The "KMUJ: KHYBER MEDICAL UNIVERSITY JOURNAL " is the official journal of KHYBER MEDICAL UNIVERSITY (KMU), Peshawar Pakistan, and is published from Khyber Medical University Institute of Medical Sciences (KIMS), Kohat, Khyber Pakhtunkhwa, Pakistan. KMUJ is an OPEN ACCESS JOURNAL and included in <a href="https://doaj.org/toc/2305-2651?source=%7B%22query%22%3A%7B%22filtered%22%3A%7B%22filter%22%3A%7B%22bool%22%3A%7B%22must%22%3A%5B%7B%22terms%22%3A%7B%22index.issn.exact%22%3A%5B%222305-2643%22%2C%222305-2651%22%5D%7D%7D%5D%7D%7D%2C%22query%22%3A%7B%22match_all%22%3A%7B%7D%7D%7D%7D%2C%22size%22%3A100%2C%22sort%22%3A%5B%7B%22created_date%22%3A%7B%22order%22%3A%22desc%22%7D%7D%5D%2C%22_source%22%3A%7B%7D%7D" target="_blank" rel="noopener">Directory of Open Access Journals ." KMUJ (KMJ) is Indexed & abstracted in: Web of Science, Scopus, WHO IMEMR Current Contents, CAB Abstract & Global Health UK, SafetyLit, Pakistan Scientific and Technological Information Centre (PASTIC), Pakmedinet Recognized by: Higher Education Commission (HEC) Pakistan (Category X), Pakistan Medical & Dental Council, & College of Physicians and Surgeons (CPSP) Pakistan (for submission of paper(s) in lieu of dissertations for trainees). Included in "<a href="https://doaj.org/toc/2305-2651?source=%7B%22query%22%3A%7B%22filtered%22%3A%7B%22filter%22%3A%7B%22bool%22%3A%7B%22must%22%3A%5B%7B%22terms%22%3A%7B%22index.issn.exact%22%3A%5B%222305-2643%22%2C%222305-2651%22%5D%7D%7D%5D%7D%7D%2C%22query%22%3A%7B%22match_all%22%3A%7B%7D%7D%7D%7D%2C%22size%22%3A100%2C%22sort%22%3A%5B%7B%22created_date%22%3A%7B%22order%22%3A%22desc%22%7D%7D%5D%2C%22_source%22%3A%7B%7D%7D" target="_blank" rel="noopener">Directory of Open Access Journals" (<a href="https://doaj.org/toc/2305-2651?source=%7B%22query%22%3A%7B%22filtered%22%3A%7B%22filter%22%3A%7B%22bool%22%3A%7B%22must%22%3A%5B%7B%22terms%22%3A%7B%22index.issn.exact%22%3A%5B%222305-2643%22%2C%222305-2651%22%5D%7D%7D%2C%7B%22term%22%3A%7B%22_type%22%3A%22article%22%7D%7D%5D%7D%7D%2C%22query%22%3A%7B%22match_all%22%3A%7B%7D%7D%7D%7D%2C%22size%22%3A100%2C%22_source%22%3A%7B%7D%7D" target="_blank" rel="noopener">DOAJ); Asian Digital Library Registered with: International Serials Data System of France Covered by: Google Scholar ISSN (Print): 2305-2643 ISSN (Online): 2305-2651 KMUJ is a member of the Committee on Publication Ethics and follows the COPE guidelines regarding publication ethics and malpractices. KMUJ also follows the ICMJE Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals
Khyber Medical University (KMU) Peshawar PAKISTAN
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Treatment approaches for traumatized youth in low- and middle-income countries
Trauma exposure in childhood is disproportionately high in low-and-middle-income countries (LMICs), exacerbating mental health disorders like post-traumatic stress disorder (PTSD) and depression. However, research into effective treatments has been limited, and access to quality mental healthcare is often scarce. This paper reviews interventions for PTSD and related conditions in youth living in LMICs. Prevalence data indicate high rates of trauma exposure (80-90% in some studies) and PTSD (up to 87%) among children and adolescents in LMIC conflict zones. Classroom- and group-based cognitive-behavioral approaches show promise, with medium effect sizes overall, though results vary across studies. For example, Teaching Recovery Techniques (TRT), a trauma-focused Cognitive Behavioral Therapy (CBT), and Narrative Exposure Therapy (NET), which facilitates trauma narrative reconstruction, demonstrate small-to-medium effects on reducing symptoms. However, many studies lack controlled research to confirm results. Additionally, PTSD interventions designed for high-income settings are often unavailable in LMICs. Scalable, culturally adapted treatments are needed. Stigma also limits mental healthcare utilization, though anti-stigma campaigns can increase help-seeking. In sum, childhood trauma burden is extremely high in LMICs, but data on evidence-based interventions is limited. More research into accessible, cost-effective treatments tailored to LMIC youth is critically needed.
Copyright (c) 2026 Cynthia Kaplan, Kelly V Klein, Ella Cannon, Leila Sachner, Blaise Aguirre https://creativecommons.org/licenses/by/4.0
Flossing and stroke prevention: an overlooked public health opportunity
Dear editor, Maintaining good oral hygiene is well-documented to play a vital role in preventing oral diseases.1 However, the connection extends far beyond the mouth. Research increasingly links oral health to the development and progression of systemic conditions, including cardiovascular disease, diabetes, rheumatoid arthritis, and Alzheimer's disease.2 Therefore, oral health is not merely about healthy teeth and gums; it is an integral component of overall well-being and disease prevention. One of the biggest concerns after COVID-19 is strokes, which have been rapidly increasing in recent times and are a leading cause of disability and mortality globally.3 While medical advancements have provided various strategies to mitigate the risk of ischemic stroke,4 a recent study conducted by researchers in the United States highlights a remarkably simple preventative measure: flossing.5 The Atherosclerosis Risk in Communities (ARIC) study examined the relationship between flossing, incident stroke, stroke subtypes, and atrial fibrillation in over 6,000 dentate participants who were monitored for a period of over 25 years. Approximately 65% of the participants reported flossing at least once a week. The analysis indicated that regular flossing, compared to non-flossers, was associated with a 22% reduction in the risk of ischemic stroke, a 44% reduction in the risk of cardioembolic stroke, and a 12% reduction in the risk of atrial fibrillation. These findings suggest that flossing at least once a week is linked to a decreased risk of stroke due to blood clots and irregular heart rhythms.5 This research highlights how crucial good oral hygiene is for our overall health and indicates that something as simple and inexpensive as regular flossing could be a game-changer in preventing strokes, with the potential to save countless lives, reinforcing the vital link between a healthy mouth and a healthy body.
Copyright (c) 2026 Enis Veseli https://creativecommons.org/licenses/by/4.0
Surge of episiotomies in Pakistan: a call for better practices
Dear Editor, An episiotomy is a planned incision made through the perineal body to widen the vaginal opening and facilitate delivery during the second stage of labor. This intervention is among the most frequently performed procedures in the delivery room. It has been suggested that episiotomy may benefit the fetus by shortening the second stage of labor and reducing the risk of fetal skull fractures and cephalohematomas. Although episiotomy is a frequently performed surgical procedure globally, the decision to perform it depends on various factors and indications, such as fetal position, shoulder dystocia, breech delivery, fetal macrosomia, and assisted vaginal delivery using instruments like vacuum extractors or forceps. As childbirth transitioned from a home-based natural process to a hospital-based medical procedure, episiotomy was initially recommended by clinicians to prevent maternal injury and improve fetal outcomes.1 Current guidelines now advocate a more restrictive use of episiotomy, with the World Health Organization (WHO) recommending that it be performed in no more than 10% of normal deliveries. 2 Despite this, there is an alarming increase in the rate of episiotomy, particularly among primigravida women in resource-limited countries such as Pakistan. A study by Majeed T, et al., reported an incidence of routine episiotomy of 80% in primigravida during normal vaginal delivery.3 A similar rate of 78% was reported by Khan N, et al., in Karachi,4 raising concerns regarding obstetric practices and emphasizing the need for a restrictive rather than routine use of episiotomy. In comparison, rates in developed countries such as the United States have significantly declined, reaching 4.6% in 2022 compared to 67% in 2012. In France, the prevalence of episiotomy has been reported at 19.4%, while in the United Kingdom it ranges between 12% and 15%. In contrast, developing countries such as India, Oman, and Taiwan continue to report widespread use of episiotomy, with high rates of the procedure performed during vaginal deliveries.5 While episiotomy was originally intended to prevent complications such as postpartum pain, incontinence, and sexual dysfunction, evidence suggests that it may, in fact, contribute to these outcomes. Consequently, many experts recommend limiting the procedure to cases where significant perineal trauma is imminent. Modern medical practice has therefore shifted towards a more restrictive approach, abandoning the traditional liberal use of episiotomy. The routine practice of episiotomy should be discouraged, as evidence shows no significant difference in outcomes between women undergoing vaginal delivery with or without episiotomy.6 Pregnant women should receive comprehensive antenatal counseling regarding the potential complications associated with episiotomy during and after delivery. Furthermore, regular training and awareness programs should be conducted for healthcare personnel and traditional birth attendants, such as LHVs and Dais, to highlight the benefits of normal vaginal delivery and discourage the routine use of episiotomy. In developing countries like Pakistan, where hospital-acquired infection rates are high and follow-up attendance is often poor, the routine use of episiotomy is particularly questionable. Adoption of evidence-based practices is essential to reduce its unnecessary use.
Copyright (c) 2026 Mohammad Osama, Rida Asghar, Nawazish Ali https://creativecommons.org/licenses/by/4.0
Clinical epidemiology of multiple sclerosis in the Aran region of Azerbaijan
Objective: To investigate the clinical and epidemiological characteristics of multiple sclerosis (MS) in the Aran region of Azerbaijan. Methods: This prospective, single-center longitudinal study was conducted at Neurology Center under the Ministry of Health of Azerbaijan from January 2013 to December 2022. Patients from the Aran region were evaluated using standardized national diagnostic protocols based on the 2010 McDonald criteria. Of 267 individuals assessed, 241 with confirmed MS were included. Data on demographic characteristics, clinical features, and epidemiological indicators were collected. Incidence and prevalence rates per 100,000 population were calculated and age-standardized using World, European, and national reference populations. Statistical analysis was performed using SPSS version-27. Results: Of the 241 patients, 150 (62.2%) were women and 91 (37.8%) were men. Mean age at diagnosis was 35.91±8.16 years, higher in men than women (p<0.05). The mean diagnostic delay was 5.90±5.27 years and was longer in rural residents (p=0.009). Relapsing-remitting MS was the predominant clinical subtype, observed in 190 patients (78.8%). The 10-year average incidence rate was 1.13±0.26 per 100,000 population, with no significant differences by gender or residence. By the end of 2022, the overall prevalence was 13.49±0.88 per 100,000 population (95% CI: 11.75–15.22), higher in women and urban populations (p<0.001). The highest prevalence was recorded in Central Aran Economic Region (16.20±1.50 per 100,000 population). Conclusion: MS in Aran region shows moderate prevalence with female predominance, relapsing-remitting dominance, and diagnostic delays, particularly in rural populations. Findings highlight the disparities and need for improved access to neurological services and earlier referral.
Copyright (c) 2026 Rahim R. Aliyev, Shahla N. Mehtiyeva, Rana K Shiraliyeva https://creativecommons.org/licenses/by/4.0
Living with HIV/AIDS in Balochistan: gendered stigma, social challenges and quality of life among women
Objective: To explore the impact of HIV/AIDS on the quality of life (QoL) of women living with HIV/AIDS in Balochistan-Pakistan, with specific focus on gender-related stigma, family dynamics, and regional disparities. Methods: This convergent parallel mixed-methods study was conducted at provincial HIV/AIDS Control Centre, Bolan Medical College Hospital Quetta, Balochistan, between January and April 2025. Ethical approval was obtained from Institutional Review Board of Bolan University of Medical and Health Sciences, (Ref: 1067/BUMHS/25). Registered women aged ≥18 years with confirmed HIV infection were eligible. Quantitative data were collected from 150 participants using a structured questionnaire developed with reference to established HIV-specific QoL frameworks, including WHOQOL-HIV. Descriptive statistics and Chi-square tests were applied using SPSS version-27. Qualitative data were obtained through semi-structured in-depth interviews with 15 participants and analyzed using inductive thematic analysis. Results: Among 150 participants, 60.0% were unaware of HIV/AIDS before diagnosis and 78.1% had disclosed their diagnosis to family members. Increased family support after disclosure was reported by 42.0%. More than half (52.3%) reported no discrimination in public spaces, while 40.6% felt comfortable discussing their diagnosis. Significant associations were observed between awareness and knowledge of transmission routes (p<0.001), diagnosis disclosure and family behavior (p<0.001), comfort discussing diagnosis and anxiety/stress levels (p=0.010), and region and perceived sufficiency of resources (p=0.010). Qualitative analysis identified six major themes reflecting stigma, psychological distress, and social challenges. Conclusion: Women living with HIV/AIDS experience considerable psychosocial challenges. Strengthening awareness, reducing stigma, and improving psychosocial and family‑centered support are essential to improve their lived experiences.
Copyright (c) 2026 Shabana Fazal, Nabiha Farasat Khan, Muhammad Saim, Usama Saeed https://creativecommons.org/licenses/by/4.0
Intolerance of uncertainty and cyberchondria among Pakistani young adults
Objectives: To examine the relationship between intolerance of uncertainty (IU), including its components inhibitory IU and prospective IU, and cyberchondria, and to compare IU and cyberchondria across demographics such as gender, work status, education, and family system. Methods: This cross-sectional study was conducted from April to August 2023 at National Institute of Psychology, Quaid-i-Azam University, Islamabad, after ethical approval. A purposive sample of 302 young adults aged 18–29 years who used the internet for health-related searches was included. Participants completed the Cyberchondria Severity Scale (CSS-12), the Intolerance of Uncertainty Scale (IUS-12), and a demographic questionnaire. The data were analyzed using SPSS version 25. Results: The sample comprised 177 females (58.6%) and 125 males (41.4%). IU showed a significant positive correlation with cyberchondria (rs=0.59, p<0.01). Inhibitory IU demonstrated a stronger positive association with cyberchondria (rs=0.64, p<0.01) compared with prospective IU (rs=0.38, p<0.01). Hours spent on the internet daily for health-related searches (rs=0.26, p<0.01) and age (rs=0.28, p<0.01) were also positively correlated with cyberchondria, whereas family monthly income (FMI) was negatively correlated with cyberchondria (rs=−0.41, p<0.01). Cyberchondria scores were significantly higher among males, working individuals, participants with PhD-level education, and those living in nuclear family systems. Conclusion: Intolerance of uncertainty, particularly inhibitory IU, is strongly associated with cyberchondria among young adults. Demographic factors also influence these psychological tendencies. Interventions targeting uncertainty management and responsible online health information use may help reduce cyberchondria.
Copyright (c) 2026 Syed Zain Abbas, Nelofar Kiran Rauf https://creativecommons.org/licenses/by/4.0
Prevalence of dental caries and its association with nutritional status among school-going children from remote, rural communities of Pakistan
Objective: To assess the prevalence of dental caries and its association with nutritional status among school-going children in a remote rural community of district Swat, Pakistan. Methods: This cross-sectional study was conducted in Swat from July to August 2023 among 482 children aged 10–16 years, selected through multistage sampling from public and private schools. Data were collected using a structured questionnaire adapted from WHO oral health surveys, anthropometric measurements, and clinical oral examination using Decayed, Missing, and Filled Teeth index. Nutritional status was assessed using BMI-for-age Z-scores (BAZ) based on WHO growth standards. Data were analyzed using SPSS version-29. Results: Out of 482 elementary-level students assessed, 154 (32%) were females, with mean age of 12.9±2.73 years. Prevalence of dental caries was 250 (51.7%). Regarding nutritional status, 99 (20.5%) children were wasted, 46 (9.5%) were at risk of being overweight, and 12 (2.5%) were overweight/obese. A statistically significant difference was observed in BAZ scores between children with and without caries (p<0.001). Multivariable analysis showed that higher BAZ scores were associated with a lower likelihood of dental caries. Additionally, oral healthcare-seeking behavior and self-reported feelings of frustration, depression, or irritation were significantly associated with dental caries (p<0.001 and p=0.018, respectively). Conclusion: Dental caries is highly prevalent among school-going children in this rural setting and is significantly associated with poor nutritional status. Lower BAZ score is linked with increased caries risk. Integrated interventions addressing both oral health and nutrition are essential to improve child health outcomes in low- and middle-income countries.
Copyright (c) 2026 Muhammad Shahzad, Ziad Khan, Syed Touseef Aman, Khalid Iqbal, Ahsan Saidal https://creativecommons.org/licenses/by/4.0
Correlation of retinal nerve fiber layer thickness with optic disc parameters and disc damage likelihood scale in primary open-angle glaucoma: a cross-sectional study
Objective: To evaluate the relationship between retinal nerve fiber layer (RNFL) thickness and various optic disc parameters and Disc Damage Likelihood Scale (DDLS) in patients with primary open-angle glaucoma (POAG). Methods: This cross-sectional study, conducted at Lahore General Hospital, included 295 eyes of 148 diagnosed/suspected POAG patients, aging >18 years. Patients with significant refractive errors, media opacities, history of trauma, and poor OCT signal strength were excluded. Comprehensive ocular examination was performed, and optic disc measurements were recorded. RNFL thickness was assessed using optical coherence tomography (OCT). Disease severity was staged DDLS. Statistical analysis involved descriptive statistics, Kolmogorov-Smirnov test for normality, and Spearman correlation coefficients. Results: Of the 148 patients (90 males, 58 females; mean age 52.41±15 years), mean RNFL thickness was 82.21±14.75 µm. Mean RNFL thickness was 82.3±14.8 µm. The mean average CDR was 0.67±0.12 and mean vertical CDR was 0.64±0.12. The mean rim-to-disc ratio was 0.17±0.13. The median DDLS stage was 4 (IQR 3–5). Correlation analysis revealed a moderate negative correlation between RNFL thickness and vertical cup-to-disc (CD) ratio (r= -0.45), a strong positive correlation between RNFL thickness and rim-to-disc ratio (r=0.70), and a strong negative correlation with DDLS (r= -0.65). DDLS showed a moderate positive correlation with vertical CD ratio (r=0.55) and a very strong negative correlation with rim-to-disc ratio (r= -0.80). Conclusions: DDLS and rim to disc ratio are more reliable methods for assessing glaucomatous damage than the vertical or average CD ratios. Therefore, DDLS and rim-to-disc ratios should be integral parts of glaucoma assessment.
Copyright (c) 2026 Hina Khalid, Tayyaba Gul Malik, Fatima Khalid, Rabail Alam, Muhammad Muslim, Iqra Aslam https://creativecommons.org/licenses/by/4.0
Evaluation of pulmonary arteries and source of pulmonary blood supply in children with pulmonary atresia and ventricular septal defect using CT angiography
Objective: To evaluate pulmonary arteries and determine the sources of pulmonary blood supply in children with pulmonary atresia and ventricular septal defect (PA-VSD) using computed tomography angiography (CTA). Methods: This retrospective cross-sectional study was conducted at Pediatric Cardiology Clinic, Hayatabad Medical Complex, Peshawar, Pakistan, from January 2009 to December 2019. Pediatric patients (≤18 years) with confirmed PA-VSD who underwent CTA for preoperative anatomical assessment were included. CTA was used to evaluate pulmonary artery morphology, patent ductus arteriosus (PDA), and major aortopulmonary collateral arteries (MAPCAs). Based on CTA findings, patients were classified according to the source of pulmonary blood supply into Type A (native pulmonary arteries supplied via PDA), Type B (native pulmonary arteries supplied by both PDA and MAPCAs), and Type C (absence of native pulmonary arteries with MAPCAs only). Statistical analysis was performed using SPSS version-22. Results: Ninety-one patients were included, with a mean age of 3.2±2.8 years; 58 (63.7%) were males. Cyanosis was the most common presenting symptom (94.5%). Type B PA-VSD was the most frequent anatomical pattern (46.2%), followed by Type C (27.5%) and Type A (26.4%). Twenty-four patients (26.4%) had oxygen saturations below 60%, 50 patients (54.9%) had oxygen saturations between 60% and 80%, and 17 patients (18.7%) had oxygen saturations above 80% (p=0.018). CTA demonstrated higher detection rates than echocardiography for MAPCAs (83.3% vs 47.4%, p<0.001) and pulmonary artery stenosis (25.6% vs 10.3%, p=0.012). Conclusion: CTA provides comprehensive anatomical delineation of pulmonary arteries and collateral circulation in PA-VSD and is valuable for accurate preoperative evaluation.
Copyright (c) 2026 Zia Ullah, Kamran Khattak, Yasir Rehman https://creativecommons.org/licenses/by/4.0
Awareness and practice of breast self-examination among women in Khyber Pakhtunkhwa, Pakistan: a cross-sectional study
Objectives: To assess awareness and practice of breast self-examination (BSE), identify factors contributing to the gap between awareness and practice, and determine key sources of information among women in Khyber Pakhtunkhwa, Pakistan. Methods: This cross-sectional study was conducted from September to November 2022 in Khyber Teaching Hospital, Hayatabad Medical Complex, Rehman Medical Institute and Kuwait Teaching Hospital in Peshawar. A total of 385 married women aged 20–65 years were recruited through purposive sampling. Data were collected via a pretested, validated questionnaire assessing demographics, BSE awareness, and practice. Awareness and practice were scored using predefined criteria. Data were analyzed through SPSS version-22. Results: Of 425 approached participants, 385 (90.6%) were included (mean age 36.5±11.5 years). Only 42.7% (n=164/385) had heard of BSE, and overall awareness was low, with 84% (n=323/385) not aware, 12.9% (n=50/385) partially aware, and 3.1% (n=12/385) substantially aware. Among those aware, social media (26.2%) and home sources (25.0%) were the main information channels. Practice of BSE was suboptimal; 62.8% (n=103/385) had never been taught by healthcare staff. Overall, 26.8% (n=44/164) demonstrated excellent practice, 53 (32.3%) had good, 51 (31.1%) had average, and 16 (9.8%) had poor practice. Higher educational level was significantly associated with better awareness (p=0.032), and higher awareness was strongly associated with better practice (p<0.001). Conclusion: Awareness and practice of BSE among women in Khyber Pakhtunkhwa are suboptimal, with significant gaps influenced by education and information sources. Targeted health education strategies, particularly through social media platforms, are essential to improve early breast cancer detection practices.
Copyright (c) 2026 Wahab Zia, Syed Abdur Rehman Shah, Aqsa Haider, Muhammad Adeel Khan, Junaid Imran, Rubeena Gul https://creativecommons.org/licenses/by/4.0
Comparison of iron, zinc and ferritin among the mothers of small for gestational age and appropriate for gestational age: a case control study
Objective: To evaluate and compare the nutritional status of mothers of small for gestational age (SGA) and appropriate for gestational age (AGA) infants by assessing dietary intake and biochemical parameters, including serum iron, ferritin, and zinc levels. Methods: This case–control study was conducted from October 2020 to June 2021 in tertiary care hospitals of Peshawar, Pakistan. Eighty postnatal mothers (40 SGA; 40 AGA), aged 15–35 years with singleton pregnancies, were enrolled. Socio-demographic, socioeconomic, and reproductive data were collected using structured questionnaires. Dietary intake was assessed through 24-hour recall and analyzed using WinDiet® software adapted for local foods. Anthropometric measurements were recorded for BMI calculation. Hemoglobin, serum iron, ferritin, and zinc levels were measured using standardized laboratory techniques. Data were analyzed using SPSS version 20. Results: Among 80 mothers (Mean age: 24.75±5.06 years), 40% had a normal BMI. Maternal age and BMI did not differ significantly between groups; however, SGA mothers were significantly shorter and had lower pregnancy weight gain and fewer antenatal visits (P <0.01). Anemia was present in 48.8% of mothers, with iron deficiency observed in 50% and zinc deficiency in 37.5%, but no significant differences in biochemical parameters were found between groups. Dietary analysis revealed significantly lower energy, macronutrient, mineral (iron, zinc, calcium, magnesium, iodine), and vitamin intake among SGA mothers (P <0.05). Conclusion: Although biochemical micronutrient levels were comparable, mothers of SGA infants had significantly poorer dietary intake. Maternal nutritional inadequacy may contribute to impaired fetal growth, emphasizing the need for strengthened antenatal nutritional interventions.
Copyright (c) 2026 Nida Khan, Sadia Fatima, Rubina Nazli, Jamila Haider, Faryal Shams https://creativecommons.org/licenses/by/4.0
Impact of diabetes mellitus on pain intensity and health-related quality of life in knee osteoarthritis: a cross-sectional study
Objectives: To examine the association between diabetes mellitus (DM) and knee pain severity, as well as health-related quality of life (HRQoL), in adults with knee osteoarthritis (KOA). Methods: This cross-sectional study was conducted from December 2022 to March 2023 at three healthcare centers in Bahawalpur, Pakistan. A total of 360 patients aged 45–80 years diagnosed with KOA, with or without DM, were recruited through convenience sampling. Knee pain intensity was assessed using the Visual Analogue Scale, and HRQoL was evaluated using the Short Form-36 questionnaire. Demographic and clinical data were collected through structured questionnaires. Chi-square tests were applied to examine associations, with statistical significance set at p <0.05. Results: Among the 360 participants, 215 (59.7%) were females. Most participants were aged 45–54 years (38.9%), followed by 55–64 years (33.6%), 65–74 years (19.7%), and 75–80 years (7.8%). Socioeconomic status was predominantly middle-class (159, 44.2%). Knee pain intensity was moderate in 176 (48.9%) participants and severe in 139 (38.6%). Diabetes mellitus was present in 198 (55.0%) participants. HRQoL was reported as severe in 137 (38.0%) and very severe in 36 (10.0%) participants. Chi-square analysis showed a significant association between knee pain intensity and HRQoL (χ²=366.14, p=0.001), while the association between diabetes and HRQoL was not statistically significant (χ²=5.040, p=0.283). Conclusion: Diabetes mellitus was not significantly associated with knee pain severity or HRQoL in patients with KOA. However, increasing pain severity was strongly linked to worsening HRQoL, highlighting the importance of effective pain management in improving patient outcomes.
Copyright (c) 2026 Muhammad Sabir, Muhammad Waqas Ghauri, Mahad Saleem, Shabana Rahim, Muhammad Aamir, Ali Akbar https://creativecommons.org/licenses/by/4.0
Effect of Bruegger’s and Egoscue exercise on anterior pelvic tilt in lower crossed syndrome: a randomized clinical trial
Objective: To investigate the comparative effects of Bruegger’s exercise and Egoscue exercise on anterior pelvic tilt in individuals with lower crossed syndrome (LCS). Methods: This single-center, parallel-group randomized clinical trial (NCT06303388) was conducted at Pakistan Railway General Hospital, Rawalpindi. A total of 34 participants (aged 20–50 years) with LCS were randomly allocated into two groups. Group A received Bruegger’s exercise, while Group B received Egoscue exercise, alongside standardized conventional physiotherapy (hot packs and muscle stretching). The intervention comprised 12 sessions over four weeks. Anterior pelvic tilt was measured pre- and post-intervention using a pelvic inclinometer. Data were analyzed using the Wilcoxon signed-rank test for within-group comparisons and the Mann–Whitney U test for between-group differences. Results: The mean age of participants was 26.45±4.41 years, with 85.3% females. Both groups demonstrated significant reductions in anterior pelvic tilt after four weeks (Bruegger’s: median 12 to 9, p <0.001; Egoscue: median 12 to 9, p <0.001). Within-group effect sizes were large (Bruegger’s r = 0.63; Egoscue r = 0.64). However, no statistically significant difference was observed between groups at baseline (p = 0.327) or post-intervention (p = 0.793), with a negligible between-group effect size (r = 0.04). Conclusion: Both Bruegger’s and Egoscue exercises significantly improve anterior pelvic tilt in individuals with LCS, with no evidence of superiority of one intervention over the other. However, given its simplicity and ease of execution, Bruegger’s exercise may offer a more practical and feasible option in clinical settings.
Copyright (c) 2026 Azka Batool, Muhammad Affan Iqbal https://creativecommons.org/licenses/by/4.0
Tube cholecystostomy as a bridge to cholecystectomy in acute cholecystitis: a retrospective study
Objective: To determine the efficacy and safety of percutaneous cholecystostomy tube placement preceding cholecystectomy in the management of acute cholecystitis. Methods: This descriptive retrospective study was conducted at Interventional Radiology Department at Shifa International Hospital, Islamabad after obtaining ethical approval (IRB# 0381-23, October 10, 2023). Medical records of patients who underwent ultrasound-guided percutaneous cholecystostomy from January 2016 to December 2023 were reviewed using Radiology Information System. Fifty-eight patients with acute cholecystitis were included. Patients with gallbladder perforation, biliary peritonitis, coagulopathy, contrast allergy, or incomplete records were excluded. Data were collected on a structured proforma and analyzed using SPSS version-25. Outcomes assessed included demographic characteristics, comorbidities, type of cholecystitis, subsequent cholecystectomy, and procedure-related complications. Results: Fifty-eight patients underwent cholecystostomy tube placement; 31 (53.4%) were males and 27 (46.6%) females, with a mean age of 69.4±10.3 years. Calculous cholecystitis was present in 50 (86.2%) patients, while 8 (13.7%) had acalculous cholecystitis. Hypertension (27.5%) and diabetes mellitus (31.0%) were the common comorbidities. Following stabilization, 23 (39.6%) patients underwent cholecystectomy at an average interval of 32 days, predominantly laparoscopic (82.6%). Among acalculous cases, two patients expired, while three had successful tube removal after tubogram confirmation of biliary patency. The remaining calculous cases were managed conservatively. Major complications included accidental tube slippage (n=2; 3.4%), drain dislodgement into the peritoneum (n=1; 1.7%), and death (n=2; 3.4%). Conclusion: Percutaneous cholecystostomy is a safe and effective temporizing or definitive management option in high-risk patients with acute cholecystitis, facilitating delayed surgery or conservative treatment with a low complication rate.
Copyright (c) 2026 Zahid Amin Khan, Ahmed Moqeet, Amna Mehboob, Atif Iqbal Rana, Jamshaid Anwar, Maria Rauf https://creativecommons.org/licenses/by/4.0
Impact of HbF inducers use on anti-cardiolipin and anti-beta2-glycoprotein I antibody levels in beta-thalassemia patients: a pilot study
Objective: To determine the levels of anti-cardiolipin (aCL) IgM/IgG and anti-β2-glycoprotein I (anti-β2-GPI) IgM/IgG antibodies in β-thalassemia patients receiving fetal hemoglobin (HbF) inducers. Methods: This cross-sectional study was conducted from June-2024 to November-2025 at Peshawar General Hospital, Peshawar. Ethical approval was obtained from Institute of Pathology and Diagnostic Medicine, Khyber Medical University (Ref# KMU/IPDM/IEC/2024/21). Forty-two diagnosed β-thalassemia patients aged ≥1 year receiving HbF inducers (hydroxyurea 10–20 mg/kg and/or thalidomide 2–3 mg/kg) for at least six months were enrolled using convenient sampling. Patients with prior thromboembolic events, bleeding disorders, or acute illness were excluded. Serum aCL (IgM, IgG) and anti-β2-GPI (IgM, IgG) antibodies were measured using chemiluminescence immunoassay. Appropriate Statistical analysis was performed using GraphPad Prism 10.2.3, with p ≤0.05 considered statistically significant. Results: Out of 42 β-thalassemia patients, 66.7% were male with a median age of 4.0 years (range 1.3–25). Majority (n=34) received combination HbF-inducing therapy, while four received thalidomide monotherapy and four received hydroxyurea monotherapy. Median antibody levels were as follows: anti-cardiolipin (aCL) IgM 2.22 U/mL and IgG 2.49 U/mL; anti-β2-glycoprotein I (anti-β2-GPI) IgM 2.23 U/mL and IgG 1.11 U/mL. All measured values were below the established positivity cut-off (≥20 AU/mL). No statistically significant differences were observed between males and females, and no correlation was found between antibody levels and age (p >0.05). Conclusion: In β-thalassemia patients receiving HbF inducers, no detectable aCL or anti-β2-GPI antibodies were identified, and no association with age or gender was observed, suggesting no antibody elevation with hydroxyurea or thalidomide therapy.
Copyright (c) 2026 Gulab Fatima Rani, Hazrat Bilal, Komal Khan, Ahmad Al-Ibad https://creativecommons.org/licenses/by/4.0
Nursing faculty perception on simulation-based education: a qualitative exploratory study at public and private nursing schools
Objective: To explore the perceptions of nursing faculty regarding simulation-based education (SBE), and to identify its facilitators and barriers in undergraduate nursing education. Methods: An exploratory qualitative study was conducted in four nursing institutions (three private, one public) in Pakistan. Faculty members meeting inclusion criteria were recruited through purposive sampling. Data were collected through face-to-face, focus group discussions using a semi-structured, pilot-tested interview guide developed from literature. Discussions were audio-recorded, transcribed verbatim, and analyzed manually using content analysis as described by Creswell and Creswell (2018). Trustworthiness was ensured through member checking, peer review, and detailed contextual descriptions. Ethical approval was obtained from Aga Khan University Ethical Review Committee (Ref: 2023-7968-23860). Results: Thirty-three participants contributed to the study. Four major themes emerged: (1) nursing faculty viewpoints on SBE, (2) facilitators of SBE, (3) barriers to SBE, and (4) future directions of simulation. Faculty perceived SBE as an effective teaching-learning strategy that enhances clinical skills, critical thinking, and patient safety. Facilitators included student engagement and proactive faculty initiatives. Major barriers were limited financial and material resources, lack of regulatory support, and insufficient faculty training. The fourth theme highlighted the future of simulation, emphasizing faculty development, resource availability, and strengthened institutional and regulatory support for effective SBE implementation. Conclusion: SBE is recognized as a valuable pedagogical approach in nursing education; however, its implementation is constrained by resource limitations, lack of expertise, and inadequate regulatory frameworks. Strengthening faculty capacity, infrastructure, and policy support is essential to optimize the integration of SBE in nursing curricula.
Copyright (c) 2026 Saira Mehboob Ali Lalani, Salma Rattani, Zohra Kurji, Sadaf Zindani, Barbara Wilson-Keates https://creativecommons.org/licenses/by/4.0
V-set immunoregulatory receptor gene mutation and neonatal combined immunodeficiency in a consanguineous family
Objective: To explore the potential association between a VSIR gene mutation and primary combined immunodeficiency (CID) in a patient from a consanguineous family. Methods: This family-based genetic study was conducted after obtaining ethical approval from the Institutional Review Board of HBS Medical and Dental College, Islamabad (Ref: HBS/IRB/19/25). A 2-month-old female presenting with recurrent infections was clinically evaluated. Laboratory investigations included complete blood count, serum immunoglobulins, and lymphocyte subset analysis by flow cytometry. Whole exome sequencing (WES) was performed to identify potential genetic variants, followed by variant filtering, in-silico pathogenicity prediction, and segregation analysis using Sanger sequencing in available family members. Results: The patient presented with recurrent infections, marked leukocytosis (WBC: 86.5 × 10⁹/L), thrombocytosis, and hypogammaglobulinemia (low IgA, IgM, and IgG). Flow cytometry demonstrated elevated CD3⁺, CD4⁺, and CD8⁺ T-cell counts with reduced NK cells. Whole-exome sequencing identified a rare homozygous missense variant in the VSIR gene (c.593C>T; p.Thr198Met), encoding VISTA, a negative immune checkpoint regulator. The variant lies in a conserved region, has a very low allele frequency (0.00008122), and was predicted to be deleterious (CADD score: 26.2). Segregation analysis confirmed autosomal recessive inheritance, and no other pathogenic variants were identified in known primary immunodeficiency genes. Conclusion: This study highlights a potential role of VSIR mutations in immune dysregulation and combined immunodeficiency, particularly in consanguineous populations. The identified variant may contribute to abnormal T-cell regulation and hypogammaglobulinemia. Further functional studies are required to establish causality and clarify the role of VISTA in immune homeostasis.
Copyright (c) 2026 Muhammad Imran, Laibah Mariam Akbar, Harris Romaan Raja, Maria Batool, Rabea Nasir, Muhammad Hussain, Syed Irfan Raza https://creativecommons.org/licenses/by/4.0
Digital professionalism and social media use among healthcare workers in tertiary care hospitals of Peshawar, Pakistan: a cross-sectional study
Objective: To examine digital professionalism and social media use among healthcare workers in tertiary care hospitals of Peshawar, Pakistan. Methods: This cross-sectional analytical study was conducted from July-September 2024 at three tertiary care hospitals in Peshawar: Khyber Teaching Hospital, Hayatabad Medical Complex, and Lady Reading Hospital. A total of 301 healthcare workers (doctors, nurses, and paramedics) who were active social media users were recruited through convenience sampling. Data were collected using a validated 27-item questionnaire assessing digital professionalism across eight domains. Responses were recorded on a 5-point Likert scale. Data were analyzed using SPSS version-23. Results: The mean age of participants was 32.62±7.83 years, with a predominance of males (73.4%). Doctors constituted 59.1% of the sample. Most participants reported daily use of technology (80.1%) and engagement in digital professional networks (59.5%), with WhatsApp being the most used platform (44.9%). High levels of adherence were observed in domains of confidentiality (78.1%), respect for colleagues (82.1%), and ethics (77.1%). However, gaps were noted in conflict-of-interest disclosure, with 22.6% never reporting financial or commercial interests. The mean digital professionalism score was highest among doctors (116.96), followed by nurses (112.94) and paramedics (111.74), with a statistically significant difference between groups (F=3.61, p=0.028). Conclusion: Healthcare workers in Peshawar demonstrated generally high levels of digital professionalism, with comparatively higher scores among doctors, particularly in domains of ethical conduct and confidentiality. However, gaps in conflict-of-interest disclosure and boundary management persist. Targeted training and clear institutional guidelines are recommended to promote responsible social media use in healthcare settings.
Copyright (c) 2026 Ishfaq Ali, Humera Adeeb, Fawad Iqbal, Ayesha Khan https://creativecommons.org/licenses/by/4.0
Violence against doctors: a wound as old as medicine
There is something deeply contradictory about a civilization that claims to hold its healers in the highest regard yet tolerates violence against them as a routine occupational hazard. Violence directed at physicians is not a recent social pathology; it is a wound as old as medicine itself, and one that has widened with each passing decade. The Code of Hammurabi, inscribed around 1754 BCE, mandated the cutting off of a surgeon’s hands if his patient died or lost an eye.1 This was institutionalised retribution, the earliest formal codification of the idea that a physician’s failure merited physical punishment. Civilizations change; this impulse, it appears, does not. The historical record is unambiguous. During the Black Death, when the plague killed at least a third of Europe’s population between 1347 and 1351, plague doctors contracted by municipalities to treat the dying were attacked, defamed, and abandoned to the disease they were expected to cure.2 The fourteenth-century surgeon Guy de Chauliac, who served as papal physician in Avignon during the outbreak, recorded that physicians felt useless and ashamed, many refusing to visit the sick out of fear of infection, while those who did faced fury from bereaved and desperate families.2 In nineteenth-century Edinburgh, the Burke and Hare murders exposed how public contempt for the methods of medicine could erupt into mob violence directed at anatomists and their institutions.3 These are not isolated historical curiosities; they are the deep roots of a problem that continues to grow. Contemporary data confirm that violence against doctors is a global crisis of considerable magnitude. Between 8 and 38 percent of health workers worldwide suffer physical violence at some point in their careers, with many more experiencing threats or verbal aggression.4 A systematic review and meta-analysis of 253 studies involving more than 331,000 healthcare workers found that 61.9 percent had been exposed to some form of workplace violence in the preceding year, with verbal abuse accounting for 57.6 percent of incidents and physical violence affecting 24.4 percent.5 From 2002 to 2013, the rate of serious violent incidents in healthcare settings was more than four times greater than in private industry as a whole, with healthcare accounting for nearly as many serious violent injuries as all other industries combined.6 The 2023 CDC Vital Signs report documented that harassment at work among healthcare workers more than doubled between 2018 and 2022, rising from 6 to 13 percent.7 In China, the Ministry of Health recorded approximately 10,000 violent incidents against medical staff in 2005, a figure that rose to more than 17,000 by 2010.8 In March 2012, a seventeen-year-old patient at the First Affiliated Hospital of Harbin Medical University fatally stabbed Wang Hao, a junior doctor uninvolved in his case, and injured three other physicians; an online poll found that 65 percent of respondents selected happiness as their reaction to the killing.8 Between 2003 and 2013, 101 serious incidents of medical violence in China resulted in 24 deaths among healthcare workers.9 In India, three quarters of doctors report facing verbal or physical abuse, with relatives initiating violence in 70 percent of cases.10 Pakistan demands particular attention from this journal’s readership. Earlier data from a public teaching hospital in Lahore documented that 73.8 percent of healthcare workers had experienced violence in the preceding year, with patients’ relatives identified as the most common assailants.11 A more recent nationwide survey across Pakistan found that 77.6 percent of Pakistani doctors had been exposed to violence in the preceding ten months, with patient attendants responsible in 87 percent of cases and 67.8 percent of physicians reporting that they felt unsafe at work.12 Doctors in Khyber Pakhtunkhwa were specifically identified as more likely to experience workplace violence than those in any other province of Pakistan.12 The Khyber Pakhtunkhwa Healthcare Service Providers and Facilities (Prevention of Violence and Damage to Property) Act was enacted in 2020, yet remained largely unimplemented as late as 2024, prompting repeated strikes by the Young Doctors Association and the Provincial Doctors Association, who described hospital staff working in fear while the government dragged its feet on enforcement.13 The recent murder of a female doctor in Kohat, shot while returning home from duty, and the subsequent suspension of healthcare services across the province, brought these failures into sharp and tragic relief.14 That our own province leads the country in this grim statistic is not merely a public health failure; it is a governance failure of the most consequential kind. The causes of this crisis are structural, cultural, and psychological in equal measure. Overcrowded hospitals, long waiting times, inadequate resources, and the absence of effective grievance redressal mechanisms create environments in which the fear and grief of patients’ relatives are directed at the most visible available target.4,5 Mental illness, alcohol or drug use, and a history of volatile behaviour in patients or their companions are recognised risk factors, as are emergency and psychiatric settings, which consistently carry the highest burden of violence globally.5,6 Media narratives that default to blaming doctors when patients die, unrealistic public expectations of medicine’s power, and near-total impunity for perpetrators together degrade the social covenant that once protected the physician’s person. Under-reporting compounds the problem; studies indicate that only a minority of incidents are formally recorded, in part because physicians have correctly concluded that reporting changes nothing.4 In Khyber Pakhtunkhwa, a law exists on paper that could change this calculus. Its non-implementation is an institutional abdication that has already cost lives.13,14 The consequences extend far beyond the individual harmed. Healthcare workers who experience violence suffer posttraumatic stress disorder, depression, anxiety, and burnout at rates substantially higher than the general population, and the organisational costs include lost wages, staff replacement, reduced patient satisfaction, and preventable errors in care.5 Physicians who feel unsafe withdraw from the public sector, reduce clinical engagement, practise defensive medicine, or emigrate. The healthcare system injures itself through the very act of attacking those who sustain it. Addressing this crisis requires more than legislation, though legislation that is actually implemented is an essential beginning. Comprehensive prevention frameworks built on management commitment, hazard identification, engineering controls, training, and robust post-incident support have been shown to reduce violence in healthcare settings and are strongly recommended by occupational safety authorities.6 Global medical bodies and leading journals have called on governments and institutions alike to treat violence against doctors not as an occupational inevitability but as a preventable public health emergency requiring urgent, coordinated action.4,15 These frameworks require institutional leadership that supports rather than abandons its clinical workforce, media that bring the same nuance to death in hospitals that they would bring to any other complex human tragedy, and a social recognition that the hospital is not an arena for the settlement of grievances, but a sanctuary where the shared work of healing takes precedence over every other claim. The historical record, stretching from Hammurabi to the streets of Kohat, has been making this argument for nearly four thousand years. It is time the argument was finally heard.
Copyright (c) 2026 Shiraz Jamal Khan https://creativecommons.org/licenses/by/4.0
The use of multiple true/false and single-best-answer questions across the medical curriculum: strengths and limitations from an evidence-informed perspective
The adoption of Single Best Answer (SBA) and Multiple True or False (MTF) questions in the assessment of medical students within an Outcome-Based Education (OBE) framework continues to evolve toward competency-based training. This necessitated an urgent effort to evaluate the effectiveness of various assessment methods in fostering clinical reasoning, knowledge application, and decision-making skills. The current viewpoint highlights the strengths and limitations of both SBA and MTF formats, emphasizing their suitability in different stages of medical education. While MTF questions offer broad content coverage and efficiency in assessing foundational knowledge in preclinical years, SBA questions are better suited for higher-order cognitive skills and real-world clinical decision-making in the later clinical years. The discussion underscores the necessity of a strategic combination of these formats to align with OBE principles, ensuring that medical graduates are well-equipped for professional practice. This viewpoint is an attempt to provide insights for medical educators, curriculum designers, and policymakers seeking to refine assessment strategies in undergraduate medical training. By advocating for a balanced approach to assessment, the article contributes to ongoing efforts to enhance the validity, reliability, and effectiveness of medical examinations. This topic aligns well with the journal’s focus on medical education innovation and curriculum development, making it a timely and relevant addition to your publication.
Copyright (c) 2026 Marwan Saad Azzubaidi https://creativecommons.org/licenses/by/4.0
Artificial intelligence and the future of physicians: replacement or partnership?
As artificial intelligence (AI) tools are becoming more integrated in healthcare, claims that AI will soon displace physicians are also growing. We believe that this assertion is premature and warrants deeper examination. This viewpoint first acknowledges the emerging and promising roles of AI in various specialties such as radiology, pathology, and cardiology, where AI tools and algorithmic models can assist in image analysis, predictive risk modelling, and optimize clinical workflow. It then challenges the narrative of “doctor replacement,” by proposing four arguments: (1) A “physician” encompasses many roles and many cannot be automated; (2) passing standardized exams or diagnostic challenges cannot be equated with true clinical competence and clinical care provided in a variety of setting; (3) medical practice extends beyond accurate diagnosis to include clinical judgment, experience, ethical reasoning, and individualized management strategies; (4) patients seek human connection, empathy, trust, and presence; qualities that AI cannot authentically replicate. We propose a roadmap for physician–AI cooperation, promoting AI literacy for physicians at all levels, hybrid workflows, and improving human clinical skills in the time of rapid technological advancements. We argue that AI should augment, not replace, physicians.
Copyright (c) 2026 Farooq Azam Rathore, Fareeha Farooq https://creativecommons.org/licenses/by/4.0