Association between achieving adequate antenatal care and health-seeking behaviors: A study of Demographic and Health Surveys in 47 low- and middle-income countries.

BACKGROUND: Antenatal care (ANC) is essential for ensuring the well-being of pregnant women and their fetuses. This study models the association between achieving adequate ANC and various health and health-seeking indicators across wealth quintiles in low- and middle-income countries (LMICs). METHODS AND FINDINGS: We analyzed data from 638,265 women across 47 LMICs using available Demographic and Health Surveys from 2010 to 2022. Via multilevel logistic regression analyses adjusted for a series of confounding variables and country and wealth quintile fixed effects, we estimated the projected impact of achieving adequate ANC utilization and quality on a series of health and health care indicators: facility birth, postnatal care, childhood immunizations, and childhood stunting and wasting. Achieving adequate levels of ANC utilization and quality (defined as at least 4 visits, blood pressure monitoring, and blood and urine testing) was positively associated with health-seeking behavior across the majority of countries. The strongest association was observed for facility birth, followed by postnatal care and child immunization. The strength of the associations varied across countries and wealth quintiles, with more significant ones observed in countries with lower baseline ANC utilization levels and among the lower wealth quintiles. The associations of ANC with childhood stunting and wasting were notably less statistically significant compared to other indicators. Despite rigorous adjustments for potential confounders, a limitation to the methodology is that it is possible that unobserved variables may still impact outcomes. CONCLUSIONS: Strengthening ANC is associated with improved use of other health care in LMICs. ANC could serve as a critical platform for improving health outcomes for mothers and their children, emphasizing its importance beyond direct impact on maternal and neonatal mortality.

A Journey of Innovation: 40 years of Pioneering Medical Education at the Aga Khan University Medical College in Karachi, Pakistan.

This article presents an overview of Aga Khan University's (AKU) pioneering medical education initiatives over the past 40 years, exploring its impact on healthcare in the region and its commitment to advancing medical education and research in the developing world. Established in 1983 as the first private university in Pakistan, AKU has evolved into a global institution with a focus on improving healthcare standards and addressing healthcare needs in the developing world. The article also discusses the undergraduate and postgraduate medical education programs at AKU Medical College, Pakistan, highlighting their unique features and pioneering approaches to medical education. The institution's journey highlights its ability to adapt to the evolving healthcare landscape while maintaining a focus on quality and excellence, offering a model for other institutions striving to meet healthcare needs in low- and middle-income countries.

SWI/SNF regulates a transcriptional program that induces senescence to prevent liver cancer.

Oncogene-induced senescence (OIS) is a potent tumor suppressor mechanism. To identify senescence regulators relevant to cancer, we screened an shRNA library targeting genes deleted in hepatocellular carcinoma (HCC). Here, we describe how knockdown of the SWI/SNF component ARID1B prevents OIS and cooperates with RAS to induce liver tumors. ARID1B controls p16INK4a and p21CIP1a transcription but also regulates DNA damage, oxidative stress, and p53 induction, suggesting that SWI/SNF uses additional mechanisms to regulate senescence. To systematically identify SWI/SNF targets regulating senescence, we carried out a focused shRNA screen. We discovered several new senescence regulators, including ENTPD7, an enzyme that hydrolyses nucleotides. ENTPD7 affects oxidative stress, DNA damage, and senescence. Importantly, expression of ENTPD7 or inhibition of nucleotide synthesis in ARID1B-depleted cells results in re-establishment of senescence. Our results identify novel mechanisms by which epigenetic regulators can affect tumor progression and suggest that prosenescence therapies could be employed against SWI/SNF-mutated cancers.

Ligation of intersphincteric fistula tract: A retrospective, single centre, individual surgeons' experience for the management of complex fistula in ano.

Objectives: To identify early treatment outcomes among patients having undergone ligation of intersphincteric fistula tract for complex fistula-in-ano in a tertiary care setting. METHODS: The single-centre retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised data from January 2016 to January 2021 of adult complex fistula-in-ano patients who underwent ligation of intersphincteric fistula tract procedure. All surgeries were done by a single surgeon. Pre- and post-operative Wexner continence scores were measured, and various factors, including change in continence, complete wound healing, postoperative infection and recurrence, were assessed. Data was analysed using SPSS 23. RESULTS: Of the 20 patients, 15(75%) were females and 5(25.0%) were males. The overall mean age was 38.4±13.8 years. The median duration of surgery was 65 minutes (interquartile range: 57-99 minutes). There were 2(10%) patients who showed a change in continence after surgery to flatus alone. Complete healing was noted in 11(55%) patients. Recurrence was noted in 8(40%) patients; trans-sphincteric fistula-in-ano in 2(10%) patients, and inter-sphincteric fistula in 6(30%). Body mass index had a significant association with the change in continence (p=0.028). CONCLUSIONS: There was a comparable risk of recurrence after ligation of intersphincteric fistula tract surgery, but among those without recurrence, the post-operative outcomes were optimal and no faecal incontinence was noted.

Oxidative stress in polycystic ovary syndrome: a case-control study.

OBJECTIVE: To compare the serum levels of biochemical and oxidative stress markers i.e., malondialdehyde (MDA) and paraoxonase-1(PON1) in polycystic ovary syndrome (PCOS) patients and healthy female individuals of reproductive age group (18-40 years). METHODS: This case-control study was conducted in Dow University of Health Sciences (DUHS), Karachi from June 2019 to October 2020. Seventy Subjects including 35 PCOS patients that have primary subfertility problem (cases) and 35 healthy and fertile females (controls) were recruited. Serum samples were collected for analysis of insulin, sex hormone-binding globulin, testosterone, fasting blood glucose and lipid profile. PON 1 and MDA levels were estimated by ELISA. Comparison between the two groups was done using independent t-test. RESULTS: The patients had significantly increased mean body mass index (28.5+4.6 kg/m2 vs 25.7+4.5 kg/m2, p=0.014), systolic (129.6±13.9 mm of Hg vs 113±7.7 mm of Hg, p<0.001) and diastolic (78.7±8.8 mm of Hg vs 74.6±6.7 mm of Hg, p=0.032) blood pressures compared to controls. The high-density lipoprotein cholesterol levels were significantly lower in PCOS (42.2±8.6mg/dl) than controls (48.8±11.8mg/dl, p=0.009, p=0.009). Serum insulin (14.3±5.8 uIU/mL) vs (10.0±5.2 uIU/mL), p=0.002 and testosterone levels (1.3±0.9 nmol/L) vs (0.82±0.3 nmol/L), p<0.001 were significantly higher whereas sex hormone binding globulin (SHBG) levels (35.2±19.7nmol/L vs 58.8±31.0 nmol/L) were significantly lower in patients than healthy controls (p<0.001). Both oxidative stress markers, paraoxonase 1 (7.7±2.4 vs 6.4±2.6 µg/mL, p=0.04) and malondialdehyde (2.5±1.0 vs 1.9+0.51µg/mL, p=0.034) levels were significantly elevated in PCOS patients than controls. No significant correlation was found between dietary habits and life style between cases and controls. CONCLUSIONS: The study reported significantly elevated levels of oxidative stress markers in PCOS patients.

Much room for change: access to surgical care for stateless individuals in Pakistan.

BACKGROUND: As developing countries take steps towards providing universal essential surgery, ensuring the equitable distribution of such care for underrepresented populations is a vital function of the global surgery community. Unfortunately, in the context of the global "stateless", there remains much room for improvement. KEY ISSUES: Inherent structural deficiencies, such as lack of adequate population data on stateless communities, absent health coverage policies for stateless individuals, and minimal patient-reported qualitative data on barriers to surgical service delivery prevent stateless individuals from receiving the care they require - even when healthcare infrastructure to provide such care exists. The authors therefore propose more research and targeted interventions to address the systemic issues that prevent stateless individuals from accessing surgical care. CONCLUSION: It is essential to address the aforementioned barriers in order to improve stateless populations' access to surgical care. Rigorous empirical and qualitative research provides an important avenue through which these structural issues may be addressed.

Machine Learning Model for Assessment of Risk Factors and Postoperative Day for Superficial vs Deep/Organ-Space Surgical Site Infections.

Background. Deep and organ space surgical site infections (SSI) require more intensive treatment, may result in more severe clinical disease and may have different risk factors when compared to superficial SSIs. Machine learning (ML) algorithms provide the opportunity to analyze multiple factors to predict of the type and time of development of SSI. Therefore, we developed a ML model to predict type and postoperative week of SSI. Methodology. A case-control study was conducted among patients who developed a SSI after undergoing general surgery procedures at a tertiary care hospital between 2019 to 2020. Patients were followed for 30 days. Six ML algorithms were trained as predictors of type of infection (superficial vs deep/organ space) and time of infection, and tested using area under the receiver operating characteristic curve (AUC-ROC). Results. Data for 113 patients with SSIs was available. Of these 62 (54.8%) had superficial and 51 had (45.2%) deep/organ space infections. Compared with other ML algorithms, the XG boost univariate model had highest AUC-ROC (.84) for prediction of type of SSI and Stochastic gradient boosting univariate, logistic regression univariate, XG boost univariate, and random forest classification univariate model had the highest AUC-ROC (.74) for prediction of week of infection. Conclusions. ML models offer reasonable accuracy in prediction of superficial vs deep SSI and time of developing infection. Follow-up duration and allocation of treatment strategies can be informed by ML predictions.

Retrospective on Exploring MXene-Based Nanomaterials: Photocatalytic Applications.

Nanostructural two-dimensional compounds are grabbing the attention of researchers all around the world. This research is progressing quickly due to its wide range of applications in numerous industries and enormous promise for future technological breakthroughs. Growing environmental consciousness has made it vital to treat wastewater and avoid releasing hazardous substances into the environment. Rising consumer expectations have led to the emergence of new, frequently nonbiodegradable compounds. Due to their specific chemical and physical properties, MXenes have recently been identified as promising candidates. MXenes are regarded as a prospective route for environmental remediation technologies, such as photocatalysis, adsorption, and membrane separation, and as electrocatalytic sensors for pollution recognition because of their high hydrophilicity, inherent chemical nature, and robust electrochemistry. The development of catalysts based on MXene materials for the photocatalytic breakdown of pharmaceutical wastes in polluted water is critically evaluated in this study. With an emphasis on the degradation mechanism, the photocatalytic degradation of antibiotics using MXenes and MXene-based nanocomposites is explained in depth. We emphasize the significant difficulties in producing MXenes and their composites, as well as in the degradation of drugs. The successful use of MXenes in water filtration and suggestions for future study are also presented.

Ensuring competence of essential skills: clinical examination for final year medical students.

OBJECTIVE: To ensure competence of essential skills of final year medical students in clinical examination by identifying essential skills and by revisiting and practising them before the examination. Methods: The cross-sectional study was conducted at the Aga Khan University, Karachi, from February to November, 2019, and comprised final year medical students and internal examiners from various academic disciplines. An overview of the organisational context, exam structure and process was noted. RESULTS: There were 96 medical students. The four key areas highlighted were development of the list of essential skills across five years of undergraduate medical curriculum with consensus from all disciplines, student motivation for attendance in practice sessions, unfamiliarity of examiners with the assessment tool, and the need for capacity-building. The key areas were based on the feedback received from all the stakeholders, and post-hoc analysis. Conclusion: This form of assessment would enable a thorough analysis of the preparedness of the students to function as independent physicians as undifferentiated doctor at the start of their careers as interns, and improve the quality of subsequent exams based on feedback and suggestions of faculty and students.

Leveraging the potential of silver nanoparticles-based materials towards sustainable water treatment.

Increasing demand of pure and accessible water and improper disposal of waste into the existing water resources are the major challenges for sustainable development. Nanoscale technology is an effective approach that is increasingly being applied to water remediation. Compared to conventional water treatment processes, silver nanotechnology has been demonstrated to have advantages due to its anti-microbial and oligodynamic (biocidal) properties. This review is focused on environmentally friendly green syntheses of silver nanoparticles (AgNPs) and their applications for the disinfection and microbial control of wastewater. A bibliometric keyword analysis is conducted to unveil important keywords and topics in the utilisation of AgNPs for water treatment applications. The effectiveness of AgNPs, as both free nanoparticles (NPs) or as supported NPs (nanocomposites), to deal with noxious pollutants like complex dyes, heavy metals as well as emerging pollutants of concern is also discussed. This knowledge dataset will be helpful for researchers to identify and utilise the distinctive features of AgNPs and will hopefully stimulate the development of novel solutions to improve wastewater treatment. This review will also help researchers to prepare effective water management strategies using nano silver-based systems manufactured using green chemistry.

PakSurg: The first trainee-lead model for multicenter surgical research collaboration in Pakistan.

We describe creation and piloting of the PakSurg Collaborative, devised via integration of existing trainee-led collaborative models in the United Kingdom with the resource-limited surgical care in Pakistan. This is the first trainee-lead surgical research collaborative in Pakistan, established by the student-lead Surgery Interest Group from the Aga Khan University. The project involved creation of a model that included a steering committee comprising of five teams which worked in conjunction with collaborators from multiple hospitals. To facilitate this collaboration, a comprehensive and cost-efficient study management pathway was developed. The PakSurg Collaborative has the potential to deliver methodologically robust, high-quality, multicenter surgical evidence from Pakistan. This nationally representative data could inform evidence-based surgical guidelines, potentially translating into improved outcomes for patients undergoing surgery.

Factors Affecting Women Surgeons' Careers in Low-Middle-Income Countries: An International Survey.

BACKGROUND: Despite increasing numbers of women surgeons globally, barriers to career advancement persist. While these barriers have been extensively discussed in high-income countries (HICs), the topic has received minimal attention in lower-middle-income countries (LMICs) like Pakistan. METHODS: The Association of Women Surgeons of Pakistan (AWSP)-an organization in Pakistan consisting of female surgeons and trainees-carried out this international cross-sectional study over July-Sept 2019. An anonymous online survey was disseminated via social media platforms and various institutions across Pakistan and internationally. RESULTS: A total of 218 female surgeons responded to the survey, with 146 (67%) from Pakistan and 72 (33%) from HICs. While HIC surgeons were more likely to report gender discrimination/bias (GD/bias) during residency (29.2% vs 11.6%; p = 0.001), more Pakistani surgeons reported that GD/bias negatively affected their job satisfaction (80.7% vs. 64.9%; p = 0.024). GD/bias manifested most commonly as differences in mentoring relationships (72%). A higher percentage Pakistani surgeons reported having experienced a family-related interruption in their career (24.7% vs. 11.1%; p = 0.019). The vast majority (95%) felt that surgery was perceived as a masculine field, and the majority (56.4%) of respondents reported having been told that they could not be a surgeon because of their gender. CONCLUSION: Our study highlights keys factors that must be addressed to provide equal career opportunities to women surgeons. It is the responsibility of surgical educators, policy makers, and healthcare organizations to facilitate women surgeons' career progression by developing systems that support equitable career growth for women surgeons.

Effect of rectal washout on local recurrence of rectal cancer in the era of total mesorectal excision: Meta-analysis.

INTRODUCTION: Presence of intraluminal viable cancer cells implanting into the anastomosis has been proposed as a potential cause for developing local recurrence in patients undergoing anterior resection for rectal cancer. Rectal washout has been proposed as a method to prevent this from happening. There have been conflicting reports in literature regarding the effect of rectal washout on local recurrence. We aim to look at the role of rectal washout in preventing local recurrence of rectal cancer in patients undergoing total or tumor-specific mesorectal excision (TME). MATERIALS AND METHODS: A literature review of studies evaluating the role of rectal washout on rectal cancer local recurrence was performed using PubMed, Scopus, EMBASE and non-English language literature search using CiNii (Japanese) and CNKI (Chinese). Inclusion criteria were use of TME, comparison of rectal washout with no washout, and evaluation of local recurrence as outcome. RESULTS: Four studies were identified according to inclusion criteria. The meta-analysis showed a protective effect of rectal washout on local recurrence (OR 0.45 95% CI 0.45-0.75). However, one of the studies included had more than 90% weightage. Excluding this study from analysis showed no difference on local recurrence with rectal washout (OR 0.94, 95% CI 0.37-2.36). CONCLUSION: The effect of rectal washout on rectal cancer local recurrence in patients who undergo TME is questionable and needs to be evaluated further by prospective studies.

Global Surgery Hackathons: A Case Study From Pakistan.

Background. Hackathons aim to solve problems in a selected field by bringing together people from multiple domains and combining their expertise. Global surgery is an emerging field with a huge burden of disease and massive implications for bettering health care. In this study, we describe the first Global Surgery Hackathon held in Pakistan and analyze the impacts of the hack and post-hack incubation. Methods. This research study used data collected from a Hackathon held at the Aga Khan University (AKU) in Karachi, Pakistan, and progress from the post-hack incubation teams. Data were collected from applications, from sign-in attendance, via evaluation forms, and milestone tracking of the incubation teams. A list of factors such as sectors addressed by winning projects and grants received was made. Results. The evaluations provided by the participants were positive, with mean scores of 4.00 (SD = .78) out of 5 on a Likert scale. Pitches made (n = 69, 68%) by the 109 participants were sorted into 5 categories: workplace, access, quality, safety, and design. Fifteen teams were formed, out of which 5 were accepted for incubation. All teams had a minimum viable product at the one-year mark. Conclusion. Hackathons are a reliable way to come up with effective solutions for targeted problems in various areas of health care and using the methodology of a Hackathon, a pool of low-cost, innovative solutions can be generated. These solutions can definitely impact health outcomes, especially for the field of global surgery. Further statistics should be collected to affirm the incubated solutions' impact.

Supramolecular Chemistry: Host-Guest Molecular Complexes.

In recent times, researchers have emphasized practical approaches for capturing coordinated and selective guest entrap. The physisorbed nanoporous supramolecular complexes have been widely used to restrain various guest species on compact supporting surfaces. The host-guest (HG) interactions in two-dimensional (2D) permeable porous linkages are growing expeditiously due to their future applications in biocatalysis, separation technology, or nanoscale patterning. The different crystal-like nanoporous network has been acquired to enclose and trap guest molecules of various dimensions and contours. The host centers have been lumped together via noncovalent interactions (such as hydrogen bonds, van der Waals (vdW) interactions, or coordinate bonds). In this review article, we enlighten and elucidate recent progress in HG chemistry, explored via scanning tunneling microscopy (STM). We summarize the synthesis, design, and characterization of typical HG structural design examined on various substrates, under ambient surroundings at the liquid-solid (LS) interface, or during ultrahigh vacuum (UHV). We emphasize isoreticular complexes, vibrant HG coordination, or hosts functional cavities responsive to the applied stimulus. Finally, we critically discuss the significant challenges in advancing this developing electrochemical field.

Monolayer and Bilayer Formation of Molecular 2D Networks Assembled at the Liquid/Solid Interfaces by Solution-Based Drop-Cast Method.

In recent years, extending self-assembled structures from two-dimensions (2D) to three-dimensions (3D) has been a paradigm in surface supramolecular chemistry and contemporary nanotechnology. Using organic molecules of p-terphenyl-3,5,3',5'-tetracarboxylic acid (TPTC), and scanning tunneling microscopy (STM), we present a simple route, that is the control of the solute solubility in a sample solution, to achieve the vertical growth of supramolecular self-assemblies, which would otherwise form monolayers at the organic solvent/graphite interface. Presumably, the bilayer formations were based on π-conjugated overlapped molecular dimers that worked as nuclei to induce the yielding of the second layer. We also tested other molecules, including trimesic acid (TMA) and 1,3,5-tris(4-carboxyphenyl)-benzene (BTB), as well as the further application of our methodology, demonstrating the facile preparation of layered assemblies.

Case-control study for assessment of factors associated with periodontitis among adults attending a university hospital in Karachi, Pakistan.

OBJECTIVE: To compare the physiological and biochemical markers in healthy and periodontitis subjects, and to relate these markers with the periodontal health condition. METHOD: The case-control study was conducted at the Dow University of Health Sciences, Karachi, from April 2017 to March 2018, and comprised systematically healthy controls and periodontitis cases. Periodontal probing depth, clinical attachment loss, oral hygiene indices, educational status and body mass index were recorded for all the subjects. Serum levels of biochemical markers, including calcium, phosphate and interleukin-6, were also measured. Data was analysed using SPSS 16. RESULTS: Of the 150 subjects, 75(50%) each were in the case and control groups. The overall mean age was 31.23±3.7 years (range: 22-42 years). The cases had relatively poor oral hygiene indices and educational status compared to the controls (p<0.05). Serum calcium level was lower, whereas mean body mass index was higher in the cases compared to the controls (p<0.05). No significant difference was found in interleukin-6 and phosphate levels (p>0.05). Clinical attachment loss showed significant correlation (p<0.05). CONCLUSIONS: Low serum calcium and educational levels, higher body mass index and poor oral hygiene were found to be the risk factors for the progression of periodontitis.

Peer-led surgery education: A model for a surgery interest group.

We present a systematic, sustainable, student-led model for a Surgery Interest Group in a low and middle-income country setting to encourage other medical students to establish similar groups in their institutions. Our model was developed at the Aga Khan University Medical College, Karachi, and is comprised of medical students, teaching associates, residents, faculty and alumni. The group focuses on connecting medical students with an interest in surgery with opportunities to help them match in surgery training programs. The opportunities include, but are not limited to, skill development, personal development, mentorship and research. Our model has shown growth and expansion over the last four years, and can be successfully replicated in medical colleges across similar settings.

Telementoring for breast surgeons practicing in remote areas.

Telementorship allows an expert surgeon to mentor another surgeon through an advanced procedure from a remote location via 2-way audio-visual communication. The current article was planned to review the existing literature and evaluate the utility of telementorship regarding educating rural surgeons in Pakistan about multidisciplinary breast cancer care. Publications from 2016 to 2020 were searched on PubMed and GoogleScholar and 10 most recent publications were selected. Review of literature revealed that even though telementorship in this context might be comparable to onsite mentorship, multiple concerns need to be addressed before its implementation. These include lack of concrete evidence regarding its effectiveness, legal, security and financial issues. Thus, a pilot project evaluating the efficacy of telementorship needs to be conducted for rural breast surgeons working in Pakistan. If these studies show promise and an affordable, convenient and effective method of telementorship is devised, then it may become the future of breast surgery training in far-flung regions of Pakistan.

Clinical Practice Guidelines For The Management Of Colorectal Cancer, A Consensus Statement By The Society Of Surgeons® And Surgical Oncology Society Of Pakistan®.

A joint effort by the Society of Surgeons Pakistan and Society of Surgical Oncology Pakistan, these guidelines provide a framework for the practicing surgeons involved in care and management of patients with colorectal cancer. The guidelines take into account the issues related to our local circumstances and provide a minimum standard of care that must be given to these patients. The Guideline Committee had members from all disciplines, including surgery, surgical oncology, medical oncology and radiation oncology. The guidelines have attempted to simplify things to understand and follow for the practicing surgeons. With these guidelines we wish to eliminate disparities in treatment among institutions and prevent any under treatment of patients.