to sleep hungry during the last month due to financial problems. The depressed mothers had less social support and poorer quality of life compared to non depressed mothers.

Maternal depression in this health care setting is high and it is associated with social stress and poor social support. Paediatric appointments may be an opportunity for care and care delivery for maternal depression.

Female patients tend to be more often diagnosed with ADHD inattentive subtype. Many of these females deny an earlier childhood history of hyperactivity or disruptive behaviours and hence may have been clinically overlooked in childhood, while their male counterparts may have presented with ADHD combined subtype which tends to be more easily identified and diagnosed.

Participants will learn about gender differences in ADHD diagnosis and epidemiology.

To examine gender differences in the age of first diagnosis of ADHD in a clinical population.

The study sample consisted of 118 males and 61 females (ages 17–69). Each patient was evaluated and diagnosed by an experienced psychiatrist. Clinical measures (administered by a trained psychometrist) included the CAARS (self and observer versions), BRIEF (self and informant versions), CAADID (history and structured interview), ASRS, CPT, Beck Anxiety and Beck Depression Inventories. Patients were referred by family physicians to a large out-patient metropolitan psychiatry program specializing in ADHD. Information regarding childhood diagnosis was collected retrospectively during the clinical interview.

In this study the mean age of diagnosis (ADHD) for males was 31.2 years versus 32.1 for females. Neither t-test (p = 0.44) nor non-parametric testing using Mann-Whitney U Test (p = 0.67) showed any statistical differences between the two groups.

In the present study there were no difference in the mean age of first diagnosis between male and female subjects. In the present study Further studies are needed to clarify this question. Selection factor may have been a factor in these results.

A disaster is a consequence of natural hazards and terrorist acts, which have significant potential to disrupt the entire wireless communication infrastructure. Therefore, the essential rescue squads and recovery operations during a catastrophic event will be severely debilitated. To provide efficient communication services, and to reduce casualty mortality and morbidity during the catastrophic events, we proposed the Tethered Balloon technology for disaster preparedness, detection, mitigation, and recovery assessment.

The proposed Tethered Balloon is applicable to any type of disaster except for storms. The Tethered Balloon is being actively researched and developed as a simple solution to improve the performance of rescues, facilities, and services of emergency medical communication in the disaster area. The most important requirement for rescue and relief teams during or after the disaster is a high quality of service of delivery communication services to save people’s lives.

Using our proposed technology, we report that the Tethered Balloon has a large disaster coverage area. Therefore, the rescue and research teams are given higher priority, and their performance significantly improved in the particular coverage area.

Tethered Balloon features made it suitable for disaster preparedness, mitigation, and recovery. The performance of rescue and relief teams was effective and efficient before and after the disaster as well as can be continued to coordinate the relief teams until disaster recovery. (Disaster Med Public Health Preparedness. 2018;12:222–231)

Poor auditory speech perception in geriatrics is attributable to neural de-synchronisation due to structural and degenerative changes of ageing auditory pathways. The speech-evoked auditory brainstem response may be useful for detecting alterations that cause loss of speech discrimination. Therefore, this study aimed to compare the speech-evoked auditory brainstem response in adult and geriatric populations with normal hearing.

The auditory brainstem responses to click sounds and to a 40 ms speech sound (the Hindi phoneme |da|) were compared in 25 young adults and 25 geriatric people with normal hearing. The latencies and amplitudes of transient peaks representing neural responses to the onset, offset and sustained portions of the speech stimulus in quiet and noisy conditions were recorded.

The older group had significantly smaller amplitudes and longer latencies for the onset and offset responses to |da| in noisy conditions. Stimulus-to-response times were longer and the spectral amplitude of the sustained portion of the stimulus was reduced. The overall stimulus level caused significant shifts in latency across the entire speech-evoked auditory brainstem response in the older group.

The reduction in neural speech processing in older adults suggests diminished subcortical responsiveness to acoustically dynamic spectral cues. However, further investigations are needed to encode temporal cues at the brainstem level and determine their relationship to speech perception for developing a routine tool for clinical decision-making.

To examine the associations between serum 25-hydroxyvitamin D (25(OH)D), dietary Ca intake and presence of the metabolic syndrome (MetS).

A stratified cluster sample of a population aged 18–75 years from the Victorian Health Monitor survey.

Non-institutionalized adults living in private dwellings in Victoria, Australia.

Adults (n 3404) with complete data and without type 1 or type 2 diabetes.

Adjusted for sociodemographic factors, physical characteristics and dietary covariates including Ca intake, every 10 nmol/l increase in serum 25(OH)D was significantly associated with decreased odds of MetS (adjusted odds ratio (AOR)=0·85, 95 % CI 0·80, 0·89; P<0·001). Relative to the low 25(OH)D tertile (median 33 nmol/l), there was a progressive decrease in odds of MetS that reached significance with the high 25(OH)D tertile (median 77 nmol/l; AOR=0·35, 95 % CI 0·26, 0·48; P<0·001). Every 500 mg/d increase in Ca intake adjusted for 25(OH)D did not reduce odds of MetS (AOR=0·81, 95 % CI 0·66, 1·06; P=0·141) but approached significance if unadjusted for 25(OH)D in the final model (AOR=0·81, 95 % CI 0·64, 1·02; P=0·073). No significant effect was obtained for tertiles of Ca intake. However, Ca and vitamin D tertile combinations suggested a beneficial effect of high Ca (median 1233 mg/d) only at low and medium 25(OH)D. The high 25(OH)D tertile was associated with significantly decreased odds of MetS regardless of Ca intake.

A high vitamin D status significantly reduced the odds of MetS. A high Ca intake may have a similar favourable outcome but only at lower circulating concentrations of 25(OH)D.

This study aimed to compare the interpretations of temporal bone computed tomography scans by an otologist and a radiologist with a special interest in temporal bone imaging. It also aimed to determine the usefulness of this imaging modality.

A head and neck radiologist and an otologist separately reported pre-operative computed tomography images using a structured proforma. The reports were then compared with operative findings to determine their accuracy and differences in interpretations.

Forty-eight patients who underwent pre-operative computed tomography scans in a 30-month period were identified. Six patients were excluded because complete operative findings had not been recorded. Positive and negative predictive values and accuracy of the anatomical and pathological findings were calculated for 42 patients by both reporters. The accuracy was found to be less than 80 per cent, except for identification of the tegmen and lateral semicircular canal erosion. Overall, there was no significant difference in interpretations of computed tomography scans between reporters. There was a slight difference in interpretation for tympanic membrane retraction, facial canal erosion and lateral semicircular canal fistula and/or erosion.

Pre-operative computed tomography scanning of the temporal bone is useful for predicting anatomy for surgical planning in patients with chronic otitis media, but its reliability remains questionable.

A systematic review was performed to evaluate the role and effectiveness of head bandages after routine elective middle-ear surgery.

Studies that compared the effectiveness of head bandage use after elective middle-ear surgery (e.g. myringoplasty, mastoidectomy and cochlear implantation) were identified using the following databases: Ovid Medline and Embase, the Ebsco collections, the Cochrane Library, PubMed, and Google Scholar. An initial search identified 71 articles. All titles and abstracts were reviewed. Thirteen relevant articles were inspected in more detail; of these, only five met the inclusion criteria. These included three randomised, controlled trials, one retrospective case series and one literature review.

The three randomised, controlled trials (level of evidence 1b) showed no statistically significant differences in post-operative outcomes (in terms of complications) associated with head bandage use in middle-ear surgery. This finding was supported by the retrospective case series involving patients undergoing cochlear implantation.

Current available evidence shows no advantage of head bandage use after middle-ear surgery. Head bandages may not be required after routine, uncomplicated middle-ear surgery.

There has been a surge in the popularity of loom bands amongst children in recent months. These small rubber bands, which can be woven together to make colourful bracelets and necklaces, have become the world's most popular toy. Foreign bodies in paediatric nasal and aural cavities are a common presentation to ENT units across the country. Whilst most are removed without incident, foreign bodies in nasal passages represent a potential risk for inhalation, leading to airway obstruction.

This paper reports a case series of four paediatric patients who presented with a loom band associated foreign body in the nose over a 7-day period at a district general hospital in Scotland.

Although the four cases presented were resolved without the need for general anaesthetic, the ever-soaring prevalence and popularity of loom bands necessitates a degree of caution and vigilance from parents, retailers and manufacturers alike. We believe there is an urgent need for greater public awareness of their potential hazards.

The January 2010 earthquake affected many services in Haiti, including health care. After the disaster, top-down response from international sources seemed like the only solution. While the existing health system was fragile, opportunities likely existed for incorporating bottom-up approaches in the capital and other cities, such as Cap Haitien in the North.

The study aims to: (1) identify available local health-related resources; (2) examine how these were, or were not, utilized in response efforts; and (3) evaluate the level of coordination among health delivery groups, particularly preparedness and recovery.

This case study included 11 key informant interviews at two hospitals (six at Justinian and five at Milot) and an organizational analysis of cooperation among 16 health-related organizations operating in northern Haiti. Disaster preparedness and recovery data for the health-sector organizations were obtained using a validated survey instrument and the Program to Analyze, Record, and Track Networks to Enhance Relationships (PARTNER) tool that uses the principles of Social Network Analysis (SNA) to elucidate the makeup of collaborative relationships.

During the response phase, command-and-control approaches from international healthcare organizations had a roll given the numbers of people affected and the overwhelmed local response capabilities. Pre-disaster vulnerabilities limited response capacity. Even during response, opportunities existed for integrating established groups. Generally, this was not a model utilized by international organizations, although some examples were present.

The external infusion of money, priorities, and forces potentially may harm the current system, rather than build upon it. International aid provides free health services beyond treatment of earthquake-related injuries, taking the place of some service functions of the Haitian system. Eventually, this could erode aspects of the Haitian health system. Alternative models of aid may better incorporate and integrate existing structures. Disaster planning is linked intrinsically to strengthening the health system as a whole.