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Colorectal polyps are structural abnormalities of the gastrointestinal tract that can potentially become cancerous in some cases. The study introduces a novel framework for colorectal polyp segmentation named the Multi-Scale and Multi-Path Cascaded Convolution Network (MMCC-Net), aimed at addressing the limitations of existing models, such as inadequate spatial dependence representation and the absence of multi-level feature integration during the decoding stage by integrating multi-scale and multi-path cascaded convolutional techniques and enhances feature aggregation through dual attention modules, skip connections, and a feature enhancer. MMCC-Net achieves superior performance in identifying polyp areas at the pixel level. The Proposed MMCC-Net was tested across six public datasets and compared against eight SOTA models to demonstrate its efficiency in polyp segmentation. The MMCC-Net's performance shows Dice scores with confidence interval ranging between 77.43 ± 0.12, (77.08, 77.56) and 94.45 ± 0.12, (94.19, 94.71) and Mean Intersection over Union (MIoU) scores with confidence interval ranging from 72.71 ± 0.19, (72.20, 73.00) to 90.16 ± 0.16, (89.69, 90.53) on the six databases. These results highlight the model's potential as a powerful tool for accurate and efficient polyp segmentation, contributing to early detection and prevention strategies in colorectal cancer.

Abstract Efficient Waste management plays a crucial role to ensure clean and green environment in the smart cities. This study investigates the critical role of efficient trash classification in achieving sustainable solid waste management within smart city environments. We conduct a comparative analysis of various trash classification methods utilizing deep learning models built on convolutional neural networks (CNNs). Leveraging the PyTorch open-source framework and the TrashBox dataset, we perform experiments involving ten unique deep neural network models. Our approach aims to maximize training accuracy. Through extensive experimentation, we observe the consistent superiority of the ResNext-101 model compared to others, achieving exceptional training, validation, and test accuracies. These findings illuminate the potential of CNN-based techniques in significantly advancing trash classification for optimized solid waste management within smart city initiatives. Lastly, this study presents a distributed framework based on federated learning that can be used to optimize the performance of a combination of CNN models for trash detection.

Abstract Background Liver disease is within the top five causes of premature death in adults. Deaths caused by complications of cirrhosis continue to rise, whilst deaths related to other non-liver disease areas are declining. Portal hypertension is the primary sequelae of cirrhosis and is associated with the development of variceal haemorrhage, ascites, hepatic encephalopathy and infection, collectively termed hepatic decompensation, which leads to hospitalisation and mortality. It remains uncertain whether administering a non-selective beta-blocker (NSBB), specifically carvedilol, at an earlier stage, i.e. when oesophageal varices are small, can prevent VH and reduce all-cause decompensation (ACD). Methods/design The BOPPP trial is a pragmatic, multicentre, placebo-controlled, triple-blinded, randomised controlled trial (RCT) in England, Scotland, Wales and Northern Ireland. Patients aged 18 years or older with cirrhosis and small oesophageal varices that have never bled will be recruited, subject to exclusion criteria. The trial aims to enrol 740 patients across 55 hospitals in the UK. Patients are allocated randomly on a 1:1 ratio to receive either carvedilol 6.25 mg (a NSBB) or a matched placebo, once or twice daily, for 36 months, to attain adequate power to determine the effectiveness of carvedilol in preventing or reducing ACD. The primary outcome is the time to first decompensating event. It is a composite primary outcome made up of variceal haemorrhage (VH, new or worsening ascites, new or worsening hepatic encephalopathy (HE), spontaneous bacterial peritonitis (SBP), hepatorenal syndrome, an increase in Child–Pugh grade by 1 grade or MELD score by 5 points, and liver-related mortality. Secondary outcomes include progression to medium or large oesophageal varices, development of gastric, duodenal, or ectopic varices, participant quality of life, healthcare costs and transplant-free survival. Discussion The BOPPP trial aims to investigate the clinical and cost-effectiveness of carvedilol in patients with cirrhosis and small oesophageal varices to determine whether this non-selective beta-blocker can prevent or reduce hepatic decompensation. There is clinical equipoise on whether intervening in cirrhosis, at an earlier stage of portal hypertension, with NSBB therapy is beneficial. Should the trial yield a positive result, we anticipate that the administration and use of carvedilol will become widespread with pathways developed to standardise the administration of the medication in primary care. Ethics and dissemination The trial has been approved by the National Health Service (NHS) Research Ethics Committee (REC) (reference number: 19/YH/0015). The results of the trial will be submitted for publication in a peer-reviewed scientific journal. Participants will be informed of the results via the BOPPP website ( www.boppp-trial.org ) and partners in the British Liver Trust (BLT) organisation. Trial registration EUDRACT reference number: 2018–002509-78. ISRCTN reference number: ISRCTN10324656. Registered on April 24 2019.

This study sought to evaluate the influence of knowledge, attitude, and practices assessment on diabetes related to obesity in Pakistani society. Data was collected both through door to door and online survey approaches from 518 participants by using a pre-validated questionnaire. A total of 15.6% were underweight, 61.2% were normal weight, 17.2% were overweight and 5.8% were in obesity class I and 2.9% were classified as obesity class II. The co-occurrence of obesity and diabetes was 29% (n = 22) among diabetic individuals (n = 84). A majority of the residents (59.1%) were from cities. While 94% of the participants responded to what obesity was, 83.8% knew what diabetes was. Fast food, soft drinks, and mayonnaise were deemed to be healthy by 75.1% of the respondents. Obesity was viewed as a disease by 94.8%, a major health issue by 78.2%, and a weight-loss necessity by 44.6% of participants. Only 24.9% exercised every day, and 23.9% engaged in any physical activity daily. The majority of respondents (50.6%) never tried to lose weight and 23.2% ate junk food daily. The sociodemographic variables showed that the age ranges of 25–34 years (P

Abstract Introduction Bronchoalveolar lavage (BAL) is frequently used in pulmonary medicine though it requires further optimization. Practical obstacles such as patient safety and procedural limitation have to date precluded large, controlled trials aimed at standardization of BAL procedure. Indeed, BAL guidelines are based on observational data. Innovative research methods are necessary to advance the clinical practice of BAL. Methods In our study, we evaluated the effect of injecting a gelatinized barium solution into different lobes and segments of cadaveric lungs. As the technique requires an irreversible injection into lung airspaces, it is not suitable for in vivo purposes. We measured the volume returned from BAL as well as the distribution of BAL injection via dissection. Segmental anatomic orientation was compared to a radiologist's impression of plain film radiographs taken of injected lungs. Results Mean injected volume distributions were greatest in the upper lobes and lowest in the lower lobes; mean ratios of injected volume distribution to lung lobe volume also followed this trend. Cannulated bronchi orders favored lower branches in the upper lobe and higher branches in the lower lobes. Segmental anatomy varied by the lung lobe injected and was most varied in the lower lobes. Conclusion This novel gelatinized‐barium injection technique provides a minimally complex method to yield clinically meaningful feedback on the performance of BAL. The technique is also adaptable to study of procedural parameters in the context of variable lung anatomies and pathologies.

Background: Multiple factors may influence women’s experiences of urinary tract infection (UTI) and its clinical management. Aim: To explore how women’s background, symptoms, and severity of symptoms influence UTI reporting and management. Design & setting: Internet questionnaire targeting women in England, focusing on UTI symptoms, care seeking, and management. Method: A total of 1096 women aged ≥16 years with UTI symptoms in the previous year completed the questionnaire in March and April 2021. Multivariable logistic regression was ued to estimate the odds of relevant outcomes while adjusting for background characteristics. Results: Women with children in their household, who were aged under 45 years, or who were married or cohabitating were more likely to experience UTI symptoms. The odds of antibiotic prescribing were lower if women reported dysuria (adjusted odds ratio [AOR] = 0.65, 95% confidence interval [CI] = 0.49 to 0.85), frequency (AOR = 0.63, 95% CI = 0.48 to 0.83), or vaginal discharge (AOR = 0.69, 95% CI = 0.50 to 0.96), but higher if reporting haematuria (AOR = 2.81, 95% CI = 1.79 to 4.41), confusion (AOR = 2.14, 95% CI = 1.16 to 3.94), abdominal pain (AOR = 1.35, 95% CI = 1.04 to 1.74), or systemic symptoms (AOR = 2.04, 95% CI = 1.56 to 2.69). Those with abdominal pain or two or more of nocturia, dysuria, or cloudy urine had lower odds of receiving a delayed antibiotic, while those with incontinence, confusion, unsteadiness, or low temperature had higher odds of a delayed prescription. Increasing symptom severity was associated with greater odds of receiving antibiotics. Conclusion: Except for reduced prescribing if a woman had dysuria and frequency, antibiotic prescribing followed an expected pattern, aligning generally with national guidance. Symptom severity and the likelihood of systemic infection probably influenced care seeking and prescribing. Sexual intercourse and childbirth may be key times to target women with messages about UTI prevention.

Abstract Background Despite its importance, teaching at the bedside is declining over time. This purported decline has not been quantified. Quantifying bedside teaching is challenging, and we found only one study quantifying bedside teaching on a hospitalist service. Objective We conducted a study to understand the prevalence of bedside teaching in our medical intensive care unit. Methods We conducted a single-center single-unit study in the medical intensive care unit of an academic tertiary care institution. We used a survey tool to assess perceived time spent on bedside teaching, quality of teaching, and total rounding time. In parallel, independent observers objectively measured time spent on rounds and on bedside teaching. Residents were asked to complete the survey once a week. Independent observers collected data daily and weekly averages were obtained. Results 43 responses were collected over a 4-month period. Most respondents (73%) reported a total rounding time of either 90–120 min or greater than 120 min. Median reported bedside teaching time was 16–20 min with 16 respondents (37%) reporting less than 15 min and 27 respondents (63%) reporting 16 min or more. The amount of time spent on bedside teaching was reported as adequate or more than adequate by 77% (33) of respondents with 58% (25) reporting that bedside teaching was very or extremely effective in helping them learn. Mean census reported by the independent observers was 12.75 patients per team. Bedside teaching represented an average of 12% of total rounding time, 16.85 min per day. While total rounding time increased with increasing census, there was no decline in bedside teaching time. Conclusion It is reported that bedside teaching has decreased over time. Our study has demonstrated that bedside teaching occurs in our Medical ICU, and though it represents a minority of the time spent on rounds, residents still reported teaching in the ICU to be adequate.

Cystic echinococcosis (CE) is an important zoonotic diseases caused by larval form of Echinococcus granulosus sensu lato. The material of this study was the gray wolf (Canis lupus), which was found dead in the rural area of Bingol province of Turkey. The animal was brought to Veterinary Faculty for necropsy and many of adult Echinococcus spp. obtained. A total of 9 whole adult worms were morphologically examined under the microscope, gDNA was isolated from individual samples, a partial mt-CO1 gene fragment (875 bp) was amplified with PCR and sequenced. According to the phylogenetic analysis, six worms were characterized as E. equinus, while three were reported as E. canadensis (G6/7). It was found that the haplotypes of both species were similar to previously published haplotypes. This is the first report in which E. equinus and E. canadensis (G6/7) adult parasites were detected together in a gray wolf's intestine. The findings are important in that it draws attention to the importance of wild cycle in the spread of CE.

IntroductionDiabetic retinopathy (DR) is the leading cause of preventable blindness in Saudi Arabia. With a prevalence of up to 40% of patients with diabetes, DR constitutes a significant public health burden on the country. Saudi Arabia has not yet established a national screening program for DR. Mounting evidence shows that Artificial intelligence (AI)-based DR screening programs are slowly becoming superior to traditional screening, with the COVID-19 pandemic accelerating research into this topic as well as changing the outlook of the public toward it. The main objective of this study is to evaluate the perception and acceptance of AI in DR screening among eye care professionals in Saudi Arabia.MethodsA cross-sectional study using a self-administered online-based questionnaire was distributed by email through the registry of the Saudi Commission For Health Specialties (SCFHS). 309 ophthalmologists and physicians involved in diabetic eye care in Saudi Arabia participated in the study. Data analysis was done by SPSS, and a value of p < 0.05 was considered significant for statistical purposes.Results54% of participants rated their level of AI knowledge as above average and 63% believed that AI and telemedicine are interchangeable. 66% believed that AI would decrease the workforce of physicians. 79% expected clinical efficiency to increase with AI. Around 50% of participants expected AI to be implemented in the next 5 years.DiscussionMost participants reported good knowledge about AI. Physicians with more clinical experience and those who used e-health apps in clinical practice regarded their AI knowledge as higher than their peers. Perceived knowledge was strongly related to acceptance of the benefits of AI-based DR screening. In general, there was a positive attitude toward AI-based DR screening. However, concerns related to the labor market and data confidentiality were evident. There should be further education and awareness about the topic.

This study aimed to detect Hepatozoon spp. in ticks infesting asymptomatic domestic animals and to provide insight into their potential spillover from wild to domestic animals. In total, 537 tick specimens were collected in Khyber Pakhtunkhwa, Pakistan, and morphologically identified. The most prevalent tick species was Haemaphysalis cornupunctata (69; 12.8%), followed by Haemaphysalis kashmirensis (62; 11.5%), Rhipicephalus microplus (58; 10.8%), Haemaphysalis montgomeryi (51; 9.5%), Rhipicephalus sanguineus (49; 9.1%), each Haemaphysalis bispinosa and Haemaphysalis sulcata (43; 8.0%), each Hyalomma anatolicum and Rhipicephalus turanicus (37; 6.9%), Rhipicephalus haemaphysaloides (33; 6.1%) Hyalomma scupense (30; 5.6%), and Hyalomma isaaci (25; 4.7%). The extracted DNA from a subset of each tick species was subjected to PCR to amplify 18S rRNA fragments of Hepatozoon spp. By BLAST analysis, the Hepatozoon sp. detected in Hy. anatolicum infesting cows and in Ha. sulcata infesting sheep showed 99.7% maximum identity with Hepatozoon colubri. Similarly, the Hepatozoon sp. detected in R. haemaphysaloides infesting goats shared 99.49% maximum identity with Hepatozoon ayorgbor, and the Hepatozoon sp. detected in R. sanguineus infesting dogs exhibited 99.7% identity with Hepatozoon canis. Having an overall infection rate (9.3%; 16/172), the highest infection rate was recorded for each H. canis, and H. colubri (3.5%; 6/172), followed by H. ayorgbor (2.3%; 4/172). In the phylogenetic tree, H. colubri clustered with corresponding species from Iran, H. ayorgbor clustered with the same species from Croatia, Ghana, and Portugal, and H. canis clustered with the conspecifics from Iran, Israel, Romania, and Zambia. Regarding the potential spillover of Hepatozoon spp. from wildlife through ticks, free ranging animals was at higher risk compared to confined animals (RR = 3.05), animals consuming food from wildlife habitats were at higher risk compared to those consuming domestic food (RR = 3.06), and animals residing in farm buildings located in wildlife habitats were at higher risk compared to those residing in farm buildings located in villages (RR = 3.28). In addition to the first report on H. canis in R. sanguineus in Pakistan, this is the earliest data showing H. ayorgbor in R. haemaphysaloides and H. colubri in Ha. sulcata and Hy. anatolicum. These preliminary findings suggest a potential spillover of Hepatozoon spp. from wild to domestic animals via ticks under certain risk factors.

Abstract Iron deficiency is associated with a substantial burden of morbidity. However, supplementation of iron has been linked to increased rates of serious infection in randomised trials of children in sub-Saharan Africa. Randomised trials in other settings have been inconclusive and it is unknown if changes in levels of iron biomarkers are linked to sepsis in these other settings. We used genetic variants associated with levels of iron biomarkers as instrumental variables in a Mendelian randomisation (MR) analysis to test the hypothesis that increasing levels of iron biomarkers increase the risk of sepsis. In observational and MR analyses we found that increases in iron biomarkers increase the odds of sepsis. In stratified analyses, we show that this risk may be larger in those with iron deficiency and/or anaemia. Taken together, results here suggest a required caution in supplementation of iron and underline the role of iron homeostasis in severe infection.

BackgroundBreast cancer (BC) is the most common cancer in women globally. The North Africa and Middle East (NAME) region is coping hard with the burden of BC. We aimed to present the latest epidemiology of BC and its risk factors in this region.MethodsWe retrieved the data on BC burden and risk factors from the Global Burden of Disease Study 2019 to describe BC status in the 21 countries of the NAME region from 1990 to 2019. We explored BC incidence, prevalence, deaths, disability-adjusted life years (DALYs), and attributable burden to seven risk factors of female BC, namely, alcohol use, diet high in red meat, low physical activity, smoking, secondhand smoke, high body mass index, and high fasting plasma glucose. Decomposition analysis on BC incidence trend was done to find out the contributing factors to this cancer’s growth.ResultsIn 2019, there were 835,576 (95% uncertainty interval: 741,968 to 944,851) female and 10,938 (9,030 to 13,256) male prevalent cases of BC in the NAME region. This number leads to 35,405 (30,676 to 40,571) deaths among female patients and 809 (654 to 1,002) deaths in male patients this year. BC was responsible for 1,222,835 (1,053,073 to 1,411,009) DALYs among female patients in 2019, with a greater proportion (94.9%) of burden in years of life lost (YLLs). The major contributor to female BC incidence increase in the past three decades was found to be increase in age-specific incidence rates of BC (227.5%), compared to population growth (73.8%) and aging (81.8%). The behavioral risk factors were responsible for majority of attributable female BC burden (DALYs: 106,026 [66,614 to 144,247]). High fasting plasma glucose was found to be the risk factor with the largest effect (DALYs: 84,912 [17,377 to 192,838]) on female BC burden.ConclusionThe increasing incidence and burden of BC in the NAME region is remarkable, especially when considering limited resources in the developing countries of this region. Proper policies like expanding screening programs and careful resource management are needed to effectively manage BC burden.

Introduction: Toxoplasmosis is a well-known zoonotic disease caused by Toxoplasma gondii. The main causes of the disease range from eating undercooked or contaminated meat and shellfish to cleaning litter trays into which cats that excreted toxoplasma via faeces. This pathogen can live for a very long time, possibly a lifetime, within the bodies of humans and other animals. Aims and objectives: This study aimed to predict and analyse candidate immunogenic epitopes for vaccine development by evaluating the physio-chemical properties, multiple sequence alignment, secondary and tertiary structures, phosphorylation sites, transmembrane domains, and signal peptides, of T. gondii rhoptry proteins ROP7, ROP21, and ROP22 using bioinformatics tools. Methods: To find immunogenic epitopes of rhoptry proteins, numerous bioinformatics web servers were used containing multiple sequence alignment, physiochemical properties, antigenicity and allergenicity, post-translational modification sites (PTMs), signal peptides, transmembrane domains, secondary and tertiary structures, and screening of predicted epitopes. We evaluated immunogenic linear B-cell epitopes as candidate proteins for vaccine development. Results: Nine epitopes were identified for each protein, and analysis of immunogenicity, revealed three candidate epitopes for ROP7, one for ROP21, and four for ROP22. Among all candidate epitopes, ROP22 contained the most immunogenic epitopes with immunogenicity score of 0.50575. Conclusion: We acquired detailed information on predicted immunogenic epitopes using in-silico methods. The results provide a foundation for further experimental analysis of toxoplasmosis, and potential vaccine development.

Summary: Background: The COVID-19 pandemic highlighted gaps in health surveillance systems, disease prevention, and treatment globally. Among the many factors that might have led to these gaps is the issue of the financing of national health systems, especially in low-income and middle-income countries (LMICs), as well as a robust global system for pandemic preparedness. We aimed to provide a comparative assessment of global health spending at the onset of the pandemic; characterise the amount of development assistance for pandemic preparedness and response disbursed in the first 2 years of the COVID-19 pandemic; and examine expectations for future health spending and put into context the expected need for investment in pandemic preparedness. Methods: In this analysis of global health spending between 1990 and 2021, and prediction from 2021 to 2026, we estimated four sources of health spending: development assistance for health (DAH), government spending, out-of-pocket spending, and prepaid private spending across 204 countries and territories. We used the Organisation for Economic Co-operation and Development (OECD)'s Creditor Reporting System (CRS) and the WHO Global Health Expenditure Database (GHED) to estimate spending. We estimated development assistance for general health, COVID-19 response, and pandemic preparedness and response using a keyword search. Health spending estimates were combined with estimates of resources needed for pandemic prevention and preparedness to analyse future health spending patterns, relative to need. Findings: In 2019, at the onset of the COVID-19 pandemic, US$9·2 trillion (95% uncertainty interval [UI] 9·1–9·3) was spent on health worldwide. We found great disparities in the amount of resources devoted to health, with high-income countries spending $7·3 trillion (95% UI 7·2–7·4) in 2019; 293·7 times the $24·8 billion (95% UI 24·3–25·3) spent by low-income countries in 2019. That same year, $43·1 billion in development assistance was provided to maintain or improve health. The pandemic led to an unprecedented increase in development assistance targeted towards health; in 2020 and 2021, $1·8 billion in DAH contributions was provided towards pandemic preparedness in LMICs, and $37·8 billion was provided for the health-related COVID-19 response. Although the support for pandemic preparedness is 12·2% of the recommended target by the High-Level Independent Panel (HLIP), the support provided for the health-related COVID-19 response is 252·2% of the recommended target. Additionally, projected spending estimates suggest that between 2022 and 2026, governments in 17 (95% UI 11–21) of the 137 LMICs will observe an increase in national government health spending equivalent to an addition of 1% of GDP, as recommended by the HLIP. Interpretation: There was an unprecedented scale-up in DAH in 2020 and 2021. We have a unique opportunity at this time to sustain funding for crucial global health functions, including pandemic preparedness. However, historical patterns of underfunding of pandemic preparedness suggest that deliberate effort must be made to ensure funding is maintained. Funding: Bill & Melinda Gates Foundation.

Ticks are hematophagous ectoparasites that transmit pathogens to animals and humans. Updated knowledge regarding the global epidemiology of tick-borne Rickettsia hoogstraalii is dispersed, and its molecular detection and genetic characterization are missing in Pakistan. The current study objectives were to molecularly detect and genetically characterize Rickettsia species, especially R. hoogstraalii, in hard ticks infesting livestock in Pakistan, and to provide updated knowledge regarding their global epidemiology. Ticks were collected from livestock, including goats, sheep, and cattle, in six districts of Khyber Pakhtunkhwa (KP) Pakistan. Overall, 183 hosts were examined, of which 134 (73.2%), including goats (number = 39/54, 72.2%), sheep (23/40, 57.5%), and cattle (71/89, 80%) were infested by 823 ticks. The most prevalent tick species was Rhipicephalus microplus (number = 283, 34.3%), followed by Hyalomma anatolicum (223, 27.0%), Rhipicephalus turanicus (122, 14.8%), Haemaphysalis sulcata (104, 12.6%), Haemaphysalis montgomeryi (66, 8.0%), and Haemaphysalis bispinosa (25, 3.03%). A subset of 210 ticks was selected and screened for Rickettsia spp. using PCR-based amplification and subsequent sequencing of rickettsial gltA and ompB fragments. The overall occurrence rate of R. hoogstraalii was 4.3% (number = 9/210). The DNA of Rickettsia was detected in Hy. anatolicum (3/35, 8.5%) and Ha. sulcata (6/49, 12.2%). However, no rickettsial DNA was detected in Rh. microplus (35), Rh. turanicus (35), Ha. montgomeryi (42), and Ha. bispinosa (14). The gltA and ompB fragments showed 99–100% identity with R. hoogstraalii and clustered phylogenetically with the corresponding species from Pakistan, Italy, Georgia, and China. R. hoogstraalii was genetically characterized for the first time in Pakistan and Hy. anatolicum globally. Further studies should be encouraged to determine the role of ticks in the maintenance and transmission of R. hoogstraalii in different hosts.

Ixodes ticks transmit Theileria and Anaplasma species to a wide range of animals. The spreading of ticks and tick-borne pathogens has been attributed to transhumant herds, and research on these uninvestigated issues has been neglected in many countries, including Pakistan. Recently, we used internal transcribed spacer (ITS) and 16S ribosomal DNA partial sequences to genetically characterize Ixodes kashmiricus ticks and their associated Rickettsia spp. However, the data on its cox1 sequence and associated Theileria spp. and Anaplasma spp. are missing. This study aimed to genetically characterize I. kashmiricus based on the cox1 sequence and their associated Theileria spp. and Anaplasma spp. The I. kashmiricus ticks were collected from small ruminants: sheep (Ovis aries) and goats (Capra hircus) of transhumant herds in district Shangla, Dir Upper and Chitral, Khyber Pakhtunkhwa (KP), Pakistan. Out of 129 examined hosts, 94 (72.87%) (56 sheep and 38 goats) were infested by 352 ticks, including adult females (175; 49.7%) followed by nymphs (115; 32.7%) and males (62; 17.6%). For molecular analyses, 121 ticks were subjected to DNA isolation and PCR for the amplification of the cox1 sequence for I. kashmiricus, 18S rDNA for Theileria spp. and 16S rDNA sequences for Anaplasma spp. The obtained cox1 sequence showed 89.29%, 88.78%, and 88.71% identity with Ixodes scapularis, Ixodes gibbosus, and Ixodes apronophorus, respectively. Phylogenetically, the present cox1 sequence clustered with the Ixodes ricinus complex. Additionally, the 18S rDNA sequence showed 98.11% maximum identity with Theileria cf. sinensis and 97.99% identity with Theileria sinensis. Phylogenetically, Theileria spp. clustered with the T. cf. sinensis and T. sinensis. In the case of Anaplasma spp., the 16S rDNA sequence showed 100% identity with Anaplasma capra and phylogenetically clustered with the A. capra. PCR-based DNA detection targeting the amplification of groEL and flaB sequences of Coxiella spp. and Borrelia spp., respectively, was unsuccessful. This is the first phylogenetic report based on cox1 and new locality records of I. kashmiricus, and the associated T. sinensis-like and A. capra. Significant tick surveillance studies are needed in order to determine the epidemiology of Ixodes ticks and their associated pathogens.

BackgroundSnails play an important role as an intermediate host in various parasitic diseases, which are referred to as snail-borne parasitic diseases (SBPDs). The prevalence of the SBPDs, schistosomiasis and fascioliasis is low in Pakistan compared to other countries. The present study investigated knowledge, attitudes, and practices related to these two SPBDs and risk factors associated with them among the humans living in close contact with livestock and pets from three regions of Pakistan: Punjab, Islamabad and Azad Jammu and Kashmir (AJK).MethodsA cross-sectional survey was conducted using a structured questionnaire to assess participants' knowledge, attitude and practices related to schistosomiasis and fascioliasis during 2021–2022.ResultsThe majority of the 507 participants who were interviewed had good knowledge of schistosomiasis and fascioliasis: 43% were aware of schistosomiasis and 57% were aware of fascioliasis, but only 25% knew about snails as an intermediate host. Most respondents had a positive attitude toward treatment, prevention and control of the diseases but they did not have any healthcare facilities.ConclusionThis study highlights the importance of the public's awareness for the need to control SBPDs. It also draws attention to the need for health education for risk reduction and the prevention of SBPDs in endemic areas.

Trichinellosis is considered as a cosmopolitan zoonosis caused by different species of the small nematodes of the genus Trichinella. The present study aimed to provide a broad review for exploring Trichinella sp. infection in humans and animals of Iran and Turkey. Additionally, we aimed to explore bases for trichinellosis prevention and control. Two reports of human trichinellosis following the consumption of meat of wild boar are available in the northern Iran. A large outbreak of trichinellosis and some other sporadic cases are reported mainly as a result of eating wild boar or pork meat from Turkey, where T. britovi is present. Field studies show that Trichinella sp. infections occur in wild carnivores of Iran, particularly the golden jackal (Canis aureus) as the most frequently infected species. T. britovi has been reported to be present elsewhere in Iran in wild mammals, where wild boar is the main source of Trichinella sp. infection. In Turkey, Trichinella spp. has been reported from animals including both domesticated and wild pigs and gray wolf (Canis lupus). However, current data on the distribution of Trichinella taxa are fragmentary in the Anatolian region.

A 68-year-old male with past medical history 84 pack year smoking history (quit in 2000), mild chronic obstructive pulmonary disease (COPD), adenocarcinoma of right upper lobe treated with surgery and chemoradiation, and melanoma resection in 2013 presented with a one-month history of cough with sputum production and progressive dyspnea on exertion. He did not improve with standard treatment of antibiotics and steroids. He underwent flexible bronchoscopy that revealed an aspirated pill. This was successfully removed in the same session with the flexible bronchoscope.

Ticks are ectoparasites that act as vectors for transmission of various pathogens to wild and domesticated animals and pose a serious threat to human health. Because of the hot and humid conditions in different agro-ecological zones of Pakistan, ticks are abundant and parasitize a variety of animals. The aim of this study was to identify different tick species and distribution on different hosts especially livestock, such as sheep, goat, cattle, buffalo, and camel, and livestock associated canines and equines, such as horse, donkey, and dog, across different agro-ecological zones of Pakistan. The ticks samples were collected and morphologically identified at genus and species level using morphological keys under stereomicroscope. A total of 2,846 animals were examined for the tick infestation, and 408 animals were tick-infested. Eleven tick species belonging to 4 genera were identified: Hyalomma anatolicum, Hyalomma scupense, Hyalomma dromedarii, Hyalomma isaaci, Rhipicephalus microplus, Rhipicephalus haemaphysaloides, Rhipicephalus turanicus, Haemaphysalis cornupunctata, Haemaphysalis montgomeryi, Haemaphysalis bispinosa, and Ixodes kashmiricus. The overall tick prevalence was 14.3%; host-wise infestation rate was 12.2% in sheep; 12.6%, goat; 11.7%, buffalo; 11.7%, cattle; 19.6%, camel; 27.4%, donkey; 23.5%, horse; and 24.3%, dog. Tick infestation of different animals differed on the basis of the zones. Camels showed the highest tick infestation rate in zones 1 and 2 (21.4 and 26.7%, respectively), whereas donkeys showed the highest infestation rate in zones 3, 4, 6, and 7 (25, 39.3, 3.3, and 21.4%, respectively). The infestation rates of Hyalomma and Rhipicephalus were the highest in zone 2 (71.4 and 52.9%, respectively). The infestation rate of Hyalomma was the highest (47.4%) in sheep; Haemaphysalis (46.9%), goat; Rhipicephalus (69.7%), buffalo; Rhipicephalus (62.3%), cattle; Hyalomma (70%), camel; Ixodes (60.9%), donkey; Ixodes (75%), horse; and Rhipicephalus (61.1%), dog. This study showed the diversity and infestation rate of different ticks with respect to their hosts and agro-ecological zones of Pakistan. High tick burdens and infestation rates are responsible for the spread of different tick-borne infections, resulting in loss of animal productivity and posing a threat to animal and human health. Understanding different tick species and their distribution across different zones will be helpful for developing efficient control strategies against different tick born infections.

BackgroundHuman alveolar echinococcosis (AE) is a neglected zoonotic disease. Prevalence of AE in humans is reported in Pakistan as a result of poor economic and sanitary conditions, close proximity to wildlife and limited knowledge of AE. Studies on the prevalence and transmission of AE have been limited, especially for rural Pakistan. The study objectives were to identify knowledge, attitudes and practices relating to AE, to determine awareness of the disease, and to identify knowledge about possible risk factors of infections involving the landscape epidemiological attributes of rural villages in Hunza, one of the districts of Gilgit-Baltistan, a region of Pakistan that borders China.MethodsA community-based cross-sectional study was conducted among the general population of Hunza to establish the level of awareness, knowledge, attitudes, practices, landscape epidemiology, and disease management and control relating to AE in rural areas of Hunza. Data were collected by questionnaire.ResultsA total of 387 questionnaires was received. Statistical analysis showed that the population's knowledge about the disease was poor. The attitudes and practices of the participants indicated that their risk of infection was low. Knowledge of landscape epidemiology of the disease was poor but knowledge about AE disease management was good. The attitudes of residents toward disease treatment and control strategies were positive, although the overall knowledge of participants about prevention of infection was poor.ConclusionKnowledge of AE is poor among the residents of Hunza, Pakistan. Our study demands continued and strengthened awareness of the changes to lifestyle and practices associated with AE, not only in the study locality but throughout other areas of Pakistan.

BackgroundThyroid cancer is the leading cause of mortality and morbidity among cancers of the endocrine system. We aimed to describe the trends of thyroid cancer burden in North Africa and Middle East for 1990–2019.MethodsData on burden of thyroid cancer in North Africa and Middle East from 1990 to 2019 were obtained from the Global Burden of Disease (GBD) Study 2019. Decomposition analysis was used to estimate the effects of population growth, aging, and change in incident numbers on overall change of thyroid cancer incidence. Also, we used the comparative risk assessment framework of GBD to determine the burden of thyroid cancer attributable to a high body mass index (BMI).ResultsIn 2019, the age-standardized incidence rate (ASIR) and age-standardized mortality rate (ASMR) of thyroid cancer were 3.5 (2.9–4) and 0.5 (0.5–0.7) per 100,000, respectively. The highest age-standardized incidence, deaths, and disability-adjusted life year (DALY) rate were in Lebanon, Afghanistan, and United Arab Emirates, respectively. The ASIR of thyroid cancer in region was about 2.5 times higher among women, which had a positive association with increasing age. In 2019, the age-standardized deaths attributable to a high BMI was 16.7% of all deaths due to thyroid cancer. In 1990–2019, the overall change in thyroid cancer incident cases was a 396% increase which was mostly driven by the increase in disease-specific incidence rate (256.8%).ConclusionsWomen, the elderly above about 60 years old, and countries with a higher sociodemographic index showed higher incidence rates of thyroid cancer. Regarding our findings, it is recommended to establish preventive plans by modification in life style like weight reduction programs.

BackgroundProstate cancer (PCa) is the second most prevalent cancer among men worldwide. This study presents estimates of PCa prevalence, incidence, death, years-of-life-lost (YLLs), years-lived-with-disability (YLDs), disability-adjusted-life-years (DALYs), and the burden attributable to smoking during 1990-2019 in North Africa and Middle East using data of Global Burden of Diseases (GBD) Study 2019.MethodsThis study is a part of GBD 2019. Using vital registration and cancer registry data, the estimates on PCa burden were modeled. Risk factor analysis was performed through the six-step conceptual framework of Comparative Risk Assessment.ResultsThe age-standardized rates (95% UI) of PCa incidence, prevalence, and death in 2019 were 23.7 (18.5-27.9), 161.1 (126.6-187.6), and 11.7 (9.4-13.9) per 100,000 population. While PCa incidence and prevalence increased by 77% and 144% during 1990-2019, respectively, the death rate stagnated. Of the 397% increase in PCa new cases, 234% was due to a rise in the age-specific incidence rate, 79% due to population growth, and 84% due to population aging. The YLLs, YLDs, and DALYs of PCa increased by 2% (-11.8-23.1), 108% (75.5-155.1), and 6% (-8.9-28.1). The death rate and DALYs rate attributable to smoking have decreased 12% and 10%, respectively. The DALYs rate attributable to smoking was 37.4 (15.9-67.8) in Lebanon and 5.9 (2.5-10.6) in Saudi Arabia, which were the highest and lowest in the region, respectively.ConclusionsThe PCa incidence and prevalence rates increased during 1990-2019; however, the death rate stagnated. The increase in the incidence was mostly due to the rise in the age-specific incidence rate, rather than population growth or aging. The burden of PCa attributable to smoking has decreased in the past 30 years.

Introduction There is increasing interest in the relationship between acute infections and acute cardiovascular events. Most previous research has focused on understanding whether the risk of acute cardiovascular events increases following a respiratory tract infection. The relationship between urinary tract infections (UTIs) and acute cardiovascular events is less well studied. Therefore, the aim of this study is to determine whether there is a causal relationship between UTI and acute myocardial infarction (MI) or stroke.Methods and analysis We will undertake a self-controlled case series study using linked anonymised general practice, hospital admission and microbiology data held within the Secure Anonymised Information Linkage (SAIL) Databank. Self-controlled case series is a relatively novel study design where individuals act as their own controls, thereby inherently controlling for time-invariant confounders. Only individuals who experience an exposure and outcome of interest are included.We will identify individuals in the SAIL Databank who have a hospital admission record for acute MI or stroke during the study period of 2010–2020. Individuals will need to be aged 30–100 during the study period and be Welsh residents for inclusion. UTI will be identified using general practice, microbiology and hospital admissions data. We will calculate the incidence of MI and stroke in predefined risk periods following an UTI and in ‘baseline’ periods (without UTI exposure) and use conditional Poisson regression models to derive incidence rate ratios.Ethics and dissemination Data access, research permissions and approvals have been obtained from the SAIL independent Information Governance Review Panel, project number 0972. Findings will be disseminated through conferences, blogs, social media threads and peer-reviewed journals. Results will be of interest internationally to primary and secondary care clinicians who manage UTIs and may inform future clinical trials of preventative therapy.

Fasciolosis is a parasitic disease caused by Fasciola spp. It is a prevalent helminth infection globally. Clostridial hepatitis is a general name refer to disorders caused by a few clostridial agents that most severely affect the liver. Migration of young parasite forms (mostly Fasciola hepatica) in the parenchymal tissue of the liver causes necrosis and anaerobic environment, stimulating the proliferation of C. novyi type B spores. This study investigated the occurrence of Clostridium spp in adult Fasciola spp isolates. Isolates (n = 100) were collected from the bile ducts of infected cattle after slaughter. Total genomic DNA was extracted from each sample. A multiplex-PCR based on the flagellin C (fliC) gene was used for quick identification of C. chauvoei, C. haemolyticum, C. novyi types A and B, and C. septicum. In addition, a pair of primers Cpa (F) and Cpa (R) were used for detection of the C. perfringens alpha toxin gene. The products were sequenced. No band was obtained after multiplex-PCR of the fliC gene. A 247 bp band was detected in two isolates using the Cpa primers. BLAST analysis of these two isolates characterized both as C. perfringens alpha toxin. This is the first description of the molecular detection of C. perfringens in flukes. Further studies are needed to investigate whether Clostridum species is also carried by other developmental forms (egg and larval stages) of Fasciola spp.

Introduction: Current UKHSA UTI diagnostic guidance advises empirical antibiotics if two of the following symptoms are present: cloudy urine, dysuria, and new onset nocturia. Hormonal changes during menopause may impact UTI symptoms, and qualitative studies suggest women with recurrent UTIs may present with different UTI symptoms. This study aims to assess whether menopausal status and the presence of recurrent UTIs impact UTI symptoms in women. Methods: An e-survey was conducted between 13 March 2021 and 13 April 2021. Women aged 16 years or older with a history of a UTI in the last year were eligible for inclusion. We defined menopause as those aged 45–64 years; pre-menopause as those less than 45 years; and post-menopause as those 65 years and older. Recurrent UTIs were defined as three or more UTIs in the last year. The data were weighted to be representative of the UK population. Crude unadjusted and adjusted odds ratios were estimated using logistic regression. Results: In total, 1096 women reported a UTI in the last year. There were significant differences in UTI symptoms based on menopausal status and the presence of recurrent UTIs. Post-menopausal women self-reported more incontinence (OR 2.76, 95% CI 1.50,5.09), whereas menopausal women reported more nocturia. Women with recurrent UTIs reported less dysuria, more severe symptoms (OR 1.93 95% CI 1.37,2.73) and a greater impact on daily life (OR 1.68, 95% CI 1.19,2.37). Conclusions: This survey provides evidence that acute UTIs present differently based on menopausal status and in women with recurrent UTIs. It is important that healthcare professionals are aware of these differences when assessing women presenting with an acute UTI and, therefore, further research in this area is needed.

Przhevalskiana silenus (warble fly) grubs cause myiasis in goats, in mountainous and semi-mountainous areas and different regions in Pakistan, and cause substantial losses to livestock. The palpation method for detecting warble flies generally neglects the infestation intensity; therefore, the development of a reliable and efficient diagnostic technique is extremely necessary. This study compared three indirect enzyme-linked immunosorbent assay (ELISA) methods for detecting anti-P. silenus antibodies using the hypodermin C (HyC) purified from Hypoderma spp. Larvae collected in cattle (local isolate, Microbiology Laboratory, PMAS-Arid Agriculture University, Rawalpindi), the crude antigen from the first instar stage of P. silenus, and a commercial Bovine Hypodermosis Antibody ELISA kit (IDEXX Laboratory), for accurately estimating the seroprevalence of goat warble fly infestation (GWFI) in the Pothwar plateau, Punjab, Pakistan. The ELISA with the crude antigen of P. silenus proved very sensitive and specific, 91% and 93%, respectively. The optical density exhibited a monthly variation, and the antibody titer began increasing from June, continually increased from July to December, and gradually decreased thereafter until March. The study confirmed the endemic status of GWFI in the Pothwar region and identified that ELISA based on the crude antigen of P. silenus was a more sensitive and specific immunodiagnostic method for determining seroprevalence, and could be employed for initiating nationwide eradication campaigns.

Objectives A Sore Throat Test and Treat (STTT) service was introduced in selected community pharmacies to screen against Streptococcus A and appropriately treat infections, relieving pressure on General Practices (GP). The long-term impact on patient and NHS outcomes is unclear. A robust evaluation is required to inform future policy and roll-out. Approach A matched cohort study comparing patients who received an STTT consultation in community pharmacy (exposed) compared to consultation with GP (unexposed). Individual-level data from participating STTT pharmacies were extracted from the Choose Pharmacy IT platform, anonymised and acquired into the Secure Anonymised Information Linkage (SAIL) Databank. Both cohorts were linked to other longitudinal health and administrative data within SAIL to create study outcomes (e.g. antibiotic prescribing, re-consultation, attendance/admission at Emergency Department/hospital). The impact of the STTT service was evaluated by modelling the outcomes using logistic regression to calculate odds ratios. Results 7553 patients exposed to the STTT service (8,313 consultations) in community pharmacies in Cwm Taf Morgannwg and Betsi Cadwaladr University Health Boards between 1st November 2018 and 28th February 2020, were successfully anonymised and acquired into the SAIL Databank (97.16%). 99.5% of these individuals were then linked to the Welsh Demographic Service Dataset (WDSD), enabling demographics to be generated. 6,665 distinct consultations remained in the exposed group after exclusion criteria were applied. A matched unexposed cohort will be created, and odds ratios will be presented to compare the risk of each outcome for those exposed to the STTT service compared to usual care. Conclusion This innovative study is the first to link national pharmacy service data to individual-level population-scale longitudinal health and administrative data in the SAIL Databank. Our findings will inform clear and actionable recommendations regarding the service design and future roll-out of STTT services across the UK and internationally.

Abstract Background Invasive urodynamics is used to investigate the causes of lower urinary tract symptoms; a procedure usually conducted in secondary care by specialist practitioners. No study has yet investigated the feasibility of carrying out this procedure in a non-specialist setting. Therefore, the aim of this study was to explore, using qualitative methodology, the feasibility and acceptability of conducting invasive urodynamic testing in primary care. Methods Semi-structured interviews were conducted during the pilot phase of the PriMUS study, in which men experiencing bothersome lower urinary tract symptoms underwent invasive urodynamic testing along with a series of simple index tests in a primary care setting. Interviewees were 25 patients invited to take part in the PriMUS study and 18 healthcare professionals involved in study delivery. Interviews were audio-recorded, transcribed verbatim and analysed using a framework approach. Results Patients generally found the urodynamic procedure acceptable and valued the primary care setting due to its increased accessibility and familiarity. Despite some logistical issues, facilitating invasive urodynamic testing in primary care was also a positive experience for urodynamic nurses. Initial issues with general practitioners receiving and utilising the results of urodynamic testing may have limited the potential benefit to some patients. Effective approaches to study recruitment included emphasising the benefits of the urodynamic test and maintaining contact with potential participants by telephone. Patients’ relationship with their general practitioner was an important influence on study participation. Conclusions Conducting invasive urodynamics in primary care is feasible and acceptable and has the potential to benefit patients. Facilitating study procedures in a familiar primary care setting can impact positively on research recruitment. However, it is vital that there is a support network for urodynamic nurses and expertise available to help interpret urodynamic results.

As a zoonotic parasitic disease, echinococcosis is a severe global public health issue caused by the larvae of Echinococcus spp. Not only does echinococcosis threaten human health, but echinococcosis also causes enormous economic losses. China ranks first in the range of echinococcosis endemic areas, the number of infected patients, and the number of threatened populations worldwide, hence the most severe echinococcosis epidemic currently exists in China. Cystic echinococcosis (CE) is the most important form of echinococcosis. Accounting for nearly 80% of all echinococcosis cases, CE is the most important cause of the echinococcosis disease burden. Echinococcus granulosus sensu lato ( s.l. ) is the causative agent of CE and is considered a multi-genotype complex. The different genotypes of E. granulosus s.l. exhibit differences in morphology, transmission route, and epidemic characteristics. The corresponding clinical characteristics, clinical treatment, and vaccine responses also differ between the genotypes of E. granulosus s.l. During the past two decades, China has implemented echinococcosis control and prevention programs in endemic areas with impressive results. Specifically, the prevalence of echinococcosis has decreased. With such extraordinary achievements, precise control and prevention of the genotypes of E. granulosus s.l. have never been more important. Nevertheless, insufficient attention has been devoted to molecular epidemiology in the current control programs, and the lack of genotype data from humans and animal hosts exacerbates the situation. Hence, based on the ongoing control and surveillance programs, collecting additional molecular epidemiologic data and geographic information from humans and animals, as well as monitoring the clinical manifestations and drug and vaccine responses of the different genotypes, are invaluable for establishing a molecular epidemiologic database, which in turn can enhance the precise control and prevention of echinococcosis.

As a vector of wide range of pathogenic agents, ticks pose health threats to wild and domestic animals, and humans. Information is unavailable about the prevalence and spatial survey of Hyalomma kumari ticks and associated Rickettsia spp. in Pakistan. Concerning this knowledge gap, the present study aimed to molecularly detect Rickettsia species associated with H. kumari infesting small ruminants in Khyber Pakhtunkhwa (KP), Pakistan. A total of 409 H. kumari ticks were collected from 163/295 infested hosts with an infestation rate of 55.25%. A total of 204 females, 158 males, and 47 nymphs were collected. Goats were heavily infested by 224 ticks having an infestation rate of 58.33% (98/168), whereas sheep were infested by 185 ticks having a lesser infestation rate of 51.18% (65/127). Genomic DNA extracted from ticks was used for the amplification of tick (cox I, 16S rRNA, ITS-2) species and Rickettsia (gltA, ompA, and ompB) partial genes. Eighty-three ticks were subjected to PCR, and 8/83 (9.6%) were found positive for rickettsial agents. The cox I and 16S rRNA sequences of H. kumari showed 98.90–99.74% identity with H. kumari sequences reported from Pakistan, and phylogenetically clustered to the corresponding species reported from Pakistan and India. The obtained rickettsial gltA, ompA, and ompB sequences showed 100% identity with Rickettsia sp. of the Rickettsia conorii reported from Pakistan. In the phylogenetic trees, rickettsial sequences clustered with uncharacterized Rickettsia sp. from Pakistan and R. conorii from Israel, Russia, South Africa, and India. The present molecular based detection of H. kumari-associated R. conorii will facilitate effective surveillance in the region.

Glaucoma is an incurable eye disease that leads to slow progressive degeneration of the retina. It cannot be fully cured, however, its progression can be controlled in case of early diagnosis. Unfortunately, due to the absence of clear symptoms during the early stages, early diagnosis are rare. Glaucoma must be detected at early stages since late diagnosis can lead to permanent vision loss. Glaucoma affects the retina by damaging the Optic Nerve Head (ONH). Its diagnosis is dependent on the measurements of Optic Cup (OC) and Optic Disc (OD) in the retina. Computer vision techniques have been shown to diagnose glaucoma effectively and correctly with little overhead. These techniques measure OC and OC dimensions using machine learning based classification and segmentation algorithms. This article aims to provide a comprehensive overview of various existing techniques that use machine learning to detect and diagnose glaucoma based on fundus images. Readers would be able to understand the challenges glaucoma presents from an image processing and machine learning stand-point and will be able to identify gaps in current research.

Background: Hyperemesis gravidarum (HG), if untreated, can lead to malnutrition, dehydration, and Wernicke’s encephalopathy. Foetal complications include low birth weight and neurodevelopmental delay. Recent evidence supports increased rates of termination of pregnancy and suicidal ideation. Drivers included difficulty in accessing medications, which thus contributed to poor perception of care. Aim: To identify factors that may influence prescribers’ confidence and knowledge regarding pharmacological therapy for HG. Design & setting: Cross-sectional study of qualified GPs and GP trainees in Wales. Method: Distribution of a 22-item online survey. Statistical analysis was carried out using SPSS. Results: In total, 241 responses were received, with 216 included in the analysis (59% qualified GPs, 41% GP trainees). In total, 93% of responders correctly identified cyclizine as being safe in pregnancy, but no other drug recommended in the Royal College of Obstetrics and Gynaecology guidance was considered safe by more than 58%. Those reporting higher confidence levels in managing HG were more likely to correctly report guideline-recommended drugs as safe in pregnancy (P = 0.04). Additional qualifications related to obstetrics and gynaecology (O&G) and/or prior clinical experience increased confidence levels (P = 0.0001 and P = 0.0002, respectively). Only 19% of participants routinely screened for signs of mental health complications, and prior experience or education did not increase likelihood of this happening. The majority of participants (87%) would like additional education and/or access to evidence-based resources. Conclusion: This study demonstrates a demand for improved dissemination of evidence-based education on HG to support those working in primary care. The extent to which HG is covered in pre-existing educational programmes should also be revisited.

Abstract Background Echinococcosis is a zoonotic parasitic disease causing serious health problems in both humans and animals in different endemic regions across the world. There are two different forms of human echinococcosis: Cystic Echinococcosis (CE) and Alveolar Echinococcosis (AE). CE is caused by the larval stage of Echinococcus granulosus sensu lato and AE by the larval stage of Echinococcus multilocularis. Geographically, CE is universally distributed, while AE is prevalent in the northern hemisphere. Although the disease is endemic in neighboring countries (China, Iran and India) of Pakistan, there are limited reports from that country. Besides, there are no comprehensive data on the genotyping of Echinococcus species in humans based on sequence analysis. This study aimed to detect the presence of human CE and to identify Echinococcus spp. in human isolates through genetic characterization of hydatid cysts in the Punjab Province of Pakistan. Methods Genetic analysis was performed on 38 human hydatid cyst samples collected from patients with echinococcosis using mitochondrial cytochrome c oxidase subunit 1 (cox1), cytochrome b (cytb) and NADH subunit 1 (nad1). Patient data including age, epidemiological history, sex, and location were obtained from hospital records. Results According to the sequence analysis we detected E. granulosus sensu stricto (n = 35), E. canadensis (G6/G7) (n = 2), and E. multilocularis (n = 1). Thus, the majority of the patients (92.1%, 35/38) were infected with E. granulosus s.s. This is the first molecular confirmation of E. canadensis (G6/G7) and E. multilocularis in human subjects from Pakistan. Conclusions These findings suggested that E. granulosus s.s. is the dominant species in humans in Pakistan. In addition, E. canadensis (G6/G7) and E. multilocularis are circulating in the country. Further studies are required to explore the genetic diversity in both humans and livestock.

Breast cancer is type of tumor that occurs in the tissues of the breast. It is most common type of cancer found in women around the world and it is among the leading causes of deaths in women. This article presents the comparative analysis of machine learning, deep learning and data mining techniques being used for the prediction of breast cancer. Many researchers have put their efforts on breast cancer diagnoses and prognoses, every technique has different accuracy rate and it varies for different situations, tools and datasets being used. Our main focus is to comparatively analyze different existing Machine Learning and Data Mining techniques in order to find out the most appropriate method that will support the large dataset with good accuracy of prediction. The main purpose of this review is to highlight all the previous studies of machine learning algorithms that are being used for breast cancer prediction and this article provides the all necessary information to the beginners who want to analyze the machine learning algorithms to gain the base of deep learning.

Skin segmentation plays an important role in human activity recognition, video surveillance, hand gesture identification, face detection, human tracking and robotic surgery. The accurate segmentation of the skin is necessary to recognize the human activity. Segmentation of skin is easy to realize in ideal situations because of similar backgrounds. But it becomes complicated because of presence of skin-like pixels, background illuminations, and certain changes in environment. These problems are addressed by incorporating preprocessing stages in current studies, but this raises the total cost of the system. However, there are some limitations associated with these methods in terms of accuracy and processing speed. In this work, we propose a skin semantic segmentation network (SSS-Net) that is able to capture the multi-scale contextual information and refines the segmentation results especially along object boundaries. Moreover our network helps to reduce the cost of the preprocessing as well. We have performed experiments on the five open datasets of human activity recognition for the segmentation of skin. Experimental results show SSS-Net outperforms the state-of-the-art methods in skin segmentation in terms of accuracies.

BackgroundThe Beta-blockers Or Placebo for Primary Prophylaxis of oesophageal varices (BOPPP) trial is a 3-year phase IV, multi-centre clinical trial of investigational medicinal product (CTIMP) that aims to determine the effectiveness of carvedilol in the prevention of variceal bleeding for small oesophageal varices in patients with cirrhosis. Early engagement of General Practitioners (GPs) in conversations about delivery of a potentially effective secondary care-initiated treatment in primary care provides insights for future implementation. The aim of this study was to understand the implementation of trial findings by exploring i) GP perspectives on factors that influence implementation beyond the context of the trial and ii) how dose titration and ongoing treatment with carvedilol is best delivered in primary care.MethodsThis qualitative study was embedded within the BOPPP trial and was conducted alongside site opening. GP participants were purposively sampled and recruited from ten Clinical Commissioning Groups in England and three Health Boards across Wales. Semi-structured telephone individual interviews were conducted with GPs (n = 23) working in England and Wales. Data were analysed using reflexive thematic analysis.FindingsFive overarching themes were identified: i) primary care is best placed for oversight, ii) a shared approach led by secondary care, iii) empower the patient to take responsibility, iv) the need to go above and beyond and v) develop practice guidance. The focus on prevention, attention to holistic care, and existing and often long-standing relationships with patients provides an impetus for GP oversight. GPs spoke about the value of partnership working with secondary care and of prioritising patient-centred care and involving patients in taking responsibility for their own health. An agreed pathway of care, clear communication, and specific, accessible guidance on how to implement the proposed treatment strategy safely and effectively are important determinants in the success of implementation.ConclusionsOur findings for implementing secondary care-initiated treatment in primary care are important to the specifics of the BOPPP trial but can also go some way in informing wider learning for other trials where work is shared across the primary-secondary care interface, and where findings will impact the primary care workload. We propose a systems research perspective for addressing implementation of CTIMP findings at the outset of research. The value of early stakeholder involvement is highlighted, and the need to consider complexity in terms of the interaction between the intervention and the context in which it is implemented is acknowledged.Trial registrationISRCTN10324656.

Background: Urinary tract infections (UTIs) are a common and significant problem for patients, clinicians, and healthcare services. Recurrent UTIs (rUTIs) are common, with a 3% prevalence in the UK. Although acute UTIs have a significant negative impact on the lives of patients, evidence of the impact of rUTIs is limited. To enhance shared decision-making around rUTI management, it is important to understand both the patients’ and healthcare professionals’ (HCPs’) perspectives. The objective of this qualitative evidence synthesis is to understand patients’ and HCPs’ experiences and views in the management of rUTIs. Methods: A qualitative evidence synthesis (QES) was performed that included primary qualitative studies involving patients with rUTIs or primary care HCPs who manage patients with rUTIs, up to June 2022. The following databases were searched: MEDLINE, Embase, CINAHL, PsycInfo, ASSIA, Web of Science, Cochrane Database of Systematic Reviews, Epistemonikos, Cochrane Central Registry of Controlled Trials, OpenGrey, and the Health Management Information Consortium (HMIC). The QES was prospectively registered on PROSPERO (CRD42022295662). Reciprocal translation was conducted and developed into a line of argument synthesis. We appraised the confidence in our review findings by using GRADE-CERQual. Results: Twelve studies were included in the final review; ten of those included patients, and three included HCPs (one study included both). Our review demonstrates that women with rUTIs have a unique experience, but it is generally of a chronic condition with significant impacts on numerous aspects of their lives. Antibiotics can be “transformative”, but patients have serious concerns about their use and feel non-antibiotic options need further research and discussion. HCPs share similar views about the impacts of rUTIs and concerns about antibiotic use and find the management of rUTIs to be complex and challenging. Based on our GRADE-CERQual assessment of the review findings, we have moderate confidence in those related to patients and low confidence in those related to HCPs. New conceptual models for both patients and HCPs are presented. Conclusions: This review has significant clinical implications. Patients require information on antibiotic alternative acute and preventative treatments for rUTIs, and this is not currently being addressed. There are communication gaps around the impact of rUTIs on patients, their perceived expectation for antibiotics, and the reasons for treatment failure. Further development of current clinical guidance and a patient decision aid would help address these issues.

A wide range of novelties and significant developments in the field of veterinary science to treat helminth parasites by using natural plant products have been assessed in recent years. To the best of our knowledge, to date, there has not been such a comprehensive review of 19 years of articles on the anthelmintic potential of plants against various types of helminths in different parts of the world. Therefore, the present study reviews the available information on a large number of medicinal plants and their pharmacological effects, which may facilitate the development of an effective management strategy against helminth parasites. An electronic search in four major databases (PubMed, Scopus, Web of Science, and Google Scholar) was performed for articles published between January 2003 and April 2022. Information about plant species, local name, family, distribution, plant tissue used, and target parasite species was tabulated. All relevant studies meeting the inclusion criteria were assessed, and 118 research articles were included. In total, 259 plant species were reviewed as a potential source of anthelmintic drugs. These plants can be used as a source of natural drugs to treat helminth infections in animals, and their use would potentially reduce economic losses and improve livestock production.

Cystic echinococcosis (CE) is a neglected zoonotic disease of worldwide geographical distribution. CE is most common in underdeveloped and herding communities where people survive on animal husbandry and agricultural activities. The prevalence of CE in livestock and its risk factors are widely underreported, because of inefficient surveillance systems. The aim of this study was to evaluate the epidemiological characteristics and prevalence of CE in cattle in Punjab, Pakistan. Data were collected from slaughterhouses from September 2021 to February 2022. Ante- and postmortem examination and cyst characterization were performed. Epidemiological, demographic, and one health data were collected. A total of 8877 animals (8096 buffalo, 781 cattle) were examined, and the prevalence of CE was 6.22% (n = 552) in all animals, with a higher prevalence in cattle (15.20% vs. buffalo 5.83%). Prevalence was not significantly different in males and females. Of the 23 districts studied, the highest prevalence was in the Haripur district of KP (20.85%). The majority of animals studied were older than 3 years. Most cysts were found in animals older than 5 years. Lungs and liver were the predominant sites for the presence of cysts (65.58% and 31.34%, respectively. Of the collected cysts, 29.71% were fertile. The findings may be useful in estimating the eco-epidemiology of CE and improving surveillance and prevention programs in Pakistan.

Ectoparasites, including lice, ticks, and mites, inhabit the host skin and depend on their host for sustenance, maturation, and multiplication. Among these, ticks are more prevalent in various regions of Pakistan because of favorable climatic conditions, lack of awareness of livestock keepers' regarding ectoparasite infestation rate, insufficient veterinary services, and inadequate control measures. Ectoparasitic infestation is a primary threat to cost-effective livestock production by damaging skin and transmitting multiple diseases between animals. This review aimed to determine the infestation rates of various ectoparasites in cattle, buffaloes, sheep, goats, camels, equids and to ascertain the prevalence and epidemiology of ectoparasites in different regions of Pakistan. This review could be useful in devising prevention and control strategies and identifying the risk factors associated with ectoparasites to enhance animal productivity. It provides directions for veterinary schools, researchers, and organizations aiming to collaborate with neighboring countries to eradicate these parasites. Future studies could support working veterinarians and administrators and contribute to human well-being.

Background: Loose bowels is a clinical sign of gastrointestinal transport channel proteins, channels, and physical and chemical boundaries being harmed, prompting issues of water and electrolyte transport in the intestinal system. It is still considered as a major reason for emergency visits to hospitals in low-middle income countries. Zinc is a suitable treatment along with ORS for diarrhea. KAP surveys are usually conducted to collect information about general or specific topics of a particular population. The objective of this study was to investigate the knowledge, attitude, practices (KAP), and one health perspective regarding diarrhea among the participants from urban and rural populations of Rawalpindi and Islamabad, Pakistan.Methods: Data was collected by conducting a survey among residents of twin cities over a period of 6 months (from July 2020 to December 2020). The questionnaire compromised socio-demographic features and the degree of KAP with respect to diarrhea management and control. One way ANOVA tests were applied to observe the demographic relationship and various factors influencing knowledge, attitude, practices, and one health perspective about diarrhea.Results: A total of 338 subjects participated in the study. Female subjects were in the majority with 63% while the rest were male. A majority of the participants were between 15–25 years of age and 79.6% participants were un-married. The leading ethnic group was Punjabi with 52.7%; the lowest ethnic group were of Sindhi ethnicity with 8.6%. Age has a significant association with respect to knowledge and attitude. Religion has a significant association with respect to knowledge, practices, and one health, while education/qualification has an association with knowledge. The rest of the variables found no association with each other.Conclusion: It is concluded from the recent study that most residents of the twin cities of Pakistan knew about diarrhea and had a good attitude and practices toward it. Age, religion, and education have different roles regarding different diseases in the population of Pakistan. The current study has its limitations as well. Parts of the study were conducted in the capital of Pakistan which is more developed as compared to other areas of Pakistan. It would be better to explore the remote areas of Pakistan where basic amenities of life such as education, wealth, and unemployment are not available. It is important to create more awareness among community members. They should be aware how dangerous these viruses and bacteria can be. Other parts of Pakistan should also be explored for better understanding that will help in making a nationwide health policy.

Toxoplasmosis is a zoonotic disease caused by Toxoplasma gondii, a protozoan that infects warm-blooded animals and humans. Approximately one third of the global population is infected by T. gondii. We conducted a cross-sectional study to assess the risk factors and One Health knowledge of toxoplasmosis in Rawalpindi and Islamabad, Pakistan. From July through December 2020, we collected data using questionnaires. The results showed that 60% of participants had heard or read about the disease, 23.3% of participants had no knowledge about the disease, and 16.8% participants were not sure about the disease. More than half of the participants (53.3%) reported that toxoplasmosis was caused by toxins, 5.3% reported that toxoplasmosis was an animal disease, 13.8% reported that toxoplasmosis was a human disease, 65.8% reported that it was both an animal and human disease, and 15.3% reported that it was neither an animal nor a human disease. Approximately 80.5% of participants reported that individuals acquired toxoplasmosis by changing cat litter. Our study findings revealed a low level of knowledge and awareness about toxoplasmosis among males. Therefore, there should be awareness programs to educate individuals about the risks of this deadly disease and to provide information on the major routes of transmission.

Toxoplasmosis, a parasitic disease caused by Toxoplasma gondii, results in congenital disorders and miscarriages among livestock and humans worldwide. This systematic review and meta-analysis were conducted to determine the prevalence of T. gondii infection in sheep and goats in Pakistan from 2000 to 2020. We searched the PubMed, Scopus, EMBASE, and Google Scholar databases and selected 17 publications that fulfilled our inclusion criteria. Eight studies were conducted in Southern Punjab, six in Khyber Pakhtunkhwa, two in Northern Punjab, and one in Central Punjab. The diagnostic tests used in the included articles to confirm toxoplasmosis were the latex agglutination test in 56% of the studies, the enzyme-linked immunosorbent assay in 38%, and the indirect hemagglutination assay in 6%. The infection rates were substantially higher among sheep > 1 year of age (37%) than among sheep ≤ 1 year old (19%). Statistically significant differences in infection rates were found between male and female sheep and goats. The overall infection rate by age was also significant among sheep and goats. Sex and age variability between sheep investigations were significant, and sex heterogeneity and age homogeneity were significant among goats. Hence, robust infection control protocols should be implemented to prevent infection in animals and humans.

Echinococcus granulosus sensu lato is the causative agent of cystic echinococcosis (CE), which is a neglected zoonotic disease with an important role in human morbidity. In this study, we aimed to investigate the haplotype diversity, genetic variation, population structure and phylogeny of human E. granulosus sensu stricto (s.s.) (G1 genotype) isolates submitted to GenBank from different parts of the world by sequencing the mitochondrial CO1 and ND1 genes. The sequences of the mt-CO1 (401 bp; n = 133) and mt-ND1 (407 bp; n = 140) genes were used to analyze the haplotype, polymorphism and phylogenetic of 273 E. granulosus s.s. (G1 genotype) isolates. Mutations were observed at 31 different points in the mt-CO1 gene sequences and at 100 different points in the mt-ND1 gene sequences. Furthermore, 34 haplotypes of the mt-CO1 sequences and 37 haplotypes of the mt-ND1 sequences were identified. Tajima’s D, Fu’s Fs, and Fu’s LD values showed high negative values in both mt-CO1 and mt-ND1 gene fragments. The haplotype diversities in the sequences retrieved from GenBank in this study indicate that the genetic variation in human isolates of E. granulosus s.s. in western countries is higher than in eastern countries. This may be due to demographic expansions due to animal trades and natural selections.

Fasciolosis is a highly prevalent helminthic infection caused by Fasciola hepatica and F. gigantica. With the aim of identifying hybrid Fasciola flukes, multiplex PCR was performed to amplify the pepck gene. Furthermore, to determine Fasciola haplotypes, mitochondrial nad1 gene was amplified and sequenced, and phylogenetic analyses were performed. Adult Fasciola isolates were collected from 51 cattle and 51 sheep, genomic DNA was isolated, and one-step multiplex PCR was subsequently performed to amplify pepck. Isolates that generated a 510 bp band were identified as F. gigantica, those that generated a 241 bp band were identified as F. hepatica, and those that generated both bands were identified as hybrid (aspermic) flukes. Multiplex PCR data identified four isolates as F. gigantica and 84 as F. hepatica. Fourteen hybrid isolates (five cattle and nine sheep) were identified. On unidirectional DNA sequence analysis of nad1 PCR products, three sequences were identified as F. gigantica and 99 as F. hepatica. In addition, only 4 of 87 haplotypes detected for F. hepatica nad1 sequences were found to be previously reported, while the remaining 83 are unique to this study. To summarize, this study is the first to report the existence of hybrid Fasciola flukes and 83 unique haplotypes of F. hepatica in Turkey.

Background: The parasitic disease, cystic echinococcosis (CE), is a serious health problem in Pakistan. Risk of disease transmission is increased by economic and political instability, poor living conditions, and limited awareness of hygienic practices. The current study aimed to investigate the community perception and awareness regarding the risk factors of CE in Pakistan, from a One Health perspective.Methods: We conducted a community-based survey involving 454 participants in the major cities of Pakistan. Quantitative data based on knowledge, attitude, and practices (KAP), the One Health concept, risk factors, and community perception of CE among the general population of the major cities of Pakistan were collected. The questions included those related to knowledge, attitude, practices, One Health concept, risk factors, and community perception. The Chi-squared test was applied to determine the associations regarding KAPs across socio-demographic parameters.Results: KAPs had no significant associations with sociodemographic aspects such as age, sex, religion, ethnicity, education, marital status, occupation, or financial status of the participants. The findings indicated a lack of awareness about CE among the participants. Respondents were unaware of the risk factors and the One Health concept of CE. However, the community attitude and perception were positive toward the control of CE.Conclusion: Illiteracy, deficient sanitation systems and lack of awareness are the contributing factors to CE in Pakistan. It is necessary to make the community aware regarding CE and its importance. Increasing this awareness represents an important step toward the eradication and control of CE.