Adolopment of clinical practice guidelines and creation of referral pathways for psychiatric conditions in Pakistan

Psychiatric disorders are highly prevalent in Pakistan and burdens the scarce number of psychiatrists present in the country. The establishment of evidence-based clinical practice guidelines (EBCPGs) and primary-care referral pathways within the local context is imperative to make the process efficient. In this Health Policy, we aimed to develop EBCPGs and primary-care referral pathways that are specific to Pakistan's primary-care setting, with the aim of facilitating the management of psychiatric conditions. Ten EBCPGs were created through the GRADE-ADOLOPMENT process; two recommendations were adopted with minor changes, 43 were excluded, and all others were adopted without any changes. Ten primary-care referral pathways for managing ten psychiatric disorders were created and 23 recommendations were added which will help to bridge the gap in care provision. These psychiatric referral pathways and EBCPGs will bring Pakistan's healthcare system a step closer to achieving optimal health outcomes for patients.

GRADE-ADOLOPMENT of hyperthyroidism treatment guidelines for a Pakistani context

INTRODUCTION

The prevalence of hyperthyroidism in Pakistan is 2.9%, which is two times higher than in the United States. Most high-quality hyperthyroidism clinical practice guidelines (CPGs) used internationally originate from high-income countries in the West. Local CPGs in Pakistan are not backed by transparent methodologies. We aimed to produce comprehensive, high-quality CPGs for the management of hyperthyroidism in Pakistan.

METHODS

We employed the GRADE-ADOLOPMENT approach utilizing the 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis as the source CPG. Recommendations from the source guideline were either adopted as is, excluded, or adapted according to our local context.

RESULTS

The source guideline included a total of 124 recommendations, out of which 71 were adopted and 49 were excluded. 4 recommendations were carried forward for adaptation via the ETD process, with modifications being made to 2 of these. The first addressed the need for liver function tests (LFTs) amongst patients experiencing symptoms of hepatotoxicity while being treated with anti-thyroid drugs (ATDs). The second pertained to thyroid status testing post-treatment by radioactive iodine (RAI) therapy for Graves' Disease (GD). Both adaptations centered around the judicious use of laboratory investigations to reduce costs of hyperthyroidism management.

CONCLUSION

Our newly developed hyperthyroidism CPGs for Pakistan contain two context-specific modifications that prioritize patients' finances during the course of hyperthyroidism management and to limit the overuse of laboratory testing in a resource-constrained setting. Future research must investigate the cost-effectiveness and risk-benefit ratio of these modified recommendations.

Developing and piloting an online course on osteoporosis using a multidisciplinary multi-institute approach- a cross-sectional qualitative study

INTRODUCTION

Postgraduate medical trainees (PGs) in developing nations face various educational hurdles due to limited access to quality resources and training facilities. This study aimed to assess the effectiveness of e-learning, particularly Massive Open Online Courses (MOOCs), within postgraduate medical education. It involved the development of a customized online course focused on osteoporosis for PGs and an examination of their perspectives and preferences concerning online learning methods like Virtual Learning Environment (VLE) platforms.

METHODS

The study was conducted from January 2018 to December 2020. A multi-institutional, multidisciplinary team was assembled to design an osteoporosis course on the VLE platform. PGs (n = 9) from diverse disciplines and institutions were selected with informed consent. Focus group discussions (FGDs) among these PGs identified their preferences for the online course, which subsequently guided the development of the MOOC. The modular MOOC comprised recorded micro-lectures, flashcards, videos, case challenges, and expert interviews. The educational impact of the VLE was assessed using pre- and post-module tests among the participants, and their perceptions of the PGs and course facilitators were gathered via an online survey.

RESULTS

The study identified the involvement of PGs in the course design process as beneficial, as it allowed for content customization and boosted their motivation for peer-to-peer learning. During the FGDs, PGs expressed a strong preference for flexible learning formats, particularly short downloadable presentations, and micro-lectures. They also identified challenges related to technology, institutional support, and internet connectivity. In the subsequently customized MOOC course, 66% of PGs (n = 6) attempted the pre-test, achieving a mean score of 43.8%. Following the VLE module, all PGs (n = 9) successfully passed the end-of-module test, averaging a score of 96%, highlighting its impact on learning. The majority (n = 8, 88.9%) agreed that the course content could be applied in clinical practice, and 66.7% (n = 6) expressed extreme satisfaction with the learning objectives and content. Participants favoured end-of-module assessments and the use of best-choice questions for evaluation.

CONCLUSION

This study highlights the importance of virtual learning, particularly MOOCs, in addressing the educational challenges faced by developing nations. It emphasizes the need for tailored online courses that cater to the preferences and requirements of PGs. The findings suggest that MOOCs can foster collaboration, networking, and opportunities for professional development, and interdisciplinary collaboration among faculty members can be a key strength in course development. This research provides valuable insights for educators, institutions, and e-learning developers seeking to enhance their teaching methodologies and establish accessible educational environments in the digital age.

The CalculAuthor: determining authorship using a simple-to-use, fair, objective, and transparent process

Authorship determination on a research article remains a largely subjective process. Existing guidelines on authorship taxonomy lack objectivity and are more useful in determining who deserves authorship rather than determining the order of authors. To promote best practices in authorship taxonomy, we developed an authorship rubric that provides a fair, objective, and transparent means of crediting authorship. We christened this tool the "CalculAuthor". The following steps are to be undertaken to create a scoring system based on the requirements of the projects: determining creditable criteria, assigning credit weightages, deciding levels of contribution, determining each author's contribution, calculating authorship scores and ranking. These must be performed by or in close collaboration with the primary investigator (PI), with conflicts being resolved at the PI's discretion. All team members should be informed about the authorship determination process early in the project and their agreement regarding its use must be obtained. While the CalculAuthor was developed to be used in medical research, its customizability enables it to be employed in any field of academia. We recommend that the CalculAuthor be piloted within institutions before its mainstream adoption, and any institution-specific factors should be considered to make the process more efficient and suitable.

Generalized complex cilia tip modeled flow through an electroosmotic region

In this analysis, we explore a nanofluid model that represents the role of ciliary carpets in the transport of magnetohydrodynamic fluid in an electroosmotic channel. Hybrid nanofluid features are also taken into interpretation. The equations leading the flow analysis are converted into non-dimensional form by supposing long wavelength and low Reynolds number approximations. Analytical solutions for velocity distribution, pressure gradient and stream function are acquired and solved by a mathematic solver. The effects of the relevant physical parameters are graphically noted. The consequence of the present model has remarkable applications, which can be used in various areas of biological transport processes, artificial cilia design and in the operation of other mechanical devices.

GRADE-ADOLOPMENT of clinical practice guideline for postmenopausal osteoporosis management-a Pakistani context

Due to its high prevalence, we aimed to create postmenopausal osteoporosis clinical practice guideline via GRADE-ADOLOPMENT for Pakistan. We recommend a higher dose (2000-4000 IU) of vitamin D for osteoporotic patients who are old, have malabsorption, or are obese. The guideline will help standardize care provision and improve health care outcomes for osteoporosis.

PURPOSE

Postmenopausal osteoporosis affects one in every five postmenopausal women in Pakistan. An evidence-based clinical practice guideline (CPG) is needed to standardize care provision to optimize health outcomes. Hence, we aimed to develop CPG for the management of postmenopausal osteoporosis in Pakistan.

METHODS

The GRADE-ADOLOPMENT process was used to adopt (as is or with minor changes), exclude (omit), or adapt (modify based on local context) recommendations to the source guideline (SG)-clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis-2020 update from American Association of Clinical Endocrinology (AACE).

RESULTS

The SG was "adoloped" to cater to the local context. The SG consisted of 51 recommendations. Forty-five recommendations were adopted as is. Due to unavailability of drugs, 4 recommendations were adopted with minor changes, and one was excluded, while one recommendation was adopted with the inclusion of use of a surrogate FRAX tool specific for Pakistan. One recommendation regarding vitamin D dosage was adapted to recommend a dose of 2000-4000 IU of vitamin D in patients with obesity, malabsorption, and old age.

CONCLUSION

The developed Pakistani postmenopausal osteoporosis guideline consists of 50 recommendations. The guideline created recommends a higher dose (2000-4000 IU) of vitamin D for patients who are old, have malabsorption, or are obese, which is an adaptation from the SG by the AACE. This higher dose is justified as lower doses prove to be suboptimal in these groups and should be complemented with baseline vitamin D and calcium levels.

GRADE-ADOLOPMENT of clinical practice guidelines and creation of clinical pathways for the primary care management of chronic respiratory conditions in Pakistan

INTRODUCTION

In Pakistan, chronic respiratory conditions contribute a large burden of morbidity and mortality. A major reason for this is the lack of availability of local evidence-based clinical practice guidelines (EBCPGs) in Pakistan, particularly at the primary care level. Thus, we developed EBCPGs and created clinical diagnosis and referral pathways for the primary care management of chronic respiratory conditions in Pakistan.

METHODS

The source guidelines were selected by two local expert pulmonologists after a thorough literature review on PubMed and Google Scholar from 2010 to December 2021. The source guidelines covered idiopathic pulmonary fibrosis, asthma, chronic obstructive pulmonary disorders, and bronchiectasis. The GRADE-ADOLOPMENT process consists of three key elements: adoption (using recommendations as is or with minor changes), adaptation (effective context-specific changes to recommendations) or additions (including new recommendations to fill a gap in the EBCPG). We employed the GRADE-ADOLOPMENT process to adopt, adapt, adopt with minor changes, or exclude recommendations from a source guideline. Additional recommendations were added to the clinical pathways based on a best-evidence review process.

RESULTS

46 recommendations were excluded mainly due to the unavailability of recommended management in Pakistan and scope beyond the practice of general physicians. Clinical diagnosis and referral pathways were designed for the four chronic respiratory conditions, explicitly delineating the role of primary care practitioners in the diagnosis, basic management, and timely referral of patients. Across the four conditions, 18 recommendations were added (seven for IPF, three for bronchiectasis, four for COPD, and four for asthma).

CONCLUSION

The widespread use of the newly created EBCPGs and clinical pathways in the primary healthcare system of Pakistan can help alleviate the morbidity and mortality related to chronic respiratory conditions disease in the country.

Adolopment of adult diabetes mellitus management guidelines for a Pakistani context: Methodology and challenges

Introduction

Pakistan has the highest national prevalence of type 2 diabetes mellitus (T2DM) in the world. Most high-quality T2DM clinical practice guidelines (CPGs) used internationally originate from high-income countries in the West. Local T2DM CPGs in Pakistan are not backed by transparent methodologies. We aimed to produce comprehensive, high-quality CPGs for the management of adult DM in Pakistan.

Methods

We employed the GRADE-ADOLOPMENT approach utilizing the T2DM CPG of the American Diabetes Association (ADA) Standards of Medical Care in Diabetes - 2021 as the source CPG. Recommendations from the source guideline were either adopted as is, excluded, or adapted according to our local context.

Results

The source document contained 243 recommendations, 219 of which were adopted without change, 5 with minor changes, and 18 of which were excluded in the newly created Pakistani guidelines. One recommendation was adapted: the recommended age to begin screening all individuals for T2DM/pre-diabetes was lowered from 45 to 30 years, due to the higher prevalence of T2DM in younger Pakistanis. Exclusion of recommendations were primarily due to differences in the healthcare systems of Pakistan and the US, or the unavailability of certain drugs in Pakistan.

Conclusion

A CPG for the management of T2DM in Pakistan was created. Our newly developed guideline recommends earlier screening for T2DM in Pakistan, primarily due to the higher prevalence of T2DM amongst younger individuals in Pakistan. Moreover, the systematic methodology used is a significant improvement on pre-existing T2DM CPGs in Pakistan. Once these evidence based CGPs are officially published, their nationwide uptake should be top priority. Our findings also highlight the need for rigorous expanded research exploring the effectiveness of earlier screening for T2DM in Pakistan.

The impact of the COVID-19 pandemic on the career choice of medicine: A cross-sectional study amongst pre-medical students in Pakistan

Background

The COVID-19 pandemic has significantly affected the lives of healthcare workers due to the frontline nature of their work. Their hard work and sacrifice have forged new perceptions of healthcare workers. These changes may potentially influence students' interest in medicine. This study explores how the COVID-19 pandemic has affected premedical students’ decisions to pursue medicine as a career.

Methods

A cross-sectional study using a self-designed online questionnaire was carried out amongst pre-medical students across Pakistan.

Results

A total of 1695 students from 93 public and private schools filled in the survey. After the onset of the COVID-19 pandemic, significantly more pre-medical students want to pursue medicine (60.7%–62.9%) and less are unsure (20.2%–17%). Students are significantly more likely to be motivated to pursue medicine due to altruistic benefits to society (57% vs. 62.7%) and be deterred by the risk of contracting infections on duty (10%–14.6%). There is a minor but significant increase in the popularity of internal medicine (17.1%–18.9%), public health (4.1% vs. 5.7%), emergency medicine (3.8% vs. 5.7%), pediatrics (3.8% vs. 4.7%), and radiology (2.1% vs. 2.9%). Most pre-medical students felt that doctors routinely undergo physical and emotional turmoil (84%).

Conclusions

Although awareness of hardships faced by medical professionals has increased, motivation to pursue medicine has grown. Through understanding trends in the motivations of students to pursue medicine, medical schools can accommodate the expectations of incoming students and reach out to potential applicants.

•

More pre-medical students want to pursue medicine since the onset of the pandemic.

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The major motivation to pursue medicine remains altruistic.

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Since the pandemic, students are more likely to be deterred by occupational risks.

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Some specialties have become more popular choices since the pandemic.

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These include pediatrics, public health, and internal medicine.

Telemedicine During a Pandemic: Challenges, Opportunities & Way Forward at a Tertiary Care Hospital

Telemedicine is utilized to deliver health care services remotely. TM gained popularity as a result of pandemics, it can help the patients to get required medical care while sitting in the comfortable environment of their homes. In the future, it will continue to be used as a convenient, cost-effective patient care modality. This cross-sectional study was conducted in a tertiary care hospital, the objectives were to identify challenges faced by physicians during teleconsultations, recognize the opportunities and strengths of this modality during pandemic in a lower-income country. The self-made questionnaire was filled through an online medium and responses were recorded on a five-point Likert scale. A total of 83 participants were enrolled in this study. Most of them were Associate professors (29.8%), Assistant professors (26.2%), the ratio of the females was (52.4%) greater than males (47.6%). 46 (54.8%) lie between the age group 30-40 years. Pediatricians and senior instructors faced more difficulty in using telemedicine. The ones having clinical experience of less than 15 years or categorized in the age of 50-60 years faced challenges while using this modality. During the current pandemic, situation telemedicine is the only glimmer of light to provide better quality health care. Telemedicine is an innovative strategy and it is important to understand the perception of physicians about it. Incomplete and inadequate infrastructure and attitude of the physicians are the main obstacles toward successful implementation of telemedicine. Successful installation and deployment of this technology require a complete grasp of the process among physicians.

Factors Influencing the Intention to Pursue Surgery among Female Pre-Medical Students: A Cross-Sectional Study in Pakistan

BACKGROUND

While gender disparities in surgery are documented worldwide, it is unclear to what extent women consider surgery as a career before embarking on their medical school journey. This study aimed to report the percentage of pre-medical women in Pakistan who intend to eventually specialize in surgery and assess the factors motivating and deterring this decision.

METHODS

An online survey was conducted among female pre-medical (high school) students across Pakistan. Multivariable logistic regression was performed to determine motivating and deterring factors associated with the intention to pursue surgery.

RESULTS

Out of 1219 female high-school students, 764 (62.7) intended to join medical school. Among these 764, only 9.8% reported an exclusive intent to pursue surgery, while just 20.3% reported considering other specialties in addition to surgery. Significant motivators to pursue surgery exclusively were the intellectual satisfaction of pursuing surgery (adjusted odds ratio: 2.302), having opportunities to travel internationally for work (2.300) and use cutting-edge technology (2.203), interest in the specialty of surgery (2.031), the social prestige of becoming a surgeon (1.910), and considering one's personality well-suited to surgery (1.888). Major deterrents included the lack of interest in surgery (adjusted odds ratio: 3.812), surgical education and training being too difficult (2.440) and lengthy (1.404), and the risk of aggressive behavior from patients (2.239).

CONCLUSION

Even before entering medical school, most female pre-medical students have already decided against considering a future surgical career. Deterrents likely stem from women being pressured to conform to deep-seated societal expectations to dedicate their time and energy to domestic responsibilities.

Perceptions and Understanding of Diabetes Mellitus Technology in Adults with Type 1 or Type 2 DM: A Pilot Survey from Pakistan

INTRODUCTION

Diabetes mellitus technology (DMT) is increasingly used for routine management in developed countries, yet its uptake in developing countries is not as consistent. Multiple factors may influence this, including country specific patient perception regarding DMT. We conducted a pilot study in Pakistan to understand this important question which has not been studied yet.

METHODS

A cross-sectional pilot study was conducted in Pakistan. An anonymous survey exploring perceptions of diabetes technology was circulated on social media platforms, collecting responses over 2 weeks. Target population included adults (≥18 years) living in Pakistan, with DM1 or 2.

RESULTS

A total of 40 responses were received. The majority (36/40) reported using conventional glucometers. Nine used continuous glucose monitoring (CGM). Thirty-two of 40 patients believed DMT improved diabetes care, 22 felt it helped decreased risk of Diabetes-related complications. 15/40 stated that DMT results in increased cost of care. Sixteen reported their diabetes care teams had never discussed wearable DMT options whereas 11 disliked them because they did not want a device on their self.

CONCLUSION

In our pilot study we have identified broad themes of opportunity and challenges to DMT use in Pakistan. Patients' perceptions regarding DMT were generally positive but significant barriers to its acceptance included high cost, lack of discussion between doctor and patient about available technology and personal hesitation. Limitations of our study include sampling bias (online survey) and small sample size, but this data can help inform larger studies, to look at this important topic in greater detail.

Is Hypothyroidism Associated With Outcomes in Fracture Patients? Data From a Trauma Registry

BACKGROUND

Previous research reports suggesting the susceptibility of patients with hypothyroidism to fragility fractures. The current study aimed to compare injury factors, patient factors, and outcomes of fractures in patients with and without hypothyroidism.

METHODS

Study data were extracted from an ongoing single-center prospective orthopaedic trauma registry at a tertiary care hospital. Patients recruited between June 2015 and March 2020 were selected. Patients were grouped into those with and without hypothyroidism, and data on injury factors, management, clinical, and functional outcomes up to 6 mo were compared. Relation of fracture with TSH levels and age was analyzed, and prescription of bone-strengthening supplements was recorded in the hypothyroid group.

RESULTS

Among 1347 patients recruited in the trauma registry, 35 patients had hypothyroidism of which 77% were females compared to 30% of euthyroid subjects (P = 0.0001). The most commonly involved anatomic sites identified were the proximal femur and proximal humerus. Low-energy trauma more likely occurred in hypothyroid (71%) compared to 32% of euthyroid subjects (P < 0.001). Osteoporosis was identified in 90% of hypothyroid subjects who underwent a DEXA scan. The clinical and functional outcomes of patients seem to be similar in both groups, possibly due to adequate control of hypothyroidism or the effect of bone-strengthening supplements given to hypothyroid patients. Serum TSH level and age were not related to low-energy trauma in hypothyroid patients.

CONCLUSIONS

The current study identified that patients with hypothyroidism presenting with fractures are more likely females with low-energy trauma, involving the proximal femoral, and humeral fractures. Thyroid status was not associated with post-management outcomes.

Bioenergetics adaptations and redox homeostasis in pregnancy and related disorders

Pregnancy is a challenging physiological process that involves maternal adaptations to the increasing energetics demands imposed by the growing conceptus. Failure to adapt to these requirements may result in serious health complications for the mother and the baby. The mitochondria are biosynthetic and energy-producing organelles supporting the augmented energetic demands of pregnancy. Evidence suggests that placental mitochondria display a dynamic phenotype through gestation. At early stages of pregnancy placental mitochondria are mainly responsible for the generation of metabolic intermediates and reactive oxygen species (ROS), while at later stages of gestation, the placental mitochondria exhibit high rates of oxygen consumption. This review describes the metabolic fingerprint of the placental mitochondria at different stages of pregnancy and summarises key signs of mitochondrial dysfunction in pathological pregnancy conditions, including preeclampsia, gestational diabetes and intrauterine growth restriction (IUGR). So far, the effects of placental-driven metabolic changes governing the metabolic adaptations occurring in different maternal tissues in both, healthy and pathological pregnancies, remain to be uncovered. Understanding the function and molecular aspects of the adaptations occurring in placental and maternal tissue's mitochondria will unveil potential targets for further therapeutic exploration that could address pregnancy-related disorders. Targeting mitochondrial metabolism is an emerging approach for regulating mitochondrial bioenergetics. This review will also describe the potential therapeutic use of compounds with a recognised effect on mitochondria, for the management of preeclampsia.

Clinical characteristics and outcomes of patients presenting with hip fractures at a tertiary care hospital in Pakistan

Osteoporosis remains under-recognized and sub-optimally managed in Pakistan, with a lack of awareness that minimal impact hip fracture is a manifestation of low bone mineral density (BMD).

PURPOSE

Hip fracture is often the first clinical presentation of osteoporosis and an opportunity to intervene and reduce future fracture risk. Our aim was to understand the current practices in Pakistan related to bone health in patients presenting with a hip fracture.

METHODS

This is a retrospective study at a tertiary care center in Pakistan of patients admitted with a hip fracture. Data collected includes previous fracture history, known preceding diagnosis of low BMD medication details, comorbidities, and DXA results.

RESULTS

Two hundred ten patients were studied. The mean age of patients was 73.1 years, with 112 (53.3%) women. Most (195 (92.9%)) had presented with a low-impact hip fracture, with 17 (8.1%) reporting previous history of fracture. None had been treated with osteoporosis medications prior to fracture. Nineteen (9%) were on calcium and vitamin D supplements prior to fracture; of the minority who were screened, all were vitamin D deficient and subsequently discharged on vitamin D supplements. No one was prescribed medications to reduce fracture risk at discharge.

CONCLUSION

This study reveals that patients admitted with minimal impact hip fractures in Pakistan are rarely evaluated for low BMD and not started on osteoporosis medications even after presenting with a typical osteoporosis-related fracture. This underscores the need for health provider education about osteoporosis as a major cause for hip fractures and the need to intervene for future fracture risk reduction.

Clinical practice recommendations for the detection and management of hyperglycemia in pregnancy from South Asia, Africa and Mexico during COVID-19 pandemic

The human coronavirus disease 2019 (COVID-19) pandemic has affected overall healthcare delivery, including prenatal, antenatal and postnatal care. Hyperglycemia in pregnancy (HIP) is the most common medical condition encountered during pregnancy. There is little guidance for primary care physicians for providing delivery of optimal perinatal care while minimizing the risk of COVID-19 infection in pregnant women. This review aims to describe pragmatic modifications in the screening, detection and management of HIP during the COVID- 19 pandemic. In this review, articles published up to June 2021 were searched on multiple databases, including PubMed, Medline, EMBASE and ScienceDirect. Direct online searches were conducted to identify national and international guidelines. Search criteria included terms to extract articles describing HIP with and/or without COVID-19 between 1^st March 2020 and 15^th June 2021. Fasting plasma glucose, glycosylated hemoglobin (HbA1c) and random plasma glucose could be alternative screening strategies for gestational diabetes mellitus screening (at 24–28 weeks of gestation), instead of the traditional 2 h oral glucose tolerance test. The use of telemedicine for the management of HIP is recommended. Hospital visits should be scheduled to coincide with obstetric and ultrasound visits. COVID-19 infected pregnant women with HIP need enhanced maternal and fetal vigilance, optimal diabetes care and psychological support in addition to supportive measures. This article presents pragmatic options and approaches for primary care physicians, diabetes care providers and obstetricians for GDM screening, diagnosis and management during the pandemic, to be used in conjunction with routine antenatal care.

Magneto-hydro dynamic squeezed flow of Williamson fluid transiting a sensor surface

The present article reports the combined effects of radiation and heat origination on the electro-kinetically induced hydromagnetic squeezed flow of a pseudoplastic fluid. The fluid is passing over a microcantilever sensor surface positioned in the superficial free stream. Microcantiliver sensor can detect the flow rate and the variance in the temperature of the fluid. The thermal conductivity and fluid viscosity are assumed as a function of temperature. Boundary layer approximations are considered to construct a pseudoplastic fluid flow model. The governing system is then resolved into a non-dimensional form with the assistance of an appropriate set of control parameters. The solution to these non-dimensional equations has calculated with the assistance of familiar numerical techniques i.e. Shooting technique. The results specify that flow of fluid, temperature, and velocity profiles are remarkably influenced by the radiation parameter, fluid parameter, heat generation parameter, thermal relaxation parameter, magnetic parameter, and the squeezing number. A comprehensive graphical and tabular study is constructed to check the convergence of the obtained results. One can detect that the temperature curve is changing slightly for the Christov-Cattaneo heat transfer model as compared to classical Fourier's law of heat transfer. Further, the physical quantities, i.e. free stream velocity, variable viscosity, thermal conductivity, Weissenberg number, and Prandtl number have strong impacts on the boundary layer flow equations. It is perceived that the fluid velocity profile rises for the growing value of the magnetic parameter, but reduces for squashed flow index b. Also, a positive variation is found in the temperature profile for rising values of β and Q.

Applications and pitfalls of hemoglobin A1C and alternative methods of glycemic monitoring

INTRODUCTION

Intensive glycemic control minimizes the risks of microvascular complications in diabetes. A1C is a convenient estimate of mean blood glucose, but is not the only marker available. The practical use and limitations of alternative markers and continuous glucose monitors are the focus of this review.

METHODS

PubMed and the Cochrane Library were searched for studies concerning applications or limitations of A1C, fructosamine, glycated albumin, 1,5-anhydroglucitol, skin autofluorescence, and continuous glucose monitoring. Papers reporting on strengths, limitations, or comparisons of these methods were reviewed for inclusion.

RESULTS

A1C reflects three months of glycemic control and is not an ideal marker in all patient populations. Fructosamine and glycated albumin reflect mean blood glucose over three weeks. 1,5-Anhydroglucitol can measure hyperglycemic excursions in days to weeks. Continuous glucose monitors provide immediate feedback for timely intervention to reduce glycemic excursions and can assess glycemic variability. Current barriers to continuous glucose monitor use include inexperience, cost, discomfort, and medication interference.

CONCLUSIONS

Many promising alternative glycemic markers exist. The main limitations for all alternative methods of glycemic monitoring are a lack of standardization for clinically useful cut-offs or guidelines, and a lack of long-term data on their association with complications, particularly in varied patient populations.

Inspection of hybrid based nanofluid flow over a curved surface

BACKGROUND

In this paper, we discussed the Cu - Al₂O₃/H₂O (Hybrid nanofluid) flow over permeable exponentially stretching channel. The hybrid nanofluid involves two kinds of nanoparticles along with base fluid (pure water). Our research objective is to evaluate the heat transfer rate of hybrid nanofluid.

METHOD

The resulting system is numerically tackled via shooting method (bvp4c).

RESULTS

The hybrid nanofluid gains larger rate of heat transfer as compared to simple nanofluid. The impact of non-dimension parameter on temperature profile, boundary layer will be analyzed for enormous values of dimensionless parameter. Also, boundary layer thickness when γ < 0 (injection) and when γ > 0 (suction) will be compared. The present results with the existence literature will be compared for justification/validation.

Corrigendum to "Transportation of magnetized micropolar hybrid nanomaterial fluid flow over a Riga curface surface" [Comput Meth Prog Bio 185 (2020) 105,136]

This corrigendum corrects the dimensions of partial differential equations in the paper [1], where these mistakes are occurred during typing processes. But the results in [1] does not affect the scientific and mathematical validity of the paper.

Numerical analysis of water based CNTs flow of micropolar fluid through rotating frame

BACKGROUND

In this article, the nanomaterial flow of micropolar fluid in rotating frame is considered. The SWCNT and MWCNT with base fluid namely pure water is also taken into account to analyze the flow behavior over stretching surface. Mathematical model have been constructed under the nanomaterial of micropolar fluid.

METHOD

The governing equations have been developed in the form of system of partial differential equations. The partial differential equations are transformed into ordinary differential equations using similarity transformations. The transformed system has been solved through MAPLE software.

RESULTS

The physical parameters like as thermal slip effects, velocity slip effects and magnetic hydrodynamics on the micropolar nanofluid are presented by tables and graphs. Surprisingly in the rotating parameter, F''(0) and - θ'(0) increases for higher values of the rotating parameter while opposite to be noted for G''(0). The Nusselt number and skin friction increases for higher values of micropolar parameter but MWCNT achieves higher heat transfer as associated to SWCNT.

Transportation of magnetized micropolar hybrid nanomaterial fluid flow over a Riga curface surface

We deliberated the flow of magnetized micropolar hybrid nanoparticles fluid flow over the Riga curved surface. Exponentially stretching and slip effects are also considered in this analysis. Mathematical model has been established on the base of assumptions in the form of partial differential equations. Such equations are renewed into ordinary differential equations utilizing similarity transformations. Reduced model has been elucidated by means of bvp4c scheme. Impacts of physical parameters namely as stretching parameter R₀, curvature parameter K, solid nanoparticle volume fraction Φ₂, micropolar parameter K₁, microgyration parameter n, thermal slip parameter M, partial slip parameter γ, modified Harman number ∅ and dimensionless parameter ω. Magnetic parameter β and reciprocal magnetic Prandtl number λ are depicted by means of numerically and graphically. Our results help in the field of engineering and industrial. This model is presented in the first time through literatures. Our interest of study is to be analyzed about the heat transfer rate of magnetized micropolar hybrid nanomaterial fluid over a Riga curved surface. Comparison with the literature has been worked out and excellent agreement is found.

Utilization of Cu-nanoparticles as medication agent to reduce atherosclerotic lesions of a bifurcated artery having compliant walls

OBJECTIVE

A theoretical analysis is presented to study the bio-nanofluid with copper as medication agent for atherosclerotic bifurcated artery with flexible walls.

DESIGN/APPROACH

The circulatory framework in human body is comprised of a system of veins that incorporate the bifurcation in this way the impact of copper nanoparticles on parent, at apex and on daughter artery regions (in the wake of being bifurcated) is watched. Streaming of blood along vessel segment is recognized to be newtonian. The consistent idea of the atherosclerotic arterial wall is additionally considered to make relationship with permeability aspects with arterial wall thickness. Copper nanoparticles are utilized to reduce the atherosclertic lesions for bifurcated stenotic artery.

FINDINGS

The designed equations along with the experimental values of copper nanoparticles and blood are utilized for theoretical investigation. Moreover, hemodynamics impacts are also figure out to examine the flow of blood for atherosclertic artery. Comparison between parent and daughter artery is plotted through velocity profile. To see the theoretical assistance of this copper mediated model in biomedical field, graphical illustration is presented. At the end, noticed that the inclusion of copper nanoparticles enhances the velocity significantly both for parent as well as daughter artery.

CONCLUSIONS

The circulation of blood is considered to be different from pressure between portions of atherosclerotic and non-atherosclerotic artery. Shear stress is reduces by changing the bifurcation angle for daughter artery while trend is reversed for parent artery. The size of inner circularting bolus decreases by changing compliant parameter for parent artery while shape is changed for daughter artery.

Abstract P4-16-10: Bone health in young women with breast cancer

Introduction:

There are limited data and consensus regarding bone mineral density (BMD) monitoring, and management of bone loss in younger women with breast cancer (BC). Adjuvant endocrine therapy for estrogen receptor positive (ER+) BC may include ovarian function suppression (OFS) plus use of aromatase inhibitors (AIs) for 5-10 years, both of which contribute to bone loss. The WHO risk prediction tool FRAX does not include BC or AI use as independent risk factors in its calculation thus underestimating risk of fracture. This study aims to evaluate current screening and management of bone health in young women with BC.

Methods:

A retrospective, IRB-approved chart review was performed in consecutive women ≤40 with BC diagnosed at Loyola University Chicago Medical Center between 01/01/2015 and 12/13/17. Demographic data, BC treatment, and factors contributing to secondary causes of bone loss were collected through 4/1/18. A descriptive analysis included summary values for all categorical and continuous risk factors.

Results:

BC ≤40yrs was identified in 136 women; 18 were excluded due to missing data. The analysis was performed on 118 patients (pts). Mean pt age was 34.6 yrs (SD 4.7). Stage at diagnosis included: stage 0 = 9 (7.6%), stage 1 = 26 (22%), stage 2 = 44 (37.3%), stage 3 = 23 (19.5%), stage 4 = 7 (5.9%), unknown = 9 (7.6%). Seventy-nine (67%) had ER+ BC; 32 (27.1%) had HER2-positive disease. The majority of pts (101, 85.6%) received chemotherapy in their treatment plan. Menopause was documented in 69 (59.0%) pts. Goserelin was used in 31 pts (44.9%), oophorectomy in 17 (24.6%), both in 5 (7.2%). Tamoxifen was used in 44 (55.7%) ER+ pts; 34 (43.0%) received an AI, and 18 (22.8%) received sequential tamoxifen and AI. 25 Hydroxy-Vitamin D (25 OHD) levels were checked in 61 (51.7%); 43 (70.5%) had levels &lt;30 ng/ml; 24 (55.8%) received vitamin (vit) D supplementation. There was no difference in the 25 OHD in pre- and post-menopausal women (p=0.64). Pts with vit D deficiency had a median BMI of 26.8 vs 23.8 in those with sufficient vit D levels (exact p=.049). Secondary diagnoses contributing to low BMD were identified in 14 (11.8%). Dual energy xray absorptiometry (DXA) scans were checked in 23 pts (19.7%), 18 of whom were post-menopausal. At the femur, 0 pts had a z-score (age-matched standard deviation) of ≤-2.0, 9 pts (39.1%) had a score between 0 to -2.0. At the lumbar spine, 1 pt (4.3%) had a z-score ≤-2.0, 9 pts (39.1%) had a z-score between 0 to -2.0. No T-scores were in the osteoporosis range; 11 pts had T-scores at both femur and lumbar spine in the osteopenia range. The median 10 yr probability of a major osteoporotic fracture (FRAX score) was 1.9% (1.6-2.7%); the median 10 yr probability for hip fracture was 0.1% (0.10-0.20%). There were no differences in FRAX scores between pre- and post-menopausal women. No fractures were reported in the time period studied. Anti-resorptive therapy was used only in patients with metastatic bone disease.

Conclusions:

25 OHD and DXA scans are not routinely checked in younger women diagnosed with BC. Vit D deficiency and evidence of bone loss is prevalent in those pts who do undergo testing. Further research and guidelines are necessary to address management of bone health in young women with BC to minimize future fracture risk and morbidity.

Citation Format: Wendell KB, Nadeem S, Martin B, Camacho PM, Albain KS, Robinson P, Lo SS. Bone health in young women with breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-16-10.

Numerical simulation of oscillatory oblique stagnation point flow of a magneto micropolar nanofluid

The particular inquiry is made to envision the characteristics of magneto-hydrodynamic oscillatory oblique stagnation point flow of micropolar nanofluid. The applied magnetic field is assumed parallel towards isolating streamline. A relative investigation is executed for copper and alumina nanoparticles while seeing water type base fluid. To be more specific, in the presence of both weak and strong concentration, the physical situation of micropolar fluid is mathematically modeled in terms of differential equations. The transformed mixed system is finally elucidated by midpoint method with the Richardson extrapolation development and shooting mechanism with fifth order R–K Fehlberg technique. The impact of governing parameters are shown and explored graphically. The obtained results are compared with existing published literature. Moreover, it is found that the magnetic susceptibility of nanofluids shows provoking nature towards copper as compared to Alumina. Also it is perceived that Cu–water shows higher wall shear stress and heat transfer rate than Al₂O₃–water. Additional, the thickness of momentum boundary layer is thin for weak concentration as related to strong concentration.

The particular inquiry is made to envision the characteristics of magneto-hydrodynamic oscillatory oblique stagnation point flow of micropolar nanofluid.

Rotating flow of Ag-CuO/H2O hybrid nanofluid with radiation and partial slip boundary effects

The main object of the present paper is to examine and compare the improvement of flow and heat transfer characteristics between a rotating nanofluid and a newly discovered hybrid nanofluid in the presence of velocity slip and thermal slip. The influence of thermal radiation is also included in the present study. The system after applying the similarity transformations is solved numerically by using the bvp-4c scheme. Additionally, numerical calculations for the coefficient of skin friction and local Nusselt number are introduced and perused for germane parameters. The comparison between water, nanofluid and hybrid nanofluid on velocity and temperature is also visualized. It is observed that the velocity and temperature distributions are decreasing functions of the slip parameter. Temperature is boosted by thermal radiation and rotation. It is found that the heat transfer rate of the hybrid nanofluid is higher as compared to the traditional nanofluid.

Non-linear Radiation Effects in Mixed Convection Stagnation Point Flow along a Vertically Stretching Surface

Present phenomenon is dedicated to analyze the combine effects of linear and non-linear Rosseland thermal radiations for stagnation point flow along a vertically stretching surface. For better variation in fluid flow and heat transfer, mixed convection is also considered to sustain this mechanism for significant influence. After incorporating these effects, the pertinent mathematical model is constructed in the form of non-linear partial differential equations and then be transformed into the system of coupled ordinary differential equations with the help of similarity transformation to be further solved numerically. Significant difference in the heat transfer enhancement can be observed through temperature profiles and tables of Nusselt number. Though histogram and isotherms plots, finally it is concluded that non-linear radiation provides better heat transfer rate at the surface of sheet as compare to the linear or absence of radiation effects.