An Update Summary on the Learning Sciences Within an Ophthalmic Context.

Clinical reasoning, specifically diagnostic decision-making, has been a subject of fragmented literature since the 1970s, marked by diverse theories and conflicting perspectives. This article reviews the latest evidence in medical education, drawing from scientific literature, to offer ophthalmologists insights into optimal strategies for personal learning and the education of others. It explores the historical development of clinical reasoning theories, emphasising the challenges in understanding how doctors formulate diagnoses. The importance of clinical reasoning is underscored by its role in making accurate diagnoses and preventing diagnostic errors. The article delves into the dual process theory, distinguishing between type 1 and type 2 thinking and their implications for clinical decision-making. Cognitive load theory is introduced as a crucial aspect, highlighting the limited capacity of working memory and its impact on the diagnostic process. The zone of proximal development (ZPD) is explored as a framework for optimal learning environments, emphasising the importance of scaffolding and deliberate practice in skill development. The article discusses semantic competence, mental representation, and the interplay of different memory stores-semantic, episodic, and procedural-in enhancing diagnostic proficiency. Self-regulated learning (SRL) is introduced as a student-centric approach, emphasising goal setting, metacognition, and continuous improvement. Practical advice is provided for minimising cognitive errors in clinical reasoning, applying dual process theory, and considering cognitive load theory in teaching. The relevance of deliberate practice in ophthalmology, especially in a rapidly evolving field, is emphasised for continuous learning and staying updated with advancements. The article concludes by highlighting the importance of clinical supervisors in recognising and supporting trainees' self-regulated learning and understanding the principles of various teaching and learning theories. Ultimately, a profound comprehension of the science behind clinical reasoning is deemed fundamental for ophthalmologists to deliver high-quality, evidence-based care and foster critical thinking skills in the dynamic landscape of ophthalmology.

Risk Factors and Outcome of Gram-Negative Bloodstream Infection in Living-Donor Renal Transplant Recipients: A Case-Control Study From Pakistan.

OBJECTIVES: Gram-negative rods are the most common cause of bloodstream infection in renal transplant recipients. Acute rejection, urologic abnormalities, and ureteral stents are risk factors. Graft dysfunction is independently associated with gram-negative rod bloodstream infection. Our aim is to investigate the incidence, risk factors, and outcome among living donor renal transplant recipients from Pakistan. MATERIALS AND METHODS: In this case-control study, we reviewed the medical records until June 2021 of renal transplant recipients seen from 2015 to 2019 for gram negative bacteremia. For every case, controls were matched by age, date of transplant, and sex. Demographics, risk factors, graft function, and mortality were compared. Clinical features, immunosuppression, source of blood stream infection, and microbiology were noted in cases. RESULTS: Of 1677 renal transplant recipients, 44 developed gram negative bacteremia. The incidence was 5.9 per 1000 person-years. Median time since transplant was 5 months. The most common source was urinary tract infection. On univariate analysis, antithymocyte globulin, urinary tract infection, and recurrent urinary tract infections were associated with gram negative bacteremia. On multivariate analysis, urinary tract infection (adjusted odds ratio = 3.46; 95% CI, 1.27-9.37) and recurrent urinary tract infections (adjusted odds ratio = 4.03; 95% CI, 1.15-14.15) were significant risk factors. We found no difference in 30-day mortality and estimated glomerular filtration rate on last follow-up between cases and controls. Kaplan-Meier survival curves showed significant differences in graft survival in patients with gram negative bacteremia. Escherichia coli was the most common organism, with 75% ceftriaxone and 13% imipenem resistance. CONCLUSIONS: The most significant risk factor for gram negative rod bloodstream infection was recurrent urinary tract infections. Timely treatment and prevention of recurrent urinary tract infections areimperative for prevention of gram negative bacteremia.

Investigations of Electronic, Structural, and In Silico Anticancer Potential of Persuasive Phytoestrogenic Isoflavene-Based Mannich Bases.

Isoflavenes have received the greatest research attention among the many groups of phytoestrogens. In this study, various isoflavene-based Mannich bases were selected for their theoretical studies. The purpose of this research was to discover the binding potential of all the designated Mannich bases acting as inhibitors against cancerous proteins EGFR, cMet, hTrkA, and HER2 (PDB codes: 5GTY, 3RHK, 6PL2, and 7JXH, respectively). For their virtual screening, DFT calculations and molecular docking studies were undertaken using in silico software. Docking studies predicted that ligands 5 and 15 exhibited the highest docking score by forming hydrogen bonds within the active pocket of protein 6PL2, ligands 1 and 15 both with protein 3RHK, and 7JXH, 12, and 17 with protein 5GTY. Rendering to the trends in polarizability and dipole moment, the energy gap values (0.2175 eV, 0.2106 eV) for the firm conformers of Mannich bases (1 and 4) replicate the increase in bioactivity and chemical reactivity. The energy gap values (0.2214 eV and 0.2172 eV) of benzoxazine-substituted isoflavene-based Mannich bases (9 and 10) reflect the increase in chemical potential due to the most stable conformational arrangements. The energy gap values (0.2188 eV and 0.2181 eV) of isoflavenes with tertiary amine-based Mannich bases (14 and 17) reflect the increase in chemical reactivity and bioactivity due to the most stable conformational arrangements. ADME was also employed to explore the pharmacokinetic properties of targeted moieties. This study revealed that these ligands have a strong potential to be used as drugs for cancer treatment.

Outcome, risk factors and therapeutic strategies in carbapenem-resistant Gram-negative bacteraemia from Pakistan.

Background: Carbapenem-resistant Gram-negative (CRGN) bacteraemia has high mortality and limited therapeutic options. We assessed the risk factors and outcome of CRGN bacteraemia treated with limited options. Methods: A prospective cohort study done at a tertiary care hospital in Pakistan, from October 2021 to August 2022. All patients >18 years with CRGN bacteraemia were assessed for demographics, source, risk factors and treatment received. Outcome was assessed as bacterial clearance and all-cause mortality at Day 14 of bacteraemia. Results: We included 175 patients. Median age was 45 years (IQR 30-58) and the majority of our patients were on haemodialysis (75%). We found 14 day mortality in 26.8% of our patients; in addition, microbiological clearance was achieved in 95%. The central line (49.7%) was the most common source and Klebsiella spp. (47%) the most common organism. On multivariate analysis, risk factors for mortality were Foley's catheter [aOR 2.7 (95% CI 1.1-6.5)], mechanical ventilation [aOR 5.1 (95% CI 1.6-15.8)] and Pitt bacteraemia score >4 [aOR 3.48 (95% CI 1.1-10.5)]. Source control was a significant protective factor [aOR 0.251 (95% CI 0.09-0.6)]. The majority received a colistin-based regimen with no difference in mortality between monotherapy and combination therapy. Conclusions: Our cohort of CRGN bacteraemia is unique, comprising younger patients mostly on haemodialysis with a central line as the source of bacteraemia and we have found 14 day mortality of 27%. Colistin with various combinations can be an effective option in patients with renal failure having prompt source control.

Intravitreal Fluocinolone Acetonide Implant (ILUVIEN®) for the Treatment of Retinal Conditions. A Review of Clinical Studies.

Fluocinolone acetonide (FAc) intravitreal implant (Iluvien®) is a corticosteroid implant indicated for the treatment of diabetic macular oedema (DMO) in patients who have previously received conventional treatment without good response, non-infectious posterior uveitis, and as an off-label treatment of the macular oedema secondary to retinal vein occlusion. FAc is a non-biodegradable 0.19 mg intravitreal implant which is designed to release FAc over 3 years at a rate of approximately 0.2 mcg per day. The aim of this review is to describe the special pharmacological properties of Iluvien and display the outcomes of the most important clinical trials and real-world studies regarding its efficacy and safety for the management of the above retinal disorders.

Evaluating multidisciplinary glaucoma care: visual field progression and loss of sight year analysis in the community vs hospital setting.

BACKGROUND: A variety of shared care models have been developed, which aim to stratify glaucoma patients according to risk of disease progression. However, there is limited published data on the rate of glaucoma progression in the hospital vs community setting. Here we aimed to compare rates of glaucomatous visual field progression in the Cambridge Community Optometrist Glaucoma Scheme (COGS) and Addenbrooke's Hospital Glaucoma Clinic (AGC). METHODS: A retrospective comparative cohort review was performed. Patients with five or more visual field tests were included. Zeiss Forum software was used to calculate the MD progression rate (dB/year). Loss of sight years (LSY) were also calculated for both COGS and AGC. RESULTS: Overall, 8465 visual field tests from 854 patients were reviewed. In all, 362 eyes from the AGC group and 210 eyes from COGS were included. The MD deterioration rate was significantly lower in the COGS patients compared with the AGC group (-0.1 vs -0.3 dB/year; p < 0.0001). No patients in the COGS group were predicted to become blind within their lifetime by LSY analysis. Fifteen patients were at risk in the AGC group. CONCLUSION: This service evaluation shows that COGS is an effective scheme to stratify lower risk glaucoma patients, increasing the capacity within hospital eye services. COGS patients have a lower rate of visual field deterioration compared to AGC patients. Effective communication between community and tertiary schemes is essential to facilitate transfer of patients requiring further hospital management reliably and efficiently, with the potential for low-risk patients to be followed safely in the community.

Evaluation and modelling of methane production from corn stover pretreated with various physicochemical techniques.

Lignocellulosic by-products from agricultural crops represent an important raw material for anaerobic digestion and clean renewable, which is a key component of the circular economy. Lignocellulose is recalcitrant to biodegradation and pretreatments are required to increase methane yield during anaerobic digestion. In this work, the efficacy of different physicochemical pretreatments was compared using corn stover biomass as substrate. Anaerobic digestion of untreated and pretreated corn stover was performed in batch mode at mesophilic temperature (38°C) and organic matter solubilization of pretreated substrates was also investigated. The highest organic matter solubilization occurred in autoclave pretreatment (soluble chemical oxygen demand = 5630 ± 42 mg O2 L-1). However, the highest methane yield was obtained using alkaline pretreatment (367 ± 35 mL CH4 g-1 VSadded). Alkaline pretreatment increased methane yield by 43.3% compared to untreated control (256 ± 15 mL CH4 g-1 VSadded). Two mathematical models (i.e. first-order kinetics and transfer function) were utilized to fit the experimental data with the aim of assessing anaerobic biodegradation and to obtain the kinetic constants in all cases studied. Both models adequately fit the experimental results. The kinetic constant, k, of the first-order model increased by 92.8% when stover was pretreated with sulphuric acid compared with control. The transfer function model revealed that the maximum methane production rate, Rm, was obtained for the sulphuric acid treatment, which was 63.5% higher compared to control.

SARS-CoV-2 RNA Dependent RNA polymerase (RdRp) - A drug repurposing study.

The outbreak of SARS-CoV-2 in December 2019 in China subsequently lead to a pandemic. Lack of vaccine and specific anti-viral drugs started a global health disaster. For a sustained control and protection, development of potential anti-viral drugs is one of the targeted approach. Although, designing and developing a panel of new drugs molecules are always encouraged. However, in the current emergency, drug repurposing study is one of the most effective and fast track option. The crystal structure of a SARS-CoV-2 (Severe acute respiratory syndrome coronavirus 2) RNA Dependent RNA Polymerase (RdRp) has recently been deciphered through X-ray crystallography. The single-chain of core RNA Dependent RNA Polymerase relies on virus-encoded cofactors nsp7 and two units of nsp8 for its optimum function. This study explored the FDA approved database of 7922 molecules and screened against the core polymerase along with cofactors. Here we report a panel of FDA approved drugs that show substantial interactions with key amino acid residues of the active site. Interestingly, some of the identified drugs (Ornipressin, Lypressin, Examorelin, Polymyxin B1) bind strongly within the binding pockets of both forms of RdRp. Besides, we found strong candidates for the complex form as well which include Nacortocin, Cistinexine, Cisatracurium (among others). These drugs have the potential to be considered while contriving therapeutic options.

Evaluation of pressurised carbon dioxide pre-treatment aimed at improving the sanitisation and anaerobic digestibility of co-settled sewage sludge.

This work reports on the use of pressurized CO2 pretreatment to improve methane yield and pathogen indicator organism die-off in co-settled sewage sludge (SS). Four semi-continuous mesophilic anaerobic digesters were fed on co-settled SS to establish a baseline for performance and stability. One pair of digesters was then fed with co-settled SS pretreated by P CO2 at 2800 kPa for 23 h. The trial continued for 70 days during which specific biogas and methane production, volatile solids destruction and loss of viability of Escherichia coli was monitored in test and control digesters. The pretreatment had no positive influence on any of these parameters, which was further confirmed using batch biochemical methane potential tests and direct measurement of die-off of E. coli and Salmonella enterica in samples of different sizes treated in pressure vessels of different sizes and in matrices of nutrient medium and co-settled SS. Pressurised CO2 pretreatment was effective at killing fecal indicator bacteria in nutrient medium but ineffectual in SS, strongly suggesting that the nature of suspending matrix was a principle determining factor. Paper concludes that pressurized CO2 pretreatment is not a satisfactory approach to improve either biogas production or pathogen destruction in anaerobic digestion.

Depression In Myocardial Infarction Patients At Ayub Teaching Hospital Abbottabad.

BACKGROUND: There is a considerably high prevalence of depression in post myocardial infarction (MI) patients. This study was designed with an aim to detect depression in patients with acute MI admitted to the CCU at Ayub Teaching Hospital Abbottabad.. METHODS: This descriptive crosssectional study enrolled 246 male and female patients with acute MI. The patients were interviewed on the 3rd day of admission and their answers were marked according to the HADS-D scale. RESULTS: With a cut-off score of 11, the frequency of depression in study participants was 27.24% (n=67). No statistically significant association was found between the age and sex of patients and depression. CONCLUSIONS: Depression is fairly common following acute MI and the management plans should include a consultation with psychiatric for individualized management of depression in post myocardial infarction patients..

Effectiveness of pressurised carbon dioxide for inactivation of Escherichia coli isolated from sewage sludge.

This research explored the possible application of pressurised carbon dioxide (P CO(2)), a promising non-thermal sterilisation technique, for the treatment of sewage sludge (SS) before anaerobic digestion to inactivate pathogenic microorganisms. Escherichia coli was selected as the test organism and was isolated from SS and maintained in pure culture. The growth curve of the isolated strain was determined by measuring the optical density (OD) in liquid culture medium and relating this information to the spread plate count so that a culture of known cell density could be grown for optimisation experiments. Inactivation of E. coli was enhanced by increase in pressure (1,500, 2,000 and 2,800 kPa) and treatment time (from 0.75 to 24 h). A short exposure time at high pressure was sufficient to provide a degree of inactivation which could also be achieved by longer exposure at lower pressure. Complete inactivation (8 log(10) reduction) was possible at all three pressures. scanning (SEM) and transmission (TEM) electron microscopy studies of E. coli treated with P CO(2) revealed that the cell walls were ruptured, and the cytoplasm was unevenly distributed and had lost its density, indicating the possible leakage of intracellular substances.