bluuebunny/crossref_metadata_2025 huggingface dataset:
The physical activity paradox in relation to work ability and health-related productivity loss in Korea
Authors: Ko Heejoo , Kim Dohwan , Cho Seong-Sik , Kang Mo-Yeol
Published: November 2023

OBJECTIVES: The physical activity paradox suggests that occupational physical activity (OPA), unlike leisure-time physical activity (LTPA), may detrimentally impact health. We explored the relationships of OPA and LTPA with work ability (WA) and health-related productivity loss (HRPL).METHODS: This study included 5,501 workers in Korea who were recruited in 2021 through a web-based cross-sectional questionnaire. The questionnaire was utilized to quantify OPA and LTPA in metabolic equivalents, while WA and HRPL were also measured. Non-parametric regression, using a generalized additive model (GAM), was employed to visualize the relationships of LTPA and OPA with WA and HRPL. Mean differences in WA and HRPL, in relation to OPA and LTPA, were examined using linear regression models. These models were adjusted for covariates including sex, age, body mass index, education level, alcohol consumption, smoking history, insomnia, occupation, hours worked, and income.RESULTS: The GAM and linear regression analyses revealed that higher LTPA corresponded with higher WA and lower HRPL. In contrast, as OPA increased, WA decreased and HRPL increased. However, within the group with high OPA, HRPL was not significantly lower in the high-LTPA subgroup relative to the low-LTPA subgroup (mean difference=1.92%, p=0.343). This pattern was especially pronounced among workers aged 60 years and older, with an increase in HRPL observed with increasing LTPA among the respondents with high OPA.CONCLUSIONS: High LTPA levels were associated with elevated WA and diminished HRPL. In contrast, higher levels of OPA were associated with lower WA and higher HRPL.
Evaluation of combined efficiency of conventional coagulation-flocculation process with advanced oxidation process (sulfate-hydroxyl radical) in leachate treatment
Authors: Zazouli Mohammad Ali , Yousefi Zabihollah , Babanezhad Esmaeil , Ala Alireza
Published: November 2023

This study evaluated a novel municipal solid waste leachate (MSWL) treatment system called the Batch flow leachate treatment system (BFLTS). This process uses a combination of coagulation/flocculation (C-F), advanced oxidation (sulfate-hydroxyl radical), and extended aeration of activated sludge (EAAS) to treat MSWL. The results indicated that the primary treatment phase using coagulation/flocculation with 0.8 g L-1 FeCl3 at pH 6 achieved 67% turbidity and 63% chemical oxygen demand (COD) reduction. The secondary treatment phase with the presence of both K2S2O8 and H2O2 peroxides was more efficient than single peroxide processes. While PS-based or H2O2-based single peroxide processes are less effective (UV-PS 65.7%, UV-H2O2 43.2%, Heat-PS 58.6%, Heat-H2O2 34.5%, and Heat-PS/H2O2 74.8%). The UV-PS/H2O2 system achieved the highest COD removal rate of 89.4%. In the third treatment phase, the efficient removal of COD and Biochemical oxygen demand (BOD) under optimal operating conditions was 87.3% and 94.7% respectively. Overall, the BFLTS treatment system has demonstrated high efficiency in removing COD, BOD, TSS, Turbidity, TKN, and Heavy metals by 99%, 98%, 97%, 89%, 86%, and 98%, respectively. This hybrid process has potential for reducing organic load in MSWL and can be used for various leachates.
Leveraging a Diverse Collaboration in Tertiary Education to Develop Capability for Workplace Innovation
Authors: Carey Thomas , Baregheh Anahita , Nobis Felix , Stevenson Mathias
Published: November 2023

Recent developments in tertiary education are demonstrating teaching and learning methods to develop students’ capability for employee-led Workplace Innovation. In this article, we describe an international collaboration to develop shared learning resources and activities in workplace innovation for adaptation in diverse tertiary education contexts. We are intentionally seeking out additional collaborating institutions that differ in mission, size, location and student demographics, to leverage our team’s diversity and encourage innovation.

When shared learning resources and activities are to be used in a diverse contexts, some core principles underlying instructional success must also be shared in order to ensure adaptations do not remove key properties. We outline four instructional principles underlying the learning design and illustrate how these principles are applied in our current learning resources.  

We then describe some of the ways that these shared resources have been adapted for different tertiary education environments. We also discuss some of the benefits emerging from the collaboration, including how the inclusion of new resources targeting specific work domains and the transfer of new teaching and learning ideas across contexts.

We conclude by describing some of the ways we are also collaborating with workplace partners, to ensure that our graduates have the capabilities needed to contribute to workplace innovation practice and to help advance the workplace innovation capability of their own employees.
Special issue: Call for Papers
Authors: Abrahamsson Kenneth
Published: November 2023

Not necessary
An Obituary for Olav Eikeland
Authors: Ennals Richard , Garmann Johnsen Hans Christian
Published: November 2023

Obituary of Olav Eikeland
STRATEGI PENGEMBANGAN USAHA KECIL MENENGAH (UMKM) KEDAI KOPI ONGAKU KOTA BENGKAYANG BERDASARKAN ANALISIS SWOT
Authors: Manggu Blasius , Beni Sabinus
Published: November 2023

Penelitian ini dilatarbelakangi oleh banyaknya  Usaha Mikro Kecil Menengah (UMKM) yang berwirausaha dalam bidang yang sejenis yaitu kedai kopi di kota Bengkayang yang nota bene saling berkompetitif satu sama lain untuk meraih konsumen. Oleh karena itu, perlu merumuskan suatu strategi yang tepat agar tetap bertahan merebut pangsa pasar.  Deskriptif kualitatif termasuk jenis dari pada penelitian ini. Populasi penelitian ini adalah konsumen Kedai Kopi Ongaku dengan jumlah responden berjumlah 30 orang. Pengumpulan data dilakukan melalui wawancara dengan responden dan menyebarkan kuesioner. Teknik analisis data menggunakan SWOT (Strength, Weaknesses, Opportunities, dan Threats). Untuk mengidentifikasi rumusan strategi yang secara sistematis berbagai faktor pada perusahaan maka analisis SWOT sangatlah disarankan. Berdasarkan pada logika hasil analisis yang dapat memaksimalkan kekuatan (strengths) dan peluang (opportunities), namun secara bersamaan dapat meminimalkan kelemahan (weaknesses) dan ancaman (threats), juga menyertakan penggunaan tabel IFAS dan EFAS. Tabel IFAS, tabel untuk mengetahui lingkungan internal dalam perusahaan, kekuatan dan dan kelemahannya, IFAS, tabel yang memuat faktor eksternal yang mempengaruhi lingkungan perusahaan. Berdasarkan analisis dari penelitian ini menunjukkan bahwa Usaha Mikro Kecil Menengah (UMKM) Kedai Kopi Ongaku  berada pada kuadran IV pemanfaatan  strategi diversifikasi, yaitu memanfaatkan kekuatan (strength) yang dimiliki dalam menghadapi ancaman (threats) guna bersaing dengan para kompetitor
MODEL EVALUASI MANAJEMEN KEUANGAN USAHA EKONOMI KELURAHAN SIMPAN PINJAM (UEK-SP) DI KOTA PEKANBARU
Authors: Riadi R M , Gusnardi Gusnardi , Trisnawati Fenny
Published: November 2023

Penelitian ini bertujuan untuk mengetahui model evaluasi UEK-SP sebagai bahan keputusan pendeteksian kesehatan dan mengindikasikan terjadinya penyimpangan dan tunggakan di 58 kelurahan. Teknik analisis data menggunakan analisis deskriptif dengan menggunakan pendekatan kesesuaian analisis kesehatan koperasi. Berdasarkan paparan tersebut peneliti membuat evaluasi manajemen keuangan UEK-SP di Kota Pekanbaru dengan mengadopsi Peraturan Deputi Bidang Pengawasan Kementerian Koperasi Dan Usaha Kecil Dan Menengah Republik Indonesia Nomor: 06 /Per/Dep.6/IV/2016 tentang pedoman penilaian kesehatan koperasi simpan pinjam dan unit simpan pinjam koperasi. Menurut model evaluasi manajemen keuangan UEK-SP, hasil penghitungan analisis model evaluasi yaitu diketahui perbandingan antara modal sendiri terhadap total asset, perbandingan modal sendiri terhadap pinjaman yang diberikan, hasil analisis data dan penghitungan untuk cadangan modal terhadap pinjaman yang diberikan, cadangan modal terhadap pinjaman yang bermasalah, efisiensi yang terdiri dari yang terdiri dari beban usaha terhadap SHU, perbandingan biaya karyawan terhadap SHU, rasio likuiditas, rasio kemandirian dan pertumbuhan yang terdiri dari Perbandingan SHU terhadap Total Aset, perbandingan SHU terhadap modal sendiri. Secara umum, hasil model evaluasi manajemen keuangan UEK-SP diperoleh penghitungan dengan kondisi “Dalam Pengawasan”. Hal ini diperkuat dengan jumlah kas yang kecil bahkan ada yang minus serta tunggakan atau piutang usaha yang rata-rata mengalami kemacetan. Hasil analisis sementara piutang usaha macet diakibatkan adanya indikasi pengelola yang melakukan lapping atau penundaan pembayaran kas dan juga pemakaian tanpa prosedur dan persetujuan pihak otoritas yang ada, adanya Pemanfaat yang tidak membayar dan meninggal dunia serta kurang efektifnya pelaksanaan tugas oleh pendamping kelurahan terhadap UEK-SP yang ada selama ini.
TEKNIK BUDIDAYA JAMUR SEBAGAI DIVERSIFIKASI PRODUK AGROFORESTRY DI KELOMPOK TANI HUTAN (KTH) MEKAR BAKTI, KARANG JOANG, BALIKPAPAN
Authors: Herawati Elisa , Murniyati Agustina , Rositah Erna , Kardika Adelia Juli , Ningsih Rusdiana , Lubis Putri Patricia
Published: November 2023

Jamur adalah salah satu alternatif bahan pangan kaya gizi dan antioksidan alami. Jamur tiram (Pleurotus ostreatus) merupakan salah satu jamur yang paling banyak dibudidayakan. Jamur tiram banyak dipelajari karena memiliki rasa dan kandungan nutrisi dan khasiat sebagai obat, sebagai sumber nutrisi, karbohidrat, vitamin ,kalsium dan zat besi. Mitra dalam kegiatan Pengabdian Kepada Masyarakat ini adalah Kelompok Tani Hutan (KTH) Mekar Bakti. Adapun permasalahan yang dihadapi oleh KTH ini yaitu pandemi covid-19 masih ada; hasil komoditi yang diusahakan petani bersifat musiman; diperlukan jenis komoditi yang yang dapat dipanen setiap hari; limbah pertanian dan lahan yang tersedia belum benar-benar dimanfaatkan secara optimal; dan masyarakat petani KTH Mekar Bakti belum memiliki pengalaman, kapasitas dan keterampilan sumber daya manusia khususnya dalam hal budidaya jamur. Metode pelaksanaan kegiatan pengabdian ini berupa pemaparan domestikasi jamur konsumsi dan praktik pelatihan domestikasi. Hasil dari kegiatan  pengabdian ini telah memberikan manfaat pengetahuan berupa pengenalan jamur yang dapat dikonsumsi dan dibudidayakan serta pengembangan kemampuan dalam berwirausaha para angota KTH Mekar Bakti. Kegiatan pembudidayaan ini mendorong para angota untuk mempraktekkan secara langsung, yang nantinya dapat mereka gunakan untuk memenuhi kebutuhan mereka sehari-hari ataupun dapat dijual. Tentunya dengan kondisi seperti ini, produktivitas masyarakat dapat ditingkatkan. Pembudidayaan ini juga melalui kegiatan konsumsi jamur dapat menambah gizi bagi orang-orang yang mengkonsumsinya.
KAJIAN PENGEMBANGAN SEKTOR PARIWISATA DI MALUKU UTARA MENUJU PEREKONOMIAN MAPAN
Authors: Runtunuwu Prince Charles Heston , Jabid Abdullah W. , Soamole Bakri
Published: November 2023

Kepariwisataan di kota Ternate ditunjang oleh potensi kondisi alam dan benda-benda peninggalan kebudayaan masa lalu sehingga wisata alam purbakala, dan wisata bahari dapat dikembangkan di kota Ternate. Banyak tempat wisata yang tersebar hampir diseluruh kabupaten/kota. Melihat kondisi tersebut, maka kota Ternate memiliki potensi yang besar di bidang pariwisata. Tujuan dari penelitian ini adalah untuk menganalisis faktor internal dan strategi dalam pengembangan sektor pariwisata di kota Ternate. Metode analisis yang digunakan adalah analisis SWOT. Hasil akhir menunjukkan bahwa: faktor-faktor internal yang mendukung pengembangan pariwisata di kota Ternate adalah Sektor Pariwisata yang semakin berkembang dan semakin diminati, Suasana objek wisata yang memberikan kenyamanan, keramahan masyarakat sekitar, Jarak tempuh objek wisata yang dekat dengan kota, dan kondisi keamanan yang baik. Faktor-faktor eksternal yang mendukung pengembangan pariwisata di kota Ternate meliputi adanya penyerapan tenaga kerja di daerah sekitar objek wisata yang dapat mengurangi pengangguran, banyaknya wisatawan yang ingin berkunjung, besamya minat dari masyarakat untuk pengembangan kawasan wisata berdasarkan potensi yang ada, rumah penduduk yang dapat dijadikan sebagai homestay, dan menambah penghasilan masyarakat sekitar. Strategi prioritas berdasarkan SWOT adalah pengembangan pariwisata secara keseluruhan, membangun jaringan dengan wisata bekerjasama dengan agen perjalanan dan membuat website khusus.
Validation of an assessment tool for professionalism in medical students: a mixed method study
Authors: Khan Humaira Fayyaz , Yasmeen Raheela , Ali Shabana
Published: November 2023

Objective: To develop and validate a tool for the assessment of professionalism in medical students during clerkship.
Method: The mixed-method study was confucted from February to September 2018 at the Islamic International Medical College, Riphah University, Islamabad, Pakistan. A preliminary focus group discussion ws followed by two rounds of Delphi technique to validate micro-scenarios for the relevance of each item of the instrument alongside its content validity. For content and construct validation of the tool, content validity, cognitive validity, cognitive pretesting, confirmatory factor analysis and reliability assessment was done. Piloting was done on medical students doing clerkship. Data was analysed using SPSS 21 and AMOS 21.
Results: A 35-item preliminary tool from micro-scenarios generated after focus group discussion was developed for the first Delphi round. For the second round, a 29-item tool was resent to the experts for validation. After the second round, the content validity scale was 0.94. Removal of 1 item produced a 28-item tool. Pre-cognitive testing of the 28 items resulted in rephrasing of 4, modification of 2, and deletion of 1 and a tool with 27 items. Piloting was carried out and after CFA resulted in a reduced 21 item tool. Cronbach’s alpha value was 0.96. A good to excellent model fit was produced after performing confirmatory factor analysis.
Conclusion: A tool comprising of 21 items scored on a 5-point Likert scale that had acceptable construct validity and good content validity was developed. It can be used to evaluate the level of professionalism of local medical students doing clerkship.
Key Words: Professionalism, Delphi, Focus group, Medical students, Factor analysis.
Congenital diarrhoea in a neonate with hypernatraemia and dehydration
Authors: Ammara Kaleem  , Javaria Younus  , Farah Haroon  , Bushra Fatima  , Faria Afzal  , Shumaila Chaudhry
Published: November 2023

Diarrhoea, vomiting, and dehydration are frequently encountered in neonatal emergency. However, it is challenging to manage resistant hypernatraemia and metabolic acidosis associated with it. Diagnosing the exact cause is even more difficult. Glucose-galactose malabsorption commonly presents with hypernatraemia and repeated dehydration. In the case described here, the baby started to have diarrhoea in the first week of life and presented in the neonatal emergency with severe dehydration and hypernatraemia. Higher sodium levels were difficult to manage throughout the course of illness. Hypernatraemia and diarrhoea worsened on feeding, whether formula or mother’s feed, which raised suspicion of glucose and galactose malabsorption. So, genetic testing was performed and fructose based formula was started which led to improvement in the condition. Later, genetic testing confirmed our diagnosis.
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Effect of Graston technique versus ischaemic compression in students who developed neck pain during distance learning in Covid-19: a pilot study preceding the randomised clinical trial
Authors: Iqbal Mushyyaida , Noreen Hafsa , Tasawar Tuba Ureeda , Tajammul Khansa
Published: November 2023

Many people experienced neck pain during Covid-19 quarantine period due to prolonged use of electronic devices for academic activities and work from home. The aim of this study was to determine the effects of Graston Technique versus Ischaemic Compression on pain, range of movement (ROM), and functional performance in students with neck pain, due to distance learning during Covid-19 pandemic. A pilot study (randomised clinical trial) was performed. Fifty-four subjects were included in the study on the basis of sample selection criteria and were divided into two groups, Group A and Group B. The outcome measures were pain, range of movement (ROM), and disability assessed by Numeric pain rating scale (NPRS), goniometry and Neck disability index (NDI) respectively. Group A received treatment with hot pack and Graston technique, while Group B received a hot pack and Ischaemic compression.
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Folliculotropic mycosis fungoides in a child: a rare case
Authors: Fatima Zahoor  , Junaid Shakila , Ghazal Afzal
Published: November 2023

Folliculotropic mycosis fungoides (FMF) is a variant of mycosis fungoides characterized by infiltration of hair follicle epithelium by neoplastic lymphoid cells. Generally, it is usually typified by indurated plaques and tumours mainly on the head and neck. However, a wide range of clinical signs have been noted. The clinical presentation of FMF may include prurigo-like lesions, acneiform lesions, cysts, nodules, areas of scarring alopecia, and hypopigmented plaques or papules with follicular prominences. The average age of diagnosis is 60 years while it is rare in childhood and adolescence. We discuss the case of a 12-year-old boy patient who had an asymptomatic, erythematous, infiltrating plaque across his left nasolabial fold for three months prior to presentation. Histological assessment of lesion showed characteristic findings of follicular mucinosis with predominance of CD4+ lymphocytes and immunohistochemical studies were positive for CD3+ stains. An increased CD4:CD8 ratio and negative CD20 was also shown.
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Usefulness of Sofosbuvir and Daclatasvir combination in the treatment of HCV infection in childhood cancer patients: experience from a tertiary care hospital
Authors: Imam Uzma , Parkash Ait , Daryani Nandlal , Mumtaz Fahad
Published: November 2023

Objective: To determine the usefulness of Sofosbuvir-Daclatasvir combination in the treatment of hepatitis c virus infection in paediatric cancer.
Method: The retrospective study was conducted at the Oncology Department of the National Institute of Child Health, Karachi, and comprised medical charts of patients who received sofosbuvir and daclatasvir from January 2018 to January 2022. Efficacy was documented by clearance of hepatitis C virus ribonucleic acid as rapid viral response, early viral response and sustained viral response at weeks 4, 12 and 24, respectively. Drug efficacy was determined by monitoring and recording adverse effects. Chemotherapy protocol for the treatment of patients concomitantly receiving direct acting antivirals was modified while looking at drug-drug interactions. The total duration of direct acting antiviral therapy was 12 weeks. Data was analysed using SPSS 24.
Results: Of the 804 patients with different malignancies, 132(16.4%) were found positive for hepatitis C virus. Of them, 28(21.21%) patients were started on direct acting antivirals; 17(60.71%) boys and 11(39.28%) girls. The overall mean age was 9.93±6.12 years. The diagnosis was pre-B acute lymphoblastic leukaemia in 18(64.28%) cases, 16(57.14%) were on maintenance chemotherapy, and 18(64.28%) had genotype 1. Pre- and post-treatment mean alanine transaminase levels were 328.00±324.00IU and 36.00±29.00IU, respectively (p=0.003). Pre- and post-treatment mean serum bilirubin levels were 3.13±3.95mg/dl and 0.61±0.21mg/dl (p=0.022). Rapid viral response was achieved in 26(92.85%) children, while early viral response and sustained viral response were achieved in all 28(100%) patients. Minor side effects were noted in 4(14.28%) patients and chemotherapy was continued in all 28(100%) cases as per the designed protocol.
Conclusion: The sofosbuvir-daclatasvir combination was found to be effective in hepatitis C virus treatment in paediatric cancer patients.
Key Words: Childhood cancer, HCV infection, Direct acting antiviral agents.
Foetal akinesia deformation sequence; a rare lethal entity- A case report
Authors: Shafqat Gulnaz , Fatima Kulsoom , Hanif Farida
Published: November 2023

Foetal akinesia deformation sequence (FADS) represents a group of disorders resulting from absent or diminished in utero foetal mobility. The aetiology is multifactorial, including genetic, environmental, maternal, and foetal causes. The absence of foetal movements leading to multiple joint contractures, pulmonary hypoplasia, and intrauterine growth restriction are the key features of foetal akinesia deformation sequence. Herein we describe the case of a 30-year-old gravida 4 (para 2+1) who came for foetal ultrasound at 28 weeks of gestation due to decreased foetal movements. Ultrasound showed features of FADS with fixed flexed position of foetal limbs, pulmonary hypoplasia, polyhydramnios, and intrauterine growth restriction. The timely use of ultrasound enables early detection of these cases and aids in appropriate counselling and management.
Keywords: Foetal arthrogryposis, antenatal, foetal akinesia, ultrasound.
World Health Organization success in rehabilitation 2030 including refugees’ rehabilitation across South Asia: a narrative review
Authors: Mumtaz Nazia , Saqulain Ghulam
Published: November 2023

Despite acknowledging the inadequacy of rehabilitation systems to meet the ever-increasing burden of disability, the World Health Organization’s Rehabilitation 2030 initiative has not highlighted nor adequately analysed the deficiencies of the rehabilitation care structures of populous countries in South Asia. The pragmatic and operational realisation of the initiative is not high in terms of visibility in developing countries with fragmented rehabilitative care structures. Hence, the current narrative review was planned to highlight the spectrum of rehabilitation healthcare in the perspective of Sustainable Development Goal-3 with reference to the most populous South Asian countries, including Pakistan. A total of 40 relevant English-language, articles, publications, reports and online resources were reviewed. The narrative review is significant since it may result in mainstreaming the individuals with disabilities, improving their quality of life, enhance their productivity and lessen the burden and socio-economic costs of disability on the community.
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Clinical audit: a necessity or a formality?
Authors: Ajaz Sami , Ahmad Muhammad , SARFRAZ RAZA
Published: November 2023

Dear Editor, Clinical auditing is a widely accepted practice world wide to assess the quality of health care given by a provider (1). It is described as a quality improvement approach that aims to enhance patient care and outcomes by systematically examining of treatment against stated criteria and implementing change (2). A clinical audit provides a service with the capacity to identify deficiencies, areas of excellence, and generate relevant suggestions that would drive change. It enhances the practice of evaluating against established standards (1). In developed countries, it is an essential component of clinical practice; nevertheless, it has yet to achieve equal status in developing countries. As a result, the demand for a structured Clinical Audit program is long overdue.
Surprisingly, a thorough online literature search from 2021 till date was conducted on PakMediNet and PubMed that yielded only three clinical audit studies in Pakistan as shown in Table - 1. All these studies are closed-loop audits that follow accurate guidelines and reported significant improvement after intervention in the re-audit cycle. Ashraf M et al. reported that operative notes can be improved, by using audits to identify poor areas (3). According to Shah MH et al. standard venous thromboembolism (VTE) risk assessment and prophylactic prescription guidelines were not followed, but after intervention and re-audit, it was discovered that a simple and effective educational intervention improved VTE risk assessment and prophylactic prescribing practices (4). Similarly, Rabbani RA et al. emphasize the need for clinical audits in improving standard surgical procedures (5).
No doubt that clinical audits are a tool that, when used correctly, can result in a change in the quality of care provided by a service (1). New research and clinical audit programs are crucial to the future of quality care in Pakistan (2). As a result, it is critical that our future healthcare workers understand how to conduct clinical audits and lead them during their training (2). Continuous improvement can be achieved by a healthcare unit that incorporates frequent audits with clinical practice in its curriculum. Clinical auditing will help to strengthen and increase their clinical knowledge and communication abilities. At the end of the day, it will result in improved patient care and outcomes. Therefore, the need of the hour is to promote clinical audit studies among healthcare workers.
The myth of superfluous pre-operative NPO after midnight
Authors: Eman Alamgir  , Alamgir Unsa , Iqra Alamgir
Published: November 2023

Madam,
Pre-operative nil per or nothing by mouth from midnight practice has been in work since 1960s.1 Its indiscriminate use is believed to prevent perioperative aspiration causing pneumonia 2, respiratory failure, morbidity and mortality. In almost every hospital in Pakistan and globally, the fasting orders from midnight are excessively used in case of morning elective surgical and medical procedures using general or regional anaesthesia.3 These not take into account the duration and type of surgery, type of sedation, choice of airway, risk stratification for increased chances of aspiration such as obesity, age, esophageal disorders. 4
However, the revolutionised current guidelines for pre-operative fasting by ASA 5-6 suggest the much shorter “2-4-6” hour rule, with NPO for two hours for clear liquids, four hours for breast milk and six hours for solids. Hence, the awareness about this myth needs to change in Pakistani healthcare centres.
Recent studies have led to a more sophisticated understanding of gastric emptying and pH of gastric contents. For instance, a cochrane review showed no statistical difference in gastric volumes or stomach pH in patients on a prolonged standard fast vs shortened (<180 minute) liquid fast.7 Furthermore, the 2-4-6 rule minimises the risk of dehydration, electrolyte imbalance, patient discomfort (thirst, hunger, nausea, vomiting, anxiety) 8, hypoglycemia, intraoperative haemodynamic instability, post- operative dehyhydration and extended hospital stay. In this way patient cooperation and satisfaction can be increased.
Therefore, it is high time to change the highly controversial NPO policy to reach the international healthcare standard.
Is Pakistan ready to implement Artificial Intelligence?
Authors: Hamna Tariq  , Areeba Sajid
Published: November 2023

Madam,
The phrase "artificial intelligence" (AI) refers to the capacity of computers to accomplish activities that humans can typically performed by utilising an Artificial Neural Network (ANN) (1). The Artificial intelligence has become an exceptionally desirable analytical tool in medicine due to its ability to generalise, handle imprecise information, analyse non-linear data, and learn from historical precedents (2). According to Tata Consultancy Services Global Trends Study focusing on artificial intelligence and its impact on the healthcare industry, 86% of healthcare companies use AI", indicating its significance in improving healthcare (3). AI is employed everywhere, ensuring accuracy and speed in every aspect of a patient's diagnosis to their prognosis and treatment, revolutionising medicine (4)
Despite all the benefits of AI, multiple factors need to be kept in mind before it can be successfully applied. AI works on software that is designed in accordance with data sets. If the data used in programming is not diverse, it will inevitably result in prejudice worsening the discriminatory outcomes in healthcare. There are numerous examples of AI being biased. For example, gender discrimination was a problem with facial recognition algorithms developed by Microsoft, IBM, and Face++; these AI systems were better at identifying the gender of white males than those with a darker complexion (5). When an advanced company like Amazon faces such issues, do we think a developing country like Pakistan will be equipped to successfully implement AI in a vast field like medicine? In Pakistan, women are typically responsible for the care of the home and are restricted in their capacity to travel alone and prioritise the health of their male family members (6). So will women be able to contribute their confidential information for AI data sets while they are confined to their houses? This could result in data that is weighted towards men (6).
Conducting surveys is a crucial part of data collection (7). We must be cognizant that not all of Pakistan is accessible and that people there have a variety of objections and obstinate attitudes (7). The most recent COVID-19 outbreak was the ideal illustration of their ignorant behaviour (7). This demonstrates how unlikely it is to obtain data from the Pakistani population, which means only limited data can be collected. Since AI data sets heavily rely on Volume, variety and velocity so it is natural for AI not to prevail in Pakistan (7).
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The road to crisis: State of Pakistan’s Research Output in Dementia
Authors: Ahmed Tehniat Faraz , Ahmed Affan
Published: November 2023

Dear Madam,
With an estimated 6.5 million people living with dementia in the South Asian region, these areas are at the forefront of tackling the growing epidemic. However, there is a scarcity of population-based studies particularly in lower-middle-income countries, which hampers accurate estimation of the economic burden posed by dementia (1). Pakistan, with the world’s third largest growing population is a model of these countries. Although the Global Action Plan for Public Health Response to Dementia highlights seven action areas, the Global Dementia Observatory (GDO) report has Pakistan underperforming in almost all areas. In comparison, her neighbors, India, China and Iran are significantly better. With no health information systems for dementia, and no support or care for people with dementia, Pakistan has failed to consider dementia as a public health priority (1). Reports show that Pakistan is drafting a national policy for dementia, yet no surveys on national prevalence and cost have been conducted (2). Apart from an ageing population, low literacy levels and high prevalence of heart diseases and diabetes, make the population highly susceptible to developing AD in the coming future.
Furthermore, a challenge especially to LMICs is the stigma associated with dementia and the lack of awareness, not just in the general population, but also in the healthcare providers. Alzheimer’s Disease International reports that almost 2 in 3 healthcare practitioners worldwide consider dementia as part of normal ageing (3). Only if these beliefs are reformed can the disease be tackled efficiently.
For a nation with no infrastructure to support patients with AD and where MRI is unaffordable to the majority and scarcely available PET scans are not used for the diagnosis of AD, the population would rely on the establishment of fluid biomarkers not only for diagnosing AD, but for its identification at a stage where it is possible to reduce the years lost to dependence. Unfortunately, our search on PubMed and Google Scholar revealed only one AD biomarker study conducted by the current authors on our population (4).
Recently a constructive step was taken by lay and professional experts where a SWOT analysis was done of dementia research capacity in Pakistan.
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AI Chatbots and Psychotherapy: A Match Made in Heaven?
Authors: Saqib Huzaifa , Sumyia  , Alizeh Saqib
Published: November 2023

Dear Editor,
Artificial Intelligence (AI) is revolutionizing psychotherapy by combating its inaccessibility.1 AI chatbots and conversational agents are among the most promising integrations in psychiatry and psychology. By harnessing the power of machine learning and artificial intelligence (Figure I), AI chatbots and conversational agents can provide a level of interaction and support previously unattainable in the landscape of mental health. In this letter, I will explore some of their numerous benefits.
Chatbots have evolved from early examples such as ELIZA, a programmable natural language processing program, and PARRY, a program that mimicked the behaviour of a human with schizophrenia, to modern ones such as Woebot, Tess, and Replika, which offer cognitive behavioural therapy, sessions, and self-understanding, respectively. Some chatbots such as Kaspar and Nao are also embodied in physical robots, which help children with autism spectrum disorder (ASD) learn social skills and facial recognition. AI chatbots can address the challenges of mental health care, such as the shortage of professionals2, especially in underdeveloped countries; the stigma of seeking help, which is prevalent in many cultures; the cost of therapy, which can be prohibitive for many people; and the limitations of human therapists, who can have variable attention spans, attention-to-detail, and memory capacities. AI chatbots can also offer benefits such as accessibility, anonymity, personalization, and effectiveness. Studies have shown that AI chatbots can improve the outcomes and experiences of mental health patients in various ways, such as enhancing the performance of those with ASD with robotic "therapists"1, increasing their disclosure of sensitive information to chatbots2, and reducing their distress after talking about their problems with conversational agents3.
The benefits of AI chatbots for mental health are clear. However, they also face many challenges that limit their usability and reliability. They may lack the emotional skills of human therapists and may not be accountable for their diagnoses and recommendations. They may also not be based on sound mental health knowledge and evidence, as technology companies may not have expertise and experience in this field. Therefore, technology companies and mental health professionals must collaborate and adopt a rational approach to develop and evaluate chatbots. Only then can chatbots realize their full potential and complement existing mental health services safely and ethically.
Women suffering from endometrioma-related symptoms may benefit from Silymarin, an antioxidant
Authors: Mufti Amna Faheem , Rizwan Abdul Wahid , Farooq Hassan
Published: November 2023

Madam,
Endometriosis is a potentially debilitating disease in which endometrial tissue is present outside the uterine cavity. It can be symptomless in some women, while causing severe pelvic pain, dysmenorrhea, dyspareunia, and decreased fertility in others.1 According to the World Health Organisation (WHO), endometriosis affects 10% (190 million) of reproductive age women globally.2 Endometriomas are the most common manifestation of endometriosis on the ovary, indicating a more severe disease state.3
In October 2022, a randomised trial was conducted to study Silymarin's efficacy on endometrioma-related manifestations. 4 The trial was the first of its kind. It showed that Silymarin, a herbal supplement with potent antioxidant effects, significantly decrease endometrioma size and the chronic pelvic pain related to it.4 Oxidative Stress, an imbalance between ROS and antioxidants, is known as a primary factor in the endometriosis pathogenesis5, and Silymarin may be ten times as potent as Vitamin E, another antioxidant which has been investigated in relation to endometriosis treatment.4
In Pakistan, the estimated prevalence of endometriosis is 16.8%6, which means a significant number of women are living with the manifestations that come with the disease, including endometriomas, which are seen in 17 to 44% of individuals with endometriosis.3 Silymarin is already available and used in Pakistan for its hepatoprotective effects. In light of this, it is of great importance that this new treatment and its effects are studied on a larger scale, specifically on the Pakistani population to learn more about its potential in reducing the suffering and improving the quality of life of these women.
Prediction of Seizures in Patients with Temporal Lobe Epilepsy, more than 30 minutes before onset
Authors: Shahid Sameen , Kamran Haneen , Hafiz Muhammad Qasim Zafar
Published: November 2023

Dear Madam,
Around 52.5 million people worldwide suffer from the neurological illness known as epilepsy, which is frequently characterized by recurring seizures. (1, 2) As epilepsy is a chronic disorder that can lead to cognitive deficits, sadness, and anxiety in sufferers, it has a considerable negative impact on individuals and society. The most common type of seizures, affecting around 61% of persons with epilepsy, are focal seizures, which raise the risk of injury and early death (2). One of the most common forms of focal epilepsy, temporal lobe epilepsy (TLE), is characterized by recurring spontaneous seizures that begin in the temporal lobe. (s). (3)
In the last two decades, many new antiseizure medications (ASMs)have been developed; however, about 40% of people with epilepsy may be drug-resistant, meaning ASMs are unable to control their seizures; therefore, despite the advent of new treatments, a high unmet need remains unaddressed. (2) Surgery is an alternate treatment, however, it cannot be used if larger areas of the brain are affected, in such cases, neuromodulation is a novel and successful therapeutic tool developed. (4) Conventionally, neural activity in epilepsy is categorized into interictal, and post-ictal states. With the help of continuous EEG, researchers have subdivided interictal state into a pre-ictal and pro-ictal state in temporal lobe epilepsy patients (which is the typical drug-resistant focal epilepsy targeted for interventions such as neuromodulation). The pre-ictal states indicate imminent seizure onset, while pro-ictal states reflect changes in neural activity that create a propensity for seizures over longer periods. The EEG-based pro-ictal state detection is critical to adaptive neuromodulation, with early detection of seizure allowing electrodes to be applied therapeutically to the brain's seizure onset zone and thalamus enabling treatment to be modified as per seizure risk. (5)
A prospective cohort study was conducted on adults with drug-resistant temporal lobe epilepsy at UTHealth Houston, in which pro-ictal state – i.e., pathologic brain activities during periods of heightened seizure risk could be detected up to one-half hour prior to seizure onset. A classifier was developed that could reasonably accurately distinguish between physiological and pathologic brain states in temporal lobe epilepsy. Thalamocortical dynamics were used to identify pro-ictal states in each patient. As the limbic thalamus exerts a diverse influence on cortex activity, thalamocortical EEG was used for pro-ictal state detection as opposed to previous paradigms derived solely from cortical structures.
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Proton pump inhibitors- Adversaries in our fight against antibiotic resistance?
Authors: Umar Sumayya , Ejaz Zoya , Masood Faizan
Published: November 2023

Madam,
The proton-pump inhibitors (PPIs) belong to a class of medications that reduce stomach acid production by irreversibly inhibiting the stomach's H+/K+ ATPase pump. These medications are used in the treatment of many conditions, such aspeptic ulcer, gastroesophageal reflux, as part of H. Pylori eradication, gastrinomas, Barrett’s oesophagus and many other conditions. They are considered to be the most potent inhibitors of acid secretion, and have largely supplanted the H2 receptor antagonists and antacids. They are also among the most widely sold medications worldwide. The class of proton pump inhibitors is listed on WHO’s list of essential medicines.1Proton pump inhibitors are generally well tolerated. However, headache, nausea, diarrhoea, abdominal pain, fatigue, and dizziness are identified as some of the common side effects. Due to their efficacies and low risk profile, PPIs are often prescribed for extend than required period.
Several recent studies have shown that long-term PPI use is associated with various adverse outcomes. A 2023 study published in JAMA Network Open demonstrated that long-term use of PPIs may lead to an increased risk of acquiring extended-spectrum beta-lactamase (ESBL) and carbapenemase-producing enterobacterales.2Another study3 published in 2022 showed that PPI use was the only modifiable factor associated with the carriage of ESBL producers in residents of long-term care facilities. These studies add to the expanding list of adverse outcomes associated with PPIs. Other adverse events of long-term PPI use, include the risk of fractures, pneumonia, Clostridium difficile diarrhoea, hypomagnesaemia, vitamin B12deficiency, chronic kidney disease, and dementia.4
Proton pump inhibitors are still used widely in Pakistan. These new findings are concerning as ESBL-producing Enterobacteriaceae are highly prevalent in Pakistan. A meta-analysis showed that the overall pooled proportion of ESBLs in Pakistan is 40%5 whereas the German population showed an estimated ESBL proportion in the range of 10 to 15% and a US census reported 4 to 12% resistance due to ESBLs.5 This calls for a strict prescription control of PPIs by Pakistani physicians, and the duration of PPI use should not extend for longer than needed. In addition, the practice of PPI’s over the counter sale by the pharmacists in Pakistan should be stopped. Additional precautions should be taken in hospitalized patients who are using PPIs to prevent them from getting multi-drug resistant infections.
The Dilemma of Pharmaceutical Companies in Pakistan: Navigating Price Regulations During a Time of High Inflation
Authors: Mansoor Noman , Warsi Aimen
Published: November 2023

Dear Madam,
An ever-worsening economic crisis, has hit Pakistan, and the political crisis and recent floods have added to the worsening situation [1]. The inflation rate in Pakistan has hit a record high of 35.4%, leading to the manufacturers’ increase in the cost of essentials and amenities [2]. However, pharmaceuticals have still not been allowed to increase their products’ prices, making it difficult for them to thrive, which has led to their decrease in number over the last few years [3].
Since 2018, the number of foreign pharmaceutical companies in Pakistan has been reduced from 48 to 22. [4]. The local sector is in no better position. Pakistan's pharmaceutical industry has warned that local businesses will have to cease due to extortionate production costs and the devaluation of the rupee, difficulties with imports, and rising inflation [5]. As many as 770 drug manufacturers in Pakistan have been impacted by the medicine shortage crisis consequent to a lack of essential raw products and materials imports [6]. More companies are expected to stop producing medicines owing to high costs in the upcoming days, which may lead to the number of scarce drugs in the country increasing from 500 to 2,500 [7].
Pakistan is the only country with a regulatory authority that controls the prices of all medicines. [8]. This entire situation has created an immense burden for consumers, who are compelled to face the consequence of medicine shortage, forcing them to buy medicines at a much higher cost. The deficit has also led to the production of counterfeit drugs, hurting not only the existing industries but also putting patients’ lives at very high risk. The industry's greatest worry is the complete freezing of pharmaceutical product prices. The government-set pricing structure prevents the pharmaceutical industry from raising the price of any drugs, even those whose costs have increased by more than 100%. With significantly increasing input, associated costs like fuel, electricity, labour, and raw materials have made it difficult for the industry to survive [8].
The government should pay immediate attention to this problem.  The Drug Regulatory Authority of Pakistan (DRAP) needs to implement new policies allowing pharmaceutical to increase their products’ prices, ensuring not to overburden consumers with it. DRAP should be strengthened by upgrading to maintain global standards.
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Can the Monkeypox virus pose a potential threat for Pakistan with new emerging cases?
Authors: Haiqa Zulfiqar  , Uzma Aslam  , Yusuf Hasan Ali
Published: November 2023

Madam,
Monkeypox (MPX) is a viral disease belonging to the orthopoxvirus genus with a clinical presentation strikingly similar to that of smallpox which includes fever, rash and lymphadenopathy [1]. The disease is primarily transmitted through direct contact with an infected person, animal, or contaminated material. Recently, Pakistan reported its first two confirmed cases of Monkeypox, and there has been a global outbreak of over 78,000 people infected [2]. Given the statistics, Pakistan should also take preventive actions to control the country-wide spread of the disease.
The symptoms of the Monkeypox virus usually begin within a week but may range between 1-21 days after the initial exposure. Initial signi in most individuals is a rash beginning on the face and eventually spreading over the body extending to the palms and soles. The distinct lesions typically appear in stages, beginning with macular, then papular, then vesicular and eventually pustular. Moreover, there can be serious complications including pneumonitis, encephalitis, sight-threatening keratitis and secondary bacterial infections [3]. Cases in the current outbreak have been atypical, with the characteristic rash starting in the genital and perianal areas with or without dissemination to other body parts[4]. The clinical recognition of Monkeypox can be challenging especially in resource-poor endemic regions. Diagnosis is usually done through identification of viral DNA by collecting swabs from the crusts of lesions. According to the Center for Disease Control and Prevention (CDC), no specific vaccine or treatment for the Monkeypox virus is currently available.[5]
Prevention is better than cure, it is important to highlight the need for better surveillance and early detection systems nationwide. Promoting campaigns on both small and large scales is crucial to raise awareness about the disease. These campaigns can include awareness sessions in educational institutions and setting up roadside camps in high-risk areas. The public should be advised to take necessary precautions to protect themselves and their communities by restraining contact with infected individuals and practicing isolation if infection is suspected. Front- line health officials are particularly vulnerable and should follow strict standard operating procedures, while airports should be closely monitored for potential cases. While the world is still challenged by the  COVID19 pandemic, the emergence of new outbreak by monkeypox virus has raised concerns and therefore, it is high time for the government to plan and implement appropriate actions on emergency basis to control the spread of this disease.