Pakistan Journal of Health Sciences

Postoperative Outcomes of Interlay Versus Underlay Tympanoplasty: A Randomized Controlled Trial

2026-10-01T06:03:12+00:00

One of the main causes of conductive hearing loss is still chronic otitis media with tympanic membrane perforation. Surgical repair aims to restore hearing and membrane integrity. Objective: To compare the postoperative anatomical and functional outcomes of interlay versus underlay tympanoplasty techniques in patients with chronic otitis media. Methods: This randomized controlled trial was carried out at the Department of Otorhinolaryngology, Shaikh Zayed Medical Complex, Lahore, from January to June 2025 after approval by the institutional ethical review board. Consecutive Sampling of Patients with Chronic Otitis Media and Large Central Tympanic Membrane Perforations. At the conclusion of the trial period, 78 patients who had both substantial central tympanic membrane perforation and chronic otitis media were included. Post-enrolment, participants were randomly assigned to either underlay or interlay tympanoplasty using simple randomization to minimize allocation bias. Standardized endoscopic procedures using temporalis fascia grafts were performed under general anesthesia. Outcomes were assessed at 12 weeks, and 62 patients completed follow-up and were analyzed. Results: Analysis was done on 62 patients in total. The baseline features of the groups were similar (p>0.05). The mean air-bone gap was 25.08 ± 4.07 dB before surgery, compared to 26.27 ± 4.03 dB (p=0.254). At 12 weeks, postoperative air–bone gap improved to 15.95 ± 4.03 dB versus 11.79 ± 3.70 dB (p < 0.001), with greater mean hearing gain in the interlay group (14.48 ± 4.48 dB vs 9.14 ± 3.12 dB; p<0.001). Conclusions: Interlay tympanoplasty resulted in significantly greater hearing improvement than the underlay technique, with comparable anatomical success.

Effect on Thrombolysis in Myocardial Infarction Flow by Stent Post-Dilatation in Patients with ST-Segment-Elevated Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

2026-10-01T06:03:15+00:00

The common intervention for ST-segment elevation myocardial infarction is primary percutaneous coronary intervention (PCI). Post-dilatation of the stent is commonly used to obtain the best stent expansion, but its effect on end-tidal thrombolysis of myocardial infarction flow and microvascular perfusion is not clear in low-resource settings, e.g., Pakistan. Objectives: The study will assess the effectiveness of stent post-dilatation on end-TIMI flow in patients undergoing primary PCI in STEMI, and the relationship between stent post-dilatation and no-reflow and in-hospital outcome measures. Methods: The research was a prospective cohort study conducted in the department of cardiology, Sheikh Zayed Medical College/hospital, Rahim Yar Khan, in a span of four months. The non-probability consecutive sampling included 193 patients with STEMI undergoing primary PCI. The operator randomly assigned the patients to two groups: post-dilatation (n = 96) and no post-dilatation (n=97). Clinical measurements, angiographic, and echocardiographic measurements were obtained. Results: TIMI 3 flow during the last time was also achieved in 68.7/80.4% of the post-dilated group and non-post-dilated group, respectively (p=0.036). There was a higher incidence of no-reflow or slow-flow post-dilatation (19.8% vs 9.3, p=0.029). Mean ejection fraction was lower with post-dilatation (45.1 ± 7.8% vs 47.3 ± 7.0%, p=0.046). Suboptimal final TIMI flow was predicted by post-dilatation alone (OR 2.03, 95% CI 1.05–3.91, p=0.034). Conclusions: Post-dilatation stent in this Pakistani STEMI cohort was associated with lower final TIMI 3 flows and greater no-reflow, and was an independent predictor of suboptimal epicardial reperfusion after primary PCI.

Comparison of Thyroid Dysfunction in Women with or Without Pregnancy-Induced Hypertension: A Comparative Cross-Sectional Study

2026-10-01T06:02:28+00:00

Pregnancy-induced hypertension has been linked with altered thyroid function, yet local comparative data remain limited. Objective: To compare the prevalence of thyroid dysfunction in women with or without pregnancy-induced hypertension. Methods: This comparative cross-sectional study was performed at the Department of Obstetrics and Gynecology, Combined Military Hospital, Multan, for six months. A total of 208 pregnant females, 18-45 years of age, with singleton pregnancies beyond 20 weeks of gestation were enrolled. Out of these, 104 had pregnancy-induced hypertension, and 104 were normotensive. Women with chronic hypertension or pre-existing thyroid disease were excluded. Serum free T3, T4, and TSH were measured from a single laboratory, and thyroid dysfunction was defined using standard biochemical cut-offs. Quantitative variables are summarized as median with interquartile ranges and compared using the Mann-Whitney U test. In contrast, categorical variables are compared using the chi-square test, with p<0.05 taken statistically significant. Results: The median age was 22.5 (21-39) years, and 65.4% (n=136) were below 30 years of age. Baseline characteristics, including age, gestational age, gravidity, and obesity, were comparable between the groups. Overall, thyroid dysfunction was identified in 15.9% (n=33) of the participants, with subclinical hypothyroidism 6.7% (n=14), being the most frequent abnormality. Women with pregnancy-induced hypertension had a significantly higher proportion of thyroid dysfunction compared to normotensive women (25.0% vs. 6.7%, p<0.001), and all categories of thyroid dysfunction were more frequent in the hypertensive group. Conclusion: Thyroid dysfunction is more prevalent among women with pregnancy-induced hypertension.

Comparison of Efficacy of Topical Finasteride Versus Topical Minoxidil in Treatment of Androgenetic Alopecia

2026-10-01T06:02:26+00:00

Comparative monotherapy data on topical finasteride versus topical minoxidil in androgenetic alopecia remain limited. Objective: To compare the efficacy and safety of topical finasteride 0.25% and topical minoxidil 5% in adults with androgenetic alopecia. Methods: This assessor-blinded, parallel-group randomized comparative clinical trial was conducted at the Department of Dermatology, Sheikh Zayed Medical College and Hospital, Rahim Yar Khan, from 21-03-2024 to 20-09-2024. Fifty-eight participants aged 18-45 years were randomized by an opaque-slip lottery method to topical finasteride once nightly or topical minoxidil twice daily for 24 weeks. Normality was assessed with the Shapiro-Wilk test. Categorical variables were compared using Pearson chi-square or Fisher exact tests, between-group continuous outcomes with the Mann-Whitney U test, and within-group baseline versus week-24 changes with paired t-test or Wilcoxon signed-rank test as appropriate. Results: Baseline characteristics were comparable between groups. Responder rate was higher with minoxidil than finasteride (13/29, 44.8 vs 2/29, 6.9; p=0.001). Hair density improved significantly within both groups from baseline to week 24. The between-group difference in week-24 hair density was not statistically significant (p=0.184), but percent change in hair density (p=0.020) and Global Photographic Assessment Score (p=0.046) favored minoxidil. Adverse effects were mild and comparable, and no sexual side effects were reported. Conclusions: Over 24 weeks, topical minoxidil achieved a higher response rate and better photographic improvement than topical finasteride, although absolute week-24 hair density did not differ significantly between groups. Both treatments were generally well tolerated.

Comparison of Whole Blood Impedance Platelet Aggregation Using Adenosine Diphosphate and Arachidonic Acid Between Smokers and Non-Smokers

2026-10-01T06:03:11+00:00

Smoking enhances platelet aggregability and related ischemic and vascular events. However, data on whole blood impedance platelet aggregation in relation to both smoking duration and daily cigarette consumption separately in apparently healthy Pakistani adults are limited. Objective: To assess the association of smoking duration and number of cigarettes smoked daily with increased platelet aggregation and find out factors independently predicts increased aggregation. Methods: A comparative cross-sectional study was done at the Department of Pathology, Lahore General Hospital. Sixty-five smokers and non-smokers each (a total of 130) were enrolled using non-probability convenience sampling. History and venous samples were taken, and whole blood platelet aggregometry was performed using Arachidonic Acid and Adenosine diphosphate. Chi-Square and Logistic Regression tests were applied, p-value<0.050 was considered significant. Results: 84.6% of non-smokers had normal aggregation with both agonists. The percentage of individuals with enhanced aggregation increased as the duration of smoking and the number of daily cigarettes increased. Analysis showed a statistically significant association between abnormal aggregation and increased duration of smoking and number of daily cigarettes. Logistic Regression showed duration of smoking as an independent predictor of increased aggregation with ADP only (p-value=0.006, Exp(B)=15). The number of cigarettes smoked daily was not an independent predictor after adjusting for confounders. Results for age and hematocrit were not significant. Conclusions: Cigarette smoking is associated with increased platelet aggregation. Longer duration of smoking independently predicts high ADP-induced platelet aggregation after adjusting for age and hematocrit. The number of cigarettes smoked daily is not an independent predictor of increased aggregation.

Prevalence and Predictors of Depression and Anxiety among Women Using Hormonal and Non-Hormonal Contraceptives: A Comparative Cross-Sectional Study

2026-10-01T06:03:13+00:00

There is still debate over the psychological effects of hormonal contraceptives, and there is little data from low-resource countries like Pakistan. Objectives: To assess the prevalence and predictors of depression and anxiety among women using hormonal and non-hormonal contraceptives. Methods: A comparative cross-sectional study was carried out at the Department of Obstetrics and Gynecology, Aziz Fatimah Hospital, Faisalabad, from May to September 2025. A total of 376 women were recruited through non-probability consecutive sampling. Data were collected using a pre-developed questionnaire, which included sociodemographic characteristics, obstetric history, and the PHQ-9 and GAD-7 scales. Associations were examined by chi-square tests, and multiple logistic regression was applied to identify independent predictors. Results: The rates of clinically significant depression and anxiety were found to be 68.1% and 70.7%, respectively. Both conditions were strongly linked to contraceptive method (p<0.001), with combined oral contraceptive users presenting the highest rates (83.0% for both) and implant users the lowest (27.7% and 21.7%). Regression analysis showed that being employed was a protective factor for depression (AOR = 0.50). After controlling for sociodemographic variables, hormonal contraceptives were not an independent predictor of depression; nevertheless, the best predictor of anxiety (AOR = 2.92) was medical reasons for using contraceptives. Conclusions: Women using hormonal contraceptives, particularly combined oral and injectables, had increased rates of anxiety and depression. Following the adjustment, there was no independent correlation between the usage of contraceptives and depression. The most significant psychological risk factors were higher parity, unemployment, and medical reasons for using contraceptives.

Functional Outcome of Intramedullary Nailing vs Plating in Tibial Shaft Fracture

2026-10-01T06:01:48+00:00

Fractures of the tibial shaft are typical long-bone injuries that are accompanied by a high rate of morbidity. Surgical procedures such as intramedullary nailing and plate fixation are common, although there is controversy over the most effective approach owing to variations in healing rates and complication rates. Objective: To compare the functional outcomes of intramedullary nailing and plate fixation in patients with tibial shaft fractures. Methods: This was a prospective comparative study conducted in the Department of Orthopedics, Hayatabad Medical Complex, Peshawar, from March 2023 to August 2024. 110 patients aged between 18 and 60 years were enrolled. Both closed fractures and Gustilo-Anderson type I and II open fractures were considered eligible. Pathological fracture, polytrauma with intensive care, neurovascular injury, Gustilo type III open fracture, or previous surgery of the affected limb in patients were excluded. Results: A total of 110 patients were included. Mean time to union was significantly shorter in the intramedullary nailing group than in the plating group (16.2 ± 3.8 vs. 19.1 ± 4.5 weeks; p=0.001). Overall, union was achieved in 92.7% of patients. Excellent to good functional outcomes were higher in the intramedullary nailing group compared with the plating group (83.6% vs. 72.7%), although the difference was not statistically significant (p=0.180). Conclusions: Intramedullary nailing offers earlier fracture union and faster recovery, while both techniques provide comparable functional outcomes. The choice of fixation should be individualized based on patient and fracture characteristics.

Effect of Nutritional Rehabilitation on Neurodevelopmental Status of Children with Severe Acute Malnutrition (SAM)

2026-10-01T06:01:52+00:00

Severe acute malnutrition (SAM) is a major public health problem in children, contributing to high morbidity, mortality, and impaired neurodevelopment. While nutritional rehabilitation improves survival and physical growth, its effect on cognitive, motor, language, and social development remains inadequately explored. Objective: To evaluate the impact of nutritional rehabilitation on neurodevelopmental outcomes in children aged 1–6 years with SAM. Methods: This prospective observational study was conducted over six months in the Department of Paediatrics of Khairpur Medical College, Sindh. A total of 150 children aged 1–6 years diagnosed with SAM (according to WHO criteria: weight-for-height Z-score < −3 SD or mid-upper arm circumference < 11.5 cm) were enrolled. Participants received eight weeks of standardized nutritional rehabilitation, including therapeutic feeding and micronutrient supplementation, along with management of associated complications. Anthropometric parameters and neurodevelopmental domains (cognitive, motor, language, and social) were assessed at baseline and post-intervention. Data were analysed using SPSS version 23, applying paired t-tests and chi-square tests, with p<0.05 considered significant. Results: Significant improvements were observed in weight (7.3 ± 1.4 vs. 9.2 ± 1.6 kg), MUAC (10.4 ± 0.9 vs. 12.5 ± 1.1 cm), and weight-for-height Z-score (−3.42 ± 0.51 vs. −2.18 ± 0.47) (p < 0.001). Neurodevelopmental scores improved significantly across all domains (p < 0.001). The proportion of children with normal development increased from 20.0% to 53.3%, while moderate developmental delay decreased from 33.3% to 14.7%. Conclusions: Nutritional rehabilitation significantly improves both growth and neurodevelopment in children with SAM. Early identification and timely intervention are crucial for optimal developmental recovery.

Faculty Readiness for Interprofessional Education at Public Sector University in Pakistan

2026-10-01T06:02:46+00:00

Interprofessional Education (IPE) promotes collaborative practice and improves patient-centered care. Faculty engagement is critical for implementation; however, evidence from public-sector health sciences universities in Pakistan remains limited. Objective: To assess faculty attitudes and readiness toward IPE, compare mean attitude and readiness scores across disciplines and demographic groups, and examine correlations with teaching experience. Methods: An observational cross-sectional study was done among 250 faculty members from Medicine, Dentistry, Surgery, Basic Sciences, Nursing, Pharmacy, and Allied Health disciplines. Data were collected using a structured questionnaire including reverse-coded items. Descriptive statistics summarized Likert-scale responses. One-way ANOVA compared mean scores across disciplines and age groups, independent t-tests assessed gender differences, and Pearson’s correlation examined associations between attitude, readiness, and teaching experience (p<0.05). Results: Over 80% of the participants agreed with items showing that IPE fosters cooperation, communication, and mutual respect among health professionals, while those reverse-coded received agreement levels of ≤10%. There was a statistically significant difference in the readiness level based on discipline (p=0.04), whereby nursing and medicine had higher mean scores, while pharmacy and basic sciences had lower mean scores. Gender (p=0.06) and age (p=0.056) did not show statistically significant differences. A weak, yet significant correlation was noted between attitude and readiness (r=0.279, p<0.001). Teaching experience correlated moderately and positively with both attitude (r=0.622) and readiness (r=0.716) (p<0.001). Conclusion: Faculty demonstrate positive attitudes toward IPE, with disciplinary and experience-related variations influencing readiness.

Comparison of Outcomes of High-Dose Versus Low-Dose Caffeine Citrate in the Treatment of Apnea of Prematurity: A Randomized Clinical Trial

2026-10-01T06:02:43+00:00

Apnea of prematurity (AOP) is common in preterm neonates, and the optimal caffeine citrate dose remains uncertain. Objective: To compare outcomes of high-dose versus low-dose caffeine citrate for AOP. Methods: This open-label randomized clinical trial (NCT06905496) was conducted at Nishtar Hospital, Multan, from January to October 2025 after approval (7028) and written consent. Preterm neonates 32 to less than 37 weeks’ gestation with AOP were randomized 1:1. High-dose caffeine citrate comprised a 40 mg/kg loading dose followed by 20 mg/kg/day for 7 days; low-dose comprised 20 mg/kg then 10 mg/kg/day for 7 days. The primary outcome was extubation failure within 48 hours; secondary outcomes were apnea episode frequency, need and duration of mechanical ventilation, duration of oxygen therapy, and in-hospital mortality. Statistical Package for the Social Sciences version 26.0 was used with a probability value (p) < 0.05. Results: One hundred fourteen neonates were allocated (57 per group). Baseline characteristics were similar except for sex distribution (p=0.036). Apnea episodes were lower with high-dose therapy (10.74 ± 2.91 vs 12.89 ± 2.20), mean difference −2.16 (95% confidence interval −3.12 to −1.20; p<0.001). Mechanical ventilation requirement was similar (38.6% vs 43.9%; p=0.568). In ventilated neonates (47), extubation failure was reduced (27.3% vs 56.0%; p=0.047) and ventilation duration was shorter (median 2 vs 4 days; p=0.027). Oxygen therapy duration (median 10 vs 11 days; p=0.555) and mortality (5.3% vs 8.8%; p=0.463) did not differ. Conclusion: In conclusion, high-dose caffeine reduced apnea burden and improved extubation outcomes without differences in oxygen days or in-hospital mortality.

Frequency, Patterns, and Associated Factors of Postoperative Complications After Pediatric Strabismus Surgery: A Prospective Observational Study

2026-10-01T06:02:50+00:00

Strabismus surgery is a common intervention in pediatric ophthalmology aimed at restoring ocular alignment and improving binocular vision. While effective, the procedure carries a risk of postoperative complications that may affect long-term outcomes. Objectives: To determine the frequency, pattern, and associated factors of postoperative complications in children undergoing strabismus surgery during follow-up assessments. Methods: This prospective, observational cohort study was conducted from Jan 2023 to May 2025 at the Department of Ophthalmology, Hayatabad Medical Complex (HMC), Peshawar, Pakistan. Institutional ethical approval was obtained before commencement of the study. Written consent from the legal guardian (s) was also obtained for all children included in the study before their inclusion. Results: A total of 34 (28.3%) children developed postoperative complications. Amongst which the most common complications were under correction (5.8%), overcorrection (4.2%), diplopia/loss of binocular fusion (2.5%), postoperative inflammation (2.5%), and granuloma formation (2.5%). 9 children (7.5%) required reoperation because of recurrence or severe residual deviation. Each patient had an average of 2.1 ± 0.6 extraocular muscle procedures. Intraoperative complications were uncommon and occurred in 4 children (3.3%), including scleral thinning without perforation and minor muscle hemorrhage. Conclusions: Postoperative complications were observed in a considerable proportion of children undergoing strabismus surgery in this cohort. There were several clinical and operative variables, such as older age, complex strabismus, surgery, intraoperative complications, and amblyopia, which were linked to higher postoperative risk.

Risk Factors, Complications, and Outcome of Early and Late Onset Pre-Eclampsia in a Tertiary Care Hospital

2026-10-01T06:01:54+00:00

Early-onset preeclampsia is linked to a greater number of maternal and neonatal complications than late-onset preeclampsia. Objective: To evaluate the risk factors, maternal complications, and neonatal outcomes associated with early- versus late-onset preeclampsia in a tertiary care setting. Methods: A 4-month comparative analytical study was performed at the Gynecology Ward at Civil Hospital, Karachi, from October 2025 to January 2026. The study included 90 pregnant women with hypertensive disorders of pregnancy who were recruited (45 EO-PE and 45 LO-PE). Women aged between 15 and 40 years old who spontaneously conceived without artificial insemination were eligible. SPSS version 26 was used to analyze the data. Associations were investigated using descriptive statistics. Associations were evaluated using binary logistic regression; a p-value <0.05 was considered statistically significant. Results: The mean age of women with early-onset preeclampsia was 28.6 ± 5.4 years compared with 29.2 ± 5.1 years among those with late-onset preeclampsia, while an interpregnancy interval >10 years was also more frequent among eligible multiparous women with early-onset preeclampsia (56.5% vs. 24.0%; p=0.013).. EO-PE was correlated with more maternal complications, such as abruption placentae (15.6% vs. 2.2, p=0.020), HELLP syndrome (11.1% vs. 0%, p=0.010), and eclampsia (8.9% vs. 0%, p=0.040). Neonates born to EO-PE mothers were found to have lower birth weights (2.25 =0.45 kg vs. 2.78 =0.38 kg, p=0.001) and increased NICU admissions (46.7% vs. 20%, p=0.007). EO-PE was found to increase the odds of both maternal complications and NICU admission. Conclusion: Preeclampsia in the first trimester is linked with increased maternal and neonatal risks compared to those experienced in the latter.

Perinatal Mortality in Booked and Unbooked Pregnancies: An Analytical Cross-Sectional Study

2026-10-01T06:02:29+00:00

Perinatal mortality remains a major public health challenge in developing countries, where inadequate antenatal care contributes significantly to preventable fetal and early neonatal deaths. Objectives: To compare perinatal mortality between booked and unbooked women presenting to a tertiary care hospital and to identify factors associated with adverse perinatal outcomes. Methods: This analytical cross-sectional study was conducted at Imran Idrees Teaching Hospital, Sialkot, from January to August 2025 after ethical approval (MRC/IRB/24043). A total of 310 women with singleton pregnancies beyond 28 weeks of gestation were enrolled through non-probability consecutive sampling and categorized as booked or unbooked based on antenatal care status. Data were analyzed using SPSS version 25. Quantitative variables were expressed as Mean ± SD, and qualitative variables as n (%). Chi-square test was used for comparison. A p-value ≤0.050 was considered statistically significant. Results: Out of 310 participants, 158 (51.0%) were booked, and 152 (49.0%) were unbooked. Overall perinatal mortality was 30 (9.7%). Mortality was significantly higher among unbooked women compared to booked women [24 (15.8%) vs 6 (3.8%); p=0.001]. Birth asphyxia (5.2%) and neonatal sepsis (3.9%) were the leading causes. Maternal age, parity, previous caesarean section, and mode of delivery were not significantly associated with perinatal mortality (p>0.050). Conclusions: Perinatal mortality was significantly higher among unbooked women. Strengthening antenatal booking services may reduce preventable perinatal deaths.

Comparison of the Efficacy of Once Weekly Dose of Trelagliptin Versus Once Daily Dose of Vildagliptin on the Levels of HbA1c in Type-2 Diabetes Patients

2026-10-01T06:02:24+00:00

Once-weekly dipeptidyl peptidase-4 inhibition represents a potential strategy to reduce dosing burden while maintaining glycaemic efficacy in type 2 diabetes mellitus. Objectives: To compare once-weekly trelagliptin with once-daily vildagliptin in adults receiving background metformin, using change in glycated hemoglobin and attainment of glycated hemoglobin below 7%, with secondary assessment of body weight and body mass index. Methods: A randomized, open-label, parallel-group clinical trial was conducted at a tertiary care hospital. Adults aged 30 to 60 years with type 2 diabetes mellitus, glycated hemoglobin 7.5% to 9.5% on metformin, were randomized by lottery to trelagliptin 100 mg once weekly or vildagliptin 50 mg once daily for 12 weeks. Independent-samples t testing and chi-square or Fisher's exact testing were applied as appropriate. Prespecified stratified analyses were performed for the efficacy endpoint. Results: A total of 102 participants were randomized, and 93 completed follow-ups. Baseline characteristics were comparable. Glycated hemoglobin change was −1.24±0.78% with trelagliptin and −1.52±0.67% with vildagliptin, mean difference 0.28% (95% CI −0.02 to 0.58), p=0.068. Target attainment was 53.2% versus 63.0%, p=0.336. Weight and body mass index changes did not differ significantly, and stratified analyses showed no significant subgroup effects. Conclusions: No statistically significant difference was detected between once-weekly trelagliptin and once-daily vildagliptin in glycaemic improvement over 12 weeks in patients. Short-term changes in body weight and body mass index were also not significantly different between the two treatment groups.

Impact of Induction Timing on Maternal and Neonatal Outcomes in Term and Late Preterm Prelabor Rupture of Membranes: A Prospective Observational Study

2026-10-01T06:02:23+00:00

Prelabor rupture of membranes (PROM) is a significant obstetric complication predisposing a woman to chorioamnionitis, neonatal sepsis, and placental abruption. The optimal timing of labour induction, particularly in late preterm pregnancies, remains a clinical challenge requiring a balance between infectious risk and prematurity-related morbidity. Objectives: To evaluate the association between early versus late induction of labour and maternal and neonatal outcomes in women with term and late preterm PROM. Methods: This prospective study was conducted at the Combined Military Hospital, Malir, from October 2023 to September 2024. A total of 111 women with singleton pregnancies ≥34 weeks with confirmed PROM were grouped as term (≥37 weeks) or late preterm (34–36+6 weeks) and stratified by induction timing: early (6–12 hours) or late (>12 hours). Maternal and neonatal outcomes were analyzed using SPSS version 27.0, with Chi-square and Fisher’s exact tests applied; p<0.05 was considered significant. Results: Of 111 participants, term PROM was present in 59 (53.2%) and late preterm PROM in 52 (46.8%); 61 (55.0%) underwent early and 50 (45.0%) late induction. Spontaneous vaginal delivery was the predominant mode (63.1%). Late preterm PROM was associated with significantly worse neonatal outcomes than term PROM across all parameters, while induction timing had no significant effect on any maternal or neonatal outcome. Conclusions: Gestational age at membrane rupture is a stronger determinant of neonatal morbidity than induction timing. Thus, we cannot claim that early induction is definitively 'safe'—only that it was not associated with worse outcomes in this specific cohort.

The Efficacy of Oral Labetalol Versus Oral Methyldopa for the Management of Pregnancy-Induced Hypertension: A Quasi-Experimental Study

2026-10-01T06:02:45+00:00

Hypertensive disorders of pregnancy are a common complaint faced by obstetricians in routine clinical practice. Careful monitoring of both the mother and fetus is a crucial part of treatment. Numerous anti-hypertensive drugs are available in the market. Objectives: To compare the efficacy and safety of oral labetalol versus oral methyldopa in the management of pregnancy-induced hypertension during the third trimester. Methods: This quasi-experimental comparative study was carried out in the Department of Obstetrics and Gynecology, Avicenna Hospital, Lahore. Hundred females were enrolled and divided into two groups. Half of the females were prescribed labetalol (Group A), and half were prescribed methyldopa (Group B). After 5 days, the efficacy and safety of the drugs were noted. Data were analyzed in SPSS version 26.0. Results: The mean age of females was 28.62 ± 6.91 years in the labetalol group, while 29.86 ± 6.69 years in the methyldopa group. The mean SBP was reduced from 148.50 ± 4.43 mmHg to 122.00 ± 9.26 mmHg with labetalol and from 148.40 ± 4.99 mmHg to 127.50 ± 14.44 mmHg with methyldopa. Likewise, mean DBP was reduced from 98.10 ± 4.62 mmHg to 73.10 ± 12.37 mmHg with labetalol and from 98.20 ± 4.71 mmHg to 78.60 ± 11.56 mmHg with methyldopa. Target BP was achieved in 42 (84%) with labetalol, while in 30 (60%) females with methyldopa (p<0.05). Hypotension was noted in 4 (8%) females in the methyldopa group only (p<0.005). Conclusion: Labetalol has been proven to be more efficient in controlling blood pressure than methyldopa.

Frequency of Cesarean Section According to the Robson Classification in a Tertiary Care Hospital in Lahore

2026-10-01T06:02:22+00:00

The Robson Ten-Group Classification System (TGCS) uses basic obstetric characteristics to categorize birthing women into ten different groups. The World Health Organization (WHO) recommended TGCS in its 2015 Executive Statement as a standard tool for monitoring and evaluating cesarean section rates at health facilities and national levels. Objectives: To determine the frequency of cesarean section according to Robson’s criteria in the Tertiary care hospital of Lahore. Methods: This descriptive cross-sectional study was conducted in the Department of Gynecology and Obstetrics, Services Hospital, Lahore, from July 2023 to December 2023. A total of 135 women aged 18- 40 years undergoing delivery were selected, and those with major obstetric complications were excluded. Data were collected by non-probability, consecutive sampling. Patients were assessed for Robson classification by the researcher herself, and cesarean section was recorded for each group. Data were analyzed by computer software SPSS version 25.0. Results: Most of the patients, 81 (60.0%), were between 18 and 30 years of age. The frequency of cesarean section was found in 53 (39.3%) patients. Cesarean section rate in different groups (1-10) according to Robson’s classification was found to be 18.2%, 29.2%, 52.9%, 27.3%, 60.0%, 80.0%, 30.0%, 37.5%, 60.0%, and 100.0%, respectively. Conclusions: Robson Groups 3 and 5 were primary contributors to cesarean section rates, followed by Groups 6 and 2. These results underline the importance of the minimization of primary cesarean sections and the encouragement of normal delivery.

Frequency of Return of Spontaneous Circulation After Effective Cardiopulmonary Resuscitation Monitored by End Tidal Carbon Dioxide

2026-10-01T06:02:18+00:00

Cardiac arrest is a critical emergency with high mortality despite advances in resuscitation. Objectives: To determine the frequency of ROSC after effective CPR and to evaluate the role of ETCO₂ monitoring as a predictor of resuscitation outcomes. Methods: This analytical cross-sectional study was conducted in the Department of Emergency Medicine, Central Park Teaching Hospital, Lahore, from May 2024 to September 2024. A total of 127 patients aged 40-70 years who experienced cardiopulmonary arrest were enrolled using non-probability consecutive sampling. CPR was performed with continuous capnography monitoring. Results: The mean age of patients was 56.8 ± 8.5 years; 64.6% were male. The most common cause of arrest was acute myocardial infarction (48.0%), followed by arrhythmias (22.0%), sepsis (16.5%), and respiratory failure (13.5%). ROSC was achieved in 45 patients (35.4%). Patients with ROSC had significantly shorter CPR duration (15.2 ± 5.3minutes vs. 20.6 ± 7 minutes; p<0.001. AnETO₂ ≥ 10mmHg after 20 minutes and an abrupt rise in ETCO₂were strongly associated with ROSC (p<0.001). No significant association was found with gender (p=0.610). Myocardial infarction as the cause of arrest was significantly linked with higher ROSC compared to non-cardiac causes (p=0.004). Conclusions: The frequency of ROSC after CPR was 35.4%. ETCO₂ monitoring was found to be a reliable predictor of resuscitation success, with higher values and abrupt rises strongly associated with ROSC. Shorter CPR duration and cardiac causes of arrest were favorable prognostic factors.

Improvement in Uroflowmetry Parameters After Transurethral Resection of Prostate for Bladder Outlet Obstruction in Benign Prostatic Hyperplasia

2026-10-01T06:02:17+00:00

Benign prostatic hyperplasia (BPH) commonly causes bladder outlet obstruction and lower urinary tract symptoms in older men. Transurethral resection of the prostate (TURP) is a standard surgical option, but the outcome should be assessed objectively. Objectives: To determine changes in uroflowmetry parameters and International Prostate Symptom Score (IPSS) after TURP in BPH. Methods: This prospective before-and-after interventional study was conducted at the Multan Institute of Kidney Diseases, Multan, from February to May 2026. Forty-five consecutive men undergoing TURP for BPH were enrolled. Qmax, Qavg, voided volume, voiding time, time to maximum flow, post-void residual urine (PVR), and IPSS were recorded before surgery and four weeks postoperatively. Paired t-test and McNemar test were applied. Results: Mean age was 67.98 ± 7.18 years, and mean prostate volume was 65.87 ± 17.16 mL. After TURP, Qmax increased from 8.08 ± 1.58 to 19.87 ± 2.35 mL/s and Qavg from 4.32 ± 0.84 to 10.64 ± 1.57 mL/s. PVR decreased from 157.69 ± 41.90 to 37.16 ± 16.10 mL, and IPSS from 24.13 ± 3.96 to 8.20 ± 2.35. All changes were significant (p<0.001). Severe IPSS category decreased from 36 (80.0%) cases to 0, and all patients converted from obstructed to normal flow patterns. Conclusions: TURP significantly improved flow parameters, residual urine, symptom severity, and flow pattern. Uroflowmetry with IPSS is useful for postoperative assessment.

Comparative Analysis of Local Anaesthesia with Two Different Concentrations of Adrenaline in Mandibular Third Molar Extraction: A Quasi-Experimental Study

2026-10-01T06:02:27+00:00

Local anaesthesia is often used in dental procedures to eliminate pain during procedures. Lignocaine mixed with adrenaline is popular because it extends the time of anaesthesia and reduces the drug's absorption into the bloodstream, thus decreasing the risk of toxicity. Objective: To assess the efficacy and cardiovascular effects of a two-per-cent lidocaine solution containing two concentrations of adrenaline, 1:80000 and 1:100000, during the extraction of mandibular third molars. Methodos: A quasi-experimental study was conducted on 50 patients selected for bilateral mandibular third molar surgery. The patients’ sites were equally divided into two groups: Group 1-2% lignocaine with adrenaline concentration of 1:80,000, and Group 2 – 2% lignocaine with adrenaline concentration of 1:100,000. The study recorded the onset and duration of anesthesia, pulse rate, blood pressure, and pain intensity, which was assessed using the Visual Analog Scale (VAS). Data were compiled and analyzed using SPSS version 26. Results: Group 1 (1:80,000) had a longer duration of anesthesia (149.79 ± 18.05 min) than Group 2 (116.82 ± 12.74 min, p=0.001). Time of onset showed minor differences; VAS pain scores were slightly higher in Group 1 (3.5 ± 1.12) than in Group 2 (2.5 ± 1.12, p=0.100). Cardiovascular parameters showed no significant changes. Time of onset showed minor differences. Conclusions: Local anaesthesia with 1:80,000 adrenaline provided a longer duration of anaesthesia compared to 1:100,000 adrenaline, with comparable onset times and pain scores. Both concentrations provide effective anesthesia. 1:100,000 adrenaline is safer for patients with cardiovascular risk.

Prevalence of Intestinal Parasitic Infections in HIV-Positive Patients with Acute Diarrhoea: A Cross-sectional Study

2026-10-01T06:02:20+00:00

Intestinal parasitic infections are one of the primary determinants of morbidity and mortality in people with HIV, especially in resource-limited environments. Objective: To determine the prevalence of intestinal parasitic infections in HIV-positive patients presenting with acute diarrhoea. Methods: This cross-sectional study was conducted at Allama Iqbal Teaching Hospital, Dera Ghazi Khan, from October 2025 to February 2026. A total of 153 HIV-seropositive patients (18–60 years) with acute diarrhoea and CD4 count <200 cells/mm³ were enrolled, and their stool specimens were examined by direct wet-mount microscopy with normal saline and Lugol’s iodine, modified acid-fast (Kinyoun) staining for coccidian parasites, and formal-ether concentration. Data were analysed using SPSS version 25.0. Results: Of 153 patients (mean age 34.8±9.6 years; 74.5% male), intestinal parasitic infection was detected in 68 (44.4%; 95% CI 36.8–52.4). Cryptosporidium spp. was the most prevalent organism (30.1%), followed by Entamoeba histolytica (13.1%), Cystoisospora belli (11.8%) and Blastocystis spp. (9.8%). Infection rates were significantly higher in patients with CD4 <50 cells/mm³ (100%) versus 101–200 cells/mm³ (31.8%) (χ²=19.94, p<0.001), and in WHO clinical Stage IV (75.6%) versus Stage I (14.3%) (χ²=30.57, p<0.001). In multivariable logistic regression, each one-cell/mm³ increase in CD4 count was associated with lower odds of infection (aOR 0.968, 95% CI 0.955–0.982, p<0.001). Conclusions: Intestinal parasitic infections are frequent in HIV-positive patients with acute diarrhoea, with Cryptosporidium species being the most common. Lower CD4 count and advanced WHO clinical stage were the only variables independently associated with infection.

Comparison of Continuous Infusion and Bolus Phenylephrine for Prevention of Spinal-Induced Hypotension in Cesarean Section: A Quasi-experimental Study

2026-10-01T06:02:47+00:00

Cesarean section spinal anesthesia is often associated with maternal hypotension, which causes poor maternal and infant outcomes. Phenylephrine is commonly used as prophylaxis and treatment of spinal-induced hypotension, but the most effective mode of administration, bolus or continuous infusion, is controversial. Objectives: To compare the effectiveness of continuous phenylephrine infusion versus intermittent bolus administration in preventing spinal anesthesia–induced hypotension during elective cesarean section. Methods: A quasi-experimental study was carried out at the Department of Anesthesia, Gulab Devi Teaching Hospital, Lahore. Sixty-six ASA II patients, who had an elective cesarean section, were randomly divided into two groups, namely Group A (infusion, n=33), which received continuous phenylephrine infusion 30mL/hour, and Group B (bolus, n=33), which received 100 µg phenylephrine boluses when required. The data on hemodynamic, maternal side effects, and neonatal outcomes were taken and analyzed with SPSS version 28.0. Results: Continuous infusion resulted in significantly fewer hypotensive episodes (30.3% vs. 54.5%, p<0.001) and lower prevalence of nausea and vomiting (9.1% vs. 21.2%, p<0.004). Reactive hypertension occurred less frequently in the infusion group (3.0% vs. 12.1%, p<0.05). Neonatal outcomes were improved with infusion, including higher umbilical cord pH (7.37 ± 0.05 vs. 7.33 ± 0.06, p<0.002). Conclusion: Phenylephrine infusion was found to be better than bolus dosing in maternal hypotension prevention, reducing adverse maternal outcomes, and neonatal outcomes in cesarean section under spinal anesthesia. Infusion should be regarded as the regimen of choice in clinical practice.

Early Clearance of Lactate and Its Outcome in Septic Patients

2026-10-01T06:01:51+00:00

Sepsis persists as a major cause of in-hospital mortality, with the highest burden in low- and middle-income countries. Early lactate clearance is proposed as a dynamic, low-cost biomarker of tissue perfusion, yet locally generated evidence from Pakistan is scarce. Objectives: To evaluate the frequency of early lactate clearance and its association with 30-day all-cause mortality and multiorgan failure in adults admitted with sepsis. Methods: This prospective cohort study with a 30-day follow-up was conducted in the Department of General Medicine, Jinnah Postgraduate Medical Centre, Karachi (14 October 2025 and 14 January 2026) after ethical approval. A total of 195 adults aged 18–65 years with Sepsis-3-defined sepsis and admission venous lactate >4 mmol/L were enrolled by consecutive sampling. Early lactate clearance was defined as a ≥10% reduction in venous lactate at 6 hours. Outcomes were SOFA-defined multiorgan failure and 30-day mortality. Continuous variables were summarized as median (IQR) after Shapiro-Wilk testing; binary logistic regression & survival analysis were performed. Results: Early lactate clearance occurred in 106/195 (54.4%) patients. Thirty-day mortality was significantly lower with clearance than without (12.3% vs 24.7%; OR 0.43, 95% CI 0.20–0.91; p=0.024), persisting after adjustment (aOR 0.43, 95% CI 0.20–0.94; p=0.035). Multiorgan failure did not differ significantly (17.0% vs 22.5%; OR 0.71, 95% CI 0.35–1.44; p=0.335). Conclusions: Early lactate clearance was associated with significantly lower 30-day mortality in this underpowered exploratory analysis; however, these findings require confirmation in larger adequately powered studies.

Discriminatory Ability of Hemoglobin and Red Cell Indices in Differentiating Iron Deficiency Anemia and Beta-Thalassemia Trait in a Rural Population Of Sindh

2026-10-01T06:02:49+00:00

Anemia is a significant health issue in Pakistan, especially in the rural regions where nutritional deficiencies are prevalent. In resource-constrained environments such as rural Sindh, new diagnostic tests are very expensive. Thus, red cell indices that are readily available and easy to use can provide a viable and cost-effective method of distinguishing the types of anemia. Objective: To assess the most appropriate diagnostic indicators of hemoglobin and red cell distribution indices to distinguish the type of anemia in patients of the rural population of Sindh. Methods: A Cross-sectional descriptive study was conducted at Indus Medical College and Hospital, the University of Modern Sciences, Tando Muhammad Khan, Sindh, Pakistan. 254 patients who were suspected of having anemia were enrolled. The parameters of complete blood count, such as hemoglobin, RBC, MCV, MCH, MCHC, and RDW, were assessed using an automated hematology analyzer. Results: Among 254 participants, 44.90% had normal hemoglobin levels, 20.50% had iron deficiency anemia (IDA), 5.10% had beta thalassemia trait (BTT), 26.40% other etiologies of anemia, and 3.10% severe anemia. The average level of hemoglobin in males (12.26 ± 2.18 g/dL) was much greater than in females (10.58 ± 2.04 g/dL, p<0.001). The discriminatory index of the RBC showed a very good ability to distinguish between IDA and BTT, with MCV, MCH, and RDWI showing significant differences. Conclusion: The red cell distribution indices are accurate, inexpensive, and easily accessible parameters that can be used to distinguish between the various types of anemia in resource-constrained rural areas.

Physiology-Based Individualized PEEP Titration and Its Effect on Respiratory Mechanics and Oxygenation in ARDS: A Prospective Observational Study

2026-10-01T06:02:19+00:00

Acute Respiratory Distress Syndrome (ARDS) has high morbidity and mortality and often requires mechanical ventilation. Bedside, physiology-guided titration of positive end-expiratory pressure (PEEP) may improve lung mechanics, oxygenation, and reduce ventilator-induced lung injury. Objectives: To determine the impact of physiology-based PEEP titration individualized on respiratory mechanics, oxygenation, hemodynamics, and clinical outcome in patients with ventilated ARDS. Methods: This is a pre and post-quasi-experimental study (Jan-Dec 2025) at the Medical and Surgical ICUs of Bahria International Hospital, Lahore. Adult patients with ARDS in need of invasive ventilation were enrolled. PEEP was progressively regulated at the bedside depending on compliance, driving pressure, oxygenation, and imaging. The main outcome measurements consisted of compliance, driving pressure, and PaO2/FiO2 changes, whereas secondary measures were the length of ventilation, ICU hospitalization, barotrauma, and death in the ICU. Results: Among 120 patients (mean age 54.2 ± 14.6 years; 60% male), individualized PEEP titration improved compliance (32.5 ± 6.8 → 38.7 ± 7.2 mL/cmH₂O, p<0.01), reduced driving pressure (15.6 ± 3.4 → 12.8 ± 3.0 cmH₂O, p<0.01), and increased PaO₂/FiO₂ (140 ± 35 → 195 ± 42 mmHg, p<0.01). There were minimal hemodynamic effects. Median ventilation period was 9 days, ICU stay 12 days; barotrauma 5%, ICU mortality 28%. Conclusions: PEEP titration based on physiology and monitored at the bedside is safe, feasible, and effective in enhancing lung mechanics and oxygenation in patients with ARDS, and it should be included in lung-protective ventilation.

Comparison of Occurrence of Placenta Accreta Spectrum in Patients with Previously Operated Elective versus Emergency Lower Segment Caesarean Section: An Analytical Cross-Sectional Study

2026-10-01T06:01:46+00:00

Placenta accreta spectrum (PAS) is a serious obstetric condition characterised by abnormal placental invasion into the uterine wall, leading to severe maternal complications such as massive haemorrhage and hysterectomy. The rising rate of caesarean section has increased the burden of PAS worldwide. Objective: To compare the occurrence of PAS in women with a history of elective versus emergency lower segment caesarean section (LSCS). Methods: This analytical cross-sectional study enrolled 105 women at Jinnah Postgraduate Medical Centre, Karachi, from March to September 2025. Women aged 25–45 years with parity >1, gestation >24 weeks, and a previous caesarean section were recruited by non-probability consecutive sampling and grouped by the mode of the previous LSCS (elective or emergency) as the two primary comparison groups. PAS occurrence was compared between the groups using the chi-square or Fisher’s exact test (p≤0.05). Results: Of 105 women, 24 had a previous elective and 81 a previous emergency LSCS. PAS occurred in 23 of 24 (95.8%) elective versus 70 of 81 (86.4%) emergency cases, a non-significant difference (Fisher’s exact p=0.289). Overall PAS frequency was 88.6%, with percreta predominating (42.9%). Mean maternal age was significantly higher among women with PAS (32.83 ± 3.97 vs 29.19 ± 4.93 years; p=0.001). Conclusions: PAS occurred with high frequency after prior caesarean section, with no significant difference between elective and emergency LSCS. As the study was underpowered for this comparison, the finding is hypothesis-generating; advanced maternal age was significantly associated with PAS, underscoring the primacy of uterine scar burden.

Efficacy of Upper Airway Angle and Glottic Height in Unanticipated Difficult Laryngoscopy Prediction

2026-10-01T06:01:49+00:00

Unanticipated difficult laryngoscopy is a significant problem in airway management and is linked to higher morbidity. Objectives: To determine the diagnostic accuracy of upper airway angle and glottic height to predict unanticipated difficult endotracheal intubation, taking Cormack–Lehane classification as the gold standard. Methods: This study was a cross-sectional research work conducted at Sindh Institute of Urology and Transplantation, Karachi, during the period of six months from 7 August, 2025 to 31^st January, 2026. A sample size of 150 patients aged between 18 and 80 years, subjected to general anesthesia with direct laryngoscopy, was included. The 2 x 2 contingency tables were used to calculate the diagnostic accuracy indices, and the effect modifiers were stratified; an independent t-test was used, where p≤0.05 was regarded as significant. Results: UAA showed a sensitivity of 73.7%, a specificity of 85.7%, a PPV of 63.6%, an NPV of 90.6%, and a total accuracy of 82.7%. The sensitivity of GH was 78.9%, specificity was 78.5%, PPV was 55.6%, NPV was 91.7%, and accuracy was 78.7%. Conclusions: UAA and GH are non-invasive and easy to use and predict difficult laryngoscopy, especially because they show high negative predictive values. These measurements of the anatomy should be considered in the standard airway evaluation to improve preoperative prediction and patient safety.

Rate of Infection in Arthroplasty in Comparison to Surgical Time

2026-10-01T06:01:55+00:00

Surgical site infections (SSIs) and periprosthetic joint infections (PJIs) are among the major complications seen after an arthroplasty procedure; they lead to morbidity, surgical revisions, and medical cost escalation. The operating time has been shown as one of the risk factors for these infections, and hence can be modified by proper intervention. Objective: To determine the rate of surgical site infection in arthroplasty and evaluate its association with operative duration among patients undergoing primary total knee arthroplasty. Methods: From January to June of 2025, this prospective observational cohort study was carried out at the Department of Orthopaedics & Spine Centre, GTTH, Lahore. Included were 94 patients having elective primary total knee arthroplasty. Clinical, perioperative, and demographic information was documented. Using CDC criteria, patients were monitored for ninety days to determine whether surgical site infections had occurred. SPSS version 27.0 was used for statistical analysis. Results: In total, surgical site infections occurred in 8 out of 94 patients (9%). 12% of patients who had surgery for more than 120 minutes had SSI (p=0.07), whereas those who had surgery for less than 120 minutes had no infections. Logistic regression analysis revealed a not statistically significant correlation between an elevated risk of SSI and an operative duration of ≥120 minutes (OR=3.80, p=0.03). Conclusions: After a primary total knee replacement, a longer operating time is linked to a higher risk of surgical site infection. There was a greater chance of postoperative infection in patients whose operations took longer than 120 minutes.

A Decade of Divergence: Climate Change and Health in Pakistan

2026-10-01T06:01:45+00:00

Ten years ago, climate change was still perceived as a risk that could be modelled, mitigated, and planned for, and Pakistan's engagement with the phenomenon was still in the future tense. The "that framing" has not passed into the past decade. From 2016 to 2026, Pakistan shifted from the phase of anticipating health emergencies due to climate change to facing such emergencies on repeat basis; the epidemiological records now enable direct comparison of the current situation with the past. This warming has been very rapid at the end of this period in Pakistan.

The 2025 regional temperature anomalies have been reported as the highest in 65 years of observation in 2025 in Azad Jammu and Kashmir (+1.56°C), Khyber Pakhtunkhwa (+1.29°C) and Gilgit-Baltistan (+1.24°C) in the Government's own Economic Survey for 2025–26 [1].

The increase in glacial melting has also led to an increase in glacial lake outburst floods (GLOFs) in Pakistan: in Gilgit-Baltistan, the glaciers producing GLOFs are now occurring at three times the historical average, with a rate of at least 16 GLOFs recorded in 2022, compared with 5-6 GLOFs per year on average over the past 30 years, and an estimated 7.1 million people living at risk from the 33 glacial lakes that are classified as hazardous in this region [2]. The most obvious sign of this trend is the difference in the severity of the two worst natural disasters of recent years in the country: the floods of 1982 and 2000. In 2010, over 1600 people died in the Indus floods, and there was a financial loss of approximately $10 billion [3]. The 2022 floods resulted in financial losses estimated to be in the range of $15–30 billion, depending on the approach; these floods impacted 33 million people, displaced 8 million, affected more than a million homes, and were the costliest in the preceding 30 years [4, 5].

In this case, the one-decade-to-10-decade data are very clear. Malaria cases across the WHO Eastern Mediterranean Region, of which Pakistan is the largest contributor, rose to an estimated 10.2 million in 2023, a 137% increase compared with 2015 [6]. Nationally, there were 399,097 cases of malaria in Pakistan in 2021, and the floods in 2022 contributed 6.6 million more cases over the following three years, peaking at 2.7 million cases in 2023, with the World Health Organization and the Government of Pakistan's Ministry of Health reporting more than 2 million malaria cases each year as the new baseline [5, 6]. The 2022-2023 outbreak is the worst in 50 years according to Pakistan's Directorate of Malaria Control. Here, the mortality pattern is not a straightforward increase, but is a harbinger of a wider surveillance issue. The most clearly established toll has been the Karachi heatwave in June 2015, where 1,233 people died and approximately 65,000 people were admitted with heatstroke in a week in Sindh's Provincial Disaster Management Authority (PDMA) [7]. In contrast, the widely reported death toll of 568 in June 2024, linked to the Sindh heat wave, was based on bodies found at the Edhi Foundation morgues, but not on confirmed heat-wave-attributed mortality; even the Sindh health department recommended that the heat wave should not be blamed for deaths other than 13 deaths that month as heat exposure, but as confirmed, not bodies found, deaths Sindh's chief meteorologist "regardless of which count" called the worst heat wave since 2015 [8]. The same benchmark was set during 2015, a decade ago, when near-record temperatures and a second wave of heatwave warnings occurred in April, and was again triggered when temperatures in May 2024 approached the global record temperature for that month (47.8°C), as a consequence of which the 2024 toll was again invoked [9].

The current level of hunger in Pakistan is classified as a 'serious' level, with a 28-point increase in the Global Hunger Index score in 2024 compared to 2016, and the current stunting, wasting, and undernourishment rates are 33.2%, 10%, and 20.7%, respectively [10]. This has happened despite the low level of investment in health over the decade: public health spending is consistently low at 0.8 – 0.9% of GDP, compared to the South Asian average of 3.1% during the decade, and one doctor per 750,000 people in the country.

The climate change that Pakistan has been facing over the last decade is not just prominent; it is a transformation-like problem, from responding to discrete disasters to increasing health system stress, which is especially evident in the increased burden of vector-borne diseases, but is most urgently evident in the disconnect between the growing hunger index and lack of investment in health financing. The figures of heat-related deaths in 2024, which are disputed, also indicate a clear ground-level issue that needs to be addressed: Pakistan lacks a standardized real-time heat-mortality surveillance system after 2015 showed that such a system is required. The information points to an approach of embedding climate-sensitive disease monitoring, GLOF early-warning systems, verified heat-mortality monitoring, and nutrition financing in national health planning policies, as opposed to piecemeal disaster response.