The PEP++ study protocol: a cluster-randomised controlled trial on the effectiveness of an enhanced regimen of post-exposure prophylaxis for close contacts of persons affected by leprosy to prevent disease transmission

BACKGROUND

Leprosy is an infectious disease with a slow decline in global annual caseload in the past two decades. Active case finding and post-exposure prophylaxis (PEP) with a single dose of rifampicin (SDR) are recommended by the World Health Organization as measures for leprosy elimination. However, more potent PEP regimens are needed to increase the effect in groups highest at risk (i.e., household members and blood relatives, especially of multibacillary patients). The PEP++ trial will assess the effectiveness of an enhanced preventive regimen against leprosy in high-endemic districts in India, Brazil, Bangladesh, and Nepal compared with SDR-PEP.

METHODS

The PEP++ study is a cluster-randomised controlled trial in selected districts of India, Brazil, Bangladesh, and Nepal. Sub-districts will be allocated randomly to the intervention and control arms. Leprosy patients detected from 2015 - 22 living in the districts will be approached to list their close contacts for enrolment in the study. All consenting participants will be screened for signs and symptoms of leprosy and tuberculosis (TB). In the intervention arm, eligible contacts receive the enhanced PEP++ regimen with three doses of rifampicin (150 - 600 mg) and clarithromycin (150 - 500 mg) administered at four-weekly intervals, whereas those in the control arm receive SDR-PEP. Follow-up screening for leprosy will be done for each individual two years after the final dose is administered. Cox' proportion hazards analysis and Poisson regression will be used to compare the incidence rate ratios between the intervention and control areas as the primary study outcome.

DISCUSSION

Past studies have shown that the level of SDR-PEP effectiveness is not uniform across contexts or in relation to leprosy patients. To address this, a number of recent trials are seeking to strengthen PEP regimens either through the use of new medications or by increasing the dosage of the existing ones. However, few studies focus on the impact of multiple doses of chemoprophylaxis using a combination of antibiotics. The PEP++ trial will investigate effectiveness of both an enhanced regimen and use geospatial analysis for PEP administration in the study communities.

TRIAL REGISTRATION

NL7022 on the Dutch Trial Register on April 12, 2018. Protocol version 9.0 updated on 18 August 2022 https://www.onderzoekmetmensen.nl/en/trial/23060.

Hyphenation of lipophilic ruthenium(II)-diphosphine core with 5-fluorouracil: an effective metallodrug against glioblastoma brain cancer cells

Glioblastoma multiforme (GBM) is the most common highly aggressive malignant brain tumor, with a very limited chance for survival post-diagnosis and post-treatment. Despite significant advancement in GBM genomics implicated in molecularly targeted chemotherapies, the prognosis remains poor and requires new drug discovery approaches. We used fluoropyrimidine 5-fluorouracil (5-FU), an antimetabolite anticancer drug conjugated or 'caged' within a lipophilic Ru(II)-diphosphine (dppe) core formulated as [RuII(dppe)2(5-FU)]PF6 (Ru-DPPE-5FU), where dppe = 1,2-bis(diphenylphosphino)ethane, and evaluated its in vitro cytotoxicity in depth with aggressive GBM cells (LN229). The hydrophilic nature of 5-FU limits its passage through the blood-brain barrier (BBB), which prevents its effective accumulation and efficacy for GBM tumors. Herein, we attempted to modulate the lipophilicity of 5-FU by inserting it within a well-designed lipophilic {Ru(dppe)2}-core with anticipated higher efficiency towards GBM. The physicochemical properties of [RuII(dppe)2(5-FU)]PF6 (Ru-DPPE-5FU) were studied using various spectroscopic and analytical techniques. The molecular structure was determined using X-ray crystallography, showing a distorted {RuP4NO} octahedral geometry with bidentate (N, O) binding of 5-FU and its aromatization in the Ru(II)-bound form. The 31P-NMR spectra of Ru-DPPE-5FU showed four closely spaced distinct 31P-signals, indicating four unique chemical environments around P, and the strong coupling constants between them make it a second-order spectrum. The RuII/RuIII redox potential in Ru-DPPE-5FU shifted by ∼0.91 V towards the anodic region as compared to its precursor complex cis-[Ru(dppe)2Cl2] (Ru-DPPE-Cl). DFT-based theoretical calculations have been performed to correlate the experimental electronic absorption spectra and redox behaviours of the complexes. The electrostatic potential (ESP) plots indicate the delocalization of the charge density on the O-/F-atom from the 5-FU ligand towards Ru(II) upon its complexation. The antioxidant properties of all the compounds were quantified by a 2,2-diphenyl-1-picrylhydrazyl (DPPH) radical scavenging assay. The hyphenation of the 5-fluorouracil (5-FU) ligand to the lipophilic {Ru(dppe)2}-core endowed lipophilicity to Ru-DPPE-5FU with higher in vitro cytotoxicity (IC50 = 2.37 μM) against the LN229 GBM cells as compared to the hydrophilic 5-FU, suggesting efficient cellular uptake. Further biological assays indicated that the complex is highly potent in inhibiting significant proliferation and spheroid formation and restricting the migratory potentials of the GBM cells. Increased caspase 3/7 activity and the presence of apoptotic bodies at the center of 3-D GBM spheroids as revealed by AO/EB dual staining indicated a deeper penetration of the lipophilic complex. The Ru-DPPE-5FU complex displayed lower cytotoxicity in HaCaT normal cells (IC50 = 7.27 μM) in comparison to LN229 cancer cells with a selectivity index (S.I.) of ≥3. Overall, the synergism and caging of 5-FU within the hydrophobic {Ru(dppe)2}-core improves the pharmacokinetic profile of Ru-DPPE-5FU as a potent anticancer agent for glioblastoma.

Liposomes Containing Zinc-Based Chemotherapeutic Drug Block Proliferation and Trigger Apoptosis in Breast Cancer Cells

Platinum-based chemotherapeutic drugs are effective in killing malignant cells but often trigger drug resistance or off-target side effects. Unlike platinum, zinc is used as an endogenous cofactor for several cellular enzymes and may, thus, display increased biocompatibility. In this present study, we have rationally designed and synthesized two substituted phenanthro[9,10-d]imidazole-based ligands L1 and L2 with pyridine and quinoline substitution at the 2 position and their corresponding Zn(II) complexes; (L1)2Zn and (L2)2Zn, which are characterized by standard analytical and spectroscopic methods. (L2)2Zn, but not (L1)2Zn has intrinsic fluorescence, indicating its potential utility in imaging applications. To facilitate cellular uptake, we generated liposomal formations with a phospholipid DMPC (1,2-Dimyristoyl-sn-glycero-3-phosphocholine) through molecular self-assembly. These liposomal formulations Lip-(L1)2Zn and Lip-(L2)2Zn were able to enter breast cancer cells, induce DNA fragmentation, arrest the cell cycle at the G0/G1 phase, decrease proliferation, and promote apoptosis by activating the DNA damage response. Importantly, both Lip-(L1)2Zn and Lip-(L2)2Zn decreased the size of breast cancer cell-based spheroids, indicating they may be capable of suppressing tumor growth. Our work represents an important proof-of-concept exercise demonstrating that successful liposomal formation of phenanthro[9,10-d]imidazole-based Zn(II) complexes with inherent optical properties have great promise for the development of imaging probes and efficient anticancer drugs.

Intermittent or Sequential Topical Tacrolimus in Atopic Dermatitis: Systematic Review and Meta-Analysis

Topical calcineurin inhibitors (TCIs) and topical corticosteroids (TCS) are the mainstays of flare management for atopic eczema or atopic dermatitis (AD). Tacrolimus (an immunomodulator), belongs to the class of calcineurin inhibitors, with promising efficacy in AD. We performed this systematic review to obtain an up-to-date coverage map of controlled clinical trials of sequential or intermittent treatments with TCI as a therapeutic intervention for AD. Articles of interest were retrieved from PubMed, Google Scholar, and EMBASE published between between January 2000 and March 2023. Key words were "calcineurin inhibitors," "corticosteroids," "atopic dermatitis," "pruritus," "sequential," "intermittent" and "consecutive" while fixed language search consisted of "Intermittent topical calcineurin inhibitors AND topical corticosteroids AND atopic dermatitis OR eczema" AD patients who were administered sequential and/or intermittent applications of TCI for management of atopic eczema were included. Outcome measures included but were not limited to Scoring of Atopic Dermatitis (SCORAD) and the Eczema Area Severity Score (EASI). Four clinical trials were considered for the purpose of review. A total of 101 patients with AD were analysed. The risk of bias was low in two studies, while the other two had an unclear risk of bias. Overall, pooled data from two trials revealed that sequential therapy with TCS/TCI was comparable to monotherapy or emollients, as the test for overall effect determined was non-significant with a p-value of 0.33. The two studies were highly heterogeneous, as indicated by a very high I2 of 92% and an extremely significant p-value (p=0.0005). Sequential therapy with TCS and TCIs was effective and well tolerated in the management of AD and it may be considered an important treatment approach during the initial period.

Ruthenium(II) Polypyridyl-Based Photocages for an Anticancer Phytochemical Diallyl Sulfide: Comparative Dark and Photoreactivity Studies of Caged and Precursor Uncaged Complexes

The spatiotemporal control over the drug's action offered by ruthenium(II) polypyridyl complexes by the selective activation of the prodrug inside the tumor has beaconed toward much-desired selectivity issues in cancer chemotherapy. The photocaging of anticancer bioactive ligands attached synergistically with cytotoxic Ru(II) polypyridyl cores and selective release thereof in cancer cells are a promising modality for more effective drug action. Diallyl sulfide (DAS) naturally found in garlic has anticancer, antioxidant, and anti-inflammatory activities. Herein, we designed two Ru(II) polypyridyl complexes to cage DAS having a thioether-based donor site. For in-depth photocaging studies, we compared the reactivity of the DAS-caged compounds with the uncaged Ru(II)-complexes with the general formula [Ru(ttp)(NN)(L)]+/2+. Here, in the first series, ttp = p-tolyl terpyridine, NN = phen (1,10-phenanthroline), and L = Cl- (1-Cl) and H2O (1-H2O), while for the second series, NN = dpq (pyrazino[2,3-f][1,10]phenanthroline), and L = Cl- (2-Cl) and H2O (2-H2O). The reaction of DAS with 1-H2O and 2-H2O yielded the caged complexes [Ru(ttp)(NN)(DAS)](PF6)2, i.e., 1-DAS and 2-DAS, respectively. The complexes were structurally characterized by X-ray crystallography, and the solution-state characterization was done by 1H NMR and ESI-MS studies. Photoinduced release of DAS from the Ru(II) core was monitored by 1H NMR and UV-vis spectroscopy. When irradiated with a 470 nm blue LED in DMSO, the photosubstitution quantum yields (Φ) of 0.035 and 0.057 were observed for 1-DAS and 2-DAS, respectively. Intriguing solution-state speciation and kinetic behaviors of the uncaged and caged Ru(II)-complexes emerged from 1H NMR studies in the dark, and they are depicted in this work. The caged 1-DAS and 2-DAS complexes remained mostly structurally intact for a reasonably long period in DMSO. The uncaged 1-Cl and 2-Cl complexes, although did not undergo substitution in only DMSO but in the 10% DMSO/H2O mixture, completely converted to the corresponding DMSO-adduct within 16 h. Toward gaining insights into the reactivity with the biological targets, we observed that 1-Cl upon hydrolysis formed an adduct with 5'-GMP, while a small amount of GSSG-adduct was observed when 1-Cl was reacted with GSH in H2O at 323 K. 1-Cl after hydrolysis reacted with l-methionine, although the rate was slightly slower compared with that with DMSO, suggesting varying reaction kinetics with different sulfur-based linkages. Although 1-H2O reacted with sulfoxide and thioether ligands at room temperature, the rate was much faster at higher temperatures obviously, and thiol-based systems needed higher thermal energy for conjugation. Overall, these studies provide insight for thoughtful design of new generation Ru(II) polypyridyl complexes for caging suitable bioactive organic molecules.

Total Reflection X-ray Fluorescence Spectrometric Analysis of Ten Lanthanides at the Ultratrace Level Having a High Degree of Overlap in the Emission Lines

The extensive use of lanthanide elements in the medical, electrical, agricultural, and nuclear fields has increased their contamination in the environment. The detrimental effect of lanthanides on human health can be reduced or eliminated by their fast determination in the concerned specimen. For this purpose, an offline conjugation of the cloud point extraction (CPE) process with total reflection X-ray fluorescence (TXRF) spectrometry was done. This process was found to provide simple, quick, and precise simultaneous determination of ten lanthanides whose emission lines have a high degree of overlap at the ultratrace level. N,N,N',N'-tetra-octyl-diglycolamide in triton X-114 micelles was found to offer a selective CPE of all of the lanthanides in the presence of higher concentrations of naturally abundant cations and anions. A multivariative partial least-squares regression (PLSR) calibration approach was preferred due to the complex overlapped spectra of L lines of the lanthanides. Ten lanthanides, viz., La, Nd, Sm, Eu, Gd, Tb, Dy, Ho, Tm, and Lu, were simultaneously determined by this method, having concentrations in the range from 10 to 5 × 103 μg L-1. The proposed method was validated by analyzing three certified reference materials (CRMs), viz., NASS-7 seawater, SRLS-6 river water, and NIST 1640a natural water, via standard addition with the relative standard deviations of ≤10%.

Filaggrin gene polymorphisms in Indian children with atopic dermatitis: A cross-sectional multicentre study

Background Filaggrin (FLG) gene encoding the protein filaggrin plays an important role in barrier function of the skin and its alteration is a predisposing factor for atopic dermatitis. FLG gene variants result in absent or decreased filaggrin protein. Worldwide, the prevalence of FLG variants ranges from 14 to 56%. FLG null variants are distinct in each population. Objectives To study the FLG gene polymorphisms in Indian children and attempt a genotype-phenotype correlation in atopic dermatitis. Methods This was a cross-sectional, multicentre study conducted on 75 Indian children. Demographic details, clinical features and identified FLG null variants were recorded. We performed a whole gene sequencing of the entire FLG coding region using next-generation sequencing technology. Results The prevalence of FLG null variants was 34.7%. A total of 20 different FLG loss of function variants in 26 children were documented. Sixteen (80%) variants were novel and four (20%) were previously reported in Asian and European populations. We found a statistically significant association between FLG variants with early age of onset of atopic dermatitis (P = 0.016) and elevated serum IgE levels (P = 0.051). There was no significant difference between atopic dermatitis phenotypes in children having one variant as compared to children harbouring two or more null variants. Limitation Small sample size. Conclusion Our study reports a unique set of FLG variants different from Asian and European populations, with these variants being significantly associated with an early age of onset of atopic dermatitis and elevated serum IgE levels.

Co-Existence of Nodular Purpura and Vaccine Induced Panniculitis in a 4-Month-Old Baby-A Diagnostic Dilemma

Vitamin K deficient bleeding (VKDB) disorder is a rare but fatal disorder that needs prompt diagnosis and timely intervention. Among its varied clinical manifestations, nodular purpura is rare one. Proper knowledge of this presentation helps clinicians to exclude other close differentials and avoid unnecessary delays in diagnosis. Though bleeding from the vaccination site could be a manifestation of VKDB, the concomitant presence of nodular purpura and vaccine-induced panniculitis in the same patient is rare. We report a case of a 4-month-old baby presenting with both, posing a diagnostic dilemma.

Conversion of Laparoscopic to Open Cholecystectomy: Experience in A Tertiary Care Hospital

Now-a-days Laparoscopic cholecystectomy is regarded as the gold standard treatment for benign gallbladder disease but in certain situations conversion to open cholecystectomy is extremely important for the safety of the patient. The objective of this study was to evaluate the reason for conversion of this operation to open surgery. This prospective study was carried out on 392 patients in a single unit of Department of Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh and in a private hospital from July 2013 to December 2018. Maximum (28.3%) patients were 31-40 years age group. Majority (75.3%) was female and 24.7% were male. It was observed that only 2.1% were converted due to dense adhesion (n=3), severe inflammation (n=2), difficult to define anatomy of Calot's triangle (n=2) and Mirizzi syndrome (n=1). Meticulous dissection and proper case selection can reduce the rate of conversion to open surgery.

Selective Extraction of Thorium(IV) from Uranium and Rare Earth Elements Using Tetraphenylethane-1,2-diylbis(phosphoramidate)

Tetraphenylethane-1,2-diylbis(phosphoramidate) in conjugation with a room temperature ionic liquid in chloroform medium is reported for the first time in the liquid-liquid extraction of thorium (Th). The extracted Th(IV) is collected as a white solid in the organic medium, thereby facilitating its easy separation. A high distribution ratio (D) of (12.4 ± 0.1) × 10³ in 2-8 mol L^-1 acidity range and high decontamination factors (α) of Th(IV) from uranium, lanthanides, and a number of transition elements makes this extraction process versatile and selective. A number of experimental investigations in synergism with extended X-ray absorption fine structure (EXAFS) spectroscopy and density functional theory (DFT) studies are interpreted to confirm the structure of the chelated complex. A 1:2 metal/ligand complex in which the two oxygen and two nitrogen atoms of each bis(phosphoramidate) molecule satisfying the eight coordination sites of Th(IV) is found to be formed. The extracted white solid thorium complex is easily converted to ThO₂ after washing and heating at 1300 °C under O₂ atmosphere. This work is expected to find direct application in the thorium fuel cycle, especially in the mining process of thorium from its ores and in the separation of fissile ²³³U from fertile ²³²Th in irradiated fuel.

PSS functionalized and stabilized carbon nanodots for specific sensing of iron in biological medium

Carbon Quantum Dots (CQDs) are already emerged as an excellent sensing element for its exceptional behavior in fluorescence, biocompatibility, and water dispersibility. However, its poor stability, selectivity and reproducibility in complex medium still be a big problem for its practical application. To overcome this, in the work, we have developed a new type of carbon quantum dot-PSS fluorescent nanocomposites which has been used for specific Fe³⁺ detection. The polystyrene sulfonate (PSS) polymer not only stabilize the QDs but also produces specific sites for Fe³⁺ to make a co-ordinate complex via Fe³⁺-SO3. The detection limit is calculated as low as 1 ppm which is adequate for measuring Fe³⁺ in blood or water samples. The mechanism of the quenching is very specific towards the Fe³⁺ ion due to the presence of PSS which makes the sensor selective among other metal ions and possible interferences. The rapid process of sensing, simple instrumentation, and excellent performances in presence of 1 % BSA and serum samples indicates the possible application for diagnostic usage in near future.

Evaluation of Fecal Pancreatic Elastase-1 as a Measure of Pancreatic Exocrine Function in Children with Pancreatitis

Pancreatic exocrine insufficiency occurs as a clinical consequence of chronic pancreatitis leading to fat maldigestion, malabsorption and malnutrition. Fecal elastase-1 is a laboratory-based test used for the diagnosis or exclusion of pancreatic exocrine insufficiency. The aim of the study was to observe the value of fecal elastase-1 in children with pancreatitis as an indicator of pancreatic exocrine insufficiency. This was a cross-sectional descriptive study conducted from January 2017 through June 2018. Thirty children with pain abdomen as control and 36 patients with pancreatitis as cases were included. An ELISA technique which recognizes human pancreatic elastase-1 from spot stool sample was employed for the test. Fecal elastase-1 activity in spot stool samples in acute pancreatitis (AP) ranged from 198.2-500μg/g with a mean of 342.1±136.4μg/g, acute recurrent pancreatitis (ARP) ranged from 15-500μg/g with a mean of 332.8±194.5μg/g and chronic pancreatitis (CP) ranged from 15-492.8μg/g with a mean of 222.2±197.1μg/g was obtained. In controls, fecal elastase-1 ranged from 28.4-500μg/g with a mean of 398.8±114.9μg/g. Disease severity was classified as mild to moderate pancreatic insufficiency (fecal elastase-1 100 to 200μg/g stool) was found in AP (14.3%) and CP (6.7%) cases. The severe pancreatic insufficiency (fecal elastase-1<100μg/g stool) was observed in ARP (28.6%) and CP (46.7%) cases. Malnutrition was observed in severe pancreatic insufficiency cases. This study result showed that fecal elastase-1 can be used as a measure of pancreatic exocrine function in children with pancreatitis.

An extended DNMA-based multi-criteria decision-making method and its application in the assessment of sustainable location for a lithium-ion batteries' manufacturing plant

Lithium-ion battery (LiB), a leading residual energy resource for electric vehicles (EVs), involves a market presenting exponential growth with increasing global impetus towards electric mobility. To promote the sustainability perspective of the EVs industry, this paper introduces a hybridized decision support system to select the suitable location for a LiB manufacturing plant. In this study, single-valued neutrosophic sets (SVNSs) are considered to diminish the vagueness in decision-making opinions and evade flawed plant location assessments. This study divided into four phases. First, to combine the single-valued neutrosophic information, some Archimedean-Dombi operators are developed with their outstanding characteristics. Second, an innovative utilization of the Method based on the Removal Effects of Criteria (MEREC) and Stepwise Weight Assessment Ratio Analysis (SWARA) is discussed to obtain objective, subjective and integrated weights of criteria assessment with the least subjectivity and biasedness. Third, the Double Normalization-based Multi-Aggregation (DNMA) method is developed to prioritize the location options. Fourth, an illustrative study offers decision-making strategies for choosing a suitable location for a LiB manufacturing plant in a real-world setting. Our outcomes specify that Bangalore (L ₂), with an overall utility degree (0.7579), is the best plant location for LiB manufacturing. The consistency and robustness of the presented methodology are discussed with the comparative study and sensitivity investigation. This is the first study in the current literature that has proposed an integrated methodology on SVNSs to select the best LiB manufacturing plant location by estimating both the objective and subjective weights of criteria and by considering ambiguous, inconsistent, and inexact manufacturing-based information.

Vanillin Benzothiazole Derivative Reduces Cellular Reactive Oxygen Species and Detects Amyloid Fibrillar Aggregates in Alzheimer's Disease Brain

The misfolding of amyloid beta (Aβ) peptides into Aβ fibrillary aggregates is a major hallmark of Alzheimer's disease (AD), which responsible for the excess production of hydrogen peroxide (H₂O₂), a prominent reactive oxygen species (ROS) from the molecular oxygen (O₂) by the reduction of the Aβ-Cu(I) complex. The excessive production of H₂O₂ causes oxidative stress and inflammation in the AD brain. Here, we have designed and developed a dual functionalized molecule VBD by using π-conjugation (C═C) in the backbone structure. In the presence of H₂O₂, the VBD can turn into fluorescent probe VBD-1 by cleaving of the selective boronate ester group. The fluorescent probe VBD-1 can undergo intramolecular charge transfer transition (ICT) by a π-conjugative system, and as a result, its emission increases from the yellow (532 nm) to red (590 nm) region. The fluorescence intensity of VBD-1 increases by 3.5-fold upon binding with Aβ fibrillary aggregates with a high affinity (K_d = 143 ± 12 nM). Finally, the VBD reduces the cellular toxic H₂O₂ as proven by the CCA assay and DCFDA assay and the binding affinity of VBD-1 was confirmed by using in vitro histological staining in 8- and 18-month-old triple transgenic AD (3xTg-AD) mice brain slices.

Chemical biology tools to interrogate the roles of O-GlcNAc in immunity

The O-linked β-N-acetylglucosamine (O-GlcNAc) glycosylation of proteins is an essential and dynamic post-translational modification in mammalian cells that is regulated by the action of two enzymes. O-GlcNAc transferase (OGT) incorporates this monosaccharide on serine/threonine residues, whereas O-GlcNAcase (OGA) removes it. This modification is found on thousands of intracellular proteins involved in vital cellular processes, both under physiological and pathological conditions. Aberrant expression of O-GlcNAc has been implicated in diseases such as Alzheimer, diabetes, and cancer, and growing evidence over the last decade has also revealed key implications of O-GlcNAcylation in immunity. While some key signaling pathways involving O-GlcNAcylation in immune cells have been discovered, a complete mechanistic understanding of how O-GlcNAcylated proteins function in the immune system remains elusive, partly because of the difficulties in mapping and quantifying O-GlcNAc sites. In this minireview, we discuss recent progress on chemical biology tools and approaches to investigate the role of O-GlcNAcylation in immune cells, with the intention of encouraging further research and developments in chemical glycoimmunology that can advance our understanding of O-GlcNAc in immunity.

Entropy and discrimination measures based q-rung orthopair fuzzy MULTIMOORA framework for selecting solid waste disposal method

Fastest growing population, rapid urbanization, and growth in the disciplines of science and technology cause continually development in the amount and diversity of solid waste. In modern world, evaluation of an appropriate solid waste disposal method (SWDM) can be referred as multi-criteria decision-making (MCDM) problem due to involvement of several conflicting quantitative and qualitative sustainability indicators. The imprecision and ambiguity are usually arisen in SWDM assessment problem, and the q-rung orthopair fuzzy set (q-ROFS) has been recognized as one of the adaptable and valuable ways to tackle the complex uncertain information arisen in realistic problems. In the context of q-ROFSs, entropy is a significant measure for depicting fuzziness and uncertain information of q-ROFS and the discrimination measure is generally used to quantify the distance between two q-ROFSs by evaluating the amount of their discrimination. Thus, the aim of this study is to propose a novel integrated framework based on multi-attribute multi-objective optimization with the ratio analysis (MULTIMOORA) method with q-rung orthopair fuzzy information (q-ROFI). In this approach, an integrated weighting process is presented by combining objective and subjective weights of criteria with q-ROFI. Inspired by the q-rung orthopair fuzzy entropy and discrimination measure, objective weights of criteria are estimated by entropy and discrimination measure-based model. Whereas, the subjective weights are derived based on aggregation operator and the score function under q-ROFS environment. In this respect, novel entropy and discrimination measure are proposed for q-ROFSs. Furthermore, to display the feasibility and usefulness of the introduced approach, a case study related to SWD method selection is presented under q-ROFS perspective. Finally, comparison and sensitivity investigation are presented to confirm the robustness and solidity of the introduced approach.

A Simplified Approach for the Aqueous Synthesis of Luminescent CdSe/ZnS Core/Shell Quantum Dots and Their Applications in Ultrasensitive Determination of the Biomarker 3-Nitro-l-tyrosine

In contrast to the hot-injection organometallic routes, synthesizing stable and highly luminescent core/shell nanocrystals with encapsulation of biocompatible groups through an aqueous route is a long-standing challenge. In recent years, relatively high quantum efficiency and unique properties of core/shell nanostructured materials (quantum dots) have contributed toward enhancement in sensing capability. The present work reports a facile aqueous synthesis process of core/shell CdSe/ZnS quantum dots (QDs) with encapsulation of glutathione (GSH). The optimal conditions for the synthesis of the most stable particles were ascertained, and the different experimental analyses suggest that the stable core/shell QDs in question have good crystallinity with a size around 4.7 nm with a shell thickness of 0.7 nm and a photoluminescence quantum yield of about 35%. Further, it is demonstrated that the as-synthesized material has great potential in detecting as low as 0.28 nM 3-nitro-l-tyrosine (3-NT), an important marker for oxidative stress, the level of which in our body signals several chronically diseased conditions. The enthalpy-driven interactions of CdSe/ZnS-GSH QDs with 3-NT were characterized through steady-state and time-resolved luminescence spectroscopy and isothermal microcalorimetry. The devised method of probing 3-NT was further validated with human serum samples. Thus, the proposed strategy may provide a protocol for selective determination of 3-NT under different pathological conditions.

Vapor Pressure versus Temperature Relations of Common Elements

The vapor pressure values of common elements are available in the literature over a limited temperature range and the accuracy and reliability of the reported data are not generally available. We evaluate the reliability and uncertainty of the available vapor pressure versus temperature data of fifty common pure elements and recommend vapor pressure versus temperature relations. By synthesizing the vapor pressure values from measurements reported in the literature with the values computed using the Clausius Clapeyron relation beyond the boiling point, we extend the vapor pressure range from 10^-8 atm to 10 atm. We use a genetic algorithm to optimize the fitting of the vapor pressure data as a function of temperature over the extended vapor pressure range for each element. The recommended vapor pressure values are compared with the corresponding literature values to examine the reliability of the recommended values.

Evaluation of diagnostic utility and performance of rapid SARS-CoV- 2 antigen detection assay in comparison with Real-Time RT-PCR in Kolkata, India

Background: COVID-19 has so far affected millions of people in India. The present study was undertaken to find out the performance and reliability of rapid antigen test (RAT) in compared to reverse transcription polymerase chain reaction (RT-PCR).Methods: The pre and existing medical conditions and clinical signs and symptoms were noted. The nasopharyngeal swab samples were taken for RAT, while both nasopharyngeal and oropharyngeal swab samples were mixed in a sterile viral transported medium (VTM) for RT-PCR. All patients were examined by RAT, while symptomatic negative in RAT were re-examined by RT-PCR.Results: Total 18,965 samples were examined by RAT and 3,998 samples by RT-PCR. Among them, only 5,753 patients (30.3%) were symptomatic and 1,757 patients (9.2%) were symptomatic positive. RAT showed overall 15.2% positive cases. Only 3.7% samples exhibited false negative results in RAT, which were found positive in RT-PCR. Interestingly, Ct (cycle threshold) values were >30 in all these samples.Conclusion: Hence, specific antigen-based rapid diagnostic test (RDT) will be most useful and reliable among any other qualitative tests for screening purpose.

AI-assisted biparametric MRI surveillance of prostate cancer: feasibility study

OBJECTIVES

To evaluate the feasibility of automatic longitudinal analysis of consecutive biparametric MRI (bpMRI) scans to detect clinically significant (cs) prostate cancer (PCa).

METHODS

This retrospective study included a multi-center dataset of 1513 patients who underwent bpMRI (T2 + DWI) between 2014 and 2020, of whom 73 patients underwent at least two consecutive bpMRI scans and repeat biopsies. A deep learning PCa detection model was developed to produce a heatmap of all PIRADS ≥ 2 lesions across prior and current studies. The heatmaps for each patient's prior and current examination were used to extract differential volumetric and likelihood features reflecting explainable changes between examinations. A machine learning classifier was trained to predict from these features csPCa (ISUP > 1) at the current examination according to biopsy. A classifier trained on the current study only was developed for comparison. An extended classifier was developed to incorporate clinical parameters (PSA, PSA density, and age). The cross-validated diagnostic accuracies were compared using ROC analysis. The diagnostic performance of the best model was compared to the radiologist scores.

RESULTS

The model including prior and current study (AUC 0.81, CI: 0.69, 0.91) resulted in a higher (p = 0.04) diagnostic accuracy than the current only model (AUC 0.73, CI: 0.61, 0.84). Adding clinical variables further improved diagnostic performance (AUC 0.86, CI: 0.77, 0.93). The diagnostic performance of the surveillance AI model was significantly better (p = 0.02) than of radiologists (AUC 0.69, CI: 0.54, 0.81).

CONCLUSIONS

Our proposed AI-assisted surveillance of prostate MRI can pick up explainable, diagnostically relevant changes with promising diagnostic accuracy.

KEY POINTS

• Sequential prostate MRI scans can be automatically evaluated using a hybrid deep learning and machine learning approach. • The diagnostic accuracy of our csPCa detection AI model improved by including clinical parameters.

Multiple attribute decision making based on Pythagorean fuzzy Aczel-Alsina average aggregation operators

A useful expansion of the intuitionistic fuzzy set (IFS) for dealing with ambiguities in information is the Pythagorean fuzzy set (PFS), which is one of the most frequently used fuzzy sets in data science. Due to these circumstances, the Aczel-Alsina operations are used in this study to formulate several Pythagorean fuzzy (PF) Aczel-Alsina aggregation operators, which include the PF Aczel-Alsina weighted average (PFAAWA) operator, PF Aczel-Alsina order weighted average (PFAAOWA) operator, and PF Aczel-Alsina hybrid average (PFAAHA) operator. The distinguishing characteristics of these potential operators are studied in detail. The primary advantage of using an advanced operator is that it provides decision-makers with a more comprehensive understanding of the situation. If we compare the results of this study to those of prior strategies, we can see that the approach proposed in this study is more thorough, more precise, and more concrete. As a result, this technique makes a significant contribution to the solution of real-world problems. Eventually, the suggested operator is put into practise in order to overcome the issues related to multi-attribute decision-making under the PF data environment. A numerical example has been used to show that the suggested method is valid, useful, and effective.

Platform for Active Vaccine Formulation Using a Two-Mode Enhancement Mechanism of Epitope Presentation by Pickering Emulsion

The efficiency of epitope-based vaccination (subunit vaccines) is tightly correlated with heterogeneity and the high density of epitope presentation, which maximizes the potential antigenic determinants. Here, we developed a two-mode platform for intensifying the epitope presentation of subunit vaccines. The two-mode epitope presentation enhancement includes a covalent attachment of high concentrations of SARS-CoV-2-S1 peptide epitope to the surface of virus-like-particles (VLPs) and the subsequent assembly of VLP/epitope conjugates on the oil droplet surface at an oil/water interface of an emulsion as Pickering stabilizers. The resultant emulsions were stable for weeks in ambient conditions, and our platform was challenged using the epitope of the SARS-CoV-2-S1 peptide that served as a model epitope in this study. In vivo assays showed that the αSARS-CoV-2-S1 immunoglobulin G (IgG) titers of the studied mouse antisera, developed against the SARS-CoV-2-S1 peptide under different epitope preparation conditions, showed an order of magnitude higher IgG titers in the studied VLP-based emulsions than epitopes dissolved in water and epitopes administered with an adjuvant, thereby confirming the efficacy of the formulation. This VLP-based Pickering emulsion platform is a fully synthetic approach that can be readily applied for vaccine development to a wide range of pathogens.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Defining core patient descriptors for perforated peptic ulcer research: international Delphi

BACKGROUND

Perforated peptic ulcer (PPU) remains a common condition globally with significant morbidity and mortality. Previous work has demonstrated variation in reporting of patient characteristics in PPU studies, making comparison of studies and outcomes difficult. The aim of this study was to standardize the reporting of patient characteristics, by creating a core descriptor set (CDS) of important descriptors that should be consistently reported in PPU research.

METHODS

Candidate descriptors were identified through systematic review and stakeholder proposals. An international Delphi exercise involving three survey rounds was undertaken to obtain consensus on key patient characteristics for future research. Participants rated items on a scale of 1-9 with respect to their importance. Items meeting a predetermined threshold (rated 7-9 by over 70 per cent of stakeholders) were included in the final set and ratified at a consensus meeting. Feedback was provided between rounds to allow refinement of ratings.

RESULTS

Some 116 clinicians were recruited from 29 countries. A total of 63 descriptors were longlisted from the literature, and 27 were proposed by stakeholders. After three survey rounds and a consensus meeting, 27 descriptors were included in the CDS. These covered demographic variables and co-morbidities, risk factors for PPU, presentation and pathway factors, need for organ support, biochemical parameters, prognostic tools, perforation details, and surgical history.

CONCLUSION

This study defines the core descriptive items for PPU research, which will allow more robust synthesis of studies.

Unravelling the mystery of porta hepatis for surgical benefit

BACKGROUND

Hepatobilliary surgery is nowadays growing with increasing popularity throughout the world with advent of newer liver imaging modalities. Anticipating a wide range of morphological variations of porta hepatis (PH), a precise understanding is pertinent to preoperative diagnosis, operative procedure and post-operative outcome of hepatobiliary disease.

MATERIALS AND METHODS

Considering recent interest, present study was undertaken. One-hundred and ten isolated adult cadaveric livers of unknown age and sex were dissected to explore detail morphology and morphometry of PH.

RESULTS

Classical picture of PH was observed in 20% liver. The standard representation of structures was highest in hepatic artery (59.1%) followed by portal vein (55.5%) and hepatic duct (51.8%). On the basis of structural distribution PH was described as 16 types. Maximum variable number was found in hepatic artery followed by portal vein and hepatic duct. In morphometric analysis, transverse diameter of PH was more than antero-posterior diameter, indicated that PH was slightly oval in transverse plane. Position of PH was more towards posterior and slightly right in inferior surface of liver.

CONCLUSIONS

Variations of portal anatomy regarding circulatory and biliary dynamics is worth knowing in successful planning of hepatobiliary surgeries with least complications.

Fermatean fuzzy copula aggregation operators and similarity measures-based complex proportional assessment approach for renewable energy source selection

Selecting the optimal renewable energy source (RES) is a complex multi-criteria decision-making (MCDM) problem due to the association of diverse conflicting criteria with uncertain information. The utilization of Fermatean fuzzy numbers is successfully treated with the qualitative data and uncertain information that often occur in realistic MCDM problems. In this paper, an extended complex proportional assessment (COPRAS) approach is developed to treat the decision-making problems in a Fermatean fuzzy set (FFS) context. First, to aggregate the Fermatean fuzzy information, a new Fermatean fuzzy Archimedean copula-based Maclaurin symmetric mean operator is introduced with its desirable characteristics. This proposed operator not only considers the interrelationships between multiple numbers of criteria, but also associates more than one marginal distribution, thus avoiding information loss in the process of aggregation. Second, new similarity measures are developed to quantify the degree of similarity between Fermatean fuzzy perspectives more effectively and are further utilized to compute the weights of the criteria. Third, an integrated Fermatean fuzzy-COPRAS approach using the Archimedean copula-based Maclaurin symmetric mean operator and similarity measure has been developed to assess and rank the alternatives under the FFS perspective. Furthermore, a case study of RES selection is presented to validate the feasibility and practicality of the developed model. Comparative and sensitivity analyses are used to check the reliability and strength of the proposed method.

P-FLUX: A phosphorus budget dataset spanning diverse agricultural production systems in the United States and Canada

Quantifying spatial and temporal fluxes of phosphorus (P) within and among agricultural production systems is critical for sustaining agricultural production while minimizing environmental impacts. To better understand P fluxes in agricultural landscapes, P-FLUX, a detailed and harmonized dataset of P inputs, outputs, and budgets, as well as estimated uncertainties for each P flux and budget, was developed. Data were collected from 24 research sites and 61 production systems through the Long-term Agroecosystem Research (LTAR) network and partner organizations spanning 22 U.S. states and 2 Canadian provinces. The objectives of this paper are to (a) present and provide a description of the P-FLUX dataset, (b) provide summary analyses of the agricultural production systems included in the dataset and the variability in P inputs and outputs across systems, and (c) provide details for accessing the dataset, dataset limitations, and an example of future use. P-FLUX includes information on select site characteristics (area, soil series), crop rotation, P inputs (P application rate, source, timing, placement, P in irrigation water, atmospheric deposition), P outputs (crop removal, hydrologic losses), P budgets (agronomic budget, overall budget), uncertainties associated with each flux and budget, and data sources. Phosphorus fluxes and budgets vary across agricultural production systems and are useful resources to improve P use efficiency and develop management strategies to mitigate environmental impacts of agricultural systems. P-FLUX is available for download through the USDA Ag Data Commons (https://doi.org/10.15482/USDA.ADC/1523365).

Pharmacophore Based Design of Probable FGFR-1 Inhibitors from the 3D Crystal Structure of Infigratinib - A Drug Used in the Treatment of Cholangiocarcinomas

Background:

Pemigatinib (INCB054828) and Infigratinib (BGJ398) are the few selective drugs that are approved by the FDA to treat cholangiocarcinoma, a rare form of bile duct cancer. Infigratinib is a pan FGFR inhibitor and has been found promising in Phase-3, first-line PROOF clinical trial. So, screening drug-like compounds having similar pharmacophoric features like infigratinib is the inspiration of the present work.

Objective:

The objective was to identify drug-like compounds with similar pharmacophoric features as in infigratinib. The compounds screened through the 3D query pharmacophore of infigratinib were also predicted for ADMET properties so that the compounds may have good bioavailability.

Method:

A pharmacophore was generated from the crystal structure of infigratinib with several pharmacophoric features such as hydrogen bond donor, hydrophobic, positive ionizable, and ring aromatic. MayBridge database containing 65,263 compounds was used for virtual screening (VS) using LibDock. The initial Hit compounds were subjected to ADMET predictions. Finally, two Hit compounds were selected and docked with the FGFR-1 receptor to predict the interaction of the ligand atoms with the amino acid residues of the receptor's active site.

Result:

The fit score for infigratinib, N-(4-fluorophenyl)-2-(5-((2-(4-methoxy-2,5-dimethylphenyl)-2- oxoethyl)thio)-4-methyl-4H-1,2,4-triazol-3-yl)acetamide (Hit-1) and 4-(4-((2-(5,6-dimethyl-1H-benzo[d] imidazol-2-yl)ethyl)carbamoyl)pyridin-2-yl)-1-methylpiperazin-1-ium (Hit-4) is 4.58901, 4.36649, and 3.71732, respectively. The LibDock score of infigratinib, Hit-1, and Hit-4 is 122.474, 123.289, and 123.353, respectively. The binding affinity score (-PLP1) of infigratinib, Hit-1, and Hit-4 is -143.19, - 102.72, and -91.71.

Conclusion:

The present study concluded that the two compounds designated as Hit-1 and Hit-4 have been identified as binders of FGFR-1, and Hit-4 occupies the whole pharmacophoric space of infigratinib, and both the compounds LibDock scores are better than the infigratinib. The two compounds Hit-1 and Hit-4 may be synthesized and studied for their enzyme inhibition assay on FGFR-1 and biologically evaluated on different cell lines for Cholangiocarcinoma.

Cloud vendor selection for the healthcare industry using a big data-driven decision model with probabilistic linguistic information

The role of cloud services in the data-intensive industry is indispensable. Cision recently reported that the cloud market would grow to 55 billion USD, with an active contribution of the cloud to healthcare around 2025. Inspired by the report, cloud vendors expand their market and the quality of services to seek growth globally. The rapid growth of the cloud sector in the healthcare industry imposes a challenge: making a rational choice of a cloud vendor (CV) out of a diverse set of vendors. Typically, the healthcare industry 4.0 sees the issue as a large-scale group decision-making problem. Previous studies on a CV selection face certain challenges, such as (i) a lack of the ability to handle multiple users’ views, as well as experts’/users’ complex linguistic views; (ii) the confidence level associated with a view is not considered; (iii) the transformation of multiple users’ views into holistic data is lacking; and (iv) the systematic prioritization of CVs with minimum human intervention is a crucial task. Motivated by these challenges and circumventing them, a new big data-driven decision model is put forward in this paper. Initially, the data in the form of complex expressions are collected from multiple cloud users and are further transformed into a holistic decision matrix by adopting probabilistic linguistic information (PLI). PLI represents complex linguistic expressions along with the associated confidence levels. Later, a holistic decision matrix is formed with the missing values imputed by proposing an imputation algorithm. Furthermore, the criteria weights are determined by using a newly proposed mathematical model and partial information. Finally, the evaluation based on the distance from average solution (EDAS) approach is extended to PLI for the rational ranking of CVs. A real-time example of a CV selection for a healthcare center in India is exemplified so as to demonstrate the usefulness of the model, and the comparison reveals the merits and limitations of the model.

Limited-resource preparable chitosan magnetic particles for extracting amplification-ready nucleic acid from complex biofluids

Extraction and concentration of pure nucleic acid from complex biofluids are the prerequisite for nucleic acid amplification test (NAAT) applications in pathogen detection, biowarfare prevention, and genetic diseases. However, conventional spin-column mediated nucleic acid extraction is constricted by the requirement for costly power-intensive centralized lab infrastructure, making it unsuitable for limited-resource settings. Significant progress in lab-on-a-chip devices or cartridges (e.g., Cepheid GeneXpert®) that integrate nucleic acid extraction and amplification has been made, but these approaches either require additional equipment or are costly. Similarly, their complexities make them difficult to fabricate in low-resource settings by the end-user themselves. The application of magnetic particles such as silica-coated iron oxide beads for nucleic acid extraction is relatively instrument-free, rapid, user-friendly, and amenable to automation. But, they rely on hazardous chaotropic salt chemistry and ethanol desalting that could limit their efficacy for downstream NAATs. Recent advances in several types of novel material (e.g., polyamine) coated magnetic bead-based chaotropic salt-free extraction methods offer a possible solution to this problem. However, these materials also involve multistep synthesis impermissible in limited-resource settings. To offer a possible instrument-free magnetic particle-based nucleic acid extraction doable at limited-resource settings, we investigated the nucleic acid capture ability of two chitosan-coated magnetic particles that are preparable by minimally trained personnel using only a water bath and a magnetic stirrer within 6-8 h. We quantitatively probed the efficiency of the passive (without any electrical shaking or vortex-aided) DNA magnetocapture (i.e., binding to chitosan magnetic particles, physical separation from its sample of origin, and release from the particles) using UV₂₆₀. To explore their suitability towards clinically relevant sensitive downstream NAATs, 100-1000 copies (i.e., in the order of zeptomole) of Escherichia coli (E. coli) or human genomic DNA from aqueous solution, crude cell lysate, and fetal bovine serum were extracted by them and then successfully detected using quantitative real-time loop-mediated isothermal amplification (LAMP) or real-time polymerase chain reaction (PCR). Alongside, their suitability with gel-based LAMP, colorimetric LAMP, and in situ (on beads) LAMP was also probed. The required optimization of the amplification methods has been discussed. Overall, the turnaround time for the magnetocapture combined with NAAT was 1.5-2 h and is thus expected to aid in rapid clinical decision making. With the ease of preparation, reproducibility, and compatibility with downstream NAATs, we anticipate that these magnetic particles would facilitate the expansion and decentralization of nucleic acid-based diagnosis for limited-resource settings.

Determinants of Pre-Hospital Delay after Myocardial Infarction in Bangladesh: A Rural Center Experience

Determinants of pre-hospital delay after myocardial infarction, strictly among South-Asian rural community, till now is largely unknown. And Bangladesh is not an exception. It is a fact that though around two third of its population still live in villages, we do not know what factors are having influence on such delay. To find out these primers of time consumption before seeking medical help, this is a picture of a medical college hospital situated in a rural precinct. This cross-sectional analytical study was conducted among 98 patients came with Myocardial Infarction (MI) who had met inclusion and exclusion criteria from July 2019 and December 2019. Both STEMI & NSTEMI patients were selected as they have similar attributes. Data was collected in the coronary care unit using a preformed questionnaire. Among 98 MI patients, where 16 female and 82 male patients had average age 53±12 years. Average income rural community was around 100 USD. Almost 50% of sample were illiterate or below 5th grade. On average 6.6 hours (95% CI: 3.5-12.3) were required to reach CCU after symptom onset, whereas distance to first medical contact (FMC) was about 10.2 Km (95% CI: 6.4-16.2). Median distance to nearest PCI-capable hospital was 140 Km (IQR- 20 Km). Only 28% of patients could reach hospital within 2 hours, where 85% had onset of symptom while they were at home. Tertiary level medical college (74.5%) followed by Upazilla (Sub-urban) government health complex (22.4%) were frequent site of FMC. Principle mode of transport to hospital was CNG-three-wheeler (75% of cases). Logistic regression analysis showed only low literacy was as significant predictor about more than 2 hours pre-hospital delay (OR=2.58; p=0.043). Other factors such as low income (OR=2.51; p=0.126), diabetes mellitus (OR=2.99; p=0.059), female sex (OR=1.56; p=0.753), house wife (OR=1.88; p=0.547), previous MI (OR=1.52; p=1.000), symptom ignorance (OR=2.14; p=0.455) increases pre-hospital delay and distance to FMC <10 Km (OR=0.44; p=0.079) no significant prediction of pre-hospital delay after myocardial infarction. As rural community has less access to education low literacy has a significant impact on pre-hospital delay after myocardial infarction. So measures should be taken in rural areas through patient education and social awareness program regarding MI symptom and danger of delayed medical attention.