Journal of Health, Wellness and Community Research
Journal of Health, Wellness and Community Research (JHWCR) ISSN (Electronic): 3007-0570 DOI Prefix: 10.61919 Publisher: Link Medical Interface (Private) Limited Publication Frequency: Biweekly — two issues per month (from April 2025) License: Creative Commons Attribution 4.0 International (CC BY 4.0) About the Journal The Journal of Health, Wellness and Community Research (JHWCR) is a peer-reviewed, open-access journal published biweekly by Link Medical Interface (Private) Limited, Lahore, Pakistan. The journal is dedicated to publishing high-quality interdisciplinary research that advances health, wellness, and community well-being across the health sciences, allied health, social sciences, and humanities. JHWCR strongly encourages submissions from early-career and young researchers, supporting the next generation of scholars in global health. Frequency History: January 2023 – March 2025: Biannual April 2025 onwards: Biweekly (two issues per month) Open Access Policy JHWCR is committed to immediate, unrestricted, and free open access to scholarly research. All articles are made freely available online upon publication with no embargo period. Readers may read, download, copy, distribute, print, search, or link to the full text of any article without registration, payment, or prior permission, provided appropriate attribution is maintained. All content is published under the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits sharing and adaptation for any purpose, including commercial use, provided the original work is properly cited. No subscription fees are charged to readers or institutions. → Read Full Open Access Policy Aims and Scope JHWCR invites original research, reviews, and clinical studies across the following disciplines: Epidemiology & Biostatistics — population health, statistical methods, disease burden Public & Behavioral Health — health promotion, behavioral interventions, community health Rehabilitation Sciences — physical, occupational, and allied health rehabilitation Chronic & Infectious Diseases — prevention, management, and outcomes research Environmental & Global Health — environmental determinants, global health equity Healthcare Innovations & Allied Health — emerging technologies, allied health practice Basic and Allied Sciences — biomedical and applied sciences with human healthcare implications Article types accepted: Original Research, Systematic and Narrative Reviews, Case Reports, Short Communications, Commentaries, and Letters. 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JHWCR does not require copyright transfer as a condition of publication. → Read Full Copyright Policy Author Charges Article Processing Charge (APC): PKR 18,000 This is the only charge associated with publishing in JHWCR. It applies to all authors equally regardless of nationality, and becomes payable only after a formal written acceptance decision has been issued following completion of peer review. No charges of any kind are collected at submission, during review, or at any point before acceptance. Waiver Policy: Partial or full waivers are available for authors from low- and middle-income countries, early-career researchers without institutional funding, and authors experiencing documented financial hardship. Waiver requests must be submitted in writing after acceptance and before payment, with a brief justification. Waiver decisions are made independently of the editorial process and have no bearing on the acceptance decision already issued. → Read Full APC & Waiver Policy Peer Review Process JHWCR employs a double-blind peer review model in which neither authors nor reviewers are aware of each other's identity at any stage of evaluation. All submissions are assessed on scientific merit, originality, methodological soundness, ethical compliance, and relevance to the journal's scope. Stage-by-stage timeline: Stage Duration Initial administrative screening — plagiarism check, scope fit, documentation 0–3 days Editor-in-Chief assessment — suitability, originality, desk rejection if warranted 3–7 days Reviewer selection and invitation — minimum two independent experts 7–14 days Double-blind peer review — full scientific evaluation by each reviewer 21–30 days Editorial decision — Accept / Minor Revision / Major Revision / Reject 5–7 days Minor revision turnaround by authors Up to 14 days Major revision turnaround by authors 4–6 weeks Re-review and final decision after revision 7–14 days Copyediting, typesetting, proof approval, and publication Following acceptance Total time from submission to first decision: typically 5 to 9 weeks, depending on reviewer availability and manuscript complexity. JHWCR does not offer expedited or fast-track review. All manuscripts follow the same process regardless of author affiliation, nationality, or APC status. All manuscripts undergo plagiarism screening via Turnitin prior to peer review. Manuscripts with overall similarity exceeding 15%, or more than 5% from a single source, are returned to authors before proceeding to review. Where two reviewers reach substantially divergent conclusions, a third independent reviewer is invited before an editorial decision is issued. All special issue articles are subject to the same double-blind peer review process as regular submissions. Guest editor manuscripts are handled through an independent editorial pathway with no involvement of the guest editor in any aspect of their own manuscript's review. → Read Full Peer Review Policy Publication Ethics JHWCR adheres to internationally recognized standards for authorship, data integrity, conflict of interest, plagiarism prevention, and post-publication corrections. The journal follows COPE and ICMJE guidelines across all editorial decisions. All parties — authors, reviewers, and editors — are bound by clearly defined ethical responsibilities. → Publication Ethics & Malpractice Statement → Conflict of Interest Policy → Data Sharing & Research Transparency Policy → Generative AI & Automated Tools Policy Complaints & Appeals Authors, reviewers, and readers may submit complaints or appeal editorial decisions in writing to editor@jhwcr.com. All complaints are acknowledged within three working days and a full response provided within two to four weeks. → Read Full Complaints & Appeals Policy Editorial Team Chief Editor Dr. Maryam Shabbir — Associate Professor, Doctorate, Physical Therapy The University of Lahore, Pakistan Editor Dr. Umair Ahmed — Associate Professor, Doctorate, Neuro-Physical Therapy The University of Lahore, Pakistan Managing Editor Dr. Muhammad Tahir — Consultant, MS, Neuro-Physical Therapy Therapy Plus Clinics, Pakistan Editorial Board Name Designation Specialization Institution Country Dr. Ahmed Hassan Senior Medical Officer FCPS – ENT Mansorah Hospital Pakistan Dr. Namra Yousaf Assistant Professor FCPS – Microbiology Fatima Memorial Hospital Pakistan Dr. Sabiha Abbas Assistant Professor Food Technology University of Okara Pakistan Dr. Fatirah Aziz Senior Demonstrator Hematology Fatima Memorial Hospital Pakistan Dr. Khurram Malik Senior Registrar Ophthalmology Fatima Memorial Hospital Pakistan Dr. Muhammad Abbas Khan Senior Registrar FCPS – General Medicine Muhammad Teaching Hospital Peshawar Pakistan Dr. Eman Fayed Assistant Professor Physical Therapy University of St. Augustine for Health Sciences USA Dr. Usman Janjua Professor Rehabilitation Elite College of Management Sciences Pakistan Dr. Ayesha Kamal Butt Senior Lecturer Educational Management Manchester Metropolitan University UK Dr. Kashif Iqbal Sahibzada Postdoctoral Fellow Biochemistry Henan University of Technology China Dr. Saqlain Raza Assistant Professor Applied Statistics Imam Abdulrahman bin Faisal University Saudi Arabia Advisory Board Name Designation Specialization Institution Country Dr. Ghazal Usman Senior Demonstrator FCPS Fatima Memorial Hospital Pakistan Dr. Hafiz Ahmed Haroon Dermatologist & Cosmetologist FCPS – Dermatology Novimed Specialist Clinic Pakistan Dr. Saima Akhtar Chattha Assistant Professor English Linguistics COMSATS University Islamabad (Lahore Campus) Pakistan Dr. Rabbiya Sarwar Lecturer Public Health University of Health Sciences Pakistan Dr. Aisha Ansari Lecturer Cardiopulmonary Physical Therapy University of Hai'l Saudi Arabia Dr. Ajediran Idowu Bello Associate Professor Physical Therapy University of Ghana Ghana Dr. Francisco Arroyo Professor Sports Medicine Sport Med Medical Centre, Guadalajara Mexico Dr. Mohamed Khallaf Associate Professor Physical Therapy University of St. Augustine for Health Sciences USA Dr. Muhammad Shahid Lecturer Cardiopulmonary Physical Therapy University of Hail Saudi Arabia → Editorial Endogeny & Self-Publication Policy Author Guidelines & Submission Full submission requirements, article types, formatting standards, reporting guidelines, and ethical documentation requirements are detailed in the Author Guidelines. → View Full Author Guidelines & Submission Instructions Submission Email: editor@jhwcr.com Publisher Information Publisher: Link Medical Interface (Private) Limited Address: 8 Commercial, Sunny Park, Lahore 54000, Pakistan Website: https://lmi.education/ Editorial Contact: editor@jhwcr.com → Ownership & Management Disclosure Archiving & Preservation JHWCR ensures permanent long-term preservation of all published content through: PKP Preservation Network (PKP PN) — distributed digital preservation via the Keepers Registry LOCKSS — distributed preservation through participating library networks CLOCKSS — dark archive ensuring long-term access in the event of journal discontinuation → Read Full Archiving Policy Self-Archiving Policy Authors may deposit any version of their manuscript (preprint, accepted manuscript, or published PDF) in any institutional or subject repository, preprint server, or personal website at any time. No embargo applies to any version. All self-archived versions must include a complete citation to the published JHWCR article and a link to the CC BY 4.0 license. → Read Full Self-Archiving Policy Indexing JHWCR is indexed and registered with Google Scholar, CrossRef (DOI prefix 10.61919), EuroPub, PakMediNet, and Afro-Asian Research Index. All content published in JHWCR is licensed under the Creative Commons Attribution 4.0 International License (CC BY 4.0). Authors retain full copyright. © Link Medical Interface (Private) Limited, Lahore, Pakistan
Link Medical Interface, Lahore, Pakistan
Diagnostic Accuracy of X-Ray Chest for the Diagnosis of Interstitial Lung Disease Keeping High Resolution Computed Tomography Chest as Gold Standard
Background: Interstitial lung disease (ILD) comprises a heterogeneous group of diffuse parenchymal lung disorders in which early and accurate detection is critical for prognosis and management. Although high-resolution computed tomography (HRCT) is the reference imaging modality, chest radiography (CXR) remains the most accessible first-line investigation in resource-constrained settings, and its diagnostic performance requires contextual evaluation. Objective: To determine the diagnostic accuracy of chest radiography for detecting ILD using HRCT as the reference standard in adults with clinical suspicion of ILD. Methods: This cross-sectional diagnostic accuracy study included 108 consecutive patients aged 18–75 years presenting to a tertiary-care radiology department from January to December 2024. All participants underwent standardized CXR followed by HRCT within two weeks. CXR findings were interpreted independently and blinded to HRCT results. Sensitivity, specificity, predictive values, likelihood ratios, diagnostic odds ratio, and 95% confidence intervals were calculated using a 2×2 contingency table. Results: HRCT confirmed ILD in 60 of 108 patients (55.56%). CXR demonstrated a sensitivity of 90.0% (95% CI 79.9–95.3) and specificity of 87.5% (95% CI 75.3–94.1), with positive and negative predictive values of 90.0% and 87.5%, respectively. Overall diagnostic accuracy was 88.89% (95% CI 81.6–93.5), with LR+ of 7.2 and LR− of 0.11. Conclusion: Chest radiography exhibits high diagnostic performance in clinically suspected ILD within a tertiary-care cohort; however, given residual false-negative cases, HRCT remains essential for definitive diagnosis and disease characterization.
Interstitial lung disease; Chest radiography; High-resolution computed tomography; Diagnostic accuracy; Sensitivity; Specificity.
Copyright (c) 2025 Ambreen Khan, Tahira Nishtar, Tasleem Khan, Shabana Ashiq, Seemab Kamal, Shawal Amjad (Author) https://creativecommons.org/licenses/by/4.0
Musculoskeletal Pain in Undergraduates With Psychological Distress and Poor Sleep Quality
Background: Musculoskeletal pain is common among university students and may be amplified by poor sleep and psychological distress, collectively impairing wellbeing and academic functioning. Objective: To examine the association between sleep quality and musculoskeletal pain and to assess psychological distress correlates of sleep quality among undergraduate students. Methods: A descriptive cross-sectional study was conducted in Karachi, Pakistan (August 2024–January 2025) across multiple universities and coaching centers. Undergraduate students aged 18–25 years completed the Nordic Musculoskeletal Questionnaire (12-month pain), Pittsburgh Sleep Quality Index (PSQI), and Depression Anxiety Stress Scale-21 (DASS-21), alongside demographic items. Multivariable logistic regression evaluated the association between PSQI global score and presence of musculoskeletal pain, adjusting for age, gender, and occupation. Multivariable linear regression examined predictors of PSQI score. Results: Among 299 students (mean age 21.6±1.68; 65.9% female), 76.6% reported musculoskeletal pain, most commonly in the neck (53.5%), lower back (50.8%), and shoulders (43.5%). Poor sleep quality was prevalent (mean PSQI 9.27±5.88; 39.1% categorized as poor). Higher PSQI score was independently associated with musculoskeletal pain (adjusted OR 1.116 per unit; 95% CI 1.037–1.202; p=0.004), and females had higher odds of pain than males (adjusted OR 4.336; 95% CI 2.051–9.167; p<0.001). Difficulty winding down (p=0.021), reduced positive emotion (p=0.034), breathing difficulty (p=0.042), and low motivation (p=0.035) were associated with poorer sleep. Conclusion: Musculoskeletal pain and sleep impairment are highly prevalent in undergraduates; poorer sleep quality is independently associated with increased odds of musculoskeletal pain, with psychological distress contributing to impaired sleep, particularly among females.
Musculoskeletal pain; psychological distress; Pittsburgh Sleep Quality Index; sleep quality; undergraduate students; low back pain
Copyright (c) 2026 Noor-e-Arsh, Poonam Mahraj, Bheesham Kumar, Kamlesh Kumar, Neelam Mahraj (Author) https://creativecommons.org/licenses/by/4.0
Transforming Waste into Utility: A Critical Investigation of Edible Cutlery as a Sustainable Alternative
Plastic-cutlery can be replaced by creative and eco-sustainable edible cutlery based on innovation. Stale bread is a major waste and can become a strong yet biodegradable cutlery as alternative to plastic disposables. The present study was done to develop edible cutlery with stale bread, lentils and wheat in different ratios. Five treatments were prepared for comparison study. After edible cutlery development, proximate, mineral, microbial, texture and sensory evaluation was done. A required statistical procedure was done after data collection. T3 have highest mean value for protein 11.4% and ash 2.62% while T5 have highest mean value for fiber 15.03% and T1 have highest mean value for fat 10.42% in physico-chemical analysis. T5 and T4 showed highest mean values for iron 5.03 ± 0.02 mg/100g and zinc 2.31 ± 0.03 mg/100g respectively. All treatments were in safe limits for microbial analysis under 1000 CFU/g. T3 was having least mean value of microbial count (200 ± 1.24 CFU/g). T3 showed highest mean value of hardness (170.2 ± 3.9 N). T3 was the most accepted according to mean value 8.33 ± 0.58% of sensory analysis. The cutlery produced in this research is being discovered to be tasty, nutritious, healthy and environment friendly plastic alternative.
Copyright (c) 2026 Noor Bakht, Amaila Sehar, Futrus Abid, Sadia Hassan, Moazama Anwar, Huzaifa Malik, Ishmal Mazhar, Jannat Sohail, Khadija Fatima (Author) https://creativecommons.org/licenses/by/4.0
Comparative Analysis of The Efficacy of Upper Lip Bite Test and Thyromental Distance for Prediction of Difficult Intubation
Background: Unanticipated difficult intubation remains a major contributor to perioperative morbidity and mortality, underscoring the need for reliable bedside airway assessment tools. The Upper Lip Bite Test (ULBT) and Thyromental Distance (TMD) are commonly used preoperative predictors, yet their comparative diagnostic performance remains clinically debated. Objective: To compare the diagnostic accuracy of ULBT and TMD in predicting difficult intubation among adult patients undergoing elective surgery under general anesthesia. Methods: In this comparative cross-sectional observational study, 119 adult patients scheduled for elective surgery requiring endotracheal intubation were consecutively enrolled. Preoperative airway assessment included ULBT and TMD classification using standardized criteria. Difficult intubation was defined as Cormack–Lehane grade III/IV or intubation requiring more than three attempts or prolonged duration. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), likelihood ratios, and accuracy were calculated with 95% confidence intervals. Results: Difficult intubation occurred in 21 patients (17.7%). ULBT demonstrated higher sensitivity than TMD (66.7% vs 47.6%) with comparable specificity (87.8% vs 89.8%). ULBT showed superior NPV (92.5% vs 88.9%) and lower negative likelihood ratio (0.38 vs 0.58), indicating improved rule-out capability, while PPV was moderate for both tests (53.8% vs 50.0%). Conclusion: ULBT provides greater sensitivity and stronger exclusion performance compared with TMD, supporting its preferential use as a primary bedside screening tool within a multimodal airway assessment strategy.
Difficult intubation; Airway management; Upper Lip Bite Test; Thyromental Distance; Diagnostic accuracy; Preoperative assessment
Copyright (c) 2026 Muhammad Abdul Sattar, Abdul Wadood, Fatima Noreen, Awais Akhtar, Inam Ullah (Author) https://creativecommons.org/licenses/by/4.0
Psychosocial Impact on Parents of Children with Thalassemia Major Receiving Regular Blood Transfusions at a Tertiary Care Thalassemia Center in Azad Kashmir
Background: Transfusion-dependent β-thalassemia major is a lifelong hematological disorder requiring regular blood transfusions and iron chelation therapy, imposing substantial clinical and psychosocial burden on affected families, particularly primary caregivers. Evidence from low- and middle-income countries suggests elevated levels of stress, emotional distress, and financial strain among parents; however, disease-specific quantitative assessments in the Kashmiri context remain limited. Objective: To quantify domain-specific psychosocial burden—including parental stress, emotional impact, perceived social support, coping capacity, and financial/practical strain—among parents of children with transfusion-dependent thalassemia major in Azad Kashmir and to examine associated sociodemographic predictors. Methods: A cross-sectional observational study was conducted among 109 parents recruited from two tertiary thalassemia centers. Data were collected using the Parenting Stress Index–Thalassemia Major (PSI–TM), a 20-item Likert-based instrument. Domain scores were standardized to percentages and analyzed using descriptive statistics, independent t-tests, and multivariable linear regression in SPSS version 26. Results: Severe burden was observed in parental stress (81.8%), emotional impact (81.0%), and financial/practical domains (85.4%), while social support (48.6%) and coping (52.6%) were moderate. Lower income and female caregiver status independently predicted higher overall psychosocial burden (p<0.05). Financial strain demonstrated the largest socioeconomic gradient (mean difference 9.6 points). Conclusion: Parents of children with transfusion-dependent thalassemia major experience profound psychosocial distress, particularly in stress and financial domains, underscoring the need for integrated psychosocial screening and targeted socioeconomic support within routine thalassemia care.
Thalassemia major, caregiver burden, parental stress, psychosocial impact, coping, social support, financial strain, cross-sectional study
Copyright (c) 2026 Muhammad Imran, Muhammad Aslam, Anbreen Younis, Fakhra Azeem, Madiha Bibi, Malik Naeem, Sarash Nisar, Nadra Akram, Saima Naseem, Maria Ramzan (Author) https://creativecommons.org/licenses/by/4.0
Assessment of Spinal Deformity in Adolescents with Scoliosis and Its Association with Functional Limitation During Daily Activities: A Cross-Sectional Study
Background: Adolescent Idiopathic Scoliosis (AIS) is a three-dimensional spinal deformity that may influence physical function beyond radiographic curvature; however, the relationship between curve severity and objective task-specific functional performance remains insufficiently characterized. Objective: To examine the association between spinal deformity severity and functional limitation during daily activities in adolescents with AIS using patient-reported and performance-based measures. Methods: In this cross-sectional observational study, 100 adolescents aged 10–18 years with radiographically confirmed AIS (Cobb angle ≥10°) were evaluated. Radiographic parameters included Cobb angle, vertebral rotation, thoracic kyphosis, and lumbar lordosis. Functional outcomes comprised the SRS-22 function domain, Pediatric Outcomes Data Collection Instrument (PODCI) global function score, six-minute walk test (6MWT), stair-climbing time, and sit-to-stand time. Correlation analyses and multivariable linear regression adjusted for age, sex, and BMI were performed. Results: The mean Cobb angle was 27.6° ± 11.8°. Cobb angle demonstrated moderate negative correlations with SRS-22 (r = −0.46, p < 0.001), PODCI (r = −0.42, p < 0.001), and 6MWT distance (r = −0.39, p = 0.002), and positive correlations with stair-climbing (r = 0.34, p = 0.006) and sit-to-stand time (r = 0.29, p = 0.010). Each 10° increase in Cobb angle was independently associated with a 22.4-meter reduction in 6MWT distance and a 0.88-second increase in stair-climbing time. Functional performance declined progressively across mild, moderate, and severe categories (p < 0.001). Conclusion: Greater AIS severity is independently associated with measurable reductions in endurance and transitional mobility, supporting integration of standardized functional assessment alongside radiographic evaluation.
Adolescent Idiopathic Scoliosis; Cobb Angle; Functional Limitation; Six-Minute Walk Test; Stair-Climbing; Pediatric Outcomes
Copyright (c) 2026 Huma Khan, Atif Wahab, Ayesha Sabir, Naeem Ullah, Amna Sabir, Asad Ullah Khan (Author) https://creativecommons.org/licenses/by/4.0
Prevalence of Thumb Pain Among Physiotherapists of Lahore
Background: Work-related musculoskeletal disorders are highly prevalent among physiotherapists, particularly those performing repetitive manual therapy techniques that impose sustained compressive forces on the thumb, which functions as a pseudo weight-bearing joint. Despite substantial international evidence, epidemiological data on work-related thumb pain among physiotherapists in Pakistan remain limited. Objective: To determine the prevalence, severity, and occupational exposure association of current work-related thumb pain among physiotherapists engaged in manual therapy in Lahore, Pakistan. Methods: A descriptive cross-sectional study was conducted over six months in six tertiary care hospitals and rehabilitation centers in Lahore. A total of 146 physiotherapists with ≥2 years of clinical experience and active manual therapy involvement were recruited using convenience sampling. Data were collected through a structured, validated questionnaire and the Numeric Pain Rating Scale (NPRS). Prevalence was calculated with 95% confidence intervals (CI), and associations between manual therapy exposure and thumb pain were analyzed using chi-square tests and odds ratios (OR). Results: The prevalence of current work-related thumb pain was 76.0% (95% CI: 68.3%–82.6%). Moderate pain was most common (54.1%), followed by severe pain (20.7%). Dominant-thumb involvement was reported in 70.3% of symptomatic participants (p < 0.001). Physiotherapists performing manual therapy for 61–100% of working time had significantly higher odds of thumb pain (OR = 3.44; 95% CI: 1.18–10.05; p = 0.018). Conclusion: Work-related thumb pain is highly prevalent among physiotherapists in Lahore and demonstrates a significant dose–response relationship with manual therapy workload, highlighting the need for targeted ergonomic and preventive strategies.
Work-related musculoskeletal disorders; Thumb pain; Physiotherapists; Manual therapy; Occupational exposure; Numeric Pain Rating Scale
Copyright (c) 2026 Iqra Dilbar, Muhammad Nouman Tabassum (Author) https://creativecommons.org/licenses/by/4.0
Comparative Analysis of Hemodynamic Changes During Laparoscopic and Open Cholecystectomy
Background: Laparoscopic cholecystectomy has largely replaced open cholecystectomy because of reduced postoperative morbidity; however, carbon dioxide (CO₂) pneumoperitoneum may induce respiratory and cardiovascular alterations, while open surgery may provoke greater sympathetic stimulation due to tissue trauma. The comparative intraoperative effects of these techniques on end-tidal carbon dioxide (EtCO₂) and hemodynamic stability remain clinically relevant. Objective: To compare intraoperative EtCO₂ dynamics and hemodynamic responses between laparoscopic and open cholecystectomy in ASA I–II adult patients undergoing elective surgery under general anesthesia. Methods: In this cross-sectional observational study, 54 patients (27 laparoscopic, 27 open) were consecutively enrolled. Standardized general anesthesia and mechanical ventilation protocols were applied. EtCO₂, heart rate (HR), systolic (SBP), diastolic (DBP), and mean arterial pressure (MAP) were recorded at baseline, post-induction, 5, 15, and 30 minutes intraoperatively, and at the end of surgery. Linear mixed-effects modeling assessed group–time interactions with adjustment for baseline covariates. Results: Baseline characteristics were comparable except for modestly higher baseline MAP and DBP in the open group. At 5 minutes, open cholecystectomy demonstrated significantly higher HR (+6.6 beats/min; p<0.001), SBP (+7.0 mmHg; p=0.034), DBP (+5.2 mmHg; p=0.023), and MAP (+6.9 mmHg; p=0.008). End-of-surgery DBP and MAP remained significantly elevated in the open group (+6.7 mmHg; p<0.001 and p=0.001, respectively). Group×time interaction was significant for DBP and MAP (p<0.05). Conclusion: Open cholecystectomy is associated with greater early and late intraoperative hemodynamic variability, whereas laparoscopic cholecystectomy demonstrates comparatively stable cardiovascular profiles under controlled ventilation.
End-tidal carbon dioxide; pneumoperitoneum; hemodynamic stability; laparoscopic cholecystectomy; open cholecystectomy.
Copyright (c) 2026 Atzaz Farooq, Sadam Rasheed, Sameen Hanif, Inam Ullah, Awais Akhtar, Farhan Zia, Taimoor Riaz Ullah (Author) https://creativecommons.org/licenses/by/4.0
Comparative Analysis of Bone Mineral Density in Smokers and Non-Smokers Through Dual-Energy X-ray Absorptiometry Scan at Hayatabad Medical Complex, Peshawar
Background: Osteoporosis is an under-recognized health problem in men and is influenced by modifiable lifestyle factors, including cigarette smoking, which can disrupt bone remodeling and reduce bone mineral density, thereby increasing fracture risk. Objective: To compare BMD between smokers and non-smokers and evaluate exposure response relationships between smoking burden and low BMD among adult men undergoing DEXA scanning at Hayatabad Medical Complex, Peshawar. Methods: An analytical cross-sectional observational study was conducted among 312 adult male patients (156 smokers and 156 Non-smokers) who underwent lumbar spine DEXA between May and July 2025. BMD was categorized using WHO T-score criteria into normal, osteopenia, and osteoporosis. Smoking exposure was operationalized using cigarettes/day, duration of smoking, and pack-years. Group comparisons used chi-square tests and independent-samples tests as appropriate. Multivariable logistic regression estimated adjusted odds of low BMD (osteopenia/osteoporosis) controlling for age, BMI, physical activity, alcohol use, and diabetes. Results: Low BMD was more prevalent in smokers than non-smokers (67.9% vs 51.3%; p=0.004), and smokers had nearly twice the adjusted odds of low BMD (AOR=1.99; 95% CI: 1.28–3.09). Mean lumbar spine T-score was significantly lower in smokers (−1.78±1.02) than non-smokers (−1.34±0.96; mean difference −0.44; 95% CI: −0.69 to −0.19; p=0.001). A dose–response gradient was observed with higher cigarettes/day and longer smoking duration. Conclusion: Cigarette smoking is independently associated with lower lumbar spine BMD in Pakistani men, with evidence of an exposure response relationship, supporting targeted DEXA screening and smoking cessation to reduce osteoporosis risk
Bone mineral density; Osteoporosis; Smoking; DEXA; Men; Pakistan; Osteopenia
Copyright (c) 2026 Hassan khan, Mawa Ahmad, Jalwa Murad, Hayat Khan, Hafiza Bahisht Noor (Author) https://creativecommons.org/licenses/by/4.0
Impact of Nurse–Patient Communication on Patient Satisfaction: An Empirical Study in South Punjab
Background: Effective nurse–patient communication is a core component of patient-centered care and a recognized determinant of patient satisfaction; however, quantitative evidence from secondary-level public hospitals in South Punjab remains limited. Objective: To assess the association between perceived nurse–patient communication and patient satisfaction among admitted patients at a district-level public hospital. Methods: A cross-sectional observational study was conducted at THQ Hospital Kot Addu over five months, including 100 adult inpatients selected through consecutive sampling. Data were collected using a structured Likert-scale questionnaire measuring communication (listening, clarity, respect, involvement, cultural sensitivity) and satisfaction domains. Composite scores were calculated, internal consistency assessed using Cronbach’s alpha, and associations examined through Pearson correlation and multivariable linear regression adjusting for age, sex, ward type, education, and length of stay. Results: Participants had a mean age of 41.8±13.6 years, with 58% males. Communication and satisfaction scores were high (4.09±0.74 and 4.12±0.69, respectively). Communication demonstrated an exceptionally strong positive correlation with satisfaction (r=0.975; 95% CI: 0.964–0.983; p<0.001). In adjusted regression, communication remained the only significant predictor (β=0.91; standardized β=0.95; p<0.001), explaining 95.1% of satisfaction variance (R²=0.951). Conclusion: Perceived nurse–patient communication is strongly and independently associated with patient satisfaction in this public-sector inpatient setting, underscoring communication-focused interventions as a strategic priority for quality improvement.
Nurse–patient communication; Patient satisfaction; Inpatient care; Public hospital; Cross-sectional study; Pakistan.
Copyright (c) 2026 Alvisha Munir, Aimen charagh, Aqsa Rehman, Muhammad Ahsan Rafique, Zahid Riaz (Author) https://creativecommons.org/licenses/by/4.0
RNA-Targeting Therapeutics via CRISPR-Cas13: Mechanisms, Applications, and Future Directions — A Narrative Review
Background: Pathogenic RNA transcripts underlie a substantial proportion of human diseases, yet existing RNA-targeting platforms — antisense oligonucleotides and RNA interference — are constrained by mechanistic inflexibility, saturation of endogenous machinery, and inability to perform precise transcript editing. CRISPR-Cas13, a family of RNA-guided RNA endonucleases, has emerged as a programmable, reversible alternative capable of targeted transcript knockdown, precise base editing, and splicing modulation without altering genomic DNA. Objective: This narrative review synthesises current evidence on the mechanisms, therapeutic applications, delivery platforms, safety considerations, and ethical dimensions of the CRISPR-Cas13 system, with the objective of providing a structured, evidence-grounded account of its translational trajectory as of 2024. Methods: A structured literature search was conducted across PubMed/MEDLINE, Scopus, Web of Science, and Embase, covering January 2016 through October 2024. Search terms combined Cas13 subtype nomenclature with therapeutic and disease-specific keywords. Articles were screened for relevance to Cas13 mechanisms, applications, or translational barriers; English-language peer-reviewed publications and pre-reviewed preprints with corroborating evidence were eligible. The review was organised thematically across eight conceptual domains and reported in accordance with the Scale for the Assessment of Narrative Review Articles (SANRA). Results: Across nine therapeutic application areas, CRISPR-Cas13 — primarily Cas13d (CasRx) — has demonstrated robust preclinical efficacy, including phenotypic rescue in Huntington's disease rodent models, potent antiviral activity against SARS-CoV-2 and HIV-1, and selective oncogenic mRNA knockdown in xenograft cancer models. Catalytically dead Cas13 fused to adenosine deaminase (dCas13-ADAR) enables A-to-I RNA base editing with measurable codon correction in patient-derived cell lines. Lipid nanoparticles and AAV vectors represent the dominant delivery modalities; collateral RNase activity, immunogenicity, and transient effect duration remain the principal translational barriers. Conclusion: CRISPR-Cas13 constitutes a promising and mechanistically distinct RNA-targeting platform with broad therapeutic reach. Realisation of its clinical potential depends on engineering of collateral-minimised Cas13 variants, development of tissue-specific delivery architectures, and initiation of first-in-human trials in monogenic disorders where reversibility of effect offers a meaningful safety advantage over permanent DNA editing.
CRISPR-Cas13; RNA editing; RNA therapeutics; gene therapy; transcriptome engineering; lipid nanoparticles; RNA-guided endonuclease
Copyright (c) 2026 Zunaira Amin, Hafiz Ayaz Ahmad, Tahira Batool (Author) https://creativecommons.org/licenses/by/4.0
Resilience, Self-Esteem, and Self-Efficacy in Caregivers of Schizophrenia Patients
Background: Schizophrenia is a severe mental disorder that leads to significant functional impairment, necessitating substantial long-term care from informal caregivers. While the burdens of caregiving are well-documented, there is limited research from India on the protective psychological resources that enable caregivers to cope effectively. Objective: To evaluate the levels of resilience, perceived social support, self-esteem, and self-efficacy among caregivers of patients with schizophrenia, and to examine the correlations between these variables and their association with caregiver duration. Methods: A cross-sectional study was conducted at the Department of Psychiatry, Timergara Teaching Hospital from June 2025 to December 2025. A total of 150 caregivers of patients diagnosed with schizophrenia (ICD-10 criteria) were recruited using convenience sampling. Data were collected using a semi-structured proforma and four standardized scales: the Connor-Davidson Resilience Scale (CD-RISC), Rosenberg Self-Esteem Scale (RSES), General Self-Efficacy Scale (GSE), and Multidimensional Scale of Perceived Social Support (MSPSS). Statistical analysis employed descriptive statistics, Pearson's correlation coefficient (p < 0.001), and appropriate tests of significance. Results: The majority of caregivers were female (52.7%), married (72.7%), and had middle school education (43.3%). Most caregivers demonstrated moderate resilience (44.7%, mean 61 ± 14.6), with 28.7% showing high resilience and 26.7% low resilience. Perceived social support was moderate overall (47.34 ± 12.33), with family support (21.22 ± 4.5) being substantially higher than friend support (7.11 ± 3.4). Mean self-esteem and self-efficacy scores were 20.22 ± 3.4 and 19.34 ± 2.3 respectively. Significant positive correlations were found among all psychological variables (p < 0.001), particularly between resilience and perceived social support (r = 0.856). Caregiver duration showed significant negative correlations with all study variables, most strongly with perceived social support (r = -0.724, p < 0.001). Conclusion: Caregivers of schizophrenia patients demonstrate moderate resilience and family support but markedly low support from friends, likely attributable to stigma. The significant decline in all protective factors with increasing caregiver duration highlights the progressive toll of long-term caregiving. The strong intercorrelations among resilience, social support, self-esteem, and self-efficacy suggest these factors are mutually reinforcing. Community-based psychoeducational interventions are recommended to enhance these protective resources and reduce stigma
Resilience, Self-Esteem, Self-Efficacy, Schizophrenia
Copyright (c) 2026 Syed Iftikhar Ahmad, Imran, Waleed Khan (Author) https://creativecommons.org/licenses/by/4.0
Prevalence of Stress and Coping Strategies Among Nursing Students During Clinical Rotations in Bannu
Background: Clinical rotations are a high-demand learning context for nursing students and can precipitate stress that undermines psychological well-being and clinical learning if not effectively managed. Objective: To estimate the point prevalence and severity distribution of stress and to describe coping strategies among BSN nursing students during clinical rotations in Bannu. Methods: A quantitative cross-sectional observational study was conducted among BSN students (2nd, 4th, 6th, and 8th semesters) from government and private nursing colleges in Bannu. Using proportionate stratified sampling, 160 students completed a structured online questionnaire. Stress was measured using the DASS-21 stress subscale and categorized into standard severity bands; coping strategies were assessed using a structured Likert-scale questionnaire and summarized as individual strategy frequencies and overall coping level (poor/moderate/good). Results: Normal stress was observed in 51.9% (83/160), while 48.1% (77/160; 95% CI 40.3–55.9) had elevated stress (≥ mild), including 11.3% (18/160) with severe/extremely severe stress. Elevated stress differed by semester (p=0.032; Cramér’s V=0.23) and clinical exposure duration (p=0.041; Cramér’s V=0.21), peaking in the 6th semester (62.5%) and among those with 6–12 months exposure (73.3%). Common “always” coping strategies were prayer/religious practices (67.5%), positive reframing (61.3%), and planning (37.5%). Poor coping was associated with higher odds of elevated stress versus good coping (OR=3.14; 95% CI 1.29–7.66; p=0.002; Cramér’s V=0.28). Conclusion: Nearly half of nursing students experienced elevated stress during clinical rotations, with a distinct mid-program peak and a strong inverse association between coping capacity and stress burden, supporting targeted mentorship and structured stress-management interventions during higher-risk training phases.
DASS-21; clinical rotations; nursing students; stress; coping strategies; nursing education; Bannu
Copyright (c) 2026 Asma Ghani, Muhammad Rizwan, Sadaf, Kalsoom, Muqadas, Nadia, Uroosa, Meherun Nisa (Author) https://creativecommons.org/licenses/by/4.0
Computational Analysis of Acquired Antimicrobial Resistance Genes in Mycobacterium Plasmid
Mycobacterium species are becoming an increasing health challenge worldwide due to antimicrobial resistance (AMR). Although chromosomal mutations are well characterized, not much is known about the contribution of acquired AMR genes acquired via plasmids in this genus. In this study, a computational pipeline was used to examine acquired AMR genes in plasmids in both pathogenic Mycobacterium species. Out of 195 species, 51 species were identified to be pathogenic; 18 of which harbored a total of 301 plasmids that were obtained in NCBI nucleotide database. The acquired AMR genes in all plasmids were screened with ResFinder 4.0, which was designed to screen 15 antibiotic classes. The resistance hits of plasmids were additionally analysed with KmerResistance and ResFinderFG, and such basic genomic characteristics as size and GC content were analysed. The detection of acquired AMR genes was done by comparative sequence analysis with the help of BLAST and MEGA X by detecting three plasmids, which were parts of the Mycobacterium abscessus complex, and contained a total of 15 resistance genes. These plasmids contained a high GC content (64.25-64.3 percent), which was quite similar to that of their host genome, hence indicating adaptation. Comparison of sequences showed that there was close relatedness between the resistance plasmids, which was in line with recent divergence and horizontal gene transfer in the complex. Even though a small proportion of Mycobacterium plasmids already harbor acquired AMR genes, the genes are in clinically relevant, hard-to-treat species, and thus, genomic surveillance and wise antibiotic intake are still necessary.
Copyright (c) 2026 Sania Saleem, Faizan Raza, Azlan Akbar, Zahra Firdous, Hamza Noman, Mehreen Fatima (Author) https://creativecommons.org/licenses/by/4.0
Clinicopathological Profile of Breast Cancer Patients and Its Association with Treatment Outcomes
Background: Breast cancer remains a leading cause of cancer-related morbidity and mortality worldwide. Variability in clinical outcomes is largely influenced by tumor biology and stage at presentation. Understanding the clinicopathological characteristics of breast cancer within specific populations is essential for improving prognostic assessment and guiding treatment strategies. Objective: To describe the clinicopathological profile of breast cancer patients and evaluate its association with treatment outcomes, including survival and recurrence. Methods: A retrospective data analysis was conducted on 284 histopathologic ally confirmed breast cancer patients treated at a tertiary care hospital in the Islamabad–Rawalpindi region. Demographic, pathological, and treatment-related variables were extracted from institutional records. Tumors were classified according to TNM staging and Nottingham grading systems, with receptor status determined by immunohistochemistry. Disease-free survival, overall survival, and recurrence were analyzed using Kaplan–Meier survival curves, chi-square tests, independent t-tests, ANOVA, and Pearson correlation analysis. A p-value <0.05 was considered statistically significant. Results: The mean age at diagnosis was 48.6 ± 11.2 years. Lymph node positivity was observed in 60.2% of patients, and Grade II tumors were most common (52.5%). Recurrence occurred in 22.5% of cases. Tumor size demonstrated a negative correlation with disease-free survival (r = –0.42, p <0.001), while lymph node involvement significantly reduced survival duration (p = 0.001). Higher histological grade was associated with increased recurrence and reduced overall survival (p = 0.002). Hormone receptor positivity correlated with improved disease-free survival. Conclusion: Tumor size, nodal status, histological grade, and receptor expression were significant predictors of survival and recurrence. These findings reinforce the importance of early detection and individualized treatment strategies to optimize outcomes in breast cancer patients.
Breast Neoplasms; Disease-Free Survival; Immunohistochemistry; Lymphatic Metastasis; Neoplasm Recurrence, Local; Prognosis; Treatment Outcome
Copyright (c) 2026 Farida Jafar, Muhammad Afraz Numan, Syeda Fatima Rizvi, Muhammad Qasim, Fatima Perveen, Shahzada Khalid Sohail, Muhammad Hassam Mehdi (Author) https://creativecommons.org/licenses/by/4.0
Peptidoglycan-Mimetic Inhibitors of D,D- and L,D-Transpeptidases: Mechanistic Design Principles and Translational Barriers in the Post-β-Lactam Era
Background: Peptidoglycan cross-linking is essential for bacterial cell-wall integrity and is catalyzed by D,D-transpeptidases (penicillin-binding proteins, PBPs) and L,D-transpeptidases (Ldts). Escalating β-lactam resistance driven by β-lactamases, altered PBPs, and compensatory reliance on Ldt-mediated 3→3 cross-links has intensified interest in non-β-lactam strategies that directly inhibit transpeptidases. Objective: This narrative review critically synthesizes mechanistic, structural, and medicinal chemistry evidence supporting peptidoglycan-mimetic inhibition of PBPs and Ldts, with emphasis on covalent warhead design, structural validation, and translational barriers. Methods: A structured narrative literature search of PubMed/MEDLINE, Scopus, and Web of Science was conducted for January 2010–March 2025, supplemented by reference list screening. Eligible articles reported transpeptidase inhibitor design with biochemical potency metrics, structural evidence of binding, and/or microbiological activity. Results: Substrate-mimetic and conformationally constrained scaffolds can reproduce key recognition motifs, including m-DAP pocket interactions, while boronic acids/cyclic boronates enable reversible covalent inhibition of serine-dependent PBPs via tetrahedral transition-state mimicry, and electrophilic warheads such as nitriles/cyanamides can covalently modify catalytic cysteine residues in Ldts. Structural studies validate active-site engagement across representative PBPs and Ldts, but whole-cell translation is frequently limited by Gram-negative outer membrane permeability, efflux susceptibility, and potential off-target reactivity of electrophiles. Conclusion: Peptidoglycan-mimetic transpeptidase inhibition is mechanistically compelling, yet clinically meaningful antibacterial development will require integrated optimization of target engagement, selectivity, and bacterial accumulation alongside pharmacokinetic feasibility
Peptidoglycan-mimetic inhibitors; penicillin-binding proteins; L,D-transpeptidases; covalent warheads; boronates; antibacterial drug design
Copyright (c) 2026 Maham Kanwal, Maira Khan, Arfa Akram (Author) https://creativecommons.org/licenses/by/4.0
Meta Analysis on Medical and Surgical Management and Rehabilitation in Rhematoid Arthritis
Background: Rheumatoid arthritis (RA) is a systemic, chronic, autoimmune disorder, which is characterized by persistent synovial inflammation, progressive destruction of joints and marked functional impairment. A significant number of patients still report irreversible structural damage, pain, and poor quality of life despite significant improvements in the disease control due to the improvement in disease-modifying antirheumatic drug (DMARD) therapy. This has brought the need to have integrated management approaches with an emphasis that is not limited to pharmacological treatment. Purpose: This was a systematic review and synthesis of evidence of medical, surgical and rehabilitation interventions in rheumatoid arthritis, in the context of their combined effects on pain and functional outcomes, complication rates and health-related quality of life. Methods: A meta-analysis and systematic review were done as per the PRISMA 2020 guidelines. They were searched in electronic databases such as PubMed, Scopus, Web of Science, Cochrane Library, and Google Scholar that used peer-reviewed articles published between January 2010 and December 2025. The studies that were eligible were systematic reviews, meta-analyses, randomized controlled trials, and high-quality observational studies carried out on adult patients with RA. Intervention of interest included pharmacological intervention, surgery and rehabilitation measures. Random-effects meta-analysis were applied to extract and synthesize data where the quality of the studies was assessed with validated appraisal tools. Findings: 58 studies were incorporated in the qualitative synthesis and 15 studies were used in the quantitative meta-analysis. Essential taping of the activity of the diseases with the help of the early introduction of csDMARDs and their further increase to biologic or targeted synthetic agents was accompanied by considerable disease activity, radiographic progression, and the chances of having a joint replacement surgery. Surgical procedures, such as total knee and hip arthroplasty and spinal surgery, resulted in great pain relief and functional improvement but also had more complication rates among RA patients than those of the osteoarthritis population. Rehabilitation interventions, especially biopsychosocial and technology-assisted interventions, were found to have a high degree of benefits in terms of pain, functional recovery and quality of life. The use of integrated management approaches that involved optimization of medicine, surgery as well as rehabilitation brought about cumulative improvements in major clinical outcomes. Conclusion: The current meta-analysis results highlight the significance of the multidisciplinary and integrated strategy of managing rheumatoid arthritis. Integrating convenience pharmacological treatment and timely surgical intervention with more advanced rehabilitation plans can result in the highest potential to decrease disability and improve functional results and quality of life of RA patients.
Rheumatoid arthritis; Systematic review; Meta-analysis; Disease-modifying antirheumatic drugs; Joint replacement surgery; Spine surgery; Rehabilitation; Biopsychosocial care.
Copyright (c) 2026 Muhammad Faraz Uddin, Saoud Javed, Anesh Kumar, Nauman Zarwali, Usman Arshad, Subhan Ali Jakhrani, Saqib Ali, Nazish Marvi (Author) https://creativecommons.org/licenses/by/4.0
Evaluation of Serum Creatinine Levels as an indicator of Renal Dysfunctioning in Patients with Liver Cirrhosis
Background: Liver cirrhosis is a chronic progressive disease associated with multiple complications, including renal dysfunction. Serum creatinine is a key biomarker for evaluating renal function, and its elevation often indicates impaired kidney function, which significantly affects prognosis in cirrhotic patients. Early identification of renal impairment is essential for optimal management and improved outcomes. Objective: To evaluate serum creatinine levels in patients with liver cirrhosis and determine the prevalence of renal dysfunctioning in patients with liver cirrhosis. Methods: This cross-sectional study included 100 patients diagnosed with liver cirrhosis. Serum creatinine levels were measured for all participants. The normal reference range for serum creatinine was 0.7–1.2 mg/dL. Descriptive statistics were applied using SPSS version 26.0 to summarize the data. Continuous variables were expressed as mean, median, standard deviation (SD), and range, while categorical variables were presented as frequencies and percentages. Results: Out of 100 patients, 58 patients (58%) had elevated serum creatinine levels exceeding 1.2 mg/dL, indicating impaired renal function, while 42 patients (42%) had values within the normal range. The mean serum creatinine level was 1.45 mg/dL, with a median of 1.4 mg/dL and an SD of 0.5 mg/dL. The observed range of serum creatinine values was 0.8–3.2 mg/dL. These findings demonstrate a high prevalence of renal dysfunction among patients with liver cirrhosis. Conclusion: Renal impairment, as indicated by elevated serum creatinine, is highly prevalent in patients with liver cirrhosis. Elevated serum creatinine levels may serve as an important indicator of acute kidney injury (AKI) in patients with liver cirrhosis. These findings may highlight the need for routine and periodic monitoring of serum creatinine within 48 hours for early detection of AKI, enabling timely clinical interventions and potentially improving patient outcomes. Therefore, regular assessment of renal function should be an integral component of the management strategy for patients with liver cirrhosis.
Liver cirrhosis, serum creatinine, acute kidney injury, renal impairment, early biomarker
Copyright (c) 2026 Munib Ahmad, Ayesha Hameed, Muneeba Bibi, Isra Saeed, Khalid Nazeer, Muhammad Bilal, Muhammad Umar (Author) https://creativecommons.org/licenses/by/4.0
Comparative Effectiveness and Cost Considerations of Manual Therapy Techniques in Peripheral Nerve Entrapments: A Narrative Review of Recent Evidence (2021–2024)
Background: Peripheral nerve entrapments are common neuromuscular disorders that cause pain, sensory disturbance, and functional impairment, with increasing emphasis on conservative, non-surgical management. Objective: To synthesize recent evidence (2021–2024) on the clinical effectiveness and cost-related considerations of manual therapy techniques—neural mobilization, Maitland mobilization, the Mulligan concept, myofascial release, and Cyrix friction massage—for peripheral nerve entrapments. Methods: This narrative review searched PubMed/MEDLINE, Scopus, Google Scholar, and PEDro for English-language, peer-reviewed studies published from January 2021 to December 2024 (search conducted and updated in January 2025), supplemented by hand-searching reference lists. Eligible studies included adults with clinically or electrophysiologically diagnosed entrapment neuropathies receiving one or more target manual therapy techniques. Results: Thirty-two studies were included (14 randomized controlled trials, 6 non-randomized/quasi-experimental studies, 5 observational/case series studies, and 7 systematic reviews/meta-analyses), most frequently addressing carpal tunnel syndrome. Across conditions, neural mobilization and Mulligan-based interventions showed the most consistent improvements in pain and functional outcomes, with occasional accompanying gains in grip strength and nerve conduction parameters in carpal tunnel syndrome. Maitland mobilization and myofascial release demonstrated mixed or adjunctive benefits, while Cyrix friction massage showed limited and inconsistent effects. No study reported formal cost-effectiveness outcomes; cost-related findings were restricted to indirect indicators such as session burden and treatment duration. Conclusion: With moderate certainty and acknowledging heterogeneous protocols and variable risk-of-bias across primary studies, neural mobilization and the Mulligan concept appear to be the most consistently supported manual therapy options for conservative management of peripheral nerve entrapments, while other techniques may be considered adjunctive based on clinical presentation. Future trials should prioritize standardized protocols, longer follow-up, and integrated health-economic outcomes.
Peripheral nerve entrapments; manual therapy; neural mobilization; Mulligan concept; conservative treatment; cost considerations
Copyright (c) 2025 Shamma Tabbassum, Maria Monem Qasmi, Arif Hussain, Hamna Khan, Sanjina Moolchandani, Muhammad Faisal Qureshi (Author) https://creativecommons.org/licenses/by/4.0
The Patterns of Emergency Presentations in Patients With Chronic Liver Disease
Background: Chronic liver disease (CLD) is a major cause of emergency department (ED) utilization due to acute decompensating events that carry high short-term morbidity and mortality. Local data describing ED presentation patterns in Pakistan remain limited, constraining protocol development and resource planning. Objective: To determine the patterns of emergency presentations, underlying etiologies, and immediate disposition outcomes among adults with CLD presenting to the ED of Lady Reading Hospital, Peshawar. Methods: This prospective cross-sectional observational study enrolled consecutive adults (≥18 years) with known or newly diagnosed CLD presenting with CLD-related emergency complications from 1 January 2025 to 30 June 2025. Data on demographics, CLD etiology, primary ED presentation, key clinical and laboratory abnormalities, and ED disposition were recorded using a structured proforma and analyzed using SPSS v26. Results: Among 120 patients (mean age 52.4 ± 11.6 years; 65% male), hepatitis C was the most common etiology (48.3%), followed by hepatitis B (18.3%). The leading primary presentations were upper gastrointestinal bleeding (26.7%), hepatic encephalopathy (23.3%), and tense ascites with respiratory compromise (16.7%); SBP/sepsis (11.7%) and AKI/HRS (8.3%) were also observed. Overall, 56.7% required ward admission, 23.3% ICU care, 15.0% were discharged after stabilization, and ED mortality was 5.0%. Conclusion: Upper gastrointestinal bleeding and hepatic encephalopathy were the predominant and most resource-intensive ED presentations in CLD, with hepatitis C as the leading etiology, underscoring the need for strengthened hepatitis control and standardized ED management pathways.
Chronic liver disease; Emergency department; Hepatitis C; Upper gastrointestinal bleeding; Hepatic encephalopathy; Ascites; Sepsis; Acute kidney injury
Copyright (c) 2026 Muhammad Abas Khan, Jahanzeb Raza, Hamnah Aman, Ayisha Maqsood, Omair Qaseem, Zoya Riaz, Waqas Akhtar (Author) https://creativecommons.org/licenses/by/4.0
Antioxidant Properties and Hepatoprotective Potential of Milk Thistle (Silymarin marianum) in Chronic Hepatitis C Patients with Elevated Liver Enzymes
Background: Chronic hepatitis C is frequently associated with persistent hepatocellular injury manifested by elevated alanine aminotransferase (ALT) and aspartate aminotransferase (AST), and adjunctive hepatoprotective strategies with antioxidant potential remain of clinical interest. Objective: To characterize milk thistle (Silybum marianum) seed powder and evaluate its hepatoprotective effect on elevated liver enzymes in adult male chronic hepatitis C patients. Methods: In a single-center, parallel-group randomized controlled trial, 45 men (30–50 years) with chronic hepatitis C and elevated transaminases were allocated (1:1:1) to control (no supplementation), milk thistle seed powder 250 mg/day, or 500 mg/day for 45 days. Milk thistle powder underwent proximate analysis, mineral profiling, and phytochemical quantification of total phenolics (TPC) and total flavonoids (TFC). Fasting serum ALT and AST were measured at baseline and day 45. Between-group effects were evaluated using ANCOVA adjusted for baseline values and reported as adjusted mean differences with 95% confidence intervals (CIs). Results: Milk thistle powder contained moisture 25.20±1.77%, ash 16.81±2.13%, nitrogen-free extract 35.10±3.12%, crude protein 7.30±0.72%, crude fat 22.17±2.31%, and crude fiber 5.77±0.11%, with TPC 34.28±0.02 mg GAE/g and TFC 28.36±0.11 mg QE/g. Compared with control, ALT decreased by −11.34 U/L (95% CI: −18.22 to −4.46; p=0.002) with 250 mg/day and −14.05 U/L (95% CI: −21.12 to −6.98; p<0.001) with 500 mg/day; AST decreased by −8.42 U/L (95% CI: −15.01 to −1.83; p=0.013) and −17.31 U/L (95% CI: −24.40 to −10.22; p<0.001), respectively. Conclusion: Milk thistle seed powder supplementation for 45 days significantly reduced elevated ALT and AST in adult males with chronic hepatitis C, with greater reductions at 500 mg/day, supporting a dose-responsive hepatoprotective effect and warranting confirmation in larger placebo-controlled trials.
Milk thistle; Silybum marianum; silymarin; flavonolignans; total phenolics; total flavonoids; antioxidants; alanine aminotransferase; aspartate aminotransferase; hepatitis C
Copyright (c) 2026 Adan Amjad, Abida Liaquat, Rimsha Tariq, Azka Momina Irfan, Moazma Noor, Kiran Aslam, Rameesa Shahbaz, Aiza (Author) https://creativecommons.org/licenses/by/4.0
The Reliability and Validity of Neck Disability Index-Urdu Mobile App in Chronic Mechanical Neck Pain Patients
Background: Neck pain is prevalent and disabling, and literacy barriers may limit accurate completion of written patient-reported outcome measures in Urdu-speaking populations. A voice-supported mobile application version of the Urdu Neck Disability Index (NDI-U App) may improve accessibility but requires psychometric evaluation. Objective: To determine the reliability, internal consistency, structural validity, and convergent construct validity of the NDI-U App in adults with chronic mechanical neck pain. Methods: A cross-sectional observational psychometric validation study was conducted across three centers in Kotli, Azad Kashmir, Pakistan (2023). Adults aged 18–65 years with chronic mechanical neck pain (≥3 months) completed the NDI-U App, Urdu Northwick Park Neck Pain Questionnaire (NPQ-U), and Visual Analogue Scales (VAS) for pain and disability at baseline; the NDI-U App was repeated after 48 hours. Test–retest reliability was assessed using ICC(2,1); internal consistency using Cronbach’s alpha; floor/ceiling effects using extreme-score proportions; convergent validity using Pearson correlations; and structural validity using principal component analysis with varimax rotation. Results: Among 300 participants, test–retest reliability was excellent (ICC=0.95; 95% CI: 0.93–0.96; p<0.001) with SEM=1.73 and MDC95=4.79. Internal consistency was fair (α=0.675; 95% CI: 0.63–0.72). Floor and ceiling effects were minimal (1.0% and 0.3%, respectively). Convergent validity was moderate with NPQ-U (r=0.584; 95% CI: 0.50–0.66; p<0.001) and weak with VAS pain (r=0.253) and disability (r=0.266) (both p<0.001). Two components explained 33.34% variance (KMO=0.584; Bartlett p<0.001). Conclusion: The NDI-U App demonstrates excellent reliability, minimal extreme-score effects, and moderate convergent validity, supporting its clinical and research use for disability assessment in Urdu-speaking chronic mechanical neck pain populations.
Neck Disability Index; Urdu; mobile application; chronic mechanical neck pain; reliability; validity; NPQ; VAS.
Copyright (c) 2026 Aabirah Siddique, Nusrat Prveen, Usman Ejaz, Ifra Zulqarnain Awan, Misha Zahid, Hafiza Mahnoor Shabbir, Attia Mehboob, Akhtar Rasul (Author) https://creativecommons.org/licenses/by/4.0
Assessment of Knowledge, Attitude, and Screening Practices Regarding Diabetic Cardiovascular Risk Among Males with Type 2 Diabetes in Islamabad Capital Territory (ICT), Pakistan
Background: Type 2 diabetes mellitus (T2DM) substantially increases cardiovascular disease (CVD) risk, yet preventive screening uptake remains suboptimal in many low- and middle-income settings, including Pakistan. Objective: To assess knowledge, attitudes, and screening practices regarding diabetic cardiovascular risk among males with T2DM in Islamabad Capital Territory (ICT), Pakistan, and to examine differences by educational field (medical vs non-medical). Methods: A cross-sectional online survey was conducted in ICT between January and April 2025 among 480 adult males with physician-diagnosed T2DM. A structured questionnaire captured socio-demographics, knowledge of diabetic cardiovascular risk, attitudes toward physician-recommended screening, and self-reported preventive screening within the preceding 12 months. Group differences were evaluated using Chi-square tests and effect sizes, and multivariable logistic regression estimated adjusted odds ratios (AORs) controlling for age group, overall education, employment, and marital status. Results: Awareness that T2DM increases heart disease risk was 72.9% (350/480), and familiarity with lipid profile testing was 54.2% (260/480). Willingness to undergo screening if advised by a physician was 62.5% (300/480), whereas only 33.3% (160/480) reported receiving a cardiovascular health check-up in the past 12 months. Medical-background participants demonstrated higher awareness (81.8% vs 65.4%; p<0.001) and screening uptake (40.9% vs 26.9%; p=0.002); medical background independently predicted awareness (AOR 2.23; 95% CI 1.41–3.52) and screening uptake (AOR 1.86; 95% CI 1.20–2.88). Conclusion: Despite moderately high risk awareness and favorable attitudes, preventive cardiovascular screening uptake among males with T2DM in ICT remains limited, with significant educational disparities, underscoring the need for structured physician-led screening integration and targeted risk literacy interventions.
Type 2 diabetes mellitus; cardiovascular disease risk; lipid profile; preventive screening; knowledge attitude practice; educational background; Islamabad Capital Territory; Pakistan.
Copyright (c) 2026 Aqib Muhammad, Dilawar khan panezai, Bashir Ahmed Abro, Mian Fahad Tasneem, Moeez zafar, Maria Ishfaq, Wardah Shahid, Hafiz Muhammad Usman Abid (Author) https://creativecommons.org/licenses/by/4.0
Hypertension And Its Associated Factors Among Type 2 Diabetes Mellitus Patients
Background: Hypertension is the most prevalent cardiovascular comorbidity among patients with Type 2 Diabetes Mellitus (T2DM), substantially increasing the risk of cardiovascular and renal complications. The coexistence of these conditions reflects shared pathophysiological mechanisms including insulin resistance, endothelial dysfunction, and activation of the renin–angiotensin–aldosterone system. Despite global evidence, district-level data from Pakistan remain limited. Objective: To determine the prevalence of hypertension and identify its associated factors among patients with T2DM attending a secondary-level healthcare facility. Methods: A hospital-based cross-sectional observational study was conducted among 90 adults with T2DM at DHQ Hospital Sheikhupura. Data were collected using structured interviews, anthropometric measurements, standardized blood pressure assessment, and medical record review. Hypertension was defined as systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg or current antihypertensive use. Multivariable logistic regression was performed to identify independent predictors. Results: The prevalence of hypertension was 61.1%. Age >60 years (AOR 2.41; 95% CI 1.01–5.74), diabetes duration >10 years (AOR 2.21; 95% CI 1.00–4.92), obesity (AOR 2.96; 95% CI 1.25–7.01), and poor glycemic control (AOR 2.39; 95% CI 1.01–5.66) were independently associated with hypertension. Smoking and residence were not significant after adjustment. Conclusion: Hypertension is highly prevalent among T2DM patients, with modifiable metabolic factors significantly increasing risk. Integrated screening and risk-based management are essential to reduce cardiovascular burden.
Type 2 Diabetes Mellitus; Hypertension; Prevalence; Obesity; Glycemic Control; Risk Factors.
Copyright (c) 2026 Ali Sher, Nouman Rafique, Muhammad Hanif, Inam Ullah (Author) https://creativecommons.org/licenses/by/4.0
Coagulation Pathologies in Patients With Chronic Liver Disease at a Tertiary Care Hospital, Peshawar
Background: Chronic liver disease (CLD) disrupts hemostasis through impaired hepatic synthesis of coagulation factors and thrombopoietic dysfunction, producing laboratory abnormalities such as prolonged prothrombin time (PT), activated partial thromboplastin time (aPTT), and thrombocytopenia that complicate clinical assessment in resource-limited settings. Objective: To determine the frequency of laboratory-defined coagulopathy among adults with CLD and evaluate its association with age, gender, and body mass index (BMI). Methods: This descriptive cross-sectional study was conducted at Hayatabad Medical Complex, Peshawar, from 16 November 2021 to 16 May 2022. A total of 174 patients aged 40–60 years with CLD of ≥6 months’ duration were enrolled by consecutive sampling. PT, aPTT, and platelet count were measured using standardized laboratory methods. Coagulopathy was defined as prolonged PT and/or prolonged aPTT (above the institutional upper reference limit) and/or thrombocytopenia (<150,000/µL). Associations were assessed using chi-square or Fisher’s exact tests with odds ratios (OR) and 95% confidence intervals (CI). Results: Coagulopathy was present in 112/174 patients (64.4%; 95% CI: 57.3–71.5). Prevalence was higher in BMI ≥30 kg/m² versus <30 kg/m² (75.0% vs 58.8%; OR 2.10; 95% CI: 1.03–4.29; p=0.03). Coagulopathy occurred in 56/78 (71.8%) aged 40–50 years and 56/96 (58.3%) aged 51–60 years (OR 1.82; 95% CI: 0.94–3.51; p=0.06). All males had coagulopathy (94/94, 100.0%) compared with 18/80 females (22.5%; Fisher’s exact p<0.001). Conclusion: Laboratory-defined coagulation abnormalities were highly prevalent in CLD, with significant associations observed for male gender and obesity, supporting routine screening with PT, aPTT, and platelet count for risk stratification in tertiary-care practice.
Chronic liver disease; Coagulopathy; Thrombocytopenia; Prothrombin time; Activated partial thromboplastin time; Body mass index.
Copyright (c) 2026 Wafa Ahmad, Asadullah, Saba Nadeem, Ataur Rahman, Asad Ali (Author) https://creativecommons.org/licenses/by/4.0
Comparison of Lower Extremity Function and Hamstring Tightness in Individuals With or Without Plantar Fasciitis
Background: Plantar fasciitis is a prevalent source of plantar heel pain that may reflect broader kinetic-chain dysfunction, including posterior muscle tightness and impaired lower-limb performance. Objective: To compare hamstring tightness and lower extremity function in young adults with and without plantar fasciitis and to determine the association between plantar fasciitis, hamstring tightness, and functional limitation. Methods: A cross-sectional observational study was conducted in multiple hospitals in Sialkot, Pakistan over six months. Using convenience sampling, 375 adults aged 19–35 years were enrolled and classified as plantar fasciitis positive (n=187) or negative (n=188) based on clinical assessment. Hamstring tightness was assessed using the Active Knee Extension (AKE) test with goniometric measurement, and lower extremity function was evaluated using the Lower Extremity Functional Scale (LEFS; 0–80). Group comparisons were performed using Mann–Whitney U and chi-square tests with effect sizes and 95% confidence intervals. Results: Participants with plantar fasciitis demonstrated significantly lower AKE range of motion than controls (right: 57.31±10.16° vs 71.85±8.74°; left: 58.01±9.98° vs 72.21±8.51°; both p<0.001) and a higher prevalence of hamstring tightness (72.7% vs 28.2%; OR 6.78, 95% CI 4.32–10.65). LEFS scores were significantly lower in plantar fasciitis (45.74±9.87) compared with controls (58.94±8.91), with a mean difference of 13.20 points (95% CI −15.1 to −11.2; p<0.001). Conclusion: In young adults, plantar fasciitis is strongly associated with increased hamstring tightness and clinically meaningful reductions in lower extremity function, supporting comprehensive posterior-chain assessment and targeted flexibility rehabilitation.
Plantar fasciitis; plantar heel pain; hamstring tightness; Active Knee Extension test; Lower Extremity Functional Scale; lower extremity function
Copyright (c) 2026 Arshman Sagar, Asifa Quratulain, Eman Shahid, Ayesha Sohail, Raveena Rajput (Author) https://creativecommons.org/licenses/by/4.0
Prevalence of Speech and Hearing Impairment in Children with Cerebral Palsy in Muzaffarabad Azad Jammu and Kashmir and Its Suburbs
Background: Cerebral palsy (CP) is a non-progressive neurodevelopmental disorder frequently accompanied by communication-related comorbidities that can substantially limit rehabilitation participation and long-term functioning, particularly in resource-constrained settings. Objective: To determine the prevalence of speech and hearing impairment among children with CP in Muzaffarabad, Azad Jammu and Kashmir (AJK), and to assess associations with CP subtype and gross motor severity, alongside patterns and barriers to accessing relevant services. Methods: A cross-sectional observational study was conducted at the Muzaffarabad Rehabilitation Centre using retrospective record review of children with CP aged ≥2 years who attended between January 2018 and February 2020. Sociodemographic and clinical variables, CP subtype, GMFCS level, documented speech and hearing impairment, and service utilization/barriers were extracted using a structured proforma. Associations were examined using chi-square tests with effect sizes. Results: Among 225 children (mean age 5.03±3.31 years), speech impairment was present in 70.2% (158/225; 95% CI 64.2–76.2), comprising 58.7% (132/225) with speech impairment only and 11.6% (26/225; 95% CI 7.4–15.8) with combined speech and hearing impairment; isolated hearing impairment was not documented. Combined impairment was more frequent in spastic quadriplegic than spastic diplegic CP (22.3% vs 7.3% within the speech-impaired subgroup; p=0.03), and CP subtype was strongly associated with GMFCS severity (p<0.001). Service uptake was minimal: 94.3% (149/158) had never consulted a speech therapist and no child received therapy sessions; no child with hearing impairment underwent ENT evaluation. Conclusion: Speech impairment was highly prevalent and clustered with severe motor phenotypes, while hearing impairment was less frequently documented and occurred with speech impairment; profound gaps in access to speech and hearing services highlight the need for integrated multidisciplinary care pathways in AJK.
cerebral palsy; speech impairment; hearing impairment; GMFCS; rehabilitation; service access; Pakistan; Azad Jammu and Kashmir
Copyright (c) 2026 Maryum Naseer Butt, Wajida Perveen, Hafiz Muhammad Usama Basheer, Maria Khalid, Zainab Javed, Bushra Raheem (Author) https://creativecommons.org/licenses/by/4.0
Neuromuscular Electrical Stimulation Combined With Progressive Resistance Training Versus Resistance Training Alone on Muscle Strength and Functional Outcomes in Post–Anterior Cruciate Ligament Reconstruction Patients: A Randomized Controlled Trial
Background: Persistent quadriceps weakness after anterior cruciate ligament reconstruction (ACLR) is common and is partly driven by arthrogenic muscle inhibition, limiting voluntary activation and delaying functional recovery. Objective: To compare the effects of neuromuscular electrical stimulation (NMES) combined with progressive resistance training (PRT) versus PRT alone on quadriceps strength and functional outcomes in post-ACLR patients. Methods: In this assessor-blinded randomized controlled trial conducted at Therapy Plus Clinic, 60 participants (18–40 years; 4–8 weeks post-primary unilateral ACLR) were randomized (1:1) to NMES+PRT or PRT alone for 8 weeks (3 sessions/week). Quadriceps strength (Nm/kg) and limb symmetry index (LSI) were primary outcomes; functional hop tests (single-leg hop, triple hop, 6-m timed hop) and IKDC subjective scores were secondary outcomes. Analyses followed intention-to-treat with multiple imputation for missing data, using repeated-measures ANOVA and between-group comparisons at α=0.05. Results: At 8 weeks, NMES+PRT produced greater strength gains than PRT alone (Δ+0.59±0.21 vs +0.39±0.19 Nm/kg; between-group difference 0.20, 95% CI 0.09–0.31; p=0.001) and higher LSI improvement (+21.3±6.8% vs +13.5±7.2%; difference 7.8, 95% CI 4.2–11.4; p<0.001). NMES+PRT also improved single-leg hop distance (difference 12.1 cm; p=0.003), triple hop distance (difference 32.8 cm; p=0.002), 6-m timed hop (difference −0.21 s; p=0.016), and IKDC change (difference 7.7 points; p<0.001). Conclusion: NMES added to PRT yields statistically and clinically meaningful improvements in quadriceps strength, symmetry, functional performance, and patient-reported knee function after ACLR compared with PRT alone.
anterior cruciate ligament reconstruction; neuromuscular electrical stimulation; progressive resistance training; quadriceps strength; limb symmetry index; hop tests; IKDC
Copyright (c) 2025 Laiba Fatima, Muhammad Tahir, Muhammad Junaid Ilyas (Author) https://creativecommons.org/licenses/by/4.0
Assessment of Knowledge, Attitude, and Practice Regarding Exclusive Breastfeeding Among Lactating Mothers in Tertiary Hospital Rawalpindi, Punjab (A Cross-Sectional Study)
Background: Exclusive breastfeeding (EBF) for the first six months is a core child-survival intervention, yet gaps persist between maternal awareness and guideline-concordant practice in many low- and middle-income settings. Objective: To assess knowledge, attitudes, and practices regarding EBF among lactating mothers attending a tertiary care hospital in Rawalpindi, Punjab, and to examine factors associated with EBF practice. Methods: A hospital-based cross-sectional study was conducted at Holy Family Hospital, Rawalpindi, from 25 August 2025 to 16 January 2026 among 384 lactating mothers selected via convenience sampling. Data were collected using a structured interviewer-administered questionnaire assessing socio-demographics and KAP domains. Good knowledge was defined as achieving ≥70% on a composite knowledge score; attitude was assessed using a composite Likert-based score. EBF practice was operationalized using the WHO 24-hour recall definition. Associations were evaluated using chi-square tests and multivariable logistic regression in SPSS v20 with p<0.05. Results: Good knowledge was observed in 65.1% (95% CI: 60.2–69.7) and positive attitude in 74.2% (95% CI: 69.6–78.4). EBF practice prevalence was 50.3% (95% CI: 45.3–55.2). Independent predictors of EBF included good knowledge (AOR 2.01; 95% CI: 1.32–3.06; p=0.001), positive attitude (AOR 1.68; 95% CI: 1.05–2.68; p=0.029), and secondary or higher education (AOR 1.74; 95% CI: 1.13–2.69; p=0.012). Conclusion: Despite favorable knowledge and attitudes, only half of mothers practiced EBF per WHO criteria; strengthening targeted antenatal and postpartum counseling and addressing cultural supplementation practices are essential to improve adherence.
Exclusive breastfeeding; knowledge; attitude; practice; lactating mothers; cross-sectional study; Pakistan
Copyright (c) 2026 Muhammad Imran, Sana, Naveed Ahmad, Muhammad Ishaq, Sayed Amjad Ali, Jawad Ahmad, Misbah Noor, Hamayoun Saeed, Bilal, Abdar Ali (Author) https://creativecommons.org/licenses/by/4.0
INTRA-Operative and Post-Operative Common Complications of Hysterectomy
Background: Hysterectomy is a common gynecological procedure with potentially significant intra-operative and early post-operative morbidity; context-specific complication profiling is essential to optimize surgical planning, training allocation, and perioperative safety. Objective: To determine the incidence and pattern of intra-operative and early post-operative complications among women undergoing hysterectomy in a tertiary-care hospital and to assess associations with surgical route and key perioperative risk factors. Methods: A hospital-based cross-sectional observational study was conducted at Jinnah Hospital from 1 January 2024 to 30 April 2024. Consecutive eligible women undergoing vaginal, abdominal, or laparoscopic hysterectomy were enrolled after informed consent, excluding patients with severe systemic comorbidities. Standardized definitions were used to record intra-operative events (e.g., bladder/bowel/ureteric injury, hemorrhage) and early post-operative outcomes (e.g., bleeding, surgical-site infection, hematoma) during index admission/within 7 days. Associations were examined using chi-square/Fisher’s exact tests and multivariable logistic regression. Results: Among 94 hysterectomies, any intra-operative complication occurred in 55.3% (52/94; 95% CI: 45.2–65.1) and any early post-operative complication in 53.2% (50/94; 95% CI: 43.1–63.1). Complication incidence was lower after vaginal hysterectomy (intra-operative 44.9%; post-operative 42.9%) than abdominal hysterectomy (66.7%; 64.1%). Prior pelvic surgery independently predicted intra-operative (aOR 3.02; 95% CI: 1.10–8.28; p=0.03) and early post-operative complications (aOR 2.76; 95% CI: 1.01–7.55; p=0.04); operative duration ≥120 minutes predicted intra-operative complications (aOR 2.89; 95% CI: 1.09–7.64; p=0.03), and abdominal route predicted early post-operative morbidity (aOR 2.58; 95% CI: 1.00–6.65; p=0.05). Conclusion: Perioperative complications were frequent, with higher risk associated with prior pelvic surgery, prolonged operative duration, and abdominal approach; prioritizing vaginal routes when feasible and strengthening risk-stratified perioperative protocols may reduce morbidity.
Hysterectomy; intra-operative complications; post-operative complications; bladder injury; bowel injury; surgical-site infection; post-operative bleeding; tertiary-care hospital.
Copyright (c) 2026 Muskan Shahzadi, Uzia Jamil, Sameen Hanif, Inam Ullah, Sumbal Shahbaz, Awais Akhtar, Taimoor Riaz Ullah, Saqib Hussain Dar (Author) https://creativecommons.org/licenses/by/4.0