bluuebunny/crossref_metadata_2025 huggingface dataset:
Mixing it Up: Exploring Fizzical-Science through Play
Authors: Beisly Amber , Moffitt Anne
Published: January 2025

Young children have many opportunities to investigate physical science and chemistry concepts through play and exploration. While formal chemistry lessons are not within the scope of an early childhood classroom, there are ways to encourage children to engage in the processes of chemists.  This article presents a framework for how to structure science lessons in the classroom that build upon children’s theories and prior experiences. With a focus on mixing and how physical objects transform, we then present a variety of activities based on the framework, where children may deepen their knowledge of materials and interact through child-led explorations. We provide examples of how this can be done across many spaces (i.e. outdoors, the arts center) to honor the important work of play in early childhood classrooms and to highlight the many ways that children engage in science and theory-building throughout their day.
Phosphate solubilization by rhizobacteria isolated from the rhizosphere of Mimosa pudica: an investigation into microbial mobilization of phosphorus
Authors: Izomor Ray Niofunimbi , Nwankwo Peace Chidimma , Okafoanyali James Ogochukwu
Published: January 2025

Phosphorus (P), in addition to nitrogen (N) and potassium (K), makes up the essential macronutrients needed by plants for growth and development. P is also one of the most abundant elements present in the Earth’s crust, and it occurs in both organic and inorganic forms. Although present in high concentrations, only a very minute amount is bioavailable to plants because of its poor solubility due to its high binding affinity to calcium, aluminium, and iron in the soil, forming insoluble calcium phosphate, aluminium phosphate, and ferrous phosphate, thereby becoming recalcitrant for plant utilization. In this study, bacteria isolated from the rhizosphere of Mimosa pudica from different locations at Nnamdi Azikiwe University, Awka, were screened for their ability to solubilize phosphate using point inoculation on Pikovskaya (PVK) media agar plates with tricalcium phosphate (Ca3(PO4)2) as a source of phosphate. The result showed that of the twenty-one (21) rhizobacteria screened, four (4) were able to solubilize phosphate with varying phosphate solubilizing index (PSI). The degrees of PSI were in the following order: isolate SVM5 and UBG13 > isolate UBG14> isolate FEA6. Isolate SVM5 and UBG13 had the highest PSI of 4.0, while isolate FEA6 had the lowest PSI of 3.1. The biochemical tests of the isolates revealed that the phosphate-solubilizing bacteria were members of Klebsiella spp. (FEA6, SVM5, and UBG14) and Pseudomonas sp. (UBG13). This study, therefore, suggests the need to include rhizobacteria as part of biofertilizer formulations to improve plant yield via the solubilization of phosphate into forms that are bioavailable for plant growth.
AQUAPONICS: A SUSTAINABLE TECHNOLOGY FOR AQUACULTURE AND AGRICULTURE FOOD SECURITY
Authors: Abdul Manan Norhidayah , Mohamad Siti Jalilah , Kamaruzzan Amyra Suryatie , Ahmad Razman Mohammad Mukmin , Kasan Nor Azman , Ikhwanuddin Muhammad
Published: January 2025

Aquaponics are one of green technologies and that would allow for the production of multiple food products like fish and vegetables in one complete system. Aquaponic systems also have potential as a sustainable food security practice as the production of vegetables and fish can be done simultaneously. The process also supports global Sustainable Development Goals (SDG); SDG 1 (no poverty) and SDG 2 (zero hunger), with the implementation of aquaponic systema by local communities. The aquaponic concept is characterised by the recycling of fish waste into beneficial products and as a source of nutrients and natural fertilisers for plant growth. The synergy between the plants, fish and bacteria in the soil and fish waste benefits all components in the system and promotes a circular economy. This review emphasises the types of aquaponic systems, the fish that are suitable for aquaponic cultivation, the types of vegetables that are suitable for aquaponic cultivation and the benefits of the application of aquaponic systems. Aquaponic systems, help promote a sustainable environment, for the recycling of fish and plant waste into fertilisers that maximise resources use and production yields. In this manner, the system helps the local community improve socioeconomic and income generation as well as supports national and global food security agenda.
NUMERIČKA SIMULACIJA I OPTIMIZACIJA STRUJANJA FLUIDA U BIOREAKTORU POSTROJENJA ZA PREČIŠĆAVANJE OTPADNIH VODA
Authors:   Energoprojekt Hidroinženjering AD, JOVANOVIĆ Sofija , BOŽIĆ Ivan ,   University of Belgrade, Faculty of Mechanical Engineering, Serbia, STOJANOVIĆ Biljana ,   IMLEK AD, Serbia, LEKIĆ Branislava ,   University of Belgrade, Faculty of Civil Engineering, Serbia, KILIBARDA Nikola ,   Energoprojekt Hidroinženjering AD
Published: January 2025

In bioreactors of wastewater treatment plants, biological
processes based upon an adequate fluid flow are taking
place. In order to achieve as effective as possible
operation of a bioreactor, of utmost importance are
knowledge and analysis of the flow field in it,
determination of unfavorable flow zones, as well as the
establishment of the corresponding designs for
improvement of flow field and general improvement of
water treatment. In present paper an analysis of a flow
field in the bioreactor of the specific wastewater
treatment plant (WWTP) in Republic of Serbia was
performed by means of computational fluid dynamics
(CFD). Flow analysis in this paper is focused on
identification of influence of the individual mixer
parameters upon the mixing processes in a bioreactor. In
order to achieve optimal mixing of treated water in the
anaerobic and anoxic tanks of the bioreactor, in addition
to reviewing the selection of the number of mixers and
their locations, a special attention was given to the
effects of changes of structural (mixer diameter and
installation angle) and operational (mixer runner speed)
parameters upon the velocity field. The results obtained
indicate that there is room for improvement of
prescribed measures with the objective of optimization
of operation not only of the analyzed one, but the other
existing WWTPs too.
KORIŠĆENJE ZAPLAVA BUJIČARSKE PREGRADE ZA INDIVIDUALNO VODOSNABDEVANJE DOMANĆISTVA U BRDSKO-PLANINSKIM OBLASTIMA
Authors:   University of Belgrade, Faculty of Forestry, Serbia, NIKIĆ Zoran , RISTIĆ Ratko ,   University of Belgrade, Faculty of Forestry, Serbia
Published: January 2025

Rural households in hilly and mountainous areas in
Serbia (as well as in the surrounding areas), in addition
to numerous other infrastructural facilities, usually do
not have a fixed water supply. In order to alleviate this
problem, the approach to put into operation all water
resources in the immediate environment with favorable
qualitative and quantitative characteristics was adopted.
In conditions where there is no alternative for solving
water supply in a conventional way in hilly and
mountainous areas, the solution is conditioned by what
is available. This was the starting point for research
conducted through several phases of field and cabinet
activities. One of the conclusions is that the function of
water supply for rural households in hilly-mountainous
areas can be put to torrential deposits where there are
prerequisites for that. Obtained results show that a
torrential deposits of significant distribution and power
(thickness) with a constant inflow of river water is a
potential source of groundwater. Intergranular porosity
of deposits enables infiltration of surface river waters
and thus formation of groundwater accumulation within
deposits. Formed outcrop of compact type is
characterized by possibility of filtration, accumulation
and release of groundwater. Contribution of water
supply from flash floods in addition to improving living
conditions of members of a rural household in hilly and
mountainous areas, is reflected in possibility of bridging
lack of capacity of existing source, then creating a water
supply system at a relatively modest price, properly
observing and understanding limitations of quality water
resources, especially in current climate conditions
events and more. In this way, in addition to the primary
role (protection against flash floods), flood barrier also
has an important secondary role (individual water
supply).
KALIBRACIJA I VALIDACIJA MODELA EPIZODA U KARSTNOM SLIVU
Authors:   Hydro-Engineering Institute Sarajevo, Bosnia and Herzegovina, MUJČIĆ Mirza , MULAOMEROVIĆ – ŠETA Ajla ,   University of Sarajevo, Faculty of Civil Engineering, Bosnia and Herzegovina
Published: January 2025

For the assessment of the hydrological regime, the impact
of natural or anthropogenic changes on the watershed,
and the evaluation of flood events in gauged and
ungauged watersheds, hydrological models are
increasingly being used. The HEC-HMS model for
rainfall-ruoff events was utilized to model three distinct
events from different periods prone to floods at the
hydrological station in Drvar on the Unac River.
Considering that this is a karst watershed, modeling
runoff presents a unique challenge. This study examined
the applicability of a relatively simple model,
parsimonius in parameters and input data, as well as the
transfer of model parameters from one event to another.
The input data for the calibration and validation of the
model consisted of hourly discharge and precipitation
data.
The study performed manual calibration by adjusting one
parameter at a time. Based on efficiency measures
(PBIAS, NSE, RSR), a set of parameters was selected for
each rainfall event. The final calibration results
demonstrated a good agreement between the observed
and computed hydrographs according to all efficiency
measures. In the validation process, the efficiency
measures were poorer, and the transfer of parameters
from one event to another was partially successful.
KOMPLEKSNA GEOLOŠKA ISTRAŽIVANJA ZA PROJEKTOVANJE HIDROTEHNIČKIH OBJEKATA
Authors:   Energoprojekt – Hidroinženjering a.d., Srbija, Beličević Vladimir
Published: January 2025

To accurately determine the construction and operational
conditions of electro-energy hydrotechnical facilities,
systematic research of the geological characteristics of
the terrain on which the structures is to be placed is
necessary. This research encompasses various aspects,
including geomorphology, lithostratigraphy, structural
geology, seismology, hydrogeology, physicalmechanical properties, and more, as well as mathematical
modeling of the interaction between the structure and the
geological environment. The primary goal of this
research is to gather all relevant data on the properties of
the geological medium, which are crucial for selecting
optimal technical solutions.
Given the complexity of this topic, the guidelines of this
work do not aim to provide precise solutions for every
individual case; rather, they are directed towards
providing additional information and experiences for the
Client, Designer, and Contractor of the research works.
Considering all aspects and the complexity of the issues,
which depend on geological conditions, the
characteristics of the structure, and the design phase, each
specific case is addressed through the development and
control of the Research Project, which precedes all
phases of research and design. The results of the
geological investigations and the conclusions drawn from
them are presented in a comprehensive Report on the
research results, which, in accordance with legal
regulations, forms part of the Project Documentation of
the structure.
By "geological investigations for the design of
hydrotechnical structures", which is the subject of this
work, we refer to complex studies of the composition,
properties, and condition of the geological environment
before, during, and after the construction of the
hydrotechnical structure, including the prediction and
monitoring of its behavior in interaction with the
structure.
This represents a specific contribution to the
systematization of geological research for engineering
and hydrotechnical. structures, specifically referring to
dams, reservoirs, and associated facilities.
METODOLOGIJA PREDIKCIJE REŽIMA PODZEMNIH VODA U USLOVIMA UREĐENJA PROSTORA NA LEVOJ OBALI DUNAVA U NOVOM SADU
Authors:   Jaroslav Černi Water Institute, LUKIĆ Vladimir , JEVTIĆ Goran ,   Jaroslav Černi Water Institute, PUŠIĆ Milenko ,   Jaroslav Černi Water Institute, TRIPKOVIĆ Vesna ,   Jaroslav Černi Water Institute
Published: January 2025

The left bank of the Danube in the area of Novi Sad,
specifically in the Kamenička Ada and Ribarsko ostrvo
zones, is currently an unprotected, hydrotechnically
undeveloped, and non-urbanized area. Contemporary
city development trends emphasize utilizing riverbanks
for multifunctional purposes. For the left bank of the
Danube in the Kamenička Ada and Ribarsko Ostrvo
zones, it is proposed to shift the existing defense (flood
protection) line of the embankment approximately 500
meters closer to the riverbed. The arrangement of the
protected area formed in this manner, in accordance
with the defined project documentation, involves the
creation of a rowing path to replace the existing Šodroš
backwater of the Danube. The concept for the rowing
path envisions establishing direct hydraulic contact with
the aquifer while ensuring a consistently maintained
water level. This approach ensures its hydraulic role as a
regulator of the groundwater regime in the area. As part
of developing the General Urban Plan for this area, it
was necessary to assess the impact of the proposed
changes on the groundwater regime. To assess the
impact of the planned works on groundwater regime
changes, a hydrodynamic groundwater flow model was
created for the given area. The model aims to define and
quantify the changes that would occur in an acceptable
engineering manner. Accordingly, the hydrodynamic
model was developed, calibrated and verified, and
predictive calculations were performed based on defined
computational scenarios. By comparing the calculation
results for the current state with those for the planned
state, the impact of the proposed changes on the
groundwater regime was assessed and quantified. The
analysis of the obtained results revealed that shifting the
embankment closer to the Danube does not significantly
affect the groundwater regime. Constructing the rowing
track under the given premises would have a positive
impact on the groundwater regime in the area. During
periods of high Danube water levels, the rowing path
would act as a drain, collecting excess groundwater.
Conversely, during low water levels in the Danube and
aquifer, it would replenish the aquifer, compensating for
water deficits.
Indonesia's Value Added Tax (VAT) Reform: Fiscal Benefits and Sectoral Impacts
Authors: Fathoni Muchamad Irham
Published: January 2025

This study comprehensively analyzes the impact and implications of the planned increase in Value Added Tax (VAT) rates from 11% to 12% in the wider context of the Indonesian economy. Using an analytical-descriptive approach with a literature review method, this study examines various dimensions of policy impacts, including fiscal, macroeconomic, sectoral, and implementation feasibility aspects. This study found that the increase in VAT has the potential to increase state revenues by IDR 85-95 trillion per year, but also has potential consequences of inflationary pressures of 1.1-1.4% and a short-term slowdown in economic growth of 0.3-0.4%. From a sectoral perspective, MSMEs face significant pressure with a decline in margins of 2-3%, while the formal sector shows better resilience. The implementation feasibility analysis indicates that the readiness of the tax administration system has reached 85%, although there are still several challenges in the supervision aspect. This study recommends a gradual implementation approach with an increase of 0.5% per year, accompanied by strengthening social assistance programs and special incentives for MSMEs. Periodic monitoring and evaluation framework are key to ensuring the effectiveness of this policy while minimizing negative impacts on the economy. This study concluded that the success of this policy depends on the right timing of implementation, institutional readiness, and comprehensive supporting policies.
Antibiotic Susceptibility Profile of Gram-Negative Bacteria Isolated From Pond Catfish in Ketu Adie-Owe, Ado-Odo Local Government Area of Ogun State, Nigeria
Authors:   Crawford University, Km 8, Atan- Agbara Road, Igbesa, Nigeria, E. O. Lateef, , T. T. Banjo, ,   Crawford University, Km 8, Atan- Agbara Road, Igbesa, Nigeria, T. C. Dunkwu ,   Crawford University, Km 8, Atan- Agbara Road, Igbesa, Nigeria, H. O. Okodogbe, ,   Omark school of Health Technology, Igando. Lagos, O. M. Olabode, ,   Crawford University, Km 8, Atan- Agbara Road, Igbesa, Nigeria
Published: January 2025

The increasing number of fish ponds in Nigeria is driven by the demand for fish and fishery products. Catfish, specifically Clarias gariepinus, is popular for cultivation due to its economic significance. However, bacterial infections pose a threat to the health of catfish in these ponds, resulting in the need for antibiotic usage. This study is aimed to assess the antibiotic susceptibility pattern of Gram-negative bacteria isolated from pond catfish. This study involved isolating bacteria from the catfish skin and intestine, analyzing their biochemical characteristics, and conducting antimicrobial susceptibility testing. Fungi present in the catfish samples were also identified. The Gram-negative isolates were subjected to antibiotic susceptibility testing, revealing the prevalence of multidrug-resistant strains. The findings contribute to the understanding of antibiotic resistance in aquaculture and highlight the need for appropriate management strategies. The bacterial load in different catfish samples was examined through total plate counts and dilution effects. The results revealed variations in colony counts and CFU/ml values among the samples, with the highest bacterial load observed in the skin of large catfish. The bacterial load observed in the skin of catfish ranged from 4.7 X 103 CFU/ml to 9.8 X 103 CFU/ml, while the bacterial load observed in the intestine of catfish ranged from 3.1 X 103 CFU/ml to 5.4 X 103 CFU/ml. Biochemical testing identified specific organisms, including Enterobacter cloacae, Aeromonas hydrophila, Klebsiella pneumoniae, Citrobacter brakii, Citrobacter freundii, and Enterobacter aerogenes. Varying resistance patterns emphasize the need for careful antibiotic use and infection control in catfish aquaculture. Therefore, continuous monitoring and preventive measures are recommended.
Validity and reliability of a sport participant psychosocial well-being instrument: a preliminary study
Authors: Sepdanius Endang , Binti Sanuddin Nurul Diyana , Bin Mohd Nor Mohad Anizu , Mohd Sidi M. Adli Bin , Erhan Orhan Bekir , Aman Mohd Salleh , Afriani Rini
Published: January 2025

Purpose: This study aims to evaluate the validity and reliability of an instrument designed to measure the psychosocial well-being of sports participants.
Method: This study has four phases: preparation, translation, field trials, and validation methods. Seven experts evaluated the study based on content, clarity, and feasibility. The study involved 55 participants in 12 different sports using the test-retest approach. The participants were 19 women and 36 men, with an average age of 15 years and 7 months.
Result: The analysis results show that each item meets the validity criteria, with a Pearson correlation value higher than the r table value (0.266). Intraclass correlation test shows the reliability of each sub-variable is 1) Psychosocial Well-being of 0.938, Social Integration of 0.871, Social Contribution of 0.923, Social Actualisation of 0.926, Social Coherence of 0.916, and Social Acceptance of 0.995 indicating all sub-variables have high consistency. With valid and reliable results, this instrument is ready for further research.
Conclusion: This study shows that the Psychosocial Well-being Instrument for sports participants has excellent validity and reliability, with validation results from experts and test-retest tests showing strong consistency. This instrument is ready for further research and practical applications, such as assisting coaches, psychologists, and counselors in assessing the psychosocial well-being of sports participants and supporting psychosocial development programs that improve the performance and mental well-being of sports participants. In addition, this instrument can support the development of policies that pay attention to psychosocial aspects in sports participant development and open up opportunities for further research on the relationship between psychological well-being and other factors in sports
Participación deportiva, capacidad espacial motriz y autoeficacia percibida en jóvenes con altas capacidades intelectuales
Authors: Marcen Celia , López Centeno Francisco David , Lara Sánchez Amador J. , Quílez Robres Alberto
Published: January 2025

Introducción: el estudio de la participación deportiva entre la población de altas capacidades intelectuales se ha desarrollado muy tardíamente, debido en parte a una tradicional concepción cartesiana del ser humano.
Objetivo: este estudio pretende aportar conocimiento a esta temática, analizando los hábitos deportivos de una población joven con altas capacidades intelectuales en relación con la inteligencia verbal y no verbal.
Metodología: en el mismo participaron 128 jóvenes de entre 14 y 25 años identificados con altas capacidades intelectuales, quienes respondieron a un cuestionario que incorporaba datos sociodemográficos y de hábitos deportivos, así como la evaluación de la inteligencia mediante un test breve, y dos escalas para medir el disfrute en la práctica de actividades físicas y la autoeficacia motriz.
Resultados: entre los resultados destaca que los jóvenes de altas capacidades, deportivamente, siguen tendencias similares a las de su grupo de edad. No se encontraron correlaciones significativas entre las variables relacionadas con la inteligencia y la capacidad espacial motriz tal como se planteaba en la hipótesis. Sin embargo, sí se encontraron relaciones significativas entre disfrute con la práctica y autoeficacia motriz, así como en el modelo centrado en el factor verbal y en la capacidad espacial motriz; es decir que, a mayor nivel de razonamiento verbal, mayor capacidad espacial motriz.
Conclusiones: este estudio puede contribuir a una mejor incorporación de la población de altas capacidades a las actividades físico-deportivas, promoviendo de esta forma su desarrollo integral.
Optimalisasi Preferensi Mahasiswa Dalam Pemilihan Laptop Menggunakan Metode TOPSIS
Authors: Erikasari Vivie Zuliani , Zulaeha Zulaeha , Mulqiya Wafha Zahra , Maharani Tyanshi Firli , Anshor Abdul Halim
Published: January 2025

Mahasiswa menghadapi tantangan dalam memilih laptop yang sesuai dengan kebutuhan dan anggaran karena banyaknya fitur dan spesifikasi yang tersedia di pasaran. Untuk memenuhi kebutuhan mahasiswa, khususnya di Universitas Pelita Bangsa, penelitian ini akan menganalisis dan mengembangkan sistem pendukung keputusan untuk memilih laptop yang tepat. Metode preference ranking technique with similarity to the ideal solution (TOPSIS) digunakan untuk mengevaluasi dan merangking laptop berdasarkan kriteria penting seperti harga, performa, kapasitas penyimpanan, dan portabilitas. Hasil penelitian menunjukkan bahwa merek laptop LENOVO THINKPAD E14 menjadi rekomendasi teratas dari 15 merek laptop yang dipilih. Diharapkan sistem ini dapat membantu mahasiswa dalam mengambil keputusan pembelian laptop yang lebih sesuai dengan kebutuhan akademik dan sesuai dengan preferensi mereka.
Toripalimab: A new age in fighting Nasopharyngeal Carcinoma
Authors: Ahmad Siddiqui Taha , Wakil Aamrah , Imran Maham
Published: January 2025

Madam,
Nasopharyngeal carcinomas (NPCs) lie amongst a group of malignant tumours whose incidence has steadily increased over the past 30 years.[1] These have a significantly higher incidence rate in Asian populations, which account for over 70% of new cases worldwide.[2] The leading risk factors associated with NPCs are tobacco and alcohol consumption, followed by HPV infections. Usually diagnosed at advanced stages, a combination of chemo and radiotherapy is the standard treatment. However, they have one of the lowest survival rates compared to other cancers.[1]
Programmed cell death protein 1(PD - 1) is a receptor that is expressed on T cells, B cells, macrophages, dendritic cells and natural killer cells. Binding of PD-1 with its ligands, namely PD-L1 and PD-L2, transmits an inhibitory signal, which decreases the proliferation and production of cytokines by T cells, thereby inhibiting immune system stimulation. Toripalimab is a monoclonal antibody that blocks interactions between the PD - 1 and PD-L1 or PD-L2.[3]
Toripalimab was approved by the FDA on 10/27/2023 with the following indications; first line treatment of locally advanced, recurrent or metastatic NPC(RM-NPC) in combination with standard chemotherapy using cisplatin plus gemcitabine, and as a lone agent in patients with RM-NPC showing disease progression despite being on or after platinum containing chemotherapy.[3] The approval was based off of two clinical trials; POLARIS-02 and JUPITER-02,[4][5] which suggested that toripalimab combined with standard chemotherapy provided statistically as well as clinically significant, progression free survival and overall survival benefits compared to standard chemotherapy alone.
The aforementioned clinical trials showed a manageable safety profile with the overall rate of grade 3 or greater side effects being similar in the two groups- toripalimab plus standard chemotherapy versus standard chemotherapy alone and that the most common side effects were mainly due to standard chemotherapy itself. The main immune related adverse effects reported were hypothyroidism, hyperthyroidism, abnormal liver function, interstitial lung disease and dermatomyositis.[4][5]
In recent years immunotherapy has emerged as a highly effective avenue when used in combination with targeted therapies. This combination enhances the immune cells’ attack capabilities and thereby enhances the efficacy of the treatment.[3] Toripalimab is the first FDA- approved immune checkpoint mediator for the treatment of RM-NPC and the promising results from the clinical trials alongside the tractable safety profile support the use of Toripalimab in combination with gemcitabine-cisplatin chemotherapy as the new standard of care for this population.
Cost-Related medication non-adherence in Pakistan: a pervasive public health challenge
Authors: Iqbal Khan Muhammad Fahad , Shah Izhar Muhammad , Khan Shahzaib
Published: January 2025

Madam,
Cost-related medication non-adherence (CRMNA) refers to failing to adhere to a prescribed medication regimen due to financial constraints. Predictors for CRMNA include high out-of-pocket medication costs, limited financial resources, lack of medication insurance, younger age, and poorer overall health.(1) Being one of the major determinants of non-adherence, CRMNA remains a significant barrier to effective treatment for patients in many countries, especially in developing countries like Pakistan. This is because, unlike developed nations with robust healthcare systems and widespread health insurance coverage, Pakistan relies heavily on out-of-pocket spending for medications. A recent study conducted in Pakistan found high medication costs to be a major cause of non-adherence to medication, with 92.7% of the patients’ responses reporting it as a factor.(2)
Non-adherence to medication reduces the effectiveness of the recommended treatment and therefore leads to disease progression, lower quality of life, and even death. Furthermore, non-adherence substantially increases the financial burden on the healthcare system by increasing the use of resources such as nursing homes, emergency services, hospital admissions, etc.(3) In this way, CRMNA creates a crippling cycle: As patients skip medications due to the high cost, their conditions worsen, leading to more expensive interventions, which subsequently further inflate medication costs. This is especially problematic for Lower Middle Income Countries (LMIC) such as Pakistan where the situation is further compounded by a healthcare system riddled with limitations including insufficient financing, weak healthcare infrastructure and a limited healthcare workforce. The introduction of the ‘Sehat Sahulat Program’ (SSP) in 2015 in Pakistan was a remarkable step towards Universal Health Coverage (UHC), an initiative by the World Health Organization (WHO), which aims to provide essential healthcare facilities to everyone protecting them from out-of-pocket health expenditures. However, since the program does not cover OPD facilities, it still does not solve the serious problem of CRMNA.(4)
Breaking the cycle of CRMNA necessitates a multi-pronged approach. Physicians should be encouraged to practice cost-conscious prescribing which may involve promoting the use of generic medications and considering the overall cost of treatment plans for patients. Government intervention is crucial to regulate drug pricing and foster competition within the pharmaceutical market. To improve access, public health insurance should fully cover or significantly subsidize essential medications. By proactively addressing CRMNA and prioritizing affordable healthcare solutions, we can pave the way for a healthier and more prosperous future for all Pakistanis.
Concerns and Considerations Regarding Azithromycin Use by Physicians
Authors: Arain Nimra Razaque
Published: January 2025

Dear Editor,
Azithromycin is a macrolide antibiotic that targets a wide range of bacteria. It inhibits the growth of many Gram-positive and Gram-negative bacteria, as well as other pathogens like Mycoplasma pneumoniae and Mycobacterium avium complex. Azithromycin is also used to treat bacterial enteritis, cholera, traveller's diarrhoea, as well as complicated enteric fever. It works by decreasing protein synthesis within the bacteria. Azithromycin is commonly prescribed for respiratory and genitourinary infections because of its long half-life and optimal tissue penetration. Ideal for its function, it is often preferred for some specific sexually transmitted infections like non-gonococcal urethritis and cervicitis. Besides its antibacterial properties, azithromycin also exhibits immunomodulatory effects, which can be beneficial in managing chronic respiratory inflammatory conditions. Potential adverse events include cardiovascular arrhythmias and hearing impairment. [1,2] Due to its broad-spectrum coverage, there is a rising concern about azithromycin being misused for minor ailments and not being reserved for severe life-threatening conditions.
According to a 2020 review article, 5,274 cases of XDR typhoid fever were documented in Pakistan. Azithromycin remains the only feasible oral antibiotic to which XDR typhoid remains susceptible, emphasizing that only three antimicrobial drugs including azithromycin (oral), carbapenems, and tigecycline (parenteral) remain effective against extensively drug-resistant strains. [3] In a study conducted by Khan et al. in Pakistan during the COVID-19 pandemic, researchers analysed 562 blood samples of typhoid patients, out of which 71 contained Salmonella typhi. Among these, majority were MDR. The isolates exhibited complete resistance to antibiotics from the fluoroquinolone, chloramphenicol, cephalosporin, and penicillin classes. This underscores the efficacy of azithromycin and carbapenems in treating every MDR or XDR Salmonella Typhi isolate.[4] This emphasizes the urgent need to preserve and carefully manage azithromycin for treating XDR typhoid infections. In a recent systematic review conducted by Kuitunen et al., azithromycin significantly reduced the risk of sepsis in the postpartum period in mothers who received azithromycin before delivery. [5]
These findings once again raise the question of whether we are using and prescribing azithromycin appropriately, as bronchitis and unspecified upper respiratory tract infections are the most common conditions for which azithromycin is prescribed in primary care. In Pakistan, this drug continues to be used as first-line management for upper respiratory tract infections in primary care settings. Physicians must exercise caution when prescribing azithromycin, considering its critical role as a potential life-saving treatment for severe conditions.
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More than just a broken limb: Unmasking CRPS in Pakistan
Authors: Zahra Aamir Khan
Published: January 2025

Madam,
Complex Regional Pain Syndrome (CRPS) is a debilitating pain disorder, usually affecting one limb, and occurring after a trauma. It is marked by intense pain out of proportion to the severity of the initial injury. Because CRPS is a rare condition, its pathophysiology, diagnosis, and treatment are not completely understood. The pathophysiology might involve an interplay between inflammation, genetics, nervous system changes, and psychological influences1.
Despite the challenges in diagnosis, the currently accepted diagnostic criteria is the Budapest Criteria, established after revising the previous IASP Criteria which led  to overdiagnosis.2 Once CRPS is identified, therapy can be just as complicated. The UK Royal College of Physicians outlines a multidisciplinary approach based on each patient’s individual needs.3 This involves patient education, utilizing intervention and medications for the pain, physical rehabilitation, and psychological intervention. Each of these elements is equally important for recovery.
Older studies indicate a significant delay in CRPS diagnosis, with patients waiting an average of 4 years.4 The lack of knowledge among physicians, unnecessary surgeries, and the belief that patients might be exaggerating about their pain, all contribute to a delayed diagnosis. This leads to a further decline in limb function, muscle wasting, difficulty in performing everyday activities, and eventually, social isolation.
To improve the understanding of CRPS in low-resource settings with limited patient data, Lewis et al. presented a global series from 9 different countries, including Pakistan.5 Despite being the world’s 5th most populous country, Pakistan lacks sufficient CRPS prevalence and presentation data. Out of the identified patients, only 16% were diagnosed according to the globally recognized Budapest criteria, and for 65% of patients, only pharmacological intervention was used. The essential multidisciplinary approach was rarely used. This highlights several issues that need to be resolved.
This letter calls for localized research to help refine management protocols tailored to the Pakistani population. By raising awareness about the clinical features of CRPS and the consequences of neglect towards patients, we can promote timely diagnoses and avoid long-term complications. Physicians need to build trust with their patients and make them feel heard. CRPS is a complicated condition, so a culture of strict adherence to standardized diagnostic and management approaches must be created. Integration of said protocols into the healthcare curriculum is also essential. This comprehensive approach requires immediate implementation to improve quality of life and reduce unnecessary suffering.
Misuse of sedative hypnotics: A call to awareness
Authors: Abdullah Ghazi , Zafar Areesha
Published: January 2025

Dear Madam,
Sedative Hypnotics, including Benzodiazepines and Non-Benzodiazepine drugs produce Sedative Hypnotic, anxiolytic, anti-convulsive, and anti-depressant effects. BZDs work by increasing the concentration of GABA in the brain, producing a calming effect. This is why they have a wide-spectrum use, primarily for insomnia and anxiety.1 Benzodiazepines are known to act as mechanisms that affect bone metabolism and increase bone resorption, thus leading to osteoporotic fractures.2
A recent meta-analysis of 20 observational studies in over six million individuals showed that Benzodiazepine Receptor Agonists (BRAs) including Benzodiazepines and non-benzodiazepine BRAs, such as Zolpidem, are likely to cause a statistically significant increase in osteoporotic fractures with an odds ratio ranging from 1.2 to 1.4. A study conducted worldwide suggests a rise in the use of sedative hypnotics in the past few years, particularly after the COVID-19 pandemic.3 Furthermore, a study conducted in Taiwan, revealed that the use of benzodiazepines in adults > 65 years increases the risk of developing hip fractures, even at a moderate dosage and short-term exposures.4
In South-Asian countries, particularly Pakistan, recommending and dispensing medication without prescription is a significant issue. A previous study shows that self-medication is quite a common practice in Pakistan for a lot of common illnesses. The factors contributing to the rampant self-medication in Pakistan include easy access to medicines, poor availability of healthcare facilities, and lack of enforcement of regulatory policies.5
Benzodiazepines are widely prescribed in many countries including Pakistan, and a general increase in trend is observed, but differences in drug type and exposure remain. A comprehensive needs assessment as to the quantity of the drug and the duration of its administration should be conducted before its prescription to an older adult. There should be a thorough evaluation of the drug response and it must be checked for drowsiness or residual fatigue, which can lead to falls and fractures. Further research is warranted to estimate the adverse effects of sedative hypnotics on various age groups and sexes with variable dose administration.
Student-run free clinics (SRFC) can solve three problems for Pakistan
Authors: Ahmad Bashir , Wazir Rabia
Published: January 2025

Madam,
Student-run free clinics are primary care bodies run by medical schools where students provide care under the supervision of senior faculty. SRFCs serve three main purposes in society i.e. undergraduate education, primary care and social justice providing care to the socially deprived. (1) It adds an extra layer of primary care and lessens the burden on secondary and tertiary care hospitals. In the United States, more than 75% of institutions are running SRFCs which provide care in chronic disease management, specialty care, imaging, laboratories, pharmaceuticals, and interdisciplinary services. (2) Care provided at these clinics is at par with other primary health care facilities. (3) They are equally important as a tool of undergraduate medical education (UME) as well as a social justice initiative.
Considering Pakistan’s current economic status, SRFCs appear as an option worth trying. These free clinics if reasonably funded, could save thousands of dollars for Pakistan’s healthcare system. Such clinics will help monitor chronically ill patients and will be more cost effective as compare to advanced care units. According to the International Diabetes Federation, Pakistan is ranked third highest in number of diabetic cases. (4) These free clinics can reduce the burden by monitoring and providing necessary care to the diabetic population. Depending on the capabilities of the parent institution, the SRFC can provide care in various other areas as well.
The SRFCs can serve as a potentially viable training ground for future doctors. Students from academically advanced years can be assigned different types of work at the clinics. Even first and 2nd-year students can be engaged in history taking and vitals monitoring whereas 3rd and 4th-year students can perform clinical examinations and interpretation of lab reports. Fifth year and interns can work under the direct supervision of senior faculty to prescribe medicine, perform minor procedures and lead other junior colleagues as well. This approach could foster a culture of collegiality, leadership, peer-assisted learning (PAL), and community involvement and at the end of all improve students’ clinical skills and confidence in patient management. Students managing such clinics will also get hands-on experience in running a healthcare setup and dealing with governance and legal issues.
Advocacy and social justice in medicine can be encouraged using such initiatives. Students who work at these clinics will be introduced to public health, social work, global health initiatives and the importance of primary health care.
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Withholding diagnostic and prognostic information from patients in Pakistan: ethical and cultural perspectives
Authors: Bhatti Muhammad Osama , Ameer Hamza  , Noor Ul Eman
Published: January 2025

Dear Editor,
I am writing to highlight a critical and often overlooked issue in our medical practice: withholding diagnostic and prognostic information from patients in favour of communicating primarily with family members. This practice raises significant ethical and legal concerns that merit urgent discussion. A significant portion of Pakistan's population—about 61%—resides in rural areas, where the literacy rate is approximately 59% [2,3]. Additionally, socio-economic factors play a major role, with over 37% of the population living below the poverty line [1]. Research indicates that patients with low literacy levels experience poorer health outcomes, including lower health knowledge, worse disease markers, higher morbidity, poorer general health status, and increased use of health resources. These patients are generally 1.5 to 3 times more likely to experience adverse health outcomes [4]. Consequently, medical decisions and treatment plans are frequently deferred to the household's primary earner rather than the patient, undermining the patient's autonomy.
In countries such as the United States and Canada, patient autonomy is a fundamental principle of medical practice. Patients have the right to be fully informed about their health conditions and make care decisions. In his seminal work The Silent World of Doctor and Patient, bioethicists like Jay Katz argued that excluding patients from decision-making processes is a profound affront to their dignity and autonomy. Similarly, Beauchamp and colleagues, in Principles of Biomedical Ethics, stress the importance of respecting patient autonomy alongside beneficence and nonmaleficence. A recent cohort study concluded that when medical decision-making was conducted through shared decision-making, daily controller therapy adherence in patients with asthma was 84%, a considerable achievement [5]. Respecting patient autonomy does not mean indiscriminately sharing all information but fostering a trust-based relationship where the patient’s preferences for receiving information and involvement in clinical decisions are carefully considered.
Healthcare providers must prioritize effective communication and uphold ethical standards by ensuring that patients are fully informed about their diagnoses and involved in their treatment plans. Educational institutions and healthcare organizations should emphasise the importance of these skills in medical training and continuing education programmes. I urge my fellow healthcare professionals to commit to promoting patient autonomy and transparency, ensuring that our patients are respected and their rights upheld in all aspects of their care.
Immunotherapy in Type 1 Diabetes: Emerging Therapies and Future Directions
Authors: Simran Thakkar  , Saptarshi Bhattacharya  , Lakshmi Nagendra  , Sanjay Kalra
Published: January 2025

Type 1 Diabetes Mellitus (T1D) is an autoimmune disordermarked by the destruction of insulin-producingpancreatic beta-cells. While insulin therapy remains thestandard of care, advancements in immunotherapypresent promising alternatives aimed at halting diseaseprogression and reducing insulin dependence. This briefreview highlights key immunomodulatory therapies,including teplizumab, which has demonstrated the abilityto delay the onset of T1D, and rituximab, known forpreserving beta-cell function, though its effects tend to betransient. Emerging treatments, such as stem-celltherapies, also show potential. However, significantchallenges remain, including high costs, long-term safetyconcerns, and the need for personalized care. As thistherapeutic landscape evolves, further research is criticalto optimizing these strategies and moving closer to apotential cure for T1D.Keywords: Type 1 diabetes mellitus, autoimmunity,immunotherapy, anti-CD3 monoclonal antibody,teplizumab,
Emotional Intelligence and Leadership Effectiveness – Are Women Leaders Better
Authors: Ms. Aparna Kulkarni  , Prof. Ritesh Tondase  , Prof. Pradnya Bhambure  , Prof. Manasi Joshi
Published: January 2025

Emotional intelligence plays a vital role in the formation women's leadership characteristics.  Women leaders displaying high emotional intelligence excel in managing their own and others' emotions, resulting in team unity, better communication, and conflict resolution. Moreover, emotional intelligence enhances women leaders' ability to adjust their leadership approaches to various contexts and individuals, thus augmenting their overall efficacy. The success of leadership effectiveness ultimately relies on the collaboration between emotional intelligence and leadership competencies which enables women to exploit on their strengths in mentorship, motivation, and collaboration. This research emphasis on women in executive positions in Indian corporate sector. The study involves a qualitative approach, applying thematic analysis. Data collection involved interviews with twelve women executives who have acquired senior leadership roles in Indian corporations. The analytical process enabled the identification of patterns and themes within the gathered data relating to emotional intelligence. The emergent themes incorporate self-awareness, self-regulation, empathy, motivation, and social skills. These components discover the impact of women leadership on subordinates, focusing how their unique leadership style improves transparency in communication, employee participation, team cohesion, inclusiveness, and trustworthiness within the workforce. The exclusive approach of women leaders contributes for developing positive organizational characteristics. Finally, the study concludes that women leaders achieve a competitive advantage in organizational leadership effectiveness. Their discriminating emotional awareness enables them to empathize with team members, nurture healthy relationships, and foster inclusive work environments.