Highly soluble and stable 'insertion domain' of the capsid penton base protein provides complete protection against infections caused by fowl adenoviruses.

In the current study, we have evaluated the protective efficacy of the 'insertion domain' which is commonly found in the capsid penton base protein of many adenoviruses. Using the 'insertion domain' of the penton base protein of a representative fowl adenovirus, fowl adenovirus serotype 4 (FAdV-4), we find that the 'insertion domain' can readily be expressed in a soluble form in the bacterial system, and can be purified in sufficient quantities through simple chromatographic methods. We demonstrate that the 'insertion domain', when employed as a subunit vaccine candidate, provides complete protection against hydropericardium syndrome, caused by FAdV-4, in chickens. The data presented here indicate that the protein, adjuvanted with Montanide™ ISA71 VG, provides complete protection in chickens against a lethal FAdV-4 challenge after administration of two doses (100 µg of the protein per dose) two weeks apart (the first dose at the 7th day of life and a booster dose at the age of 21 days). Furthermore, the purified protein can be stored at low temperatures without any observable loss in the protein integrity up to one year, tested so far. Due to the conserved nature of the 'insertion domain' across the penton base protein of fowl adenoviruses, it is suggested that homologous insertion domains could be employed as highly stable and cost-effective subunit vaccine candidates against infections caused by respective fowl adenoviruses.

Threshold concepts encountered by second year medical students in a Basic Health Science module; a qualitative study.

OBJECTIVE: To explore threshold concepts in a Basic Health Sciences module. METHODS: The qualitative study was conducted at the Islamabad Medical and Dental College, Islamabad, Pakistan, in March 2019, and comprised students and faculty members in the gastrointestinal tract module of spiral I of the integrated modular curriculum in Basic Health Sciences. Data on student experiences was collected using semi-structured interviews with open-ended questions. The data was coded and themes were identified by the researchers independently. A thematic matrix was produced, cross-referencing data relating to troublesome areas identified by the students against the threshold concept criteria. The identified themes were discussed among the researchers to reach consensus. Only the identified themes were taken as the expected threshold concepts in the gastrointestinal tract module. RESULTS: Of the 18 subjects, 14(77.8%) were students and 4(22.2%) were facilitators. There were 8 areas identified by the students as troublesome in the module; development of gastrointestinal tract, anatomical relations, electron transport chain, histology of gastrointestinal tract mucosa, peritoneal disposition, anal canal and ischioanal fossae, peristalsis, and absorption across gastrointestinal tract mucosa. Only development of gastrointestinal tract appeared to cross-match with all the criteria outlined for threshold concepts. The troublesome areas identified by the teachers were development of gastrointestinal tract, peritoneal disposition, anatomical relations, absorption across gastrointestinal tract and peristalsis. CONCLUSIONS: Development of gastrointestinal tract was found to be the threshold concept in the system-based integrated module of gastrointestinal tract. Most of the students found their previous knowledge inadequate in learning concepts of the module.

COMFORT LEVEL OF POST GRADUATE RESIDENTS WORKING IN DIFFERENT CLINICAL DOMAINS IN MANAGING COMMON OPHTHALMIC CONDITIONS.

BACKGROUND: Ophthalmological conditions are frequently encountered in almost all clinical specialties. Assessing the adequacy of ophthalmology teaching in undergraduate medical education is important in order to diagnose and manage different ophthalmological conditions. The objective of this study was to determine the comfort level of post graduate residents working in different clinical domains in managing common ophthalmic conditions. METHODS: A cross sectional survey involving 277 post graduate residents was carried out over a period of six months in both private and public tertiary care hospital. A questionnaire containing two sections and 17 variables in total were distributed among Medical Residents of different specialties except ophthalmology residents. Participants of the study were selected through consecutive non probability sampling. RESULTS: Mean hours of classroom based ophthalmology instruction during undergraduate program was 59.38 hours (55.9) and mean hours of clinical based ophthalmology instruction during undergraduate program was 62.73 hours (60.8) 54% were either "not comfortable" or "somewhat comfortable" in managing common ophthalmic condition. Conclusion: Teaching hours in under graduate program meet or exceed requisite criteria. However graduating doctors generally feel that the time spent does not provide them with the comfort and skill level required to care for patients with ocular presentations.

Effect Of Intra Vitreal Injection Of Bevacizumab On Intra-Ocular Pressure.

BACKROUND: Bevacizumab has been in use as a therapeutic agent for macular oedema for several years. While its efficacy has been well documented, its use has been shown to cause a transient rise in the intra-ocular pressure. The aim of this study was to evaluate the long term effect of intravitreal injection of Bevacizumab on Intra-ocular pressure. METHODS: One hundred eyes (n=100) of one hundred patients, requiring intra-vitreal injection of Bevacizumab for diabetic macular oedema were recruited from Shifa Foundation Community Health Centre (SFCHC) between January and December 2014. Patients of glaucoma, ocular hyper-tension, known allergy to Bevacizumab or had injections of Bevacizumab prior to the study were excluded. Intra-ocular pressure was measured using a Goldmann applanation tonometer, prior to, and at six and twelve months after the injection. The pre- and post- injection Intra-ocular pressure was entered into the database. Test of significance was applied to investigate whether there was a significant change in intra-ocular pressure after the injection. RESULTS: The mean age of the patient was 56.97 years (±14.97). The mean intra-ocular pressure was 13.86 (±3.16) mmHg before injection, while postinjection mean Intra-Ocular pressure was 14.21 (±3.12) mmHg and 13.79 (±3.07) at six and twelve months respectively. Between baseline and six months there was a statistically significant difference in intra-ocular pressure (p=0.03), while no significant difference existed in the intraocular pressure between baseline and twelve months (p=0.92). CONCLUSIONS: Intra-vitreal injection of Bevacizumab is associated with a statically significant rise in intra-ocular pressure at six months, while no significant difference was seen at twelve months compared to baseline.

Pain management with retrobulbar alcohol injection in absolute glaucoma.

Ocular pain can be multi-factorial and often refractory to treatment, in spite of the myriad options available to the ophthalmologist for its management. Initial therapy entails the use of topical and systemic pressure lowering agents as well as anti-inflammatory/analgesics for the provision of relief. Those refractory to medical therapy may require surgical intervention in the form of cyclodestructive procedures, retrobulbar injection of absolute alcohol and evisceration or enucleation. A case series of 5 patients of absolute glaucoma who were successfully treated with retrobulbar alcohol injection is reported. Pain was recorded on a verbal analogue score (VAS).All the patients were pain free twelve months after the injection. No significant long term complications were observed. This case series emphasizes the fact that retrobulbar alcohol injection can play an important role in the alleviation of pain in patients with absolute glaucoma.

Exome sequencing identifies a novel and a recurrent BBS1 mutation in Pakistani families with Bardet-Biedl syndrome.

PURPOSE: To determine the genetic cause of Bardet-Biedl syndrome (BBS) in two consanguineous Pakistani families. METHODS: Clinical characterization of the affected individuals in both families was performed with ophthalmic examination, electroretinography, electrocardiography, and liver and renal profiling. Seventeen genes are known to be associated with BBS, so exome sequencing was preferred over candidate gene sequencing. One affected individual from both families was selected for exome sequencing. Segregation of the identified variants was confirmed with Sanger sequencing. RESULTS: Retinitis pigmentosa, obesity, and learning difficulties were present in the affected individuals in both families. In family A, a sixth finger (polydactyly) of the proband's sister was removed by a surgical operation leaving a scar on the little finger. Polydactyly was also present in both affected individuals from family B. All diagnostic symptoms were characteristic of BBS in both families. In both affected individuals from family A, exome sequencing identified a novel homozygous mutation (c.47+1G>T) in BBS1 that inactivates the splice donor site at the end of exon 1. In family B, a previously reported mutation, c.442G>A; p.(Asp148Asn), was detected. CONCLUSIONS: Exome sequencing is an efficient and cost-effective technique for identifying mutations in genetically heterogeneous diseases. In addition, intrafamilial phenotypic variability in family A argues for the modifying effect of other still unknown modifier alleles.

Analysis of retinal nerve fibre layer changes in anisometropic amblyopia by Heidelberg retina tomograph.

OBJECTIVE: To identify if anisometropic amblyopia is associated with changes in optic disk morphology. METHODS: The study comprised a total of 80 eyes recruited from Shifa Foundation Community Health Centre and the Pakistan Institute of Medical Sciences, Islamabad between May and October 2012. Anisometropic amblyopia was the only cause of disability (visual acuity > or = 6/12) in amblyopic eyes whereas normal eyes had a best corrected visual acuity of 6/6 and no morbidities. Patients with other causes of amblyopia, co-morbid ocular diseases, and in whom a good-quality image could not be obtained were excluded. Mean retinal nerve fiber layer thickness was analysed using Heidelberg retina tomograph. Analysis of frequency distribution, probability and regression were run on the data collected during the study using SPSS version 15.0. RESULTS: The mean age of the patients was 23.85 +/- 5.85 years. The retinal nerve fibre layer thickness ranged between 0.09 mm and 0.35 mm (mean: 0.23 mm +/- 0.07) in amblyopic eyes, and between 0.18 mm and 0.36 mm (mean: 0.25 mm +/- 0.05) in normal eyes. The difference was not statistically significant (p = 0.087). No association was found between the retinal nerve fiber layer thickness or the age and refractive error of patients. CONCLUSION: The optic disk does not appear to be the site of morphological changes in amblyopia.

Management of anisometropic abmlyopia in adults.

Amblyopia is characterised by decrease in vision in one or both eyes as a result of processing defect in the visual pathways of the brain. It is considered an irreversible process if detected in the adult age group. This study was conducted from July 1 to December 31, 2010, at Shifa Foundation Community Health Centre, Islamabad, to determine if anisometropic amblyopia detected in adults can be reversed. A total of 15 adults, 11 (73.33%) males and 4 (26.66%) females, were managed for anisometropic amblyopia. All the patients were prescribed full cycloplegic correction in the anisometropic eye simultaneously with part-time occlusion therapy. Success was defined as visual acuity of 6/18 or better at the end of the therapy. All patients were required to complete a structured questionnaire regarding their experiences with the therapy. Reversal of amblyopia was observed in 11 (73.33%) patients who felt more confident about performing tasks for which they had earlier considered themselves unsuitable. Poor compliance was responsible for not producing the desired outcome in 4 (26.66%) patients. Anisometropic amblyopia in adults is reversible with dedicated efforts on behalf of both the ophthalmologist and the patient.

Enhancing Empathy in Medical Students by Focused Learner Centered Activities.

OBJECTIVES: To determine the change in empathy levels of medical students during their progress in professional years internship, and to examine change in empathy after targeted empathy enhancing activities during the course of medical school. STUDY DESIGN: Longitudinal Study. PLACE AND DURATION OF STUDY: Shifa College of Medicine/ Shifa Tameer-e-Millat University, Islamabad, from January 2015 to December 2019. METHODOLOGY: Student version of Jefferson Scale of Physician Empathy was administered sequentially from 2015 to 2019 which evaluated the change in empathy of medical students in a class of 2019. Targeted empathy-enhancing activities included patient-centered module in year-three and stress management workshops in the final year of medical school. RESULTS: Empathy scores rose from the first year of study (4.27 ±0.38) to the third year (4.52 ±0.70). It fell over the next two years of study (4.25 ±0.62 & 4.21 ±0.40) before rising again during the internship (4.39 ±0.43) with focused empathy-enhancing activities. CONCLUSION: Patient-centered module which focused on activities that help develop empathy may have been a factor in the increase of empathy scores in the third year and internship. Placing recurring formal activities throughout all clinical years may help in enhancing empathy in medical students. KEY WORDS: Medical student empathy, Empathy enhancing targeted activities, JSPE.

Spontaneous idiopathic true exfoliation of the anterior lens capsule during capsulorhexis.

We report a unique case of spontaneous per-operative idiopathic development of true exfoliation of the anterior lens capsule during capsulorhexis. A 45 year old female who underwent phacoemulsification for a cataract in the left eye, developed a partial split (the double ring sign) and eventual complete separation of the superficial lamina of the lens capsule during capsulorhexis. Radial tears developed in the remaining lamina making the capsular bag unstable. The surgery was converted to manual nucleus expression. An intra ocular lens was implanted via scleral fixation. The final best corrected visual acuity in the left eye was 6/6. The patient is comfortable with the vision. Though a rare event, the surgeon must always be alert to the development of spontaneous idiopathic per operative true exfoliation of the lens capsule.

Using Pensieve: Guiding and Evaluating a Learning Session on Reflections.

The objectives of this study were to guide students on reflective essay writing, evaluate their understanding and explore the immediate impact of a well-designed session on learning of students. A 1.5-hour learning session was designed following Gagne's nine events of instruction and conducted on final year MBBS students to guide them on reflective practice and its significance. The session was evaluated by a self-designed, structured questionnaire given as a pre-test and post-test. Of 158 students, self-scoring of reflective essay, by hand raising method, revealed that nearly 60% students were critical reflectors, 30% were reflectors and 10% were non-reflectors. Five out of nine questions showed a significant effect (p <0.001) in two-tailed t-test. This learning session led to a significant improvement in understanding of students regarding role of reflective practice in modifying their future behaviour, and its role in making them a better professional. Key Words: Learning, Reflections, Satisfaction, Feedback, Written, Educational assessment, Medical students.

Transfusion strategies in patients with acute coronary syndrome and anemia: a meta-analysis.

BACKGROUND: Anemia is a known risk factor for ischemic heart disease and serves as an independent predictor of major adverse cardiovascular events (MACE) in patients with acute coronary syndrome (ACS). This meta-analysis pools data from randomized controlled trials (RCTs) to better define hemoglobin (Hb) thresholds for transfusion in this setting. RESULTS: MEDLINE, EMBASE, and Cochrane databases were searched using the terms "Acute Coronary Syndrome" AND "Blood Transfusion" including their synonyms. A total of three randomized controlled trials were included. Restrictive transfusion strategy (RTS) was defined as transfusing for Hb ≤ 8 g/dl with a post-transfusion goal of 8 to 10 g/dl. Liberal transfusion strategy (LTS) was defined as Hb ≤ 10 g/dl and post-transfusion goal of at least 11 g/dl. The primary end point was 30-day mortality. Secondary outcomes included recurrent ACS events, new or worsening CHF within 30 days, and major adverse cardiac events (MACE). The primary analytic method used was random effects model. Out of 821 patients, 400 were randomized to LTS, and 421 to RTS. Mean age was 70.3 years in RTS versus 76.4 in LTS. There was no statistically significant difference for 30-day mortality in LTS compared to RTS [odds ratio (OR) 1.69; 95% CI 0.35 to 8.05]. Similarly, there was no difference in MACE (OR 0.74; 95% CI 0.21 to 2.63), CHF (OR 0.82; 95% CI 0.18 to 3.76), or the incidence of recurrent ACS (OR 1.21; 95% CI 0.49 to 2.95). CONCLUSIONS: In the setting of ACS, there is no difference between LTS and RTS for the outcomes of mortality, MACE, recurrent ACS, or CHF at 30 days. Further evidence in the form of high-quality RCTs are needed to compare RTS and LTS.

The utility of ultrasound and computed tomography in the assessment of carotid artery plaque vulnerability-A mini review.

As the burden of cardiovascular and cerebrovascular events continues to increase, emerging evidence supports the concept of plaque vulnerability as a strong marker of plaque rupture, and embolization. Qualitative assessment of the plaque can identify the degree of plaque instability. Ultrasound and computed tomography (CT) have emerged as safe and accurate techniques for the assessment of plaque vulnerability. Plaque features including but not limited to surface ulceration, large lipid core, thin fibrous cap (FC), intraplaque neovascularization and hemorrhage can be assessed and are linked to plaque instability.

Therapeutic Hypothermia Is Associated With a Decrease in All-cause Mortality in Cardiac Arrest Due to Shockable Rhythm.

BACKGROUND: The benefits of therapeutic hypothermia (TH) in comatose patients postcardiac arrest remain uncertain. While some studies have shown benefit, others have shown equivocal results. We pooled data from randomized controlled trials to better study the outcomes of TH. METHODS: Electronic research databases were queried up till September 21, 2021. Randomized controlled trials comparing TH (32-34 °C) with control (normothermia or temperature ≥36 °C) in comatose postcardiac arrest patients were included. RESULTS: The study included 10 randomized controlled trials with 3988 subjects (1999 in the TH arm and 1989 in the control arm). There was no difference in all-cause mortality between TH and control (odds ratio [OR], 0.83; 95% confidence interval [CI], 0.66-1.05; P = 0.08; I2 = 41%). There was no difference in the odds of poor neurological outcomes (OR, 0.78; 95% CI, 0.61-1.01; P = 0.07; I2 = 43%). Subgroup analysis showed a decrease in all-cause mortality and poor neurological outcomes with TH in shockable rhythms (OR, 0.55; 95% CI, 0.37-0.80; P = 1.00; I2 = 0% and OR, 0.48; 95% CI, 0.32-0.72; P = 0.92; I2 = 0%, respectively). CONCLUSIONS: TH may be beneficial in reducing mortality and poor neurological outcomes in comatose postcardiac arrest patients with shockable rhythms.

Thirty-Day Readmissions After Percutaneous Left Atrial Appendage Occlusion: Insights from the Nationwide Readmissions Database.

Percutaneous left atrial appendage occlusion (LAAO) provides a nonpharmacological alternative of preventing stroke in patients with non-valvular atrial fibrillation who are poor candidates for oral anticoagulation. Data on 30 day readmission measures following LAAO is limited. Index LAAO procedures and 30 day readmissions were identified using the Nationwide Readmissions Database (NRD) from 2016 to 2018. The rates and causes of 30 day readmissions were studied. Complex samples multivariable logistic regression models were used to identify predictors of 30 day readmission. Among 29,367 patients undergoing LAAO, the rates of 30 day readmissions were 9.2%. The most common overall cause of 30 day readmission was gastrointestinal bleeding (18.5%), followed by heart failure (13.1%), and infection (7.3%). Female gender (OR1.22; 95% CI 1.08-1.38), HF (OR 1.30; 95% CI 1.15-1.47), anemia (OR 1.37; 95% CI 1.11-1.68), chronic lung disease (OR 1.42; 95% CI 1.25-1.62), End stage renal disease (OR 2.75; 95% CI 2.13-3.55), Acute kidney injury (OR 1.66; 95% CI 1.25-2.20), bleeding/transfusion (OR 1.63; 95% CI 1.28-2.09) were found to be independent predictors of 30 days Readmission. The overall rate of 30 day readmission after LAAO was 9.2% with non-cardiac causes (gastrointestinal bleeding) being the most common. Reducing in-hospital complications and identifying optimal post procedural anticoagulation/antithrombotic regimen may help decrease readmissions following LAAO.

Identification of potent epitopes on hexon capsid protein and their evaluation as vaccine candidates against infections caused by members of Adenoviridae family.

Adenoviruses cause economically important diseases in vertebrates. Effective vaccines against adenoviral diseases are currently lacking. Here, we report a highly conserved epitopic region on hexon proteins of adenoviruses that generate a strong immune response when used as a virus-like-particle (VLP) vaccine, produced by inserting the epitopic region into the core protein of hepatitis B virus. For evaluation of its protective efficacy, the epitopic region from a representative adenovirus, fowl adenovirus serotype 4 (FAdV-4), was tested as a VLP vaccine which conferred 90% protection against challenge with a virulent FAdV-4 isolate in chickens. Importantly, such a high level of protection is not achieved when the epitopic region is employed as a part of a subunit vaccine. As the sequence and the structure of the epitopic region are highly conserved in hexon proteins of adenoviruses, the epitopic region could be employed as a promising VLP vaccine candidate against adenoviral diseases, in general.

Association of Severity of Allergic Conjunctivitis with Skin Prick Test.

OBJECTIVE: To investigate the association between skin prick test and severity of allergic conjunctivitis. STUDY DESIGN: Cross sectional observational study. Study Place and Duration of Study: Akbar Niazi Teaching Hospital, Bara Kahu, Islamabad, between March and September 2019. METHODOLOGY: 150 eyes of 150 diagnosed cases of allergic conjunctivitis, who had had a skin prick test, were included in the study. Cases with other concurrent ocular surface diseases, conjunctivitides, systemic allergies, and those on systemic steroids, anti-histamines and tricyclic antidepressant agents were excluded. Signs of allergic conjunctivitis were graded via slit-lamp examination using a 5-5-5 exacerbation grading scale. Allergic conjunctivitis was classified as being severe if the total score was ≥230, moderate if the score was >20 and <230, and mild if the score was ≤20. Frequency distribution was reported for age, gender and result of skin prick test. Test of significance and correlation analysis was carried out between the result of skin prick test and the severity of allergic conjunctivitis using Statistical Package for Social Sciences version 20.0. A p-value of <0.05 was taken as significant. RESULTS: Mean age was 18.62 (±8.15) years in 91 males and 59 females. Mild (n = 28), moderate (n = 77), and severe (n = 45) cases showed no statistically significant correlation with the skin prick test (positive or negative) in any of the three categories (mild p = 0.44, r = 0.153, moderate p = 0.89, r = 0.016, and severe p = 0.73, r = 0.052). CONCLUSION: Skin prick test did not show a significant association or correlation with the severity of allergic conjunctivitis. Key Words: Allergic conjunctivitis, Hypersensitivity, Skin prick test.

Design of a Low Scattering Metasurface for Stealth Applications.

The design of a metasurface with low radar cross section (RCS) property is presented in this paper. The low scattering of the metasurface is achieved by applying the artificial magnetic conductor (AMC) unit cells in three different configurations. Two different AMC unit cells with an effective phase difference of 180 ± 37° are first designed to analyze the out of phase reflection in a wideband frequency range from 5.9 to 12.2 GHz. Then, the unit cells are placed in a chessboard-like configuration, newly constructed rotated rectangular-shaped configuration, and optimized configuration to study and compare the RCS reduction performance. All designs of the metasurface with different configurations show obvious RCS reduction as compared with the metallic plate of the same size. However, the relative bandwidth of the optimized metasurface is larger than the chessboard-like configuration and rotated rectangular-shaped configuration. To certify the results of the simulations, the metasurface with the optimized configuration is fabricated further to measure the RCS reduction bandwidth. The measured results are in good accordance with the simulated results. Therefore, the proposed metasurface can be a good option for applications where low RCS is desirable.

Wideband RCS Reduction Using Coding Diffusion Metasurface.

This paper presents a radar cross-section (RCS) reduction technique by using the coding diffusion metasurface, which is optimised through a random optimization algorithm. The design consists of two unit cells, which are elements '1' and '0'. The reflection phase between the two-unit cells has a 180° ± 37° phase difference. It has a working frequency band from 8.6 GHz to 22.5 GHz, with more than 9 dB RCS reduction. The monostatic RCS reduction has a wider bandwidth of coding diffusion metasurface as compared to the traditional chessboard metasurface. In addition, the bistatic performance of the designed metasurfaces is observed at 15.4 GHz, which shows obvious RCS reduction when compared to a metallic plate of the same size. The simulated and measured result shows the proficiency of the designed metasurface.

Relationship between Student Performances in Non-Cognitive Skills in Multiple Mini Interview and Integrated Practical Examination.

OBJECTIVE: To investigate the relationship between the performances of students in non-cognitive skills in Multiple Mini Interview (MMI) and Integrated Practical Examination (IPE) of the first year of medical school. STUDY DESIGN: Cross-sectional observation study with statistical support. PLACE AND DURATION OF STUDY: Shifa College of Medicine/Shifa Tameer-e-Millat University, Islamabad between December 2015 and March 2016. METHODOLOGY: Student performance in communication skills, domain of the 8-station Multiple Mini Interview, was compared with their scores in communication skills in the first Integrated Practical Examination taken at the end of first block. Descriptive statistics were calculated for student demographics, scores in communication skills in MMI as well as IPE. Pearson's Correlation was calculated to investigate the relationship between the two scores. A p-value of <0.05 was taken as significant. RESULTS: The mean score in MMI was 130.38 ±9.90 as compared to a score of 79.96 ±19.74 in the IPE. This relationship has a statistically significant (p<0.001) positive correlation, with a Pearson's correlation of 0.52. CONCLUSION: Student performance shows a positive correlation in non-cognitive skills between Multiple Mini Interview and Integrated Practical Examination.