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PurposeThe issue of customer mistreatment in food and retail sectors has come under the spotlight during the COVID-19 crisis. The purpose of this paper is to examine the problem in the COVID-19 pandemic context and study its implications for employee counterproductive behavior in the workplace. Specifically, this study aims to investigate the relationship between customer mistreatment and employee counterproductive behavior by considering the mediating role of cognitive rumination and moderating role of servant leadership at coffee cafés that operated during the COVID-19 smart lockdown period.Design/methodology/approachStructured questionnaires were distributed to 479 frontline staff working at cafés and coffee shops located in two large cities of Pakistan. The questionnaire data were analyzed by using bootstrapped regression procedures to determine how the investigated variables influenced counterproductive work behavior during the pandemic.FindingsThe findings revealed a positive influence of customer mistreatment on counterproductive work behavior both directly as well as indirectly in the presence of employee rumination as a mediator. Furthermore, the presence of servant leadership at cafés and coffee shops was found to moderate the impact of customer mistreatment during the pandemic.Originality/valueThe study offers a novel insight into the relationships between mistreatment by customers, counterproductive work behavior, employee rumination and servant leadership in the COVID-19 pandemic context, hitherto unexplored.

Highlights • Papillary thyroid carcinoma is the most widely recognized pediatric carcinoma. • Thyroid paraganglioma is rare, arises from inferior laryngeal paraganglioma. • It’s hard to separate from thyroid carcinomas as it arises from thyroid capsule. • The only way to differentiate the two diseases is through immunohistochemistry., Background Papillary thyroid carcinoma is a common neoplasm arising from follicular cells of the thyroid. Differentiating the neck mass between thyroid paraganglioma and papillary thyroid carcinoma is often difficult. Case report We report a 16-year-old girl with painless neck mass. Physiological goiter was suspected initially but we found papillary thyroid carcinoma. Results CT neck revealed hyper vascular lesions in bilateral lobes of thyroid. DSA imaging was done for further evaluation which showed high flow fistulous type of lesion supplying from superior thyroidal artery raising suspicion of paraganglioma. Postoperative biopsy ultimately revealed papillary carcinoma of thyroid in the background of hashimotos’ thyroiditis with metastatic deposits in neck lymph nodes. Conclusion Thyroid paraganglioma is a rare type of tumor, it arises from inferior laryngeal paraganglioma within thyroid capsule and is as thus difficult to distinguish from thyroid carcinomas. A biopsy is the best diagnostic choice but immunohistochemistry is the only investigation which is considered as the gold standard for distinguishing between these two diseases.

Introduction: Mechanical thrombectomy has become the cornerstone and standard of care for acute stroke patients. Early reperfusion in patients experiencing acute ischemic stroke is the most important factor. The motivation behind this investigation is to display the aftereffects of mechanical thrombectomy in patients with large vessel occlusion in anterior and posterior circulation and to demonstrate that it lessens the level of handicap 3 months post stroke. Methods: A retrospective analysis was conducted of patients who presented with acute ischemic stroke at our center from 2015 to 2018 and received mechanical thrombectomy using combined manual aspiration with a stent retriever and with large bore catheters without the bridging technique. Result factors including recanalization rate and modified Rankin Scale at 90 days post procedure were assessed. An aggregate of 30 patients were included. Results: About 30 patients presented at the institute and met the inclusion criteria for the study. Successful recanalization (the Thrombolysis in Cerebral Infarction Score [TICI 2B]) was accomplished in 90% of patients, TICI 3 score was accomplished in 56% of the patients. 67% of the patients had good modified Rankin Scale score 0-2 result at 90 days. There were 3 symptomatic hemorrhages and 3 procedure and comorbidity-related deaths (10%). Conclusion: Mechanical thrombectomy using combined manual aspiration with a stent retriever and with large bore catheters alone without the bridging technique is an effective and safe procedure for endovascular revascularization of large vessel occlusion presenting with acute ischemic stroke.

BackgroundDuring the COVID-19 pandemic, decreased volumes of stroke admissions and mechanical thrombectomy were reported. The study’s objective was to examine whether subarachnoid haemorrhage (SAH) hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines.MethodsWe conducted a cross-sectional, retrospective, observational study across 6 continents, 37 countries and 140 comprehensive stroke centres. Patients with the diagnosis of SAH, aneurysmal SAH, ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases, 10th Revision, codes. The 3-month cumulative volume, monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before (1 year and immediately before) and during the pandemic, defined as 1 March–31 May 2020. The prior 1-year control period (1 March–31 May 2019) was obtained to account for seasonal variation.FindingsThere was a significant decline in SAH hospitalisations, with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic, representing a relative decline of 22.5% (95% CI −24.3% to −20.7%, pInterpretationThere was a relative decrease in the volume of SAH hospitalisations, aneurysmal SAH hospitalisations and ruptured aneurysm embolisations during the COVID-19 pandemic. These findings in SAH are consistent with a decrease in other emergencies, such as stroke and myocardial infarction.

Background Long term results of endovascular coiling are yet scarce. This study reviews the impact of comorbidities on the success of endovascular coiling of both ruptured and unruptured intracranial aneurysms. Endovascular treatment has become thetreatment of choice after the ISAT trials. Independent risk factors that influence recovery are age, sex, smoking, and hypertension. Methods This is a 3-year retrospective analysis, performed to assess the clinical and radiological outcome of patients with cerebral aneurysms treated with detachable coils in an Asian population with relation to comorbidities including smoking and hypertension with age and gender as mediators. From July 2015 to August 2018, a total of 297 consecutive patients (mean age: 45.5 years) with cerebral aneurysms both ruptured and unruptured who were treated at a single center with endovascular coiling procedures are included in the study. Clinical information and radiological outcomes were evaluated on regular follow-ups and telephonic interviews. A modified Rankin Scale was used to measure the clinical outcomes in patients. Results We have found that smoking harmed clinical outcome, with smokers 35% less likely to recover, while hypertension played a smaller role with only 15%. It was found that while aneurysms are more prevalent in women than men, women not only have a higher chance of getting an aneurysm but also have poorer outcomes. Similarly, patients who were above the age of 40 had a lower chance of recovery compared to younger patients due to comorbidities irrespective of gender. Conclusion Asian sub-continent has different genetic markers that lead to poorer outcomes of aneurysms in women, while outcomes are similar in men and women in developed nations. Smoking does not play a major role in women’s recovery. Men with comorbidity seemed to be at higher risk and age played a major role in their recovery.

Purpose To present a case series of percutaneous sclerotherapy of para-orbital and orbital venous malformations. Method Seven patients with venous malformations in the orbital and para-orbital region were reviewed. Puncture venogram was performed on all patients and image guided bleomycin injections using biplane digital subtraction in angiography suite. Results Average age of patients at the time of the procedure was 22 years old with the youngest being five years of age and the oldest being 50 years. Follow-ups ranged from 3 months to 18 months and the average follow-up duration was 13 months. The patients had no intraprocedural complications and reported symptomatic relief of pain as per the last follow-up. Patients have shown no symptoms or signs of recurrence of lesions with uneventful recovery so far. Conclusions Percutaneous sclerotherapy of orbital Venous Malformations with bleomycin is a safe and well-controlled procedure done in real time; it has no major systemic adverse side effects and higher efficacy than other sclerosing agents.

Objectives: Dissecting aneurysms are rare as contrasted with their saccular counterparts, yet they stay hard to treat and are related with high rates of rebleeding and morbidity. Material & methods: In this study, we have reviewed dissecting aneurysms of both anterior and posterior circulation, both ruptured and unruptured, including natural history, endovascular treatment and clinical outcome. They account for 3–7% of cases of nontraumatic subarachnoid hemorrhage. Surgical treatment carries a significant risk of neurological complications predominantly lower cranial nerve deficits because of the close relationship of the posterior circulation aneurysm with the brain stem and cranial nerves. Results: A total of 28 ruptured and unruptured dissecting aneurysms in both anterior and posterior circulation were treated endovascularly from January 2015 till October 2018. Out of 28, 23 of the aneurysms were in posterior circulation and 5 were in anterior circulation. All the cases were technically successful except in 1 case. Procedure related complications were seen in 9 patients which were transient except in one patient who died. Follow up studies showed stable and complete occlusion of aneurysms in all patients except in 1 case in which recanalization was seen. Conclusion: Dissecting aneurysms are dynamic lesions with variable and unpredictable evolution and a through treatment is warranted. Endovascular treatment by coiling and parent artery occlusion is relatively safe and effective treatment of dissecting intracranial aneurysms. Keywords: Dissecting aneurysms, Ruptured aneurysms, Endovascular, Aneurysms

Takayasu arteritis is a chronic, inflammatory, progressive and idiopathic disease that mainly effects the aorta, its branches and pulmonary artery. It causes narrowing and occlusion of major vessels which manifest as a cerebrovascular insufficiency. Intracranial aneurysms are rarely observed in these patients. We report a case of basilar tip aneurysm with Takayasu arteritis. To our knowledge only 26 cases of Takayasu disease with basilar aneurysm have been reported in the literature. Management of Takayasu disease includes immunosuppression therapy; but coil embolization of co-incidental aneurysm can be hampered by limited and tortuous access routes. Hence, management of these patients requires great care and accurate selection of suitable guiding catheter, microcatheters and microwires. Microsurgery is the treatment of choice in case of intracranial aneurysm due to limited and tortuous access routes, however, coil embolization can be done with great care and accurate selection of suitable guiding catheter, microcatheters and microwires.

Pure subdural hematoma with subarachnoid haemorrhage brought about by ruptured intracranial aneurysm is uncommon and is related to delayed analysis and treatment. We present an uncommon instance of spontaneous subdural hematoma because of intracranial aneurysmal rupture. Case description A 26-year-old female presented with sudden onset of thunderclap headache at midnight followed by an episode of generalized tonic-clonic seizure and loss of consciousness. There was no associated history of trauma. Computed tomography showed convexity subdural hematoma extending into tentorium without subarachnoid haemorrhage. The catheter angiography revealed a distal anterior cerebral artery aneurysm at the anterior internal frontal artery. Consequently, this aneurysm was embolized with squid with no residual filling. The patient was neurologically intact and was discharged on the third post-procedure day with left partial third nerve palsy. Conclusion This paper demonstrates characteristics, diagnostics, and treatment modalities of this rare condition of intracranial aneurysmal rupture associated with subdural hematoma along with the literature review.

Purpose We analyzed results of percutaneous sclerotherapy for venous malformations (VMs) in head, neck and extremities. Materials and methods Thirty-five patients with head and neck and extremities VM treated by sclerotherapy with bleomycin and sodium tetradecyl sulphate (STS) were retrospectively reviewed. A pre-treatment magnetic resonance imaging was done for all patients to diagnose the lesion. Each lesion received 1 to 11 sessions (average, 2.7; standard deviation [SD], 2.03). We evaluated percentage reduction in swelling size and a Likert scale review of subjective feelings of the patients. Results Sixteen had a complete obliteration; by sclerotherapy alone (n=13) and surgery after a 75% reduction (n=3). Ten patients had a significant reduction up to 75% and three patients by 50%. Four had a minimal decrease with reduction of 25% or less. Follow-up duration of the patients varied from a minimum of 6 months up to 3 years (average, 15.7 months; SD, 7.8 months). Of all patients, three refused further treatment and were lost to follow-up, while another two were referred to a dermatologist. Thirteen patients reported feeling excellent after the sessions. Eight patients claimed to feel slightly better compared to before the sessions started. Only three patients complained of feeling the same before and after the sessions. None of the patients still in follow-up have reported a recurrence of a lesion thus far. Conclusion Sclerotherapy using bleomycin and STS as sclerosants is a safe and effective primary treatment for VMs in the head and neck as well as in extremities.

Background Traumatic brain and spine injuries make up a significant fraction of cases presented for forensic examination. Such cases involve violent head injuries, including blunt head injuries and penetrating head injuries, and non-violent injuries as well. Our purpose is to evaluate the main clinical, radiological and medicolegal features of these cases and to determine the relationship between the variables associated with such cases. Materials & methods We retrospectively analyzed patients admitted in a 1 year period from 1st January 2019 to 1st January, 2020 at the Department of Neurosurgery at the Lahore General Hospital, Pakistan. Data contained medical and medicolegal reports. Severity of brain injury was analyzed according to GCS (Glasgow Coma Scale). Statistical analysis was done via GraphPad Prism 8.4.1.676 software. Five interesting cases are also discussed in further detail. Results A total of 61 cases were analyzed. 50 were male (82.0%) and 11 were female (18.0%), representing an age range from 2.5 years to 80 years. Among the 61 cases, 28 patients had mild brain injuries (45.9%), 13 had moderate brain injuries (21.3%) and 20 had severe brain injuries (32.8%). 4 patients had spinal injuries. The most common outcome was complete recovery in 38 patients (62.3%). Blunt head trauma was the most frequent type of trauma (50.8%), and all cases of this type of trauma were due to criminal assault. The most common mechanism of injury was direct impact. Intracranial hemorrhage was the most common type of intracranial lesion (27/86 injuries). The cause of death was severe head injury in 20 patients and exacerbation of moderate head injuries in 3 patients. The variables Gender and Medical Management have no significant association with any other variable or with each other. Other variables, such as the Severity of Injuries, Medical Outcome, Type of Incident (blunt force trauma, penetrative force trauma, etc.) and the Nature of the Case (criminal or non-criminal) were significantly associated with each other, with statistical significance being defined at p Conclusion Based on our results, the conclusion is the need to identify severe head injuries early and timely management is necessary as these injuries are the most common cause of death. In addition, mild to moderate head injuries must be cautiously managed to prevent the exacerbation of traumatic brain injury. Furthermore, case information (whether criminal or otherwise and cause of injury) can be deemed necessary for the neurosurgeon who is responsible for the management of the injuries.

Highly infectious disease epidemics such as COVID-19 put healthcare workers at higher risk of infection than regular people as they come into more potential contact with contaminated respiratory droplets and so caution is warranted in the use of personal protective equipment (PPE) to lessen risk. It is not clear what kind of PPE best offers protection and the best way to remove PPE. PPE is used by Healthcare workers in the COVID-19 virus disease situation. Its use is an integral part of the strategy to combat COVID-19 and prevent its spread. Optimal PPE use is hard and thus healthcare workers may alter the delivery of care because of improper PPE use. Preventing contamination of PPE during donning and doffing therefore becomes crucial and requires improvisation. Donning and doffing of PPE should include adherence to protocols as well as COVID- 19 specific design of PPE and further research into the risks, benefits, and best practices of PPE use. Lastly, training of users must be stressed to minimize protocol deviations and in turn guarantee the best protection to HCWs. While ranked as the lowest in infection control hierarchy due to its effectiveness as compared to other measures and high cost, PPE is nonetheless extremely important and often overlooked aspect during early outbreak stages of a pandemic where neither drugs nor vaccines are available and access to them is limited. This paper sheds light on the donning and doffing protocols that should be used as well as discusses this often-overlooked aspect of the virus control measure.

Background Direct puncture embolization with glue is an effective technique for pre-operative devascularization of craniofacial arteriovenous malformations. Venous outflow and arterial inflow of the lesion need to be limited during injection of embolic material. Manual compression is the standard procedure for flow reduction, but when an AVM has multiple channels of venous drainage, achieving successful blockage of blood is technically difficult. This study demonstrates the use of a circumferential cookie cutter ring to reduce flow, with better results compared to manual compression. Design and methods This is a retrospective study of ten patients, over a period of two years, with craniofacial arteriovenous malformations who were treated with direct percutaneous injection of glue. Pre-embolization angiography was performed to see arterial feeders and venous draining veins. Adjunctive maneuvers were used during embolization, including external compression of venous pouch with circular cookie cutter rings of different sizes varying based on lesion size. Glue cast was localized within and around the margins of circular cookie cutter ring without any distal migration. Results No neurological complications secondary to the embolization procedure were observed. The arteriovenous shunts were successfully occluded in all cases. There was partial occlusion in two cases. Total occlusion achieved in five cases when embolization was followed by surgery. Only one case required a second session to achieve total occlusion. Post embolization, there was minimal residual flow in one patient, who declined further treatment due to mitigation of symptoms. The shape of glue cast was changed in two cases after removal of cookie cutter when low concentrated glue was used. No skin necrosis was seen post embolization. Conclusions Percutaneous direct puncture embolization with glue saves time and is a safer method for superficial craniofacial AVMs with prominent venous pouch when external compression was applied with circumferential cookie cutters to reduce venous outflow.

Objectives: The characteristics of intracranial aneurysms display ethnic variations. The management strategy of unruptured aneurysms is influenced by the prevalence because the incidence of subarachnoid hemorrhage has been properly accessed. Data on this disease from Pakistan is non-existent.The objective of this retrospective study was to generate data on the local prevalence of ruptured and unruptured intracranial aneurysms in Pakistani population. Methods: All records of patients (1000) with intracranial aneurysms seen at our institution, the largest referral hospital of the country, drains whole country as well as neighboring countries on the west and north where still no dedicated NeuroIntervention facilities are present, over the period from January 2015 to January 2019, were examined for site, age, gender distribution, multiplicity and mirror aneurysms. Results: The study found the mean age of patients to be 43 years, females presented with same mean age but showed large number of patients in the age bracket of 30–39 and 50–59. Males only showed a large number of patients between 50 and 59. There were 622 females and 378 males in the study. The most common site for aneurysm was ACoA followed by MCA and ICA coming on third. 68% patients presented with ruptured aneurysms. Conclusion: This study provides valuable information on the epidemiology of intracranial aneurysms in the Pakistan population. This study finds the epidemiology of ruptured and unruptured aneurysms in Pakistan. It highlights the age and gender of patients that were presented as well as the locations and multiplicity and mirror aneurysms. Keywords: Epidemiology, Aneurysm, Population

Objectives Endovascular embolization of hyper vascular head and neck tumors is performed as a palliative measure and in order to reduce blood loss. We report the procedure and results of head and neck tumors embolized via trans-arterial route showing the safety and positive impact of our approach as well as contrasting various embolic agents and their results. Methods We collected data of all head and neck tumors embolized at our institution during a nineteen-month period from August 2016 to May 2018. Embolization procedure was conducted 3–7 days before surgery to allow for necrosis. Bilateral angiogram was performed, followed by super selective catheterization of feeding vessel. Particle size was decided according the lumen of the vessel, for smaller vessels we used smaller particles (45–150 μ) and increased particle size up to (150–250 μ) as we moved to larger vessels. Results A total of thirty-six patients who underwent the pre-operative and palliative embolization procedure were examined. All embolizations were completed in a single session. No procedure related clinical or technical complications were observed. Intra-operative blood loss was between 200 and 600 ml which is far lower as compared to surgery alone. Total devascularization was achieved in all cases by complete occlusion of supplying arterial feeders. Conclusion Pre-surgical embolization is an adjunct therapy that radically improves the surgical outcomes in patients. We found complete excision can easily be achieved using this adjunct therapy which is almost never the case when using surgery alone. Secondly, we found that in patients who could not be operated on embolization was a highly effective palliative measure that gives great symptomatic relief.

Background Few studies have examined the prevalence of intracranial aneurysms in association with other syndromes and cerebrovascular diseases. This study looks at the syndromes and diseases that are associated with intracranial aneurysms. Material and methods We discuss the fact that although there are various case studies reporting presence of intracranial aneurysms in association with other syndromes and cerebrovascular conditions, there is general lack of reviews, original articles and prospective studies on the subject and this article aims to fill that gap. We looked at more 300 cases, across the span of one year from June 2018 to May 2019, of intracranial aneurysms and found five cases with rare occurrences of aneurysms with other syndromes and other diseases. Conclusion The difference observed in the manifestation of intracranial aneurysms in such disease pathologies encourage future studies in better characterization of the pathophysiology, prevalence and ideal treatment options of neurovascular lesions in these patients who were presented with these rare combinations.

Glutamine is a potent stimulus for the release of glucagon-like peptide-1, which increases postprandial insulin and slows gastric emptying (GE). We determined the effects of glutamine on GE of, and glycaemic responses to, low- and high-nutrient drinks in eight healthy males (mean age 21.6 &plusmn, 0.7 years and BMI 22.9 &plusmn, 0.7 kg/m2). Participants were studied on four occasions on which they consumed either a low-nutrient (beef soup, 18 kcal) or high-nutrient (75 g dextrose, 255 kcal) drink, each with or without 30 g of glutamine (120 kcal), in a randomised, crossover design. GE (2D ultrasound), blood glucose and plasma insulin concentrations were measured concurrently. Glutamine slowed GE (half emptying time (T50)) of both low- (45 &plusmn, 3 min vs. 26 &plusmn, 2 min, p &lt, 0.001), and high-nutrient, (100 &plusmn, 5 min vs. 77 &plusmn, 5 min, p = 0.03) drinks, however, there was no effect on GE of the high nutrient drinks when expressed as kcal/min (3.39 &plusmn, 0.21 kcal/min vs. 3.81 &plusmn, 0.20 kcal/min, p = 0.25). There was no change in blood glucose after the low-nutrient drinks with or without glutamine, despite a slight increase in plasma insulin with glutamine (p = 0.007). The rise in blood glucose following the high-nutrient drink (p = 0.0001) was attenuated during the first 60 min by glutamine (p = 0.007). We conclude that in healthy subjects, glutamine slows GE of both low- and high-nutrient drinks comparably and attenuates the rise in blood glucose after the high-nutrient glucose drink.

Chronic expanding hematoma is a rare pathology, which has not been previously described as a complication of gunshot injury with retained bullet fragments. Because of the similar characteristics of chronic expanding hematoma to malignancy, it can present a diagnostic challenge for clinicians. Imaging and biopsy evaluation is needed to reach a conclusive diagnosis and implement appropriate treatment. In this case report, we will discuss the development, diagnosis, and management of a chronic superficial cervicothoracic mass in a patient who presented 30 years post-gunshot injury with retained bullet fragments.