Hybrid whale algorithm with evolutionary strategies and filtering for high-dimensional optimization: Application to microarray cancer data.

The standard whale algorithm is prone to suboptimal results and inefficiencies in high-dimensional search spaces. Therefore, examining the whale optimization algorithm components is critical. The computer-generated initial populations often exhibit an uneven distribution in the solution space, leading to low diversity. We propose a fusion of this algorithm with a discrete recombinant evolutionary strategy to enhance initialization diversity. We conduct simulation experiments and compare the proposed algorithm with the original WOA on thirteen benchmark test functions. Simulation experiments on unimodal or multimodal benchmarks verified the better performance of the proposed RESHWOA, such as accuracy, minimum mean, and low standard deviation rate. Furthermore, we performed two data reduction techniques, Bhattacharya distance and signal-to-noise ratio. Support Vector Machine (SVM) excels in dealing with high-dimensional datasets and numerical features. When users optimize the parameters, they can significantly improve the SVM's performance, even though it already works well with its default settings. We applied RESHWOA and WOA methods on six microarray cancer datasets to optimize the SVM parameters. The exhaustive examination and detailed results demonstrate that the new structure has addressed WOA's main shortcomings. We conclude that the proposed RESHWOA performed significantly better than the WOA.

Factors associated with medical students' career choices at a private university: a cross-sectional study.

This study aimed to identify the factors associated with students' career choices and the decision whether they wanted to be trained abroad or in Pakistan. The study utilised a cross-sectional design and was conducted between July 2021 and February 2022. An anonymous survey was distributed among the medical students at Aga Khan University, Karachi, Pakistan. All analysis was carried out using Stata 17. A total of 269 students participated in the study. The most sought-after specialties were surgery 68 (25.3%), medicine 25(9.3%), and paediatrics 14(5.2%), and the decision was highly influenced by positive mentors and lifestyle. In addition, 259 (96%) of the students expressed a desire to practice abroad for training due to higher financial prospects and quality of training. This study revealed that providing enthusiastic mentors may encourage medical students to pursue a broader range of specialties. Furthermore, there is a need for advances in postgraduate training and increase in salaries to restore trust in Pakistan's healthcare system.

Hybridizing video-based learning with simulation for flipping the clinical skills learning at a university hospital in Pakistan.

BACKGROUND: While learning and practicing on actual patients is a major mode of teaching clinical skills, concerns about patient safety, unavailability, and lack of standardization have led to the development of simulation for medical education. Simulation-based teaching is affected by challenges such as lack of protected time for faculty, inexperienced learners, and the number of students per group. These have led to the integration of various eLearning formats in the curriculum. The hybridized format changes the traditional clinical skills teaching into the flipped classroom. This study aims to measure the effectiveness of hybridizing video-based learning with simulation for flipping the clinical skills teaching of fourth-year medical students at the Department of Paediatrics and Child Health at Aga Khan University, Pakistan. METHODS: The study employed a mixed-methods design. Fourth-year medical students of the batch 2020-21 (n = 100) consented to participate in the study. The quantitative component focuses on identifying the effect of the intervention on the perceived self-efficacy of medical students (batch 2020-21) relevant to the clinical skill. Along with this, the performance of the intervention batch of 2020-21 on the end of clerkship objective structured clinical exam (OSCE) was compared with the previous batch of 2019-20, taught using simulation alone. Focused group discussions (FGDs) were used to explore the experiences of medical students (batch 2020-21) about the intervention. Quantitative data underwent descriptive and inferential analysis using Stata v16 while qualitative data underwent content analysis using NVivo software. RESULTS: Hybridization of video-based learning with simulation significantly improved self-efficacy scores for all examinations (cardiovascular, respiratory, neurological, and abdomen) with p-value < 0.05. OSCE scores of the intervention group were significantly higher on the neurological and abdominal stations as compared to the previous batch (p-value < 0.05). In addition, the overall structure of the intervention was appreciated by all the students, who stated it allowed reinforcement of basic concepts, retention, and further insight into clinical applications. CONCLUSION: The hybridization of video-based learning with simulation facilitated in creation of better opportunities for medical students to revive their prior knowledge, apply core concepts for the problem and engage in clinical reasoning.

Process evaluation of paediatric fellowship training programs at a University Hospital in Pakistan.

BACKGROUND: Fellowship programs offer training in a subspecialty focusing on distinct and advanced clinical/academic skills. This advanced postgraduate training allows physicians, who desire a more specialized practice, to further develop clinical, academic, research, and leadership/administrative skills. The Aga Khan University (AKU) is one of the few institutes offering paediatric sub-specialty training in Pakistan. We aimed to evaluate the current Paediatric fellowship programs at AKU. METHODS: Process evaluation of six paediatric fellowship programs (cardiology, neurology, endocrinology, critical care medicine, neonatology, and infectious disease) was conducted from September 2020 to April 2021 by senior clinicians and medical educationists. Evidence was collected through document review (using existing postgraduate medical education program information form), observation of teaching and learning support, and focused group discussions/interviews with program faculty and fellows were conducted. A review of the evaluation report was done as part of this study. This study received an exemption from the ethical review committee. The quantitative data were analyzed using SPSS (22.0) while the reports of discussion with fellows and friends underwent content analysis. RESULTS: All fellowship programs met the criteria for having a robust competency-based fellowship curriculum as per the institutional and national guidelines. Formative assessment in the form of continuous evaluation was found to be integrated into all the fellowship programs, however, most of the programs were found to lack a summative assessment plan. Fellows in training and program faculty were satisfied with the opportunities for mentorship, teaching, and learning. Thematic analysis of the discussion reports with faculty and fellows revealed three key themes including, program aspects translating into strengthening the training, gaps in the training program in delivering the expectations, and making ways to reach par excellence. CONCLUSIONS: The process evaluation of paediatric fellowship programs provided an opportunity to holistically review the current strengths and quality of the training in individual programs along with the unmet needs of the trainees. This will help the program stakeholders to prioritize, align and allocate the resources to further enhance the quality of training and outcome of individual fellowship programs to ensure wider impacts at a regional, national, and international health system level.

Flexible Topical Hydrogel Patch Loaded with Antimicrobial Drug for Accelerated Wound Healing.

A hydrogel topical patch of neomycin was developed by using sodium alginate (SA) and hydroxyethylcellulose (HEC) as polymers. Free radical polymerization in an aqueous medium was initiated by using acrylic acid (AA) and N,N'-methylenebisacrylamide (MBA). Prepared hydrogels were characterized for pH sensitivity and sol-gel analysis. In addition, the effect of reactant contents on the developed formulation was evaluated by swelling behavior. SEM assay showed the rough structure of the hydrogel-based polymeric matrix, which directly enhances the ability to uptake fluid. FTIR spectra revealed the formation of a new polymeric network between reactant contents. TGA and DSC verified that fabricated polymeric patches were more thermodynamically stable than pure components. Gel fractions increased with increases in polymer, monomer, and cross-linker contents. The swelling study showed the pH-dependent swelling behavior of patches at pH 5.5, 6.5, and 7.4. The release pattern of the drug followed zero-order kinetics, with diffusion-controlled drug release patterns according to the Korsmeyer-Peppas (KP) model. Ex vivo studies across excised rabbit skin verified the drug retention in the skin layers. The hydrogel patch effectively healed the wounds produced on the rabbit skin, whereas the formulation showed no sign of irritation on intact skin. Therefore, neomycin hydrogel patches can be a potential candidate for controlled delivery for efficient wound healing.

Student experiences of simulation-based learning and its impact on their performance in Objective Structured Clinical Examination in Pediatrics - A mixed method study.

Objective: This study aims to assess the effectiveness of integrating simulation for teaching pediatric clinical examination skills to undergraduate, MBBS Year-IV medical students at The Aga Khan University, Karachi, Pakistan. Methods: In this mixed method study, the Objective Structured Clinical Examination (OSCE) scores of the students who were taught using simulation (batch 2017-2018) were compared with the batch of the academic year 2016 -2017 (taught via traditional methods). In order to explore the experiences of the intervention group, a questionnaire with four open-ended questions was administered at the end of the clerkship. Results: Students who were taught by simulation, scored significantly higher on the clinical skills stations in Objective Structured Clinical Examination, than in the pre-intervention group (p-value <0.01). The students quoted safety of the learning environment, opportunities for deliberate practice, debriefing and facilitation skills maximized quoted that their experience of learning through simulation, however, some challenges were identified for future improvement. Conclusion: The result of the study suggested simulation as a useful instructional strategy for teaching examination skills to students in their early years. The student gained confidence through deliberate practice and feedback without compromising patient safety, which translated into improved performance in the high-stakes OSCE examination at the end of the clerkship.

Identification and characterization of a novel begomovirus, Withania leaf curl virus associated with leaf curl disease of Withania somnifera.

Begomovirus is the largest genus of the family Geminiviridae with wide host range and responsible for a considerable amount of economic damage to many important crops globally. Withania somnifera (Indian ginseng) is an important medicinal plant with high demand in pharmaceutical industries worldwide. During the routine survey in 2019, typical characteristic viral symptoms such as severe leaf curling, downward rolling of the leaves, vein clearing, and poor growth of Withania plants with 17-20% disease incidence were observed in Lucknow, India. Typical symptoms, abundant presence of whiteflies, PCR and RCA based detection indicated the amplification of ~ 2.7 kb and suspected the causal pathogen to be a begomovirus, associated with a betasatellite (~ 1.3 kb). Transmission electron microscopy revealed the presence of twinned particles of ~ 18-20 nm in diameter. Full genome sequencing (2758 bp) of the virus and its analysis showed only 88% sequence identity with the begomovirus sequences present in the database. Hence, based on the nomenclature guidelines we concluded that the virus associated with the present disease of W. somnifera is a novel begomovirus and its name is proposed as Withania leaf curl virus.

Needs assessment for faculty development in health professions education at a medical university in Karachi, Pakistan.

Faculty Development (FD) embraces all educational activities used by teachers to improve their knowledge and skills for enhancing their academic competencies. This study aimed to identify the areas in Health Professions Education (HPE) in which formal faculty development is required. A needs assessment survey was conducted from among the faculty members at the Aga Khan University (AKU), Karachi, Pakistan, and the French Medical Institute for Mother and Children, Afghanistan. Data was analysed using SPSS 20.0 and reported frequencies and percentages according to various academic tracks. Competency-based curricula (51%), providing effective feedback (51%), developing Objective Structured Clinical Exam (51%), and clinical supervision (48%) were identified as significant areas for faculty development. Faculty in clinician teacher and clinician educator track require advanced training, i.e., Masters and PhD in HPE. The needs assessment facilitated prioritising the areas for FD. This will contribute to enhancing academic practices and inculcating the culture of lifelong learning.

Teaching Clinical Skills Using Online Modality through Modified Peyton's Framework: An Experience from a Medical University in Pakistan.

Introduction: Medical institutions worldwide faced an unprecedented situation during COVID-19 of identifying alternative strategies to sustain the continuum of learning process. This led to several innovations in the traditional medical curriculum. This study explored the effectiveness and feasibility of using the Peyton's framework modified for a virtual platform (Microsoft Teams) for teaching clinical skills to first and second-year medical students at The Aga Khan University, Karachi, Pakistan. Methods: In 2020-2021, the modified Peyton's framework was integrated in the clinical skills (CS) curriculum for all first- and second-year students (N=200). For evaluation, a mixed-method design was used, with pre-and post-session questionnaires. Students' satisfaction was obtained through the standard session evaluation tool of the university. For the qualitative arm, to explore the instructors' experiences, purposive sampling was used (n=8) and a focused group discussion (FGD) was conducted. Finally, performance of the students at the end of year summative Objective Structured Clinical Examination (OSCE) was compared with the students of previous year. Quantitative data were analysed using STATA® version 15.1, using paired t-test to compare the differences in OSCE scores in selected CS stations. A p-value of <0.05 was considered significant for all tests. The FGD was transcribed and analysed through manual content analysis. Results: Nine clinical skills (that included history and examination skills) were taught using the virtual platform. There was a significant improvement in post-session questionnaires in seven of these skills (p value <0.01). Session evaluations showed that most students were satisfied with the learning experience. The instructors showed that the online teaching offered a promising platform for teaching history taking skills. The OSCE scores showed mixed results, with significant improvement in two out of four repeated stations by using paired t-test [abdominal exam (87.33 ± 8.99, <0.001); and precordial examination (88.45 ± 8.36, 0.001)]. Conclusions: Modifying Peyton's framework to a virtual platform allowed us to sustain the continuum of clinical education during the COVID-19 pandemic. The results support the use of a blended learning environment for teaching clinical skills.

Perspectives of residents, students and faculty about residents as teachers at a University Hospital in Karachi.

This was a cross sectional study, conducted at the Aga Khan University, Karachi, from December 2018 to December 2019, to determine the residents' performance as teachers and understand the difficulties they faced. Anonymous feedback was obtained from students (n=200) to rate the teaching skills of residents in the paediatric department. The residents (n=60) also filled out an anonymous survey to assess their teaching performance and barriers to teaching. Furthermore, the faculty rated the residents' teaching abilities on a 5-point scale. A total of 145 (98.7%) students considered teaching as an important role of the residents. Ten (40%) residents identified themselves as beginners in teaching. The main barriers were time limitation (n=19, 76%), critical patients (n=3, 12%) and lack of appropriate skills (n=3, 12%).

Enhancing the knowledge of parents on child health using eLearning in a government school in the semi-rural community of Karachi, Pakistan.

Education is one of the vital social determinants of health. Health and education share a symbiotic relationship for all cadre including children and adolescents to ensure that they are well equipped to combat the health risk in the environment. The current literature globally found some initiatives to create health awareness among school children. However, there is a dearth of studies available addressing parental health awareness through school platforms. Therefore, the current study aims to fill this gap, and the Aga Khan University School of Nursing and Midwifery initiated the School Health Program (SHP) in one of the remote communities in Sindh, Pakistan. The overall goal of the study was to improve children's health by enhancing the health awareness of the parents through school platforms utilizing online modalities. Another objective of this study was to identify the effect of using eLearning on parental knowledge and perceptions. The study utilized a sequential explanatory mixed-method design. Twelve health awareness sessions relevant to children's health using eLearning were conducted over one year. Parents' knowledge was assessed through a pre-posttest, which was administered after each teaching session. Subsequently, focused group discussions were carried out with parents, community leaders, and schoolteachers to gain insights regarding the effectiveness of the health education program. The pre-and post-test results showed again in knowledge in nine out of twelve sessions. The findings from qualitative content analysis yielded three key themes: Perceived usefulness of eLearning, Barriers affecting usability, and Way forward for eLearning through school platforms. The study showed parental satisfaction with the online health education awareness program. They exhibited enthusiasm and desire for further similar sessions in the future. The results demonstrated an enhancement in parental awareness about common health conditions among school children. This study may be replicated on a larger scale in the schools of Pakistan.

Masqueraders: how to identify atypical diabetes in primary care.

Diabetes mellitus is a complex set of conditions that impacts 34 million Americans. While type 1 diabetes, type 2 diabetes, and gestational diabetes are most frequently encountered, there are many other types of diabetes with which healthcare providers are less familiar. These atypical forms of diabetes make up nearly 10% of diabetes cases and can masquerade as type 1 or 2 diabetes mellitus (T1DM or T2DM), and the treatment may not be optimized if the diagnosis is not accurate. Atypical forms include monogenic diabetes (formally known as maturity-onset diabetes of the young [MODY]), latent autoimmune diabetes of the adult (LADA), ketosis-prone diabetes, and secondary diabetes. This paper will detail the defining characteristics of each atypical form and demonstrate how they can masquerade as type 1 or 2 diabetes mellitus. Gestational diabetes mellitus will not be discussed in this article.

Flower orientation influences floral temperature, pollinator visits and plant fitness.

Effective insect pollination requires appropriate responses to internal and external environmental cues in both the plant and the pollinator. Helianthus annuus, a highly outcrossing species, is marked for its uniform eastward orientation of mature pseudanthia, or capitula. Here we investigate how this orientation affects floral microclimate and the consequent effects on plant and pollinator interactions and reproductive fitness. We artificially manipulated sunflower capitulum orientation and temperature in both field and controlled conditions and assessed flower physiology, pollinator visits, seed traits and siring success. East-facing capitula were found to have earlier style elongation, pollen presentation and pollinator visits compared with capitula manipulated to face west. East-facing capitula also sired more offspring than west-facing capitula and under some conditions produced heavier and better-filled seeds. Local ambient temperature change on the capitulum was found to be a key factor regulating the timing of style elongation, pollen emergence and pollinator visits. These results indicate that eastward capitulum orientation helps to control daily rhythms in floral temperature, with direct consequences on the timing of style elongation and pollen emergence, pollinator visitation, and plant fitness.

Strengthening the feedback culture in a postgraduate residency program.

Background: Feedback is defined as specific information presented to a learner that facilitates professional development through the process of reflection. Timely provision of constructive feedback to learner is important in optimizing the learning curve. The aim of the current study was to see the effectiveness of various interventions on feedback practices of faculty members. Methods: This is a quasi-experimental study (pre- and postdesign). It was conducted from November 2009 to March 2011 at The Aga Khan University, Pakistan. Faculty development workshops, allotment of specified feedback time, and restructuring of residency feedback forms were done as interventions. Data collection was done pre- and postintervention. Resident's and faculty satisfaction regarding the feedback process were evaluated using a prepiloted questionnaire. Paired t-test was applied to assess the effect of interventions on faculty and resident's satisfaction. Results: The mean satisfaction scores of residents were significantly improved (P < 0.05). Pre- and postintervention faculty satisfaction score also demonstrated significant difference in overall satisfaction level, from 47.88 ± 13.92 to 63.40 ± 8.72 (P < 0.05). Discussion: This study showed improved faculty engagement and satisfaction for the provision of feedback to the trainee resident. Strengthening this, culture requires continuous reinforcement, individualized feedback to the faculty members regarding their feedback practices, and continuing faculty development initiatives.

The Pathological Mechanisms and Treatments of Tinnitus.

Tinnitus is defined as the ringing, hissing, clicking or roaring sounds an individual consciously perceives in the absence of an external auditory stimulus. Currently, the literature on the mechanism of tinnitus pathology is multifaceted, ranging from tinnitus generation at the cellular level to its perception at the system level. Cellular level mechanisms include increased neuronal synchrony, neurotransmission changes and maladaptive plasticity. At the system level, the role of auditory structures, non-auditory structures, changes in the functional connectivities in higher regions and tinnitus networks have been investigated. The exploration of all these mechanisms creates a holistic view on understanding the changes the pathophysiology of tinnitus undertakes. Although tinnitus percept may start at the level of cochlear nerve deafferentation, the neuronal changes in the central auditory system to the neuronal and connectivity changes in non-auditory regions, such as the limbic system, become cardinal in chronic tinnitus generation. At the present moment, some tinnitus generation mechanisms are well established (e.g., increased neuronal synchrony) whereas other mechanisms have gained more traction recently (e.g., tinnitus networks, tinnitus-distress networks) and therefore, require additional investigation to solidify their role in tinnitus pathology. The treatments and therapeutics designed for tinnitus are numerous, with varied levels of success. They are generally two-fold: some treatments focus on tinnitus cessation (including cochlear implants, deep brain stimulation, transcranial direct current stimulation and transcranial magnetic stimulation) whereas the other set focuses on tinnitus reduction or masking (including hearing aids, sound therapy, cognitive behavioral therapy, tinnitus retraining therapy, and tailor made notched musical training).  Tinnitus management has focused on implementing tinnitus masking/reducing therapies more than tinnitus cessation, since cessation treatments are still lacking in streamlined treatment protocols and long-term sustainability and efficacy of the treatment. This review will focus on concisely exploring the current and most relevant tinnitus pathophysiology mechanisms, treatments and therapeutics.

Posteroanterior cervical transcutaneous spinal stimulation targets ventral and dorsal nerve roots.

OBJECTIVE: We aim to non-invasively facilitate activation of spared neural circuits after cervical spinal cord injury (SCI) and amyotrophic lateral sclerosis (ALS). We developed and tested a novel configuration for cervical transcutaneous spinal stimulation (cTSS). METHODS: cTSS was delivered via electrodes placed over the midline at ~T2-T4 levels posteriorly and ~C4-C5 levels anteriorly. Electromyographic responses were measured in arm and hand muscles across a range of stimulus intensities. Double-pulse experiments were performed to assess homosynaptic post-activation depression (PAD). Safety was closely monitored. RESULTS: More than 170 cTSS sessions were conducted without major safety or tolerability issues. A cathode-posterior, 2 ms biphasic waveform provided optimal stimulation characteristics. Bilateral upper extremity muscle responses were easily obtained in subjects with SCI and ALS. Resting motor threshold at the abductor pollicis brevis muscle ranged from 5.5 to 51.0 mA. As stimulus intensity increased, response latencies to all muscles decreased. PAD was incomplete at lower stimulus intensities, and decreased at higher stimulus intensities. CONCLUSIONS: Posteroanterior cTSS has the capability to target motor neurons both trans-synaptically via large-diameter afferents and non-synaptically via efferent motor axons. SIGNIFICANCE: Posteroanterior cTSS is well tolerated and easily activates upper extremity muscles in individuals with SCI and ALS.

Needs assessment for curricular reform of a post graduate paediatric training programme at a private university hospital in Karachi, Pakistan.

In order to make and sustain changes in the curriculum, needs assessment is the key. We conducted a need assessment survey using a questionnaire based on a 7 point Likert Scale by residents and alumni. Over all response rate in the study was 77.5%. Fifty eight percent participants were females. Highest level of agreement (mean score 5.7) was found between the alumni and residents regarding the need to revise the content, teaching and assessment strategies in the programme. Twenty seven alumni (n= 38, 71%) had cleared their FCPS exams. The alumni thought that the existing teaching and assessment strategies do not facilitate in passing professional certificate exams (mean score 3.6). The mean attempts required by the alumni for clearing this exam was 3.3, and 84.2% considered their weak clinical skills as the reason for their recurrent failure.

Evaluating the Effectiveness of Text Messaging and Phone Call Reminders to Minimize No Show at Pediatric Outpatient Clinics in Pakistan: Protocol for a Mixed-Methods Study.

BACKGROUND: Missing health care appointments without canceling in advance results in a no show, a vacant appointment slot that cannot be offered to others. No show can be reduced by reminding patients about their appointment in advance. In this regard, mobile health (mHealth) strategy is to use text messaging (short message service, SMS), which is available on all cellular phones, including cheap low-end handsets. Nonattendance for appointments in health care results in wasted resources and disturbs the planned work schedules. OBJECTIVES: The purpose of this study is to evaluate the efficacy of the current text messaging (SMS) and call-based reminder system and further explore how to improve the attendance at the pediatric outpatient clinics. The primary objectives are to (1) determine the efficacy of the current clinic appointment reminder service at pediatric outpatient clinics at Aga Khan University Hospital, (2) assess the mobile phone access and usage among caregivers visiting pediatrics consultant clinics, and (3) explore the perception and barriers of parents regarding the current clinic appointment reminder service at the pediatric outpatient clinics at Aga Khan University Hospital. METHODS: The study uses a mixed-method design that consists of 3 components: (1) retrospective study (component A) which aims to determine the efficacy of text messaging (SMS) and phone call-based reminder service on patient's clinic attendance during January to June 2017 (N=58,517); (2) quantitative (component B) in which a baseline survey will be conducted to assess the mobile phone access and usage among parents/caregivers of children visiting pediatrics consultant clinics (n=300); and (3) qualitative (component C) includes in-depth interviews and focus group discussion with parents/caregivers of children visiting the pediatric consultancy clinic and with health care providers and administrative staff. Main constructs will be to explore perceptions and barriers related to existing clinic appointment reminder service. Ethics approval has been obtained from the Ethical Review Committee, Aga Khan University, Pakistan (4770-Ped-ERC-17). RESULTS: Results will be disseminated to pediatric quality public health and mHealth communities through scientific meetings and through publications, nationally and internationally. CONCLUSIONS: This study will provide insight regarding efficacy of using mHealth-based reminder services for patient's appointments in low- and middle-income countries setup. The finding of this study will be used to recommend further enhanced mHealth-based solutions to improve patient appointments and decrease no show.