Link Medical Journal
type: channel
description: Open Access Statement LMJHCR is a fully open-access journal. All published articles are made available online immediately upon publication, without subscription or access barriers. Readers may read, download, copy, share, distribute, print, search, and link to the full text of articles and may use the content for any lawful purpose, provided appropriate attribution is given to the original author(s) and source. Journal Identity Link Medical Journal of Health and Community Research (LMJHCR) is a peer-reviewed, open-access journal published by Link Medical Interface. The journal advances multidisciplinary scholarship across medical sciences, clinical specialties, rehabilitation and allied health, biomedical sciences, and public and community health, with emphasis on clinically relevant and community-informed research. Journal Title: Link Medical Journal of Health and Community Research (LMJHCR) Publisher: Link Medical Interface Publication Frequency: Biannual (two issues per year) Online ISSN: 3007-3448 ISSN Portal Record: https://portal.issn.org/resource/ISSN-L/3007-3448 Digital Object Identifiers (DOIs): All published articles are assigned DOIs. Scholarly Visibility: Articles are discoverable through major scholarly search platforms (including Google Scholar) and through structured metadata and DOI-based linking. Recognition: HEC Recognized (as per latest official listing) Aims and Objectives LMJHCR is committed to advancing evidence-based scholarship in medical sciences, public health, and community-based research. Our primary aim is to foster innovative, ethically sound contributions that address pressing health challenges, promote equity in healthcare delivery, and enhance community well-being, with particular relevance to resource-limited settings and underrepresented populations globally. The journal also encourages early-career researchers and novice contributors by providing clear editorial guidance and constructive peer-review feedback, while maintaining rig…
publisher: Link Medical Interface, Lahore, Pakistan
language: en
publication name: Link Medical Journal
issn: 3007-3448
copyright: © The Authors. This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0).
items: Certificate of Editorial Service and Appreciation
items: https://linkmjhcr.com/index.php/lmj/article/view/211
items: Knowledge and Practicing Attitude for Diagnostic Approaches to Non-Healing Oral Ulcers Among Dental Practitioners in Pakistan: A Cross-Sectional Studies
items: Impact of Physiotherapy on Kinesiophobia and Knee Pain After Knee Replacements
items: Geographic and Socioeconomic Predictors of Postpartum Depression Identified Through Machine Learning Analysis of Pakistani Health Data
items: Neuromodulatory Impact of Low-Intensity Focused Ultrasound on Early Cognitive Decline
items: Exosomal MicroRNA-21 Expression Changes During Neoadjuvant Chemotherapy in Breast Cancer Patients
items: Low-Level Laser Therapy Versus Occlusal Splint for Myofascial Pain Reduction in Chronic TMJ Disorder Patients
items: Effect of Femtosecond Laser-Assisted Versus Manual Clear Corneal Incisions on Postoperative Corneal Stiffness in Cataract Surgery
items: MicroRNA-146a Modulation by Targeted Lipid Nanoparticles to Treat Rheumatoid Arthritis: A Proof-of-Concept RCT
items: Plane-Specific Recovery of Cervical Range of Motion after Traction-Augmented versus Exercise-Only Therapy: A Motion-Selective Reanalysis in Generalized Neck Pain
items: Predictive Value of Preoperative Myocardial Strain Imaging on Post-CABG Recovery
items: Menstrual Health Literacy and Delay in Care-Seeking Among Adolescents with Heavy Menstrual Bleeding
items: Prevalence of Lateral Epicondylitis in Carpenters; Its Impact on Their Functional Activities of Upper Limb
items: Frequency of Musculoskeletal Disorders in Tailors of Lahore, Pakistan
items: Perception and Practice Related to Postural Pain Among Breastfeeding Women in Hyderabad, Sindh
items: Cervical Joint Position Error and Its Association with Bruxism and Pain Severity in Orthodontic Patients
items: Patient Confidence in Long-Term Care Plans for Multimorbidity Management: A Qualitative Descriptive Study
items: Differential Cardiometabolic Effects of GLP-1 Receptor Agonists Versus SGLT2 Inhibitors in Early-Onset Type 2 Diabetes: A Randomized Controlled Trial
items: Left Ventricular Hypertrophy Patterns in Diabetic Versus Non-Diabetic Hypertensive Patients on Maintenance Hemodialysis in Peshawar
items: Electroencephalographic Signatures of Dexmedetomidine and Propofol Sedation: A Structured Narrative Review
items: Exploring the Relationship Between Sleep Quality and Cardiovascular Risk Factors in University Students
items: Correlation Between Upper Cross Syndrome and Smartphone Addiction in University Students
items: Self-Medication Among Pharmacy Students: A Cross-Sectional Study on Prevalence, Patterns, and Determinants
items: Plant-Based Gold Nanoparticles for Targeted Drug Delivery in Breast Cancer: Progress and Prospects in Pakistan
items: Development and Evaluation of Kiwi-Based Kombucha as a Functional Beverage Alternative to Carbonated Soft Drinks
items: Sustainable Bioethanol Production from Lignocellulosic Plant Wastes: A Renewable Solution to Energy Challenges
items: Public Trust in Laboratory Results During Emerging Infectious Disease Alerts
items: Ethical Tensions in Aesthetic Surgery Advertising on Short-Video Platforms
items: Oral Health Misinformation and Treatment Choices Among Adult Dental Patients

Certificate of Editorial Service and Appreciation
type: item
description: This certificate is issued to Dr. Muhammad Nadeem Chohan, Assistant Professor of English at Prince Sattam Bin Abdulaziz University, Al-Kharj, Kingdom of Saudi Arabia, in recognition of his valuable editorial services to the Link Medical Journal of Health and Community Research (LMJHCR) from July 2024 to Present. Certificate ID: LMJCR-213
subject: Certification and Recognition
  topic: section
subject: Nadeem Chohan
  topic: keywords
creator: Muhammad Nadeem Chohan
rights: Copyright (c) 2026 Dr. Muhammad Nadeem Chohan (Author) https://creativecommons.org/licenses/by/4.0
date: 2026-07-27
publication date: 2026-07-27
starting page: e213
ending page: e213
doi: 10.61919/273n5s69

https://linkmjhcr.com/index.php/lmj/article/view/211
type: item
title: Effectiveness of Task-Oriented Training versus Conventional Physiotherapy on Gross Motor Function, Balance, and Functional Independence in Children with Spastic Cerebral Palsy: A Randomized Controlled Trial
description: Background: Persistent upper-limb impairment after stroke restricts independence and participation in daily activities. Mirror therapy provides augmented visual feedback that may enhance task-oriented motor practice. Objective: To compare mirror therapy combined with task-oriented training with task-oriented training alone for improving upper-limb motor function and functional performance in adults with chronic stroke. Methods: This assessor-blinded, two-arm randomized controlled trial was conducted at Therapy Plus Clinic, Lahore, Pakistan. Twenty-eight adults with chronic stroke were allocated equally to mirror therapy plus task-oriented training or task-oriented training alone. Outcomes were assessed at baseline and immediately after treatment. The primary outcome was the Fugl-Meyer Assessment–Upper Extremity, and the secondary outcome was the Action Research Arm Test. Within-group changes were examined using paired-samples t tests, and change scores were compared between groups using independent-samples t tests. Results: Fugl-Meyer scores improved by 14.2 ± 5.0 points in the combined group and 7.3 ± 4.4 points in the comparison group, producing a between-group difference of 6.9 points (95% CI, 3.24–10.56; p = 0.001; Cohen’s d = 1.47). Action Research Arm Test scores improved by 14.8 ± 5.7 and 7.1 ± 4.9 points, respectively, with a between-group difference of 7.7 points (95% CI, 3.57–11.83; p = 0.001; Cohen’s d = 1.45). Conclusion: Mirror therapy combined with task-oriented training produced greater immediate improvement in upper-limb motor impairment and structured functional performance than task-oriented training alone
subject: Articles
  topic: section
subject: chronic stroke; mirror therapy; task-oriented training; upper limb; motor recovery; Fugl-Meyer Assessment; Action Research Arm Test
  topic: keywords
creator: Hafsa Zahid
creator: Rahila Suleman
creator: Zarqa Sharif
creator: Hanan Azfar
creator: Bisma Shakil
creator: Sufyan Nawaz
creator: Umar Farooq Nazir
creator: Muhammad Tahir
rights: Copyright (c) 2026 Hafsa Zahid, Rahila Suleman, Zarqa Sharif , Hanan Azfar , Bisma Shakil, Sufyan Nawaz, Umar Farooq Nazir, Muhammad Tahir (Author) https://creativecommons.org/licenses/by/4.0
date: 2026-06-30
publication date: 2026-06-30
starting page: 1
ending page: 9
doi: 10.61919/d6rhtq22

Knowledge and Practicing Attitude for Diagnostic Approaches to Non-Healing Oral Ulcers Among Dental Practitioners in Pakistan: A Cross-Sectional Studies
type: item
description: Background: Persistent oral ulcers may represent traumatic, inflammatory, infectious, potentially malignant, or malignant conditions and require timely assessment. Dental practitioners play an important role in early recognition, biopsy selection, and referral. Objective: To evaluate dental practitioners’ knowledge, attitudes, self-reported confidence, diagnostic practices, referral behaviour, and perceived barriers regarding non-healing oral ulcers in Pakistan. Methods: A cross-sectional questionnaire-based survey was conducted among 227 dental practitioners recruited through professional and academic networks. Information was collected on professional characteristics, recognition of suspicious features, biopsy awareness, initial management, referral practices, and diagnostic barriers. Data were analysed descriptively using frequencies and percentages. Results: Fair or good knowledge was reported by 207 participants (91.2%). A 14-day persistence threshold was identified by 158 (69.6%), while 179 (78.9%) recognized induration and rolled margins as suspicious. Biopsy was considered the diagnostic gold standard by 211 (93.0%), but only 54 (23.8%) selected biopsy as their first approach. Removal of local irritants followed by review was selected by 105 (46.3%), and 114 (50.2%) deferred referral until initial treatment failed. Inadequate training was the leading barrier (36.1%). Conclusion: Respondents demonstrated favourable awareness but reported less consistent implementation of timely biopsy and referral. Practical training and standardized referral pathways may help reduce this knowledge–practice gap
subject: Articles
  topic: section
subject: non-healing oral ulcer; oral cancer; biopsy; dental practitioners; diagnostic practice; Pakistan
  topic: keywords
creator: Komal Malik
creator: Maira Izhar
creator: Muhammad Ibrahim
creator: Noor ul ain waheed
creator: Muhammad Farrukh
creator: Hafsa Shahid
rights: Copyright (c) 2026 Komal Malik, Maira Izhar, Muhammad Ibrahim, Noor ul ain waheed, Muhammad Farrukh, Hafsa Shahid (Author) https://creativecommons.org/licenses/by/4.0
date: 2026-06-30
publication date: 2026-06-30
starting page: 1
ending page: 10
doi: 10.61919/pzs5t335

Impact of Physiotherapy on Kinesiophobia and Knee Pain After Knee Replacements
type: item
description: Background: Pain and fear of movement may restrict participation in rehabilitation after total knee replacement. Evidence regarding their relationship with routine physiotherapy attendance in Pakistan remains limited. Objective: To determine the association of physiotherapy-session exposure with kinesiophobia and knee-pain intensity after total knee replacement. Methods: This analytical cross-sectional study included 144 patients aged 40–60 years who were assessed one to three months after total knee replacement at hospitals and private physiotherapy clinics in Lahore. Participants were classified as having higher exposure if they had completed five or more physiotherapy sessions and lower exposure if they had completed fewer than five sessions. Pain was assessed using the Numeric Pain Rating Scale, and kinesiophobia was assessed using the 11-item Tampa Scale for Kinesiophobia. Associations were examined using Pearson’s chi-square test. Results: Each exposure group included 72 participants. Kinesiophobia was present in 12 (16.7%) participants in the higher-exposure group and 55 (76.4%) in the lower-exposure group (χ²(1)=51.61, p<0.001). The crude risk ratio was 0.22 (95% CI 0.13–0.37). No or mild pain was reported by 75.0% of the higher-exposure group compared with 12.5% of the lower-exposure group, whereas moderate or severe pain was reported by 25.0% and 87.5%, respectively (χ²(3)=59.05, p<0.001). Conclusion: Greater physiotherapy-session exposure was associated with lower kinesiophobia and less severe knee pain; however, the cross-sectional design did not establish causality
subject: Articles
  topic: section
subject: Total Knee Replacement; Kinesiophobia; Physiotherapy; Postoperative Rehabilitation; Knee Pain; Tampa Scale for Kinesiophobia.
  topic: keywords
creator: Ayesha Izhar
creator: Maham Naeem
creator: Eisha-Tur Raazia
creator: Mehwish Shahzadi
creator: Hafiza Ramal
creator: Anam Abbas
rights: Copyright (c) 2026 Ayesha Izhar, Maham Naeem, Eisha-Tur Raazia, Mehwish Shahzadi, Hafiza Ramal, Anam Abbas (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-12-30
publication date: 2025-12-30
starting page: 1
ending page: 9
doi: 10.61919/hybqp333

Geographic and Socioeconomic Predictors of Postpartum Depression Identified Through Machine Learning Analysis of Pakistani Health Data
type: item
description: Background: Postpartum depressive symptoms are frequently under-recognised in resource-constrained settings, and their geographic and socioeconomic distribution within Pakistani hospital populations remains insufficiently characterised. Objective: To identify hospital-city and socioeconomic predictors of postpartum depressive symptom severity using conventional regression and random forest analysis. Methods: This multicentre retrospective record-based analytical study included 336 postpartum women aged 18–45 years receiving care at tertiary hospitals in Karachi, Lahore, and Rawalpindi between January 2021 and December 2023. The primary outcome was the continuous Edinburgh Postnatal Depression Scale score. Geographic and socioeconomic predictors were examined using analysis of variance, multivariable linear regression, and random forest regression. Results: The mean EPDS score was 11.2 ± 5.8, and 187 women (55.7%) screened positive at an EPDS threshold of ≥10. Mean scores were highest in Rawalpindi (13.4 ± 5.9), followed by Lahore (11.1 ± 5.6) and Karachi (9.1 ± 5.2). Compared with the respective reference categories, Rawalpindi hospital-city site was associated with a 3.9-point higher score, household income below PKR 30,000 with a 5.8-point increase, no formal education with a 4.9-point increase, and overcrowding with a 3.2-point increase. The random forest model achieved a test-set R² of 0.51. Conclusion: Socioeconomic disadvantage and hospital-city context were associated with greater postpartum depressive symptom severity. Targeted screening may be warranted among women from low-income, poorly educated, and overcrowded households
subject: Articles
  topic: section
subject: Edinburgh Postnatal Depression Scale; geographic variation; household income; machine learning; maternal education; overcrowding; Pakistan; postpartum depression
  topic: keywords
creator: Sabira Feroz
creator: Sidra Irfan
creator: Fariha Muhammad Iqbal
creator: Noorulain Tariq Siddiqui
creator: Zubia Shahid
creator: Saeed Wali
creator: Iraj Siddiqui
rights: Copyright (c) 2026 Sabira Feroz, Sidra Irfan, Fariha Muhammad Iqbal, Noorulain Tariq Siddiqui, Zubia Shahid, Saeed Wali, Iraj Siddiqui (Author) https://creativecommons.org/licenses/by/4.0
date: 2026-06-30
publication date: 2026-06-30
starting page: 1
ending page: 11
doi: 10.61919/thq1qy88

Neuromodulatory Impact of Low-Intensity Focused Ultrasound on Early Cognitive Decline
type: item
description: Background: A mild neurocognitive disorder causes problems with memory, attention and thinking skills.. There are not many good ways to treat this that do not need surgery. Objective: To see how active low-intensity focused ultrasound and fake ultrasound affect memory, attention and brain connections in people with neurocognitive disorder. Methods: This study had 76 people, aged 55 to 80. They were split into two groups. One group got ultrasound that targeted parts of the brain related to thinking and memory. The other group got a treatment. They tested the brain functions of the people before the treatment one week after and two months after. Sixty-eight people finished the study. Results: One week after the treatment people who got ultrasound had better memory than those who got the fake treatment. The difference was still there two months later. People who got ultrasound also did better on a test of attention. Their brain connections between the part of the brain and the hippocampus were stronger, than those who got the fake treatment. No serious problems happened. low-intensity focused ultrasound seems to help with memory and attention and makes brain connections stronger.. More studies are needed to be sure
subject: Articles
  topic: section
subject: Attention; Cognitive Dysfunction; Double-Blind Method; Functional Connectivity; Memory; Mild Neurocognitive Disorder; Non-Invasive Brain Stimulation; Randomized Controlled Trial; Ultrasonic Waves.
  topic: keywords
creator: Abdul Rehman Naeem
creator: Mahwish Haque
creator: Saima Kanwal Attique
creator: Maqsooda Akram Butt
creator: Syeda Qaima Abbas
creator: Sameea Areeb
rights: Copyright (c) 2026 Abdul Rehman Naeem, Mahwish Haque, Saima Kanwal Attique, Maqsooda Akram Butt, Syeda Qaima Abbas, Sameea Areeb (Author) https://creativecommons.org/licenses/by/4.0
date: 2026-06-30
publication date: 2026-06-30
starting page: 1
ending page: 11
doi: 10.61919/pfm2z844

Exosomal MicroRNA-21 Expression Changes During Neoadjuvant Chemotherapy in Breast Cancer Patients
type: item
description: Background: Variability in breast cancer response to neoadjuvant chemotherapy highlights the need for minimally invasive biomarkers capable of reflecting treatment effectiveness during therapy. Circulating exosomal microRNA-21 may provide dynamic molecular information because of its stability and association with tumor progression and treatment response. Objective: To evaluate longitudinal changes in circulating exosomal miR-21 during neoadjuvant chemotherapy and examine their association with tumor response. Methods: This parallel-group randomized controlled trial enrolled 72 women with stage II–III breast cancer at a tertiary-care oncology center in Punjab, Pakistan. Participants were allocated equally to protocolized exosome-guided monitoring or routine clinical monitoring. Blood was collected at baseline and before chemotherapy cycles for exosomal miR-21 quantification using quantitative reverse-transcription polymerase chain reaction. Final outcomes were available for 67 participants. Analyses included t-tests, repeated-measures analysis of variance, risk ratios, and Pearson correlation. Results: Post-treatment miR-21 expression was lower in the intervention group than in the control group (1.42±0.39 versus 2.11±0.53; mean difference=−0.69; 95% CI: −0.92 to −0.46; p<0.001). Tumor shrinkage was greater by 15.50 percentage points (95% CI: 6.80–24.20; p<0.001). RECIST response was 84.8% versus 64.7% (p=0.058), and pathological complete response was 39.4% versus 23.5% (p=0.162). miR-21 reduction correlated with tumor shrinkage (r=0.62; 95% CI: 0.45–0.75; p<0.001). Conclusion: Serial exosomal miR-21 measurement reflected treatment-associated molecular changes and was associated with radiological tumor reduction, but larger standardized trials are required before clinical implementation
subject: Articles
  topic: section
subject: Biomarkers; Breast Neoplasms; Exosomes; MicroRNAs; Neoadjuvant Therapy; Precision Medicine; Treatment Outcome.
  topic: keywords
creator: Rameen Khalid
creator: Samira Khaliq
creator: Taram Nayab
creator: Muhammad Naveed
creator: Sehrish Siddiqui
creator: Muhammad Abbas Sadiq
creator: Nimra Sikander
rights: Copyright (c) 2026 Rameen Khalid, Samira Khaliq, Taram Nayab, Muhammad Naveed, Sehrish Siddiqui, Muhammad Abbas Sadiq, Nimra Sikander (Author) https://creativecommons.org/licenses/by/4.0
date: 2026-06-30
publication date: 2026-06-30
starting page: 1
ending page: 10
doi: 10.61919/0q4r4w06

Low-Level Laser Therapy Versus Occlusal Splint for Myofascial Pain Reduction in Chronic TMJ Disorder Patients
type: item
description: Background: Chronic myofascial temporomandibular disorders cause persistent orofacial pain, restricted mandibular movement, and functional limitation. Photobiomodulation may provide a non-invasive alternative to occlusal appliances. Objective: To compare 810 nm diode laser photobiomodulation with custom-fabricated occlusal splint therapy for reducing pain and improving jaw function. Methods: This parallel-group randomized controlled trial enrolled 72 adults with chronic myofascial temporomandibular disorders at a tertiary dental care centre in Southern Punjab, Pakistan. Participants were allocated equally to 12 laser sessions over four weeks or nighttime occlusal splint use. Outcomes were assessed by a blinded examiner at baseline and four weeks. Between-group comparisons, paired tests, repeated-measures analysis of variance, and correlation analysis were performed. Results: Sixty-seven participants completed follow-up: 34 in the laser group and 33 in the splint group. Post-intervention VAS pain scores were lower with laser therapy than with splint therapy (2.6 ± 1.1 versus 3.8 ± 1.4; mean difference −1.2, 95% CI −1.8 to −0.6; p<0.001). Jaw Functional Limitation Scale scores were also lower (16.4 ± 5.2 versus 20.7 ± 6.1; p=0.003). Maximum mouth opening and lateral mandibular movement favoured laser therapy. The VAS time × group interaction was significant (F=12.9; p<0.001). Conclusion: Photobiomodulation produced greater short-term improvements in pain and mandibular function than occlusal splint therapy
subject: Articles
  topic: section
subject: Jaw Functional Limitation; Low-Level Light Therapy; Myofascial Pain; Occlusal Splints; Photobiomodulation; Temporomandibular Disorders
  topic: keywords
creator: Mishka Amanullah
creator: Sabir Ali
creator: Uzma Zareef
creator: Areeba Zubair
creator: Sana M. Ashraf
creator: Arshad Ahmad
rights: Copyright (c) 2026 Mishka Amanullah, Sabir Ali, Uzma Zareef, Areeba Zubair, Sana M. Ashraf, Arshad Ahmad (Author) https://creativecommons.org/licenses/by/4.0
date: 2026-06-30
publication date: 2026-06-30
starting page: 1
ending page: 9
doi: 10.61919/m4epqn14

Effect of Femtosecond Laser-Assisted Versus Manual Clear Corneal Incisions on Postoperative Corneal Stiffness in Cataract Surgery
type: item
description: Background: The way we make a cut in the cornea can affect how well the wound heals, how the cornea works and what kind of vision people have after cataract surgery. Our goal was to compare how stiff the cornea is after we use a laser to make a cut and when we make a cut by hand. We did a study with 72 adults who were having cataract surgery. We divided them into two groups: one group got a cut made with a femtosecond laser and the other group got a cut made by hand. We looked at how stiff the cornea was before surgery. Then one week, one month and three months after surgery. We also looked at how well people could see, how thick the cornea was, the pressure in the eye and if the cornea was the shape. Sixty-nine people finished the study. After three months the people who got the cut made with a femtosecond laser had a cornea than the people who got a cut made by hand. The people who got the cut made with a femtosecond laser also had astigmatism, which means their cornea was closer to the right shape.. Their vision, corneal thickness and eye pressure were about the same as the people who got a cut made by hand. So making a cut with a femtosecond laser seems to be better for keeping the cornea stiff. The right shape after cataract surgery.. It does not seem to make a difference, in how well people can see
subject: Articles
  topic: section
subject: Cataract Extraction; Cornea; Corneal Biomechanics; Femtosecond Lasers; Phacoemulsification; Randomized Controlled Trial; Scheimpflug Imaging
  topic: keywords
creator: Muhammad Sulaman Khan Niazi
creator: Abdulrahman Saleh Alhadlag
creator: Abdul Nasir Safi
creator: Muhammad Zia Iqbal
creator: Rida Fatima Aslam
creator: Wadana Ahsan Afridi
creator: Samia Mustafa
rights: Copyright (c) 2026 Muhammad Sulaman Khan Niazi, Abdulrahman Saleh Alhadlag, Abdul Nasir Safi, Muhammad Zia Iqbal, Rida Fatima Aslam, Wadana Ahsan Afridi, Samia Mustafa (Author) https://creativecommons.org/licenses/by/4.0
date: 2026-06-30
publication date: 2026-06-30
starting page: 1
ending page: 9
doi: 10.61919/60kwk135

MicroRNA-146a Modulation by Targeted Lipid Nanoparticles to Treat Rheumatoid Arthritis: A Proof-of-Concept RCT
type: item
description: Background: Rheumatoid arthritis is characterized by persistent synovial inflammation and dysregulated immune signalling. MicroRNA-146a negatively regulates innate inflammatory pathways, but its therapeutic application requires an effective intracellular delivery system. Objective: To evaluate the preliminary clinical efficacy and safety of microRNA-146a encapsulated within folate-receptor-targeted lipid nanoparticles in adults with active rheumatoid arthritis. Methods: This single-centre, double-blind, randomized controlled trial enrolled 80 adults receiving stable conventional synthetic disease-modifying antirheumatic therapy. Participants were allocated 1:1 to weekly intravenous microRNA-146a lipid nanoparticles at 0.1 mg/kg or matching empty vehicle nanoparticles for six weeks. The primary outcome was change in DAS28-CRP. Week-6 effectiveness analyses included 74 completers, and safety analyses included all 80 treated participants. Results: DAS28-CRP decreased from 5.45 ± 0.71 to 3.12 ± 0.54 in the intervention group and from 5.39 ± 0.65 to 4.98 ± 0.61 in the control group. The week-6 between-group difference was −1.86 points (95% CI: −2.13 to −1.59; p < 0.001). Week-6 between-group differences also favoured the intervention for CRP (−13.9 mg/L), ESR (−17.7 mm/hour), and VAS pain (−27.9 mm; all p < 0.001). Three minor adverse events occurred in the intervention group; no serious adverse events were recorded. Conclusion: Targeted microRNA-146a delivery was associated with greater short-term reductions in disease activity, inflammation, and pain than vehicle nanoparticles. Larger, longer-duration studies are required to confirm efficacy and safety
subject: Articles
  topic: section
subject: Arthritis, Rheumatoid; C-Reactive Protein; Drug Delivery Systems; Epigenomics; Lipid Nanoparticles; MicroRNA-146a; Nanomedicine; Randomized Controlled Trial; RNA Therapeutics; Targeted Therapy.
  topic: keywords
creator: Muhammad Abbas Sadiq
creator: Samira Khaliq
creator: Muhammad Laiq
creator: Zuheeb Ahmed
creator: Zoya Zafar
creator: Hajrah Iftikhar
creator: Muhammad Hussain
creator: Muhammad Shahzaib
rights: Copyright (c) 2026 Muhammad Abbas Sadiq, Samira Khaliq, Muhammad Laiq, Zuheeb Ahmed, Zoya Zafar, Hajrah Iftikhar, Muhammad Hussain, Muhammad Shahzaib (Author) https://creativecommons.org/licenses/by/4.0
date: 2026-06-30
publication date: 2026-06-30
starting page: 1
ending page: 9
doi: 10.61919/h1fggw78

Plane-Specific Recovery of Cervical Range of Motion after Traction-Augmented versus Exercise-Only Therapy: A Motion-Selective Reanalysis in Generalized Neck Pain
type: item
description: Background: Mechanical cervical traction is frequently added to exercise-based physiotherapy for generalized neck pain, yet cervical range-of-motion outcomes may not respond uniformly across movement directions. Objective: To conduct an exploratory motion-plane-specific secondary analysis of pain and cervical mobility after traction-augmented conventional therapy compared with conventional therapy alone. Methods: Data from a randomized controlled trial of 22 adults with generalized neck pain were analysed. Participants received cervical traction plus conventional therapy (n=11) or conventional therapy alone (n=11) for six sessions over three weeks. Flexion, extension, bilateral lateral flexion, rotation, and Numeric Pain Rating Scale scores were assessed before and after treatment using paired- and independent-samples t-tests. Results: The traction-augmented group had higher post-intervention flexion (85.00 ± 2.41° vs 65.27 ± 2.28°), extension (64.73 ± 2.80° vs 46.55 ± 2.38°), left lateral flexion (39.09 ± 3.24° vs 25.27 ± 3.61°), and right lateral flexion (36.91 ± 5.49° vs 24.73 ± 3.10°), and lower pain scores (2.00 ± 0.89 vs 5.82 ± 0.75; all p<0.05). Rotation was higher after conventional therapy alone (82.73 ± 5.26° vs 60.18 ± 2.82°, p=0.003). Conclusion: The observed response was not uniform across cervical movement directions. The motion-specific pattern is exploratory and requires confirmation in adequately powered prospective studies using standardized outcomes and formal interaction analyses
subject: Articles
  topic: section
subject: cervical traction; range of motion; motion plane; generalized neck pain; exercise therapy
  topic: keywords
creator: Muneeba Khan
creator: Aruba Afreen Malik
creator: Zoaiba Aslam
creator: Javeria Shahid
creator: Asma Shahid
creator: Abdul Rashad
rights: Copyright (c) 2026 Muneeba Khan, Aruba Afreen Malik, Zoaiba Aslam, Javeria Shahid, Asma Shahid, Abdul Rashad (Author) https://creativecommons.org/licenses/by/4.0
date: 2026-06-30
publication date: 2026-06-30
starting page: 1
ending page: 9
doi: 10.61919/70gxme67

Predictive Value of Preoperative Myocardial Strain Imaging on Post-CABG Recovery
type: item
description: Background: Conventional left ventricular ejection fraction may not identify subtle myocardial dysfunction relevant to recovery after coronary artery bypass grafting. Global longitudinal strain provides a quantitative measure of myocardial deformation and may offer complementary prognostic information. Objective: To evaluate the association of preoperative global longitudinal strain with early postoperative cardiac output, intensive care unit stay, and complications following elective isolated coronary artery bypass grafting. Methods: This retrospective cohort study included 110 adults who underwent CABG at a tertiary cardiac centre in Central Punjab, Pakistan, between January 2022 and December 2024. Preoperative absolute GLS magnitude was classified as severely impaired (<11.0%), moderately impaired (11.1%–14.0%), or mild-to-preserved (>14.0%). Outcomes included early cardiac output, ICU stay, low cardiac output syndrome, new-onset atrial fibrillation, acute kidney injury, and a composite of postoperative complications. Group comparisons and adjusted regression analyses were performed. Results: ICU stay was 76.4 ± 20.5, 56.2 ± 14.8, and 49.1 ± 11.2 hours across severe, moderate, and mild-to-preserved GLS groups, respectively (p < 0.001). Corresponding cardiac output values were 3.9 ± 0.6, 4.6 ± 0.7, and 5.1 ± 0.7 L/min (p < 0.001). Low cardiac output syndrome occurred in 36.0%, 10.4%, and 0.0%, respectively (p < 0.001). Each one-percentage-point reduction in absolute GLS magnitude was associated with greater odds of postoperative complications (adjusted OR = 1.45, 95% CI: 1.12–1.88; p = 0.005). Conclusion: Impaired preoperative GLS was associated with poorer early recovery after CABG independently of baseline ejection fraction. Prospective validation is required before routine GLS-guided perioperative management can be recommended
subject: Articles
  topic: section
subject: Coronary Artery Bypass Grafting; Global Longitudinal Strain; Speckle-Tracking Echocardiography; Cardiac Output; Low Cardiac Output Syndrome; Intensive Care Unit; Postoperative Complications
  topic: keywords
creator: Muhammad Hassam Mehdi
creator: Irfan Nawaz
creator: Aqsa Javed
creator: Hira Saif
creator: Aiman Durrani
creator: Seemab Naz
rights: Copyright (c) 2026 Muhammad Hassam Mehdi, Irfan Nawaz, Aqsa Javed, Hira Saif, Aiman Durrani, Seemab Naz (Author) https://creativecommons.org/licenses/by/4.0
date: 2026-06-30
publication date: 2026-06-30
starting page: 1
ending page: 10
doi: 10.61919/w4r33231

Menstrual Health Literacy and Delay in Care-Seeking Among Adolescents with Heavy Menstrual Bleeding
type: item
description: Background: Adolescents may normalize heavy menstrual bleeding or lack sufficient knowledge to recognize symptoms requiring professional assessment, resulting in delayed consultation and continued functional impairment. Objective: To assess the association between menstrual health literacy and delayed care-seeking among adolescents with heavy menstrual bleeding and to explore the contextual barriers underlying delay. Methods: A sequential explanatory mixed-methods study was conducted among 186 adolescent girls aged 12–19 years recruited from selected schools, outpatient clinics, and community settings in Islamabad. A structured questionnaire assessed menstrual health literacy, bleeding symptoms, school absence, and care-seeking. Delay was defined as consultation more than 30 days after symptom recognition. Associations were examined using chi-square testing and logistic regression, followed by semi-structured interviews and thematic analysis. Results: Delayed care-seeking was reported by 112 participants (60.2%). Delay increased from 33.3% in the high-literacy group to 57.4% in the moderate-literacy group and 77.6% in the low-literacy group (χ²=22.52, p<0.001). Compared with high literacy, the adjusted odds of delay were greater with moderate literacy (OR=2.18; p=0.031) and low literacy (OR=4.91; p<0.001). Prolonged bleeding, clots, school absence, and weakness or fatigue were more frequent among delayed presenters. Interviews identified embarrassment, normalization of bleeding, family advice to wait, school-related concerns, and discomfort with healthcare consultation. Conclusion: Lower menstrual health literacy was associated with delayed care-seeking, while family, school, and healthcare barriers further influenced consultation
subject: Articles
  topic: section
subject: Adolescents; care-seeking delay; heavy menstrual bleeding; menstrual health literacy; mixed methods; school health.
  topic: keywords
creator: Saba Naz
creator: Madiha Saleem
creator: Maryam Jamal
creator: Dr Monica Punshi
creator: Aisha
creator: Tanzeela Ahmad
creator: Nadia Farooq
rights: Copyright (c) 2025 Saba Naz, Madiha Saleem, Maryam Jamal, Dr Monica Punshi, Aisha, Tanzeela Ahmad, Nadia Farooq (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-12-30
publication date: 2025-12-30
starting page: 1
ending page: 10
doi: 10.61919/7weqxp24

Prevalence of Lateral Epicondylitis in Carpenters; Its Impact on Their Functional Activities of Upper Limb
type: item
description: Background: Carpenters perform repetitive and forceful upper-limb activities that may increase the risk of lateral epicondylitis and associated functional limitation. Objective: To determine the prevalence of lateral epicondylitis among carpenters and evaluate its impact on pain and upper-limb functional activities. Methods: This descriptive cross-sectional study included 126 male carpenters aged 18–58 years recruited through convenience sampling from major furniture markets in Lahore, Pakistan. Lateral epicondylitis was assessed using Cozen’s test, pain intensity using the Visual Analogue Scale, and functional disability using the Patient-Rated Tennis Elbow Evaluation. Categorical variables were summarized as frequencies and percentages. Associations of working experience and smoking status with Cozen’s test results were examined using chi-square tests. Results: Twenty-four carpenters had a positive Cozen’s test, giving a prevalence of 19.0% (95% CI: 13.1%–26.8%). Most participants reported no pain (77.8%), and 76.2% had a PRTEE score of zero. Positive-test prevalence was highest among participants with 21–30 years of experience (27.3%), but working experience was not significantly associated with lateral epicondylitis (χ² = 2.281, p = 0.684). Smoking was also not significantly associated with the condition (OR = 0.66, 95% CI: 0.26–1.68; p = 0.380). Conclusion: Lateral epicondylitis affected approximately one-fifth of the surveyed carpenters, although most participants had minimal pain and functional limitation. Occupational screening and ergonomic risk reduction may be beneficial
subject: Articles
  topic: section
subject: Carpenters; lateral epicondylitis; occupational musculoskeletal disorders; PRTEE; tennis elbow; upper-limb function
  topic: keywords
creator: Asma Niaz
creator: Rahat Ayub
creator: Rabia Munawar
creator: Aqsa Waheed
creator: Anam Abbas
rights: Copyright (c) 2026 Asma Niaz, Rahat Ayub, Rabia Munawar, Aqsa Waheed, Anam Abbas (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-12-30
publication date: 2025-12-30
starting page: 1
ending page: 10
doi: 10.61919/j71fde03

Frequency of Musculoskeletal Disorders in Tailors of Lahore, Pakistan
type: item
description: Background: Tailoring is a posture-dependent occupation involving prolonged sitting, repetitive upper-limb activity, sustained visual attention, and limited postural variation. These ergonomic exposures may contribute to work-related musculoskeletal disorders, particularly in the spine, shoulder girdle, upper limbs, and lower limbs. Objective: To determine the frequency and anatomical distribution of musculoskeletal disorders among tailors working in Lahore, Pakistan. Methods: A descriptive cross-sectional study was conducted among 244 tailors selected through convenience sampling from different stitching and tailoring units in Lahore. Data were collected using a structured demographic and work-related questionnaire, Visual Analogue Scale, and Nordic Musculoskeletal Questionnaire. Demographic variables, working posture, break period, working hours, work experience, and regional musculoskeletal symptoms were recorded. Data were analyzed using SPSS version 21, and categorical variables were summarized as frequencies and percentages. Results: The mean age of participants was 32.65 ± 9.66 years. Of 244 participants, 154 (63.1%) were male and 90 (36.9%) were female. Most participants worked in sitting posture (240, 98.4%), and 187 (76.6%) worked 6 or more hours per day. The most frequently reported 12-month musculoskeletal trouble involved the lower back (42, 17.2%), shoulders (35, 14.3%), and knees (34, 13.9%). Similar patterns were observed for activity limitation, physician consultation, and 7-day trouble. Conclusion: Lower back, shoulder, and knee symptoms were the most frequently reported musculoskeletal disorders among tailors in Lahore. Ergonomic education, workstation modification, and preventive movement strategies are recommended for this occupational group
subject: Articles
  topic: section
subject: Musculoskeletal disorders; Tailors; Occupational health; Nordic Musculoskeletal Questionnaire; Ergonomics; Lower back pain; Lahore
  topic: keywords
creator: Dr Anam Shahzadi
creator: Dr Rabia Rahat
creator: Dr Hajra Rahat
rights: Copyright (c) 2025 Dr Anam Shahzadi, Dr Rabia Rahat, Dr Hajra Rahat (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-06-30
publication date: 2025-06-30
starting page: 1
ending page: 9
doi: 10.61919/k75a9a73

Perception and Practice Related to Postural Pain Among Breastfeeding Women in Hyderabad, Sindh
type: item
description: Background: Postural pain is a common but under-recognized concern among breastfeeding women because feeding often requires prolonged static posture, repetitive upper-limb loading, forward trunk or neck flexion, and inadequate ergonomic support. Limited professional guidance regarding breastfeeding posture may further increase maternal discomfort. Objective: To assess perception and practices related to postural pain among breastfeeding women in Hyderabad, Sindh. Methods: A hospital-based cross-sectional study was conducted over six months among 210 breastfeeding mothers aged 18–40 years and 6 weeks to 24 months postpartum. Participants were recruited through convenience sampling from four hospitals in Hyderabad, Sindh. Data were collected using a structured self-administered questionnaire assessing demographic characteristics, breastfeeding posture, pain/discomfort, coping responses, techniques used to reduce discomfort, and sources of advice. Pain severity was assessed using a 0–10 pain scale and categorized descriptively. Categorical variables were analyzed as frequencies and percentages. Results: Pain or discomfort during breastfeeding was reported by 177 participants (84.3%). Moderate pain was reported by 88 participants (41.9%), and severe pain by 61 participants (29.0%). Discomfort was most commonly experienced during the full feeding session (33.6%). Cradle hold was the most frequently reported breastfeeding position (43.1% of position responses), followed by cross-cradle hold (27.7%). Use of discomfort-reduction techniques was reported by 57.1% of participants, while family members were the most common source of advice (50.0% of advice responses). Conclusion: Breastfeeding-related postural pain was frequent and commonly moderate to severe among women in this sample. The findings highlight the need for structured postural education and physiotherapy-informed ergonomic guidance during antenatal and postnatal care
subject: Articles
  topic: section
subject: Breastfeeding, Postural Pain, Musculoskeletal Discomfort, Breastfeeding Position, Postpartum Women.
  topic: keywords
creator: Shuaib Manzoor
creator: Manoj Kumar
creator: Marva Memon
creator: Ume Rubab Ursani
creator: Ahsan Memon
creator: Tooba Shaikh
creator: Kainat Batool Memon
rights: Copyright (c) 2026 Shuaib Manzoor, Manoj Kumar, Marva Memon, Ume Rubab Ursani, Ahsan Memon, Tooba Shaikh, Kainat Batool Memon (Author) https://creativecommons.org/licenses/by/4.0
date: 2026-06-30
publication date: 2026-06-30
starting page: 1
ending page: 10
doi: 10.61919/7t2m1h79

Cervical Joint Position Error and Its Association with Bruxism and Pain Severity in Orthodontic Patients
type: item
description: Background: Cervical proprioception contributes to coordinated head-neck-jaw motor control, and impairment in cervical joint position sense may influence parafunctional jaw activity and pain. In orthodontic patients, occlusal changes and appliance-related neuromuscular adaptation may increase the relevance of cervical sensorimotor assessment. Objective: To determine the association of cervical joint position error with bruxism risk and pain severity among orthodontic patients. Methods: This cross-sectional observational study included 115 orthodontic patients recruited through convenience sampling from dental hospitals and clinics in Lahore, Pakistan. Cervical joint position error was assessed using a laser-based cervical joint position error test and categorized as positive when angular error exceeded 4.5°. Bruxism risk was measured using the Bruxism Evaluation Questionnaire, with scores >15 classified as high risk. Pain severity was assessed using the Visual Analogue Scale and categorized as mild, moderate, or severe. Data were analyzed using IBM SPSS version 27.0.1. Descriptive statistics and Pearson’s chi-square tests were applied, with statistical significance set at p < 0.05. Results: Of 115 participants, 56 (48.7%) had positive cervical joint position error and 88 (76.5%) were classified as high risk for bruxism. A significant association was found between cervical joint position error and bruxism risk, χ²(1) = 24.076, p < 0.001, Cramer’s V = 0.458. Among CJPE-positive participants, 54/56 (96.4%) were at high risk for bruxism compared with 34/59 (57.6%) of CJPE-negative participants. CJPE was also significantly associated with pain severity, χ²(2) = 17.743, p < 0.001, Cramer’s V = 0.393. Moderate-to-severe pain was reported by 41/56 (73.2%) CJPE-positive participants compared with 21/59 (35.6%) CJPE-negative participants. Conclusion: Cervical joint position error was significantly associated with elevated bruxism risk and greater pain severity among orthodont…
subject: Articles
  topic: section
subject: Cervical joint position error; cervical proprioception; bruxism; orofacial pain; orthodontic patients; sensorimotor control.
  topic: keywords
creator: Zoha Malik
creator: Rabia Majeed
creator: Sana Hafeez
creator: Saba Riaz
creator: Abdullah Khalid Qureshi
creator: Aimen Khurrum
creator: Wahiba Raza
rights: Copyright (c) 2026 Zoha Malik, Rabia Majeed, Sana Hafeez, Saba Riaz, Abdullah Khalid Qureshi, Aimen Khurrum, Wahiba Raza (Author) https://creativecommons.org/licenses/by/4.0
date: 2026-06-28
publication date: 2026-06-28
starting page: 1
ending page: 9
doi: 10.61919/4dyrhy69

Patient Confidence in Long-Term Care Plans for Multimorbidity Management: A Qualitative Descriptive Study
type: item
description: Background: Multimorbidity creates substantial challenges for long-term care because patients must manage multiple medicines, appointments, monitoring tasks, lifestyle recommendations, and disease-specific instructions. Although care plans are intended to improve coordination and continuity, patients may not experience them as understandable, feasible, or trustworthy in daily life. Objective: This study explored how adults with multimorbidity described the factors that strengthened or weakened their confidence in long-term care planning. Methods: A qualitative descriptive design was used. Twelve anonymized participant profiles from adults with two or more chronic conditions and experience of long-term care planning, medication planning, review planning, or coordinated management advice were analyzed using reflexive thematic analysis. The analysis was informed by treatment burden, cumulative complexity, and person-centred integrated care concepts. Results: Six interrelated themes were generated: fragmented care and unclear plan ownership, continuity and relational trust, treatment workload and limited capacity, unclear priorities and competing disease advice, family support and social negotiation, and follow-up reliability as evidence of care commitment. Confidence increased when plans were clear, coordinated, realistic, reviewed, and connected to a named professional or responsible team. Confidence decreased when advice was fragmented, workload was excessive, priorities were unclear, family support became controlling, or follow-up was unreliable. Conclusion: Patient confidence in multimorbidity care planning depends on relational continuity, practical feasibility, coordinated responsibility, explicit prioritization, respectful family involvement, and reliable follow-up. Care planning should be treated as an ongoing patient-centred process rather than a static document
subject: Articles
  topic: section
subject: Multimorbidity, patient confidence, long-term care plan, treatment burden, care coordination, shared decision-making, qualitative study
  topic: keywords
creator: Man Yaoyang
creator: Ali Napiah Nasution
creator: Tri Adi Mylano
rights: Copyright (c) 2026 Man Yaoyang, Ali Napiah Nasution, Tri Adi Mylano (Author) https://creativecommons.org/licenses/by/4.0
date: 2026-06-26
publication date: 2026-06-26
starting page: 1
ending page: 11
doi: 10.61919/2afcze46

Differential Cardiometabolic Effects of GLP-1 Receptor Agonists Versus SGLT2 Inhibitors in Early-Onset Type 2 Diabetes: A Randomized Controlled Trial
type: item
description: Introduction: Early-onset type 2 diabetes mellitus is characterized by higher exposure to cardiometabolic risk throughout life and increased risk of cardiovascular morbidity. GLP-1 receptor agonists and SGLT2 inhibitors improve the markers of cardiometabolic risk; however, a comparison between the therapies is poorly represented in the literature regarding younger population. Objective: Comparative study of the short-term effects of GLP-1 receptor agonist and SGLT2 inhibitor therapy on the markers of cardiometabolic risk in patients with early-onset type 2 diabetes mellitus. Methods: A randomized parallel group clinical trial was conducted in 84 patients with early-onset type 2 diabetes mellitus. Patients were randomized to receive once weekly GLP-1 receptor agonist therapy or once daily SGLT2 inhibitor therapy for 6 weeks. Main outcomes were changes in systolic blood pressure (SBP), diastolic blood pressure (DBP) and lipid profile. Secondary outcomes were BMI, HbA1c, fasting glucose, and frequency of treatment discontinuation due to adverse events. Results: 79 patients completed follow up and were included into available case analysis. Post-intervention SBP and DBP values were lower in SGLT2 inhibitor group in comparison with GLP-1 receptor agonist group. LDL-C values were lower in GLP-1 receptor agonist group. Mean reduction in SBP value was 8.9 ± 3.1 mmHg in GLP-1RA group vs 10.8 ± 3.5 mmHg in SGLT2 inhibitor group. Mean reduction in LDL-C level was 18.5 ± 6.2 mg/dL in GLP-1RA group and 9.2 ± 5.8 mg/dL in SGLT2 inhibitor group. Conclusion: Both therapeutic interventions led to short-term improvement of the cardiometabolic risk markers in patients with early-onset type 2 diabetes with different beneficial effects of SGLT2 inhibitors on blood pressure reduction and GLP-1RA on LDL-C level reduction
subject: Articles
  topic: section
subject: Cardiovascular Risk Markers, Early-Onset Diabetes, GLP-1 Receptor Agonists, Glycated Hemoglobin, Lipid Profile, SGLT2 Inhibitors, Type 2 Diabetes Mellitus.
  topic: keywords
creator: Marriam Abid
creator: Samia Gull Akhtar
creator: Tabinda Razzaq
creator: Zia Ullah
creator: Shah Abdul Latif
creator: Hafiz Muhammad Qasim
creator: Muhammad Abbas Sadiq
rights: Copyright (c) 2026 Marriam Abid, Samia Gull Akhtar, Tabinda Razzaq, Zia Ullah, Shah Abdul Latif, Hafiz Muhammad Qasim, Muhammad Abbas Sadiq (Author) https://creativecommons.org/licenses/by/4.0
date: 2026-06-30
publication date: 2026-06-30
starting page: 1
ending page: 9
doi: 10.61919/061x6w21

Left Ventricular Hypertrophy Patterns in Diabetic Versus Non-Diabetic Hypertensive Patients on Maintenance Hemodialysis in Peshawar
type: item
description: Background: Cardiovascular disease continues to constitute a major source of morbidity and mortality among patients with end-stage renal disease undergoing maintenance hemodialysis, with left ventricular hypertrophy being one of its structural predictors. Hypertension has been established as the important predictor of left ventricular remodeling in these patients, although diabetic patients could have an adverse myocardial phenotype. Objective: To compare the echocardiographic variables and left ventricular geometric patterns of diabetic and non-diabetic hypertensive patients undergoing maintenance hemodialysis in Peshawar, Pakistan. Methodology: This cross-sectional comparative study was conducted on 94 patients with hypertension who were on maintenance hemodialysis for at least three months, with each of the two groups having equal number of patients. Patients in each group were subjected to transthoracic echocardiography 12 to 24 hours after a mid-week dialysis session. Independent-samples t-test and Chi-square analyses were employed to compare left ventricular mass index, relative wall thickness, interventricular septum thickness, posterior wall thickness and left ventricular geometric patterns of patients belonging to the two groups. Results: Diabetic hypertensive patients had a higher left ventricular mass index than non-diabetic hypertensive patients (148.6 ± 22.4 vs 126.3 ± 18.5 g/m²; p<0.001) as well as relative wall thickness (0.48 ± 0.06 vs 0.42 ± 0.05; p<0.001). Concentric hypertrophy was observed in greater numbers of diabetic hypertensive patients than non-diabetic hypertensive patients (57.4% vs 17.0%), and eccentric hypertrophy was more prevalent in non-diabetic patients (44.7% vs 27.7%). There were significant differences in left ventricular geometry by diabetic status (χ²=13.064; p=0.004). Conclusion: Diabetic status was associated with higher left ventricular mass index, greater relative wall thickness and concentric hypertrophy in hypertensive pa…
subject: Articles
  topic: section
subject:
  topic: keywords
  value: Cardiomyopathies; Cardiovascular Diseases; Cross-Sectional Studies; Diabetes Mellitus; Heart Failure; Hypertension; Hypertrophy, Left Ventricular; Kidney Failure, Chronic; Pakistan; Renal Dialysis; Ventricular Remodeling.
creator: Shah Abdul Latif
creator: Ahmed Mustafa Nadeem
creator: Isbah Aman
creator: Nauman Akhtar
creator: Mashall Jan
creator: Zara Mushtaq
creator: Musab Bin Zubair
rights: Copyright (c) 2026 Shah Abdul Latif, Ahmed Mustafa Nadeem, Isbah Aman, Nauman Akhtar, Mashall Jan, Zara Mushtaq, Musab Bin Zubair (Author) https://creativecommons.org/licenses/by/4.0
date: 2026-06-24
publication date: 2026-06-24
starting page: 1
ending page: 9
doi: 10.61919/bm92fm18

Electroencephalographic Signatures of Dexmedetomidine and Propofol Sedation: A Structured Narrative Review
type: item
description: Background: Carpenters perform repetitive and forceful upper-limb activities that may increase the risk of lateral Background: Dexmedetomidine and propofol are frequently used intravenous sedatives with distinct molecular targets and effects on arousal networks. Although both agents can achieve clinically comparable sedation, their electroencephalographic manifestations differ in spectral composition, spatial organization, processed index behavior, functional connectivity, and emergence dynamics. These differences are clinically important because simplified depth-of-sedation indices may not represent equivalent neurophysiological states across drug classes. Objective: This structured narrative review aimed to critically synthesize contemporary evidence regarding the raw and processed electroencephalographic signatures associated with dexmedetomidine and propofol sedation in adults. Methods: PubMed/MEDLINE, Scopus, Web of Science, and CENTRAL were searched for English-language human studies and relevant reviews published principally between January 2014 and May 2024. Foundational earlier studies were considered when necessary to explain established propofol EEG mechanisms. Literature selection prioritized direct comparative studies, controlled volunteer investigations, prospective clinical studies, secondary EEG analyses, and mechanistically informative reports addressing spectral power, spectral edge frequency, bispectral index, entropy, coherence, functional connectivity, and emergence trajectories. Findings were organized through a structured thematic synthesis rather than statistical pooling. Results: Dexmedetomidine was commonly associated with increased slow-delta activity accompanied by frontal spindle- or alpha-range oscillations and relative preservation of selected coherence measures. Propofol produced prominent slow-wave activity with concentration- and state-dependent frontal alpha oscillations, reduced faster-frequency activity, and greater disruption of…
subject: Review Articles
  topic: section
subject: Dexmedetomidine; Propofol; Electroencephalography; Conscious Sedation; Bispectral Index; Spectral Analysis; Anesthesia Monitoring.
  topic: keywords
creator: Laveeza Fatima
creator: Maria Abad
creator: Syed Hassan Tanvir Ramzi
creator: Ihtisham Ud Din
creator: Abdul Wasay Toor
creator: Nosheen Munir
rights: Copyright (c) 2026 Laveeza Fatima, Maria Abad, Syed Hassan Tanvir Ramzi, Ihtisham Ud Din, Abdul Wasay Toor, Nosheen Munir (Author) https://creativecommons.org/licenses/by/4.0
date: 2026-06-30
publication date: 2026-06-30
starting page: 1
ending page: 12
doi: 10.61919/fa0r1b65

Exploring the Relationship Between Sleep Quality and Cardiovascular Risk Factors in University Students
type: item
description: Background: Cardiovascular risk factors may begin to develop during young adulthood, when sleep habits, dietary behavior, stress exposure, and lifestyle patterns become established. Poor sleep quality has been linked with cardiometabolic risk, but evidence among university students remains limited. Objective: To assess the association between sleep quality and cardiovascular risk-factor domains among university students. Methods: A cross-sectional observational study was conducted among 235 university participants aged 18–26 years. Data were collected from April to June 2024 using a structured questionnaire, the Groningen Sleep Quality Scale, and a cardiovascular risk assessment questionnaire. Demographic characteristics, body mass index category, waist circumference category, sleep-quality responses, and cardiovascular risk domains were analyzed using IBM SPSS Statistics version 25. Frequencies and percentages were used for descriptive analysis, and Pearson correlation was used to assess relationships among nonconstant risk scores. Results: Most participants were female (63.4%) and aged 19–24 years (81.7%). Sleep-related complaints were frequent, including morning tiredness (64.3%), sleep latency longer than 30 minutes (61.3%), insufficient sleep (56.2%), nocturnal rising (53.2%), and sleep duration of five hours or less (51.5%). Sleep-related cardiovascular risk was categorized as medium in 64.3% and high in 11.9%. Sleep score showed weak correlations with lifestyle (r = -0.055, p = 0.404), blood pressure (r = 0.022, p = 0.739), and diet (r = 0.127, p = 0.051). The only statistically significant correlation was between blood-pressure and diet scores (r = 0.198, p = 0.002). Conclusion: Sleep disturbance was common among university students, but sleep score was not strongly associated with other cardiovascular risk domains. The findings support the need for larger studies using validated tools and adjusted analyses to clarify sleep-related cardiovascular risk in you…
subject: Articles
  topic: section
subject: Sleep Quality; Cardiovascular Risk Factors; University Students; Blood Pressure; Diet; Cross-Sectional Study
  topic: keywords
creator: Rahat Ayub
creator: Mehak Hamna Gillani
creator: Fizza Masood
creator: Muhammad Fasih
rights: Copyright (c) 2026 Rahat Ayub, Mehak Hamna Gillani, Fizza Masood, Muhammad Fasih (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-12-30
publication date: 2025-12-30
starting page: 1
ending page: 10
doi: 10.61919/0afz2a43

Correlation Between Upper Cross Syndrome and Smartphone Addiction in University Students
type: item
description: Background: Smartphone addiction is increasingly common among university students and may contribute to sustained forward head posture, rounded shoulders, and postural muscle imbalance associated with Upper Cross Syndrome. Objective: To determine the correlation between smartphone addiction severity and clinical indicators of Upper Cross Syndrome among university students. Methods: This cross-sectional observational study included 167 university students aged 19–24 years from universities in Lahore who used smartphones for at least four hours daily and met predefined Smartphone Addiction Scale–Short Version thresholds. Smartphone addiction was assessed using the SAS-SV, while Upper Cross Syndrome-related findings were evaluated through pectoralis major contracture, middle trapezius weakness, and lower trapezius weakness tests. Descriptive statistics were used for demographic and clinical variables, and correlation analysis was performed between SAS-SV scores and Upper Cross Syndrome-related clinical findings. Results: The sample included 46 males (27.5%) and 121 females (72.5%), with a mean age of 21.51 ± 1.51 years and mean SAS-SV score of 44.37 ± 6.64. Pectoralis major contracture was present in 60 participants (35.9%), middle trapezius weakness in 109 (65.3%), and lower trapezius weakness in 102 (61.1%). SAS-SV score showed weak positive correlations with middle trapezius weakness (r = 0.24), lower trapezius weakness (r = 0.23), and composite Upper Cross Syndrome status (r = 0.22), while correlation with pectoralis major contracture was weaker (r = 0.11). Conclusion: Upper Cross Syndrome-related findings were common among students with elevated smartphone addiction scores, particularly posterior scapular stabilizer weakness. Smartphone addiction severity showed weak positive associations with trapezius weakness and composite Upper Cross Syndrome status
subject: Articles
  topic: section
subject: Upper Cross Syndrome; Smartphone Addiction; University Students; Posture; Trapezius Weakness; Musculoskeletal Disorders
  topic: keywords
creator: Isha Haseen
creator: Eman Iftikhar
creator: Qurat-ul-Ain
creator: Sana Mehmood
creator: Anam Abbas
rights: Copyright (c) 2026 Isha Haseen, Eman Iftikhar, Qurat-ul-Ain, Sana Mehmood, Anam Abbas (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-12-30
publication date: 2025-12-30
starting page: 1
ending page: 9
doi: 10.61919/cdgvam62

Self-Medication Among Pharmacy Students: A Cross-Sectional Study on Prevalence, Patterns, and Determinants
type: item
description: Background: Constraint-induced movement therapy is used to improve upper-limb recovery after stroke, Background: Self-medication is common among university students, particularly those enrolled in health-related disciplines. Pharmacy students may be more likely to self-medicate because academic exposure to pharmacology and therapeutics can increase confidence in selecting medicines without professional consultation. Inappropriate self-medication, especially antibiotic use without prescription, may contribute to adverse drug reactions, delayed treatment, drug interactions, and antimicrobial resistance. Objective: To determine the prevalence, patterns, reasons, medication classes, sources of information, and socio-demographic associations of self-medication among pharmacy students at Shahida Islam Medical College, Lodhran, Pakistan. Methods: A descriptive cross-sectional study was conducted among 263 pharmacy students using a structured questionnaire. Participants were recruited through convenience sampling. Data were analyzed using SPSS version 20. Frequencies and percentages were calculated, and chi-square tests were used to assess associations between self-medication practice and selected socio-demographic variables. Results: Self-medication was reported by 165 students, giving a prevalence of 62.7%. Physicians were the most frequently reported source of medication information (63.1%). The leading reasons were prior experience with illness (64.6%), drug availability (60.1%), and saving time (57.0%). Headache (74.5%) and common cold (71.9%) were the most frequently reported conditions, while common cold medicines (67.3%) and antibiotics (65.4%) were the most frequently reported medication classes. No statistically significant association was found between self-medication and age, gender, marital status, residence, habitation, or health insurance status. Conclusion: Self-medication was common among pharmacy students, with frequent reported antibiotic use highlighting…
subject: Articles
  topic: section
subject: Self-medication; pharmacy students; antibiotics; antimicrobial resistance; cross-sectional study; Pakistan
  topic: keywords
creator: Muhammad Shahzad Ishfaq
creator: Muhammad Faisal
creator: Muhammad Hassan Raza Durrani
creator: Muhammad Danish
rights: Copyright (c) 2026 Muhammad Shahzad Ishfaq, Muhammad Faisal, Muhammad Hassan Raza Durrani, Muhammad Danish (Author) https://creativecommons.org/licenses/by/4.0
date: 2026-06-24
publication date: 2026-06-24
starting page: 1
ending page: 10
doi: 10.61919/3dp78623

Plant-Based Gold Nanoparticles for Targeted Drug Delivery in Breast Cancer: Progress and Prospects in Pakistan
type: item
description: Background: Breast cancer remains a major cause of morbidity and mortality among women, particularly in low- and middle-income countries where delayed diagnosis, limited access to targeted therapies, and treatment-related toxicity continue to compromise outcomes. Plant-mediated gold nanoparticles have emerged as a promising area of green nanomedicine because they combine the physicochemical advantages of gold nanoparticles with the reducing, stabilizing, and bioactive properties of plant-derived phytochemicals. Objective: This narrative review aimed to critically synthesize the progress, methodological limitations, and translational prospects of plant-based gold nanoparticles for targeted drug delivery in breast cancer, with emphasis on evidence relevant to Pakistan. Methods: A structured narrative synthesis was conducted using literature related to gold nanoparticles, green synthesis, medicinal plant extracts, breast cancer models, targeted drug delivery, cytotoxicity, apoptosis, biocompatibility, and nanomedicine translation. Evidence was organized thematically according to synthesis methods, plant sources, nanoparticle characterization, anticancer mechanisms, drug-delivery potential, biosafety, methodological challenges, and translational readiness. Because of heterogeneity in plant extracts, nanoparticle preparation, experimental models, assays, and outcome reporting, pooled quantitative analysis was not performed. Results: The strongest evidence was concentrated in laboratory-scale green synthesis, physicochemical characterization, and in vitro cytotoxicity against breast cancer cell lines such as MCF-7 and MDA-MB-231. Plant-mediated gold nanoparticles were associated with enhanced cellular uptake, reactive oxygen species generation, mitochondrial dysfunction, apoptosis-related signaling, DNA fragmentation, and preliminary drug-delivery potential, including doxorubicin conjugation and sustained release. However, evidence for in vivo efficacy, pharmacokinetics, …
subject: Articles
  topic: section
subject: Breast Cancer; Gold Nanoparticles; Green Synthesis; Nanomedicine; Plant Extracts; Targeted Drug Delivery; Pakistan; Biocompatibility.
  topic: keywords
creator: Muhammad Abbas Sadiq
creator: Mian Furqan Ahmad
creator: Farooq Bashir Butt
creator: Ayesha Siddiqa
creator: Zahid Hussain Shar
creator: Maida Aslam
creator: Aqsa Maryam
rights: Copyright (c) 2026 Muhammad Abbas Sadiq, Mian Furqan Ahmad, Farooq Bashir Butt, Ayesha Siddiqa, Zahid Hussain Shar, Maida Aslam, Aqsa Maryam (Author) https://creativecommons.org/licenses/by/4.0
date: 2026-06-26
publication date: 2026-06-26
starting page: 1
ending page: 13
doi: 10.61919/ehqtjy35

Development and Evaluation of Kiwi-Based Kombucha as a Functional Beverage Alternative to Carbonated Soft Drinks
type: item
description: Background: Sugar-sweetened carbonated beverages are associated with poor nutritional quality and excess sugar intake, creating interest in fermented functional beverages with improved sensory and biochemical characteristics. Kombucha is a fermented tea beverage containing organic acids and antioxidant-related compounds, while kiwi fruit may contribute vitamin C, organic acids, and polyphenols. Objective: This study aimed to develop kiwi-based kombucha formulations and evaluate their physicochemical changes, antioxidant-related properties, alcohol formation, and sensory acceptability. Methods: An experimental food and nutrition study was conducted using kiwi-enriched kombucha formulations prepared with grapes and either honey or ginger. Fermentation was monitored using pH, total phenolic content, total flavonoid content, FRAP antioxidant activity, DPPH radical scavenging activity, and alcohol content. Sensory evaluation was performed among 25–30 adult volunteers using a 9-point hedonic scale assessing flavour, texture, aroma, appearance, and overall acceptability. Data were analyzed using IBM SPSS Statistics version 27. Results: The honey-based formulation showed higher sensory scores than the ginger-based formulation for flavour (6.84 ± 1.34 vs 5.76 ± 1.27; p = 0.005), texture (6.80 ± 1.41 vs 5.80 ± 1.55; p = 0.021), and overall acceptability (7.64 ± 1.19 vs 6.64 ± 1.82; p = 0.027). pH decreased from approximately 4.2 at baseline to 3.1–3.5 by Day 14. Alcohol peaked at Day 7 in Honey Kiwi Kombucha (3.50 ± 0.50%) and Ginger Kiwi Kombucha (3.25 ± 0.50%). Conclusion: Honey-based kiwi kombucha demonstrated better sensory acceptability than the ginger-based formulation, while fermentation produced progressive acidification and measurable alcohol formation. Further standardized testing, complete biochemical reporting, and direct comparison with commercial soft drinks are needed.
subject: Articles
  topic: section
subject: Kombucha, kiwi, functional beverage, fermentation, antioxidant activity, sensory evaluation
  topic: keywords
creator: Wafa Fatima
creator: Sara Sarbuland
creator: Malaika Irshad
creator: Zainab Masood
creator: Maida Mushtaq
rights: Copyright (c) 2026 Wafa Fatima, Sara Sarbuland, Malaika Irshad, Zainab Masood, Maida Mushtaq (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-12-30
publication date: 2025-12-30
starting page: 1
ending page: 10
doi: 10.61919/d1c12p95

Sustainable Bioethanol Production from Lignocellulosic Plant Wastes: A Renewable Solution to Energy Challenges
type: item
description: Background: Lignocellulosic agricultural residues are increasingly investigated as renewable feedstocks for second-generation bioethanol production because they support waste valorization and reduce dependence on food-based substrates. Sugarcane bagasse is a cellulose-rich agro-industrial residue, but its conversion into ethanol is restricted by lignin-associated biomass recalcitrance. Objective: This study evaluated bioethanol production from sugarcane bagasse using sodium hydroxide pretreatment, enzymatic saccharification, Saccharomyces cerevisiae fermentation, and ethanol recovery. Methods: Sugarcane bagasse was pretreated with 2.5% sodium hydroxide using autoclave-assisted treatment for 30, 60, and 90 min and microwave-assisted treatment for 10 and 20 min. Pretreated biomass was analyzed for cellulose and lignin content. Enzymatic saccharification was performed using cellulase from Trichoderma reesei, followed by batch fermentation using Saccharomyces cerevisiae. Ethanol was recovered by distillation and estimated spectrophotometrically using acidified potassium dichromate. Results: Autoclave-assisted pretreatment increased cellulose from 58.0% to 68.0% and reduced lignin from 30.7% to 11.9%. Microwave-assisted pretreatment produced the highest cellulose content of 71.0% and lowest lignin content of 8.0%. Saccharification absorbance was higher in the autoclaved sample than in the microwave-treated sample, 1.40 versus 1.20, and ethanol production was 2.0% versus 1.7%, respectively. Conclusion: Sugarcane bagasse supported laboratory-scale ethanol production after alkaline pretreatment, but the strongest delignification did not produce the highest ethanol concentration. Optimization of hydrolysis, fermentation, and ethanol yield assessment is required.
subject: Articles
  topic: section
subject: Bioethanol, Sugarcane Bagasse, Lignocellulosic Biomass, Alkaline Pretreatment, Saccharification, Fermentation, Renewable Energy.
  topic: keywords
creator: Tamknat Ilyas
creator: Zeeshan Ahmad
creator: Sana Mehmood
creator: Mamoona Anwar
creator: Zainab Masood
rights: Copyright (c) 2026 Tamknat Ilyas, Zeeshan Ahmad, Sana Mehmood, Mamoona Anwar, Zainab Masood (Author) https://creativecommons.org/licenses/by/4.0
date: 2025-12-30
publication date: 2025-12-30
starting page: 1
ending page: 9
doi: 10.61919/cq2zya80

Public Trust in Laboratory Results During Emerging Infectious Disease Alerts
type: item
description: Background: Family planning programmes in underserved areas of Sindh require more than commodity availability because contraceptive decision-making is shaped by social norms, gender power, myths about side effects, women’s mobility, and trust in service providers. Community-based models such as Marvi Markaz/BiB may improve acceptability by linking door-to-door counselling with safe local access points, but qualitative evidence is needed to understand how such models are experienced by women, men, frontline workers, and programme staff. Objective: This study explored perceptions of the Marvi Markaz/BiB family planning model, focusing on acceptability, barriers and facilitators, and conditions for sustainability. Methods: An interpretative qualitative endline evaluation was conducted using in-depth interviews and focus group discussions with married women of reproductive age, men, Marvi workers, and programme staff. Data were analysed using thematic analysis, with attention to patterns across participant groups and implementation perspectives. Results: Six themes were identified: trust in Marvi workers, safe local service space, myths and fear of side effects, gendered decision-making, commodity continuity, and sustainability through supervision and monitoring. Acceptability was linked to familiar local counselling, privacy, reduced travel barriers, and commodity linkage, while barriers included misinformation, male approval, household influence, and supply interruptions. Conclusion: The model was perceived as acceptable when trust, safe spaces, and commodity access worked together. Sustainability requires male engagement, refresher training, supervision, monitoring, and reliable supply systems.
subject: Articles
  topic: section
subject: family planning; Marvi Markaz; community health workers; qualitative endline evaluation; contraceptive access; Sindh; Pakistan.
  topic: keywords
creator: Guo Qianqian
creator: Irza Haicha Pratama
creator: Yensuari
rights: Copyright (c) 2026 Guo Qianqian, Irza Haicha Pratama, Yensuari (Author) https://creativecommons.org/licenses/by/4.0
date: 2026-06-24
publication date: 2026-06-24
starting page: 1
ending page: 11
doi: 10.61919/hyjnz850

Ethical Tensions in Aesthetic Surgery Advertising on Short-Video Platforms
type: item
description: Background: Aesthetic surgery advertising is increasingly encountered on short-video platforms where clinical procedures are presented through transformation clips, influencer testimony, before-and-after imagery, and algorithmic repetition. Although such content may improve access to procedure-related information, it can also compress medical risk, obscure commercial intent, and make bodily intervention appear routine. Objective: This study explored how adult viewers interpreted aesthetic surgery advertising on short-video platforms, with attention to perceived credibility, risk, visual evidence, influencer sponsorship, and ethical safeguards. Methods: An interpretivist qualitative design was used. Semi-structured interview material from ten adult viewers who regularly encountered beauty, wellness, aesthetic surgery, or minimally invasive cosmetic procedure content was analyzed using reflexive thematic analysis. Results: Five themes were developed: compression of medical risk into attractive transformation; credibility transfer through professional and social media cues; before-and-after imagery as persuasive evidence and distorted expectation; influencer intimacy and disclosure gaps; and algorithmic normalization with demand for safeguards. Participants valued educational explanations and realistic recovery information but expressed concern when videos omitted complications, cost, uncertainty, suitability, sponsorship, or outcome variability. Influencer narratives and repeated algorithmic exposure were perceived as especially persuasive because they made aesthetic procedures feel relatable, emotionally corrective, and socially normal. Conclusion: Ethical aesthetic surgery advertising on short-video platforms should create pause rather than urgency by making risk, recovery, qualifications, sponsorship, and individualized suitability visible within the video itself.
subject: Articles
  topic: section
subject: aesthetic surgery advertising; short-video platforms; TikTok; influencer marketing; medical ethics; body image; platform governance; qualitative research.
  topic: keywords
creator: Kou Shuming
creator: Dewi Fibrini
creator: Muhammad Faridz Syahrian
rights: Copyright (c) 2026 Kou Shuming, Dewi Fibrini, Muhammad Faridz Syahrian (Author) https://creativecommons.org/licenses/by/4.0
date: 2026-06-24
publication date: 2026-06-24
starting page: 1
ending page: 12
doi: 10.61919/dgx8x090

Oral Health Misinformation and Treatment Choices Among Adult Dental Patients
type: item
description: Background: Oral health misinformation is increasingly encountered through social media, product marketing, online reviews, family advice, and informal digital networks. Although misleading dental claims are often treated as a digital literacy problem, their influence on treatment decisions may be shaped by fear, cost, trust, symptom uncertainty, preference for natural remedies, and expectations created by visual media. Objective: This study explored how adult dental patients encountered, interpreted, and negotiated oral health misinformation during recent dental treatment decision-making. Methods: A qualitative interview-based study was conducted among 10 adult dental patients who had recently faced a dental treatment decision and had encountered oral health information through online or interpersonal sources. Semi-structured interviews explored information sources, credibility judgments, emotional and financial influences, professional consultation, and perceived effects on treatment preferences. Data were analyzed using reflexive thematic analysis. Results: Four interrelated themes were identified: self-diagnosis and symptom interpretation; persuasive credibility cues in digital spaces; cost, fear, and naturalness as decision shortcuts; and the corrective yet uneven influence of professional consultation. Misinformation was described as reshaping symptom meaning, reinforcing delay or avoidance, encouraging product use, supporting antibiotic expectations, and creating unrealistic cosmetic or procedural expectations. Respectful, specific, and transparent dental communication helped some participants revise misinformation-influenced beliefs. Conclusion: Oral health misinformation should be understood as a communication, trust, and service-experience issue embedded within dental decision-making. Myth-sensitive chairside discussion, transparent pricing, and accessible professional digital content may reduce misinformation-related uncertainty.
subject: Articles
  topic: section
subject: dental patients; oral health misinformation; treatment choice; social media; digital health literacy; shared decision-making; qualitative research.
  topic: keywords
creator: Chen Qiong
creator: Shieny
creator: Wienaldi
rights: Copyright (c) 2026 Chen Qiong, Shieny, Wienaldi (Author) https://creativecommons.org/licenses/by/4.0
date: 2026-06-24
publication date: 2026-06-24
starting page: 1
ending page: 12
doi: 10.61919/qe2bxc49