The impact of geopolitical risk, institutional governance and green finance on attaining net-zero carbon emission.

This research investigates the impact of geopolitical risk, institutional governance and green finance on environmental outcomes, specifically focusing on carbon emissions and ecological footprint. Utilizing the dynamic CS-ARDL method and aggregated mean group analysis on a panel dataset covering 21 nations from 2000 to 2021, our findings reveal that heightened geopolitical risk leads to both short and long run increases in carbon emissions and the ecological footprint. Our study finds both a direct as well as indirect connection between governance, green finance and environmental outcomes in both the short and long run, highlighting the nuanced impact of governance on the formulation of environmental policies and regulatory frameworks. The results emphasize the need for targeted strategies, including focused investments and incentives for sustainable finance, particularly in conflict-affected regions. Furthermore, our research underscores the enduring impact of historical events, such as wars, on contemporary environmental indicators, emphasizing the importance of proactive conflict prevention measures. Our research suggests that policymakers should adopt comprehensive strategies that prioritize emission reduction during short-run spikes in geopolitical risk while maintaining a steadfast commitment to long-run sustainability.

The Uncertainty Assessment by the Monte Carlo Analysis of NDVI Measurements Based on Multispectral UAV Imagery.

This paper proposes a workflow to assess the uncertainty of the Normalized Difference Vegetation Index (NDVI), a critical index used in precision agriculture to determine plant health. From a metrological perspective, it is crucial to evaluate the quality of vegetation indices, which are usually obtained by processing multispectral images for measuring vegetation, soil, and environmental parameters. For this reason, it is important to assess how the NVDI measurement is affected by the camera characteristics, light environmental conditions, as well as atmospheric and seasonal/weather conditions. The proposed study investigates the impact of atmospheric conditions on solar irradiation and vegetation reflection captured by a multispectral UAV camera in the red and near-infrared bands and the variation of the nominal wavelengths of the camera in these bands. Specifically, the study examines the influence of atmospheric conditions in three scenarios: dry-clear, humid-hazy, and a combination of both. Furthermore, this investigation takes into account solar irradiance variability and the signal-to-noise ratio (SNR) of the camera. Through Monte Carlo simulations, a sensitivity analysis is carried out against each of the above-mentioned uncertainty sources and their combination. The obtained results demonstrate that the main contributors to the NVDI uncertainty are the atmospheric conditions, the nominal wavelength tolerance of the camera, and the variability of the NDVI values within the considered leaf conditions (dry and fresh).

Evaluation of medication use and polypharmacy in postoperative cardiac patients: The clinical pharmacist's imperative in a public institute of Pakistan.

As a major concern in the healthcare sector, polypharmacy is correlated with an increased risk of potential drug-drug interactions (pDDIs), treatment costs and adverse drug reactions (ADR). To assess the prevalence of polypharmacy and its associated factors among postoperative cardiac patients admitted to the National Institute of Cardiovascular Diseases (NICVD), a hospital-based cross-sectional study was conducted between November 2021 and April 2022. Medication charts of postoperative patients were reviewed for medication utilization and polypharmacy. Data was collected using a form approved by the Ethical Review Committee (ERC) regarding patient's clinical and demographic characteristics and medications administered. Statistical analysis was performed using the SPSS software version 25.0. Patients were taking an average of 10.3±1.7 medications. The minimum number of drugs taken per patient was 5, while the maximum was 15 drugs. Only 114 (29.7%) received polypharmacy (5-9 drugs) and hyper-polypharmacy (≥10 drugs) was 270 (70.3%). The mean±SD cardiovascular drugs used were 5.45±1.18 and the mean±SD non-cardiovascular drugs were 4.83±1.18. The prevalence of hyper-polypharmacy suggests a critical need for optimized medication management strategies in this population. Incorporating clinical pharmacists within public healthcare institutions can address polypharmacy-related challenges and enhance medication safety, adherence and patient outcomes.

Exploring the path to polio eradication: insights from consecutive seroprevalence surveys among Pakistani children.

Introduction: After trivalent oral poliovirus vaccine (tOPV) cessation, Pakistan has maintained immunity to type 2 poliovirus by administering inactivated polio vaccine (IPV) in routine immunization, alongside monovalent OPV type 2 (mOPV2) and IPV in supplementary immunization activities (SIAs). This study assesses the change in poliovirus type 2 immunity after tOPV withdrawal and due to SIAs with mOPV2 and IPV among children aged 6-11 months. Methods: Three cross-sectional sequential serological surveys were conducted in 12 polio high-risk areas of Pakistan. 25 clusters from each geographical stratum were selected utilizing probability proportional to size. Results: Seroprevalence of type 2 poliovirus was 49%, with significant variation observed among surveyed areas; <30% in Pishin, >80% in Killa Abdullah, Mardan & Swabi, and Rawalpindi. SIAs with IPV improved immunity from 38 to 57% in Karachi and 60 to 88% in Khyber. SIAs with IPV following mOPV2 improved immunity from 62 to 65% in Killa Abdullah, and combined mOPV2 and IPV SIAs in Pishin improved immunity from 28 to 89%. Results also reflected that immunity rates for serotypes 1 and 3 were consistently above 90% during all three phases and across all geographical areas. Conclusion: The study findings highlight the importance of implementing effective vaccination strategies to prevent the re-emergence of poliovirus. Moreover, the results provide crucial information for policymakers working toward achieving global polio eradication.

A Low-Cost, Integrated Immunization, Health, and Nutrition Intervention in Conflict Settings in Pakistan-The Impact on Zero-Dose Children and Polio Coverage.

Pakistan is one of two countries globally still endemic for poliovirus. While increasing immunization coverage is a concern, providing equitable access to care is also a priority, especially for conflict-affected populations. Recognizing these challenges, Naunehal, an integrated model of maternal, newborn, and child health (MNCH), immunization, and nutrition services delivered through community mobilization, mobile outreach, and private-sector engagement was implemented in conflict-affected union councils (UCs) with high poliovirus transmission, including Kharotabad 1(Quetta, Balochistan) and Bakhmal Ahmedzai (Lakki Marwat, Khyber Pakhtunkhwa). A quasi-experimental pre-post-design was used to assess the impact of the interventions implemented between April 2021 and April 2022, with a baseline and an endline survey. For each of the intervention UCs, a separate, matched-control UC was identified. At endline, the proportion of fully immunized children increased significantly from 27.5% to 51.0% in intervention UCs with a difference-in-difference (DiD) estimate of 13.6%. The proportion of zero-dose children and non-recipients of routine immunization (NR-RI) children decreased from 31.6% to 0.9% and from 31.9% to 3.4%, respectively, with a significant decrease in the latter group. Scaling up and assessing the adoption and feasibility of integrated interventions to improve immunization coverage can inform policymakers of the viability of such services in such contexts.

Data Management in Multicountry Consortium Studies: The Enterics For Global Health (EFGH) Shigella Surveillance Study Example.

Background: Rigorous data management systems and planning are essential to successful research projects, especially for large, multicountry consortium studies involving partnerships across multiple institutions. Here we describe the development and implementation of data management systems and procedures for the Enterics For Global Health (EFGH) Shigella surveillance study-a 7-country diarrhea surveillance study that will conduct facility-based surveillance concurrent with population-based enumeration and a health care utilization survey to estimate the incidence of Shigella--associated diarrhea in children 6 to 35 months old. Methods: The goals of EFGH data management are to utilize the knowledge and experience of consortium members to collect high-quality data and ensure equity in access and decision-making. During the planning phase before study initiation, a working group of representatives from each EFGH country site, the coordination team, and other partners met regularly to develop the data management systems for the study. Results: This resulted in the Data Management Plan, which included selecting REDCap and SurveyCTO as the primary database systems. Consequently, we laid out procedures for data processing and storage, study monitoring and reporting, data quality control and assurance activities, and data access. The data management system and associated real-time visualizations allow for rapid data cleaning activities and progress monitoring and will enable quicker time to analysis. Conclusions: Experiences from this study will contribute toward enriching the sparse landscape of data management methods publications and serve as a case study for future studies seeking to collect and manage data consistently and rigorously while maintaining equitable access to and control of data.

Association of maternal, obstetric, fetal, and neonatal mortality outcomes with Lady Health Worker coverage from a cross-sectional survey of >10,000 households in Gilgit-Baltistan, Pakistan.

Pakistan has among the highest rates of maternal, perinatal, and neonatal mortality globally. Many of these deaths are potentially preventable with low-cost, scalable interventions delivered through community-based health worker programs to the most remote communities. We conducted a cross-sectional survey of 10,264 households during the baseline phase of a cluster randomized controlled trial (cRCT) in Gilgit-Baltistan, Pakistan from June-August 2021. The survey was conducted through a stratified, two-stage sampling design with the objective of estimating the neonatal mortality rate (NMR) within the study catchment area, and informing implementation of the cRCT. Study outcomes were self-reported and included neonatal death, stillbirth, health facility delivery, maternal death, postpartum hemorrhage (PPH), and Lady Health Worker (LHW) coverage. Summary statistics (proportions and rates) were weighted according to the sampling design, and mixed-effects Poisson regression was conducted to explore the relationship between LHW coverage and maternal/newborn outcomes. We identified 7,600 women who gave birth in the past five years, among whom 13% reported experiencing PPH. The maternal mortality ratio was 225 maternal deaths per 100,000 live births (95% confidence interval [CI] 137-369). Among 12,376 total births, the stillbirth rate was 41.4 per 1,000 births (95% CI 36.8-46.7) and the perinatal mortality rate was 53.0 per 1,000 births (95% CI 47.6-59.0). Among 11,863 live births, NMR was 16.2 per 1,000 live births (95% CI 13.6-19.3) and 65% were delivered at a health facility. LHW home visits were associated with declines in PPH (risk ratio [RR] 0.89 per each additional visit, 95% CI 0.83-0.96) and late neonatal mortality (RR 0.80, 95% CI 0.67-0.97). Intracluster correlation coefficients were also estimated to inform the planning of future trials. The high rates of maternal, perinatal, and neonatal death in Gilgit-Baltistan continue to fall behind targets of the 2030 Sustainable Development Goals.

From Pixels to Precision: A Survey of Monocular Visual Odometry in Digital Twin Applications.

This survey provides a comprehensive overview of traditional techniques and deep learning-based methodologies for monocular visual odometry (VO), with a focus on displacement measurement applications. This paper outlines the fundamental concepts and general procedures for VO implementation, including feature detection, tracking, motion estimation, triangulation, and trajectory estimation. This paper also explores the research challenges inherent in VO implementation, including scale estimation and ground plane considerations. The scientific literature is rife with diverse methodologies aiming to overcome these challenges, particularly focusing on the problem of accurate scale estimation. This issue has been typically addressed through the reliance on knowledge regarding the height of the camera from the ground plane and the evaluation of feature movements on that plane. Alternatively, some approaches have utilized additional tools, such as LiDAR or depth sensors. This survey of approaches concludes with a discussion of future research challenges and opportunities in the field of monocular visual odometry.

Effect of Maternal and Newborn Care Service Package on Perinatal and Newborn Mortality: A Cluster Randomized Clinical Trial.

Importance: In resource-constrained settings where the neonatal mortality rate (NMR) is high due to preventable causes and health systems are underused, community-based interventions can increase newborn survival by improving health care practices. Objectives: To develop and evaluate the effectiveness of a community-based maternal and newborn care services package to reduce perinatal and neonatal mortality in rural Pakistan. Design, Setting, and Participants: This cluster randomized clinical trial was conducted between November 1, 2012, and December 31, 2013, in district Rahim Yar Khan in the province of Punjab. A cluster was defined as an administrative union council. Any consenting pregnant resident of the study area, regardless of gestational age, was enrolled. An ongoing pregnancy surveillance system identified 12 529 and 12 333 pregnancies in the intervention and control clusters, respectively; 9410 pregnancies were excluded from analysis due to continuation of pregnancy at the end of the study, loss to follow-up, or miscarriage. Participants were followed up until the 40th postpartum day. Statistical analysis was performed from January to May 2014. Intervention: A maternal and newborn health pack, training for community- and facility-based health care professionals, and community mobilization through counseling and education sessions. Main Outcomes and Measures: The primary outcome was perinatal mortality, defined as stillbirths per 1000 births and neonatal death within 7 days per 1000 live births. The secondary outcome was neonatal mortality, defined as death within 28 days of life per 1000 live births. Systematic random sampling was used to allocate 10 clusters each to intervention and control groups. Analysis was conducted on a modified intention-to-treat basis. Results: For the control group vs the intervention group, the total number of households was 33 188 vs 34 315, the median number of households per cluster was 3092 (IQR, 3018-3467) vs 3469 (IQR, 3019-4075), the total population was 229 155 vs 234 674, the mean (SD) number of residents per household was 6.9 (9.5) vs 6.8 (9.6), the number of males per 100 females (ie, the sex ratio) was 104.2 vs 103.7, and the mean (SD) number of children younger than 5 years per household was 1.0 (4.2) vs 1.0 (4.3). Altogether, 7598 births from conrol clusters and 8017 births from intervention clusters were analyzed. There was no significant difference in perinatal mortality between the intervention and control clusters (rate ratio, 0.86; 95% CI, 0.69-1.08; P = .19). The NMR was lower among the intervention than the control clusters (39.2/1000 live births vs 52.2/1000 live births; rate ratio, 0.75; 95% CI, 0.58-0.95; P = .02). The frequencies of antenatal visits and facility births were similar between the 2 groups. However, clean delivery practices were higher among intervention clusters than control clusters (63.2% [2284 of 3616] vs 13.2% [455 of 3458]; P < .001). Chlorhexidine use was also more common among intervention clusters than control clusters (55.9% [4271 of 7642] vs 0.3% [19 of 7203]; P < .001). Conclusions and Relevance: This pragmatic cluster randomized clinical trial demonstrated a reduction in NMR that occurred in the background of improved household intrapartum and newborn care practices. However, the effect of the intervention on antenatal visits, facility births, and perinatal mortality rates was inconclusive, highlighting areas requiring further research. Nevertheless, the improvement in NMR underscores the effectiveness of community-based programs in low-resource settings. Trial Registration: ClinicalTrials.gov Identifier: NCT01751945.

Functional composition outweighs taxonomic and functional diversity in maintaining ecosystem properties and processes of mangrove forests.

Biodiversity loss can have significant consequences for human well-being, as it can affect multiple ecosystem properties and processes (MEPP) that drive ecosystem services. However, a comprehensive understanding of the link between environmental factors, biodiversity, and MEPP remains elusive, especially in mangrove ecosystems that millions of people along tropical coastlines worldwide depend upon. Here, we collated a comprehensive dataset on forest inventory, plant traits, and environmental factors across 93 plots in the Sundarbans Reserved Forests, Bangladesh. The functional composition (FC) of leaf area showed a stronger positive association with MEPP, being determined by total biomass and productivity of the mangroves, sediment organic carbon, and ammonium, phosphorus, and potassium contents of the sediment, than species richness (SR) or functional diversity (FD). Further, FC mediated a strong negative association of sediment salinity, and a positive association of SR, with MEPP. The similar but opposite total associations of SR and sediment salinity with MEPP suggest that species-rich mangroves could offset the negative impacts of rising salinity on MEPP. When focusing on a single aspect of MEPP, both FD and FC mattered, with the FD of leaf area showing a strong association with mangrove productivity and sediment potassium content, while the FC of leaf litter nitrogen showed the strongest associations with sediment ammonium and phosphorus contents. Therefore, to sustain mangrove ecosystems as a reliable nature-based solution for climate change mitigation, conservation and (re-)establishment projects should prioritize regionally dominant species with high leaf area and nitrogen content, plus functionally different species to support the ecosystem processes and services provided by mangroves.

Daptomycin MICs by Broth Microdilution Method Against Staphylococcus aureus in Clinical Specimens: A Cross-Sectional Study from Pakistan.

OBJECTIVE: To explore the distribution of daptomycin (DAP) minimum inhibitory concentrations (MICs) in Staphylococcus aureus isolated from complicated skin, soft tissue, and bloodstream infections collected from the Pakistani population using broth microdilution (BMD). STUDY DESIGN: Descriptive, cross-sectional study. Place and Duration of the Study: Department of Pathology and Laboratory Medicine, The Aga Khan University Hospital, from May to October 2021. METHODOLOGY: Through consecutive sampling techniques, 169 Staphylococcus aureus (S. aureus) isolated from clinical specimens including pus, tissue, and blood were collected. Patients' data including age, gender, geographical location, specimen site, and methicillin susceptibility were collected from the laboratory data. BMD was used to determine MICs of clinical isolates and S. aureus ATCC 29213. DAP MIC ≤1.0 µg/ml was considered susceptible according to the Clinical and Laboratory Standards Institute M100. RESULTS: Among all the clinical isolates, 144 (85%) and 25 (15%) were from skin and soft tissue and blood, respectively. All isolates were susceptible to DAP with MIC50, MIC90, and MIC range of 0.25 µg/ml, 0.5 µg/ml, and 0.06 - 0.5 µg/ml, respectively. CONCLUSION: These study findings demonstrated low in-vitro MICs for DAP against S. aureus in tested isolates from a diverse variety of patient specimens from across Pakistan. KEY WORDS: Daptomycin, Staphylococcus aureus, Broth microdilution, Minimum inhibitory concentrations.

A Holistic Strategy of Mother and Child Health Care to Improve the Coverage of Routine and Polio Immunization in Pakistan: Results from a Demonstration Project.

BACKGROUND: The eradication of poliovirus and improving routine immunization (RI) coverage rates present significant challenges in Pakistan. There is a need for interventions that focus on strengthening community engagement to improve routine immunization coverage. Our primary objective is to assess the impact of an integrated strategy designed to enhance community engagement and maternal and child health immunization campaigns on immunization coverage in Pakistan's high-risk union councils of polio-endemic districts. METHOD: We implemented an integrated approach for routine immunization and maternal and child health in the polio-endemic district of Pakistan. This approach involved setting up health camps and actively engaging and mobilizing the local community. An independent team conducted surveys at three key points: baseline, midline, and endline, to evaluate immunization coverage among children under the age of five. The primary outcome measures for the study were coverage of OPV, IPV, and changes in the proportion of unvaccinated and fully vaccinated children. To select clusters and eligible households in each cluster, we utilized a 30 × 15 cluster sampling technique. Multivariable associations between socio-demographic factors and changes in the proportion of fully vaccinated children at the UC level were assessed using hierarchical linear regression models. RESULTS: A total of 256,946 children under the age of five (122,950 at baseline and 133,996 at endline) were enrolled in the study. By the endline, full immunization coverage had increased to 60% or more in all three study areas compared to the baseline. Additionally, there was a significant increase in the coverage of both OPV and IPV across all three provinces at the endline. The full immunization rates were assessed on three levels of the framework: the distal, intermediate (access and environment), and proximal level (camp attendance and effectiveness). At the distal level, on multivariate analysis, family size was found to be a significant predictor of change in immunity within the families (ß = 0.68; p ≤ 0.0001). At the intermediate level, the likelihood of full immunization decreased with the decrease in knowledge about vaccination (ß = -0.38; p = 0.002), knowledge about polio vaccine (ß = -0.25; p = 0.011), and knowledge about IPV (ß = -0.06; p = 0.546). Perceived obstacles to vaccination were fear of adverse events (ß = -0.4; p ≤ 0.0001) and lack of education (ß = 0.23; p = 0.031), which were found to be significant in bivariate and multivariate analyses. At the proximal level, community mobilization (ß = 0.26; p = 0.008) and attendance at health camp (ß = 0.21; p ≤ 0.0001) were found to enhance full immunization coverage. On the other hand, the most prominent reason for not attending health camp included no need to attend the health camp as the child was not ill (ß = -0.13; p = 0.008). CONCLUSIONS: This study found that community mobilization and attendance at health camps significantly enhanced full immunization coverage. The findings highlight the importance of community engagement and targeted interventions in improving immunization coverage and addressing barriers to healthcare seeking.

Exploring testicular miRNA profiles during developmental stages in Dezhou donkeys: A preliminary insight.

Testicular development and spermatogenesis are complex phenomena controlled by various genetic factors, including miRNA-based post-transcriptional gene expression regulation. Exploring the miRNA expression patterns during testicular development in Dezhou donkeys would enhance our understanding of equine fertility and spermatogenesis. In this investigation, we examined the testicular miRNA profiles at various stages of development. The experimental animals were divided into three groups based on their developmental stages: 2 months old (juvenile: n = 3), 12 months old (adolescent; n = 3) and 24 months old (adult; n = 3) donkeys. Total RNA was extracted from dissected testicles for miRNA sequencing and analysis. In total, 586 miRNAs, including 451 known miRNAs and 135 novel miRNAs, were identified. Among identified miRNAs, 315 displayed age-dependent expression differences. The levels of miRNA expression in the juvenile group were significantly higher than in the adolescent or adult groups. The MiR-483 exhibited the maximum fold change between juvenile and adolescent groups. Several screened genes, including SLC45A4 and TFCP2L1, have been linked to male reproductive pathways in donkeys. In addition, miR-744 was predicted to regulate SPIN2B, a gene implicated in spermatocyte cell cycle progression and genomic integrity of spermatozoa. These results contribute to our comprehension of microRNA regulation during testicular development and spermatogenesis in Dezhou donkeys. The identified microRNAs and their target genes have the potential to serve as biomarkers for evaluating the reproductive capacity of stud donkeys.

Determinants of immunization in polio super high-risk union councils of Pakistan.

BACKGROUND: The current polio epidemiology in Pakistan poses a unique challenge for global eradication as the country is affected by ongoing endemic poliovirus transmission. Across the country, 40 union councils (UCs) which serve as core reservoirs for poliovirus with continuous incidences of polio cases are categorized as super-high-risk union councils (SHRUCs). METHODOLOGY: A cross-sectional survey was conducted in 39 SHRUCs using a two-stage stratified cluster sampling technique. 6,976 children aged 12-23 months were covered. A structured questionnaire was used for data collection. Data were analyzed using STATA version 17. RESULTS: Based on both vaccination records and recall, 48.3% of children were fully-, 35.4 % were partially-, and 16.3% were non-vaccinated in the SHRUC districts. A child is considered fully vaccinated when h/she completed vaccination for BCG, OPV0, OPV 1-3, Penta 1-3, PCV 1-3, IPV, and MCV1. Vaccination cards were seen for over half of the children in the SHRUC districts of Khyber Pakhtunkhwa (KP) and the majority of the SHRUC districts in Sindh, except for the SHRUC district of Malir the districts of Balochistan. Results for polio vacancies show that 60.9% of children from the SHRUC districts were vaccinated with at least three doses of OPV and one dose of IPV, while 20.4% were vaccinated with any OPV doses or IPV and 18.7% of children did not receive any polio vaccines. The dropout rate between vaccine visits was higher than the WHO-recommended cutoff point of 10% for all vaccine doses in the SHRUC districts. The likelihood of being fully vaccinated was higher among the children of educated parents. Full vaccination was found significant among the children of any SHRUC districts compared to district Killa Abdullah. CONCLUSION: Context-specific strategies with more focus on community engagement and targeted mobilization, along with robust monitoring mechanisms, would help address the underlying challenges of under-immunization in the SHRUCs.

What's important for recovery after a total knee replacement? A systematic review of mixed methods studies.

BACKGROUND: Understanding how patients perceive and prioritise various aspects of recovery following total knee replacement, including pain, function and return to activity, will help clinicians in pre-operative consultations by ensuring they effectively address patient concerns and managing their expectations. AIMS: The aim of this study is to identify aspects of recovery that are important to people after a total knee replacement. METHODS: Studies were identified from Medline, Embase, PsycInfo, Cochrane Library and Web of Science. This mixed methods review included all original study types (quantitative, qualitative, discrete choice experiments and mixed methods design). Reviews and non-peer-reviewed publications were excluded. Studies with participants (age ≥ 18 years) who had a primary TKR for osteoarthritis were included. Studies of people with unicompartmental knee, patella-femoral or revision knee replacement were excluded. Recovery attributes were extracted from individual papers and grouped into recovery themes. RESULTS: A total of 23 studies with 8404 participants and 18 recovery themes were developed. The most frequently identified overarching theme was pain, followed by activities of daily living, mobility (walking), recreational activities, specific functional movements of the knee, use of walking aids, sexual activity and range of motion of the knee. Medical complications were an infrequently reported theme, however, was deemed to be high importance. CONCLUSIONS: Reducing pain, returning of activities and daily living and mobility are the three most frequently reported recovery domains for people after TKR. Clinicians should be aware of recovery themes, to ensure they are explored sufficiently when consenting for a TKR. Future research should aim to determine the relative importance of these attributes compared to each other. Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021253699.

An integrated newborn care kit (iNCK) to save newborn lives and improve health outcomes in Gilgit Baltistan (GB), Pakistan: study protocol for a cluster randomized controlled trial.

BACKGROUND: Ongoing high neonatal mortality rates (NMRs) represent a global challenge. In 2021, of the 5 million deaths reported worldwide for children under five years of age, 47% were newborns. Pakistan has one of the five highest national NMRs in the world, with an estimated 39 neonatal deaths per 1,000 live births. Reducing newborn deaths requires sustainable, evidence-based, and cost-effective interventions that can be integrated within existing community healthcare infrastructure across regions with high NMR. METHODS: This pragmatic, community-based, parallel-arm, open-label, cluster randomized controlled trial aims to estimate the effect of Lady Health Workers (LHWs) providing an integrated newborn care kit (iNCK) with educational instructions to pregnant women in their third trimester, compared to the local standard of care in Gilgit-Baltistan, Pakistan, on neonatal mortality and other newborn and maternal health outcomes. The iNCK contains a clean birth kit, 4% chlorhexidine topical gel, sunflower oil emollient, a ThermoSpot™ temperature monitoring sticker, a fleece blanket, a click-to-heat reusable warmer, three 200 µg misoprostol tablets, and a pictorial instruction guide and diary. LHWs are also provided with a handheld scale to weigh the newborn. The primary study outcome is neonatal mortality, defined as a newborn death in the first 28 days of life. DISCUSSION: This study will generate policy-relevant knowledge on the effectiveness of integrating evidence-based maternal and newborn interventions and delivering them directly to pregnant women via existing community health infrastructure, for reducing neonatal mortality and morbidity, in a remote, mountainous area with a high NMR. TRIAL REGISTRATION: NCT04798833, March 15, 2021.

A Normotensive Case of Pheochromocytoma With Unusual Presentation of Abdominal Pain.

Multiple endocrine neoplasia (MEN) is an inherited, autosomal dominant condition characterized by primary parathyroid hyperplasia, medullary thyroid neoplasm, and pheochromocytoma. It most commonly presents with medullary thyroid cancer and less frequently with other complaints. Pheochromocytoma can also manifest through gastrointestinal complaints such as abdominal pain, nausea, and constipation. We present a normotensive case of pheochromocytoma, initially featuring abdominal pain and vomiting, which was later found to be associated with neck swelling and medullary thyroid cancer. The patient underwent an adrenalectomy and has continued to visit our endocrinology clinic for ongoing monitoring and treatment of iatrogenic hypoparathyroidism and hypothyroidism. A brief review is also provided.

Use of Virtual Reality in the Education of Orthopaedic Procedures: A Randomised Control Study in Early Validation of a Novel Virtual Reality Simulator.

Background Virtual reality (VR) simulation is a potential solution to the barriers surgical trainees are facing. There needs to be validation for its implementation within current training. We aimed to compare VR simulation to traditional methods in acquiring surgical skills for a TFN-ADVANCED™ Proximal Femoral Nailing System (TFNA; DePuy Synthes, Auckland, New Zealand) femoral nailing system. Methods Thirty-one surgical trainees were randomised to two groups: traditional-training group (control group) and a VR-training group (intervention group) for insertion of a short cephalomedullary TFNA nail. Both groups then inserted the same TFNA system into saw-bone femurs. Surveys evaluated validity of the relevant activities, perception of simulation, confidence, stress and anxiety. The primary outcomes were tip-apex distance (TAD) and user anxiety/confidence levels. Secondary outcomes included number of screw- and nail-guidewire insertion attempts, the time taken to complete and user validity of the VR system. Results There was no statistical difference in TAD between the intervention and control groups (9mm vs 15mm, p=0.0734). The only TAD at risk of cut-out was in the control group (25mm). There was no statistical difference in time taken (2547.5ss vs 2395ss, p=0.668), nail guide-wire attempts (two for both groups, p=0.355) and screw guide-wire attempts (one for both groups, p=0.702). The control group versus intervention had higher anxiety levels (50% vs 33%) and had lower confidence (61% vs 84%). Interpretation There was no objective difference in performance on a saw-bone model between groups. However, this VR simulator resulted in more confidence and lower anxiety levels whilst performing a simulated TFNA. Whilst further studies with larger sample sizes and exploration of transfer validity to the operating theatre are required, this study does indicate potential benefits of VR within surgical training.

Lung Cancer Classification in Histopathology Images Using Multiresolution Efficient Nets.

Histopathological images are very effective for investigating the status of various biological structures and diagnosing diseases like cancer. In addition, digital histopathology increases diagnosis precision and provides better image quality and more detail for the pathologist with multiple viewing options and team annotations. As a result of the benefits above, faster treatment is available, increasing therapy success rates and patient recovery and survival chances. However, the present manual examination of these images is tedious and time-consuming for pathologists. Therefore, reliable automated techniques are needed to effectively classify normal and malignant cancer images. This paper applied a deep learning approach, namely, EfficientNet and its variants from B0 to B7. We used different image resolutions for each model, from 224 × 224 pixels to 600 × 600 pixels. We also applied transfer learning and parameter tuning techniques to improve the results and overcome the overfitting problem. We collected the dataset from the Lung and Colon Cancer Histopathological Image LC25000 image dataset. The dataset acquisition consists of 25,000 histopathology images of five classes (lung adenocarcinoma, lung squamous cell carcinoma, benign lung tissue, colon adenocarcinoma, and colon benign tissue). Then, we performed preprocessing on the dataset to remove the noisy images and bring them into a standard format. The model's performance was evaluated in terms of classification accuracy and loss. We have achieved good accuracy results for all variants; however, the results of EfficientNetB2 stand excellent, with an accuracy of 97% for 260 × 260 pixels resolution images.