Pakistan Journal of Medical Research

Strengthening Community-Based Surveillance on Deaths and Diseases: Perspectives of Lady Health Workers and Supervisors

Tue, 28 Apr 2026 00:00:00 +0500

Community-based surveillance (CBS) is a proactive public health strategy that engages local health actors in the identification, reporting, and response to health-related events at the grassroots level. In Pakistan, the National Lady Health Worker Program are pivotal to CBS implementation, given their embedded role in the community and the health system.^1-3 Despite their outreach, community-level surveillance of both deaths and diseases remains fragmented and underutilized both at the hospital and community level. Understanding the lived experiences of LHWs and LHSs is critical for strengthening surveillance frameworks and improving early disease detection and mortality reporting. This study was aimed to identify and quantify the mental and socioeconomic enabling factors and challenges reported by LHWs and LHSs while performing their community-based surveillance (CBS) duties at Barakahu, Islamabad.

Koch’s Disease to Cartridge-Based Precision: The Evolving Diagnostics of Tuberculosis

Muhammad Kashif Munir — Tue, 28 Apr 2026 00:00:00 +0500

On 24^thMarch 1882, Robert Koch stood before the Physiological Society of Berlin and announced the discovery of Mycobacterium tuberculosis (M. tuberculosis). That moment marked the turning point when a mysterious, hindering illness was finally recognized and defined as a specific infectious disease and laid the scientific foundation for diagnosis, control, and, eventually, hopes for elimination. More than a century later, World TB Dayis observed 24^thMarch every year, more beyond a discovery; it reminds us that the battle against Koch’s disease is still being fought and that diagnostics remain the frontline weapon.¹

The history of tuberculosis (TB) diagnostics is, in many ways, the history of microbiology itself. From microscopy and culture to molecular assays capable of detecting resistance to multiple drugs within hours, the journey reflects the convergence of science, technology, and public health urgency. Following Koch’s discovery, Ziehl and Neelsen refined staining methods that made acid-fast bacilli visible under a light microscope. For decades, sputum smear microscopy remained the cornerstone of TB diagnosis, especially in resource-limited settings. Despite the shortcomings, microscopy established a critical principle: TB could be diagnosed by directly seeing the organism, anchoring TB control in laboratory confirmation rather than clinical suspicion alone.¹The development of culture techniques, particularly Lowenstein Jensen medium and later liquid systems, brought a leap in sensitivity and specificity. Culture allowed confirmation of viable organisms and, crucially, enabled drug susceptibility testing. However, M. tuberculosis is a slow grower. In an infectious disease where delays translate into ongoing transmission and mortality, this remained a major operational challenge.² Nevertheless, culture became the reference standard against which all new diagnostics were judged.¹

Chest radiography, tuberculin skin testing, and later interferon-gamma release assays contributed valuable supportive information but did not replace bacteriological confirmation. The true paradigm shift began with nucleic acid amplification technologies. Polymerase chain reaction (PCR) enabled direct detection of mycobacterial DNA from clinical samples. However, early PCR-based tests were complex, required sophisticated laboratories, and were not easily deployable at scale in high-burden settings.²

This changed dramatically with the introduction of cartridge-based nucleic acid amplification tests, most notably the GeneXpert MTB/RIF assay in 2010. For the first time, a near point-of-care test could detect M. tuberculosis and rifampicin resistance in under two hours with minimal hands-on time. It was automated, standardized and required limited technical expertise². GeneXpert transformed TB diagnostics by addressing a critical gap: rapid detection of rifampicin resistance as a proxy for multidrug-resistant TB (MDR-TB).³

As TB programs expanded testing, a new reality emerged. Detecting rifampicin resistance alone was insufficient. Isoniazid monoresistance, fluoroquinolone resistance, and resistance to second-line injectable drugs were increasingly recognized as significant barriers to effective treatment. The management of drug-resistant TB required more detailed resistance profiles than earlier assays could provide.

Line probe assays (LPAs) addressed part of this need by detecting mutations associated with resistance to isoniazid, rifampicin, fluoroquinolones, and injectables. However, LPAs required sophisticated laboratory infrastructure, trained personnel, and strict quality assurance, limiting their use in decentralized settings. The evolution continued with GeneXpert Ultra, which improved sensitivity, particularly in smear-negative, pediatric, and extrapulmonary cases¹. Yet the most significant recent milestone has been the introduction of GeneXpert MTB/XDR. This assay detects resistance not only to rifampicin and isoniazid but also to fluoroquinolones, ethionamide, and second-line injectables markers critical for identifying pre-XDR and XDR-TB.⁴

GeneXpert XDR represents a culmination of decades of diagnostic evolution: a rapid, cartridge-based test capable of delivering an expanded drug-resistance profile within hours. It brings sophisticated molecular insights to settings where culture and conventional DST are impractical or too slow. For high-burden countries grappling with drug-resistant TB, this is transformative. Early identification of resistance patterns enables clinicians to initiate appropriate regimens promptly, reduces amplification of resistance, and improves patient outcomes.⁵

The WHO End TB Strategy emphasizes early diagnosis, recognizing that delay leads to empirical treatment, allows transmission to continue and ensures the epidemic persists, making modern TB control increasingly diagnostics. Decisions on regimen design, infection control, and public health interventions now hinge on rapid laboratory confirmation.⁶ The shift from smear-based to molecular-first algorithms in many countries illustrates how diagnostics have moved from supportive tools to central pillars of TB control.⁷

World TB Day on 24 March is not merely historical remembrance. It is a reminder that the spirit of Koch’s discovery characterized by scientific clarity in the face of a deadly disease must guide current efforts. The tools have changed, but the mission remains the same: identify the organism quickly, understand its behavior, and interrupt transmission. In 1882, seeing the bacillus under a microscope was revolutionary. In 2026, identifying its genetic mutations and resistance patterns within a cartridge is the new revolution. Both serve the same purpose: bringing certainty to diagnosis and speed to action.

Despite remarkable advances, challenges remain. Access, cost, maintenance, and quality assurance limit the reach of advanced diagnostics in remote and underserved areas.⁵ Integration with digital reporting systems, supply-chain reliability, and training of personnel are as important as technological innovation. Future directions include portable molecular platforms, sequencing-based diagnostics, and integration of artificial intelligence with radiology and clinical data. Yet, even as we look ahead, the arc from Koch’s microscope to GeneXpert XDR reminds us of progress in TB control has always been driven by better diagnostics.

The story of TB diagnostics is a story of persistent refinement from staining bacilli to decoding genomes. Each step has brought us closer to faster, more accurate, and more actionable information.

Differences in Shade Perception among Post-Graduate Students and Dental Specialists

Asma, Wagma Tanveer , Fizza Rashid, Asifa Zubair, Sadia Saeed, Syed Nasir Shah — Tue, 28 Apr 2026 00:00:00 +0500

Background: Attaining ideal esthetics in terms of accurate shade selection is fundamental in contemporary restorative dentistry, which is affected by multiple factors. Literature suggests varied response regarding shade matching among specialists and post-graduate students.

Objective: This study aimed to evaluate differences in shade perception between post-graduate students and dental specialists, focusing on their ability to accurately match hue and chroma using standardized shade guides.

Methods: A cross-sectional study was conducted among 156 participants at Khyber College of Dentistry, Peshawar including post-graduate students and specialists from various departments. Shade perception was assessed using four preselected VITA Classical shade tabs (C3, D2, B1, A4) under standardized lighting. Participants matched the hue and chroma of each tab using a separate shade guide. Data were analyzed using SPSS v25, chi square test and one sample t-test were used to identify statistically significant differences based on operator level with varying age and gender.

Results: Out of 156 participants, differences in shade perception between postgraduate students (n=132) and dental specialists (n=24) were evaluated across four shade tabs. Specialists demonstrated significantly higher accuracy in Tab 1 chroma matching (p =0.006) and Tab 2 hue matching (p =0.005), highlighting their superior performance. However, postgraduate students exceeded specialists in certain tasks, notably in Tab 4 chroma matching (p =0.106), though this difference was not statistically significant.

Conclusion: While specialists showed superior shade perception in specific tasks, post-graduate students demonstrated comparable accuracy in many areas, indicating effective training. The findings suggest that experience enhances precision in shade-matching.

Association of Inferior Vena Cava Diameter and Compressibility Index with Central Venous Pressure

Tue, 28 Apr 2026 00:00:00 +0500

Background: In critical patients, it's often challenging to assess intravascular volume status at bedside. Central venous pressure (CVP) is commonly used to measure it in Intensive care units (ICUs) through an invasive method and associated with complications of central venous catheters (CVC). Ultrasound is alternative non-invasive tool, without radiation risk and readily available in ICUs with comparable results.

Objective: To determine the correlation between inferior vena cava (IVC) diameter and IVC Compressibility Index (CI) assessed by ultrasound with CVP value for assessing intravascular volume status in critical patients.

Methods: Cross-sectional study conducted at ICU of Mayo Hospital Lahore for a period of 6 months from January 2023 to June 2023. A total of 97 patients fulfilling selection criteria were enrolled after written informed consent. Ultrasonographic measurement of IVC diameter obtained and IVC-CI calculated. Measurement of CVP was done according to standard protocol immediately after the diameter of IVC had been measured. All findings were noted down on proforma and subjected to statistical analysis.

Results The mean age of patients was 50±13.8 years, the mean IVC diameter was 1.9±0.56 cm, the mean CVP value was 13±3.48 cm H₂O and the mean IVC-CI was 48±12.36%. There was a statistically significant positive correlation between IVC diameter and CVP as was indicated by r =0.871, p <0.001 and between IVC-CI and CVP there was a statistically significant negative correlation as was indicated by r =-0.695, p <0.001.

Conclusion: The IVC diameter positively and significantly correlated with CVP value and IVC-CI negatively .............

Clinical Spectrum of Pediatric Stroke in The Children’s Hospital and Institute of Child Health Faisalabad

Tue, 28 Apr 2026 00:00:00 +0500

Background: In different geographical regions, the clinico-etiological spectrum of childhood stroke varies widely, posing significant effects on children.

Objective: To determine etiology, types and symptoms of stroke in children presenting to the Children’s Hospital & Institute of Child Health Faisalabad.

Methods: Retrospective analysis was conducted on 108 children who presented with a focal neurological deficit lasting more than 24 hours was done from September 2022 to September 2023. Children were diagnosed with a stroke after a comprehensive clinical history, neurological assessment, and neuroimaging results. Under the direction of imaging data and clinical presentation, investigations were carried out as needed to identify the stroke's underlying etiology.

Results From a total of 108 children, 57 (52.8%) were males and 51 (47.2%) were females. Mean age of the children was 5.08±3.76 years. The most common mode of presentation was seizure 40 (37%) followed by visual disturbance in 24 (22.2%). The right side of the body was affected in 53 (49.1%) children, the left in 49 (45.4%) and bilateral in 6 (5.6%). Site of lesion in 40 (37%) children was frontal, followed by parietal and temporal in 22 (20.4%) children. Causes of strokes were vascular in 38 (35.2%) children, cardiac in 18 (16.7%) and CNS infection and hematological in 17 (15.7%) children respectively. Stroke was infarctive in 90.8% children.

Conclusion: Infarctive stroke is highly prevalent, and vascular etiologies are the most common cause of stroke in children. Frontal area of the brain is affected among significant number of children. Prompt intervention and a ..................

Epidemiological Trends and Burden of Acute Watery Diarrhea during 2022 in Khyber Pakhtunkhwa, Pakistan

Tue, 28 Apr 2026 00:00:00 +0500

Background: In developing countries like Pakistan, diarrheal disease remains a major cause of morbidity and mortality. Despite improved diagnosis and treatment, key risk factors persist.

Objective: This study assessed the trends and burden of acute watery diarrhea (AWD) in Khyber Pakhtunkhwa (KP) in 2022 to guide targeted interventions.

Methods: Retrospective one year data on AWD was extracted from the District Health Information System 2 (DHIS2) event visualizer, from primary and secondary health facilities across 26 districts of KP. Only stool culture confirmed bacterial cases were included. Standardized case report forms captured demographic, clinical, risk factor, laboratory, and outcome data. Severe cases were referred for stool culture. Data was cleaned, analyzed, and presented using tables, graphs, and maps using Epi Info 7.2.1.

Results: A total of 322 cases were recorded, with 56% males. The mean age was 19.5 years, with the 15-30 years group most affected. Passage of three or more watery stools in 24 hours was the most common symptom (74%). Cases began on 5 May 2022 and peaked on 3 June with 41 cases reported in a single day. Most cases were from Malakand, followed by Swat and Nowshera. Spring water was the main drinking source (81%), while only 10% reported using water treatment methods.

Conclusion: The findings suggest a substantial AWD burden, likely underestimated. Key risk factors include younger age, overcrowding, shared sanitation, untreated water, and seasonal variation. Strengthening prevention through safe water, improved sanitation, health education, and integrated disease surveillance is essential for early detection and control.

Dentists’ Attitudes and Practices regarding Diagnosis and Treatment of Obstructive Sleep Apnea

Tue, 28 Apr 2026 00:00:00 +0500

Background: Obstructive sleep apnea (OSA) is a breathing disorder that affects almost 20% of the adult population worldwide. Undiagnosed or untreated OSA has a high mortality. Dentists can be the first healthcare workers to diagnose this condition.

Objective: This study explored the attitudes of dentists regarding OSA, and their management, referral, and treatment practices for OSA patients.

Methods: A cross-sectional survey was conducted among dentists working in different dental teaching hospitals in Islamabad, Pakistan, from September 2021 to March 2022. A pre-designed questionnaire was used to collect data, consisting of information including demography, and dentists’ knowledge and practices regarding diagnosis, management and referral of OSA patients. The chi-square test was applied to check the association between dentists' participation in OSA management courses and their self-reported ability to identify OSA patients. The association between practitioners' designation and experience with attitude was also evaluated using chi square test.

Results: While 96.7% of participants knew about OSA, only 34% had confidence in their ability to identify high-risk OSA patients. Recognition of high-risk OSA patients was significantly associated with topic inclusion in the dental curriculum and attending additional courses on OSA management (p <0.05). Around 9.3% of participants frequently encountered OSA patients, and 35.3% regularly inquired about sleep history. Most participants preferred referring patients to physicians for management.

Conclusion: Dentists in teaching hospitals of Islamabad have a positive attitude towards managing and referring OSA patients, however there is a need for enhanced education and training in sleep medicine.

Assessment of Liver Function Test Abnormalities in Adult Dengue Patients at Mardan Medical Complex, Mardan

Tue, 28 Apr 2026 00:00:00 +0500

Background: Background: Dengue virus infection is a major public health concern in tropical regions and is frequently associated with hepatic involvement. Liver dysfunction ranging from mild transaminase elevation to severe hepatic injury has been reported in dengue patients.

Objective: To assess the clinical significance of liver function tests abnormalities in adult patients with dengue virus infection

Methods: This was across-sectional study undertaken at the Department of Medicine, Mardan Medical Complex (MMC), Mardan, from January 2022 to December 2023. A total of 200 participants were included, comprising 88 laboratory confirmed dengue patients and 112 healthy controls. Dengue infection was confirmed using dengue IgM enzyme linked immunosorbent assay (ELISA). Venous blood samples were collected and analyzed for liver function parameters, including serum bilirubin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP) and serum albumin, using standardized automated methods. Patients with chronic liver disease, alcohol use, hepatotoxic drugs exposure, Nephrotic syndrome or other confounding conditions were excluded. Data was analyzed using SPSS version 26, applying the independent t-test, with a p value <0.05.

Results: Of the 88 patients examined, 62(70.45%) were male and 26 (29.54%) were females. The patients' ages ranged from 18 to 60 years, with a mean age of 37.69 years. Most of the dengue patients were males. The highest number of dengue cases were reported among those aged between 31 to 45 years. Compare control group, LFT’s of the dengue patients showed significant elevation of S Bilirubin, ALT, AST and significantly lower level of S albumin (p <0.05)..........................

Ferritin Levels in Poorly Controlled Type II Diabetics Versus Patients with Optimal Control

Sadia Kiran, Asif Nawaz, Aamna Mehmood Gilani, Safa Awan, Hira Asif, Erum Nasir — Tue, 28 Apr 2026 00:00:00 +0500

Background: Type 2 diabetes mellitus (T2DM) is a growing global health concern characterized by chronic hyperglycemia, insulin resistance and associated complications. Serum ferritin an iron storage protein and inflammatory marker has been linked to poor glycemic control and may provide insight into the interplay between iron metabolism, inflammation and diabetes management.

Objective: To assess the correlation of glycemic control with serum ferritin levels.

Methods: This comparative cross-sectional study was performed at the Department of Pathology and Endocrinology, Fauji Foundation Hospital, Rawalpindi from December 2023 to May 2024. Data of patients attending the diabetic clinic were included and distributed into two groups: Group A (patients with good glycemic control) and Group B (patients with poor glycemic control). Blood samples from patients included in this study were collected and analyzed for the levels of serum ferritin, CRP and HbA1C. Descriptive variables were presented as frequency, percentages and median accordingly.

Results: In this study of 160 participants, divided based on glycemic control, group A had a lower median HbA1C of 5.70% compared to 8.10% in group B. Group B also had a higher median serum ferritin level (348.00 µg/L versus 161.5 µg/L). Additionally, group A had lower levels of C-reactive protein (0.3 mg/dL) compared to group B (0.4 mg/dL). Higher serum ferritin and CRP levels were strongly correlated to increased HbA1C levels.

Conclusion: Increased ferritin and CRP levels are strongly related to poorly controlled T2DM. Monitoring ferritin levels in glycemic care can enhance patient outcomes by allowing for better risk assessment ...............

Accuracy of Ultrasound Measurement of Fetal Head Station for Prediction of the Difficulty of Assisted Vaginal Delivery

Umber Arooj Tahir, Hafsa Tauseef, Faryal Akhtar — Tue, 28 Apr 2026 00:00:00 +0500

Background: Recently the use of ultrasound for the measurement of fetal head engagement during assisted vaginal delivery has increased. However, this finding has not been proved reproducible by sufficient studies and only limited-series studies have tested its accuracy.

Objective: To evaluate the accuracy of ultrasound measurement of perineum-to-skull ultrasound (PSUD) in predicting the outcome of assisted vaginal delivery.

Methods: A prospective cohort study was conducted in the Department of Gynecology and Obstetrics, Ibn-e-Siena Hospital, Multan, from September 2023 to September 2024. A total of 200 pregnant women with a gestation age of more than 34 weeks presenting with singleton pregnancies in cephalic position undergoing assisted vaginal delivery were included by consecutive sampling. Women were divided into group A, including women in whom PSUD was measured, and group B, which included women in whom PSUD was not measured. The difficulty of vaginal birth was primarily assessed by the extraction difficulty criterion. A digital vaginal examination was performed to record the fetal head station and presentation before each attempt of delivery according to ACOG classification and sections of the pelvic outlet. A suprapubic ultrasound was performed after examination.

Results The mean PSUD was 41.7±12.2 mm, and a higher PSUD was significantly related to extraction difficulty (p <0.0001). PSUD was not significantly associated with neonatal outcomes. The sensitivity for the prediction of difficult extraction was 73.5% at 40 mm PSUD, and the specificity was 48.2% (positive predictive value: 24.1% and negative predictive value: 89.4%). ....................

Comparative Analysis of Oral Misoprostol and Vaginal Misoprostol for Induction of Labour

Sehrish Razzaq, Nadia Zahid, Gulfreen Jalil , Amna Aslam — Tue, 28 Apr 2026 00:00:00 +0500

Background: Misoprostol has become an invaluable tool in cervical ripening and induction of labour. Various dosages, routes, and frequencies of administration are underoptimization. Current Study was designed to compare the efficacy and safety of oral versus vaginal misoprostol for induction of labour among pregnant women.

Objective: The research aimed to evaluate the effectiveness and safety of vaginal misoprostol vs oral misoprostol in termsof labour induction and maternal and fetal outcomes.

Methods: This cross sectional comparative study was conducted at Avicenna Medical College, Lahore, Pakistan from December 2024 to June 2025. A total of 200 term pregnant women with a Bishop score of ≤5 were randomly assigned to receive 50µg misoprostol in five instances every 4-6 hours. Oxytocin augmentationwas used to receive enough uterine contractions after the dosage limit. The key outcomes were the induction to delivery interval and the rate of vaginal delivery over 24 hours.

Results Primigravida women predominated in both groups with no significant difference between vaginal and oral misoprostol (G1: 62 vs 64; G2: 34 vs 36; G3: 4 vs 0; p=0.74, 0.73, 0.12, respectively). Low Apgar scores were observed in 24/74 (32.4%) neonates in the vaginal group and 14/86 (16.3%) in the oral group, while meconium-stained liquor occurred in 20/78 (25.6%) and 14/86 (16.3%) cases, respectively. Maternal adverse events were minimal, with hyperstimulation noted only in the vaginal group (1 case), whereas nausea and hyperpyrexia were more frequent in the oral group. No neonatal mortality was observed in either group.

Conclusion: Vaginal misoprostol appears ....................

Letter to the Editor on Harnessing New Treatment Modalities for Brain Metastases

Talha Adil, Zoha Khan — Tue, 28 Apr 2026 00:00:00 +0500

I'm writing to emphasize how urgently new treatment modalities for brain metastases must be developed and put into practice. This is a difficult oncology problem that still has a significant negative impact on patients and their families. We must address this pressing unmet need and enhance outcomes for patients as the prevalence of metastatic cancer to the brain rises, driven by advancements in cancer therapy and increased survival rates.¹

Targeted treatments, immunotherapies, and precision radiotherapy techniques are examples of emerging therapeutics that show significant potential for improving outcomes. Clinicians can detect actionable genetic changes and customize therapy regimens to target particular molecular pathways by utilizing the potential of genomic profiling and precision medicine.²

Besides targeted medicines, immunotherapy has been a game-changer in the fight against cancer by using the body's immune system to identify and destroy tumor cells. Anti-PD-1 and anti-CTLA-4 antibodies are examples of immune checkpoint inhibitors that have demonstrated notable effectiveness in treating patients with metastatic malignancies. In patients with brain metastases, ongoing clinical trials are assessing the safety and effectiveness of immunotherapy.^3,4

The management of brain metastases has also been completely transformed by developments in precision radiotherapy techniques, such as intensity-modulated radiotherapy and stereotactic radiosurgery, which allow radiation to be precisely and highly targeted to tumor lesions while sparing surrounding healthy brain tissue. In comparison to traditional whole-brain radiation therapy (WBRT), these approaches are less intrusive and more effective while lowering the risk of neurotoxicity and cognitive loss.⁵

The most aggressive and fatal kind of primary brain cancer, glioblastoma multiforme (GBM), has been shown in preclinical animals to be amenable to hydrogel-based drug delivery methods. By encasing chemotherapeutic medications, researchers were able to achieve sustained release kinetics, longer drug retention at the tumor location, and increased therapeutic benefits. Medical professionals can also surmount the blood-brain barrier, and encourage tissue regrowth, revolutionizing the field of brain tumor therapy.⁶

In conclusion, this rapidly developing discipline of treating brain metastases offers patients fresh hope by representing a frontier of potential and innovation in oncology improving their quality of life. It is our joint duty as researchers, physicians, and legislators to give priority to and encourage the development of novel brain metastasis treatment approaches in order to guarantee that every patient receives the finest care available and the chance for a better future. Thank you for considering my thoughts on this matter.

Treatment Modality	Mode of Action in Treating Brain Tumor
Immunotherapy of brain metastases.	Targeting tumor-brain microenvironment interactions and emerging treatment modalities.
Brain radiotherapy with immune checkpoint blockade.	Utilizing CTLA-4-directed blockade with or without trastuzumab in breast cancer brain metastases.
Immune-mediated therapy in NSCLC patients.	Understanding and dissecting outcomes from immune checkpoint blockade in the tumors.
Immune-checkpoint inhibition and targeted therapy in melanoma brain metastases.	Providing insights into the inhibition of biological factors leading to melanoma and its metastases in brain.

Abbreviations

PD-1 – Programmed Cell Death Protein 1, CTLA-4 – Cytotoxic T-Lymphocyte associated Protein-4, GBM – Glioblastoma Multiforme