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Cardiovascular mortality is a major health burden worldwide and the number of patients with cardiac diseases is increasing. Dilated cardiomyopathy (DCM) is the most frequent cause for patient visits in cardiac care units and emergency departments. It is commonly misdiagnosed as ischaemic cardiac disease. Middle- and low-income countries rely on pharmacological management as the only treatment option. Most of the patients cannot afford heart transplants or advanced treatment strategies. Most health professionals also do not prescribe cardiac rehabilitation for DCM patients in their routine clinical practice. There is evidence that supervised cardiac rehabilitation is safe and beneficial for DCM patients. In addition to medications, cardiopulmonary exercise testing (CPET) and supervised cardiac rehabilitation, can provide more benefits to the affected population of cardiomyopathies. CPET and cardiac rehabilitation are still novel concepts in countries like Pakistan. The present review aims to provide clinicians with an overview of an evidence-based and innovative perspective. This perspective emphasizes the utilization of the additional benefits of cardiac rehabilitation in the holistic management of DCM patients and the prevention of chronic heart failure.

Objective: To determine the effects of multifactorial inspiratory muscle training (IMT) combined with Otago Exercise Programme (OEP) on balance and quality of life (QoL) in patients with diabetes., Methods: Pretest-post-test randomised controlled trial., Setting: Rehabilitation Department of Pakistan Railway General Hospital., Participants: 70 patients with diabetes were randomly assigned to experimental or placebo groups, out of which 59 patients completed the intervention., Intervention: Patients in the experimental group performed OEP+IMT (at 50% of baseline maximum inspiratory pressure (MIP)) whereas the placebo group performed OEP+sham IMT (at 15% of MIP). Both groups exercised for 12 consecutive weeks., Outcome Measures: Outcome measures included nine variables: the Berg Balance Scale (BBS), the Biodex Postural Stability System (including postural stability test (Overall Stability Index, Anterior-Posterior Index and Mediolateral Index), fall risk test (FRT), Limits of Stability (LOS) test (time to complete test and direction control), Clinical Test of Sensory Interaction and Balance (CTSIB)) and the Audit of Diabetes Dependent Quality of Life questionnaire., Results: Out of 59 patients who completed treatment, 37.1% were men and 62.9% were women with a mean age of 58.37±5.91 years. Results show significant interaction effects on BBS scores with the mean score improving from 41.87±2.61 to 49.16±2.50 in IMT versus sham IMT group with scores improving from 41.58±2.51 to 45.74±2.30. The IMT group significantly improved in dynamic balance tested through BBS (p=0.003), anticipatory balance through LOS test (p=0.003), reactive balance tested through FRT (p=0.04), direction control (p=0.03) and sensory integration through CTSIB test (p=0.04) when compared with the sham IMT group. While no significant changes (p>0.05) between groups were observed in QoL and static balance; significant changes (p<0.05) within group were observed in both groups in QoL and static balance., Conclusion: Additional research is necessary to understand the association between inspiratory muscle strength and balance, however, we demonstrated that a multifactorial IMT intervention should be used with patients with diabetes to improve balance, postural control and reduce fall risks., Trial Registration Number: ClinicalTrials.gov, NCT#04947163., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Musculoskeletal (MSK) disorders encompass various conditions impacting bones, muscles, tendons, ligaments, and nerves. An estimated 1.71 billion individuals globally have MSK disorders, causing disability and reduced quality of life. Literature contradicts the notion that musculoskeletal pain and disability solely arise from physical impairments; psychological, behavioural, and social factors contribute significantly. These facets influence pain perception and chronic impairment development. Common interventions-medication, exercise, manual and hydrotherapy, electro-thermal modalities, behavioural and alternative therapies-address pain individually, yet lack the comprehensive response required. In contrast, a multimodal approach combines diverse therapies tailored to individual needs. It ensures lasting symptom relief, prevents recurrence, and improves function. Although proven effective, clinical implementation of this approach remains limited. This mini-review discusses the reasons behind this gap, underscores multimodal approach importance, and enlightens rehabilitation professionals on its potential for managing chronic musculoskeletal issues.

The recent advancements in medical sciences has resulted in not only increasing life expectancy of the elderly but has also improved survival rate in elderly with neurological disorders including those with head trauma . This has resulted in an increasing number of persons with cognitive deficits. Cognitive functions such as executive functioning and memory play an important role in success of a rehabilitation programme and therefore can positively contribute to public health goals. Considering cognitive decline at present has no cure and pharmacological therapies have a limited role, efforts are usually made to delay the onset and progression of cognitive decline and improve quality of life. Literature suggests that active life style, regular exercise, actively performing activities of daily living can have a significant impact on cognitive skills. In addition different models of cognitive rehabilitation and approaches can be integrated into practice to improve cognitive reserve and cause neuroplastic changes to facilitate cognitive function by providing cognitive stimulus and training. Moreover with technological advancements, the computerized cognitive intervention field is growing. This usually integrates conventional cognitive intervention with digital smart devices to provide an engaging and cost effective alternate approach. This review aims to highlight the importance of cognitive rehabilitation and suggest a few evidence based approaches that may be considered by rehabilitation professionals to promote and improve cognitive rehabilitation in Pakistan.

Objective The objectives of this study were to determine the frequency of the clinical spectrum of diseases in patients with macrocytosis and to summarize the diagnostic evaluation of patients found to have macrocytosis on laboratory testing. Background This was a cross-sectional study that took place at the Department of Medicine in Combined Military Hospital, Rawalpindi, Pakistan, from January to June 2023. Methodology One hundred and five patients with macrocytosis with mean corpuscular volume (MCV) values > 100 fL (80 to 100 fL) were inducted as per inclusion and exclusion criteria. Informed consent was obtained from all patients. Complete blood counts (CBC), peripheral blood film, serum vitamin B12 levels, serum folate levels, renal function tests (RFTs), liver function tests (LFTs), and thyroid function tests (TFTs) were performed during the assessment. Results The commonest cause of macrocytosis was vitamin B12 deficiency followed by folate deficiency, combined vitamin B12 and folate deficiency, and other causes were also found in a few cases. Conclusion Serum vitamin B12 and folate deficiency are the most common preventable causes of macrocytosis., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Shafaat et al.)

Background: Conventional treatment for alveolar cleft repair is done using autologous iliac crest alveolar bone graft (ABG). However, this method may not be ideal in all patients. Analysis of the efficacy of a mixture of demineralized bone matrix (DBX), bone morphogenic protein (rhBMP-2), and freeze-dried bone chips (FDBC) as an alternative for alveolar cleft repair was performed., Methods: Consecutive patients from August 2019 to June 2022 undergoing early alveolar cleft repair, concomitant hard palate and alveolar cleft repair, secondary alveolar cleft repair, and regrafting from a previously failed ABG were analyzed. Computed tomography scans were performed to evaluate graft take at least 6 months postoperatively. Images were reviewed and scored. Alveolar graft height and graft thickness were recorded. A standardized scoring system was developed, with a score of 0 representing no graft take and 3 representing best possible graft take., Results: Fifty-five consecutive alveolar clefts (43 patients) were identified as having undergone ABG and satisfied all the other inclusion criteria. Of these, 29 underwent first time ABG and 26 underwent redo ABG. The mean graft height and graft thickness recorded for all clefts was 2.2 and 2.0, respectively., Conclusions: Early results evaluating the efficacy of ABG using DBX, rhBMP-2, and FDBC show feasibility in regard to both graft height and thickness when using a maxillary computed tomography scan to measure the bone graft take. These results suggest that DBX, rhBMP-2, and FDBC may act as a versatile bone graft material in cleft care, although further studies are needed to determine long-term outcomes., Competing Interests: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Obesity has long been recognized as a major independent risk factor for cardiovascular diseases (CVD). However, intriguing paradoxes such as the "obesity paradox" and the "fat but fit" phenomenon have been associated with it. The "fat but fit" paradigm suggests that overweight or obese individuals might face a lower risk of developing cardiovascular disease if they possess high levels of physical fitness. In other words, higher fitness levels may mitigate the negative impact of obesity on cardiovascular risk, leading to a reduction in overall mortality due to CVD. The evidence surrounding this paradox is conflicting, highlighting the necessity for further research. The complex relationship between physical fitness, obesity, and cardiometabolic health is influenced by individual and environmental factors. Consequently, it becomes imperative to conduct more studies to comprehend this intricate interplay fully. To address this issue, it is important to focus on formulating strategies that promote the maintenance and enhancement of cardiorespiratory fitness in overweight and obese individuals. Moreover, including fitness evaluations in comprehensive risk stratification can significantly improve clinical decision-making.

Background: Solitary rectal ulcer syndrome (SRUS) is a very rare benign defecation disorder characterized by distinct clinical features and histological findings. Conventional measures are often shown to be ineffective for the treatment of ulcers. Argon plasma coagulation (APC) has recently been shown to be an effective treatment method for SRUS that is refractory to conventional therapy., Objectives: Determine the efficacy of APC treatment for patients suffering from SRUS., Design: Prospective, single center., Settings: Gastroenterology department at a military hospital in Pakistan., Patients and Methods: This prospective study included patients with symptoms of rectal bleeding diagnosed with SRUS. Patients were recruited on the basis of clinical, sigmoidoscopic, and histological findings from September 2022 to March 2023. All patients had received conventional treatment initially and were assessed for persistence of symptoms. APC was performed only for those patients who were refractory to standard treatment., Main Outcome Measures: Effectiveness of APC for resistant SRUS., Sample Size: 99 patients., Results: The 99 patients diagnosed with SRUS had a median (minimum-maximum) age of patients was 20 (9-41) years. All the patients had undergone conventional treatment, which included the use of laxatives, drinking plenty of water and practicing biofeedback. After this standard treatment, 19 patients (19.19%) recovered fully. However, the remaining 80 patients did not show improvement and underwent APC sessions, out of which 61 patients (76.3%) achieved complete healing of ulcers, while the remaining 19 (23.8%) had no improvement at all. None of the patients reported post session complications., Conclusion: APC is an effective therapy with very promising results for rectal ulcer hemorrhage. It also helps with ulcer healing and alleviates clinical symptoms. However, further controlled investigations are required to consolidate the use of APC in SRUS patients., Limitations: Single centered., Competing Interests: CONFLICT OF INTEREST: None.

Smartphone applications (apps) that utilize embedded inertial sensors have the potential to provide valid and reliable estimations of different balance and gait parameters in older adults with mild balance impairment. This study aimed to assess the reliability, validity, and sensitivity of the Gait&Balance smartphone application (G&B App) for measuring gait and balance in a sample of middle- to older-aged adults with mild balance impairment in Pakistan. Community-dwelling adults over 50 years of age (N = 83, 50 female, range 50-75 years) with a Berg Balance Scale (BBS) score between 46/56 and 54/56 were included in the study. Data collection involved securing a smartphone to the participant's lumbosacral spine. Participants performed six standardized balance tasks, including four quiet stance tasks and two gait tasks (walking looking straight ahead and walking with head turns). The G&B App collected accelerometry data during these tasks, and the tasks were repeated twice to assess test-retest reliability. The tasks in quiet stance were also recorded with a force plate, a gold-standard technology for measuring postural sway. Additionally, participants completed three clinical measures, the BBS, the Functional Reach Test (FRT), and the Timed Up and Go Test (TUG). Test-retest reliability within the same session was determined using intraclass correlation coefficients (ICCs) and the standard error of measurement (SEM). Validity was evaluated by correlating the G&B App outcomes against both the force plate data and the clinical measures using Pearson's product-moment correlation coefficients. To assess the G&B App's sensitivity to differences in balance across tasks and repetitions, one-way repeated measures analyses of variance (ANOVAs) were conducted. During quiet stance, the app demonstrated moderate reliability for steadiness on firm (ICC = 0.72) and compliant surfaces (ICC = 0.75) with eyes closed. For gait tasks, the G&B App indicated moderate to excellent reliability when walking looking straight ahead for gait symmetry (ICC = 0.65), walking speed (ICC = 0.93), step length (ICC = 0.94), and step time (ICC = 0.84). The TUG correlated with app measures under both gait conditions for walking speed (r -0.70 and 0.67), step length (r -0.56 and -0.58), and step time (r 0.58 and 0.50). The BBS correlated with app measures of walking speed under both gait conditions (r 0.55 and 0.51) and step length when walking with head turns (r = 0.53). Force plate measures of total distance wandered showed adequate to excellent correlations with G&B App measures of steadiness. Notably, G&B App measures of walking speed, gait symmetry, step length, and step time, were sensitive to detecting differences in performance between standard walking and the more difficult task of walking with head turns. This study demonstrates the G&B App's potential as a reliable and valid tool for assessing some gait and balance parameters in middle-to-older age adults, with promise for application in low-income countries like Pakistan. The app's accessibility and accuracy could enhance healthcare services and support preventive measures related to fall risk.

Objective: To study the relationship of perceived social support (PSS) and anxiety among patients of Chronic Hepatitis C (CHC)., Methods: It is a cross sectional survey conducted from March 2021 to December 2021 in different hospitals of Islamabad and Rawalpindi. Sampling was done through purposive and snowball technique. Self-administered and standardized questionnaires were used. To analyze perceived social support and anxiety, perceived social support "scale" and Beck anxiety inventory were used in patients of Hepatitis C. Patients Polymerase Chain Reaction (PCR) positive HCV patients between the ages 31 to 50 years were included. Patients with comorbid conditions and other than 31 to 50 years of age were excluded from the study., Results: Out of 250, males were 185(74%) and females 65(26%). Ages were between 31 to 50 years. PSS in both males and females was 49.8 and 49 (p=0.63%) with anxiety level 44.63 and 56.18 (p=0.00) respectively. There was no significant gender differences on PSS but women had significantly higher on anxiety ( M = 56.18, SD = 11.36) with moderate effect size (>.05). PSS had significant negative correlation with anxiety ( r = -.31, p < .05)., Conclusion: Anxiety is more common in females and perceived social support has negative correlation with anxiety in patients of Chronic Hepatitis C., Competing Interests: Conflict of interest: None., (Copyright: © Pakistan Journal of Medical Sciences.)

Introduction Acute chest pain is a frequently encountered symptom in the emergency department. Despite the availability of various chest pain risk scores, their effectiveness in identifying low-risk patients suitable for safe and early discharge is inadequate. Moreover, clinical data collected at the initial stage, which has valuable discriminatory ability, is often underutilized. This study aims to assess the effectiveness of the Symptoms, history of Vascular disease, ECG, Age, and Troponin I (SVEAT) score in predicting major adverse cardiovascular events (MACE) in acute-onset chest pain, compared with the pre-existing History, ECG, Age, Risk factors, and Troponin I (HEART) and Thrombolysis In Myocardial Infarction (TIMI) scores. Methodology This prospective study utilizing non-probability convenience sampling was conducted in the emergency medicine department of a tertiary care hospital in Rawalpindi, Pakistan, for a period of five months from July 2022 to November 2022. The study included patients aged >45 years who presented primarily with chest pain lasting for at least five minutes but less than 24 hours and with a lack of acute ECG changes indicative of ST-elevation acute coronary syndrome (STE-ACS). Patients who were hemodynamically unstable were excluded. All patients were assessed for the calculation of SVEAT, TIMI, and HEART scores. All patients were followed for a period of 30 days to assess the incidence of MACE. Results A total of 60 patients were included. The mean age was 61.5±9.1 years while 31 (51.7%) patients were females. Diabetes was the most prevalent comorbidity (n=32; 53.3%). Regarding MACE, nine (15%) patients developed ACS and underwent percutaneous coronary intervention (PCI). Two patients (3.3%) experienced heart failure. Six (10%) patients also underwent PCI in the absence of ACS while two (3.3%) patients developed sudden cardiac death. Area-under-curve (AUC) values were determined for SVEAT (0.843; 95%CI: 0.74-0.94), TIMI (0.742; 95%CI: 0.62-0.86), and HEART scores (0.840; 95%CI: 0.74-0.94). A cut-off level of 3.5 SVEAT points obtained a sensitivity of 63.2% and specificity of 75.6% in predicting 30-day MACE. Conclusion SVEAT score potentially lacks the appropriate sensitivity level to predict a significant number of major adverse cardiovascular events compared to contemporary risk stratification scores. Therefore, the SVEAT criteria need re-evaluation as a screening tool for risk assessment in acute chest pain., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Shahid et al.)

Stroke is the 2nd leading cause of death globally after ischaemic heart disease and is expected to rise more by 2030. The estimated incidence of stroke in Pakistan is about 250/100,000 individuals. Difficulty in walking is present in approximately 80% of stroke survivors. About a quarter of stroke survivors, even after receiving rehabilitation have residual gait impairments requiring assistance in activities of daily life. Almost half of stroke patients after being discharged will have episodes of fall, with majority of these falls occurring in activities like "turning". Gait is one of the key features to participate in community and occupational activities. Therefore, appropriate gait rehabilitation post stroke is crucial for functional independence and community ambulation. There are many approaches to gait rehabilitation based on different models of motor physiology and disease. Augmenting conventional therapies with novel techniques such as utilization of electromechanical means have improved gait rehabilitation in improving functions. The usage of technology in rehabilitation of patients with neurological deficits, is still novel in Pakistan. This review provides an overview of advancements in neurological and gait rehabilitation post stroke.

World Health Organization data indicates a marked rise in global obesity, with approximately 30% of the world's population classified as overweight or obese. The contributory factors include unhealthy dietary habits, lack of physical activity, urbanization, and technology dependent sedentary lifestyle. Among the various management approaches, cardiac rehabilitation has evolved from an exercise-only programme for patients with cardiac diseases to a multi-disciplinary individualised intervention plan for risk factor modification, primary and secondary prevention of cardiometabolic diseases. Evidence suggests that visceral obesity is an independent risk factor of morbidity and mortality from cardiometabolic causes. There are multiple training programmes targeting visceral fat oxidation, one of which is high intensity interval training. It appears to be a promising regime, inducing metabolic adaptations in the body. This review summarizes the multidisciplinary cardiac rehabilitation services for the management of visceral adiposity and generalised obesity, its under-utilization and scarcity of local published data, highlighting the need for future research.

Low back pain is a common musculoskeletal disorder involving the lumbar spine. It affects almost 80% of the world's population and is associated with functional limitations. The reported global prevalence ranges from15-30%. Postural control involves processing the information from sensory stimulus derivative of vestibular, visual, and somatosensory systems in a coordinated manner to precisely regulate center of mass and body positioning. Failure of one or more of these systems, or incorrect processing of sensory information leads to instability or risk of fall. Low back pain can also modify the sensory input for postural control. Biofeedback can be utilized to assist "down-train" elevated muscle activity or to "up-train" weak or inhibited, muscles. Clinicians can use biofeedback to determine if patients are able to relax and evaluate psychophysiological reactions of muscles. Using biofeedback, patients can be educated about physiological processes and how biopsychosocial factors can interact causing recurrent complaints of pain.

Soccer (football) is one of the most popular weight-bearing sports in the world, which involves activities such as jumping, running and turning. Soccer related injuries have the highest incidence in all sports and are more common in young amateur players. The most important modifiable risk factors include neuromuscular control, postural stability, hamstring strength and core dysfunction. The International Federation of Football Association introduced FIFA 11+; an injury prevention programme for reduction in the rate of injuries in amateur and young soccer players. It focusses on the training of dynamic, static and reactive neuromuscular control, proper posture, balance, agility and control of the body. This training protocol is not being used in Pakistan at amateur level who neither possess the resources, nor the knowledge or proper guidance in risk factor assessment, prevention, and subsequent sport injury management. In addition, the physicians and rehabilitation community are not much familiar with it except for those directly involved in sports rehabilitation. This review highlights the importance of including FIFA 11+ training programme in the curriculum and faculty training.

Obesity as depicted by changes in the body composition is considered a global epidemic of the 21st century, predisposing to cardiometabolic diseases. This analytical cross-sectional study evaluated body composition parameters in both genders and conducted an obesity analysis of healthy adult Pakistani population. Using non-probability purposive sampling technique, data was collected from 205 healthy adults (aged 18-45 years), who had not been participating in any structured exercise or dietary regime over the last six months. Body composition was assessed using bioelectrical impedance analyser. For data analysis, descriptive statistics, Mann-Whitney U-test and one-sample T-test were applied. The mean body mass index was 24.3±4.93 kg/m2. Body composition components which were significantly higher in males included soft lean mass, fat-free mass index, skeletal muscle mass index and bone mineral content, whereas females had significantly higher percentage of body fat (PBF), visceral fat area and fat mass index (p<0.05). For obesity analysis, the mean PBF (34.61±9.68%) of our sample was higher than White, Hispanics and European adults. Majority of healthy adults had greater body fat mass and lower skeletal muscle mass. The primary obesity index was significantly higher in Pakistani population compared to other ethnicities, with females exhibiting a higher trend towards obesity.

Objective: To determine the added benefits of short-term glucosamine and chondroitin sulfate supplementation in combination with manual therapy and resistance exercise training in the management of knee osteoarthritis., Methods: A parallel-design, double-blind randomised controlled trial was conducted from January to September 2020 at the Foundation University Institute of Rehabilitation Sciences and Fauji Foundation Hospital, Rawalpindi, Pakistan, and comprised of knee osteoarthritis patients of either gender having radiological evidence of grade III or less on Kellgren classification. The subjects were randomly allocated to active comparator group A and experimental group B. Both the groups received manual therapy and resistance exercise training, while group B additionally received glucosamine and chondroitin sulfate supplementation for 4 weeks. Study outcomes included pain, function, quality of life, range of motion, strength, fall risk, skeletal muscle mass, visceral fat area, body fat, intracellular water ratio, and segmental lean and fat mass. Data was analysed using SPSS 21., Results: Of the 24 subjects, there were 12(50%) in each of the two groups. Each groups had 9(75%) males and 3(25%) females. In terms knee osteoarthritis grade, there was no significant difference between the groups (p=1.00). No significant differences were observed in any of the outcome measures neither at 2 weeks, nor at 4 weeks post-intervention between the groups (p>0.05) except for percentage change in segmental lean mass of the right leg at 2nd week and of the left leg at 4th week (p<0.05)., Conclusions: Manual therapy and resistance exercise training are effective in the management of knee osteoarthritis, however, glucosamine and chondroitin sulfate supplementation for 4 weeks showed no additional benefits., Clinical Trial Number: NCT04654871. https://www.clinicaltrials.gov/ct2/show/NCT04654871.

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Background and objectives In comparison to real-time polymerase chain reaction (RT-PCR) testing, blood-related parameters including absolute lymphocyte count (ALC) and neutrophil-to-lymphocyte ratio (NLR) carry an indeterminate potential in the assessment of corona virus disease 2019 (COVID-19). Our main objective was to assess their efficacy in timely identification of COVID-19 patients and to determine whether these biomarkers can be employed as an early diagnostic tool in patients presenting with symptoms suggestive of COVID-19. Methodology This cross-sectional study was conducted at the Emergency Department of a Tertiary Care Hospital in Rawalpindi, Pakistan from November 2020 to March 2021. Patients suspected to have COVID-19 on a clinical basis (fever, cough or shortness of breath) were selected by using convenience non-probability sampling. RT-PCR was used to diagnose COVID-19 after evaluating NLR and ALC of the sample population. An NLR = 3.5 and ALC < 1 x 10 3 cells/mm 3 was considered as the cut-off value. Statistical analysis was conducted via SPSS 23.0 (IBM Corp., Armonk, NY). Chi-square and independent t-tests were used to correlate various data variables, while p-value <0.05 was considered significant. Results Out of the 172 subjects included in the study, the mean age was 40.6 ± 10.0 years, while 51% of individuals were males. Fever was found to be the most prevalent complaint (94%). Double RT-PCR testing showed that 51.2% of the population was RT-PCR positive, having a mean ALC of 1.4 ± 0.9 x 10 3 /mm 3 , significantly lower than RT-PCR negative cases (p < 0.001). In addition, NLR was drastically elevated for RT-PCR-positive individuals (p < 0.001) while it also had a distinctly high specificity of 91.7% among COVID-19 patients. Additionally, NLR did not correlate with any of the baseline patient-related parameters (presenting complaint, age, and gender). Conclusion NLR and ALC are potentially efficacious measures for an early diagnosis of COVID-19, and can be possibly utilized for an early diagnosis of COVID-19 suspects., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Shahid et al.)

Introduction There are conflicting studies regarding the efficacy of tocilizumab use in coronavirus disease 2019 (COVID-19) disease. There is a special need to identify the parameters that could predict its response in early COVID-19 disease. Objective To report our experience with tocilizumab and correlate the magnitude of fall in c-reactive protein (CRP) as a predictor of its response to treatment in early COVID-19 disease. Methods All confirmed COVID-19 cases admitted to a tertiary healthcare hospital in Peshawar Pakistan, receiving ≥1 dose of intravenous tocilizumab, between March and September 2020 were included. Relevant clinical data of the patients were recorded and further divided into two categories based on the relative fall in CRP levels, 48 hours after tocilizumab administration. Adequate response (≥50% fall from baseline CRP), primary outcomes (fall in oxygen requirement and inflammatory biomarkers), and secondary outcome (all-cause mortality at day 28) were recorded. All outcomes were compared based on falls in CRP levels. Results A total of 27 patients were included. Males were 24 (88.8%) while females were three (11.1%). The mean age was 60.9±11.6 years. The mean day of illness at the time of tocilizumab administration was 4.26±3 days. After 48 hours of tocilizumab administration, 17 (62.9%) patients showed clinical improvement, with the mean SaO 2 /FiO 2 ratio prior to treatment significantly increased (p<0.01). A significant reduction in CRP and ferritin levels was seen post-treatment (p <0.01 and p<0.01, respectively). Twenty (74.1%) patients demonstrated adequate response to tocilizumab while seven (25.9%) showed an inadequate response. Patients with adequate response had higher chances of improvement in oxygenation and lower in-hospital mortality ( p- value 0.009 and 0.020, respectively). Conclusions Tocilizumab shows clinical improvement in a vast majority of patients. Being an early and sensitive predictor, a fall of ≥50% in CRP at 48 hours can be used to predict the overall response to tocilizumab as a guide to treatment., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Khurshid et al.)

Objective: Sagittal synostosis is the most common form of isolated craniosynostosis. Although some centers have reported extensive experience with this condition, most reports have focused on a single center. In 2017, the Synostosis Research Group (SynRG), a multicenter collaborative network, was formed to study craniosynostosis. Here, the authors report their early experience with treating sagittal synostosis in the network. The goals were to describe practice patterns, identify variations, and generate hypotheses for future research., Methods: All patients with a clinical diagnosis of isolated sagittal synostosis who presented to a SynRG center between March 1, 2017, and October 31, 2019, were included. Follow-up information through October 31, 2020, was included. Data extracted from the prospectively maintained SynRG registry included baseline parameters, surgical adjuncts and techniques, complications prior to discharge, and indications for reoperation. Data analysis was descriptive, using frequencies for categorical variables and means and medians for continuous variables., Results: Two hundred five patients had treatment for sagittal synostosis at 5 different sites. One hundred twenty-six patients were treated with strip craniectomy and 79 patients with total cranial vault remodeling. The most common strip craniectomy was wide craniectomy with parietal wedge osteotomies (44%), and the most common cranial vault remodeling procedure was total vault remodeling without forehead remodeling (63%). Preoperative mean cephalic indices (CIs) were similar between treatment groups: 0.69 for strip craniectomy and 0.68 for cranial vault remodeling. Thirteen percent of patients had other health problems. In the cranial vault cohort, 81% of patients who received tranexamic acid required a transfusion compared with 94% of patients who did not receive tranexamic acid. The rates of complication were low in all treatment groups. Five patients (2%) had an unintended reoperation. The mean change in CI was 0.09 for strip craniectomy and 0.06 for cranial vault remodeling; wide craniectomy resulted in a greater change in CI in the strip craniectomy group., Conclusions: The baseline severity of scaphocephaly was similar across procedures and sites. Treatment methods varied, but cranial vault remodeling and strip craniectomy both resulted in satisfactory postoperative CIs. Use of tranexamic acid may reduce the need for transfusion in cranial vault cases. The wide craniectomy technique for strip craniectomy seemed to be associated with change in CI. Both findings seem amenable to testing in a randomized controlled trial.

For secondary alveolar bone grafting in cleft patients, the success of bone graft take is dependent upon creating an ideal environment for both bony and soft tissue healing. This is particularly challenging in patients with existing fistulas, wide clefts, and bilateral alveolar clefts, where large soft tissue mobilization is required to get a tensionless repair, and micro-motion around the bone graft is significantly higher. Herein we describe our method for manufacture and placement of a custom postoperative maxillary splint following secondary alveolar bone grafting. Our splint encompasses the palate and alveolus to stabilize the maxillary arch and protect the incision lines during healing. We find our splint to be a useful adjunct to facilitate postoperative healing following secondary alveolar bone grafting., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Alcohol consumption is a major risk factor for various diseases worldwide and is one of the most common causes of chronic liver disease. Alcohol use has risen over the past 30 years and is forecast to continue to rise. Concurrently, there has been an increased incidence of alcohol-associated liver disease (ALD). Alcohol use, regardless of the amount, leads to years of health loss across populations when considering the strong association between alcohol consumption and overall disease burden. Given the rising incidence of ALD and associated mortality, it is imperative to study the underlying factors driving these trends. This article summarizes the diagnosis and management of ALD, with a focus on various screening and prognostic tools and treatments for alcohol-associated hepatitis., Competing Interests: The authors have no relevant conflicts of interest to disclose., (Copyright © 2020, Gastro-Hep Communications, Inc.)

Bone marrow suppression is one of the serious consequences of treatment with cytotoxic chemotherapeutic agents such as doxorubicin (DOX). It is very difficult to treat bone marrow suppression caused by anti-cancer drugs. This study was aimed to evaluate hematological effects particularly the antimyelosuppressant effects of ethanolic extract of papaya seeds at 200, 400 and 600 mg/kg daily dose for three weeks in doxorubicin induced hematopoietic suppression in rat model. Hematological parameters were assessed on weekly basis on days 0, 1, 7, 14 and 21. The alcoholic extract was found to cause remission of induced myelosuppression as indicated by a dose dependent increase in WBCs, neutrophils, lymphocytes, platelets, RBCs, Hb, hematocrit & mean corpuscular volume. However, the maximum dose (600mg/kg) of the extract showed maximum activity (p<0.05) in normalizing hematological parameters when compared with group B (induced group) and group A (controlled animals). These effects were compareable with those produced by Filgrastim 5µgm/kg used as standard or reference drug during these experiments. It is concluded from the results that papaya seeds possess myelostimulant activity and can be used to treat myelosuppression caused by chemotherapy. The drug can also be used for curing anemia, thrombocytopenia and immunological disorders characterized by myelosuppression.

The current study emphasized on assessment of Antioxidant, Acetylcholinesterase (AChE) and Butyrylcholinesterase (BChE) inhibitory activity of the crude methanolic and chloroform leaves extracts along with their isolated compounds derived from Azadirachta indica. Phytochemical analysis revealed the manifestation of ancillary metabolites like alkaloid, anthraqinones, catechins, flavonoids, phenolic compounds, saponins, tannins and steroids. Methanolic crude extract of Azadirachta indica leaves revealed comparable antioxidant activity as that of quercetin and propyl gallate. As far as enzyme inhibitory activity was concerned, a significant AChE enzymes inhibition was observed. These findings confirm the traditional use of Azadirachticha indica as medicinal plant in the treatment of mental ailments and anti-inflammatory illnesses. Chloroform crude extract and isolated compounds showed weak antioxidant and enzyme inhibitory activities.

Myelosuppression or bone marrow suppression is one of the most common side effects caused by anti-cancer drugs. Certain nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics and viruses like B19 virus can also cause bone marrow suppression resulting in serious consequences like leukopenia, anemia and thrombocytopenia. Currently, it is mainly treated by Filgrastim, use of which is not without side effects. Certain natural drugs can be a safer alternative to treat myelosuppression. Azadirachta indica, commonly known as Neem, is an important medicinal plant of subcontinent. Keeping in view the traditional uses of Neem, present study aims to investigate its potential role in reversing myelosuppression. Albino rats were used to determine hematopoietic activity of Neem leaves after inducing myelosuppression by cyclophosphamide given subcutaneously. Filgrastim was used as reference standard to compare the antimyelosuppressant activity of the drug. The drug was evaluated in three doses i.e. 50mg/kg, 100mg/kg and 200mg/kg body weight, while blood samples were drawn on 0, 1st, 7th, 14th and 21st day. The drug was found to be effective in reversing bone marrow suppression in all three doses based on the hematological parameters (mean WBC, RBC, platelets, Hb, Hct etc.) which improved significantly. The results suggest that the drug can be used as antimyelosuppressant after establishing its safety and identifying its active constituents with their mechanism of action.

Robust, reliable, and reproducible closure of lumbosacral myelomeningocele defects remains a challenge. In infants with lumbosacral myelomeningocele defects, multiple methods of soft tissue coverage have been described. These include various cutaneous, fascial, and muscle flaps and grafts. This is done with relative ease when ample soft tissue is present but becomes extremely difficult for large and distally located defects. We present here our closure technique of lumbosacral myelomeningocele defects in newborns, with associated short- and medium-term outcomes. We demonstrate the anatomy of this technique with fresh cadaver dissection and present a review of demographic and outcome data of 12 consecutive patients treated with this method from June 2014 to August 2019. No major intra- or postoperative complications have been encountered, with a mean follow-up of 22.2 months and median follow up of 18 months. After the neurosurgical repair of lumbosacral myelomeningocele, bilateral composite fascial flaps composed of thoracolumbar and gluteus maximus fascia are elevated in continuity. The paraspinous muscle flaps are then elevated, disinserted distally, and medialized to provide complete muscular coverage of the dural repair. The bilateral composite fascial flaps are medialized and closed over the deep paraspinous muscle flap repair. Two patients experienced areas of small, superficial skin necrosis, one of which healed by secondary intention and the other by debridement and full-thickness skin grafting. Use of bilateral paraspinous muscle flaps and bilateral composite fascial flaps composed of thoracolumbar and gluteus maximus fascia provides robust coverage of lumbosacral defects following myelomeningocele repair in infants., Competing Interests: Disclosure: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Objective: To determine the occurrence of perceived stress and satisfaction with life as well as the association between the two among under graduate physical therapy students., Methods: The cross-sectional study was conducted from January to July 2015 at Riphah International University, Isra University and Foundation University, Islamabad, Pakistan, and comprised Doctor of Physical Therapy students aged 17-23 years. Perceived Stress Scale and Satisfaction with Life Scale were used as tools to measure the outcomes. Data was analysed using S P SS 2 0.., Results: Of the 306 students approached, 279(91%) responded. There were 39(14%) males and 240(86%) females with an overall mean age of 19.18±0.92 years. Mean stress and satisfaction with life scores were 21.35±5.76 and 24.49±5.77. Significant negative co-relation between the two scores was observed (p=0.001). There was no significant association of age with satisfaction with life (p=0.591) and perceived stress (p=0.283). A significant gender-based difference was observed in terms of perceived stress (p=0.037) and satisfaction with life ( (p=0.008), with females scoring higher., Conclusions: Male students were more satisfied with life compared to female students, and satisfaction with life decreased with an increase in stress.

The objective of this study was to assess the balance and fall risk among the community dwelling healthy older adults in Pakistan and to determine the correlation between balance measures and fall risk, for which a crosssectional correlation study was conducted at Foundation University Islamabad and Fauji Foundation Hospital from March 2016 to February 2017. A total of 77 individuals over 50 years were included via convenience sampling. I n di vi d u al s w i t h he a r i ng /v is ua l an d c o gn it ive impairments, infections, and orthopaedic and severe comorbid conditions were excluded. Data collection tools included Berg Balance Scale (BBS), Timed Up and Go (TUG) test, Functional Reach Test (FRT) and Fall Risk Score (FRS). Independent t-test and Bivariate Pearson Correlation (CI=95%, P<0.05) were used for analysis. Mean value of the BBS, FRS, TUG and FRT was 41.36±2.96, 3.40±1.47, 15.90±2.68 and 13.34±3.45 respectively. Age had a significant (p<0.05) positive correlation with FRS and negative correlation with BBS. A significant correlation (P<0.05) was found only between FRT & TUG and TUG & BBS.

Objective: To determine the effects of balance training with visual feedback using static and dynamic Biodex balance system for fall risk and mobility.., Methods: The two-arm pilot randomised controlled trial was conducted from July to October 2016 at Fauji Foundation Hospital Rawalpindi and comprised community-dwelling elderly individuals. Subjects having no major co-morbid conditions were recruited via non-probability purposive sampling. Subjects were randomly divided in two equal groups. The intervention group received 8-week training on Biodex balance system and the control group received no intervention. Data was collected using Biodex fall risk score, Berg balance scale and Timed Up and Go Test before and after the treatment. Data was analysed using SPSS 20., Results: There were 18 subjects in two groups of 9(50%) each. Analysis within the groups showed significant improvement in the intervention group (p<0.001) while no significant improvement (p>0.05) was observed in the control group. Post-intervention the result remained unchanged while comparing the two groups (p<0.05)., Conclusions: Dynamic postural training using static and dynamic Biodex balance system had a positive effect on mobility and balance in the elderly.

Objective: To determine the frequency of allergic asthma and 18common causative aeroallergens sensitisation among patients of bronchial asthma., Methods: This descriptive cross-sectional study was conducted at the Armed Forces Institute of Pathology, Rawalpindi, Pakistan, from March 2014 to March 2016, and comprised clinically-diagnosed adult patients of bronchial asthma referred from various hospitals of Rawalpindi and Islamabad. Detailed history of each patient was recorded. Serum total immunoglobulin E level was determined using enzyme-linked immunosorbent assay. Skin prick test for 18 common aeroallergens was performed. SPSS 20 was used for data analysis.., Results: Of the 105 patients, 62 (59.05%) were males and 43(40.95%) were females. The overall mean age for males and females was 29.9±10.2 years and 28.7±7.0 years respectively. Overall mean serum total immunoglobulin E was 285.01±241.39IU/ml. Frequency of atopy/allergic asthma was 59(56.2%) and patients with raised total immunoglobulin E had more chance of developing allergic asthma than those having normal immunoglobulin E(p <0.05). Frequency of allergen sensitisation was the highest with house dust mite 35(33.3%), followed by paper mulberry 33(31.4%) and grass 28(26.7%) cases.s., Conclusions: Prevalence of allergic asthma was high and the most common allergen causing highest sensitisation was house dust mite.

Objective: To determine the effect of <3 Mets (Metabolic Equivalent of Tasks) of physical activity on zero postoperative days for improving hemodynamic and respiratory parameters of patients after cardiac surgeries., Study Design: Randomized control trial., Place and Duration of Study: BARMWTHospital, Rawalpindi, from March to August 2015., Methodology: Arandomized controlled trial was conducted on 174 CABG and valvular heart disease patients undergoing cardiac surgical procedures. After selection of sample via non-probability purposive sampling, they were randomly allocated into interventional group (n=87) and control group (n=87). Treatment protocol for experimental group was ≤3 Mets of physical activity, i.e. chest physiotherapy, sitting over edge of bed, standing and sitting on chair at bedside, on zero postoperative day but the control group was treated with conventional treatment on first postoperative day. Pre- and post-treatment assessment was done in control and interventional groups on both zero and first postoperative days. Data was analyzed on SPSS version 21., Results: The patients' mean age was 51.86 ±13.76 years. Male to female ratio was 132:42. Statistically significant differences in respiratory rate and SpO2 (p=0.000 and 0.000, respectively) were found between both groups. Among ABG's, PCO2 and pH showed significant differences with p values of 0.039 and <0.001, respectively. No significant differences were observed between both groups regarding electrolytes (Na+, K+, Cl-, p-values of 0.361, 0.575 and 0.120 respectively) and creatinine (p=0.783). Marked improvement in oxygen saturation, dyspnea and a fall in systolic BPwas seen in interventional group. There was also observed to be a reduction in the length of ICU stay among interventional group patients as frequency with percentage of total stay was compared to control group., Conclusion: Early physical activity (≤3 METS) post-cardiac surgeries prevent respiratory complications through improvement in dyspnea, respiratory rate, and oxygen saturation.

Thrombotic phenomena are well-recognized complications of nephrotic syndrome attributable to loss of intermediate-sized antithrombotic proteins in the urine, resulting in a hypercoaguable state. As such, nephrotic syndrome may be associated with a reduction in circulating antithrombin III and free protein S levels. Associated spontaneous thrombotic complications are generally venous in nature, with arterial thrombosis occurring less frequently. Hypercoagulability caused by acquired nephrotic syndrome has not generally been recognized as a cause of acute thrombosis of arterial bypass grafts. We report two patients who after having nephrotic syndrome sustained acute thrombosis of their arterial bypass grafts. Pathogenesis and management are discussed.

Simple and composite membranes have been prepared from 2% collodion solutions containing different amounts of polystyrenesulfonic acid (PSSA). Various membrane parameters such as water content, electrolyte uptake, exchange capacity, and permselectivity of these membranes have been determined. The resistance and capacitance of simple membranes have been measured as functions of both external electrolyte concentration and internal fixed charge density. The impedance characteristics of composite membranes also have been determined and discussed in terms of the resistance and capacitance characteristics of simple membranes from which the composite structures have been formed.

Electrical potentials arising across composite membranes when they separate the same concentration of a (1:1) electrolyte or electrolytes have been measured. These potentials have been shown to arise from differences in the transport number of counterions contacting the two faces of the membrane which contained in its body a high concentration of electrolyte and polyelectrolyte. When the concentration of this trapped electrolyte or polyelectrolyte is low, the asymmetry potentials are small. Although measurements of current-voltage relations provided evidence for the existence of asymmetry between the two faces of the membrane, osmotic flow of water in either direction across the membrane and the salt flow in the two directions were symmetrical. These solvent and solute flux measurements lasted more than 30 hr. Short-term (about 4 hr) flux measurements, however, using tritiated water (THO), gave flows which were different in the two directions. Similarly, the salt flows measured using (22)Na isotope were different in the two directions. The usefulness of the present system as a model to use for studies concerned with carrier transport problems in biology has been pointed out.

The permeability of tritiated water (THO) across simple and layer-type composite membranes of collodion containing different amounts of polystyrenesulfonic acid has been measured and corrected for the effects of aqueous stationary layers present at the membrane-solution interfaces. It was found that the water permeabilities in the two opposite directions across the composite membranes were different, whereas they were the same across simple membranes. The theoretical permeability value for the composite membrane (formed by putting one simple membrane on top of another simple membrane of increasing charge density and gently pressing them together), calculated from the values due to simple membranes, was found to be always greater than the two measured values. It was shown that the aqueous layers trapped between membranes were not responsible for the low measured values. The factor causing this was ascribed to the mechanism which produced rectification of water flow in the composite membranes. Establishment of the THO concentration profile in the layered membranes showed that accumulation and depletion of THO in the membrane phase when the THO was flowing from the high charge density side to the low charge density side and vice versa, respectively, were responsible for the unequal flows observed across the composite membrane in the two directions.