What happens when private general practitioners receive incentivisation offers from pharmaceutical sales representatives? A qualitative study in Pakistan.

OBJECTIVES: Pharmaceutical incentivisation of physicians for profit maximisation is a well-documented health system challenge. This study examined general practitioners' (GPs) reactions to pharmaceutical incentivisation offers in one region in Pakistan. METHODS: We used the Standardised Pharmaceutical Sales Representative (SPSR) method and qualitative interviews with GPs. SPSRs were field researchers representing mock pharmaceutical companies who recorded their observations of 267 GPs' responses to pharmaceutical incentivisation offers. We triangulated SPSR data using qualitative interviews with a subset of the same GPs to gather information about how they interpreted different interaction outcomes. RESULTS: We found four major outcomes for GPs being offered incentives by pharmaceutical companies for prescribing medications. GPs might agree to make incentivisation deals, reject incentivisation offers, disallow PSRs to access them, or remain indeterminate with no clear indication of acceptance or rejection of incentivisation offers. GPs rejecting SPSRs' incentivisation offers indicated having active commitments to other pharmaceutical companies, not being able to work with unheard-of companies, and asking SPSRs to return later. CONCLUSIONS: The GP-pharmaceutical sales representative interaction that centres on profit-maximisation is complex as offers to engage in prescribing for mutual financial benefit are not taken up immediately. The SPSR method helps understand the extent of distortion of practices impacted by incentivisation. Such an understanding can support the development of strategies to control unethical behaviours.

In-vitro and in-vivo assessment of the anti-diabetic, analgesic, and anti-inflammatory potenstials of metal-based carboxylates derivative.

In the current research work, an amide based metal carboxylate chemical ([((5-((5-(2-hydroxyethyl)-4-methylthiazol-3-ium-3-yl)methyl)-2-methylpyrimidin-4-yl)amino)bis((4-((4-methoxy-2-nitrophenyl)amino)-4-oxobutanoyl)oxy)zinc]) was identified as anti-diabetic analgesic and anti-inflammatory. The identified chemical(MT-1) was tested for acute toxicity (the MT-1 was fund safe), antidiabetic analgesic, and anti-inflammatory potentials. The in-vitro study was conducted for antidiabetic enzyme inhibition (α-amylase and α-glucosidase) and the in-vivo studies included analgesic (acetic acid-induced writing and hot plate model) and anti-inflammatory (carrageenan etc induced edema) effects. The tested compound showed 88.63% (IC50 = 3.23 µg/ml) and 89.10%(IC50 = 5.10 µg/ml) againstα-amylase and α-glucosidase respectively. A significant (p < 0.001) analgesic effect was noted by MT-1 in acetic acid-induced animal models with a percent effect of 86.00, 60.,06, and 55.29 at the tested doses of 20, 1,0, and 5 mg/kg respectively. In the case of the hot plate model, the MT-1 showed a significant (p < 0.001) effect with maximum percent prolongation in latency observed after 60 min.08, 22.2,9, and 11.61) against 20, 1,0, and 5 mg/kg. The analgesic effect in the hot plate model was significantly (p < 0.01) reversed by the injection of naloxone (0.125 mg/kg). The paw edema induced by carrageenan, histamine, bradykinin, arachidonic acid, and PGE2 was significantly antagonized with percent attenuation of 34.09, 33.57, 34.60, 34.14, and 48.04 respectively. Furthermore, to predict the interactions between the MT-1 compound and COX-2 molecular docking was carried out and the result was compared with the standard compound. The docking score of MT-1 was predicted as -6.30 while that of Diclofenac was predicted as -6.82. Both compounds made several hydrogen bond interactions with the active site of the COX-2 enzyme. The docking study revealed the potent inhibitory potential of the compound MT-1 against the COX-2 receptor.

Nutritional Assessment in Cancer Patients.

Malnutrition in cancer patients is highly prevalent. The metabolic and physiologic changes associated with the disease and the side effects of treatment regimens all combine together to produce a detrimental effect on the patient's nutritional status. A poor nutritional status significantly reduces the efficacy of treatment methods and the patient's overall chances of survival. Therefore, an individualized nutrition care plan is essential to counter malnutrition in cancer. Nutritional assessment is the first step of this process which sets the foundation for developing an effective intervention plan. Currently, there is no single standard method for nutritional assessment in cancer. Hence, to get a true picture of the patient's nutritional state, a comprehensive analysis of all aspects of the patient's nutritional status is the only reliable strategy. The assessment includes anthropometric measurements and evaluation of body protein status, body fat, inflammation markers, and immune markers. A thorough clinical examination which factors in the medical history and physical signs, along with the dietary intake patterns of the patient, is also important components of nutritional assessment of cancer patients. To facilitate with the process, various nutritional screening tools like patient-generated subjective global assessment (PGSGA), nutrition risk screening (NRS), and malnutrition screening tool (MST) have been developed. While these tools have their own benefits, they only give a glimpse of the nutritional problems and do not bypass the need for a complete assessment employing various methods. This chapter covers all four of the elements of nutritional assessment for cancer patients in detail.

Assessment of essential and toxic elemental concentrations in tumor and non-tumor tissues with risk of colorectal carcinoma in Pakistan.

BACKGROUND: Colorectal tumor is a major cause of cancer morbidity and mortality both in USA and around the globe. Exposure to environmental toxicants such as toxic trace elements has been implicated in colorectal malignancy. However, data linking them to this cancer are generally lacking. METHODS: Accordingly, the current study was to investigate the distribution, correlation and chemometric evaluation of 20 elements (Ca, Na, Mg, K, Zn, Fe, Ag, Co, Pb, Sn, Ni, Cr, Sr, Mn, Li, Se, Cd, Cu, Hg and As) in the tumor tissues (n = 147) and adjacent non tumor tissues (n = 147) of same colorectal patients which were analyzed by flame atomic absorption spectrophometry employing nitric acid-perchloric acid based wet digestion method. RESULTS: On the average, Zn (p < 0.05), Ag (p < 0.001), Pb (p < 0.001), Ni (p < 0.01), Cr (p < 0.005) and Cd (p < 0.001) showed significantly higher levels in the tumor tissues compared with the non tumor tissues of patients, whereas mean levels of Ca (p < 0.01), Na (p < 0.05), Mg (p < 0.001), Fe (p < 0.001), Sn (p < 0.05) and Se (p < 0.01), were significantly elevated in the non tumor tissues than the tissues of tumor patients. Most of the elements revealed markedly disparities in their elemental levels based on food (vegetarian/nonvegetarian) habits and smoking (smoker/nonsmoker) habits of donor groups. The correlation study and multivariate statistical analyses demonstrated some significantly divergent associations and apportionment of the elements in the tumor tissues and non tumor tissues of donors. Noticeably, variations in the elemental levels were also noted for colorectal tumor types (lymphoma, carcinoids tumor and adenocarcinoma) and stages (I, II, III, & IV) in patients. CONCLUSION: Overall, the study revealed that disproportions in essential and toxic elemental concentrations in the tissues are involved in pathogenesis of the malignancy. These findings provide the data base that helps to oncologist for diagnosis and prognosis of colorectal malignant patients.

The healthcare field as a marketplace: general practitioners, pharmaceutical companies, and profit-led prescribing in Pakistan.

Incentivisation of general practitioners (GPs) by pharmaceutical companies is thought to affect prescribing practices, often not in patients' interest. Using a Bourdieusian lens, we examine the socially structured conditions that underpin exchanges between pharmaceutical companies and GPs in Pakistan. The analysis of qualitative interviews with 28 GPs and 13 pharmaceutical sales representatives (PSRs) shows that GPs, through prescribing medicines, met pharmaceutical sales targets in exchange for various incentives. We argue that these practices can be given meaning through the concept of 'field' - a social space in which GPs, PSRs, and pharmacists were hierarchically positioned, with their unique capacities, to enable healthcare provision. However, structural forces like the intense competition between pharmaceutical companies, the presence of unqualified healthcare providers in the healthcare market, and a lack of regulation by the state institutions produced a context that enabled pharmaceutical companies and GPs to use the healthcare field, also, as space to maximise profits. GPs believed the effort to maximise incomes and meet socially desired standards were two key factors that encouraged profit-led prescribing. We conclude that understanding the healthcare field is an important step toward developing governance practices that can address profit-led prescribing.

Scheduling and Sizing of Campus Microgrid Considering Demand Response and Economic Analysis.

Current energy systems face multiple problems related to inflation in energy prices, reduction of fossil fuels, and greenhouse gas emissions which are disturbing the comfort zone of energy consumers and the affordability of power for large commercial customers. These kinds of problems can be alleviated with the help of optimal planning of demand response policies and with distributed generators in the distribution system. The objective of this article is to give a strategic proposition of an energy management system for a campus microgrid (µG) to minimize the operating costs and to increase the self-consuming energy of the green distributed generators (DGs). To this end, a real-time based campus is considered that currently takes provision of its loads from the utility grid only. According to the proposed given scenario, it will contain solar panels and a wind turbine as non-dispatchable DGs while a diesel generator is considered as a dispatchable DG. It also incorporates an energy storage system with optimal sizing of BESS to tackle the multiple disturbances that arise from solar radiation. The resultant problem of linear mathematics was simulated and plotted in MATLAB with mixed-integer linear programming. Simulation results show that the proposed given model of energy management (EMS) minimizes the grid electricity costs by 668.8 CC/day ($) which is 36.6% of savings for the campus microgrid. The economic prognosis for the campus to give an optimum result for the UET Taxila, Campus was also analyzed. The general effect of a medium-sized solar PV installation on carbon emissions and energy consumption costs was also determined. The substantial environmental and economic benefits compared to the present situation have prompted the campus owners to invest in the DGs and to install large-scale energy storage.

Morphological and palynological assessment of taxonomically problematic genus Paspalum based on light and scanning electron microscopy.

Present research work was carried out to clarify the variations among species of genus Paspalum morphologically and palynologically as this genus is taxonomically difficult due to having multiple similar morphologically overlapping characters which make it difficult to identify. Henceforth present research work was carried out to delimit taxa within the same genus by morphological and palynological tools through light microscopy (LM) and scanning electron microscopy (SEM). Both these tools are considered as the most useful taxonomic characters for taxonomically problematic genera. The results showed a lot of variations among morphological characters. In Paspalum dilatatum, the upper glume was ovate whereas in the other two species, the upper glume was elliptic. The upper glume apex found in P. dilatatum and Paspalum scrobiculatum was obtuse whereas in Paspalum distichum, upper glume apex was acute. Glume nerves showed variation in all three species. Paspalum distichum was 3 nerved, P. scrobiculatum was 5-7 nerved, and P. dilatatum was 5-9 nerved. All three species showed variation in lemma nerves. Paspalum scrobiculatum had 3 nerved lemma whereas in P. distichum 3-5 nerved and P. dilatatum 5-9 nerved lemma were present. In polar and equatorial view, pollen grains ranged from 25 (20-30) to 37.5 (30-45) µm. Paspalum distichum appeared to be the smallest in size whereas P. dilatatum was the largest. Exine thickness ranged from 0.75 (0.5-1) to 1.35 (1.2-1.5) µm. The higher value of pollen fertility was found in P. scrobiculatum as 87.69% and the lowest value was in P. distichum as 78.08%. Morphological keys were also given for correct identification.

The UN Incheon strategy Implementation and the Pakistani quagmire; ground realities.

The Economic and Social Commission for Asia and the Pacific is the regional developmental arm of the United Nations. There are over 650 million persons with disabilities living in the region. In 2012, member countries, including Pakistan, launched the new decade of persons with disabilities from 2013 to 2022, adopting the Incheon Strategy to 'Make the Right Real', based on the Put Convention on the rights of Persons with Disabilities" and aimed at accelerating the disability inclusive development with 10 measurable goals and targets. The year 2017 marked the mid-point of that decade at which point member countries were to submit the Government Members Report on the Implementation of Incheon Strategy. The ambiguity in usage of terms, variable definition of disability, and use of impairment screens in population census of Pakistan has resulted in flawed data and underreporting of persons with disabilities. Pakistan provided data on only 13 of the 30 core indicators as part of its midpoint review. There is lack of awareness among ministries regarding the Incheon Strategy implementation.

Exploring the linkage between PM2.5 levels and COVID-19 spread and its implications for socio-economic circles.

A pneumonia-like disease of unknown origin caused a catastrophe in Wuhan city, China. This disease spread to 215 countries affecting a wide range of people. World health organization (WHO) called it a pandemic and it was officially named as Severe Acute Respiratory Syndrome Corona virus 2 (SARS CoV-2), also known as Corona virus disease (COVID-19). This pandemic compelled countries to enforce a socio-economic lockdown to prevent its widespread. This paper focuses on how the particulate matter pollution was reduced during the lockdown period (23 March to April 15, 2020) as compared to before lockdown. Both ground-based and satellite observations were used to identify the improvement in air quality of Pakistan with primary focus on four major cities of Lahore, Islamabad, Karachi and Peshawar. Both datasets have shown a substantial reduction in PM2.5 pollution levels (ranging from 13% to 33% in case of satellite observations, while 23%-58% in ground-based observations) across Pakistan. Result shows a higher rate of COVID-19 spread in major cities of Pakistan with poor air quality conditions. Yet more research is needed in order to establish linkage between COVID-19 spread and air pollution. However, it can be partially attributed to both higher rate of population density and frequent exposure of population to enhanced levels of PM2.5 concentrations before lockdown period.

Effectiveness of positive psychotherapy for young adults with depressive Symptoms.

OBJECTIVE: To analyse the level of happiness and depressive symptoms before and after positive psychotherapy.. METHODS: The experimental study was conducted from February 2018to March 2018 in Shahpur Sadar town of Sargodha district in the Punjab province of Pakistan at Govt. College, and comprised female young adults with depressive symptoms. The participants were subjected to 8 sessions (one baseline and seven other) of group positive psychotherapy. On the basis of repeated measure design, data was collected using the depression subscale of Depression Anxiety Stress Scale-21, Positive Psychotherapy Inventory, and Values in Action Inventory before, during and after therapy administration. SPSS 23 was used for data analysis. RESULTS: Of the 250 subjects assessed, 30(12%) aged 18-20 years were selected for therapy sessions as they had some level of depression; 15(50%) mild and 15(50%) moderate. Mean happiness level increased with each session from baseline value of 20.63±4.61 to post-therapy 50.67±4.63 (p<0.05). Depression level decreased from baseline value of 15.47±3.42 with each session to post-therapy 4.53±1.10 (p<0.05). CONCLUSIONS: Positive psychotherapy sessions were found to be effective in decreasing depression among female young adults.

Organochlorine pesticides in the surrounding soils of POPs destruction facility: source fingerprinting, human health, and ecological risks assessment.

The elimination of persistent organic pollutants (POPs) obsolete pesticides stockpiles, particularly the organochlorine pesticides (OCPs), is one of the critical environmental issues faced by many developing countries. This pioneering study aimed to investigate the occurrence, source fingerprinting, human health, and ecological risks of OCPs in the surroundings of the lone POPs pesticide destruction facility in Pakistan. The ΣOCPs residual levels in soil ranged from 35.98 to 566.77 ng/g dry weight (dw), with a mean concentration of 174.42 + 111.62 ng/g (dw). The OCPs contamination levels in the soil followed the pattern as ΣHCHs > Σendrins > Σendosulfans > dieldrin > Σheptachlors > ΣDDTs > Σchlordanes > methoxychlor. The ΣHCHs residual concentrations were comparatively higher than the previous national and global soil studies. The recent accumulation of HCHs, DDTs, and heptachlor was observed in the study area as identified by ß-HCH/∑HCHs, (DDE + DDD)/ΣDDTs, heptachlor/Σheptachlor, and heptachlor exo-epoxide/heptachlor ratios. The OCPs' lifetime carcinogenic risk through ingestion, dermal, and inhalation exposure routes ranged from 1.65E-08 to 2.91E-07, whereas the noncarcinogenic hazard quotient (HQ) ranged from 9.12E-05 to 1.61E-03. The risk vulnerability among age groups was in the order: adult > toddler > child > teen > infant. The calculated risk levels were within an acceptable limit of one in a million (1 × 10-6) for carcinogenic risk and HQ < 1 for noncarcinogenic risk. The current OCPs residual levels, especially dieldrin and endrin, exhibited low to medium ecological risks when compared to various worldwide limits. The upsurge of the OCPs' environmental contamination levels over the years and consideration of the food chain transfer might amplify the human health and ecological risks intensities.

Diospyros, an under-utilized, multi-purpose plant genus: A review.

The genus Diospyros from family Ebenaceae has versatile uses including edible fruits, valuable timber, and ornamental uses. The plant parts of numerous species have been in use as remedies in various folk healing practices, which include therapy for hemorrhage, incontinence, insomnia, hiccough, diarrhea etc. Phytochemical constituents such as terpenoids, ursanes, lupanes, polyphenols, tannins, hydrocarbons, and lipids, benzopyrones, naphthoquinones, oleananes, and taraxeranes have been isolated from different species of this genus. The biological activities of these plants such as antioxidant, anti-inflammatory, analgesic, antipyretic, anti-diabetic, antibacterial, anthelmintic, antihypertensive, cosmeceutical, enzyme-inhibitory etc. have been validated by means of an in vitro, in vivo, and clinical tests. As a rich reserve of pharmacologically important components, this genus can accelerate the pace of drug discovery. Accordingly, the aim of the present review is to survey and summarize the recent literature pertaining to the medicinal and pharmacological uses of Diospyros, and to select experimental evidence on the pharmacological properties of this genus. In addition, the review also aims at identifying areas that need development to make use of this genus, especially its fruit and phytochemicals as means for economic development and for drug discovery.

Phytochemical analysis, antibacterial, and antifungal assessment of aerial parts of Polygonatum verticillatum.

The current study was designed to assess the phytochemical profile, antibacterial, and antifungal activities of the crude methanol extract of the aerial parts of Polygonatum verticillatum (PA) and its various subsequent solvent fractions using agar well diffusion, agar tube dilution, and microdilution methods. Phytochemical analysis showed positive for different chemical groups and also contained marked quantity of saponin and flavonoid contents. Significant antibacterial activity was observed against various tested pathogenic bacteria. The only susceptible Gram-positive bacterium was Bacillus subtilis and their minimum inhibitory concentrations (MICs) measured ranged from 11-50 µg/ml. The sensitive Gram-negative bacteria were Salmonella typhi and Shigella flexeneri The estimated MICs were in the range of 2-7 µg/ml and 8-50 µg/ml for S. typhi and S. flexeneri, respectively. However, the antifungal activity of the plant was limited to Microsporum canis and their MICs ranged from 60 to 250 µg/ml. Our study confirmed significant antibacterial potential of the plant and substantiated its folk use in dysentery and pyrexia of multiple origins.

Assessment of stress among physiotherapy students at Riphah Centre of Rehabilitation Sciences.

OBJECTIVE: To assess stress and psychological morbidity in undergraduate students of physiotherapy at Riphah Centre of Rehabilitation Sciences (RCRS). METHODS: A cross-sectional study was conducted from 2008 to 2010 at RCRS. Two hundred and thirty one students from first semester to fourth semester were included in the study. The data was collected through a semi-structured proforma and the Student Life Stress Inventory (SLSI) scale. Data was analysed by applying t-test and ANOVA with SPSS version 17. RESULTS: Two hundred and three respondents (88%) reported feeling stressed: 97(42%) students were mildly stressed, 92(40%) were moderately stressed, and 14 (6%) were severely stressed. Significant gender differences were found on the total score of stress, stressors and reactions. The findings revealed that females face more stressors especially pressures (p<0.001), physiological, emotional (p<0.01) and behavioural (p<0.05). An analysis of variance on SLSI is significant, F = 3.747 (p<.05). Mean difference indicates that prevalence of stress is higher in 4th semester RCRS students. CONCLUSION: The findings reveal the higher level of stress in undergraduate physiotherapy students. The high psychological morbidity necessitates the need for interventions like counseling and psychological support to improve the quality of life for these allied health care professionals.

Effectiveness of Aloe Vera gel compared with 1% silver sulphadiazine cream as burn wound dressing in second degree burns.

OBJECTIVE: To assess the efficacy of Aloe Vera gel compared with 1% silver sulfadiazine cream as a burn dressing for the treatment of superficial and partial thickness burns. METHODS: This Interventional Comparative study was carried out at the Burn unit and Plastic surgery department, Nishtar Hospital Multan, Pakistan from July 2008 to December 2010. A total of 50 patients with superficial and partial thickness burns were divided into two equal groups randomly by consecutive sampling method, one group was dressed with Aloe Vera gel while the other was treated with 1% silversulphadiazine cream, and the results regarding duration of wound epithelialization, pain relief and cost of treatment were compared. RESULTS: In patients treated with Aloe Vera gel, healing of burn wounds were remarkably early than those patients treated with 1% silver sulfadiazine. All the patients of Aloe Vera group were relieved of pain earlier than those patients who were treated with SSD. CONCLUSION: Thermal burns patients dressed with Aloe Vera gel showed advantage compared to those dressed with SSD regarding early wound epithelialization, earlier pain relief and cost-effectiveness.

Assessment of potential toxicity of a smokeless tobacco product (naswar) available on the Pakistani market.

BACKGROUND: 'Naswar' is a smokeless tobacco product (STP) widely used in Pakistan. It has been correlated with oral and oesophageal cancer in recent clinical studies. The toxic effects associated with STPs have been associated with trace level contaminants present in these products. The toxin levels of Pakistani naswar are reported for the first time in this study. METHODS: A total of 30 Pakistani brands of naswar were tested for a variety of toxic constituents and carcinogens such as cadmium, arsenic, lead and other carcinogenic metals, nitrite and nitrate, and nicotine and pH. RESULTS: The average values of all the toxins studied were well above their allowable limits, making the product a health risk for consumers. Calculated lifetime cancer risk from cadmium and lead was 1 lac (100,000) to 10 lac (1,000,000) times higher than the minimum 10E-4 (0.00001) to 10E-6 (0.000001), which is the 'target range' for potentially hazardous substances, according to the US Environmental Protection Agency. Similarly, the level of arsenic was in the range of 0.15 to 14.04 µg/g, the average being 1.25 µg/g. The estimated average bioavailable concentration of arsenic is 0.125-0.25 µg/g, which is higher than the allowable standard of 0.01 µg/g. Similarly, the average minimum daily intake of chromium and nickel was 126.97 µg and 122.01 µg, as compared to allowable 30-35 µg and 35 µg, respectively; a 4-5 times higher exposure. However, beryllium was not detected in any of the brands studied. The pH was highly basic, averaging 8.56, which favours the formation of tobacco specific amines thus making the product potentially toxic. This study validates clinical studies correlating incidence of cancer with naswar use in Pakistan. CONCLUSIONS: This study shows that the production, packaging, sale and consumption of naswar should be regulated so as to protect the public from the health hazards associated with its consumption.