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Background: Graves’ disease (GD) is an autoimmune disorder with genetic predisposition and CD40 plays a pathogenic role in various autoimmune diseases. A single nucleotide polymorphism (SNP) at position –1 of the Kozak sequence of the 5 untranslated region of CD40 gene of exon 1 has been reported to be associated with the development of GD. Objective: The aim of the present study was to investigate whether CD40 gene polymorphism confers susceptibility to GD in Kumaon region. CD40 gene polymorphisms were studied in GD patients (n=50) and healthy control subjects without anti-thyroid autoantibodies or a family history of autoimmune disorders (n=50). Material and Method: CD40 gene polymorphisms were studied in fifty GD patients and fifty healthy control subjects. All samples collected from STG Hospital, Haldwani, Nainital. A C/T polymorphism at position –1 of the CD40 gene was measured using the polymerase chain reaction restriction fragment length polymorphism. Results: There was no significant difference in allele or genotype frequency of the CD40 SNP between GD and control subjects. There was a significant decrease in the TT genotype frequency in the GD patients, who developed GD after 40 years old, then those under 40 years of age. These data suggest that the SNP of CD40 gene is associated with susceptibility to later onset of GD. Conclusion : The CD40 gene was a new susceptibility gene for GD within certain families because it was both linked and associated with GD. Keywords: Autoimmune Diseases, Pathogenesis, Diagnosis, Therapy

Abstract Breast cancer (BC) significantly contributes to cancer-related mortality in women, underscoring the criticality of early detection for optimal patient outcomes. Mammography is a key tool for identifying and diagnosing breast abnormalities; however, accurately distinguishing malignant mass lesions remains challenging. To address this issue, we propose a novel deep learning approach for BC screening utilizing mammography images. Our proposed model comprises three distinct stages: data collection from established benchmark sources, image segmentation employing an Atrous Convolution-based Attentive and Adaptive Trans-Res-UNet (ACA-ATRUNet) architecture, and BC identification via an Atrous Convolution-based Attentive and Adaptive Multi-scale DenseNet (ACA-AMDN) model. The hyperparameters within the ACA-ATRUNet and ACA-AMDN models are optimized using the Modified Mussel Length-based Eurasian Oystercatcher Optimization (MML-EOO) algorithm. The performance is evaluated using a variety of metrics, and a comparative analysis against conventional methods is presented. Our experimental results reveal that the proposed BC detection framework attains superior precision rates in early disease detection, demonstrating its potential to enhance mammography-based screening methodologies.

Background Little is known about the burden and clinical characteristics of children with nutritional anemia in the population of westernUttar Pradesh. This research was conducted to assess the risk factors and clinical profile of nutritional anemia in children admitted at a tertiary care center in western Uttar Pradesh, India. Materials and methods This hospital based cross-sectional study involved 220 subjects aged 6 months to 12 year presenting with anemia (nutritional) as per WHO definition at our center. Structured questionnaires were used to collect socioeconomic and demographic characteristics of the family and child. Blood samples were collected for estimation of hemoglobin, serum iron, B12 and folate levels. Univariate and Multiple logistic regression was used to calculate adjusted odds ratios and the corresponding 95% confidence intervals. Results In our study, the majority of subjects were having moderate anemia (53.64%) followed by severe form (25.46%). Iron deficiency was found in 67.27% of the subjects. Pallor was found to be the commonest sign (71.36%) followed by tachycardia (27.27%). Majority of subjects reported microcytic hypochromic anemia (74.54%) followed by macrocytic anemia. On multiple regression: younger age, higher birth order, lower SES, poor nutritional status and lower serum iron, B12 and folate concentration were significantly associated with moderate to severe nutritional anemia. Conclusion: In northern India, nutritional anemia still poses a significant problem not only among younger children but also among older ones. Iron deficiency continues to be the primary cause of this condition, however, B12 and folate deficiencies also have substantial contributions.

Estimation of plant community composition, aboveground biomass and carbon stock is crucial for understanding forest ecology, strengthening environmental management, and developing effective tools and policies for forest restoration. This study was conducted in nine different forest reserves in Sri Lanka from 2012 to 2018 to examine the impact of community-based forest restoration (CBFR) on stand structural attributes, aboveground biomass, and carbon stock compared to state-managed forests. In total, 180 plots (90 plots in community-managed restoration blocks (CMRBs) and 90 plots assigned to state-managed restoration blocks (SMRBs)) were sampled at the study site. To conduct an inventory of standing trees, circular plots with a radius of 12.6 m (equivalent to an area of 500 square meters) were established. The Shannon diversity index, Allometric equations and Difference in Differences (DID) estimation were used to assess the data. Our study provides evidence of the positive impact of the CBFR program on enriching trees diversity. Considering stand structural attributes of both blocks showed higher trees density in the smaller diameter at breast height (DBH) category, indicating growth in both CMRBs and SMRBs. The results showed that tree biomass and carbon density were disproportionally distributed across the nine different forest reserves. On average, tree biomass and carbon density were higher in SMRBs (79.97 Mg ha−1, 37.58 Mg C ha−1) compared to CMRBs (33.51 Mg ha−1, 15.74 Mg C ha−1). However, CMRBs in Madigala reserve represent the highest biomass (56.53 and 59.92 Mg ha−1) and carbon density (26.57 and 28.16 Mg C ha−1). The results of biomass and carbon estimates were higher in all SMRBs in the nine different forest reserves compared to CMRBs. The findings suggest that future forest restoration programs in Sri Lanka should enhance participatory approaches to optimize tree species diversity, density and carbon storage, particularly in community-controlled forests. Our findings could assist developing tropical nations in understanding how CBFR impacts forest restoration objectives and improves the provision of ecological services within forests.

Abstract Long-term exposure to ambient air pollution raises the risk of deaths and morbidity worldwide. From 1990 to 2019, we observed the epidemiological trends and age-period-cohort effects on the cardiovascular diseases (CVD) burden attributable to ambient air pollution across Brazil, Russia, India, China, and South Africa (BRICS). The number of CVD deaths related to ambient particulate matter (PM) pollution increased nearly fivefold in China [5.0% (95% CI 4.7, 5.2)] and India [5.7% (95% CI 5.1, 6.3)] during the study period. The age-standardized CVD deaths and disability-adjusted life years (DALYs) due to ambient PM pollution significantly increased in India and China but decreased in Brazil and Russia. Due to air pollution, the relative risk (RR) of premature CVD mortality (

Objective: Thyroid diseases are major health problems in our society, which are manifested by alteration in hormone secretion, enlargement of the thyroid gland. FNAC plays a significant role in the diagnosis of thyroid lesions due to its simplicity and low cost and with a diagnostic accuracy rate of 92%. This study was designed to cytomorphological profile of Graves’ disease and its co relation with anti TPO antibody. Materials and Methods: This is a prospective analytical study of fifty patients with clinically enlarged thyroid gland presenting at STG Hospital, Haldwani, Nainital during Oct 2019 to Oct 2022. FNAC smears of these patients were studied and correlated with cytomorphological findings of different types, grades of thyroiditis and hormone level of T4, T3 and T.S.H. Results: Females were mostly affected by thyroid diseases than males. Female patients were 39 (78%) and male patients were 11 (22%). In the present study, patients were in the age group of 13 to 74 years of age. High T3 levels were noted in 80% high T4 levels were found in 90%. Low TSH level was found in only 64%, normal TSH level found in 34% and 2% presented with high TSH level. 34 patients (68%) found high anti-thyroid peroxidase antibody titre >34 U/ml. Cytomorphology revealed moderate to high cellularity in 88% cases, mild to moderate nuclear atypia in 86% and presence of marginal vacuoles in 82%. Lymphocytic infiltrate found in 24% cases and epithelioid cell granuloma in 14% cases. Conclusion: Thyroid cytology proves to be a reliable, simple, and cost-effective first-line diagnostic procedure with high patient acceptance and with rare, usually easily treated and not life-threatening complications. We recommend further studies with a larger population to validate our study. Keywords: Thyroiditis, Graves' Disease, Malignancy Goiter, Histopathology

Objective: To compare the use of Titanium clips and Monopolar diathermy for laparoscopic appendectomy mesoappendix closure in terms of operative time and cost. Study Design: Quasi-experiment study. Place and Duration of Study: Department of Surgery, Combined Military Hospital, Nowshera Pakistan, from Jul 2021 to Jun 2022. Methodology: A total of 70 patients who were diagnosed with acute appendicitis and were admitted for laparoscopic appendectomy were randomly divided into two groups via the lottery method. In Group-A, the closure of the mesoappendix was done using Titanium clips, and in Group-B, the ligation of the mesoappendix was done using Monopolar diathermy. Patient outcomes in terms of operative time and procedure cost were assessed. Results: Out of 70 patients, 49(70.0%) were males and 21(30.0%) were females, aged 18 to 60 years, with a mean age of 37.57±7.71 years. The overall mean weight of the patients was 65.29±12.14 kg; height was 1.71±0.12 metres; and BMI was 24.96±5.23 kg/m2, respectively. Prolonged operative time was observed in 16(45.71%) patients in Group-A, compared to 7(20.0%) in Group-B (p-value 0.022). In Group-A, the total cost of the operation was Rs. 32,000, whereas in Group-B, it was Rs. 30,000 (p-value=0.001). Conclusion: This study concluded that Monopolar diathermy for the closure of the mesoappendix is better in terms of operating time and cost as compared to the use of Titanium clips.

Abstract Pakistan is facing a high prevalence of malnutrition and Minimum Dietary Diversity (MDD) is one of the core indicators that remain below the recommended level. This study assesses MDD and its associated factors among children aged 6 to 23 months in Pakistan. The study uses a cross-sectional study using the dataset of the latest available Multiple Indicators Cluster Survey (MICS) for all provinces of Pakistan. Multistage sampling is used to select 18,699 children aged 6 to 23 months. The empirical method is the Logistic Regression Analysis and Chi-Square Test. The dataset is freely and publicly available with all identifier information removed, and no ethics approvals are required. About one-fifth (20%) of infants and young children aged 6 to 23 months had met MDD, this number varies from 17 to 29%, highest in Baluchistan and lowest in Punjab province of Pakistan. The age group (18–23) indicates a 2.45 times greater chance of having MDD. Age (

OBJECTIVES: To determine the number and configuration of canals in permanent maxillary premolars using Cone Beam Computed Tomography (CBCT) and the relationship between canals count and patient gender in northwest region of Pakistan. METHODS: This cross-sectional observational study was conducted at Khyber College of Dentistry (KCD) Peshawar, Pakistan. Data was collected from July 1st to 30th December 2020, using 133 patient’s CBCT scans with 266 maxillary premolar teeth. Roots and canals frequency as well as configurations were analyzed using Vertucci canal classification. CBCT images were obtained from Radiology department of KCD. Data were analyzed using SPSS-23 software, RESULTS: Type-I Vertucci's canal composition was most common in first premolars (45.4%), followed by Type-IV (25.9%). Type-I was the most frequent find in second premolars (64.2%), followed by Type-III (15.4%). In Maxillary first premolars, 247 (92.8%) were single-rooted and 19 (7.14%) were two-rooted. In maxillary second premolars, 155 (57.9%) were single-rooted, 110 (41.3%) were two-rooted, and one (0.37%) was three-rooted. In first & second premolar, single-root was the commonest root among males (92.7% & 58.4%) and females (30.8% and 19%) respectively. Gender-based difference in canal count in all premolars was not-significant. Mean tooth length of first and second premolar was 19.40±2.035 mm and 20.08±2.395 mm respectively. Mean crown length of first and second premolar was 6.05±0.752 mm and 5.69±0.505 mm respectively. CONCLUSION: Most of the maxillary first and second premolars had Vertucci classification Type-I configuration. Gender-based diversity for number of canals was not-significant. All Vertucci canal configuration types were observed in maxillary premolars.

Objective: To study the efficacy of per-operative angiogram and Doppler ultrasound as an adjunct to assess the cerebral vessels during intracranial aneurysm clipping surgery. Study Design: Cross-sectional study Place and Duration of Study: Department of Neurosurgery, Combined Military Hospital, Rawalpindi Pakistan, from Jan 2020 to Dec 2021. Methodology: Forty-eight diagnosed cases of subarachnoid haemorrhage secondary to ruptured aneurysm were included. All the patients who were not coiled-able (broad-based, multi-lobed, complex) were operated on (craniotomy and clipping of aneurysm). Intraoperative angiogram and Doppler ultrasound of cerebral vasculature were done in all cases to see the patency of vessels and the position of clips. Results: Mean age of the patients was 43.97±8.23 years. 24(50.00%) patients had anterior communicating artery aneurysms, 18(37.50%) had middle cerebral artery aneurysms, whereas 6(12.50%) were of an anterior cerebral artery. Craniotomy and clipping of aneurysm were done in all the cases; among them, 15(31.25%) were operated on early (between 48-96 hrs), whereas 33(68.75%) were operated on after 10-14 days. Per-operatively, cerebral angiogram and Doppler ultrasound were used to assess the cerebral vasculature and position of the clip. About of 5(10.00%) required clip readjustment, 4(8.33%) had parent vessel occlusion, 10(20.83%) required vasodilator therapy due to vasospasm, and 4(8.33%) had residual aneurysm neck. All these were rectified during the same procedure. Conclusion: Per-operative angiography and Doppler ultrasound are useful adjuncts in aneurysmal brain surgery to prevent complications like cerebral ischemia, recurrence, residual aneurysm and re-bleed.

Objective: To assess porto pulmonary hypertension by echocardiography in patients with cirrhosis and chronic viral hepatitis. Study Design: Comparative cross-sectional study. Place and Duration of Study: Gastroenterology and Cardiology Departments Combined Military Hospital, Multan Pakistan, from Mar to Dec 2020. Methodology: Fifty patients with cirrhosis due to chronic hepatitis C, B/D, with Child-Turcotte-Pugh score>6, Model for End Stage Liver Disease–Sodium score>9, were compared to a Control-Group of 50 patients with chronic liver disease due to chronic hepatitis C, B/D; for the frequency of portopulmonary hypertension in the former group. In addition to pulmonary artery pressures, tricuspid regurgitation, right ventricle to left ventricle base ratio, and right ventricle tricuspid annular plane systolic excursion were also assessed. Results: Four patients (8%) with cirrhosis (irrespective of severity) had porto pulmonay hypertension, and none in the Control-Group. The median pulmonary artery pressure in the Patient-Group was 20 mmHg (15-46), and in the Control-Group was 17 mm Hg (15-20). The Child Turcotte Pugh, Model for End Stage Liver Disease–Sodium parameters, pulmonary artery pressure and tricuspid annular plane systolic excursion were deranged in the Patient-Group and showed statistical significance. The area under the ROC curve for pulmonary artery pressure in the Patient-Group was 0.803. Conclusion: In patients with cirrhosis, 8% had portopulmonary hypertension. Echocardiography is an important screening method for the assessment of portopulmonary hypertension in this patient population.

Abstract Accurate radiogenomic classification of brain tumors is important to improve the standard of diagnosis, prognosis, and treatment planning for patients with glioblastoma. In this study, we propose a novel two-stage MGMT Promoter Methylation Prediction (MGMT-PMP) system that extracts latent features fused with radiomic features predicting the genetic subtype of glioblastoma. A novel fine-tuned deep learning architecture, namely Deep Learning Radiomic Feature Extraction (DLRFE) module, is proposed for latent feature extraction that fuses the quantitative knowledge to the spatial distribution and the size of tumorous structure through radiomic features: (GLCM, HOG, and LBP). The application of the novice rejection algorithm has been found significantly effective in selecting and isolating the negative training instances out of the original dataset. The fused feature vectors are then used for training and testing by k-NN and SVM classifiers. The 2021 RSNA Brain Tumor challenge dataset (BraTS-2021) consists of four structural mpMRIs, viz. fluid-attenuated inversion-recovery, T1-weighted, T1-weighted contrast enhancement, and T2-weighted. We evaluated the classification performance, for the very first time in published form, in terms of measures like accuracy, F1-score, and Matthews correlation coefficient. The Jackknife tenfold cross-validation was used for training and testing BraTS-2021 dataset validation. The highest classification performance is (96.84 ± 0.09)%, (96.08 ± 0.10)%, and (97.44 ± 0.14)% as accuracy, sensitivity, and specificity respectively to detect MGMT methylation status for patients suffering from glioblastoma. Deep learning feature extraction with radiogenomic features, fusing imaging phenotypes and molecular structure, using rejection algorithm has been found to perform outclass capable of detecting MGMT methylation status of glioblastoma patients. The approach relates the genomic variation with radiomic features forming a bridge between two areas of research that may prove useful for clinical treatment planning leading to better outcomes.

Introduction COVID-19 patients presenting with ocular manifestations are from 0.8% to 32% of patients seen in the ED. The available literature is scarce regarding COVID-19 patients presenting with ocular manifestations from the Middle Eastern region. Purpose This study aims to report the incidence of ocular signs and symptoms in COVID-19 patients and find any correlation between the occurrence of ocular manifestations and patients’ comorbidities. Methods All patients having the primary diagnosis of COVID-19 infection and concurrent ocular manifestations on admission to our tertiary COVID-19 health care centre were included in the study. The patient’s demographic data, comorbidities, and type of ocular manifestations were recorded from the patients’ health records retrospectively. Results In our study, 39 (7.8%) patients presented with ocular manifestations. The majority of COVID-19 patients were male, and 200 (20%) patients had a history of other comorbidities. The majority of our patients had hyperaemia (13 [33.3%]), followed by eye pain (9 [23.1%]), epiphora (8 [20.5%]), burning sensation (4 [10.3%]), and photophobia (2 [5.1%]) patients. There was no statistically significant difference in the occurrence of ocular manifestations and patients’ gender or comorbidities (p > .05). Conclusion The occurrence of ocular manifestations was lower compared to the present literature. There was no significant association between the occurrence of ocular manifestations and the patient’s gender or comorbidities.

Abstract It has been a decade since the first extensive study on the internet's adoption and use was conducted. Circumstances have changed in the last decade internet has become an essential need for every human being. Socio-psychological, economic, and personal factors play a significant role in shaping human behaviour. But their role in shaping consumer behaviour toward 5G is still unexplored. In order to determine the impact of socio-psychological elements on 5G technology adoption intention, the study integrated curiosity, perceived value, functional value, and environmental awareness into UTAUT2 and analyzed how they interact. Instead of relying on linear models, this study employed a dual-stage SEM-ANN approach because customers' decision-making process to adopt new technology is complex. Valid responses from 840 respondents were collected, investigated, and ranked using the deep learning ANN approach. All predictors were found statistically significant except social influence. ANN sensitivity analysis revealed that newly integrated predictors (environmental awareness, curiosity) are surprisingly the most important predictors, followed by facilitating conditions and perceived satisfaction. SEM-ANN hybrid two-step deep learning approach explained 83.6% variance higher than the baseline model (UTAUT2). The study improved UTAUT2 by adding new variables and expanding its canvas to predict user technology adoption. This will show how consumers react to 5G services and help telecoms grow into new markets.

Objective: To determine the efficacy of mini-craniotomy for evacuation of mix-density subdural hematoma in terms of early clinical outcome. Study Design: Quasi-experimental study. Place and Duration of Study: Neurosurgery Department, Combined Military Hospital, Rawalpindi Pakistan, from Jan to Dec 2020. Methodology: Eighty patients with mixed-density subdural hematoma were included in the study. All were subjected to minicraniotomy under general anaesthesia. Post-operative Glasgow Coma Scale (GCS) was monitored and compared with the preoperative Glasgow Coma Scale (GCS) to see the early clinical outcome of the patients. Results: Out of 80 patients with mixed-density subdural, 38(47.5%) were females, whereas 42(52.5%) were males. The mean age of the patients was 70.9±6.98 years. Improvement in Glasgow Coma Scale (GCS) after 24hrs showed that 68(85%) patients had a favourable outcome, while 12(15%) had the same condition post-operatively. Conclusion: Mini-craniotomy is a suitable surgical procedure for the treatment of mixed-density subdural hematoma.

Objective: To determine the efficacy of pre-operative meningioma embolization in terms of operating time and intraoperative bleeding. Study Design: Prospective longitudinal study. Place and Duration of Study: Department of Neurosurgery, Combined Military Hospital, Rawalpindi Pakistan, from Jan to Dec 2020. Methodology: Twelve diagnosed cases of intracerebral meningioma were included in the study. The patients were diagnosed cases of meningioma as per pre-operative signs and symptoms, radiological confirmation was done with magnetic resonance imaging, and all were subjected to pre-operative embolization of the tumour with catheter advancement in the arterial system and embolizing the target vessels with polyvinyl alcohol particles, followed by craniotomy and excision of the tumour. Results: The mean age of the patients was 47±672. 24 years. The mean operating time (from the incision to closure) was 96.17±10.23 minutes. In contrast, the intraoperative blood loss was 325.33±15.43 ml. Six (50.00%) individuals had parasagittal meningioma, 4(33.33%) were of cerebral convexity, while 2(16.66%) had lesions at sphenoid wing. Conclusion: Meningioma is a quite vascular tumour, and the operative outcome can be improved by pre-operative angioembolization. The reduced vascularity makes the resection easier by decreasing the per-op bleed and operating time. Keywords: Intraoperative bleed, Meningioma, Operating time, Pre-operative embolization.

Background. In the current era, Twitter is an increasingly popular tool for the dissemination of information as a social media voice. Social media is a valid, but underutilized, education tool at medical education institutions. Social media technologies provide opportunities for the presentation of information in alternative and multiple formats to enhance engagement, content creation, and motivation for individual and collaborative learning. Objective. This study examined the type of social structure and sub-clusters do exist regarding “MedEd” on the Twitter network. Additionally, it determined the top opinion leaders in these networks and which type of topics generates users’ interest regarding “MedEd”. Methods. This study applied NodeXL to analyze the results and retrieved Twitter data on November 1, 2022 by using the keywords “MedEd”. The data were saved and interpreted in the “vertices” and “edges” on the NodeXL worksheets. Results. We found that the top opinion leader (vertex) “Cryptovitas” had the highest in- betweenness and out-degree centrality. “Innov_medicine” had the in-degree centrality for networks. “In-Degree” and “Out-Degree” are the count of Tweets an opinion leader gets and forwards messages out, correspondingly. The study found that although “Cryptovitas” had the highest in-betweenness centrality, “taylorswift13” had the maximum number of followers (91,523,045) with in-betweenness centrality of 0.0. This indicates that the vertex having maximum influence with the largest number of in-betweenness centrality has not linked with several followers. Conclusions. Using Twitter embodies a potential prospect to engage the medical education community. The content of top networks’ tweets was around the number of “MedEd” innovations with the potential to significantly improve medical education delivery and innovative technologies in healthcare services. There is no link between the number of followers and in-betweenness centrality to influence the strength of social media voice. Although clinical and social tweets were there, not much was discussed regarding the curriculum reforms, continued professional development, technical issues in MedEd, and assessments. This triggers the insistence for rapid and innovative adaptations to the new learning environments and remarkable revolutions in medical education, including the encouragement of evidence-based education. The Twitter discussions promoted a research network circulating a wide range of informative innovations and collaborations.

Objective: To assess the outcome in patients with diabetic foot osteomyelitis being treated with antibiotics alone with those being treated with antibiotics coupled with conservative surgery. Study Design: Quasi-experimental study. Place and Duration of Study: Combined Military Hospital, Rawalpindi from Feb to Aug 2016. Methodology: Sixty patients with diabetic foot osteomyelitis, fulfilling inclusion criteria, were included in this study. They were divided into two groups of 30 each. The "Antibiotic-Group” received only antibiotics while, the "Surgical-Group" underwent surgery in addition to antibiotics. Results: There were 37 males (61.66%) and 23 females (38.33%). The average age of patients was 59.72±9.79 years. 20 patients (66.67%) had full recovery in the Surgical-Group, and in the Antibiotics-Group, 18 patients (60%) had healed wounds (pvalue=0.599) Conclusion: The outcome of antibiotics only and conservative surgery plus antibiotics is similar.

Objectives This study aimed at devising an objective method for quantifying pain in the low back region using pressure pain threshold (PPT) and demographic factors as predictive variables.Methods The research was conducted in two phases. Phase I was a longitudinal exploratory study conducted on 49 men aged 18–50 years with chronic low back pain (CLBP) recruited using non-probability purposive sampling. We used Visual Analogue Scale to record pain intensity and pain affect, and Disability Rating Index to record associated disability. PPT was measured on 12 different locations on the lower back using a manual algometer. These measurements were taken from each participant in 1 to 6-follow-up visits, depending on improvement in the individual’s symptoms. In phase II additional 33 subjects, both men and women with varying durations of low back pain were recruited using non-probability convenience sampling. Repeated measures ordinal regression and receiver’s operating characteristic curve analyses were performed to develop predictive models using STATA V.16.0 and R V.3.5.2 software. These models were given an interface using Microsoft Excel. A p value of

Background: ISARIC mortality score is a risk stratification tool that helps predict the in-hospital mortality of COVID-19 patients. However, this tool was developed and validated in a British population, and thus, the external validation of this tool in local populations is important. Objectives: External validation of the ISARIC mortality score in COVID-19 patients from a large Saudi Arabian intensive care unit (ICU). Methods: This is a retrospective study that included all adult patients with COVID-19 admitted to the ICU of King Saud Medical City, Riyadh, Saudi Arabia, from March 2020 to June 2021. Patients who were pregnant or had pulmonary tuberculosis/human immunodeficiency virus were excluded along with patients with missing variables. Data were collected to calculate the ISARIC mortality score and then fitting receiver operator characteristic curve against patients' outcome. Results: A total of 1493 critically ill COVID-19 patients were included. The mortality was 38%, the area under the curve of the score was 0.81 (95% confidence interval [CI]: 0.79–0.83, P < 0.001) and the cutoff value correctly classified 72.7% of the cohort. The cutoff value of >9 had sensitivity of 70.5% (95% CI: 66.6–74.3); specificity, 73.97% (95% CI: 71–76.8); positive predictive value, 62.4% (95% CI: 59.5–65.2) and negative predictive value, 80.2% (95% CI: 78.2–82.4). Conclusion: The ISARIC score was found to have excellent predictive ability for mortality in critically ill COVID-19 patients in our Saudi Arabian cohort. A cutoff score of >9 was the optimal criterion.

Full-house pattern on immunofluorescence (IF) on kidney biopsy in a patient without systemic lupus erythematosus is termed as nonlupus full-house nephropathy (FHN). In this study, we retrospectively compiled patients with nonlupus FHN and compared them with lupus FHN for clinicopathological presentation. We included patients with full-house IF patterns in renal biopsies collected from March 2007 to August 2018, clinical and histopathological data at the time of presentation were studied retrospectively. Treatment received and outcome at the end of follow-up was studied. Patients with nonlupus FHN who did not show any systemic disease (idiopathic group) were compared with a group of lupus nephritis patients. Of 178 patients, 34 had nonlupus FHN with 21 having idiopathic nonlupus FHN and 13 patients having secondary nonlupus FHN (membranous nephropathy, IgA nephropathy, postinfection glomerulonephritis). Males were more often in idiopathic nonlupus FHN patients than lupus FHN patients (P = 0.005). Kidney biopsies more often showed a mesangial (P = 0.0006) and less proliferative pattern of injury (P = 0.0002) and less intense C1q staining (P = 0.0001) in idiopathic nonlupus than lupus FHN. Clinically, idiopathic nonlupus FHN presented with more proteinuria (P = 0.0059) and less complement consumption (P = 0.001) than lupus FHN patients. Compared to lupus FHN, nonlupus has mainly nephrotic syndrome as clinical presentation. There was no difference in the clinical outcome between lupus FHN and idiopathic nonlupus FHN. Nonlupus FHN is not a very common condition and has less female involvement than in lupus FHN. Idiopathic nonlupus FHN has certain histopathological features with less C1q staining by IF, less frequent proliferative lesions and higher mesangial or membranous lesions by light microscopy compared to lupus FHN. Regarding outcomes, there is no significant difference between lupus FHN and idiopathic nonlupus FHN.

Abstract Cisplatin (CP) is a well-known anticancer drug used to effectively treat various kinds of solid tumors. CP causes acute kidney injury (AKI) and unfortunately, there is no therapeutic approach in hand to prevent AKI. Several signaling pathways are responsible for inducing AKI which leads to inflammation in proximal convoluted tubule cells in the kidney. Furthermore, the nucleotide-binding oligomerization domain (NOD)-like receptor containing pyrin domain 3 (NLRP3) inflammasome is involved in the CP-induced AKI. In this study, we investigated therapeutic effects of rosmarinic acid (RA) against inflammation-induced AKI. RA was orally administered at the dose of 100 mg/kg for two consecutive days after 24 h of a single injection of CP at the dose of 20 mg/kg administered intraperitoneally in Swiss albino male mice. Treatment of RA inhibited the activation of NLRP3 signaling pathway by blocking the activated caspase-1 and downstream signal molecules such as IL-1β and IL18. CP activated HMGB1-TLR4/MyD88 axis was also found to be downregulated with the RA treatment. Activation of nuclear factor-κB and elevated protein expression of cyclooxygenase-2 (COX-2) were also found to be downregulated in RA-treated animals. Alteration of early tubular injury biomarker, kidney injury molecule-1 (KIM-1), was found to be subsided in RA-treated mice. RA has been earlier reported for antioxidant and anti-inflammatory properties. Our findings show that blocking a critical step of inflammasome signaling pathway by RA treatment can be a novel and beneficial approach to prevent the CP-induced AKI.

Introduction: Pregnant females are considered as a high-risk group for the prevention and control of various communicable diseases. Therefore, this research was undertaken to study the clinic-epidemiological profile and biochemical parameters of COVID-19-positive pregnant females in a tertiary care hospital. Methods: This hospital-based retrospective study was done on COVID-19-positive pregnant females admitted during April 2020–March 2021. A total of 139 patients were included in the study. Clinical, epidemiological, hematological, and biochemical profiles were described using frequency, percentages, mean, standard deviation using Microsoft Excel software. Results: The mean age of study participants was 25.36 ± 3.79 years, mean duration of pregnancy was 37.53 ± 3.31 weeks. The majority of the patients were asymptomatic (89.2%). Abdominal pain was the most common symptom (66.7%) among symptomatic. All patients were managed conservatively. Conclusion: The study showed the mild nature of COVID-19 among pregnant females as the majority of them pregnant were asymptomatic and few presented with mild symptoms.

Objective: To compare the frequency of Pseudo-Exfoliation Syndrome (PXS) in patients undergoing cataract surgery in different regional hospitals in Pakistan. Study Design: Cross-sectional study. Place and Duration of Study: Three Tertiary Care Hospitals of Karachi, Rawalakot and Skardu Pakistan, from Sep 2017 to May 2020. Methodology: Patients aged 45 years and more undergoing age-related cataract surgery were evaluated for Pseudo-Exfoliation Syndrome. Initially, each patient underwent a complete outpatient ophthalmological workup. Demographic details like age and gender were noted. All the patients were screened for hypertension and diabetes mellitus. In addition, patients were screened for pseudo-exfoliation syndrome. Congenital, developmental, secondary and traumatic cataracts were excluded. Results: A total of 1882 patients were included in the study. Pseudo-exfoliation was carried out in 249(13.23%) patients. In Hospital-A, 23(3.23%); in Hospital-B, 145(14.92%) and Hospital-C, 81(40.70%) of the patients had pseudo-exfoliation. The frequency of pseudo-exfoliation syndrome was significantly more in Hospital-C and then in Hospital-B and least in HospitalA (p

Objectives The objective of this study was to determine the prevalence and correlates of early initiation of breast feeding and prelacteal feeding in highly disadvantaged districts in Pakistan.Design This cross-sectional study design.Settings This study was carried out in twelve districts of the Sindh province of Pakistan.Participants A total of 4800 mothers with children under 2 years, selected through a multistage random sampling method.Data analysis Bivariate association, survival analysis (Kaplan-Meier and Cox proportional hazard techniques), multivariate linear regression and the ordinary least square model were used.Results The results show that the prevalence of early initiation of breast feeding was 68% and prelacteal feeding was 32%. Adequate treatment, proper guidance at antenatal care visits, postpartum health check, normal birth with skilled birth attendants, institutional birth, skin-to-skin contact at birth and birth size were all associated with early breastfeeding initiation (p

BackgroundThis study investigates the factors associated with maternal health services utilization in Pakistan using two outcome indicators, ideal antenatal care (IANC), defined as the pregnant woman receiving all the essential services included in standard antenatal care, and skilled birth attendance (SBA).MethodsThis study used the Pakistan Maternal Mortality Survey 2019 data. The study utilized binary logistic regression models to investigate the adjusted association between the outcome variables, separately for IANC and SBA, and the independent variables, education, wealth, parity, and residence.ResultsWealth showed a positive association with utilization of IANC (adjusted odds ratio [AOR] = 11.48, 95% CI = 7.76, 16.99) and SBA (AOR = 4.37, 95% CI = 3.30,5. 80). Maternal age was associated only with IANC for women aged 35 or more years (AOR = 1.31, 95% CI = 1.06, 1.62). Increased likelihood of utilization of IANC and SBA services was also observed for women with formal education. Women who had 3-5 previous live births had higher odds of using IANC and SBA than women who had 1-2 or more than five previous live births. Urban residency was not correlated with either IANC or SBA.ConclusionWhen compared to the wealthy and educated quintile, women in the lower wealth quintile and those without any formal education were less likely to utilize ANC and SBA services. A comprehensive and multipronged approach from the health and education sectors is needed to improve maternal health in Pakistan.

Objective: To examine the impact of 30-day hospital readmission for non-communicable diseases on limited health-care resources of a low-income country like Pakistan in the light of available data from Pakistan’s Sehat Sahulat Program. Study Design: Retrospective analytical cross-sectional study. Place and Duration of Study: Health Services Academy, Islamabad Pakistan, from Jan 2016 to Jul 2020. Methodology: Secondary data of patients readmitted with non-communicable diseases in Sehat Sahulat Program, Islamabad, Pakistan. Universal sampling technique was utilized. Data was analyzed using SPSS version 27. Results: Islamabad (ICT) stands second highest for readmissions (n=1270) in which the 30-days readmission rate was 13.69%. Maximum number of readmissions were found in 50-59 years (344, 27.12%). Of 1270 ICT readmissions, 559 (44%) cases were readmitted with non-communicable diseases while rest of 711 (56%) cases were readmitted for acute infectious diseases or surgical procedures. Of 559 non-communicable diseases cases, 236 (42.21%) readmissions were having one non-communicable disease, 63 (11.27%) readmissions exhibited two or more non-communicable diseases and 260 (46.51%) were readmitted because of cancers (CA). Among males, the most common malignancy was CA lungs/ bronchus 24 (19.8%) while among females, CA Breast 80 (56.3%). Conclusion: Non-communicable diseases represent a significant burden on resource constrained, low-income countries. In view of the recurrent admissions that these chronic diseases inevitably incur, better resource allocation may help lessen this burden on fragile health systems creating better clinical outcomes for the penurious strata of Pakistan’s population.

A cross-sectional survey was conducted from February 2021 to June 2021, to assess the prevalence and nature of injuries among young professional cricketers from various academies and clubs in Lahore. The study comprised 149 cricketers representing different academies and clubs of Lahore. Injuries acquired between January and December 2019 were included as retrospective data. The findings revealed that 93 injuries were reported by 149 cricketers with a prevalence of 62.4%. Of these 41 (44%) injuries occurred during matches, 50 (54%) during practice, and 2 (2.1%) injuries were caused during fitness training. The head, neck, and face sustained 3 (3.2%) injuries, while the upper extremities received 35 (37.6%), the lower extremities 39 (41.9%), and the back and trunk 16 (17.2%). The most commonly injured players were fast bowlers 23 (24.7%). First time reported injuries were 66 (70.9%), while those repeated in the past were 16 (17.2%). --Continue

Introduction Emotional problems are leading contributors to health burden among adolescents worldwide. There is an urgent need for evidence-based psychological interventions for young people. This study aims to evaluate the effectiveness of a school-based, group psychological intervention, Early Adolescent Skills for Emotions (EASE) developed by the WHO to improve psychosocial distress in Pakistani adolescents.Method and analysis A two-arm, single-blinded, cluster randomised controlled trial, with a wait-list control arm is being conducted in school settings of rural Pakistan. Forty eligible public-school clusters have been randomised (stratified by gender) on a 1:1 allocation ratio into intervention (n=20) and control arm (n=20). Following informed consent, 564 adolescents with psychosocial distress (Youth-reported Paediatric Symptoms Checklist, cut-off ≥28) from 40 schools have been enrolled into the trial (14±3 average cluster size) between 2 November 2021 and 30th November 2021. Participants in the intervention arm will receive EASE in 7-weekly adolescents and 3-biweekly caregivers group sessions in schools. The adolescent sessions involve the components of psychoeducation, stress management, behavioural activation, problem-solving and relapse prevention. Caregivers will receive training to learn and implement active listening; spending quality time and using praise as a strategy to help their children. The primary outcome is reduction in psychosocial distress at 3 months postintervention. Secondary outcomes include symptoms of depression and anxiety, caregiver–adolescent relationship and caregivers’ well-being. Outcomes will be assessed at baseline, immediate 1 week and 3-months postintervention. Qualitative process evaluation will explore barriers and facilitators to programme implementation in low-resource school settings.Ethics Ethics approval has been obtained from Central Ethics Committee of University of Liverpool, UK, Ethics Review Committee of WHO Geneva and from the Institutional Review Board of Human Development Research Foundation (HDRF), Pakistan.Dissemination The findings of the study will be disseminated by WHO and through peer-reviewed publications.Trial registration number ISRCTN17755448.

Objective: To determine the normal value of thyroid Technetium-99m uptake value in a single centre Pakistani population. Study Design: Cross-sectional study. Place and Duration of Study: Nuclear Medical Centre, Armed Forces Institute of Pathology, Rawalpindi, from Feb 2019 to Apr 2020. Methodology: A total of 90 patients who presented to Nuclear Medical Centre for parathyroid dual radiopharmaceutical scintigraphy were included in study and selected by non-probability consecutive sampling technique. Thyroid uptake studies were calculated via gamma camera acquisition. Pre injection counts were taken from the Technetium-99m pertechnetate filled syringe, thyroid counts were taken from the anterior thyroid image 20 minutes post injection and to look for any residual radiopharmaceutical counts of the empty syringe were also taken. Results: Out of total of 90 patients, 32 (35.6%) were male while 58 (64.4%) were female with male to female ratio of 1:2. The mean age was 38.4 ± 12.7. Mean Thyroid Stimulating Hormone values were 1.6 ± 0.8 and mean T4 values were 11.9 ± 3.5. The 5th-95th percentile range was 0.4-2.2% and median was 1.2%. The interquartile range was calculated to be 0.9-1.5%. Conclusion: Normal value of thyroid Technetium-99m uptake value in a single centre Pakistani population values varies significantly as compared to global figures i.e. 0.3-4.5% and is different than the one used in our own department i.e. 0.5-2.0%.

Objective: To study clinical outcome of early versus late caffeine therapy in preterm infants. Study Design: Prospective comparative study. Place and Duration of Study: Neonatal Intensive Care Unit, Pak Emirates Military Hospital, Rawalpindi, from Jan to Jul 2018. Methodology: A total of 40 preterm infants with gestational age

OBJECTIVE: To determine the clinico-laboratory characteristics, risk factors and outcome related to acute kidney injury (AKI) in hospitalized patients. METHODS: This prospective study on 101 consecutive patients admitted to the Northwest General Hospital & Research Centre, Peshawar, Pakistan was carried out from January-March 2019. Patients were staged according to Kidney Disease Improving Global Outcomes (KDIGO) guidelines and outcomes were measured in terms of in-hospital mortality and change in KDIGO staging. RESULTS: Majority (n=57/101; 56.43%) were males. Mean age of patients was 57.90±16.93 years. Twenty-seven (26.73%) patients were in AKI stage-I, 29 (28.71%) in stage-2 and 45 (44.55%) were in stage-3. Hypertension (n=74/101; 73.27%) was the commonest co-morbid condition. Sepsis (n=39/101; 38.61%) and hypovolemia (n=21/101; 20.8%) were most common risk factors for AKI. There was complete recovery in 43 (42.57%) patients. In-hospital mortality was 6.9% (n=7/101) and 57.1% (n=4/7) of these patients had KDIGO stage-3. Serum creatinine levels declined in 22 (21.78%) cases, remained static in 23 (22.8%) and worsened in 06 (5.9%) cases. Male gender and presence of hypovolumia (p

Objective: To determine the clinical profile, selected antepartum and intrapartum risk factor for adverse short term outcomes of hypoxic ischemic encephalopathy in babies with birth asphyxia. Study Design: Cross sectional study. Place and Duration of Study: Neonatal Intensive Care Unit of Pak Emirates Military Hospital, Rawalpindi, from Jan to Dec 2018. Methodology: This study including all birth asphyxiated babies born who fulfilled the inclusion criteria. Following data was collected prospectively regarding gender, gestational age, birth weight and mode of delivery, maternal age, antenatal follow up, history of premature rupture of membranes and meconium stained liquor. Babies were categorized into different stages of hypoxic ischemic encephalopathy according to Sarnat and Sarnat staging. Selected antepartum and intrapartum risk factors leading to hypoxic insult at birth were studied and short-term outcome was recorded in the form of need of mechanical ventilation, mortality and discharge from the hospital. Results: The frequency of birth asphyxia turned out to be 122/5986 (2.03%) at our center. Thirty four (27.87%) required mechanical ventilation, mortality was recorded at 20/122 (16.39%). While 61 (50%) babies suffered from stage I hypoxic ischemic encephalopathy, 13/20 (65%) of newborn who expired were suffering from grade III hypoxic ischemic encephalopathy. Conclusion: The severity of hypoxic ischemic encephalopathy affects the outcome of newborns having birth asphyxia with hypoxic ischemic encephalopathy grade III associated with maximum mortality. Early identifycation of pregnancies at risk for asphyxia, with appropriate intervention in selected cases is the key to prevent birth asphyxia and its ensuing neonatal complications.

This study was conducted to retrospectively investigate the indications for renal biopsy in the native kidneys of children and to analyze the pathological findings in a single tertiary care hospital in North-East India for the past 12 years. All children (≤18 years) who underwent renal biopsy at our hospital from March 2007 to April 2018 were included. Renal tissue specimens were studied under light and immunofluorescence microscopy. The study group included 254 patients (female 57%). The median age was 15 years (range 6–18 years). The most frequent indications for renal biopsy were nephrotic syndrome (NS) (53.9%), urinary abnormality in systemic disease (22.1%), nephritic syndrome (15.4%), asymptomatic hematuria (4.7%), significant proteinuria (3.1%), and unexplained renal failure (0.8%). On histopathological examination, primary glomerular diseases were the most frequent (68.9%) followed by secondary glomerular diseases (30.3%) and tubulointerstitial diseases (0.8%). The most common primary glomerular diseases were minimal change disease (26.8%), focal segmental glomerular sclerosis (12.2%), diffuse proliferative glomerulonephritis (9.1%), membranous nephropathy (8.7%), IgA nephropathy (8.3%), membranoproliferative glomerulonephritis (2%), and mesangioproliferative glomerulonephritis (2%). Lupus nephritis (LN) (29.5%) was the most common secondary glomerular disease. NS was the most common indication of renal biopsy, and LN was the most common histopathological diagnosis in children ≤18 years.

Objective: To identify the most common allergy type among patients visiting an urban allergy centre. Methods: The descriptive cross-sectional study was conducted at the Allergy Centre of the National Institute of Health, Islamabad, Pakistan, from December 2019 to June 2020, and comprised subjects of either gender aged 20-50 years. Skin prick test was used to determine the skin reactivity for 11 common allergen extracts. Patients with a wheal diameter >3mm were considered positive. Data was analysed using SPSS 22. Results: Of the 100 patients, 55(55%) were males and 45(45%) were females. The overall mean age was 34.03±8.16 years. Majority of the respondents 93(93%) were sensitive to aeroallergen, 7(7%) to food allergens, and 2(2%) exhibited sensitivity against both types of allergens. Poly-sensitisation was found among 86(86%) respondents. Conclusion: Aeroallergens were found to be the main triggering factor for allergies compared to the food allergens. Continue...

Objective: To assess the safety and efficacy of Sofosbuvir based Antiviral regimens for chronic hepatitis C virus infected patients with chronic kidney disease stage 3 to stage 5D on haemodialysis. Study Design: Quasi experimental study. Place and Duration of Study: Nephrology Department, Combined Military Hospital Lahore, from Dec 2018 to Dec 2019. Methodology: Fifty patients of chronic kidney disease with stage 3 to stage 5D suffering from chronic hepatitis C were selected. Among them 30 patients were stage 3 to stage 5ND pre-dialysis patients while 20 were patients of End Stage Renal Disease (ESRD) on maintenance haemodialysis. Antiviral treatment consisted of Peg Interferon with Sofosbuvir and Ribavirin, Peg Interferon with Sofosbuvir, Ledipasvir with Sofosbuvir, Velpatsvir with Sofosbuvir and Daclatasvir with Sofosbuvir for 12 weeks. The assessments were conducted at baseline, weeks 2, 4, 8 and 12 on treatment and 12 weeks after treatment. Results: Sustained Virologic Response (SVR) was 96.8% for group treated with Ledipaspavir, Velpatsvir or Declatasvir with Sofosbuvir and 88.9% of patients in Peg IFN/Sofosbuvir/Ribavirin treated group achieved Sustained Virologic Response. Majority (90%) of the participants experienced adverse effects. Two (4%) patient on haemodialysis had treatment discontinuation due to side effects. Dose of Ribavirin was reduced in 4 (8%) patients on haemodialysis during antiviral therapy. Two deaths occurred during the study while on treatment and one death occurred four days after renal transplant. Conclusion: Sofosbuvir based antiviral regimens i.e. Peg Interferon with and without Ribavirin, Ledipasvir, Velpatsvir and Declatasvir for chronic Hepatitis C infected chronic kidney disease patients including haemodialysis patients, are well tolerated, effective and safe for treatment.

Abstract To enable delivery of a multi-component intervention comprising of strategies based on Disease Control Priorities 3rd edition for management of hypertension among hypertensive patients. The secondary objective is to test the feasibility, acceptability and adaptability of a multi-component intervention delivered at a tertiary level health-care facility in the cultural context of Pakistan. For this formative research study, we will employ qualitative research methods to explore the feasibility, applicability and acceptance of DCP3 based intervention comprising of strategies for hypertension management. Focus group discussions and in depth interviews with selected study participants will be conducted at Armed Forces Institute of Cardiology, Rawalpindi for which a prior written and verbal consent will be obtained from all research participants.

Objective: To determine the overall prevalence of overactive bladder in Pakistan, and to determine the difference in prevalence in relation to gender. Method: The multicenter study was conducted from February 2017 to October 2018 at 11 institutions across the country, and comprised randomly selected healthy subjects of either gender who were assessed on the basis of symptoms defined by the International Continence Society for overactive bladder. Data was collected using a questionnaire based on the symptoms which was filled for the respondent by designated health workers. Data was analysed using SPSS 23. Results: Of the 1291 respondents, 632(49%) were males with a mean age of 37.8+14.4 years, and 659(51%) were females with a mean age of 38.3+13.7 years. The overall prevalence of overactive bladder was 82(6.4%). Among the males, it was 15(2.4%) and among the females 67(10.2%) (p=0.001). Urgency, frequency and nocturia were reported by 82(6.4%) respondents; 15(1.2%) males and 67(5.2%) females (p=0.001). Conclusion: The prevalence of overactive bladder was found to be low when assessed with strict application of the three classical symptoms of the condition. Continuous...

Abstract Adrenal infarction is a rare cause of abdominal pain during pregnancy, and if missed, it can result in devastating clinical consequences for the mother and the child. The authors report a case of a young female who presented with severe abdominal pain and nausea. The biochemistry showed raised inflammatory markers and significant lactic acidosis. As the cause of the symptoms was not clear and the patient continued to deteriorate, a contrast‐enhanced CT abdomen and pelvis was done which was suggestive of an acute left adrenal infarction. Subsequently, the patient was confirmed to have biochemical hypoadrenalism and required replacement doses of hydrocortisone until recovery of the adrenal glucocorticoid reserve and anticoagulation for the duration of pregnancy. We discuss the workup including diagnostic imaging, follow‐up, and considerations for future pregnancies in this case.

Task allocation is a fundamental requirement for multi-robot systems working in dynamic environments. An efficient task allocation algorithm allows the robots to adjust their behavior in response to environmental changes such as fault occurrences, or other robots' actions to increase overall system performance. To address these challenges, this paper presents a Task Allocation technique based on a threshold level which is an accumulative value aggregated by a centralized unit using the Task-Robot ratio and the number of the available resource in the system. The threshold level serves as a reference for task acceptance and the task acceptance occurs despite resource shortage. The deficient resources for the accepted task are acquired through an auction process using objective minimization. Despite resource shortage, task acceptance occurs. The threshold approach and the objective minimization in the auction process reduce the overall completion time and increase the system's resource utilization up to 96%, which is demonstrated theoretically and validated through simulations and real experimentation.

SONAR signal processing plays an indispensable role when it comes to parameter estimation of Direction of Arrival (DOA) of acoustic plane waves for closely spaced target exclusively under severe noisy environments. Resolution performance of classical MUSIC and ESPRIT algorithms and other subspace-based algorithms decreases under scenarios like low SNR, smaller number of snapshots and closely spaced targets. In this study, optimization strength of swarm intelligence of Cuckoo Search Algorithm (CSA) is accomplished for viable DOA estimation in different scenarios of underwater environment using a Uniform Linear Array (ULA). Higher resolution for closely spaced targets is achieved using smaller number of snapshots viably with CSA by investigating global minima of the highly nonlinear cost function of ULA. Performance analysis of CSA for different number of targets employing estimation accuracy, higher resolution, variance analysis, frequency distribution of RMSE over the monte Carlo runs and robustness against noise in the presence of additive-white Gaussian measurement noise is achieved. Comparative studies of CSA with Root MUSIC and ESPRIT along with Crammer Rao Bound analysis witnesses better results for estimating DOA parameters which are further endorsed from the results of Monte Carlo simulations.

Buffalo represent a major source of milk in Pakistan. However, production is impacted by the disease bovine mastitis. Mastitis causes significant economic losses, with Staphylococcus aureus (S. aureus) being one of its major causative agents. While much work has been done understanding the epidemiology of bovine mastitis in Pakistan, detailed molecular characterization of the associated S. aureus is unavailable. In the current study both the epidemiological and molecular characterization of S. aureus from bovine mastitis in the Hazara division of Pakistan are examined. S. aureus was isolated from 18.41% of the animals, and left quarters more prone to infection (69.6%) than right quarters (30.4%). Sub-clinical mastitis (75.31%) was more prevalent than clinical mastitis (24.69%), with infections evenly distributed amongst the eight districts. Molecular characterization revealed that only 19.6% of the isolates were methicillin-resistant, and four strains types identified, including ST9-t7867-MSSA, ST9-MSSA, ST101-t2078-MSSA, and ST22-t8934-MRSA-IVa. Antiseptic resistance genes were not detected in the isolates, and low levels of antibiotic resistance were also noted, however the methicillin-resistant strains had higher overall antibiotic resistance. This study represents the most complete molecular typing data for S. aureus causing bovine mastitis in the Hazara district of Pakistan, and the country as a whole.

Poisonous plants cause tremendous economic losses to the livestock industry. These economic losses are deterioration in their health, decreased productivity, deformed offspring, and reduced longevity. The current study is the first comprehensive report on poisonous plants of Azad Jammu and Kashmir which systematically documents the phytotoxicological effect and mode of action in livestock. The information was gathered from 271 informants including 167 men and 104 women through semi-structured interviews and literature search through available databases. The data collected through interviews was analyzed with quantitative tools viz. the factor informant consensus and fidelity level. A total of 38 species of flowering plants belonging to 23 families and 38 genera were reported. Family Asteraceae (5 spp) was the most dominant, followed by Solanaceae (4 spp), Fabaceae (4 spp), Euphorbiaceae (4 spp) and Convolvulaceae (3 spp). Among all the species collected, herbs were the dominant life form (22 spp, 57.89%), trailed by shrubs (11 spp, 28.95%), and trees (5 spp, 13.16%). Whole plant toxicity was reported to be the highest (15 spp, 39.47%), followed by leaf toxicity (12 spp, 31.58%), seed toxicity (4 spp, 7.89%), fruit toxicity (3 spp, 10.53%), latex toxicity (2 spp, 5.26%), flowers toxicity (1 spp, 2.63%), and berries toxicity (1 spp, 2.63%). The most toxic route of administration was found oral (39 spp, 40.63%), followed by intraperitoneal (24 spp, 25%), and intravenous (21 spp, 21.88%). The most commonly affected organ was found liver (20.41%), followed by gastrointestinal tract (20.341%), CNS (16.33%), skin (14.29%), kidneys (12.24%), lungs (4.04%), reproductive organs (2.04%), spleen (1.75%), blood (1.75%), heart (1.75%), urinary tract (1.75%), and pancreas (1.75%). The maximum Fic value was found for dermatological disorders (0.91), followed by the endocrine system (0.90), gastrointestinal (0.82), neurology (0.77), nephrology (0.67), cardiovascular (0.67), urinary (0.67), respiratory (0.60), sexual (0.60) disorders. Senecio vulgaris, and Ageratum conyzoides were the most important plants with fidelity level (0.95) and (0.87). Nerium oleander, Lantana camara, Leucaena leucocephala, and Ricinus communis were the important poisonous plant with maximum fidelity level (100%). Ricinus communis with reported lowest LD50 (

Recently, pharmacists in Germany were allowed to administer influenza and COVID-19 vaccines for people aged 12 years and older in order to increase vaccination coverage rates. In order to adapt the pharmacy curriculum for clinical practice, an innovative, vaccination training course using a high-fidelity simulator (HFS) was developed, implementing clinical scenarios to manage adverse events. In a randomized controlled trial using a pre and post design with pharmacy undergraduates, the intervention group interacted with an HFS, while the control group was trained with low-fidelity injection pads. Before and after the respective training, each participant went through an objective structured clinical examination (OSCE) and completed a self-assessment questionnaire and knowledge quiz. Both training methods showed a significant increase in skills, but there was also a significant greater increase in the intervention group when compared to the control group, particularly with respect to the vaccination process. Furthermore, every individual in the intervention group improved from the pre- to post-training OSCEs. Therefore, HFS has been proven to be an appropriate tool to train pharmacy students for the purposes of vaccine administration and to prepare for future challenges. Particularly, recognizing and managing adverse reactions can be addressed in a very effective way.

Objective: To evaluate the efficacy of a new& novel technique Sphenopalatine Ganglion Block (SPG) for the treatment of post duralpunctural headache (PDPH) at Combined Military Hospital, Skardu. Study Design: Case series. Place and Duration of Study: The study was conducted at department of Anesthesiology, pain and intensive care, Combined Military Hospital, Skardu, from Mar to Oct 2017. Material and Methods: Total of 53 patients of PDPH fulfilling inclusion criteria were offered SPG block and their response was quantified on visual analogue scale (VAS) from 0-10. Results: Out of total n=53 all the patients were females, the age of the patients were between 18-37 years, with themean of 27.08 and ± SD of 5.188), VAS score before undergoing SPG block was between 8 and 10 with the mean of 9.377 ± SD 0.664. For the patients after undergoing SPG block significant decrease on mean i.e. 1.175 with ±SD 0.657 was noted with p-value

Late diagnosis of treatable breast cancer is the reason for higher breast cancer mortality. Until now, no public breast cancer facility has been established in the Islamabad Capital Territory. First, a Federal Breast Screening Center (FBSC) was established. Afterward, awareness campaigns about breast cancer were organized among the public. Subsequently, women above 40 years of age were provided with mammography screenings. Data were analyzed in SPSS version 22.0. An intervention was performed using a six tier approach to strengthening the health system. Utilizing the offices of the FBSC and the national breast cancer screening campaign, breast cancer awareness has become a national cause and is being advocated by the highest offices of the country. The number of females undergoing mammography has increased each year, starting from 39 in 2015 to 1403 in 2019. Most of the cases were BI-RAD I (n = 2201, 50.74%) followed by BI-RAD II (n = 864, 19.92%), BI-RAD III (n = 516, 11.89%), BI-RAD IV (n = 384, 8.85%), BI-RAD V (n = 161, 3.71%), and BI-RVAD VI (n = 60, 1.38%). The current study has theoretical and practical implications for the contemplation of policymakers. The FBSC can serve as a model center for the establishment of centers in other parts of the country, thereby promoting nationwide screening coverage.

The aim of this study was to investigate the seroprevalence of Q fever in sheep and goats in Kasur, Okara, and Pakpattan in the Punjab of Pakistan. Q fever is a widely reported zoonotic disease caused by Coxiella (C.) burnetii. The main reservoirs are small ruminants that excrete the bacteria in birth by-products in high numbers. Thus, the bacteria can also be detected in the air and the dust of livestock farms. The infection is often asymptomatic in ruminants, but it can lead to reproductive disorders. This cross-sectional study found that a significant number (n = 43; 11.3%) of 300 randomly selected small ruminants of nine tehsils were seropositive using a commercially available ELISA. Seroprevalence was significantly higher in goats (17.1%) than in sheep (4.9%). Binary logistic regression analysis proved that species, age, and breed have a significant effect on the prevalence of Q fever. Tick infestation, contact with animal fomites, contact with other animals, production system, and health status of an animal had a significant impact on the prevalence of Q fever. These findings on Q fever in animals can be used to improve the visibility of this zoonotic disease. These findings will help local health authorities to focus on the origin of the problem and facilitate applying preventive measures to the affected livestock farms.

Using an audience response system (ARS) is very effective to improve learning through active participation and enhanced interaction among medical students. Although the validity of ARS in engagement during the learning process is clear, we know little about its impact on self-motivation. Aim: This study aimed to investigate the effectiveness of ARS as compared to other used methods such as quizzes on paper/verbal questioning and analyzed how ARS nurture motivation among medical students. Methods: This is mixed-method research and assessed the medical student's perceptions about the use of ARS and its role in the augmentation of motivation for learning. We used a google doc questionnaire for data collection and the qualitative part of the study we conducted by semi-structured focused group discussions to explore the impact on self-motivation. For data analysis, we applied students paired t-test, and a p-value of less than 0.05 determined the significant correlation between ARS and other methods of formative assessment (quiz on paper/verbal questions). We coded the focused group discussions and identified themes based on the grounded theory. Results: There is a significant correlation (P value= 0.008) for the comfort level of the formative assessment methods with ARS as compared to quizzes on paper/verbal response. ARS helped significantly to enhance the self-evaluation and self-motivation through instant comparisons of the results with the rest of the audience with P-value=0.027 and 0.021 respectively. ARS is a validated and proficient tool to assess student's learning and generating self-motivation. Conclusion: In medical education, ARS enhances the opportunity to recognize the knowledge gaps and encouraged conceptual learning. It provided students with a powerful insight into the learning of key concepts and self-assessment. Using ARS triggers not only motivation but also generates novel ideas and lifelong learning skills.

Vehicular Ad hoc Networks (VANETs) an important category in networking focuses on many applications, such as safety and intelligent traffic management systems. The high node mobility and sparse vehicle distribution (on the road) compromise VANETs network scalability and rapid topology, hence creating major challenges, such as network physical layout formation, unstable links to enable robust, reliable, and scalable vehicle communication, especially in a dense traffic network. This study discusses a novel optimization approach considering transmission range, node density, speed, direction, and grid size during clustering. Whale Optimization Algorithm for Clustering in Vehicular Ad hoc Networks (WOACNET) was introduced to select an optimum cluster head (CH) and was calculated and evaluated based on intelligence and capability. Initially, simulations were performed, Subsequently, rigorous experimentations were conducted on WOACNET. The model was compared and evaluated with state-of-the-art well-established other methods, such as Gray Wolf Optimization (GWO) and Ant Lion Optimization (ALO) employing various performance metrics. The results demonstrate that the developed method performance is well ahead compared to other methods in VANET in terms of cluster head, varying transmission ranges, grid size, and nodes. The developed method results in achieving an overall 46% enhancement in cluster optimization and an F-value of 31.64 compared to other established methods (11.95 and 22.50) consequently, increase in cluster lifetime.