Medicine and Health Sciences Commons^™

Anti-Nmda Receptor Encephalitis, Zaid Waqar, Haris Majid Rajput, Muhammad Hassan, Iqra Athar, Neelma Naz Khattak, Mazhar Badshah

Pakistan Journal of Neurological Sciences (PJNS)

Anti N-methyl-D-aspartate receptor (NMDA)receptor encephalitis is one of the most common type of auto immune encephalitis. Its diagnosis is often delayed due to initial clinical presentation with psychiatric clinical features. Initial clinical features resemble those of acute psychosis or depression which later evolve into frank neurological dysfunction. This was first described in association with ovarian teratoma, but it was later also found to exist without neoplastic association and in men as well. It occurs more frequently in younger age group, mostly below 50 years of age. Diagnosis is established with the help of cerebrospinal fluid (CSF) analysis for oligo clonal …

Gaba-B Encephalitis In Pakistan: A Rare But Treatable Entity, Asfandyar Khan Niazi, Shafain Shaikh, Arsalan Ahmad, Ayesha Zafar, Tahir Aziz Ahmed

Pakistan Journal of Neurological Sciences (PJNS)

Autoimmune and paraneoplastic encephalitides are a group of neurologic disorders that present with cognitive decline, neuropsychiatric symptoms, movement disorders, or seizures. These diseases can present before, with, or after the diagnosis of malignancy. We report two cases of GABA-B encephalitis from Pakistan. The first patient was a 67-year-old gentleman presented with cognitive decline and neuropsychiatric symptoms. His CSF analysis showed increased protein levels and GABA-B receptor antibodies. He was treated with pulse steroids, which improved his symptoms. The second patient was a 34-year-old lady with cognitive decline and psychomotor symptoms. Her serum autoimmune antibody panel showed antibodies against GABA-B receptors. …

Association Of Hypomagnesaemia & Hypocalcemia With Intracerebral Hemorrhage And Outcome, Muhammad Hassan, Naveed Ullah Khan, Mansoor Iqbal, Haris Majid Rajput, Ehsan-Ur- Rehman, Waleed Shahzad, Mazhar Badshah

Pakistan Journal of Neurological Sciences (PJNS)

Determine if hypomagnesemia & hypocalcemia on admission was associated with ICH and outcome.

Magnesium is a vascular smooth muscle relaxant and appears to provide protection against cellular injury in experimental stroke models. The implication of low serum magnesium in primary ICH is not well defined.

All patients with a primary ICH presented to PIMS, Islamabad prospectively analyzed in a pilot study. Demographics, initial lab values, ICH location, Mg+2 level, NIHSS & MRS at presentation were recorded. All patients with INR <= 1.5 were included in this study. We took normal serum magnesium in our study was 1.8 - 2.5 mEq/dL. Statistical significance was determined using linear regression adjusting for admission systolic blood pressure (SBP).

We identified 66 patients who met the inclusion criteria. The mean age was 52.76 years with minimum and maximum age …

Criminal Thinking Styles And Criminal Social Identity Among Juvenile Delinquents: Moderating Role Of Parenting Styles, Fatima Sana, Muhammad Rafiq, Muhammad Nasar Iqbal

Pakistan Journal of Neurological Sciences (PJNS)

Parenting is considered imperative in the development of juvenile's cognitions, and beliefs. The parent-child relationship might significantly influence juvenile’s thought patterns and social communications. Different parenting styles perhaps indicate criminal involvement of juveniles, resultantly turns them into delinquent. The present study was done to discover whether parental authority styles moderate the path that links criminal thinking styles to criminal social identity amongst juvenile delinquents. Participants of the study were 211 juvenile delinquents who responded on Juvenile Criminal Thinking Styles’ Inventory (Sana & Rafiq, 2019), Measure of Criminal Social Identity (Boduszek, et al., 2012), Parental Authority Questionnaire (Babree, 1997) and approached …

Valproate Used In Women Of Childbearing Age With Epilepsy, Salman Mansoor, Kevin Murphy, Siobhan Kelly, Shoab Saadat

Pakistan Journal of Neurological Sciences (PJNS)

Valproate is one of the oldest known anti-epileptic drugs (AED) in practice which was discovered in 1881 and later in 1962 was approved for treating epilepsy. It is indicated in most of the seizure types including generalized onset (motor, non-motor and myoclonic), focal onset, unknown onset and unclassified. Valproate has other indications in migraine prophylaxis, and bipolar disorder.

Early Neurological Deterioration After Acute Stroke; Mechanism And Predictors, Bushra Ammad Taimuri, Sajid Hameed, Mohammad Wasay

Pakistan Journal of Neurological Sciences (PJNS)

Neurological deterioration after acute ischemic stroke (AIS)is a common occurrence, leading to increased mortality, morbidity, and poor quality of life among stroke survivors. Recognition of the individuals at a greater risk for neurological deterioration may contribute to making early decisions and monitoring the therapy. Neurological deterioration arises in up to 40% of subjects after AIS during hospitalization and is followed by neurological and functional debility. Numerous predictors have been devised that predict this progression. This includes preliminary assessment of the severity of stroke, brainstem infarction, hyperglycemia, atrial fibrillation, diabetes mellitus and substantial fluctuations in blood pressure. Sequential observations, in depth …

Migraine And Fasting, Lubna Ashraf Jafri, Mohammad Wasay

Pakistan Journal of Neurological Sciences (PJNS)

Migraine is considered as the second leading cause of disability worldwide, most commonly seen in young women. Skipping meals, dehydration and fasting are among many triggering factors which have been described in literature as a cause of increased frequency and severity of migraine attacks. The underlying pathophysiology, prevention and management of fasting induced migraine has been documented, however, there is a lack of randomized controlled trials for the same. This review article discusses these important aspects in the light of published literature and gives directions on future areas of research.

Juvenile Dermatomyositis And Posterior Reversible Encephalopathy Syndrome: A Rare Association., Shazma Shamim

Pakistan Journal of Neurological Sciences (PJNS)

Juvenile dermatomyositis or JDM is a rare but debilitating pediatric disease that affects the proximal muscles and skin, as implied by its name. Although rare, it is the most common childhood idiopathic inflammatory myopathy (1). The estimated incidence is 3.2 cases per million children (2). The diagnosis is based on clinical signs and symptoms supported by investigations including, but not limited to, muscle biopsy, muscle enzymes and EMG studies. Bohan and Peter’s criterion is most widely used for diagnosis. It includes the presence of Gottron’s rash, raised muscle enzymes, proximal muscle weakness and suggestive findings on muscle biopsy (3). Treatment …

Reflections Of An Earliest Established Screening And Testing Facility For Covid-19 In The Largest Metropolis, Pakistan, Fatima Kanwal, Karishma Kanhya Lal, Asra Qureshi

Department of Family Medicine

As the world struggles to deal with the COVID-19 pandemic, this article talks about the experience and findings of the first COVID-19 screening facility in a tertiary care hospital in Karachi, Pakistan. Department of Family Medicine at Aga Khan University (AKU) took initiative where COVID-19 screening of stable patients first began in a dedicated area. Since testing kits were limited and community spread had not started, nurses would screen every walk-in patient based on the presence of fever, cough, travel history and exposure to COVID-19 positive patient in the last 14 days, and advise swab testing if indicated. Out of …

Spermatocytic Tumor Of Testis In A Young Male, Madiha Bilal Qureshi, Nasir Ud Din, Zubair Ahmad, Saira Fatima

Department of Pathology and Laboratory Medicine

Spermatocytic tumor is a rare germ cell tumor not related to germ cell neoplasia in situ, and derived from postpubertal-type germ cells. It was previously called "Spermatocytic Seminoma" due to false belief of its origin from germ cell neoplasia in situ. The tumor usually occurs in an older age group and orchidectomy is curative. We present a case of spermatocytic tumor in a 25-year male who presented with right-sided testicular swelling and right-sided varicocele. Radiology revealed a 9.8 × 9 cm testicular mass and the patient underwent right-sided orchidectomy. Microscopic examination showed classic morphology with three characteristic cell types and …

Maxillofacial Prosthodontists Are Needed For The Rehabilitation Of Patients With Congenital And Acquired Craniofacial Defects, Syed Murtaza Raza Kazmi, Farhan Raza Khan

Section of Dental-Oral Maxillofacial Surgery

No abstract provided.

Mental Health Disorders Among Healthcare Workers During The Covid-19 Pandemic: A Cross-Sectional Survey From Three Major Hospitals In Kenya, Jasmit Shah, Aliza Monroe-Wise, Zohray Talib, Alphonce Nabiswa, Mohammed Said, Abdulaziz Abeid, Sood Mohamed, Mohamed Ali Mohamed, Sayed Karar

Internal Medicine, East Africa

Background: COVID-19 is an international global health emergency and has posed a great challenge to mental well-being and resilience. Little is known about the mental health impact of COVID-19 among healthcare workers (HCWs) in sub-Saharan Africa or other low-resource settings.

Methods: We conducted a cross-sectional study between August and November 2020 among HCWs recruited from three major hospitals in Kenya. The survey questionnaire consisted of six components: demographic and work title characteristics; information regarding care of patients with COVID-19; and symptoms of depression, anxiety, insomnia, distress and burnout, measured using standardised questionnaires. Multivariable logistic regression analysis was performed …

Association Between Dialysate Sodium Concentration And Interdialytic Weight Gain In Patients Undergoing Twice Weekly Haemodialysis, Soraiya Manji, Jasmit Shah, Ahmed Twahir, Ahmed Sokwala

Internal Medicine, East Africa

Multiple Sclerosis In Kenya: Demographic And Clinical Characteristics Of A Registry Cohort, Imran Jamal, Jasmit Shah, Peter Mativo, Juzar Hooker, Mitchell Wallin, Dilraj Sokhi

Internal Medicine, East Africa

Background: Multiple Sclerosis (MS) is the leading cause of non-traumatic neurological disability in young adults. There is limited literature regarding the burden of MS in sub-Saharan Africa (SSA).

Objective: To describe the demographic and clinical characteristics of patients with MS (PwMS) presenting to a tertiary referral hospital in Nairobi.

Methods: We conducted a retrospective descriptive study for PwMS presenting to Aga Khan University Hospital, Nairobi from 2008–2018.

Results: 99 cases met the diagnostic criteria for MS with a male to female ratio of 1:4. Majority (68.7%) of PwMS were indigenous Africans with a mean age of onset …

Prevalence Of Allergic Fungal Sinusitis Among Patients With Nasal Polyposis, Rahim Dhanani, Shayan Khalid, Basit Salam, Hamdan Ahmed Pasha, Farah Hafiz Yousuf, Mubasher Ikram

Section of Otolaryngology, Head & Neck Surgery

Objective: To determine the frequency of allergic fungal sinusitis among patients with nasal polyps, and to compare Lund-Mackay scores of patients with and without allergic fungal sinusitis.
Methods: The cross-sectional longitudinal study was conducted at a tertiary healthcare centre in Karachi, Pakistan, from December 2016 to November 2018, and comprised patients with sinonasal polyposis undergoing surgery. The patients were categorised as having allergic fungal sinusitis when histopathology showed allergic mucin with fungal hyphae and culture was positive for fungal growth. Lund-Mackay scoring of each patient was noted and mean scores of allergic fungal sinusitis and non-allergic fungal sinusitis patients were …

The Contribution Of Dysphagia To Acute Stroke Morbidity And Mortality In Nigeria: A Prospective Study, O O. Olajide, Philip Adebayo, F T. Taiwo, M O. Owolabi, A Ogunniyi

Internal Medicine, East Africa

Background: The assessment of time-trend morbidity and mortality in acute stroke is critical to clinical policy decisions and resource allocation.

Objectives: To determine the prevalence of dysphagia in acute stroke and the impact of dysphagia on short term stroke outcome (30 days post-stroke).

Methods: This was a prospective longitudinal study. Bedside screening for dysphagia modified Rankin score (MRS) and Barthel Index (BI) were performed on acute stroke patients on day 1, day 7, day 14 and day 30 after stroke to determine the frequency of dysphagia. Patients with dysphagia were then compared with age- and gender-matched controls (stroke patients without …

Clinical, Neuroimaging, And Molecular Spectrum Of Tecpr2-Associated Hereditary Sensory And Autonomic Neuropathy With Intellectual Disability, Sonja Neuser, Barbara Brechmann, Gali Heimer, Ines Brösse, Susanna Schubert, Lauren O'Grady, Michael Zech, Siddharth Srivastava, Shahnaz Ibrahim, Fatima Khan

Department of Paediatrics and Child Health

Bi-allelic TECPR2 variants have been associated with a complex syndrome with features of both a neurodevelopmental and neurodegenerative disorder. Here, we provide a comprehensive clinical description and variant interpretation framework for this genetic locus. Through international collaboration, we identified 17 individuals from 15 families with bi-allelic TECPR2-variants. We systemically reviewed clinical and molecular data from this cohort and 11 cases previously reported. Phenotypes were standardized using Human Phenotype Ontology terms. A cross-sectional analysis revealed global developmental delay/intellectual disability, muscular hypotonia, ataxia, hyporeflexia, respiratory infections, and central/nocturnal hypopnea as core manifestations. A review of brain magnetic resonance imaging scans demonstrated a …

Evaluating Motor Performance With The Bruininks-Oseretsky Test Of Motor Proficiency In Impoverished Pakistani Children, Zehra Habib Hasan, Fariha Shaheen, Arjumand Rizvi, Jelena Obradovic, Aisha Khan Yousafzai

Department of Paediatrics and Child Health

Objective: To evaluate the sensitivity of the modified Brief Form of Bruininks Oseretsky Test in identifying motor differences secondary to malnutrition and poverty.
Methods: This longitudinal cohort study was conducted at Nowshero Feroze, Sindh from 2013 to 2014 and comprised data drawn from children who participated in a randomised controlled trial, that assessed responsive stimulation and nutrition interventions in the first two years of life. Outcome measures included motor development assessed using Brief Form of Bruininks Oseretsky Test, child anthropometry and household economic and demographic information. Data was analysed using SPSS 15 and STATA 12.
Results: Of the 1058 children, …

Safety And Effectiveness Of Ultrasound Guided Peripheral Nerve Blocks: Audit At Tertiary Care Hospital, Asma Abdus Salam, Riffat Aamir, Robyna Irshad Khan, Aliya Ahmed, Azhar Rehman

Department of Anaesthesia

Objective: To assess the safety and effectiveness of peripheral nerve blocks using ultrasound.
Methods: The retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised data of all patients who received peripheral nerve blocks as part of anaesthesia care between January 2015 and January 2017. The data included outcomes of peripheral nerve block effectiveness, complications and limb conditions after the block. Peripheral nerve block effectiveness was assessed by monitoring pain scores at rest and on movement, and the requirement of co-analgesia. Complications, like numbness, motor block, metallic taste, hypotension and respiratory depression, were also assessed. Data was …

Ratio Of Height To Thyromental Distance: A Comparison With Mallampati And Upper Lip Bite Test For Predicting Difficult Intubation In Pakistani Population, Saman Tauheed Ali, Khalid Samad, Syed Amir Raza, Muhammad Qamarul Hoda

Department of Anaesthesia

Objective: To compare the accuracy of three diagnostic tests in predicting difficult laryngoscopy using Cormack and Lehane grade as the gold standard.
Methods: The cross-sectional study was conducted at the Aga Khan University Hospital, Karachi, from August 2014 to August 2015, and comprised patients who required endotracheal intubation for elective surgical procedures. The primary investigator used ratio of height to thyromental distance, upper lip bite test and the modified Mallampati test for assessing the airway correlated with laryngoscopic view based on Cormack and Lehane grading. Data was analysed using SPSS 19.
Results: Of the 383 patients, 59(15.4%) were classified as …

Intraoperative Hypothermia In Patients Undergoing Total Knee Arthroplasty: A Cross-Sectional Study From A Developing Country, Ronika Devi Ukrani, Aiman Arif, Anum Sadruddin Pidani, Obada Hussein Hasan, Shahryar Noordin

Medical College Documents

Background: Intraoperative hypothermia is associated with various risk factors, morbidity, and mortality in patients undergoing total knee arthroplasty (TKA), increasing the emotional and financial burden on patients. This study aimed to identify risk factors of intraoperative hypothermia in patients undergoing TKA.
Materials and methods: All adult patients (⩾18 years) who underwent TKA from January 2016 to December 2017 at a tertiary-care hospital in Pakistan were included in this retrospective, cross-sectional study. Temperature < 36 °C was defined as hypothermia.
Results: The study included 286 patients (77.6% female) with a mean age of 61.4 ± 10.4 years. The overall proportion of intraoperative hypothermia was 26.6%. Of the total …

Morphological Spectrum Of Vesiculobullous Skin Lesions: An Institutional Perspective, Javaria Ali, Sabeeh Islam, Syed Munqaad Ali, Syed Rafay Yaqeen, Anum Aslam, Qurat Ul Ain Khan, Umair Arshad Malik, Muhammad Irfan, Hanna Naqvi, Atif A. Hashmi

Section of Internal Medicine

Introduction: A vesiculobullous lesion of the skin encompasses a group of dermatological disorders with protean clinicopathological features. They usually occur as a part of the spectrum of various infectious, inflammatory, drug-induced, genetic, and autoimmune disorders. Therefore, accurate diagnosis of these lesions is essential for appropriate management and to reduce the associated morbidity and mortality. The conventional skin punch biopsy is the mainstay in the diagnosis of dermatological diseases, especially when combined with confirmatory tests, such as direct immunofluorescence (DIF). Our study evaluated the clinicopathological spectrum of vesiculobullous lesions.
Methods: We studied 150 cases of vesiculobullous lesions at the Department of …

A Review Of Toolkits And Case Definitions For Detecting Enteric Fever Outbreaks In Asian And African Countries From 1965-2019, Asif Khaliq, Mohammad Tahir Yousafzai, Salman Haq, Rahima Yaseen, Sonia Qureshi, Fahad Rind, Zahra A. Padhani, Ayub Khan, Abdul Momin Kazi, Farah Naz Qamar

Department of Paediatrics and Child Health

Background: This review assessed the case definitions, diagnostic criteria, antimicrobial resistance, and methods used for enteric fever outbreaks and utilization of any unified outbreak score or checklist for early identification and response in Asia and Africa from 1965-2019.
Methods: We searched enteric fever outbreaks using PubMed, Google Scholar, and the Cochrane library. Studies describing a single outbreak event of enteric fever in Asia and Africa from 1965-2019 were reviewed. We excluded case reports, letter to editors, studies reporting typhoid in conjunction with other diseases, the Centers for Disease Control and Prevention (CDC) trip reports, the World Health Organization (WHO) bulletins …

Does More Testing In Routine Preoperative Evaluation Benefit The Orthopedic Patient? Case Control Study From A Resource-Constrained Setting, Obada Hasan, Shah Fahad, Mohammad Mustafa, Pervaiz Hashmi, Shahryar Noordin

Section of Orthopaedic Surgery

Background: Routine preoperative tests in healthy patients not only cause extra anxiety, but may delay treatment without influencing surgical plan. This has worse impact in resource-constrained settings where fee for service rather than health insurance is the usual norm. Investigators aim to determine if "routine" pre-operative tests are justified in healthy orthopedic patients.
Methods: We conducted a non-commercialized, non-funded matched case control study in tertiary care university hospital and a level-1 trauma centre for healthy patients (ASA-1&2) admitted from January 2014-December 2016 for elective orthopedic intermediate and major procedures. Cases (patient who had a change in his/her surgical plan after …

Postdischarge 24/7 Hotline Service For Neurology And Neurosurgery Patients And 1-Year Impact On Readmission Rates, Unplanned Emergency Department Visits, And Patient Satisfaction, Shafqat Bibi, Rida Mitha, Kiran Bano, Farida Datoo, Nadia Karim, Muhammad Shahzad Shamim

School of Nursing & Midwifery

Objective: Telephone triage is a system in which trained nurses use standardized protocols to evaluate symptoms over the phone and determine the appropriate course of action.
Materials and methods: We implemented a protocol for systematic follow up phone calls and telephonic triage to families of neurology and neurosurgery patients after discharge, primarily to improve care transition and to assess its impact on the ratio of visits in the emergency department, readmissions, and overall satisfaction of patients and families. The intervention comprised the implementation of nurse led telephone triage and postdischarge follow up phone calls. After implementing hotline services in mind …

Acuity Level Of Care As A Predictor Of Case Fatality And Prolonged Hospital Stay In Patients With Covid-19: A Hospital-Based Observational Follow-Up Study From Pakistan, Aysha Almas, Zain Mushtaq, Jette Moller

Section of Internal Medicine

Objectives: To determine if there is an association between acuity level of care (ALC), case fatality and length of stay in patients admitted to hospital due to COVID-19.
Design: A hospital-based observational follow-up study.
Setting: Internal Medicine Service of the Aga Khan University Hospital, Pakistan, from 26 February 2020 to 30 June 2020.
Participants: Adult patients with confirmed COVID-19, aged ≥18 years.
Methods: ALC was categorised into low, intermediate and high level and patients were triaged using the standard emergency severity illness score. All patients were followed until the end of hospital admission for the outcome of case fatality and …

Impact Of Local Terminology On The Design Of A Community-Based Diagnostic And Management Algorithm For Postpartum Sepsis: Findings Of Formative Research, Shabina Ariff, Fatima Mir, Wafa Aftab, Farrukh Raza, Shujaat Zaidi, Sheraz Memon, Amnesty Lefevre, Linda A. Bartlett, Peter Winch, Sajid Bashir Soofi, Zulfiqar Ahmed Bhutta

Department of Paediatrics and Child Health

Background: Postpartum sepsis is one of the leading causes of maternal mortality and morbidity in developing countries. This formative research elicits local terms used for postpartum illnesses and symptoms of postpartum sepsis with the aim of improving postpartum diagnosis and management in Pakistan.
Methods: We conducted 34 in-depth interviews with recently delivered women (RDW), traditional birth attendants (TBAs), healthcare providers and family members of RDW from rural Sindh to explore local Sindhi terms used to describe postpartum sepsis and related symptoms. During interviews, all participants were asked to orally free list common symptoms of postpartum illnesses; those who were aware …

Violence And Abuse Among Working Children In Urban And Suburban Areas Of Lower Sindh, Pakistan, Meesha Iqbal, Zafar Fatmi, Kausar S. Khan, Asaad Ahmed Nafees

Community Health Sciences

Background: Child labourers are exposed to an insecure environment and higher risk of violence. Violence among child labourers is an under-studied phenomenon which requires contextual assessment.
Aims: We applied Bronfenbrenner's ecological model (micro-, exo- and macro-system) to understand the interplay of individual, community, societal and policy context fuelling violence.
Methods: Focus group discussions and family ethnographies of child-labourers working in common occupational sectors of suburban areas of Sindh were carried out to gain in-depth understanding of their immediate environment and abuse (micro-system). Frequency of emotional, physical and sexual violence (5-14 years; n = 634) was also determined. Indepth interviews with …

Improved First Trimester Maternal Iodine Status With Preconception Supplementation: The Women First Trial, Amy E. Young, Jennifer F. Kemp, Charis Uhlson, Jamie L. Westcott, Sumera Aziz Ali, Sarah Saleem, Ana Garcès, Lester Figueroa, Manjunath S. Somannavar, Shivaprasad S. Goudar

Community Health Sciences

Maternal iodine (I) status is critical in embryonic and foetal development. We examined the effect of preconception iodine supplementation on maternal iodine status and on birth outcomes. Non-pregnant women in Guatemala, India and Pakistan (n ~ 100 per arm per site) were randomized ≥ 3 months prior to conception to one of three intervention arms: a multimicronutrient-fortified lipid-based nutrient supplement containing 250-μg I per day started immediately after randomization (Arm 1), the same supplement started at ~12 weeks gestation (Arm 2) and no intervention supplement (Arm 3). Urinary I (μg/L) to creatinine (mg/dl) ratios (I/Cr) were determined at 12 weeks …

Metastatic Renal Cell Carcinoma To Pancreas And Gastrointestinal Tract: A Clinicopathological Study Of 3 Cases And Review Of Literature, Jamshid Abdul Ghafar, Nasir Ud Din, Ramin Saadaat, Zubair Ahmad

Department of Pathology and Laboratory Medicine

Background: Renal Cell Carcinoma (RCC) metastasizes in approximately 20-30% cases. The most common sites for metastases are the lungs, bones, liver, and brain. Metastases of RCC in the gastrointestinal tract (GIT) are very rare. Metastatic RCC has a poor prognosis. We herein present a case series of three patients with metastatic disease in the colon, duodenum, and pancreas following complete resection of RCC.
Methods: Hematoxylin and Eosin and immunohistochemical slides of 3 cases of RCC metastatic to GIT were reviewed. These cases were diagnosed between 2002 and 2019 at French Medical Institute for Mothers and Children (FMIC), Kabul, Afghanistan, and …