How Are We Educating Future Physicians and Pharmacists in Pakistan? A Survey of the Medical and Pharmacy Student's Perception on Learning and Preparedness to Assume Future Roles in Antibiotic Use and Resistance.

BACKGROUND: Medical and pharmacy students are future healthcare professionals who will be on the forefront in dealing with antibiotics in hospitals or community settings. Whether the current medical and pharmacy education in Pakistan prepares students to take future roles in antibiotic use remains an under-researched area. AIM: This study aims to compare medical and pharmacy students' perceived preparedness, learning practices and usefulness of the education and training on antibiotic use and resistance imparted during undergraduate studies in Pakistan. DESIGN AND SETTING: It was amulti-centre cross-sectional survey of medical and pharmacy colleges in Punjab, Pakistan. METHOD: A self-administered questionnaire was used to collect data from final year medical and pharmacy students. Descriptive statistics were used for categorical variables while independent t-test and One-way ANOVA computed group differences. RESULT: Nine hundred forty-eight respondents (526 medical and 422 pharmacy students) completed the survey from 26 medical and 19 pharmacy colleges. Majority (76.1%) of the pharmacy students had not completed a clinical rotation in infectious diseases. The top three most often used sources of learning antibiotic use and resistance were the same among the medical and the pharmacy students; included textbooks, Wikipedia, and smart phone apps. Overall self-perceived preparedness scores showed no significant difference between pharmacy and medical students. The least prepared areas by medical and pharmacy students included transition from intravenous to oral antibiotics and interpretation of antibiograms. Both medical and pharmacy students found problem solving sessions attended by a small group of students to be the most useful (very useful) teaching methodology to learn antibiotic use and resistance. CONCLUSIONS: Differences exist between medical and pharmacy students in educational resources used, topics covered during undergraduate degree. To curb the growing antibiotic misuse and resistance, the concerned authorities should undertake targeted educational reforms to ensure that future physicians and pharmacists can play a pivotal role in rationalizing the use of antibiotics.

Patterns of Antimicrobial Use in Hospitalized Children: A Repeated Point Prevalence Survey From Pakistan.

Three repeated point prevalence surveys (PPSs) were conducted in pediatric wards of 5 hospitals using the methodology developed by Global-PPS to identify key targets for interventions and antibiotic stewardship programs. Out of the 916 hospitalized patients, 865 (94.6%) were treated with at least 1 antibiotic.

Universal health coverage and COVID-19: recent developments and implications.

Universal health coverage (UHC) is meant to access the key health services including disease prevention, treatment, rehabilitation, and health promotion. UHC varies according to demographics, epidemiology, and technology-based trends, as well as according to people's expectations. Globally, the transition towards UHC has been associated with the intent of improving accessibility and affordability of healthcare. The COVID-19 pandemic has disrupted the health systems of even the most developed economies of the world in an unprecedented manner. The situation is also very challenging for the countries with the existing health inequities as well as the countries with the developing healthcare systems. This has amplified the need to accelerate efforts to build strong and resilient health systems to achieve progress towards UHC. This commentary discusses a global overview of UHC in the wake of COVID19. It also highlights the initiatives taken by Pakistan to promote the goals of UHC.

The burden of healthcare-associated infections among pediatrics: a repeated point prevalence survey from Pakistan.

BACKGROUND: Healthcare-associated infections (HAIs) are considered a major threat to public health resulting in significant morbidity, mortality, and additional costs. The present study aimed to assess the current patterns and risk factors of HAIs among hospitalized children. MATERIALS AND METHODS: Three repeated point prevalence surveys were conducted in the pediatric inpatients of four hospitals by using the methodology developed by the European Center for Disease Prevention and Control. All patients present in the ward at 8:00 AM on the survey day and not discharged from the hospital on the same day were included. A standardized data collection form containing information on the presence of HAIs and the associated risk factors was completed for the patients. FINDINGS: Out of 888 hospitalized patients, 116 (13.1%) had the symptoms of HAIs. Most common infections were bloodstream infections (BSIs) (32.8%), pneumonia (21.0%), ear, eyes, nose and throat infections (11.8%), and skin and soft tissue infections (SSTs) (19.0%). Factors significantly associated with infections were the length of hospital stay (p = 0.000), admission to the medicine ward (p = 0.034), and male gender (p = 0.010). BSIs were most common in children belonging to the age group of less than one month (78.9%), who were admitted to intensive care units (73.7%). SSTs including surgical site infections were more prevalent in surgery wards (78.3%). CONCLUSIONS: A high rate of HAIs among pediatrics was found in Pakistan. Infection control and prevention strategies are needed with a major focus on interventions to prevent the spread of most prevalent HAIs.

Multistimuli-Responsive Optical Hydrogel Nanomembranes to Construct Planar Color Display Boards for Detecting Local Environmental Changes.

Planar metal-insulator-metal (MIM) optical cavities are attractive for biochemical and environmental sensing applications, as they offer a cost-effective cavity platform with acceptable performances. However, localized detection and scope of expansion of applicable analytes are still challenging. Here, we report a stimuli-responsive color display board that can exhibit local spectral footprints, for locally applied heat and alcohol presence. A thermoresponsive, optically applicable, and patternable copolymer, poly(N-isopropylacrylamide-r-glycidyl methacrylate), is synthesized and used with a photosensitive cross-linker to produce a responsive insulating layer. This layer is then sandwiched between two nanoporous silver membranes to yield a thermoresponsive MIM cavity. The resonant spectral peak is blue-shifted as the environmental temperature increases, and the dynamic range of the resonant peak is largely affected by the composition and structure of the cross-linker and the copolymer. The localized temperature increase of silk particles with gold nanoparticles by laser heating can be measured by reading the spectral shift. In addition, a free-standing color board can be transferred onto a curved biological tissue sample, allowing us to simultaneously read the temperature of the tissue sample and the concentration of ethanol. The stimuli-responsive MIM provides a new way to optically sense localized environmental temperature and ethanol concentration fluctuations.

Interacting Metal-Insulator-Metal Resonator by Nanoporous Silver and Silk Protein Nanomembranes and Its Water-Sensing Application.

Planar and lithography-free metal-insulator-metal (MIM) resonators based on the Fabry-Pérot etalon are attractive for biochemical sensing applications because of their acceptable optical performance and cost-effectiveness. However, injecting analytes into the insulating layer where the optical field is localized (high light-matter interaction) is difficult. Here, planar and lithography-free MIM resonators interacting with their environment are reported. In the MIM, molecules of a liquid can infiltrate the inherent nanopores in the deposited silver nanomembrane and be absorbed into the silk protein hydrogel membrane. The silk layer is swollen when water molecules are absorbed, inducing a large shift in the resonance wavelength. Thus, in this study, the proposed MIM resonator was applied as a highly sensitive water sensor, and a water content as low as 0.008% in organic solvents could be determined by reading the shift in the transmission peak. This limit can be lowered further by using a high-resolution spectrometer and a thicker silk layer. In addition, the area of interaction can be artificially selected by applying an elastomer stamp and a patterned photoresist window.

Kisspeptin: A Potential Factor for Unexplained Infertility and Impaired Embryo Implantation.

BACKGROUND: Kisspeptin (KP) is a neuropeptide that causes the release of the gonadotropin releasing hormone, which controls hypothalamo pituitary ovarian axis and exerts a number of peripheral effects on reproductive organs. The primary objective of this study was to compare baseline KP levels in females with different types of infertility and identify possible correlations with risk of failure to conceive, preclinical abortion and pregnancy after intracytoplasmic sperm injection (ICSI). MATERIALS AND METHODS: A longitudinal cohort study was carried out from August 2014 until May 2015 by recruiting 124 female patients undergoing ICSI, after obtaining ethical approval from the Australian Concept Infertility Medical Center. Cause of infertility due to male, female and unexplained factors was at a frequency of 32 (24%), 33 (31%) and 59 (45%) among the individuals respectively. KP levels were measured by ELISA assay before the initiation of the ICSI treatment protocol. Outcome of ICSI was categorized into three groups of non-pregnant with beta-human chorionic gonadotropin (ß-hCG)<5-25 mIU/ml, preclinical abortion with ß-hCG>25 mIU/ml and no cardiac activity, and clinical pregnancy declared upon confirmation of cardiac activity. Results based on cause of infertility and outcome groups were analyzed by one-way ANOVA. RESULTS: Females with unexplained infertility had significantly lower levels of KP when compared with those with male factor infertility (176.69 ± 5.03 vs. 397.6 ± 58.2, P=0.001). Clinical pregnancy was observed in 28 (23%) females of which 17 (71%) had a female cause of infertility. In the non-pregnant group of 66 (53%) females, common cause of infertility was unexplained 56(85%). A weak positive correlation of KP levels with fertilized oocytes and endometrial thickness was observed (P=0.04 and 0.01 respectively). CONCLUSION: Deficiency of KP in females with unexplained infertility was associated with reduced chances of implantation after ICSI.

Association of Vitamin D with outcome after intra cytoplasmic sperm injection.

OBJECTIVE: To observe effects of vitamin D levels on pregnancy outcome after intra cytoplasmic sperm injection (ICSI). METHOD: It was a cross-sectional study conducted in Australian Concept Infertility Medical Center from July 2011 to August 2014. Estimation of 25-hydroxy cholecalciferol (25-OHD) of consented females (252) was done before treatment protocol for ICSI. Results of ß hCG performed 14 days after embryo transfer categorized groups; Pregnant with ß hCG more than 25 IU/mL and rest included in non-pregnant group. Both groups were compared by independent sample t-test and Pearson's Chi Square test. Binary Logistic Regression Analysis was used to estimate odds ratio of pregnancy outcome with its predictors including Vitamin D. RESULTS: The mean value of 25-OHD, number of oocytes, fertilized oocytes and endometrial thickness was significantly higher in pregnant women. A significant positive association of 25-OHD with clinical pregnancy and thickness of endometrium was observed. After adjustment with female age and BMI, positive association of vitamin D with endometrial thickness was observed. CONCLUSION: Deficiency of 25-OHD in females hinders the accomplishment of optimal endometrial thickness required for implantation of embryo after ICSI. The improvement in vitamin D status can thus improve success results in assisted reproductive clinics.

Kisspeptin and embryo implantation after ICSI.

A cross-sectional study was carried out at the Australian Concept Infertility Medical Centre from June 2014 to June 2015 to relate serum kisspeptin levels on human chorionic gonadotrophin (HCG) day with pregnancy outcome after intracytoplasmic sperm injection (ICSI). A total of 176 women aged 20 to 42 years, with regular menstrual cycles, normal thyroid function and prolactin levels selected for ICSI were included in the study. Patients with uterine fibroids, metabolic disorders, short agonist and antagonist protocol were excluded. Long protocol for down-regulation of ovaries was observed and kisspeptin levels were estimated on HCG day. Results were categorized into groups: Group A, non-pregnant with ß-HCG <25 mIU/ml; and Group B, clinical pregnancy with ß-HCG >25 mIU/ml and cardiac activity on transvaginal scan. Kisspeptin levels were significantly higher in Group B versus Group A (P < 0.001), independently associated with positive pregnancy (r = 0.388; P < 0.001), but just borderline with endometrial thickness (r = 0.294; P = 0.05). The area under the curve was highest for kisspeptin, 0.784 (95% CI, 0.681 to 0.886) for positive pregnancy, which indicated that kisspeptin measured on HCG day can be used as a marker for success of treatment in women after ICSI.

Anti Mullerian Hormone: Ovarian response indicator in young patients receiving Long GnRH Agonist Protocol for Ovarian Stimulation.

OBJECTIVE: Anti Mullerian hormone (AMH) is gaining place as ovarian marker, chiefly in infertility assistance. We explored its correlation with oocytes retrieval after long GnRH agonist protocol for stimulation, in younger and older infertile population. METHODS: This retrospective analysis compiled data of 166 females, receiving ICSI treatment from June 2014 to March 2015. Serum FSH, LH, Estadiol, AMH and antral follicle count were assessed. Outcomes were measured as good (5 to 19 oocytes) and bad responders. RESULTS: Higher discriminatory power of AMH (AUROC; 0.771; p < 0.05) was seen in comparison to FSH (0.692; p < 0.05) and AFC (0.690; p < 0.01). AMH reported strongest association with oocyte retrieved (odds ratio of 15.06). Subgroup analysis reported 68.6 % risk of bad response with AMH levels of less than 1.37ng/ml. This association was observed more significant in young infertile patients <35 year of age (r=0.245; p=0.012) versus older population >35 year (r=0.169; p>0.05). CONCLUSION: Our study reaffirms that serum AMH correlates well with oocytes retrieved, particularly in females younger than 35 years. We suggest incorporation of AMH in baseline assessment of infertile females, who are falsely advised to postpone interventions based on their age and normal FSH levels.

Use of Follicular Output Rate to Predict Intracytoplasmic Sperm Injection Outcome.

BACKGROUND: The measurement of follicular output rate (FORT) has been proposed as a good indicator for evaluating follicular response to the exogenous recombinant folliclestimulating hormone (rFSH). This places FORT as a promising qualitative marker for ovarian function. The objective of the study was to determine FORT as a predictor of oocyte competence, embryo quality and clinical pregnancy after intracytoplasmic sperm injection (ICSI). MATERIALS AND METHODS: This prospective study was carried out on a group of infer- tile females (n=282) at Islamabad Clinic Serving Infertile Couples, Islamabad, Pakistan, from June 2010 till August 2013. Downregulated females were stimulated in injection gonadotropins and on ovulation induction day, pre-ovulatory follicle count (PFC) was determined using transvaginal ultrasound scan (TVUS), and FORT was determined as a ratio of PFC to antral follicle count (AFC)×100. Group I consisted of females with a negative pregnancy test, while group II had a positive pregnancy test that was confirmed with the appearance of fetal cardiac activity. Linear regression analyses of categorical variables of clinical pregnancy along with other independent variables, including FORT, were performed using SPSS version 15.0. RESULTS: Pregnancy occurred in 101/282 women who were tested, recording a clinical pregnancy rate of about 35.8%. FORT values were higher in group II as compared to group I females (P=0.0001). In multiple regression analysis, 97.7, 87.1, 78.2, and 83.4% variations were explained based on the number of retrieved oocytes per patients, number of metaphase II oocytes retrieved, number of fertilized oocytes, and number of cleaved embryos, respectively, indicating FORT as an independent predictor. CONCLUSION: FORT is a predictor of oocyte competence in terms of a number of retrieved, mature and fertilized oocytes. It also gives information about the number of cleaved embryos and clinical pregnancy rate.

FSH/LH ratio in females and intracytoplasmic sperm injection.

OBJECTIVE: To observe the effect of follicle stimulating hormone-luteinizing hormone ratio on oocyte parameters, quality of embryo, implantation and clinical pregnancy rate after intracytoplasmic sperm injection. METHODS: The retrospective study was conducted at a fertility clinic in Islamabad, Pakistan, and comprised data of primary infertile females who underwent intracytoplasmic sperm injection from June 2011 to March 2013. All subjects had duration of infertility more than two years, and age range was 20-40 years. Follicle stimulating hormone and luteinizing hormone were estimated by enzyme-linked immunosorbent assay on day 3 of the cycle and the ratio was calculated. Groups were stratified on the basis of median ratio into groups I <1.26 and group II >1.26. SPSS 20 was used for data analysis. RESULTS: Of the 282 females, 143(51%) were in group I and 139(49%) in group II. Pregnancy was acquired by 79(55%) and 22(16%) females in group I and II respectively. The number of retrieved, metaphase, fertilised oocytes, cleaved embryos and endometrial thickness was significantly larger in group I (p< 0.0001). CONCLUSIONS: Follicle stimulating hormone-luteinizing hormone ratio less than 1.26 was associated with good oocyte parameters, top quality embryo and implantation after intracytoplasmic sperm injection.

Effect of flour processing on the quality characteristics of a soy-based beverage.

Four treatments (roasting, germination, autoclaving and an application of 0.5% EDTA+0.5% sodium hydroxide) were used to reduce the beany flavour of soya beans to produce a soy-based beverage. While germination significantly increased the protein level as compared to the other treatments, the maximum reduction of the beany flavour was achieved by the 0.5% EDTA+0.5% sodium hydroxide application. The soya beans that underwent this treatment were used during the second phase for optimized beverage formulation. During the second phase, a beverage was prepared according to different formulations and analysed for chemical composition and total viable count during a two-month storage period. During storage, the beverage samples exhibited variations in several parameters. The acidity, reducing sugars and total sugars increased, while the ascorbic acid, total soluble solids and pH decreased. Overall, chemical and microbial analyses showed the stability of the product during the storage period.