Jinnah Sindh Medical University

Primary caregivers of critically ill ICU patients experience substantial psychological stress, yet this burden remains understudied in lower middle-income countries such as Pakistan. This study assessed the magnitude and predictors of perceived stress among primary family caregivers of patients admitted to medical and surgical ICUs at three tertiary care hospitals in Karachi. A cross-sectional study was conducted among 161 primary caregivers at Jinnah Postgraduate Medical Center, Civil Hospital Karachi, and Liaquat National Hospital. Data were collected through interviews using the Perceived Stress Scale (PSS-10; range 0–40). Ethical approval and informed consent were obtained. Univariable multinomial logistic regression identified factors associated with stress levels, followed by multivariable multinomial logistic regression including significant or clinically relevant predictors. Overall, 65.8% experienced moderate stress (n = 106), 24.8% (n = 40) low stress, and 9.3% (n = 15) high stress. Female caregivers experienced significantly higher stress than males (p = 0.03), and those with comorbidities had elevated stress (40.0%, p = 0.02). Caregivers of medical ICU patients reported greater stress than those in surgical ICUs (p < 0.001). Sepsis, severe infection, and neurological diagnoses predicted moderate stress. Previous hospitalizations and ICU admissions were also associated with higher caregiver stress. Over half reported unaddressed psychological distress (51.2%, n = 82), and 65.4% (n = 104) had unmet mental health needs. After adjustment, medical ICU admission, caregiver comorbidities, and prior ICU admission independently predicted higher stress. Caregivers of critically ill patients experience clinically significant stress, particularly those caring for medical ICU patients and those with comorbidities. High level of unmet psychological needs highlights the urgent requirement for improved communication, targeted interventions, and the integration of psychological support in routine ICU protocols. This could help reduce caregiver burden and enhance patient care in low-resource settings.

Abstract PURPOSE In Pakistan, strong familial bonds make family members as primary caregivers for patients admitted to intensive care units (ICUs). Despite continuous multidisciplinary care in ICUs, caregivers’ mental health needs are often overlooked, creating a significant psychological burden alongside critical decision-making responsibilities. This multicenter cross-sectional study assessed the prevalence and severity of depression among primary caregivers of ICU patients in tertiary-care hospitals in Karachi, Pakistan. METHOD This study was conducted from February to July 2025 in the ICUs of Jinnah Postgraduate Medical Centre (JPMC), Liaquat National Hospital (LNH), and Civil Hospital Karachi (CHK). A total of 161 primary caregivers of medical and surgical ICU patients were enrolled. Participants completed the validated Urdu version of the Patient Health Questionnaire-9 (PHQ-9) and provided sociodemographic as well as clinical data. Eligible participants were first-degree relatives or friends able to communicate in English, Urdu, or Sindhi. Data were analyzed using SPSS version 26 with descriptive statistics, chi-square tests, and multivariable linear regression to identify independent factors associated with PHQ-9 scores. RESULTS The median PHQ-9 score was 6 (IQR: 2–11). Depression severity included 41.6% minimal, 25.5% mild, 19.3% moderate, 9.9% moderately severe depression, and 3.7% severe depression. On multivariable linear regression, admission to a medical ICU, patient mechanical ventilation, and a higher number of caregiver comorbidities were independently associated with higher PHQ-9 scores. Sleep disruption and witnessing other patients’ suffering were strongly associated with increased depressive symptoms. CONCLUSION Primary family caregivers of ICU patients experience a substantial burden of depressive symptoms, highlighting the need for targeted psychological support, language-sensitive communication, and institutional policies addressing caregiver mental health in resource-limited settings.

The author has nothing to report.

This commentary explores the pervasive challenge of malnutrition and diarrhea, particularly among vulnerable populations such as children and cancer patients, and highlights the limitations of conventional treatments such as standard oral rehydration solutions (ORSs). Drawing on recent evidence, it examines the emerging role of amino acid-based nutritional formulations, with a focus on branched-chain amino acids (BCAAs), VS001, and VS002A, in addressing both nutrient deficiencies and gut dysfunction. The commentary reviews mechanistic and clinical data demonstrating that BCAAs and specialized amino acid-enriched ORSs can promote mucosal healing, improve nutrient absorption, and reduce gastrointestinal symptoms, including those related to chemotherapy. Clinical studies show promising results for VS001 and VS002A in reducing the severity of diarrhea, enhancing hydration, and supporting recovery in both pediatric and oncology settings. While these interventions show considerable potential for transforming supportive care for malnutrition-related diarrhea, further large-scale randomized trials are needed to establish their efficacy across diverse patient populations.

Background:Hysteroscopy, a popular outpatient gynecological procedure, often requires sedation due to pain caused by endometrial manipulation and cervical dilation. Propofol, the current standard sedative, has adverse effects like respiratory depression, hypotension, and injection discomfort. Ciprofol, a novel GABA-A receptor agonist and structural analog of propofol, might be a safer choice while maintaining efficacy.Objectives:This systematic review and meta-analysis aims to compare the efficacy and safety of ciprofol versus propofol for sedation during hysteroscopy.Design:A systematic review and meta-analysis of randomized controlled trials (RCTs).Data sources and methods:This systematic review and meta-analysis adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RCTs comparing ciprofol and propofol for hysteroscopic sedation were sourced from PubMed, Cochrane, Scopus, Google Scholar, and ClinicalTrials.gov. Data extraction, quality assessment (ROB-2), and analysis were conducted independently. Outcomes included efficacy, safety, and recovery metrics.Results:Six RCTs with 1890 patients were met with inclusion. Ciprofol achieved similar sedative success as propofol (risk ratio (RR) = 1.00, 95% CI: 1.00–1.00) and surpassed propofol in important safety outcomes. It significantly reduced intraoperative body movements (RR = 0.53), injection pain (RR = 0.13), hypotension (RR = 0.58), and respiratory depression (RR = 0.67), while increasing eyelash reflex suppression (MD = 0.24). Ciprofol was also associated with a slightly longer recovery time compared to propofol (MD = 0.80 min). Bradycardia incidence and procedure duration did not differ significantly.Conclusion:Ciprofol displays a better safety profile, including enhanced hemodynamic and respiratory stability and decreased injection discomfort, and is just as effective as propofol for sedation during hysteroscopy. According to these results, ciprofol is a safe alternative to propofol for hysteroscopy. It is advised that further multicenter studies are required to confirm its effectiveness across broader populations.Trial registration:The meta-analysis has been registered with PROSPERO. The registration number is CRD420251091116.

Coronary artery bypass grafting (CABG) is a common surgical treatment for coronary artery disease; however, long-term success is limited by saphenous vein graft (SVG) occlusion. Aspirin remains the standard lifelong antiplatelet therapy; however, graft failure and adverse events persist after its use. More potent agents, such as ticagrelor, have been proposed, although the evidence is inconsistent, and concerns about bleeding risk remain.We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing ticagrelor-based therapy with aspirin monotherapy in patients who underwent CABG. A comprehensive literature search of major databases was performed until August 2025. The primary endpoints were major bleeding, MACE, and all-cause mortality. The secondary outcomes included saphenous vein graft failure, stroke, myocardial infarction, and repeat revascularization. Pooled risk ratios (RR) with 95% confidence intervals (CI) were calculated using a random-effects model.Five randomized controlled trials comprising 4,208 patients (ticagrelor-based therapy ≈ 2,108; aspirin monotherapy ≈ 2,100) were included. Across the primary clinical endpoints, ticagrelor-based therapy showed no significant advantage over aspirin, with comparable rates of MACE (RR 1.05, 95% CI 0.78-1.41; p = 0.75; I² = 20%), all-cause mortality (RR 1.02, 95% CI 0.74-1.40; p = 0.93; I² = 0%), and major bleeding (RR 1.09, 95% CI 0.68-1.74; p = 0.73; I² = 51%). Similarly, no significant differences were observed for stroke (RR 1.10, 95% CI 0.70-1.75; p = 0.67; I² = 0%), myocardial infarction (RR 1.52, 95% CI 0.94-2.46; p = 0.09; I² = 27%), or repeat revascularization (RR 1.02, 95% CI 0.71-1.45; p = 0.93; I² = 7%). In contrast to the neutral clinical outcomes, ticagrelor-based therapy was associated with a significant reduction in saphenous vein graft (SVG) failure compared with aspirin monotherapy (RR 0.62, 95% CI 0.50-0.78; p < 0.0001; I² = 0%). Subgroup analysis revealed no meaningful differences between ticagrelor monotherapy and ticagrelor plus aspirin for major clinical events.Ticagrelor-based therapy did not reduce major clinical outcomes (MACE, mortality, MI, stroke, revascularization, or major bleeding) compared with aspirin after CABG, although it was associated with improved SVG patency. Routine use cannot be recommended; ticagrelor may be considered in selected high-risk patients. Further large, long-term trials are needed to determine whether patency benefits translate into improved clinical outcomes.

Objectives: Acute aortic dissection (AAD) is a critical vascular emergency with distinct outcomes for type A and type B patients. Despite recent improvement in surgical outcomes and lower mortality, the long-term impact of the false lumen status on future patients’ outcomes remains uncertain. This systematic review and meta-analysis aimed to comprehensively evaluate the long-term prognostic implications of false lumen status in patients presenting with AAD. Methods: A meticulous literature search was conducted in PubMed, Embase, Scopus, Web of Science, and Cochrane Central, covering the period from 1995 to April 2023, in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria encompassed studies on AAD reporting the prognostic impact of false lumen status, with a follow-up duration exceeding one year. Two independent researchers conducted data extraction and quality assessment. Study quality was assessed using the Newcastle-Ottawa Scale. Meta-analysis was performed using the Comprehensive Meta-Analysis (CMA) software. Random effects. odel of data synthesis was chosen with effect size measure selected as hazard ratio, and heterogeneity was assessed with the Higgins I 2 statistic. Results: The review encompassed 20 studies involving 4247 patients with AAD. Patent false lumen was significantly associated with increased long-term mortality (hazard ratio [HR] = 1.73, 95% confidence interval [CI] 1.25–2.39, P = 0.001, I ² = 2.6%) and aortic events (HR = 2.80, 95% CI 1.71–4.75, P &lt; 0.001, I² = 55.6%), with stronger associations observed in Asian populations compared with non-Asian cohorts. The analysis revealed a significant correlation between patent false lumen and heightened risks of both long-term mortality and aortic events in both types A and B AAD patients. Partially thrombosed false lumens showed an association with increased long-term mortality, particularly in type A aortic dissection cases, while completely thrombosed false lumens did not exhibit significant associations with adverse outcomes. Subgroup analyses showed a higher risk of long-term mortality in type A compared to type B, particularly among Asian populations with smaller sample sizes and shorter follow-up durations. Conclusion: The present systematic review provides critical insights into the relationship between false lumen status and long-term outcomes in AAD. This will help in risk assessment and tailoring treatment for these patients. Strict long-term follow-up is warranted in patients with patent false lumen, and selective late intervention may be considered in high-risk individuals based on clinical judgment.

Background: The accelerating pace of urbanization worldwide has highlighted the improvement of disaster response in cities as a global priority. Yet, there remains a poor understanding of the emergency response to mass casualty incidents (MCI) in these environments. This study aimed to develop a conceptual framework for cities responses and potential policy levers. Methods: We conducted a scoping review followed by in-depth interviews (IDIs), focus group discussions (FGDs), and a modified Delphi process to develop the framework for Cities Assessment of Mass Casualty Emergency Response and Action (CAMERA). Results: CAMERA framework consists of six essential components of urban emergency response systems: 1) communication, 2) safety and security, 3) human resources, 4) policy and plans, 5) command control and coordination, and 6) care delivery. IDIs and FGDs also provided insight on assessment methodologies for evaluating response capacity. Using these components, we then developed a framework consisting of a diagnostic and management approach that city leadership can undertake in MCI management to ensure effective functioning at various levels of incident response. Conclusion: The CAMERA framework offers novel and simplified guidance to policymakers and other stakeholders in their attempt to improve MCI response systems across cities globally.