Journal of Health, Wellness and Community Research
type: channel
description: Journal of Health, Wellness and Community Research (JHWCR) ISSN: 3007-0570 | DOI Prefix: 10.61919 JHWCR is dedicated to advancing global health and community well-being by publishing high-quality, peer-reviewed, open-access research. We actively encourage submissions from early-career researchers and support interdisciplinary work across the health sciences, rehabilitation, allied health, public and behavioral health, epidemiology, biostatistics, chronic and infectious diseases, environmental and global health, healthcare innovations, and basic or allied sciences with human health implications. All manuscripts undergo double-blind peer review and strict ethical screening in line with the guidelines of the Committee on Publication Ethics (COPE) and ICMJE. Frequency: Biweekly Indexing: HEC Pakistan (Y Category), Google Scholar, EuroPub, PakMediNet, Afro-Asian Research Index, CrossRef Open Access: Creative Commons Attribution 4.0 (CC BY 4.0) Publication Fee: PKR 18,000 or equivalent in USD.
publisher: Link Medical Interface, Lahore, Pakistan
language: en
publication name: Journal of Health, Wellness and Community Research
issn: 3007-0570
items: Prevalence and Socio-Behavioral Predictors of Undiagnosed Type 2 Diabetes in Middle-Aged Adults in Urban Slums
items: Medical and Surgical Management of Osteoarthritis of Knees
items: Impact of Workload and Conflict Management on Academic Performance and Psychological Wellbeing Among Medical Students
items: Evaluating the Effectiveness of Cognitive Therapy Techniques in Managing Anxiety and Depression Among Adults in Clinical Settings
items: Effectiveness of Emergency Department Initiated Palliative Care on Hospital Admission, Symptom Control, and 6-Month Outcomes in Low and Middle-Income Countries: A Systematic Review
items: In Silico Immunoinformatics Design and Evaluation of a Protein Based Vaccine Candidate Against Type 1 Diabetes Mellitus
items: Post Pandemic Assessment of Infection Prevention and Control Program in Public Sector Hospitals of Islamabad
items: Comparative Study on Body Physique, Physical Activity, and Higher Cognitive Function of Urban and Rural Students at Universities of Lahore
items: Social Media Usage in Dentistry: Determining Social Media–Related Opportunities and Challenges for Professional Dental Practices in Pakistan – A Cross-Sectional Study
items: Hemodynamic and Respiratory Implications of Steep Position in Robotic Pelvic Surgery: Anesthesia Management Strategies
items: Systematic Review of Global Patterns of Antibiotic Resistance in Community-Acquired Infections Over the Past Decade
items: Frequency of Hyperphosphatemia in Chronic Kidney Disease Patients Admitted to Ayub Teaching Hospital Abbottabad
items: Frequency of Surgical Site Infection in Open and Laparoscopic Appendectomy in Ayub Teaching Hospital Abbottabad
items: Frequency of Eosinophilia in Patients with Acute Exacerbation of COPD
items: Patient-Centered Rehabilitation: From Philosophical Ideal to Measurable Practice
items: Association of Plantar Fasciitis With Functional Limitations and Work Productivity Among Teachers
items: Decoding Cardiac Aging: Integrative Genetic, Cellular, and Molecular Insights Through a Data-Driven Perspective
items: The Menopause - Diet Connection: A Critical Review of Nutritional Influences on Women’s Midlife Health
items: Barriers to Hand Hygiene Compliance Among Nurses at DHQ Hospital Charsadda
items: Determination of Inflammatory and Liver Markers in COVID-19 Infected Patients from Allama Iqbal Teaching Hospital Dera Ghazi Khan
items: Evaluation of Knowledge and Attitudes Toward Palliative Care Among Critical Care Nurses in Tertiary Hospitals of South Punjab, Pakistan
items: Evaluating the Gross Motor Function and Balance in Children with Cerebral Palsy: A Systematic Review and Meta-analysis
items: Knowledge and Attitude of Nurses Regarding Palliative Care: A Cross-Sectional Study of Various Tertiary Care Hospitals, Peshawar, Pakistan
items: Knowledge, Attitude and Practices Related to Physical Ergonomics Among Non-Medical Undergraduate University Students
items: Prevalence of Postoperative Delirium in Elderly Patients After Hip Fracture Surgery: A Cross-Sectional Study
items: https://www.jhwcr.com/index.php/jhwcr/article/view/935
items: Efficacy, Safety, and Tolerability of Tofacitinib in Patients with Rheumatoid Arthritis: A Multicentric Pakistani Study
items: Awareness of SLE Patients About the Disease, Its Treatment, and Potential Complications
items: Lung Patterns Diagnosed on HRCT in Patients with Acute Inflammatory Pulmonary Disease
items: Bridging the Gap: Evaluating Radiation Protection Awareness in Pakistan’s Future Dentists

Prevalence and Socio-Behavioral Predictors of Undiagnosed Type 2 Diabetes in Middle-Aged Adults in Urban Slums
type: item
description: Background: Undiagnosed type 2 diabetes is increasingly recognised as a critical driver of preventable morbidity in low-income urban settings where constrained access to screening and limited health literacy impede early detection. Middle-aged adults in informal settlements may be particularly vulnerable due to cumulative exposure to behavioural and social risk factors. Objective: To estimate the prevalence of undiagnosed type 2 diabetes among middle-aged adults living in urban slums in Pakistan and to identify key socio-behavioural predictors. Methods: A community-based cross-sectional study was conducted among adults aged 35–60 years selected through multistage sampling. Sociodemographic, behavioural, and anthropometric data were collected using a structured questionnaire, and fasting blood glucose was measured using calibrated glucometers. Undiagnosed diabetes was defined as fasting glucose ≥126 mg/dL in individuals without prior diagnosis. Logistic regression was used to identify independent predictors. Results: Of 326 participants, 14.7% had undiagnosed diabetes. Prevalence was higher in adults ≥51 years, individuals with obesity, those who were physically inactive, and those with low educational attainment. In multivariable models, age (AOR 1.08), obesity (AOR 2.91), physical inactivity (AOR 2.43), low education (AOR 2.57), and family history (AOR 2.12) were independent predictors. Conclusion: Undiagnosed diabetes is common among adults in urban informal settlements and is shaped by metabolic, behavioural, and social determinants. Community-based screening and targeted prevention strategies are essential to address detection gaps in these high-risk populations.
subject: Articles
  topic: section
subject: Type 2 diabetes; Undiagnosed diabetes; Urban slums; Prevalence; Social determinants; Obesity; Physical inactivity.
  topic: keywords
creator: Bilal Khan
creator: Ribqa Tariq
creator: Abrar Ul Haq
creator: Naheed Shah
creator: Abdul Samad
creator: Arish Noor
creator: Faseeha Iqbal
rights: Copyright (c) 2025 Bilal Khan, Ribqa Tariq, Abrar Ul Haq, Naheed Shah, Abdul Samad, Arish Noor, Faseeha Iqbal (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-11-30
publication date: 2025-11-30
starting page: e990
ending page: e990
doi: 10.61919/ajp1sd70

Medical and Surgical Management of Osteoarthritis of Knees
type: item
description: Background: Knee osteoarthritis (OA) is a progressive whole-joint degenerative disease and a major global cause of pain, disability, and reduced quality of life. Multiple medical, biologic, and surgical treatment options exist, yet optimal sequencing, patient selection, and timing of surgery remain areas of clinical uncertainty. A comprehensive synthesis of current evidence is required to guide individualized treatment pathways. Objective: To systematically review the literature on medical, intra-articular injection-based, and surgical management of knee osteoarthritis, with particular emphasis on comparative effectiveness, surgical indications, and optimal timing of operative intervention. Methods: This systematic review followed PRISMA guidelines. Searches of PubMed/MEDLINE, Scopus, Web of Science, and Cochrane Library were conducted for studies published between January 2000 and December 2024. Eligible studies included randomized controlled trials, cohort studies, and high-quality systematic reviews evaluating conservative management, intra-articular therapies, osteotomies, unicompartmental knee arthroplasty (UKA), and total knee arthroplasty (TKA). Data were extracted on patient characteristics, interventions, clinical outcomes, functional scores, and complications. Risk of bias was assessed using the Cochrane RoB tool, Newcastle–Ottawa Scale, and AMSTAR-2. A narrative synthesis was performed due to clinical heterogeneity. Results: A total of 432 records were identified, with 17 studies meeting inclusion criteria. Non-pharmacological strategies and NSAIDs provided symptomatic relief in early disease, while corticosteroids and hyaluronic acid offered short-term benefit. Platelet-rich plasma demonstrated longer-lasting improvements in early to moderate OA compared with corticosteroids and HA. High tibial and distal femoral osteotomies were effective joint-preserving procedures for younger, active patients with unicompartmental OA and malalignment. UKA yielded fast…
subject: Articles
  topic: section
subject:
  topic: keywords
  value: Knee osteoarthritis; osteotomy; unicompartmental knee arthroplasty; total knee arthroplasty; intra-articular injections; platelet-rich plasma; conservative management; surgical indications; degenerative joint disease
creator: Saoud Javed
creator: Farooq Feroz Khan
creator: Masab Ahmed
creator: Adnan Haider
creator: Muhammad Saqlain Raza
creator: Akal Zaib
creator: Syed Ali Abbas
rights: Copyright (c) 2025 Saoud Javed, Farooq Feroz Khan, Masab Ahmed, Adnan Haider, Muhammad Saqlain Raza, Akal Zaib, Syed Ali Abbas (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-11-24
publication date: 2025-11-24
starting page: e977
ending page: e977
doi: 10.61919/kypjww22

Impact of Workload and Conflict Management on Academic Performance and Psychological Wellbeing Among Medical Students
type: item
description: Background: Medical students face substantial academic and interpersonal demands that predispose them to elevated psychological distress, yet the combined influence of academic workload and conflict management styles on mental health and academic outcomes remains insufficiently understood. Objective: To examine the associations between academic workload and conflict management styles with psychological well-being and academic performance among undergraduate medical students in Lahore, Pakistan. Methods: A cross-sectional observational study was conducted among 51 medical students using validated instruments including the Student Academic Workload Scale, Rahim Organizational Conflict Inventory–II, the General Health Questionnaire–12, and a self-reported academic performance index. Descriptive statistics, Pearson correlations, and multiple linear regressions were performed using SPSS version 26. Results: Academic workload (r = 0.502, p < 0.01) and conflict management style (r = 0.561, p < 0.01) were significantly associated with poorer psychological well-being. Regression analysis showed that conflict management significantly predicted psychological distress (β = 0.407, p = 0.006), while workload demonstrated a borderline effect (β = 0.269, p = 0.052), together explaining 36.3% of variance. Neither workload nor conflict management predicted academic performance (R² = 0.021, p = 0.605). Conclusion: Academic workload and conflict management styles significantly influence psychological well-being but do not affect academic performance, underscoring the need for stress mitigation and interpersonal skills training in medical education.
subject: Articles
  topic: section
subject: Academic workload; Conflict management; Psychological well-being; Academic performance; Medical students
  topic: keywords
creator: Mehak Fatima
creator: Mehtabel Muncie
creator: Saira Aawan
creator: Shabana Nasim
creator: Rida Batool
creator: Hafsa gul
creator: Habib Ullah Riaz
rights: Copyright (c) 2025 Mehak Fatima, Mehtabel Muncie, Saira Aawan, Shabana Nasim, Rida Batool, Hafsa gul, Habib Ullah Riaz (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-11-24
publication date: 2025-11-24
starting page: e974
ending page: e974
doi: 10.61919/b308w685

Evaluating the Effectiveness of Cognitive Therapy Techniques in Managing Anxiety and Depression Among Adults in Clinical Settings
type: item
description: Background: Anxiety and depressive disorders represent a profound global public health burden, necessitating effective, evidence-based psychological interventions. Cognitive therapy, particularly Cognitive Behavioral Therapy (CBT), is a well-established first-line treatment. However, a nuanced understanding of the specific techniques that constitute this broad intervention and their practical effectiveness in diverse clinical settings is crucial for optimizing patient care. Objective: This narrative review aims to synthesize and evaluate recent literature on the application and effectiveness of specific cognitive therapy techniques—such as cognitive restructuring, behavioral activation, and mindfulness-based strategies—in managing anxiety and depression among adults in clinical settings. Main Discussion Points: The review is structured around four key themes. First, it establishes the central role of cognitive restructuring in directly modifying maladaptive thought patterns underlying both disorders. Second, it highlights behavioral activation as a potent catalyst for cognitive and emotional change, especially for depressive symptoms. Third, it examines the emergent role of mindfulness and metacognitive techniques that focus on altering the patient's relationship to thoughts rather than their content. Finally, it discusses the implementation of these techniques in real-world contexts, including the growing evidence for digital and transdiagnostic adaptations. Conclusion: The evidence robustly supports the value of a technique-informed approach to cognitive therapy. Moving forward, clinicians are encouraged to adopt a flexible, personalized application of these techniques based on individual patient presentation. Future research should prioritize identifying predictors of treatment response and conducting pragmatic trials to bridge the gap between research efficacy and clinical effectiveness.
subject: Articles
  topic: section
subject: Cognitive Therapy, Anxiety Disorders, Depressive Disorder, Cognitive Restructuring, Behavioral Activation, Narrative Review
  topic: keywords
creator: Pakeeza
creator: Noor ul Huda
creator: Fareeha F Khan
creator: Noor Javaid
creator: Asad Ali
creator: Ummama Ghazanfar Ali Soomro
rights: Copyright (c) 2025 Pakeeza, Noor ul Huda, Fareeha F Khan, Noor Javaid, Asad Ali, Ummama Ghazanfar Ali Soomro (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-11-24
publication date: 2025-11-24
starting page: e970
ending page: e970
doi: 10.61919/fxprwf53

Effectiveness of Emergency Department Initiated Palliative Care on Hospital Admission, Symptom Control, and 6-Month Outcomes in Low and Middle-Income Countries: A Systematic Review
type: item
description: Background: Emergency-department–initiated palliative care (ED-PC) has emerged as a critical strategy for improving the management of patients with advanced, life-limiting illness, particularly in low- and middle-income countries (LMICs) where late presentation, limited specialist availability, and constrained resources frequently compromise care quality. Objective: This systematic review evaluates the effectiveness of ED-PC on hospital admission, acute symptom relief, and 6-month outcomes among adults presenting with serious illness in LMIC settings. Methods: A comprehensive search of PubMed, EMBASE, Scopus, Web of Science, CINAHL, and Cochrane CENTRAL was conducted from 2010 to 2024. Eligible studies included randomized trials, quasi-experimental studies, cohort studies, and cross-sectional analyses assessing ED-initiated palliative interventions in LMICs. Two reviewers independently screened, extracted data, and assessed study quality. Outcomes included admission rates, improvement in pain and dyspnea, and 6-month healthcare utilization, mortality, and quality of life. Results: Eighteen studies involving 12,846 patients met inclusion criteria. ED-PC resulted in a 13–22% absolute reduction in hospital admission, substantially greater improvement in pain and dyspnea within hours of ED presentation, and lower 6-month readmission, ED revisits, and ICU utilization. Quality of life improved more in ED-PC groups, with better alignment between preferred and actual care settings. Conclusion: ED-initiated palliative care is effective and feasible in LMIC emergency settings, improving symptom control, reducing avoidable admissions, and enhancing longer-term patient-centered outcomes.
subject: Articles
  topic: section
subject: Emergency department, palliative care, LMICs, symptom control, hospital admission, 6-month outcomes
  topic: keywords
creator: Muhammad Abas Khan
creator: Zil-e-Fatima
creator: Mujahid Hussain
creator: Tanveer Ahmad
creator: Muhammad Mamoon
creator: Tahira Zainab
creator: Muzammil Ali
rights: Copyright (c) 2025 Muhammad Abas Khan, Zil-e-Fatima, Mujahid Hussain, Tanveer Ahmad, Muhammad Mamoon, Tahira Zainab, Muzammil Ali (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-10-24
publication date: 2025-10-24
starting page: e966
ending page: e966
doi: 10.61919/v6vpyx26

In Silico Immunoinformatics Design and Evaluation of a Protein Based Vaccine Candidate Against Type 1 Diabetes Mellitus
type: item
description: Background: Type 1 diabetes mellitus (T1DM) results from autoimmune destruction of pancreatic β-cells, and no licensed vaccine currently prevents or halts this process. Computational immunology offers a rapid approach for identifying tolerogenic antigen combinations that may modulate autoimmune responses. Objective: To design and evaluate an in silico multi-epitope vaccine candidate incorporating the CTB–GM1 system to promote antigen-specific immune tolerance in T1DM. Methods: Protein sequences were retrieved from NCBI and assessed using ProtParam, VaxiJen, AllerTOP, ToxinPred, and SolPro. T- and B-cell epitopes were predicted through IEDB, filtered by antigenicity, allergenicity, toxicity, and population coverage, and assembled using appropriate linkers and an adjuvant. Structural modelling was performed using I-TASSER, with validation by Ramachandran and ERRAT analyses. Molecular docking with GM1 was conducted via ClusPro, and immune responses were simulated using C-IMMSIM. Results: The final construct incorporated five MHC-I, five MHC-II, and four B-cell epitopes and demonstrated favourable predicted antigenicity (VaxiJen score 0.62), non-allergenicity, and non-toxicity. Structural modelling indicated a stable conformation (ERRAT >95%). Docking predicted strong interaction with GM1 (best score –1050.7). Immune simulations suggested a Th2-leaning profile with increased IL-4, IL-5, IL-13 and generation of memory subsets; however, these findings are theoretical. Conclusion: This CTB–GM1 multi-epitope construct shows promising computational characteristics, but all findings are predictive only and require comprehensive in vitro, in vivo, and clinical validation before any therapeutic relevance can be established.
subject: Articles
  topic: section
subject: Type 1 diabetes; CTB-GM1; in silico vaccine; epitope prediction; molecular docking; immune simulation.
  topic: keywords
creator: Bilal Shafiq
rights: Copyright (c) 2025 Bilal Shafiq (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-07-11
publication date: 2025-07-11
starting page: e965
ending page: e965
doi: 10.61919/er8vkf50

Post Pandemic Assessment of Infection Prevention and Control Program in Public Sector Hospitals of Islamabad
type: item
description: Background: Healthcare-associated infections (HCAIs) remain a major preventable cause of morbidity and mortality, particularly in low- and middle-income countries where infection prevention and control (IPC) systems often lack the structural and operational maturity needed to ensure patient safety. Pakistan’s public hospitals historically demonstrated inadequate IPC capacity, and the impact of COVID-19–related investments on long-term programme strengthening remains unclear. Objective: To assess post-pandemic IPC capacity in four public sector hospitals in Islamabad using the WHO IPC Assessment Framework (IPCAF), compare 2023 findings with 2019 baseline scores, and identify persistent gaps across IPC core components. Methods: A cross-sectional observational study was conducted from February to July 2023 in four tertiary public hospitals previously assessed in 2019. Data were collected using the WHO IPCAF tool through structured interviews, document review, and direct observation. Descriptive statistics were generated, and paired comparisons of overall 2019–2023 scores were performed. Results: All hospitals improved from “Inadequate” (9.7–20.6%) in 2019 to “Basic” IPC capacity (29.2–46.5%) in 2023, with a significant mean increase of 20.5 percentage points (p = 0.018). IPC Guidelines and Built Environment were the strongest components, whereas HAI Surveillance, Multimodal Strategies, and Monitoring/Audit & Feedback remained critically low across hospitals. Conclusion: IPC capacity in Islamabad’s public hospitals improved post-pandemic; however, foundational gaps in surveillance and quality-improvement systems persist. Strengthening these domains is essential for advancing hospitals toward higher IPC maturity and reducing HCAI burden.
subject: Articles
  topic: section
subject: Infection Prevention and Control; Healthcare-Associated Infections; IPCAF; Surveillance; Public Hospitals; Pakistan
  topic: keywords
creator: Imtiaz Ali
creator: Allahdad Lashari
creator: Usman
creator: Farzand Ali
rights: Copyright (c) 2025 Imtiaz Ali, Allahdad Lashari, Usman, Farzand Ali (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-06-10
publication date: 2025-06-10
starting page: e961
ending page: e961
doi: 10.61919/79jc9q13

Comparative Study on Body Physique, Physical Activity, and Higher Cognitive Function of Urban and Rural Students at Universities of Lahore
type: item
description: Background: Rural–urban differences in lifestyle, nutritional patterns, and environmental exposures may influence body physique, physical activity, and higher cognitive function in young adults, yet evidence among university populations in Pakistan remains limited. Objective: To compare body physique, physical activity levels, and higher cognitive function between urban- and rural-background university students in Lahore. Methods: A comparative cross-sectional study was conducted among 152 students (76 urban, 76 rural) aged 18–25 years. Anthropometric measurements were obtained using standardized protocols, physical activity was assessed using the International Physical Activity Questionnaire (IPAQ), and higher cognitive function was evaluated using the Cognition Self-Assessment Rating Scale (CSARS). Independent t-tests and chi-square analyses were used with effect sizes and p-values reported. Results: BMI distribution differed significantly between groups (p=0.018), with urban students showing higher underweight prevalence (38.16%) and rural students showing higher overweight prevalence (23.68%). No significant differences were observed in chest, hip, or shoulder measurements (all p>0.28). Physical activity patterns showed non-significant trends toward higher moderate and vigorous activity in rural students (p=0.327). Cognitive function categories did not differ significantly (p=0.141), although severe impairment was present only in urban students. Conclusion: Rural–urban background is associated with significant differences in BMI but not in physical activity or cognitive function. These findings highlight the need for targeted health-promotion strategies in university settings.
subject: Articles
  topic: section
subject: Body physique; BMI; cognitive function; physical activity; rural–urban differences; university students; Lahore
  topic: keywords
creator: Muhammad Taha
creator: Ahmed Javed
creator: Maryam
creator: Laiba Rani
creator: Ayesha Hafeez
creator: Aqsa Javaid
creator: Maria Umar
rights: Copyright (c) 2025 Muhammad Taha, Ahmed Javed, Maryam, Laiba Rani, Ayesha Hafeez, Aqsa Javaid, Maria Umar (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-11-22
publication date: 2025-11-22
starting page: e959
ending page: e959
doi: 10.61919/7j7ebx81

Social Media Usage in Dentistry: Determining Social Media–Related Opportunities and Challenges for Professional Dental Practices in Pakistan – A Cross-Sectional Study
type: item
description: Background: Social media has become integral to dental communication, education, and practice promotion, yet it also introduces risks related to misinformation, confidentiality, and professionalism. Evidence from Pakistan remains limited, especially regarding how dental professionals perceive both the opportunities and challenges associated with its professional use. Objective: To assess patterns of professional social media use among Pakistani dental professionals and evaluate perceived opportunities, challenges, and awareness of ethical and legal boundaries in digital practice. Methods: A nationwide cross-sectional study was conducted from October to November 2025 among final-year dental students, house officers, postgraduate trainees, and general practitioners. A validated, self-administered online questionnaire captured demographics, social media usage, perceived opportunities, and perceived challenges. Data from 335 respondents were analysed using descriptive statistics and inferential tests including chi-square, Fisher’s exact test, and non-parametric comparisons, with significance set at p<0.05. Results: Overall, 64.8% reported professional social media use, most commonly Instagram (66.3%). Key challenges included confidentiality concerns (60.9%) and misinformation (49.3%). Ethical dilemmas were reported by 34.3% and legal ambiguity by 42.1%. Opportunities were widely endorsed, with 92.2% finding content helpful, 84.5% reporting enhanced professional networking, and 85.4% identifying superior marketing value. Purchasing decisions were influenced by social media in 56.4% of respondents. Conclusion: Social media is widely used by Pakistani dental professionals and offers substantial educational and promotional benefits, but significant ethical and regulatory concerns persist, underscoring the need for clear national guidelines and digital professionalism training.
subject: Articles
  topic: section
subject: Social media; Dentistry; Professionalism; Ethics; Pakistan; Digital health; Dental education
  topic: keywords
creator: Sadia Khan
creator: Ashhad Hussain Shah
creator: Sandiya Divi
creator: Nazik Marri
creator: Muhammad Bin Afzal Saleemi
creator: Muhammad Farrukh
rights: Copyright (c) 2025 Sadia Khan, Ashhad Hussain Shah, Sandiya Divi, Nazik Marri, Muhammad Bin Afzal Saleemi, Muhammad Farrukh (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-11-22
publication date: 2025-11-22
starting page: e958
ending page: e958
doi: 10.61919/r33dyx30

Hemodynamic and Respiratory Implications of Steep Position in Robotic Pelvic Surgery: Anesthesia Management Strategies
type: item
description: Background: Robotic pelvic surgery frequently requires steep Trendelenburg positioning combined with pneumoperitoneum, producing significant cardiopulmonary alterations that challenge intraoperative anesthetic management. Changes in airway pressure, lung compliance, end-tidal CO₂ (ETCO₂), venous return, and systemic vascular resistance may compromise hemodynamic stability, yet real-world practice patterns for addressing these physiological stresses remain underexplored. Objective: To evaluate anesthesia professionals’ reported experiences of hemodynamic and respiratory disturbances during steep Trendelenburg in robotic pelvic surgery and to identify commonly implemented management strategies. Methods: A descriptive cross-sectional study was conducted among 150 anesthesia professionals from tertiary hospitals performing robotic pelvic procedures. A validated structured questionnaire captured demographic characteristics, reported physiological changes, ventilation modes, fluid therapy practices, and hemodynamic interventions. Data were analyzed using descriptive statistics, χ² tests, ANOVA, and Pearson correlations with significance set at p < 0.05. Results: Moderate (48.0%) and high (33.3%) hemodynamic instability were frequently reported. Elevated airway pressures (26–35 cmH₂O) occurred in 52.7% of cases, with pressures >35 cmH₂O in 25.3%. ETCO₂ rose progressively with airway pressure (r = 0.48), while lung compliance showed inverse correlations with both airway pressure (r = –0.51) and instability (r = –0.47). Pressure-controlled ventilation (55.3%) and restrictive fluid therapy (49.3%) were preferred. Conclusion: Steep Trendelenburg positioning produces predictable cardiopulmonary stress requiring vigilant anesthetic management; pressure-controlled ventilation and conservative fluid strategies appear central to maintaining intraoperative stability.
subject: Articles
  topic: section
subject: Steep Trendelenburg; Robotic Pelvic Surgery; Hemodynamics; Respiratory Mechanics; Pneumoperitoneum; Anesthesia Strategies
  topic: keywords
creator: Fiza Zeeshan
creator: Mukhtiar Ahmad
creator: Rafia Ali
creator: Alishba Asghar
creator: Muhammad Mubeen Tahir
creator: Mian Aqdas Rasool
rights: Copyright (c) 2025 Fiza Zeeshan, Mukhtiar Ahmad, Rafia Ali, Alishba Asghar, Muhammad Mubeen Tahir, Mian Aqdas Rasool (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-11-30
publication date: 2025-11-30
starting page: e955
ending page: e955
doi: 10.61919/ptfrdz96

Systematic Review of Global Patterns of Antibiotic Resistance in Community-Acquired Infections Over the Past Decade
type: item
description: Background: Antibiotic resistance in community-acquired infections (CAIs) has emerged as a major global health challenge, diminishing the effectiveness of empirical antimicrobial therapies. Despite numerous regional investigations, a consolidated global assessment of resistance patterns over the past decade remains limited. Objective: This systematic review aimed to synthesize global evidence on antibiotic resistance trends among key bacterial pathogens responsible for CAIs from 2014 to 2024. Methods: Following PRISMA guidelines, a comprehensive search of PubMed, Scopus, Web of Science, and the Cochrane Library identified observational studies reporting quantitative resistance rates in community-acquired urinary, respiratory, and skin and soft tissue infections. Eligible studies were screened, data extracted on pathogen profiles and resistance patterns, and risk of bias assessed using Joanna Briggs Institute (JBI) appraisal tools. Results: Eight studies comprising 45,820 isolates met inclusion criteria. Uropathogenic Escherichia coli exhibited high resistance, with third-generation cephalosporin resistance ranging from 28% to 42%, and fluoroquinolone resistance surpassing 40% across multiple regions. Streptococcus pneumoniae demonstrated macrolide resistance at approximately 28%, while community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) prevalence ranged from 12% to 25%. Conclusion: Rising resistance trends in common CAIs underscore a critical need for strengthened global surveillance, optimized empirical guidelines, and expanded antimicrobial stewardship initiatives. Investment in rapid diagnostic strategies within community healthcare settings is essential to mitigate this growing threat
subject: Articles
  topic: section
subject: Antibiotic Resistance; Community-Acquired Infections; Systematic Review; Drug Resistance, Microbial; Global Health
  topic: keywords
creator: Roomana Ali
creator: Samar Fatima
creator: Musa Khan
creator: Amna Javed
creator: Sana Abdullah
creator: Mehwish Kharal
creator: Syeda Butool Zehra
rights: Copyright (c) 2025 Roomana Ali, Samar Fatima, Musa Khan, Amna Javed, Sana Abdullah, Mehwish Kharal, Syeda Butool Zehra (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-11-14
publication date: 2025-11-14
starting page: e954
ending page: e954
doi: 10.61919/r757y737

Frequency of Hyperphosphatemia in Chronic Kidney Disease Patients Admitted to Ayub Teaching Hospital Abbottabad
type: item
description: Background: Hyperphosphatemia is a major biochemical disturbance in chronic kidney disease (CKD) and contributes to accelerated vascular calcification, cardiovascular morbidity, and CKD–mineral and bone disorder. Despite its clinical importance, limited data exist from Pakistani tertiary-care settings describing the stage-wise burden of hyperphosphatemia among hospitalized CKD patients. Objective: To determine the frequency of hyperphosphatemia in CKD patients admitted to a tertiary hospital in Abbottabad and to assess its association with demographic, socioeconomic, and clinical variables across CKD stages. Methods: This descriptive cross-sectional study included 289 adults with CKD recruited consecutively from February to May 2025. Serum phosphate was measured using a standardized enzymatic assay, with hyperphosphatemia defined as >4.5 mg/dL. Data on demographics, BMI, comorbidities, socioeconomic status, and CKD stage were collected. Statistical analysis included chi-square tests, odds ratios with 95% confidence intervals, and effect-size estimation. Results: Hyperphosphatemia was observed in 53.96% of patients (95% CI: 48.0–59.8). Its prevalence increased sharply from Stage 1 (26.19%) to Stage 5 (80.00%), with patients in Stages 4–5 having nearly nine-fold higher odds of hyperphosphatemia compared with Stages 1–2. Significant associations were found with BMI and socioeconomic status, while age, sex, diabetes, and hypertension showed no significant effect. Conclusion: Hyperphosphatemia is highly prevalent and increases markedly with declining renal function, underscoring the need for early monitoring and stage-specific management strategies.
subject: Articles
  topic: section
subject: Chronic kidney disease, hyperphosphatemia, serum phosphate, CKD-MBD, mineral metabolism
  topic: keywords
creator: Kaleem Ullah
creator: Syed Yasir Hussain Gillani
creator: Saima Akhyar
creator: Muhammad Hamza
creator: Atta Ullah
creator: Muhammad Asim
rights: Copyright (c) 2025 Kaleem Ullah, Syed Yasir Hussain Gillani, Saima Akhyar, Muhammad Hamza, Atta Ullah, Muhammad Asim, Muhammad Asim (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-07-18
publication date: 2025-07-18
starting page: e952
ending page: e952
doi: 10.61919/3pa99x82

Frequency of Surgical Site Infection in Open and Laparoscopic Appendectomy in Ayub Teaching Hospital Abbottabad
type: item
description: Background: Surgical site infections (SSIs) are a common complication following appendectomy and contribute to increased morbidity, extended hospital stay, and greater healthcare costs. Minimally invasive surgery has been associated with improved postoperative outcomes, yet comparative data from Pakistan remain limited. Objective: To determine and compare the frequency of surgical site infection following open versus laparoscopic appendectomy among adults treated at a tertiary care hospital. Methods: A descriptive cross-sectional study was conducted at Ayub Teaching Hospital, Abbottabad, from March to May 2025. Adult patients aged 20–40 years undergoing open or laparoscopic appendectomy were enrolled consecutively. Demographics, clinical variables, and surgical details were recorded using a structured proforma. SSIs were assessed over 30 days using standardized diagnostic criteria. Associations were analysed using chi-square tests and odds ratios (ORs) with 95% confidence intervals. Results: Among 200 patients, the overall SSI rate was 7.0%. SSI occurred in 10.61% of open appendectomy cases and 5.22% of laparoscopic cases (OR 2.15, 95% CI 0.76–6.03; p=0.161). Unemployment showed a significant association with SSI (OR 3.65, p=0.011), while age, sex, BMI, diabetes, and symptom duration were not significant predictors. Conclusion: Laparoscopic appendectomy demonstrated a lower frequency of surgical site infection compared with open surgery, although the difference was not statistically significant. Socioeconomic factors may influence postoperative outcomes and merit consideration in infection-prevention strategies.
subject: Articles
  topic: section
subject: Appendectomy, Laparoscopic surgery, Surgical site infection, Open appendectomy, Postoperative outcomes
  topic: keywords
creator: Saddam Hussain
creator: Shawan Asad
creator: Misbah Ullah
creator: Muhammad Umar Khan Ghauri
creator: Bahri Room
creator: Omar Khan
rights: Copyright (c) 2025 Saddam Hussain, Shawan Asad, Misbah Ullah, Muhammad Umar Khan Ghauri, Bahri Room, Omar Khan (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-07-06
publication date: 2025-07-06
starting page: e951
ending page: e951
doi: 10.61919/n0sz7e09

Frequency of Eosinophilia in Patients with Acute Exacerbation of COPD
type: item
description: Background: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) represent a major global burden, and blood eosinophils have emerged as a promising biomarker for phenotyping and treatment response. However, local data on eosinophilia prevalence among hospitalized AECOPD patients in South Asia remain limited. Objective: To determine the frequency of blood eosinophilia in patients admitted with AECOPD and to evaluate its distribution across demographic and exposure-related covariates. Methods: This descriptive cross-sectional study included 195 patients aged 20–80 years presenting with AECOPD at the Department of Pulmonology, Ayub Teaching Hospital, Abbottabad (December 2024–May 2025). COPD diagnosis was confirmed through spirometry. Blood samples were analyzed for eosinophil counts, with eosinophilia defined as ≥2% or ≥150 cells/µL. Data were recorded on a standardized proforma and analyzed using SPSS 20, applying chi-square tests with p<0.05 as significance. Results: Mean age was 51.69±14.74 years; 54.36% were male. Overall eosinophilia prevalence was 53.33%. Younger patients (20–50 years) showed higher eosinophilia (61.1%) compared with older adults (46.7%). Middle socioeconomic status had the highest prevalence (65.3%). Age and socioeconomic status were significantly associated with eosinophilia. Conclusion: More than half of hospitalized AECOPD patients exhibited blood eosinophilia, supporting its value as a practical, accessible biomarker for phenotyping and guiding individualized therapy in clinical settings.
subject: Articles
  topic: section
subject: COPD, acute exacerbation, eosinophilia, biomarkers, spirometry
  topic: keywords
creator: Masab Hanif
creator: Mohammad Yasin
creator: Musawer Hayat
creator: Wajahat Sami Malik
creator: Ahtezaz Hussain
creator: Hafeez Ullah Khan
rights: Copyright (c) 2025 Masab Hanif, Mohammad Yasin, Musawer Hayat, Wajahat Sami Malik, Ahtezaz Hussain, Hafeez Ullah Khan (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-06-11
publication date: 2025-06-11
starting page: e950
ending page: e950
doi: 10.61919/k89r9x80

Patient-Centered Rehabilitation: From Philosophical Ideal to Measurable Practice
type: item
subject: Editorial
  topic: section
creator: Farah Shaheen
creator: Syed Asadullah Arslan
rights: Copyright (c) 2025 Farah Shaheen, Syed Asadullah Arslan (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-11-12
publication date: 2025-11-12
starting page: e949
ending page: e949
doi: 10.61919/6pkeb156

Association of Plantar Fasciitis With Functional Limitations and Work Productivity Among Teachers
type: item
description: Background: Plantar fasciitis (PF) is a prevalent cause of heel pain that compromises gait and occupational functioning. Teachers experience prolonged standing on hard surfaces, yet quantitative links between PF severity and work productivity in this workforce remain under characterized. Objective: To estimate the apparent prevalence of PF in a convenience sample of teachers and assess the association of PF severity with work productivity and activity limitation. Methods: A cross-sectional study (March–August 2025) enrolled teachers aged 30–45 years from institutions in Sialkot, Daska, Gujranwala, and Hafizabad. Eligibility required 7–8 working hours/day and routine use of hard, non-cushioned footwear. PF was examined using the Windlass test; pain and function were measured by the Plantar Fasciitis Pain/Disability Scale (PFPS; 0–100, higher worse), and productivity by the Work Productivity and Activity Impairment (WPAI) questionnaire over the past 7 days. Spearman’s ρ estimated associations. Results: Of 318 participants (29.6% male; mean age 34.9 years), 122 were Windlass positive, yielding an apparent prevalence of 38.4% (95% CI 33.2–43.8). PFPS correlated with WPAI absenteeism (ρ=0.455; p<0.001), presenteeism (ρ=0.569; p<0.001), overall work impairment (ρ=0.455; p<0.001), and total activity limitation (ρ=0.601; p<0.001). Windlass positivity showed smaller associations: absenteeism (ρ=0.182; p<0.001), presenteeism (ρ=0.380; p<0.001), overall work impairment (ρ=−0.179; p<0.001), and activity limitation (ρ=0.386; p<0.001). Conclusion: In this teacher cohort, greater PF severity—especially by PFPS—was associated with higher presenteeism and activity limitation. Findings support symptom–function screening and ergonomic interventions; generalizability is limited by the exposure-conditioned, convenience design.
subject: Articles
  topic: section
subject: plantar fasciitis; teachers; work productivity; presenteeism; absenteeism; Windlass test; WPAI; PFPS; occupational health
  topic: keywords
creator: Hafiza Laibah Sufi
creator: Amna Safdar
creator: Alina Shahbaz
creator: Waleed Amir
creator: Hafiza Rabia Javed
creator: Raveena Rajput
rights: Copyright (c) 2025 Hafiza Laibah Sufi, Amna Safdar, Alina Shahbaz, Waleed Amir, Hafiza Rabia Javed, Raveena Rajput (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-11-14
publication date: 2025-11-14
starting page: e948
ending page: e948
doi: 10.61919/yhw7mq10

Decoding Cardiac Aging: Integrative Genetic, Cellular, and Molecular Insights Through a Data-Driven Perspective
type: item
description: Background: Cardiac ageing is driven by interlocking defects in mitochondrial quality control, telomere–senescence biology, endothelial–microvascular homeostasis, extracellular-matrix remodelling, and proteostasis, culminating in diastolic dysfunction, arrhythmia substrate, and impaired reserve in older adults. Mechanistic mapping and translational appraisal are needed to prioritize tractable therapeutic nodes. Objective: To synthesize genetic, cellular, and molecular mechanisms of cardiac ageing; distinguish physiological from pathological trajectories; and evaluate translational strategies spanning lifestyle, pharmacology, and targeted molecular approaches. Methods: We conducted a prespecified narrative review (searches to 10 November 2025) across MEDLINE, Embase, Web of Science, and Cochrane CENTRAL, plus trial registries and reference lists. Dual screening and domain-appropriate appraisal were applied. Evidence was thematically organized across mitochondria/oxidative stress, telomere–senescence, endothelial dysfunction, fibroblast activation, proteostasis/autophagy, epigenetics, and nodal pathways (mTOR, AMPK, FOXO, SIRT1/PGC-1α, Wnt/β-catenin, TGF-β, NF-κB). Results: Of 5,633 records, 4,419 were screened; 698 full texts were assessed; 186 studies were included (human observational n=74; human interventional n=12; animal n=82; in-vitro n=18). Consistent signals implicate diminished AMPK–SIRT1/PGC-1α and FOXO activity, heightened TGF-β/Wnt profibrotic drive, and chronic NF-κB–mediated inflammaging. Exercise robustly engages mitochondrial and autophagic programs; mTOR modulation and senescence-targeted strategies show preclinical efficacy but require cautious human translation. Conclusion: Cardiac ageing reflects convergent failures in energy, repair, and matrix homeostasis. Near-term impact is most likely from exercise-centred programs, with selective evaluation of mTOR and senescence-directed therapies in rigorously phenotyped older adults. Harmonized endpoints …
subject: Articles
  topic: section
subject: Aging; Myocardium; Mitochondria; Telomere shortening; Inflammaging; Fibrosis; Autophagy; Sirtuins; mTOR; Senolytics
  topic: keywords
creator: Bilal Shafiq
rights: Copyright (c) 2025 Bilal Shafiq (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-11-13
publication date: 2025-11-13
starting page: e947
ending page: e947
doi: 10.61919/4havng29

The Menopause - Diet Connection: A Critical Review of Nutritional Influences on Women’s Midlife Health
type: item
description: Background: Diet is a modifiable lever during the menopausal transition, yet evidence on which patterns or nutrients meaningfully affect symptoms and midlife health is heterogeneous and often observational. Objective: To critically synthesize recent evidence on associations between dietary patterns/nutrients and menopausal outcomes—vasomotor symptoms (VMS), mood/sleep, cardiometabolic markers, bone mineral density (BMD), and body composition—in peri- and postmenopausal women. Methods: We followed PRISMA. PubMed/MEDLINE, Scopus, and Google Scholar were searched (1 Jan 2020–1 Nov 2025) for randomized and non-randomized human studies assessing dietary patterns (e.g., Mediterranean, vegetarian, low–glycaemic load) or specific nutrients (e.g., omega-3, protein, vitamin D, carbohydrate quality). Two reviewers independently screened/extracted data. Risk of bias was assessed with design-appropriate tools. Pre-specified primary outcomes were VMS and cardiometabolic markers; secondary outcomes were mood/sleep, BMD, and body composition. Given heterogeneity, we used a structured synthesis-without-meta-analysis approach. Results: Of 4,144 database records and 456 manual records, 1,840 full texts were assessed and 68 studies met criteria. Across observational studies, higher-quality dietary patterns characterized by greater vegetables, fruits, and whole grains were consistently associated with lower symptom burden and more favorable metabolic profiles. Higher dietary inflammatory index scores correlated with worse menopause-specific quality of life, whereas better carbohydrate quality associated with fewer symptoms. Narrative and mechanistic reports support plausibility for Mediterranean-style patterns and omega-3 intake, though standardized interventional evidence remains limited. One randomized trial in postmenopausal women undertaking resistance training found protein intake above recommended allowances did not yield additional lean mass gains versus recommended intake. Overa…
subject: Articles
  topic: section
subject: menopause; vasomotor symptoms; Mediterranean diet; dietary inflammatory index; carbohydrate quality; body composition; bone mineral density; cardiometabolic risk; women’s health
  topic: keywords
creator: Iqra Safdar
creator: Hafiz Muhammad Jalees Ul Hassan
creator: Muhammad Asif
rights: Copyright (c) 2025 Iqra Safdar, Hafiz Muhammad Jalees Ul Hassan, Muhammad Asif (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-11-14
publication date: 2025-11-14
starting page: e946
ending page: e946
doi: 10.61919/hf8aw031

Barriers to Hand Hygiene Compliance Among Nurses at DHQ Hospital Charsadda
type: item
description: Background: Hand hygiene is a cornerstone of infection prevention, yet compliance among healthcare workers remains suboptimal in many low-resource settings. Nurses, as the largest group of frontline providers, are particularly influential in the transmission or prevention of healthcare-associated infections. Objective: To identify predominant barriers to hand hygiene and describe knowledge and practice among nurses at District Headquarters (DHQ) Hospital Charsadda. Methods: A descriptive cross-sectional study was conducted among 50 registered nurses using a structured, self-administered questionnaire and a brief observation checklist based on World Health Organization guidance. Data on demographics, knowledge, self-reported practice, perceived barriers, and observed behaviour were analysed using descriptive statistics in SPSS version 26. Results: Most nurses were older than 30 years and highly experienced, with 64% reporting more than 10 years of service. Only 36% correctly identified the WHO-recommended 40–60 seconds handwashing duration, and recognition of all WHO “key moments” was rare. While 56% reported frequently washing hands before patient contact, only 10% always wore gloves; 58% used reusable cloth towels for drying. Observations showed pre-contact hand hygiene in 76% of encounters and glove use in 44%. The principal barriers were lack of handwashing facilities (52%) and insufficient hand sanitiser (34%). Conclusion: Structural constraints, particularly inadequate infrastructure and supplies, coexist with knowledge and practice gaps and likely undermine effective hand hygiene among nurses at DHQ Hospital Charsadda.
subject: Articles
  topic: section
subject: Hand hygiene; nurses; infection control; barriers; compliance; WHO guidelines; Pakistan.
  topic: keywords
creator: Yahya Khan
creator: Sawera
creator: Zubair Ahmad
creator: Basit Ali
creator: Aamir Bacha
creator: Amjid Ali
rights: Copyright (c) 2025 Yahya Khan, Sawera, Zubair Ahmad, Basit Ali, Aamir Bacha, Amjid Ali (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-11-22
publication date: 2025-11-22
starting page: e945
ending page: e945
doi: 10.61919/65c21x88

Determination of Inflammatory and Liver Markers in COVID-19 Infected Patients from Allama Iqbal Teaching Hospital Dera Ghazi Khan
type: item
description: Background: In resource-constrained hospitals, readily available inflammatory and hepatic biomarkers can aid bedside assessment of COVID-19, but local evidence on their short-term trajectories is limited. Objective: To compare serum ferritin, C-reactive protein (CRP), lactate dehydrogenase (LDH), D-dimer, alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkaline phosphatase (ALP) between PCR-confirmed COVID-19 inpatients and healthy controls, and to characterize within-patient changes across the first three inpatient weeks. Methods: We conducted a retrospective cohort with repeated measures at Allama Iqbal Teaching Hospital, Dera Ghazi Khan. Consecutive inpatients with SARS-CoV-2 RT-PCR positivity (n=100) and healthy controls (n=50) were included. Standardized venipuncture, centrifugation, and platform assays (cobas pure 6000; HumaClot for D-dimer) were used. Cases were sampled at weeks 1–3; controls provided a single baseline sample. Primary outcomes were between-group differences at week 3 and within-patient week-wise changes. Results: Compared with controls, cases showed escalating elevations over weeks 1–3. By week 3, means (vs controls) were: ferritin 1897.25 vs 90.21 ng/mL; CRP 159.58 vs 4.20 mg/L; D-dimer 1017.93 vs 69.66 ng/mL FEU; LDH 800.72 vs 61.82 U/L; ALT 233.54 vs 24.20 U/L; AST 106.58 vs 28.40 U/L; ALP 259.27 vs 94.40 U/L. Reported paired tests within cases indicated significant week-to-week increases for ferritin and ALT, with the largest relative gains in ferritin (≈21× control), CRP (≈38×), D-dimer (≈15×), and LDH (≈13×) by week 3 Conclusion: Routine biomarkers demonstrate a coherent, week-by-week rise in hyperinflammation, tissue injury, and coagulopathy among hospitalized COVID-19 patients. Serial CRP, ferritin, LDH, and D-dimer, interpreted alongside liver enzymes, may support monitoring and triage pending prospective outcome-linked validation.
subject: Articles
  topic: section
subject: COVID-19; ferritin; C-reactive protein; D-dimer; lactate dehydrogenase; liver enzymes; retrospective cohort; Pakistan
  topic: keywords
creator: Muhammad Usman Ghani
creator: Hasnain Raza
creator: Abdul Razaq
creator: Nazakat Shafiq
creator: Najmul Hassan
creator: Shahiryar Ahmad
creator: Muhammad Ammar Yasir
rights: Copyright (c) 2025 Muhammad Usman Ghani, Hasnain Raza, Abdul Razaq, Nazakat Shafiq, Najmul Hassan, Shahiryar Ahmad, Muhammad Ammar Yasir (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-11-13
publication date: 2025-11-13
doi: 10.61919/r4g2zj08

Evaluation of Knowledge and Attitudes Toward Palliative Care Among Critical Care Nurses in Tertiary Hospitals of South Punjab, Pakistan
type: item
description: Background: Palliative care (PC) is essential in intensive care, yet nurses’ readiness for symptom control, communication, and family engagement varies widely in low- and middle-income settings. Empirical data from South Punjab’s tertiary ICUs/HDU remain limited. Objective: To quantify critical care nurses’ knowledge and attitudes toward PC in tertiary hospitals of South Punjab, Pakistan, and identify priority domains for education. Methods: A cross-sectional study was conducted from 1 November 2024 to 21 April 2025 among ICU/HDU nurses in public and private tertiary hospitals. Using a structured, expert-reviewed questionnaire, demographics, knowledge, and attitudes were collected on 5-point Likert scales. Knowledge items were polarity-coded and reverse-scored where appropriate; total knowledge and attitude scores were expressed as percentages of scale maxima and categorized a priori (Excellent >80%, Good 65–80%, Average 50–64%, Poor <50%). Results: Of 151 nurses (97.4% female; 43.7% >30 years; 43.7% >5 years’ experience), mean knowledge was 68.8% (“Good”) and mean attitude 60.58% (“Average”). High item accuracy was observed for “patient is best judge of pain” (76%) and “chronic vs acute pain differ” (79%). Misconceptions persisted for placebo appropriateness (20% correct) and emotional detachment (33% correct). Attitudes favored family involvement (educating families 77%; extending care to families 78%; family participation in care 73%) but showed discomfort with end-of-life care (change topic when asked about dying 59%; not wanting to care for dying 42%; not wanting to attend a dying patient 40%). Conclusion: ICU/HDU nurses exhibited solid pain-assessment knowledge but gaps in psychosocial/ethical domains and communication openness. Targeted, simulation-supported education and embedded ICU triggers for early PC consultation are warranted.
subject: Articles
  topic: section
subject: palliative care; intensive care; nurses; attitudes; knowledge; South Punjab; Pakistan
  topic: keywords
creator: Saima Mulazim
creator: Raffia
creator: Muhammad Bilal
creator: Suleman
creator: Nasir Khan
creator: Muhammad Danish
creator: Farrukh Jamal
rights: Copyright (c) 2025 Saima Mulazim, Raffia, Muhammad Bilal, Suleman, Nasir Khan, Muhammad Danish, Farrukh Jamal (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-11-13
publication date: 2025-11-13
starting page: e943
ending page: e943
doi: 10.61919/04je9970

Evaluating the Gross Motor Function and Balance in Children with Cerebral Palsy: A Systematic Review and Meta-analysis
type: item
description: Background: Cerebral palsy (CP) is a leading cause of childhood physical disability, with impairments in gross motor function and balance that limit independence and participation. A wide range of physical therapy (PT) approaches has been proposed, but comparative evidence across intervention types and functional severity levels remains fragmented. Objective: To synthesize randomized controlled trial (RCT) evidence on the effectiveness of PT interventions for improving gross motor function and balance in children with CP, and to explore which therapies show the most consistent benefits. Methods: PubMed, Cochrane Library, Scopus, and PEDro were searched from January 2000 to April 2025 for RCTs involving children aged 1–18 years with CP receiving PT-based interventions targeting gross motor function and/or balance. Eligible outcomes were Gross Motor Function Measure (GMFM-88 Dimensions D and E or GMFM-66) and the Pediatric Balance Scale (PBS). Two reviewers independently performed study selection, data extraction, and risk-of-bias assessment using Cochrane RoB 2.0 and the Jadad scale. Random-effects meta-analyses were conducted using standardized mean differences (SMD) with 95% confidence intervals (CI). The protocol was registered in PROSPERO (CRD420251008653). Results: Twenty-eight RCTs including 1084 children met inclusion criteria; 12 contributed to meta-analysis. Pooled analyses showed small-to-moderate benefits of PT interventions over comparison conditions for GMFM-88 Dimension D (10 studies; SMD 0.36, 95% CI 0.15–0.56; p = 0.0006; I² = 0%), GMFM-88 Dimension E (10 studies; SMD 0.48, 95% CI 0.13–0.83; p = 0.007; I² = 61%), and PBS (6 studies; SMD 0.43, 95% CI 0.16–0.71; p = 0.002; I² = 12%). Subgroup analyses suggested comparatively larger effects for task-oriented training, hippotherapy, and virtual reality–assisted programmes, particularly when added to conventional PT. Most trials were of good methodological quality, though blinding of participants and thera…
subject: Review Articles
  topic: section
subject: cerebral palsy; gross motor function; balance; physical therapy; hippotherapy; virtual reality; randomized controlled trial.
  topic: keywords
creator: Ifra Neelum
creator: Amna Aamir Khan
creator: Nazia Adeeb
rights: Copyright (c) 2025 Ifra Neelum, Amna Aamir Khan, Nazia Adeeb (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-11-15
publication date: 2025-11-15
starting page: e940
ending page: e940
doi: 10.61919/6mkm6573

Knowledge and Attitude of Nurses Regarding Palliative Care: A Cross-Sectional Study of Various Tertiary Care Hospitals, Peshawar, Pakistan
type: item
description: Background: Palliative care improves quality of life across the disease trajectory, yet misconceptions and attitudinal barriers among nurses can delay timely referral, undermine analgesic stewardship, and impair end-of-life communication. Local data from tertiary hospitals in Pakistan are limited. Objective: To quantify nurses’ knowledge and attitudes toward palliative care in tertiary hospitals of Peshawar and identify priority domains for education. Methods: A cross-sectional survey (June–August 2025) was administered to registered nurses with ≥3 months’ experience across four tertiary hospitals. A structured questionnaire adapted from validated tools captured demographics and item-level agreement on knowledge and attitudes using five-point Likert responses. Descriptive statistics and Wilson 95% confidence intervals were reported for agreement prevalences. Results: Of 262 respondents, 94.8% were female and 61.0% were aged 25–35 years; 43.5% had 1–5 years’ experience and 85.1% held a nursing diploma. Evidence-aligned beliefs were common: educating families (89.6% agreement, 95% CI 85.3–92.7), facilitating patient emotional expression (86.4%, 81.7–90.0), trusting patient self-report of pain (81.8%, 76.7–86.0), and distinguishing chronic from acute pain (81.8%, 76.7–86.0). However, misconceptions were frequent: changing the topic when asked “Am I dying?” (78.6%, 73.2–83.1), perceiving emotional detachment as required (63.7%, 57.7–69.3), limiting palliative care to downhill deterioration (57.8%, 51.7–63.6), endorsing placebo use for pain (66.3%, 60.4–71.8), and preferring intramuscular opioids (48.7%, 42.7–54.7). Conclusion: Nurses demonstrated strong family-centred orientations but substantial gaps in communication and analgesic ethics, defining a tractable training agenda focused on serious-illness dialogue, scope and timing of palliative care, and WHO-concordant pain management.
subject: Articles
  topic: section
subject: palliative care; nurses; knowledge; attitudes; pain management; end-of-life communication; Pakistan; tertiary hospitals
  topic: keywords
creator: Saad Hassan
creator: Muhammad Sohail
creator: Mehraban Khan
creator: Inam Ullah
creator: Haroon Khan
creator: Salman Nasib
creator: Zohaib Ahmad
rights: Copyright (c) 2025 Saad Hassan, Muhammad Sohail, Mehraban Khan, Inam Ullah, Haroon Khan, Salman Nasib, Zohaib Ahmad (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-11-13
publication date: 2025-11-13
starting page: e939
ending page: e939
doi: 10.61919/6m1eb675

Knowledge, Attitude and Practices Related to Physical Ergonomics Among Non-Medical Undergraduate University Students
type: item
description: Background: Musculoskeletal disorders (MSDs) are among the most common functional impairments linked to poor posture, prolonged static positions, and lack of ergonomic awareness. While ergonomic training is emphasized in clinical disciplines, non-medical university students—who also engage in prolonged computer and device use—remain understudied. Understanding their ergonomic awareness and behavior is essential for early prevention of posture-related problems and promoting musculoskeletal health. Objective: To assess the knowledge, attitude, and practices (KAP) related to physical ergonomics among non-medical undergraduate university students. Methods: A cross-sectional KAP survey was conducted among 384 non-medical undergraduate students from the University of Chenab, Gujrat, and the University of Punjab, Gujranwala Campus, Pakistan. Data were collected using a self-structured, validated questionnaire comprising four sections: demographics, knowledge (14 items), attitude (6 items), and practice (8 items). Reliability was confirmed with Cronbach’s α = 0.783. Descriptive statistics were computed, and associations among KAP components were tested using Pearson’s correlation. Analyses were performed using SPSS version 23 with significance set at p ≤ 0.05. Results: The mean age of participants was 20.27 ± 1.99 years, and 54.9% were females. More than half (55.2%) had good knowledge, 64.1% demonstrated a positive attitude, and 59.9% reported moderate ergonomic practice. Weak but statistically significant positive correlations were found among knowledge, attitude, and practice: knowledge–attitude (r = 0.188, p < 0.001), knowledge–practice (r = 0.199, p < 0.001), and attitude–practice (r = 0.112, p = 0.028). Conclusion: Non-medical students exhibited good ergonomic knowledge and favorable attitudes but only moderate practical application. The weak correlations among KAP dimensions suggest that awareness alone does not guarantee behavioral adherence. Integrating ergonomic e…
subject: Articles
  topic: section
subject: Physical ergonomics; knowledge; attitude; practice; musculoskeletal disorders; university students
  topic: keywords
creator: Hina Irshad
creator: Faryal
creator: Asim Raza
creator: Farooq Islam
creator: Razia Aslam
creator: Wajida Perveen
creator: Umer Ilyas
creator: Sahreen Anwar
rights: Copyright (c) 2025 Hina Irshad, Faryal, Asim Raza, Farooq Islam, Razia Aslam, Wajida Perveen, Umer Ilyas, Sahreen Anwar (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-11-08
publication date: 2025-11-08
starting page: e937
ending page: e937
doi: 10.61919/pe778006

Prevalence of Postoperative Delirium in Elderly Patients After Hip Fracture Surgery: A Cross-Sectional Study
type: item
description: Background: Postoperative delirium represents a frequent but under-recognized complication in elderly patients undergoing hip fracture surgery, contributing to prolonged hospitalization, increased morbidity, and mortality. Despite extensive international research, evidence from South Asian healthcare settings remains limited, where variability in anesthesia practice, medication use, and geriatric co-management may influence delirium risk. Objective: To determine the prevalence of postoperative delirium and identify its associated risk factors among elderly patients undergoing hip fracture surgery in tertiary hospitals in Lahore, Pakistan. Methods: A cross-sectional study was conducted over eight months across two tertiary centers. A total of 244 patients aged ≥65 years with preserved baseline cognition (MMSE ≥24) were consecutively enrolled. Delirium was assessed daily for five days postoperatively using the Confusion Assessment Method (CAM). Demographic, clinical, and perioperative data were collected prospectively. Univariate and multivariable logistic regression analyses were performed to identify independent predictors of delirium. Results: The mean age was 77.6 ± 6.8 years, with 55.7% females. The prevalence of postoperative delirium was 33.2% (81/244). Independent predictors included age ≥80 years (Adjusted OR 2.35; 95% CI: 1.41–3.89; p<0.001), general anesthesia (OR 1.79; 95% CI: 1.02–3.14; p=0.042), polypharmacy (OR 2.14; 95% CI: 1.25–3.66; p=0.005), and Charlson Comorbidity Index ≥5 (OR 1.68; 95% CI: 1.01–2.80; p=0.045). Delirium was associated with longer hospital stay (p<0.001) and higher postoperative complications (p=0.017). Conclusion: Postoperative delirium is a prevalent and clinically significant complication among elderly hip fracture patients in Pakistan. Advanced age, general anesthesia, comorbidity burden, and polypharmacy substantially increase risk. Integrating targeted prevention strategies—such as optimized anesthesia selection, medication r…
subject: Articles
  topic: section
subject: Postoperative Delirium, Hip Fracture, Elderly, Anesthesia, Polypharmacy, Geriatric Surgery, Pakistan
  topic: keywords
creator: Ahmad Hasan Arif
creator: Muhammad Nadeem Khan
creator: Ziggar Khan
creator: Mudassar Ijaz
creator: Sahaab Alvi
creator: Arshad Aziz
rights: Copyright (c) 2025 Ahmad Hasan Arif, Muhammad Nadeem Khan, Ziggar Khan, Mudassar Ijaz, Sahaab Alvi, Arshad Aziz (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-11-08
publication date: 2025-11-08
starting page: e936
ending page: e936
doi: 10.61919/ms732d11

https://www.jhwcr.com/index.php/jhwcr/article/view/935
type: item
title: Comparative Effectiveness of Physiotherapy Interventions in Postpartum Recovery: Pelvic Floor Rehabilitation vs. Abdominal Muscle Strengthening Exercises for Restoring Function, Mobility, and Alignment
description: Background: Pelvic Girdle Pain (PGP) is a common musculoskeletal condition during pregnancy, affecting nearly half of expectant mothers and impairing mobility, functional activity, and quality of life. Physiotherapy interventions such as manual mobilization and muscle strengthening have shown promise individually, but their combined effects remain underexplored. Objective: To evaluate and compare the effectiveness of Mulligan Mobilization, hip abductor strengthening exercises, and their combination on pain, disability, and quality of life in pregnant women with PGP. Methods: A randomized controlled trial was conducted among 60 pregnant women clinically diagnosed with PGP. Participants were randomly allocated into three groups: Mulligan Mobilization (Group A), hip abductor strengthening exercises (Group B), and a combined intervention (Group C). Interventions were administered thrice weekly for six weeks. Pain intensity, disability, and quality of life were assessed at baseline and post-intervention using the Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and Short Form-36 (SF-36), respectively. Data were analyzed using ANOVA and Bonferroni-adjusted post hoc tests at a significance level of p<0.05. Results: All groups exhibited significant improvements in pain, disability, and quality of life (p<0.05). The combined intervention group achieved the greatest reductions in VAS (3.4±1.1) and ODI (18.2±2.8) scores and the highest improvement in SF-36 (20.7±3.9), with moderate-to-large effect sizes (η²=0.17–0.21). Between-group comparisons confirmed the superiority of the combined approach over single-modality treatments (p<0.01). Conclusion: The combination of Mulligan Mobilization and hip abductor strengthening exercises is a safe, effective, and comprehensive physiotherapeutic approach for managing pregnancy-related pelvic girdle pain. This integrated strategy offers greater functional recovery and quality-of-life improvements compared with individual interv…
subject: Articles
  topic: section
subject: Pelvic Girdle Pain, Mulligan Mobilization, Hip Abductor Strengthening, Pregnancy, Physiotherapy, Pain Management, Disability, Quality of Life
  topic: keywords
creator: Nadia Rehan
creator: Muhammad Basim
creator: Huma Bukhari
creator: Sajawal Bashir
creator: Zubia Imtiaz
creator: Sana Ghafoor
creator: Zuhha Alamgeer
creator: Hafiz Ali Bin Asim
rights: Copyright (c) 2025 Nadia Rehan, Muhammad Basim, Huma Bukhari, Sajawal Bashir, Zubia Imtiaz, Sana Ghafoor, Zuhha Alamgeer, Hafiz Ali Bin Asim (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-11-07
publication date: 2025-11-07
starting page: e935
ending page: e935
doi: 10.61919/zs63ff30

Efficacy, Safety, and Tolerability of Tofacitinib in Patients with Rheumatoid Arthritis: A Multicentric Pakistani Study
type: item
description: Background: Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by progressive joint inflammation and disability. Despite the availability of conventional and biologic DMARDs, cost, parenteral administration, and variable tolerability limit long-term disease control in low- and middle-income settings. Tofacitinib, an oral Janus kinase inhibitor, offers an alternative targeted synthetic therapy with demonstrated global efficacy. However, data from South Asian populations remain limited. Objective: To determine the efficacy, safety, and tolerability of tofacitinib in Pakistani patients with rheumatoid arthritis. Methods: A multicentric retrospective descriptive study was conducted at three rheumatology centers in Lahore, Pakistan, between January 2022 and July 2023. Electronic medical records of adults with RA (ACR/EULAR 2010 criteria) receiving oral tofacitinib 10 mg daily for ≥6 months were reviewed. Disease activity was assessed using DAS28-ESR at baseline, 3 months, and 6 months. Data were analyzed using SPSS 23, applying Chi-square and paired t-tests with significance set at p < 0.05. Results: Eighty-five patients met inclusion criteria (82.4% female; mean age 42.6 ± 12.1 years). Mean DAS28-ESR decreased from 5.04 ± 0.43 at baseline to 2.85 ± 0.85 after 6 months (p < 0.001). Remission was achieved in 55.3% of patients, with higher rates in biologic-naïve (56.9%) than biologic-experienced groups (50.0%). Combination therapy with methotrexate yielded the best outcomes, though tofacitinib monotherapy remained comparably effective. Adverse events occurred in 9.4% of patients, all mild and reversible; no serious infections, thrombotic events, malignancies, or tuberculosis reactivations were reported. Conclusion: Tofacitinib demonstrated significant efficacy and excellent tolerability in achieving remission among Pakistani patients with RA, supporting its role as a cost-effective and convenient oral alternative to biologics in routine clinical pract…
subject: Articles
  topic: section
subject: rheumatoid arthritis, tofacitinib, JAK inhibitors, DMARDs, biologic-naïve, remission, Pakistan
  topic: keywords
creator: Sadaf Sarwar
creator: Sumaira Farman Raja
creator: Madeeha Siddique
creator: Aroosa Saleem
creator: Muhammad Shiraz Niaz
creator: Adnan Khalid
rights: Copyright (c) 2025 Sadaf Sarwar, Sumaira Farman Raja, Madeeha Siddique, Aroosa Saleem, Muhammad Shiraz Niaz, Adnan Khalid (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-07-13
publication date: 2025-07-13
starting page: e934
ending page: e934
doi: 10.61919/p110gp22

Awareness of SLE Patients About the Disease, Its Treatment, and Potential Complications
type: item
description: Background: Systemic lupus erythematosus (SLE) is a chronic multisystem autoimmune disease with fluctuating activity and significant morbidity, where long-term outcomes depend greatly on patient awareness and adherence to treatment. Despite therapeutic advances, many patients demonstrate inadequate understanding of their disease, contributing to delayed care, poor compliance, and increased complications. Objective: To determine the level of awareness among patients with SLE regarding the disease, its management strategies, and potential complications, and to evaluate associations with education level, disease duration, and treatment adherence. Methods: This cross-sectional descriptive study was conducted at the National Hospital, Lahore, over three months. Ninety-six patients diagnosed with SLE according to American College of Rheumatology criteria were enrolled through non-probability consecutive sampling. Data were collected via structured face-to-face interviews using a pre-validated, Likert scale–based questionnaire assessing awareness across three domains: disease knowledge, management, and complications. Statistical analysis was performed using SPSS version 25, applying chi-square tests and Pearson correlation with a significance threshold of p ≤ 0.05. Results: Low awareness was observed in 52.1% of patients, moderate in 33.3%, and high in 14.6%. Higher education, longer disease duration, and medication adherence were significantly associated with improved awareness (p < 0.05). Conclusion: Awareness of SLE and its complications remains limited, highlighting the need for structured patient education programs to enhance disease literacy, adherence, and long-term outcomes
subject: Articles
  topic: section
subject: Systemic lupus erythematosus, patient awareness, disease management, treatment adherence, complications, health education
  topic: keywords
creator: Ali Raza
creator: Sumaira Farman Raja
creator: Rizwan Ahmad
creator: M. Ans Abdullah
rights: Copyright (c) 2025 Ali Raza, Sumaira Farman Raja, Rizwan Ahmad, M. Ans Abdullah (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-07-15
publication date: 2025-07-15
starting page: e933
ending page: e933
doi: 10.61919/07nw0n96

Lung Patterns Diagnosed on HRCT in Patients with Acute Inflammatory Pulmonary Disease
type: item
description: Background: High-resolution computed tomography (HRCT) provides detailed visualization of pulmonary parenchymal abnormalities and is the imaging modality of choice for assessing acute inflammatory lung disease. Its ability to delineate consolidation, ground-glass opacity (GGO), and other parenchymal changes enhances diagnostic accuracy and reduces the need for invasive investigations. Objective: To determine the prevalence and distribution of lung patterns on HRCT among patients with acute inflammatory pulmonary disease and to evaluate their relationship with age and gender. Methods: This cross-sectional observational study included 59 adult patients (33 females, 26 males) who underwent HRCT at Services Hospital, Lahore, between January and June 2024. Eligible participants presented with acute respiratory symptoms (<4 weeks) and radiological features of inflammation. HRCT findings were independently reviewed by two radiologists. Data were analyzed using SPSS v25 with χ² and Fisher’s exact tests to assess associations between imaging patterns and demographic factors. Results: The most frequent HRCT findings were bilateral involvement (86.4%), consolidation (55.9%), pleural effusion (47.5%), and GGO (44.1%). No statistically significant associations were found between age or sex and specific HRCT patterns (p>0.05). Conclusion: Consolidation, GGO, and pleural effusion were the dominant HRCT patterns in acute inflammatory pulmonary disease. HRCT remains a crucial non-invasive diagnostic tool for timely identification and management of acute lung inflammation.
subject: Articles
  topic: section
subject: HRCT, acute inflammatory lung disease, consolidation, ground-glass opacity, pleural effusion, bilateral involvement
  topic: keywords
creator: Sadaf Abdul Qadir
creator: Romaisa Nadeem
creator: Bakhtawar Saeed
creator: Abeer Shahzad
creator: Arshia Mubeen Asif
creator: Aqsa Atta
creator: Rida Zainab
creator: Sehrish Qasim
rights: Copyright (c) 2025 Sadaf Abdul Qadir, Romaisa Nadeem, Bakhtawar Saeed, Abeer Shahzad, Arshia Mubeen Asif, Aqsa Atta, Rida Zainab, Sehrish Qasim (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-11-05
publication date: 2025-11-05
starting page: e932
ending page: e932
doi: 10.61919/wbttzp38

Bridging the Gap: Evaluating Radiation Protection Awareness in Pakistan’s Future Dentists
type: item
description: Background: Dental radiography is an essential diagnostic tool, but improper radiation use poses significant risks to both patients and clinicians. In Pakistan, limited awareness and inconsistent adherence to radiation protection guidelines among dental students highlight the need for systematic evaluation. Radiation protection training is critical to ensure safe radiographic practice and compliance with global standards. Objective: This study aimed to assess the level of radiation protection awareness and adherence to safety protocols among undergraduate dental students in Pakistan, bridging the gap between theoretical knowledge and clinical practice. Methods: A cross-sectional, questionnaire-based survey was conducted among 110 BDS students from multiple dental institutions in Lahore. The validated questionnaire evaluated knowledge of radiation hazards, understanding of deterministic and stochastic effects, and compliance with protection measures such as ALARA, use of lead aprons, and operator positioning. Data were analyzed using SPSS v25, applying descriptive statistics and chi-square tests to examine associations across academic years. Results: Among participants, 91% recognized radiation hazards, yet only 52.6% demonstrated adequate compliance with safety practices. Knowledge improved significantly across academic years (p<0.05), with fourth-year students achieving the highest mean score (5.33±2.12). However, familiarity with international safety guidelines remained limited (33.6%). Conclusion: Although awareness of radiation hazards among Pakistani dental undergraduates is moderate to high, practical adherence to safety protocols remains insufficient. Integrating structured, hands-on radiation safety modules within dental curricula is essential to strengthen protection competency and safeguard public health.
subject: Articles
  topic: section
subject: Dental Radiography, Radiation Protection, ALARA, Dental Students, Pakistan, Radiological Safety, Awareness.
  topic: keywords
creator: Syeda Malaika
creator: Mohsin Miraj
creator: Laiba Fatima
creator: Shayan Sheraz
creator: Maham Nasir
creator: Anam Fazal
rights: Copyright (c) 2025 Syeda Malaika, Mohsin Miraj, Laiba Fatima, Shayan Sheraz, Maham Nasir, Anam Fazal (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-11-05
publication date: 2025-11-05
starting page: e931
ending page: e931
doi: 10.61919/fh828a65