Journal of Liaquat University of Medical & Health Sciences

HIV infection versus Viral Hepatitis B and C: Stigma and Discrimination experienced by HIV/AIDS patients in Public Hospitals -, Sindh Pakistan

Nasreen Inayat Bughio — Tue, 08 Oct 2024 00:00:00 +0500

Human immunodeficiency virus (HIV) impairs the immune system and causes Acquired immunodeficiency syndrome (AIDS) - an advanced stage of HIV infection. HIV/AIDS is a global health problem. To date, 43 million persons have died due to AIDS-related illnesses, and 40 million persons are living with HIV/AIDS worldwide. There is no cure, but with antiretroviral therapy (ART), HIV infection has become a manageable chronic health condition.

Acalculous Gangrenous Cholecystitis in a Young Patient: A Case Report

Faiyyaz Ur Rehman, Shahzore Gul , Kanwal Hanif, Dipa Yadav, Imran Khan, Roshan — Mon, 30 Sep 2024 00:00:00 +0500

We present a 20 years old male with no known comorbid in emergency complaining of pain localized to the right upper quadrant for two days, followed by fever (101F) with 15-16 episodes of vomiting, which were non-bilious and containing food particles. The patient was vitally stable on examination and had a mild jaundiced look; the abdomen was soft and tender over the right hypochondrium. Ultrasound of the abdomen showed a hypoechoic liver and thick-walled acalculous gall bladder along with pericholecystic fluid, suggesting acute cholecystitis. On further evaluation, the diagnosis of gangrenous cholecystitis was made, and an emergency exploratory laparotomy along with a cholecystectomy was performed.

Early-Age Breast Cancer during Active Conflict in Syria: A Cross-Sectional Study

Yahya Mutair, Gohar Mushtaq, Fouad Al-Daoud, Maryam Al-Qassim, Mahmoud Hariri — Mon, 30 Sep 2024 00:00:00 +0500

OBJECTIVE: To examine the risk factors associated with breast cancer within a war-affected region enduring over a decade of conflict in Northwest Syria.
METHODOLOGY: A cross-sectional study was conducted from January to December 2022. Inclusion criteria required patients to have a palpable breast mass confirmed by biopsy. Patients residing in the region for less than 5 years were excluded from the study. The study included 164 female patients, averaging 47.14±11.31 years. Data were collected through surveys during visits to the regional cancer center. Ten risk factors were analyzed: Age, family history, Age at menarche, age at menopause, body mass index, breastfeeding, age at first birth, smoking, hormonal contraceptive use, and psychological stress. Statistical analysis was performed using IBM SPSS Statistics 25.
RESULTS: Among the breast cancer patients, 32.9% were ?40 years old (mean = 34.7, SD = 4.35), 32.9% were 41-50 years old (mean = 46.3, SD = 2.75), and 34.1% were >50 years old (mean = 59.89, SD = 6.15). Significant correlations (p < 0.05) were found between all fixed and variable risk factors except smoking, age at menarche, and hormonal contraceptive use.
CONCLUSION: Our study revealed a nearly ten-year decrease in the average age of breast cancer onset among our patients compared to global standards. Prolonged conflict is likely a key factor driving earlier and increased breast cancer cases in Syria's younger women. These findings highlight the need for targeted public health interventions and further research into the impact of chronic conflict on cancer epidemiology.

First survey of epidemiology and associated risk factors of Human intestinal parasitic infections among Gonabad residents, northeast of Iran

Mon, 30 Sep 2024 00:00:00 +0500

OBJECTIVE: To investigate the prevalence of parasitic infections in the human population and identify the related risk factors of Gonabad city, southeast of Khorasan Razavi province, northeastern Iran.

METHODOLOGY: This cross-sectional study was performed from March to April 2019 in Gonabad city in Khorasan Razavi province in northeastern Iran. One thousand thirty-eight stool samples were examined using parasitological methods like direct wet-mounting, formalin-ether concentration and Gomori's trichrome staining. Moreover, the socio-demographic data of inhabitants were recorded. All statistical analyses were performed using SPSS software (version 16). Qualitative variables were reported as numbers and percentages.

RESULTS: The overall intestinal parasitic infection prevalence was 18.1 %, whereas this value for protozoan agents was 16.7% (95% CI 14.14 to 19) and 1.3% (95% CI 0.7 to 2) for helminth parasites. The highest parasitic agent prevalence belongs to Blastocystis sp (12.4 %), Entamoeba coli (1.8%) and Enterobius vermicularis (1.2%), respectively. Giardia lamblia (1.1%) Entamoeba histolytica /dispar (0.3%), Iodamoeba butschlii (0.3%), Chilomastix mesnili (0.3%), Hymenolepis nana (0.2 %) Dientamoeba fragilis (0.2%) and Trichomonas hominis (0.3%) were other identified parasites. Multivariate logistic regression analysis revealed a significant association of parasitic intestinal infections with factors such as age, residency status and source of drinking water (P<0.05).

CONCLUSION: Our findings approved that the protozoan agents have a relatively high prevalence among the studied population. So, it could be severe enough to alarm the entities implementing healthcare services measures for parasitic intestinal infection control.

Correlation between elevated bradykinin concentrations and death by COVID-19

Mon, 30 Sep 2024 00:00:00 +0500

Objective: To investigate BK pathway dysregulation among and between COVID-19 survivors and the deceased.
Methodology: This case-control study was performed between 2020 and 2022 in Imam Hasan Hospital, Bojnurd, Iran. SARS-CoV-2 infected patients, comprising 40 deceased and 15 surviving patients, were recruited according to specific inclusion and exclusion criteria. A blood sample was taken from subjects during the disease. Blood BK levels in subjects (the groups of patients (55) and control (15)) were measured by the ELISA technique. All patients were selected from individuals over 18 years old with real-time PCR-proven SARS-CoV-2 infection. Also, the studied patients did not have metabolic syndrome (blood pressure, abdominal obesity, diabetes, cardiovascular disease). SPSS version 26 was used to compare the means.
Results: The blood serum BK level was significantly related to the outcome of COVID-19 disease (P=0.006) using a multiple logistic regression test. A week before death, a significant increase in the blood BK levels among deceased patients compared to survivors was seen (p=0.0001). The probability of death in patients with SARS-CoV-2 infection linearly increased by 4% (OR = 1.04) for each pg/ml increase in the BK level.
Conclusion: There is a close relationship between the rise in BK concentration during a COVID-19 infection and the disease outcome.

Play Intervention Applied to Hospitalized Children: Effects on Anxiety and Medical Fear

Benazeera, Priya Reshma Aranha, Yashaswini — Mon, 30 Sep 2024 00:00:00 +0500

OBJECTIVE: To ease the anxiety and medical fear before intravenous cannulation or blood collection procedures among hospitalized children.
METHODOLOGY: This study employed a pre-test, post-test quasi-experimental design during June to August 2023 from the hospital paediatric medicine ward. Sixty school-aged children (aged 6-12) were chosen through purposive sampling. The control group's data was collected first, followed by a play intervention for the experimental group. Both groups were similar in size. Baseline data on children and parents was gathered using the State-Trait Anxiety Inventory and the Children's Fear Scale.
RESULTS: The children participating in the intervention had a mean age of 9.23±1.65. Notably, a significant portion of both groups experienced respiratory illnesses, with a higher prevalence observed in the control group (33.3%) compared to the intervention group (26.6%). A three-day play intervention significantly improved outcomes for hospitalized children (p<0.001). It helped them manage anxiety both in the general sense (trait anxiety) and specifically related to medical procedures (p<0.001) such as inserting intravenous catheters (IVs) or drawing blood. The study also found a strong correlation between a child's overall anxiety level and their anxiety around medical procedures (r 0.49, p=0.000).
CONCLUSION: Play intervention had a positive impact on state anxiety, trait anxiety and fear about intravenous cannulation or blood collection procedures. Pediatric nurses and parents working together to incorporate play is one of the most important aspects of a child's hospitalization. This approach focuses on improving health outcomes by making play a part in the healing process.

Effect Cookies Made from (Musa acuminata Cavendish and Cucumis sativus) and Self Talk against Reducing Urine Protein Levels and Blood Pressure in Women of Childbearing Age Pre Hypertension

Aswita, Kartini Kartini, Titi Purnama Delano — Mon, 30 Sep 2024 00:00:00 +0500

OBJECTIVE: This study aimed to determine the influence of cookies made from (Musa acuminata cavendish and Cucumis sativus) and self-talk to reduce urine protein levels and blood pressure in women of childbearing age before hypertension.
METHODOLOGY: The study was quasi-experimental, using pretests and post-tests from September to November 2023. Random sampling was done using the Slovin formula. Samples were divided into four groups; each group consisted of 30 people. The total sample consisted of 120 people. Data collection instruments included questionnaires, booklets, and cookies. Data were analyzed using SPSS Software with an independent t-test and ANOVA.
RESULTS: There were differences in urine protein levels between the initial and final measurements. In group one, five respondents had positive urine protein, while 24 had negative urine protein. In group two, four patients had positive urine protein levels, and all of them were negative. In group three, 2 had positive proteins, and 28 had negative proteins. In group four, 2 had positive proteins, and 28 had negative proteins. A p-value of 0.000 indicates the influence of Musa acuminata Cavendish and Cucumis sativus cookies and the self-talk module on protein levels.
CONCLUSION: Musa acuminata Cavendish and Cucumis sativus cookies and the Self Talk booklet for prehypertensive mothers in Kendari City for 12 weeks can effectively reduce blood pressure and urine protein levels.

Evaluation of Knowledge and Attitude of Women Towards Abnormal Uterine Bleeding

Mon, 30 Sep 2024 00:00:00 +0500

Objective: To evaluate the knowledge and Attitude of women towards abnormal uterine bleeding (AUB).
Methodology: This descriptive cross-sectional was conducted at the Department of Obstetrics and Gynecology, The Combined Military Hospital (CMH), Rawalpindi, Pakistan, from January to December 2022. The inclusion criteria were women aged 18 to 45 who attended the outpatient obstetrics and gynaecology department. All pregnant females, those who had a history of hysterectomy, were excluded from the study. Females unwilling to be part of this study were also not involved. The participants were given pre-designed questionnaires with 30 items of knowledge and 10 items on attitude domains of AUB. A dichotomous scale (yes/no) was used for the knowledge domain. The expertise and Attitude were labeled good if females answered more than 60% of questions correctly. Statistical Package for Social Sciences version 26.0 was used for data analysis.
Results: In 151 women, the mean age and body mass index (BMI) were 27.4±6.2 years and 24.1±1.2 kg/m². Lower abdominal pain was described to be the most common presenting complaint by 98 (64.9%) females, while mood swings, weakness and irritability were the other most frequently reported presenting complaints reported by 69 (45.7%), 66 (43.7%) and 61 (40.4%) females respectively. Overall, AUB knowledge was considered good in 24.3% of females. Attitude towards AUB was good in 74 (49.0%) females.
Conclusion: Good knowledge of AUB was noted in 24.3% of females, while 49.0% reported good Attitudes towards AUB.

Outcomes of Wound Healing after Plasma-Rich Platelet Therapy

Juwereya Memon, Sana Mughal, Sumair Memon, Raima Kalhoro, Uzma Qureshi — Mon, 30 Sep 2024 00:00:00 +0500

OBJECTIVE: To identify outcomes of wound healing after using Plasma Rich platelet therapy.
METHODOLOGY: A prospective cross-sectional study was conducted at ISRA University Hospital, Hyderabad, from July to December 2022, with a sample size of 50 and a non-probability sampling technique. Both genders aged 45 to 75 years, Diabetes mellitus type II, Chronic or Non-healing wounds/ulcers for 3 to 6 months, and Wound size 2cm to 6cm were included. Participants who were not willing to study, Patients on steroid and Anticoagulant therapy and Immunosuppressive drugs, Pregnant females, those with Cardiovascular Disorders, and Associated Lymphoedema were excluded. Data was analyzed by SPSS version 21.
RESULTS: Fifty patients were enrolled after matching the inclusion and exclusion criteria. The age range was 40 years to 70 years. Thirty-one were males, and 19 were females. Co-morbid conditions included were diabetes mellitus type II and hypertension. The most common cause of lower limb ulcers was diabetic foot, and the most common site was the dorsum of the foot. 52% of patients had <2cm size ulcers, and they responded well to plasma-rich platelet therapy in a single session. PRP is a cost-effective, advanced therapy and safe procedure to manage wound healing. It improves quality of life, reduces hospitalization, and decreases hospital visits, which would lessen the patient burden. It works on cellular regeneration, so it helps in faster recovery and avoidance of old traditional methods and excessive or misuse of antibiotics.
CONCLUSION: Plasma Rich Platelet therapy is a safe method for treating chronic and non-healing ulcers.

Expression Profile of Apoptotic Genes Bak1 and Bcl2 in Pakistani Presbycusis Patients from Faisalabad and Chichawatni Populations

Mon, 30 Sep 2024 00:00:00 +0500

Objective: To analyze the expression profiles of two apoptotic genes, BAK1 and BCL2, in Pakistani ARHI patients' blood samples compared to healthy subjects.
Methodology: This expression profiles study was conducted at the Sight Centre of Bahawalpur City of Southern Punjab from August 2022 to July 2023. All of the subjects were from Faisalabad or Chichawatni, Pakistan cities. The participants exposed to head injury or trauma, noise exposure, ototoxic medication, chemical exposure, diabetes, liver cirrhosis, neurological disease, psychiatric disease, cognitive dysfunction, middle ear disease, and brain tumour factors were excluded from the study. Individuals with cold or flu were also excluded from the study. RNA was extracted from both the peripheral blood samples of healthy and affected individuals. The quantity of RNA was then determined, and cDNA was synthesized from it. This cDNA was then utilized in qPCR to assess the relative expression of the BAK1, BCL2, and ACTB genes using gene-specific primers.
Results: Our results suggested that ARHI patients had higher levels of BAK1 expression and BAK1/BCL2 ratio than healthy subjects.
Conclusion: Thus, apoptosis mediated by BAK1 may be a key mechanism controlling the development of ARHI. Furthermore, changes in BAK1 gene expression of blood samples might be utilized as a rapid test for early diagnosis of ARHI.

Frequency of Vitamin D Deficiency in Cirrhotic Versus Non-Cirrhotic Liver Disease Patients

Ali Haroon, Anita Haroon, Zahabia Sohail, Rabbia Akhtar Nizami, Ajeet Kumar — Mon, 30 Sep 2024 00:00:00 +0500

Objective: To compare the frequency of vitamin D levels between cirrhotic and non-cirrhotic liver disease patients.
Methodology: This retrospective comparative cross-sectional study compressed 296 diagnosed chronic liver disease patients who visited the Department of Gastroenterology at the Aga Khan University Hospital in Karachi, fulfilling the study inclusion criteria. Demographic and clinical characteristics such as age, sex, disease duration, etiology and severity of all patients were obtained. Cirrhotic status and vitamin D levels were noted. Data was analyzed on Statistical Package for Social Sciences (SPSS), Version 22.
Results: The mean age was 41.48+/-9.88 years, and the mean vitamin D level in chronic liver disease patients was 14.61+/-8.37 (ng/ml). In cirrhosis and non-cirrhosis patients, mean vitamin D levels were (12.97 vs 16.08; P: 0.001), respectively. Significantly reduced levels were observed in Cirrhotic patients. In cirrhotic patients, vitamin D deficiency was more prevalent than the non-cirrhotic group (80.7% vs 66%; P: 0.004); overall, 73% of chronic liver disease patients were diagnosed as vitamin D deficient.
Conclusion: In chronic liver disease patients, liver cirrhosis increases the likelihood of vitamin D deficiency. Factors like young age, male sex, and etiology (hepatitis C virus) strongly correlate with vitamin D deficiency. Furthermore, patients with advanced liver disease are more prone to be vitamin D deficient.

Effect of the Quranic Verses Recitation on Depressive Symptoms among Cancer Patients at Tertiary Care Hospital, Karachi

Farhan Ahmed, Afshan Nazly, Yasmin Noorali Amarsi, Shahzad Bashir — Mon, 30 Sep 2024 00:00:00 +0500

OBJECTIVE: To assess the effectiveness of recitation of the Quranic verses on depressive symptoms among cancer patients.
METHODOLOGY: This Pre-Post quasi-experimental single-group study was conducted from December 2021 to January 2022 in the Oncology department at Dr. Ziauddin Hospital Karachi. A total of 50 depressed Cancer patients participated in the study. Participants were recruited through the Consecutive sampling technique, which included being Muslim, having a one-month hospital stay, and a diagnosis of depression. Participants were assessed through the Hamilton Depression Scale (HAM-D). Data was analyzed through frequency and proportions for variables, and median and interquartile range differences were compared using the Wilcoxon signed-rank test. The association of depression was checked by Spearman rank correlation.
RESULTS: Out of 50 participants, 32(64%) were males, and 18(36%) were females; 46(92%) were married; 50(100%) participants were belongs to Muslim religion and had a length of stay for 1 to 3 months durations. The comparison of HAM-D total scores revealed a median of 20.5 (IQR= 21-20) in the pre-test, which decreased to 13 (IQR= 14-12) in the post-test after one month of intervention. This reduction was statistically significant (p<0.05).
CONCLUSION: The Quranic verses recitation is an effective and safe therapy for reducing depressive symptoms among cancer patients. The depression score significantly reduced after this intervention.

Association of the c.75C>A Variant in CLCC1 with Autosomal Recessive Retinitis Pigmentosa in Pakistan

Mon, 30 Sep 2024 00:00:00 +0500

Objective: To identify the disease-causing allele of retinitis pigmentosa, a heterogeneous genetic disorder in a single affected family.
Methodology: A cross-sectional descriptive study was conducted at the Sindh Institute of Ophthalmology & Visual Sciences Hyderabad from December 2022 to December 2023, with approval from the SIOVS ethical committee. A consanguineous pedigree with multiple affected members was included, while pedigrees with only one affected member or secondary causes of vision loss were excluded. After getting informed consent, each enrolled participant's blood samples (10 cc) were collected, and DNA was extracted. The family was subjected to Sanger sequencing for the CLCC1 gene.
Results: In this study, one reported c.C75A, p.Asp25Glu allele in the CLCC1 gene was identified from an endogamous pedigree in Sindh, Pakistan. The identified c.C75A, p.Asp25Glu allele is a common cause of autosomal recessive retinitis pigmentosa (arRP) in Pakistani-affected individuals. This allele is estimated to have occurred 2000-5000 years ago and has been transmitted to affected individuals of Pakistani origin and global descent across various geographical regions. All the affected patients underwent detailed clinical investigations, including fundus photography and optical coherence tomography, to confirm the retinitis pigmentosa symptoms. The Sanger sequencing method was used to detect pathogenic variants, and bioinformatics tools were utilized to investigate the pathogenesis of identified alleles and compare phenotype-genotype correlations.
Conclusion: The finding of frequent disease-causing alleles from Pakistani-affected patients will significantly improve existing genetic databases and facilitate more accurately the affected diagnosis of gene testing.

Sensory Neuropathy of the Foot Among Asymptomatic Patients of Type II Diabetes Mellitus

Mon, 30 Sep 2024 00:00:00 +0500

OBJECTIVE: This Study aimed to determine the frequency of sensory neuropathy in the feet of asymptomatic people with type II diabetes mellitus.
METHODOLOGY: This cross-sectional Study was conducted at the medical department of MTI/Lady Reading Hospital, Peshawar, between April - October 2022. A total of 133 patients were observed using a non-probability consecutive sampling technique. Patients aged 25-60 years who had type II diabetes mellitus for more than one year were included, while patients with vitamin B12 deficiency who used multivitamins were excluded from the study. SPSS version 20 was used for statistical analysis.
RESULTS: Age-wise distribution 25-30 Years (4.5%), 31-40 Years (21.8%), 41-50 Years (45.9%), and 51-60 Years (27.8%) (mean 45.56±3.3). Gender-wise, 104 (78.2%) were male and 29 (21.8%) were female. Regarding education level, 57 (42.9%) were illiterate, 46 (34.6%) had secondary education, and 30 (22.6%) had higher education. Residency status indicated 105 (78.9%) from urban areas and 28 (21.1%) from rural areas. Socioeconomic status was distributed as follows: 53 (39.8%) with a monthly income >100,000 Rs, 46 (34.6%) with an income range of 50,000 to 100,000 Rs, and 34 (25.6%) with an income range <50,000 Rs. Sensory neuropathy was found in 60 (45.1%) patients and absent in 73 (54.9%).
CONCLUSION: The Study revealed a notably high prevalence of sensory neuropathy. Prompt identification and focused treatment are essential, especially for patients over 40, sedentary lifestyles, and those with diabetes for more than two years.

Barthel Index Score and Total Serum Cholesterol Levels Correlation as Prognostic Tool for Acute Ischemic Stroke

Mon, 30 Sep 2024 00:00:00 +0500

OBJECTIVE: To find a correlation between total serum cholesterol (TSC) in acute ischemic stroke and their prognosis is assessed employing the Barthel Index (BI) score.
METHODOLOGY: This prospective study was conducted at Medical Emergency of Allied Hospital Faisalabad and Social Security Hospital Lahore from 2020 to 2021. The written informed consent was obtained. In 58 sudden-onset acute ischemic stroke subjects, 36 males and 22 females were selected by purposive sampling. Patients were aged between 18-50 years. The BI scoring system was used instantly on admission day, followed up at 48 hours, two weeks and one month of stroke to determine everyday routine in Personal care. Patients with a previous history of some stroke, transient ischemic attack (TIA), diabetes mellitus (DM), renal dysfunction, cardiac malfunctions, or valvular heart diseases were excluded. Stroke patients having an acute ischemic stroke for the first time were diagnosed and confirmed by non-contrast computed tomography (CT) scan and statistical analysis using SPSS version 17.0.
RESULTS: The mean BI score taken at four intervals was significantly correlated to the levels of TSC. The acute ischemic stroke patients with TSC level > 200 mg/dl showed better prognosis in comparison to those with TSC level < 200 mg/dl.
CONCLUSION: The present study on acute ischemic stroke patients suggests that TSC is correlated to a better future outcome as assessed by the BI score. This study demonstrates that high total serum cholesterol (HTSC) can be considered as a marker to anticipate the prognosis in patients of acute ischemic stroke.

Nurses' Knowledge, Attitude, and Practice toward Immobility Complications: A Scoping Review

Amani Alhassoon, Ruba Alharazi , Hayfa Almutary — Mon, 30 Sep 2024 00:00:00 +0500

Immobility complications are challenging for healthcare professionals because they negatively affect individuals' overall health. Following recovery from a severe illness or accident, patients' movement is often impaired, so they may be unable to perform activities of daily living, thus impacting their quality of life. Nurses play a proactive role in preventing immobility's physical and mental impacts. However, several studies have suggested that nurses worldwide lack knowledge, attitude, and practice (KAP) toward immobility complications. Therefore, stakeholders must prioritize this problem to optimize healthcare provision. Accordingly, this study aimed to explore nurses' KAP toward immobility complications. A scoping review of relevant articles utilized PubMed, Scopus, Cochrane, Web of Science, Embase, CINAHL Plus, and EBSCOhost databases. Hawker's tool assessed the risk of bias among the included primary articles. The results were analyzed according to the KAP toward four main immobility complications: pressure injury, deep vein thrombosis, ventilator-associated pneumonia, and urinary tract infection. The database search generated a total of 1398 articles. Of them, only 39 articles met the inclusion criteria for the review. Most articles concluded that nurses' KAP were below the expected level. Education and training were found to optimize nurses' KAP. The KAP toward immobility complications was good among nurses with work experience, high academic grades, and prior training. These findings indicate that nursing staff should receive continuous education and in-service training to improve their KAP toward immobility complications.

A Systematic Review on Relationship of Bisphenol-A with PCOS, with a focus on Pakistan

Ayesha Pervez, Ghazala Shaheen Tariq, Fozan Ahmad, Shafaq Bushra, Seemin Kashif — Mon, 30 Sep 2024 00:00:00 +0500

The study was done to show the association of high bisphenol-A levels with polycystic ovarian syndrome, keeping Pakistan in focus. Google Scholar, PubMed, ScienceDirect, and DOAJ were used for the literature search. Original research articles from 2018 to 2023 were included in this review. A total of 86 articles were extracted. After exclusion, fourteen (16) articles were included in the review. No human studies were found in Pakistan, the USA, Canada, Australia, or Europe. All studies included in the review were case-control studies. Most of these studies (14) showed a positive relationship between BPA levels and PCOS, but two studies could not. No animal or human studies were found in Pakistan. Only one study was found in humans in Pakistan, which showed a direct relation between BPA levels in urine and insulin resistance in diabetic patients. According to global studies, BPA was a possible etiological factor for PCOS. No such data was obtained from Pakistan, but evidence of high levels of BPA in tap water and various canned and bottled drinks in Pakistan was found. BPA should be considered an actual threat in Pakistan at the national level. So, studies must be done, and regulations must be made to control BPA use.