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BACKGROUND A subset of patients with uncomplicated type B aortic dissection (uTBAD) has been shown to possess higher risk of experiencing late adverse outcomes. Therefore, we conducted an analysis to investigate the role of descending aorta diameters, including total descending aorta diameter and false lumen diameter, as predictor of late adverse outcomes in patients with uTBAD. METHODS A systematic search was performed through Pubmed, ClinicalKey, ScienceDirect, and Cochrane Library to identify relevant studies. Our primary outcome was the composite late adverse events following their first episode of hospitalization. All meta-analyses were performed using Review Manager version 5.4. RESULTS A total of 2,339 (male 68.8%) patients from a total of 15 cohorts were included in our analysis. During follow-up period, there were 655 (27.3%) and 149 (6.3%) cases of late adverse events and mortality, respectively. Patients with higher initial descending aorta diameter were at higher risk of developing late adverse events (RR 2.99 [2.60, 3.44]; p

Osteoarthritis (OA) is the most prevalent type of arthritis worldwide, resulting in pain and often chronic disability and a significant burden on healthcare systems globally. Non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, intra-articular corticosteroid injections are of little value in the long term, and opioids may have ominous consequences. Radiotherapy of knee OA has no added value. Physical therapy, exercises, weight loss, and lifestyle modifications may give pain relief, improve physical functioning and quality of life. However, none of them has articular cartilage regenerating potential. Due to a better understanding of osteoarthritis, innovative new treatment options have been developed. In this narrative review, we focus on emerging OA knee treatments, relieving symptoms, and regenerating damaged articular cartilage that includes intra-articular human serum albumin, conventional disease-modifying anti-rheumatic drugs (DMARDs), metformin, lipid-lowering agents (statin), nerve growth factors antagonists, bone morphogenetic protein, fibroblast growth factors, Platelet-Rich Plasma (PRP), Mesenchymal Stem Cells (MSC), exosomes, interleukin-1 blockers, gene-based therapy, and bisphosphonate.

Background: Oral Submucous Fibrosis is a potent pre-malignant condition of Oral cavity, which is prevalent in South Asian countries, due to social habit of pan, gutka, areca nut and betel quid chewing, which is mostly practiced in South-East Asia. A decreased pattern of lipid profile has been observed in literature in many precancerous conditions, this study is based on observation of lipid profile pattern among Oral submucous fibrosis patients in relation with age, gender, body mass index and duration of disease. Objective: A descriptive study to determine mean lipid profile values among oral sub-mucous fibrosis patients. Study Design: Descriptive (cross-sectional) study. Settings: Department of Oral & Maxillofacial Surgery, Abbasi Shaheed Hospital-Karachi Pakistan. Duration: 1st January 2017 till 30th June 2017, for a period of six months. Methodology: Oral Sub-mucous Fibrosis (OSMF) patients, who also met with inclusion criteria of study were selected. Lipid Profile values of TC (total cholesterol), HDL (high density lipids), LDL (low density lipids) and triglycerides were observed among OSMF patients in relation to duration of disease, their different age groups, gender and body mass index (BMI). Results: Out of 104 clinically diagnosed patients of OSMF, 34 females and 70 were males. Mean age was 38.9, most of the patients were in the age group of 20-40 years. Mean and standard deviation of TC, triglycerides, LDL and HDL was 132.19±13.29, 142.25±8.71, 101.87±17.57 and 30.43±2.56 respectively. Conclusion: Results of this study revealed that there is no significant change in pattern of lipid profile among OSMF patients in relation to their different age groups, gender and BMI, but an inverse relation does exist between lipid panel and duration of disease.

To further define the epilepsy phenotype in a cohort of children with 15q13.3 microdeletion syndrome.We retrospectively reviewed the phenotypic spectrum of all children aged18 years with epilepsy and 15q13.3 microdeletion syndrome.Thirteen children were included, 69% were female. The median age of children in the cohort was 12 years (age range: 3 years-15 years). Median age at seizure onset was 4 years. Eleven children (85%) had intellectual disability. Nine of 13 children (69%) had a history of typical absence seizures with median age of onset at 5 years (2 had absence status epilepticus). Thirty-one percent (4/13) had focal with impaired awareness non-motor onset seizures. ILAE recognized absence epilepsy syndromes were diagnosed in 6/13 (46%). The remainder were classified as having genetic generalized epilepsies with overlap clinical features, combined or focal epilepsies. Electroencephalogram in the cohort showed generalized (85%) and focal epileptiform discharges (62%) and posterior dominant rhythm slowing (33%). One child had electrical status epilepticus of sleep. Neuroimaging was performed in 5 children (38%) and revealed abnormal findings in 3. Seizures were drug resistant in a third of the cohort. Valproate resulted in seizure freedom in 5 (42%). Oxcarbazepine caused clinical worsening in one child with combined seizure types. Two children tried cannabidiol and one tried the ketogenic diet; neither was effective.The epilepsy phenotype in children with 15q13.3 microdeletion syndrome is defined by childhood onset absence seizures, and may have atypical features such as, early onset absences, persistence into adolescence, status epilepticus, intellectual disability and treatment resistance. Focal seizures and focal EEG findings may be observed and should be treated cautiously, given the possibility of combined seizure types. Valproate appeared effective, although other treatments must be explored further.

Type 2 diabetes mellitus is a multifactorial illness triggered by a complicated interplay of various genetic variants with various environmental variables. The quantity of replicated common genetic variants associated with type 2 diabetes mellitus has increased rapidly with the recent genome-wide association (GWA) research. Major health issue in the public are type 2 diabetes mellitus (T2DM) is common throughout the world. Diabetes mellitus incidence is growing and is anticipated to affect 300 million individuals by 2025. Diabetes has been suggested to alter patterns of cytokine expression as an immune-dependent illness. Insulin resistance (IR) is a disease that results in less than anticipated biological impact of a specified insulin concentration. Insulin resistance and insulin secretion decreased are both defined pathophysiology of T2DM. One of the most alarming health issues of the 21st century is the spread of diabetes around the globe. Our goal in this study was to identify the role of IL-10 polymorphism in T2DM patients. The average age of 60 median patients with type 2 diabetes mellitus (31 males and 29 females) +-SD (45.91667 +-16.08799), fasting blood sugar (FBS) is +-SD (184.25 +-57.76387), hypertension (35 positive/25 negative) and 60 non-diabetic controls (32 males and 28 females) is +- SD (47.31667 +-15.13722). The group (T2DM patients and their control) had not a substantial distinction (P=0.33) and in each group (CC, TT, CT) there was a comparison between IL-10 gene polymorphism. T2DM patients and healthy individuals are not associated with the polymorphism of the gene IL-10 (SNP rs 3021097 (C/T). Keywords: Insulin, Diabetes Mellitis Type 2, Polymorphism, Interleukin-10, Genotype frequencies.

To evaluate changes in health-related and vision-related quality of life (VRQoL) among patients with noninfectious uveitis who were treated with antimetabolites.Secondary analysis of a randomized controlled trial.Patients with noninfectious uveitis from India, the United States, Australia, Saudi Arabia, and Mexico.From 2013 through 2017, 216 participants were randomized to receive 25 mg weekly oral methotrexate or 1.5 g twice daily oral mycophenolate mofetil. Median changes in quality of life (QoL) were measured using Wilcoxon signed-rank tests, and differences between treatment groups were measured using linear mixed models, adjusting for baseline QoL score, age, gender, and site. Among Indian patients, VRQoL scores from a general scale (the National Eye Institute Visual Function Questionnaire [NEI-VFQ]) and a culturally specific scale (the Indian Visual Function Questionnaire [IND-VFQ]) were compared using Pearson correlation tests.Vision-related QoL (NEI-VFQ and IND-VFQ) and health-related QoL (HRQoL; physical component score [PCS] and mental component score [MCS] of the Medical Outcomes Study 36-Item Short Form Survey [SF-36v2]) were measured at baseline, the primary end point (6 months or treatment failure before 6 months), and the secondary end point (12 months or treatment failure between 6 and 12 months).Among 193 participants who reached the primary end point, VRQoL increased from baseline by a median of 12.0 points (interquartile range [IQR], 1.0-26.1, NEI-VFQ scale), physical HRQoL increased by a median of 3.6 points (IQR, -1.4 to 14.9, PCS SF-36v2), and mental HRQoL increased by a median of 3.0 points (IQR, -3.7 to 11.9, MCS SF-36v2). These improvements in NEI-VFQ, SF-36v2 PCS, and SF-36v2 MCS scores all were significant (P0.01). The linear mixed models showed that QoL did not differ between treatment groups for each QoL assessment (NEI-VFQ, IND-VFQ, PCS SF-36v2, and MCS SF-36v2; P0.05 for all). The NEI-VFQ and IND-VFQ scores for Indian participants were correlated highly at baseline and the primary and secondary end points (correlation coefficients, 0.87, 0.80, and 0.90, respectively).Among patients treated with methotrexate or mycophenolate mofetil for uveitis, VRQoL and HRQoL improved significantly over the course of 1 year and did not differ by treatment allocation. These findings suggest that antimetabolites could improve overall patient well-being and daily functioning.

A 37-year-old Bangladeshi woman presented with low back and several joints pain and swelling for months together; there was significant morning stiffness for more than two hours. Repeated abortions, dry eye, hair fall, photosensitivity, and oral ulcer were the additional complaints. Clinical examination unveiled asymmetrical peripheral and both sacroiliac joint tenderness, positive modified Schober’s test, and limited chest expansion. Schirmer’s test was positive. The history of rheumatoid arthritis (RA) and ankylosing spondylitis (AS) among 1st-degree relatives was also significant. Biochemical analysis revealed pancytopenia, raised erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), and mild microscopic proteinuria. The patient was seropositive for rheumatoid factor (RF), antibodies against cyclic citrullinated peptides (anti-CCP), antinuclear antibody (ANA), anti-Sm antibody, anti-Sjögren’s-syndrome-related antigen A and B (anti-SSA/SSB), antiphospholipid (aPL-IgG/IgM), and HLA B27; however, serum complement (C3 and C4) levels were normal. Basal cortisol level measured elevated. Besides, X-ray and MRI of lumbosacral spines demonstrated sacroiliitis. There was radiological cardiomegaly, echocardiography unveiled atrial regurgitation, and ascending aorta aneurysm. Based on the abovementioned information, RA, AS, and systemic lupus erythematosus (SLE) have been diagnosed. Moreover, the patient developed Sjogren’s syndrome (SS), antiphospholipid lipid syndrome (APS), Cushing syndrome, ascending aorta aneurysm, and atrial regurgitation. Her disease activity score for RA (DAS28), DAS for AS (ASDAS), SLE disease activity index (SLEDAI), and Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) scores were 3.46, 2.36, 23, and 5, respectively. The patient received hydroxychloroquine (200 mg daily), pulsed cyclophosphamide, prednisolone (20 mg in the morning), and naproxen 500 mg (twice daily). To our best knowledge, this is the first report documenting RA, AS, and SLE with secondary SS and APS.

Introduction Tobacco causes more than 8 million deaths each year. Behavioral interventions such as group therapy, which provides counselling for smoking cessation, can be delivered in group form and smokers who receive cessation counselling are more likely to quit smoking compared to no assistance. We review the evidence of group-based counselling for smoking cessation for smokers in Asian countries. Methods The review aims to determine the availability of group-based therapy for smoking cessation in Asian countries. The outcome measured was abstinence from smoking following group therapy. Electronic database searches in PubMed, OVID Medline, SCOPUS, Google Scholar, and PsycINFO, using keywords such as: 'smoking', 'cigarette', 'tobacco', 'nicotine', 'group therapy' and 'cessation' (smok*, *cigarette*, tobacco, nicotine, group therap*, cessation) were used. The results were reported following PRISMA and PROSPERO guidelines. Review Manager was used for data analysis. Results A total of 21251 records were retrieved for screening the abstracts. In all, 300 articles for review were identified and assessed for eligibility. Nine articles, including Cochrane reviews, randomized control trials, cohort, observational and cross-sectional studies, were included in the final review. There were three observational qualitative studies, two prospective cohort studies, two crosssectional studies, one non-randomized quasi-experimental study and a single cluster-randomized, controlled trial. Group therapy was found to significantly increase the abstinence rate. Group therapy provided at the workplace, smoking cessation services, availability of pharmacotherapy, and socioeconomic status, appear to be key factors determining success. Conclusions Evidence of the use of group therapy for smoking cessation in Asian countries is still lacking despite publications in the Western population showed that group therapy was effective. Further research on group-based interventions for smoking cessation in Asian countries is required and direct one-to-one comparisons between group therapy and individual therapy for smokers who want to quit smoking, are needed.

BackgroundRandomized clinical trials have failed to prove that the safety and efficacy of endovascular treatment for symptomatic intracranial atherosclerotic disease (ICAD) is better than that of medical management. A recent study using a self-expandable stent showed acceptable lower rates of periprocedural complications.ObjectiveTo study the safety and efficacy of a balloon-mounted stent (BMS) in the treatment of symptomatic ICAD.MethodsProspectively maintained databases from 15 neuroendovascular centers between 2010 and 2020 were reviewed. Patients were included if they had severe symptomatic intracranial stenosis in the target artery, medical management had failed, and they underwent intracranial stenting with BMS after 24 hours of the qualifying event. The primary outcome was the occurrence of stroke and mortality within 72 hours after the procedure. Secondary outcomes were the occurrence of stroke, transient ischemic attacks (TIAs), and mortality on long-term follow-up.ResultsA total of 232 patients were eligible for the analysis (mean age 62.8 years, 34.1% female). The intracranial stenotic lesions were located in the anterior circulation in 135 (58.2%) cases. Recurrent stroke was the qualifying event in 165 (71.1%) while recurrent TIA was identified in 67 (28.9%) cases. The median (IQR) time from the qualifying event to stenting was 5 (2–20.75) days. Strokes were reported in 13 (5.6%) patients within 72 hours of the procedure; 9 (3.9%) ischemic and 4 (1.7%) hemorrhagic, and mortality in 2 (0.9%) cases. Among 189 patients with median follow-up time 6 (3–14.5) months, 12 (6.3%) had TIA and 7 (3.7%) had strokes. Three patients (1.6%) died from causes not related to stroke.ConclusionOur study has shown that BMS may be a safe and effective treatment for medically refractory symptomatic ICAD. Additional prospective randomized clinical trials are warranted.

We recently reported that adoptive transfer of cytolytic Natural Killer cells (cNKs) from the Reduced Uterine Perfusion Pressure (RUPP) rat induces a preeclampsia (PE)-like phenotype in pregnant rats, accompanied by increased TNF-α. The purpose of this study was to investigate a role for increased TNF-α to induce oxidative stress (ROS), decrease nitric oxide (NO) bioavailability, and induce vascular dysfunction as mechanisms of hypertension (HTN) and intrauterine growth restriction (IUGR) in RUPPs. Pregnant Sprague Dawley rats underwent the RUPP or a Sham procedure on gestation day (GD) 14. On GDs 15 and 18, a subset of Sham and RUPP rats received i.p.injections of vehicle or 0.4 mg/kg of Etanercept (ETA), a soluble TNF-α receptor (n = 10/group). On GD18, Uterine Artery Resistance Index (UARI) was measured, and on GD19, mean arterial pressure (MAP), fetal and placental weights were measured, and blood and tissues were processed for analysis. TNF-α blockade normalized the elevated MAP observed RUPP. Additionally, both fetal and placental weights were decreased in RUPP compared to Sham, and were normalized in RUPP + ETA. Placental ROS was also increased in RUPP rats compared to Sham, and remained elevated in RUPP + ETA. Compared to Sham, UARI was elevated in RUPPs while plasma total nitrate was reduced, and these were normalized in ETA treated RUPPs. In conclusion, TNF-α blockade in RUPPs reduced MAP and UARI, improved fetal growth, and increased NO bioavailability. These data suggest that TNF-α regulation of NO bioavailability is a potential mechanism that contributes to PE pathophysiology and may represent a therapeutic target to improve maternal outcomes and fetal growth.

Introduction: Pulmonary hypertension (PH) is a relatively common and severe complication of SCI and an independent risk factor for mortality. Sickle cell disease is considered one of the most common diseases in the Kingdom of Saudi Arabia. When a healthy disease related to cardiovascular health is highlighted, sickle cell anemia may be the most common and related disease in high pulmonary pressure. In this study, we aimed to determine prevalence of PHTN in SCA patient, and associated risk factors with it. Methodology: This is an analytical cross-sectional study conducted in kingdom of Saudi Arabia (General population, SCA patient and CVD patient), from 29/7/2020 till 15/11/2020. The study was depending on online self-reported questionnaire that included assessing the demographic factors as gender, nationality besides, disease-related information: SCA patient , CVD patient and DM patient. Results: we received 794 responses to our questionnaire where 93.5% of them were Saudi Arabian. The prevalence of sickle cell anemia is 8.8%. Male represented 29.8% of patients while female represented 52.2% of patients. In SCA patients, the prevalence of PHTN was 31.8%. Moreover, it was found that having cardiac disease is considered a risk factor for developing PHTN where 37.7% of patients having cardiac disease had PHTN compared with 6.2% of health patients (OD: 9.16, 95% CI: 5.5479 to 15.13, P=0.000) while diabetes mellitus increase risk for developing PHTN by more than seven fold (OD: 7.6, 95% CI; 4.7175 to 12.4, P=0.000) and disorder of nervous system by 12 folds (OD: 12.7; 95% CI: 7.6658 to 21.09, P=0.000). Conclusion: we had found that the prevalence if SCA among Saudi Arabia is 8.8% with a higher prevalence in female than male. Moreover, the prevalence of PHTN in SCA patients was high about 31.8% which is much higher than its prevalence in normal individuals. Moreover, it was found that having cardiac disease is considered a risk factor for developing PHTN besides, having diabetic condition and disorder of nervous system which increased risk for developing PHTN in SCA by nine, seven and 12-fold respectively.

Objective: To determine the frequency of deranged cardiac biomarkers and associated socio-demographic factors among patients of epilepsy presenting at our hospital. Study Design: Cross-sectional study. Setting: Department of Medicine, Sheikh Khalifa Bin Zyed Al-Nyhan Hospital Rawalakot. Period: August 2019 to September 2020. Material & Methods: We evaluated 85 consecutive patients who presented at Department of Medicine, Sheikh Khalifa Bin Zyed Al-Nyhan hospital. Cardiac Biomarkers (Troponin I, CK-MB and pro-BNP) and EKG were requested in all patients. The questionnaire used for interview consisted of demographic details and disease related parameters (duration of epilepsy and number of antiepileptic drugs). Results: Out of 85 patients included in the study, 35 (41.2%) were male while 45 (58.8%) were female. Out of these 85 patients of epilepsy, 15 (17.6%) had one or more cardiac biomarker positive while 70 (82.4%) had no change in ECG or any positive cardiac biomarker. All ECG changes were non-specific. After applying the logistic regression, we found that long duration of illness and poly-pharmacy had significant association with the presence of positive cardiac biomarkers among the patients of epilepsy. Conclusion: Less than 1/5th of the patients with epilepsy had positive cardiac biomarkers or ECG changes in our study. Patients with longer duration of epilepsy or those whose epilepsy has been managed with more than one drug were found more at risk of having abnormal cardiac biomarkers in our target population.

Objective: To compare midvastus and subvastus approach regarding operative parameters(lateral retinacular release, operative time, neurovascular injury) and outcome (Knee Society Score, Straight Leg Raise) at 12 weeks in single stage bilateral total knee arthroplasty. Study Design: Randomized clinical trial study Place and Duration of Study: Institute of Orthopaedic Surgery and South City Hospital Karachi from 1st January 2016 to 31st December 2018. Methodology: Fifty two patients of both genders ofmore than 50 years with osteoarthritis grade III or IV and bony changes confirmed by AP and lateral radiographs of knee were included. Patients with previous knee surgeries including high tibial osteotomy, deformities >20°(on mechanical axis), any neuromuscular problem and BMI ≥30 were excluded. Final assessment was done at 12 weeks. Isometric quadriceps strength was assessed by holding of contraction in seconds during the lifting (10cm above the plinth) phase of SLR (patient lying supine).Knee score (preoperative and final follow-up) was performed by Knee Society Score. Results: Thirty five were females and 21 males with mean age 65.3 years (50-78 years). Mean body mass index was 27.8 Kg/m2 (26.4-29.9). In midvastus TKR, the mean operative time was 61.7 minutes (range 52-70) whereas the same was 68.3 minutes (range 58-74) in subvastus TKR with p value 0.002. Rate of lateral retinacular release (LLR) was significantly (p=0.011) different between the midvastus TKR 5 (8.9%) and subvastus TKR 11 (19.6%). Neither group had neurovascular injury or early infection of the knee. Active SLR in subvastus group was achieved in shorter time (mean 3.1 days) as compared to midvastus group (mean 4.7 days). There was no difference (p=0.173) in isometric quadriceps strength at 12 weeks between subvastus TKR (mean 18 seconds) and midvastus TKR (mean 17 seconds). Knee society pain and functional scores were comparable between the two approaches at final follow up. Conclusion: Subvastus exposure has advantage of achieving active straight leg raise earlier while midvastus has lower frequency of lateral retinacular release. No difference in hospital stay and postoperative pain scores. Both subvastus and midvastus approaches are safe and offer comparable Knee Society Score outcomes. Keywords: Midvastus, Subvastus, Total knee arthroplasty, Knee Society Score, Straight leg raise

Background and Aims Although venous thromboembolism [VTE] is a well-known complication of inflammatory bowel disease [IBD] in adults, limited data exist on the risk in children. We report the incidence of VTE among children with and without IBD. Methods We conducted a matched cohort study within a distributed network of population-based Canadian provincial health administrative databases. Children Results The 5-year incidence of VTE among 3593 children with IBD was 31.2 [95% CI 23.7–41.0] per 10 000 person-years [PY] compared to 0.8 [95% CI 0.4–1.7] per 10 000 PY among 16 289 children without IBD [unadjusted IRR 38.84, 95% CI 16.59–90.83; adjusted HR 22.91, 95% CI 11.50–45.63]. VTE was less common in Crohn’s disease than ulcerative colitis [unadjusted IRR 0.47, 95% CI 0.27–0.83; adjusted HR 0.52, 95% CI 0.29–0.94]. The findings were similar for deep vein thrombosis and pulmonary embolism when comparing children with and without IBD. Conclusions The risk of VTE is much higher in children with IBD than controls without IBD. While the absolute risk is low, we found a higher incidence rate than previously described in the pediatric literature. Conference Presentation: An abstract based on the data included in this paper was presented at Canadian Digestive Diseases Week [Montréal, Canada] in March 2020.

Summary There is limited understanding of the impact of frailty on clinical outcomes in patients with myelofibrosis (MF). In this retrospective cohort study on 439 chronic phase MF patients [mean age: 68·7 ± 12 years; median follow‐up: 3·4 years (IQR 0·4–8·6)] from 2004 till 2018, we used a 35‐variable frailty index (FI) to categorise patient’s frailty status as fit (FI

Background: Previous studies have established the fact that diabetic patients are predominantly inclined towards silent myocardial infarction (SMI). The objective of the present study is to determine the incidence of SMI in diabetes mellitus (DM) patients. Methodology: In this cross-sectional study, patient data was gathered on a predesigned proforma regarding the detailed history of dyspnea, DM and its duration, chest pain either present or not. Those patients who had normal ECG labeled negative for SMI, while those who had either ST-segment elevation or ST-segment deviation on resting ECG were positive for SMI. Study was conducted at the National Institute of Cardiovascular Diseases (NICVD) Karachi- Pakistan. Results: The mean age of the enrolled patients was 54.21±8.65 (40-70) years. Out of 210, majority were female (51.90%).Overall, 94(44.76%) patients were obese, 122(58.09%) were hypertensive, 90(42.85%) had dyslipidemia and 98(46.66%) diabetic patients were smokers. There were 93 (44.3%) DM patients who had SMI. Moreover, 109(51.90%) patients had a family history of myocardial ischemia. Conclusion: The SMI incidence among diabetic patients was found higher in local population. It is proposed that diabetic patients with demonstrated cardiovascular autonomic neuropathy must be screened for the manifestation of SMI.

BackgroundIndividuals with end-stage kidney disease (ESKD) on dialysis are vulnerable to contracting COVID-19 infection, with mortality as high as 31 % in this group. Population demographics in the UAE are dissimilar to many other countries and data on antibody responses to COVID-19 is also limited. The objective of this study was to describe the characteristics of patients who developed COVID-19, the impact of the screening strategy, and to assess the antibody response to a subset of dialysis patients.MethodsWe retrospectively examined the outcomes of COVID19 infection in all our haemodialysis patients, who were tested regularly for COVID 19, whether symptomatic or asymptomatic. In addition, IgG antibody serology was also performed to assess response to COVID-19 in a subset of patients.Results152 (13 %) of 1180 dialysis patients developed COVID-19 during the study period from 1st of March to the 1st of July 2020. Of these 81 % were male, average age of 52​ years and 95 % were on in-centre haemodialysis. Family and community contact was most likely source of infection in most patients. Fever (49 %) and cough (48 %) were the most common presenting symptoms, when present. Comorbidities in infected individuals included hypertension (93 %), diabetes (49 %), ischaemic heart disease (30 %). The majority (68 %) developed mild disease, whilst 13 % required critical care. Combinations of drugs including hydroxychloroquine, favipiravir, lopinavir, ritonavir, camostat, tocilizumab and steroids were used based on local guidelines. The median time to viral clearance defined by two negative PCR tests was 15 days [IQR 6–25]. Overall mortality in our cohort was 9.2 %, but ICU mortality was 65 %. COVID-19 IgG antibody serology was performed in a subset (n = 87) but 26 % of PCR positive patients (n = 23) did not develop a significant antibody response.ConclusionsOur study reports a lower mortality in this patient group compared with many published series. Asymptomatic PCR positivity was present in 40 %. Rapid isolation of positive patients may have contributed to the relative lack of spread of COVID-19 within our dialysis units. The lack of antibody response in a few patients is concerning.

Objective: Determine the duration and post-operative complications of surgery in patients who underwent rectus sheath sling for correction of vault prolapse. We started doing this novel technique and found it very safe with least side effects so wanted to study it. Study Design: Experimental study. Setting: Nishtar Hospital Multan Pakistan. Period: July 2016 to June 2018. Material & Methods: Patients were applied autologous sling of rectus sheath at Nishtar Hospital Multan and were followed for 2 years. Patients with diabetes mellitus and any other chronic disease were excluded. Patients who had previous surgery for vault prolapse were also excluded from the study. Data were recorded and analyzed using IBM-SPSS version 23.0, percentages are given for previous surgery duration (how long before the previous surgery was done), duration of current surgery, post-operative fever, post -operative urinary tract infection(UTI), duration of stay in the hospital after surgery, parenteral analgesia requirement. Parameters were tested using Pearson Chi Square test with type of previous surgery. Results: The total number of patients in the study were 19.The mean age of the patients was 59.7 years (SD = ±9.7) and mean weight was 59.4kg (SD = ±12.5). The duration of surgery was less than 1 hour in 84 % of patients. Same percentage had less than 36 hours requirement of post- operative parenteral analgesia and thus less than 2 days of post-operative stay in hospital. Postoperatively 31.6 % had fever, 26.3% had Urinary tract infection. On 2 years follow-up of this surgery, no patient had any recurrence of vault prolapse and 85.7% showed no coital difficulty. Conclusion: This surgical procedure is a simple, time saving method with less complications and is best suited for low resource countries like Pakistan.

Objective: To determine the frequency of perinatal outcomes (macrosomia, large for gestational age, birth asphyxia) in pregnant diabetic women with low and high plasma glucose levels between 36-40 weeks. Study Design: Cross-sectional study. Setting: Department of Obstetrics & Gynaecology, DHQ Hospital, Lodhran. Period: 2017 to 2019. Material & Methods: Total 285 diabetic women of age 25-40 years with singleton pregnancy of gestational age 36-40 weeks were selected. Patients with multiple pregnancies, GDM, renal disease and hypertension were excluded. Plasma glucose levels (fasting & 2 hour post-prandial) measured and mean values (fasting + postprandial/2) calculated. The mean values falling between 100-139 mg/dl were taken as low plasma glucose level where as ≥140 mg/dl noted as high plasma glucose level. The perinatal outcomes (macrosomia, large for gestational age, birth asphyxia) were assessed at the time of delivery. Results: Mean age was 29.44 ± 6.01 years. Mean plasma glucose levels were 109.77 ± 6.81 mg/dl. Perinatal outcome i.e. macrosomia, large for gestational age infants and birth asphyxia was found in 7.72%, 27.37% and 22.81% respectively. In this study that pregnant women with mean plasma glucose of 100-139 mg/dl showed frequency of macrosomia by 3.59%, large for gestational age 16.17% and birth asphyxia 14.35% while women with mean plasma glucose of ≥140 mg/dl showed frequency of macrosomia by 13.56%, large for gestational Age 43.22% and birth asphyxia 34.75%. Conclusion: Pregnant diabetic women with high plasma glucose levels have significantly high percentage of large for gestational age, birth asphyxia and macrosomia as compared to diabetic mothers with low plasma blood glucose levels. Consider diabetic mothers at risk and implement efficacious treatment in order to reduce the perinatal complications.

Background and Purpose: Acute ischemic stroke may occur in patients with coronavirus disease 2019 (COVID-19), but risk factors, in-hospital events, and outcomes are not well studied in large cohorts. We identified risk factors, comorbidities, and outcomes in patients with COVID-19 with or without acute ischemic stroke and compared with patients without COVID-19 and acute ischemic stroke. Methods: We analyzed the data from 54 health care facilities using the Cerner deidentified COVID-19 dataset. The dataset included patients with an emergency department or inpatient encounter with discharge diagnoses codes that could be associated to suspicion of or exposure to COVID-19 or confirmed COVID-19. Results: A total of 103 (1.3%) patients developed acute ischemic stroke among 8163 patients with COVID-19. Among all patients with COVID-19, the proportion of patients with hypertension, diabetes, hyperlipidemia, atrial fibrillation, and congestive heart failure was significantly higher among those with acute ischemic stroke. Acute ischemic stroke was associated with discharge to destination other than home or death (relative risk, 2.1 [95% CI, 1.6–2.4]; P P =0.03) after adjusting for potential confounders. Conclusions: Acute ischemic stroke was infrequent in patients with COVID-19 and usually occurs in the presence of other cardiovascular risk factors. The risk of discharge to destination other than home or death increased 2-fold with occurrence of acute ischemic stroke in patients with COVID-19.

OBJECTIVES: To report changes in practice brought about by COVID-19 and the implementation of new guidelines, and to explore factors relating to unscheduled re-presentations for patients discharged from the emergency department (ED). DESIGN: Prospective multicentre national audit over 12 weeks from 6th April 2020. SETTING: UK secondary care ENT departments. PARTICIPANTS: Adult patients with acute epistaxis. MAIN OUTCOME MEASURES: Re-presentation within 10 days for patients discharged from the ED. RESULTS: Eighty three centres from all four UK nations submitted 2631 valid cases. The majority of cases were ED referrals (89.7%, n = 2358/2631). 54.6% were discharged from the ED following ENT review (n = 1267/2322), of whom 19.5% re-presented within 10 days (n = 245/1259) and 6.8% were ultimately admitted (n = 86/1259). 46.7% of patients had a non-dissolvable pack inserted by ED prior to referral to ENT (n = 1099/2355). The discharge rates for ED patients and their subsequent re-presentation rates were as follows: non-dissolvable packs, 29.5% discharged (n = 332/1125), 18.2% re-presented (n = 60/330); dissolvable products, 71.1% discharged (n = 488/686), 21.8% re-presented (n = 106/486); cautery only, 89.2% discharged (n = 247/277), 20.0% re-presented (n = 49/245); and no intranasal intervention, 85.5% discharged (n = 200/234), 15.2% re-presented (n = 30/198). Univariable logistic regression showed that not being packed by ED, antiplatelet medications, failed cautery and recent epistaxis treatment were significant predictors of re-presentation within 10 days. CONCLUSIONS: Management of acute epistaxis was notably affected during the initial peak of the pandemic, with a shift towards reduced admissions. This national audit highlights that many patients who may previously have been admitted to hospital may be safely discharged from the ED following acute epistaxis.

Background: Pain is a common complaint of patients after surgery. Different techniques or medications including local anesthetics infiltration, non-steroidal anti-inflammatory drugs or opioids have been used for postoperative analgesia. Lidocaine is an amide local anesthetic agent that works by influencing the complex phenomenon of pain. Aim: To compare the mean pain score with intraoperative lidocaine versus control in patients undergoing laparoscopic cholecystectomy under general anesthesia. Methods: 350 patients aged 20-60 years of either sex scheduled for laparoscopic cholecystectomy were included in the study. Patients with allergy to lidocaine; patients with neuromuscular disease, endocrine or metabolic disorder and pregnant patients were excluded from study. Patients were randomly divided in two groups by using lottery method after taking informed consent. On arrival to the operating room, monitor was attached to display continuous ECG, mean arterial blood pressure, and arterial oxygen saturation. Results: In lidocaine group, the mean age of patients was 39.93±11.56years. In control group, the mean age of patients was 37.93±11.83years. In lidocaine group, there were 91 (52%) males and 84 (48%) females. In control group, there were 77 (44%) males and 98 (56%) females. In lidocaine group, the mean BMI of patients was 26.66±4.81kg/m2. In control group, the mean BMI of patients was 26.77±4.76kg/m2. In lidocaine group, the mean pain score of patients was 1.00±0.84. In control group, the mean pain score of patients was 2.39±1.10. The difference was significant (p

Introduction: Pulmonary hypertension (PH) is a relatively common and severe complication of SCI and an independent risk factor for mortality. Sickle cell disease is considered one of the most common diseases in the Kingdom of Saudi Arabia. When a healthy disease related to cardiovascular health is highlighted, sickle cell anemia may be the most common and related disease in high pulmonary pressure. In this study, we aimed in this study to determine prevalence of PHTN in SCA patient, and associated risk factors with it. Methodology: This is an analytical cross-sectional study conducted in kingdom of Saudi Arabia (General population, SCA patient and CVD patient), from 29/7/2020 till 15/11/2020. The study was depending on online self-reported questionnaire that included assessing the demographic factors as gender, nationality besides, disease-related information: SCA patient , CVD patient and DM patient. Results: we received 794 responses to our questionnaire where 93.5 % of them were Saudi Arabian. The prevalence of sickle cell anemia is 8.8 %. Male represented 29.8 % of patients while female represented 52.2 % of patients. In SCA patients, the prevalence of PHTN was 31.8 %. Moreover, it was found that having cardiac disease is considered a risk factor for developing PHTN where 37.7 % of patients having cardiac disease had PHTN compared with 6.2 % of health patients (OD: 9.16, 95 % CI: 5.5479 to 15.13, P=0.000) while diabetes mellitus increase risk for developing PHTN by more than seven fold (OD: 7.6, 95 % CI 4.7175 to 12.4, P=0.000) and disorder of nervous system by 12 folds (OD: 12.7 95 % CI: 7.6658 to 21.09, P=0.000). Conclusion: we had found that the prevalence if SCA among Saudi Arabia is 8.8 % with a higher prevalence in female than male. Moreover, the prevalence of PHTN in SCA patients was high about 31.8 % which is much higher than its prevalence in normal individuals. Moreover, it was found that having cardiac disease is considered a risk factor for developing PHTN besides, having diabetic condition and disorder of nervous system which increased risk for developing PHTN in SCA by nine, seven and 12-fold respectively.

Teledentistry, with the use of an intra-oral camera (IOC), can overcome numerous challenges. The visual nature of oral diseases and dental treatments is ideal for practising teledentistry, especially during COVID-19. Images or videos of the oral cavity to evaluate caries, plaque, calculus, tooth wear, fluorosis, and stains can be captured by a trained and calibrated examiner with IOC. The IOC was shown to be a reliable tool to identify common oral diseases. Certain limitations like low illumination can be overcome by using IOC as they are equipped with a light-emitting diode which can offer superior visualisation and inbuilt magnification of the oral cavity. However, there is a possibility of overestimation of the disease. IOC can also be used for patient education through the “show and tell” concept in real-time like showing the areas where the disease may be a concern like plaque, calculus, and early signs of tooth decay. However, it may be challenging to diagnose diseases remotely in real-time and simultaneously seek specialist consultations and recommendations relating to the treatment protocols for numerous conditions. This manuscript reviews the challenges concerning communication, ethics, teamwork, consumables, data storage, and analysis which could be encountered with the use of IOC in this era of teledentistry and COVID-19.

Background The role of tracheostomy in coronavirus disease 2019 (COVID-19) is unclear, with several consensus guidelines advising against this practice. We developed both a dedicated airway team and coordinated education programme to facilitate ward management of tracheostomised COVID-19 patients. Here, we report outcomes in the first 100 COVID-19 patients who underwent tracheostomy at our institution. Methods This was a prospective observational cohort study of patients confirmed to have COVID-19 who required mechanical ventilation at Queen Elizabeth Hospital, Birmingham, UK. The primary outcome measure was 30-day survival, accounting for severe organ dysfunction (Acute Physiology and Chronic Health [APACHE]-II score>17). Secondary outcomes included duration of ventilation, ICU stay, and healthcare workers directly involved in tracheostomy care acquiring COVID-19. Results A total of 164 patients with COVID-19 were admitted to the ICU between March 9, 2020 and April 21, 2020. A total of 100 patients (mean [standard deviation] age: 55 [12] yr; 29% female) underwent tracheostomy; 64 (age: 57 [14] yr; 25% female) did not undergo tracheostomy. Despite similar APACHE-II scores, 30-day survival was higher in 85/100 (85%) patients after tracheostomy, compared with 27/64 (42%) non-tracheostomised patients {relative risk: 3.9 (95% confidence intervals [CI]: 2.3–6.4); P

The novel coronavirus-2019 (COVID-19) pandemic primarily affects the respiratory system. Elderly individuals with comorbidity are severely affected. Survivors weaned from mechanical ventilation are at a higher risk of developing post-intensive care syndrome (PICS). This scoping review, based on 40 recent publications, highlights pulmonary rehabilitation (PR) in COVID-19. There is a paucity of high-quality research on this topic. However, rehabilitation societies including the Turkish Society of Physical Medicine and Rehabilitation have issued PR recommendations in COVID-19 pneumonia with productive cough can benefit from diaphragmatic breathing, pursed-lip breathing, and resistance-breathing training. Besides, those in mechanical ventilation and post-PICS COVID-19 cases, oxygen therapy, early mobilization, airway clearance, aerobic exercise, gradual-graded limb muscle resistance exercise, nutritional and psychological interventions should be consideration. During PR, careful evaluation of vital signs and exercise-induced symptoms is also required. When in-person PR is not possible, telerehabilitation should be explored. However, the long-term effects of PR in COVID-19 need further evaluation.

Objective To ascertain the safety and efficacy of percutaneous nephrolithomy in patients with previous open renal surgery. Study design Descriptive study. Place and duration of study The Kidney Centre Postgraduate Training Institute, Karachi from January to December 2018. Methodology Patients with previous open renal surgery underwent percutaneous nephrolithomy during study period (Group A). Equal number of percutaneous nephrolithomy patients without previous open surgery taken as controls (Group B). Safety was defined in terms of 'blood loss' as change in hemoglobin (HB) level and 'blood transfusion,' while efficacy was defined in terms of 'stone clearance' and were compared between both the groups. Results There were a total of 87 patients. Both groups had comparative gender ratio [p = 0.858]. Mean age [p = 0.132] and BMI [p = 0.879] of patients in both groups was not significantly different from each other. Both groups showed no statistically significant difference in terms of values of stone size [p = 0.186], stone laterality [p = 0.437] stone location [p = 0.949], preoperative Hb [p = 0.095], postoperative Hb [p = 0.423] and change in Hb (indicating blood loss, p = 0.398). Puncture levels were significantly different among both groups (supracostal puncture in 18 and 36 patients; infracostal puncture in 63 and 51 patients in groups A and B, respectively, p = 0.006), while operative time [p = 0.787], calyx punctured [p = 0.051], double puncture [p = 0.787], nephrostomy tube [p = 0.288] were statistically not different among groups. Similar number of patients demonstrated residual stones [p = 0.773], along with residual stone sizes [Group A (0.5; 0.5) and Group B (0.65; 0.38)] [p = 0.445]. Intra- and postoperative complications like blood transfusion [p = 0.700] and fever [p = 1.000] along with hospital stay [p = 0.614] were comparable among groups. Conclusion Percutaneous nephrolithomy is safe and effective in previously operated kidneys despite the possibility of calyceal anatomy distortion and scarring. Key Words: Percutaneous nephrolithotomy, Open surgery, Kidney calculi.

Objectives: To compare the outcome in terms of carrying angle with medial versus lateral approach in the treatment of these fractures among children. Study Design: Randomized Clinical trial. Setting: Department of Orthopaedic Surgery Civil Hospital Bahawalpur and Nishtar Hospital Multan. Period: From June 2018 to September 2019. Material & Methods: A total of 154 children of both genders, aged 2-14 years having supracondylar humeral fracture of type II and III, with duration of fracture within 7 days, were enrolled. Patients were divided in two groups (77 in each group), group A and group B. Group A was managed by open reduction internal fixation (ORIF) with cross K-wire through medial approach and group B underwent lateral approach. Results: Out of 154 cases, 102 (66.2%) were boys and 52 (33.8%) were girls. Overall, mean age was noted to be 7.98 ± 2.23 years. Obesity was present in 16 (10.4%) cases. Mean duration of fracture was noted to be 4.21 ± 1.34 days while 106 (68.8%) had duration less than 5 days. There were 119 (77.3%) cases with history of fall and 35 (22.7%) had history of road traffic accidents (RTA). Sixty one (39.6 %) cases were classified as Gartland type II fractures while remaining 93 (60.4 %) were type III fractures. Excellent outcome with carrying angle 0–5o in group A was noted to be 67 (87 %) while that of group B was 54 (70.1%) (p = 0.011). Conclusion: Medial approach for the treatment of pediatric SHF was noted to be superior in terms of postoperative carrying angle having satisfactory outcome in comparison with the lateral approach.

Background Spinal arachnoid webs are a rare anatomic entity manifesting as neuropathic back pain, compressive myelopathy, radiculopathy and hydrocephalus. Typical treatments include hemi or full laminectomy with durotomy and microsurgical resection which can result in secondary scarring, and recurrent blockage of cerebrospinal fluid flow perpetuating the cycle. Case Description A 66-year-old woman presented with progressively worsening gait and memory. Magnetic resonance imaging (MRI) demonstrated an arachnoid web in the high thoracic region, causing cerebrospinal fluid flow obstruction and hydrocephalus. A standard lumbar drainage catheter was introduced percutaneously into the lumbar thecal sac, and advanced in a cephalad direction, across the arachnoid web, to the high thoracic region. The patient underwent continuous cerebrospinal fluid drainage through this catheter for a total of three days, displaying measurable clinical improvement that persisted at the three months follow up visit. Phase-contrast MRI demonstrated interval reconstitution of dorsal synchronous cerebrospinal fluid flow at the 2nd thoracic vertebral level, both on day three, as well as at the three months control imaging study. Conclusion This minimally invasive approach seems useful in achieving restoration of spinal fluid flow at the thoracic region when the underlying blockage results from an arachnoid web and leads to quantifiable clinical improvement.

Objective: To determine the frequency of anemia and its causative risk factors in patients attending the gynecology outpatient department of Nishtar Medical University and Hospital. Study Design: Cross sectional study. Setting: Gynecology Outpatient Department attendees of Nishtar Medical University and Hospital. Period: 1st September to 31st December 2019. Material & Methods: Total 361 females between 19-49 years of age were enrolled and included those patients who consented to be tested for blood hemoglobin estimation. Their brief history was taken after proper consent according to predesigned proforma to rule out the risk factors. Patients with chronic kidney disease, chronic lung diseases and liver diseases were excluded. Blood test was done by obtaining the blood sample by finger prick method. Hemoglobin analysis was performed by portable Hemocueanalyser. Frequency of anemia, severity of anemia and their stratification was performed against the risk factors like age, educational status, socioeconomic status, status of pregnancy, parity and contraception were obtained to rule the causative factors. Anemia was defined per standard criteria as hemoglobin less than 11gm/dl. Results: Majority of patients 65% were between 19-35 years of age and 34% were 36-49years of age. Frequency of pregnant patients and non-pregnant patients was 63.4% and 36.6%. Frequency of anemia was 56.8%, mean hemoglobin 10.48±1.18 with mild, moderate and severe anemia were 36.8%, 17.2% and 2.8%. Majority of females 82.9%, never went to school and had primary education, 71.70% belong to very poor and poor socioeconomic status, 79.02% were multipara and 81.95% never and infrequently practiced the contraceptive methods. Conclusion: Frequency of anemia is very high in females presenting to tertiary care hospital being more common in younger age group. Frequent pregnancies, poor socioeconomic status and low level of educational attainment were the major determinants of anemia in females.

Schizophrenia is a disorder of mental debility characterized by abnormal social behavior in which person is unable to recognize reality. The sign and symptoms are variable and heterogeneous. Due to the diverse symptoms and variable treatment response, it is challenging to treat. Recent advancements in genomic, epidemiology and neurosciences can provide the appropriate medicines and treatments for minimizing symptoms and consequences of schizophrenia. This literature review was highlights the etiology, pathophysiology, neurotransmitter system, novel treatment and management of schizophrenia.The mainstay treatment of schizophrenic patients included antipsychotic drug with psychotherapy, social rehabilitation and job training

Background Since year 2000 the diagnostic criterion for fast track (FT) referrals for patients with suspected colorectal cancer (CRC) is used in the UK. Iron deficiency anaemia (IDA) is one of the diagnostic criteria. There is a strong evidence in the literature which suggests that Iron deficiency (ID) alone has a strong relationship with CRC. Non-anaemic Iron deficiency (NAID) and all other types of anaemia are investigated outside the scope of FT clinics. We postulated that patients with ID regardless of degree of anaemia have an increased risk of CRC. By confirming this hypothesis, we can broaden the scope of the diagnostic criterion for referral that can help to increase diagnostic yield of FT CRC services. Methods A retrospective observational cohort study was conducted from a dedicated data for FT clinics from 2016-2018. Association between CRC and different forms of anaemia, Iron deficiency alone and bowel symptoms was determined. Results Patients with iron deficiency (low MCV, MCH and ferritin) regardless of degree of anaemia were found more likely to have CRC. Factors like age, gender, family history and bowel symptoms (except abdominal mass) showed a very weak association with CRC in patients with ID. Conclusions ID without anaemia has a strong relationship with CRC and should be investigated with the same priority as IDA is investigated.

Background and purpose Due to higher rates of 1-month stroke and death with Wingspan intracranial stent placement observed in SAMMPRIS, the Food and Drug Administration (FDA) announced a more limited indication for Wingspan stent. Methods We compared the results of intracranial stent placement with best medical treatment in patients recruited in SAMMPRIS who met the new "on label" criteria with those who were categorized as "off label." The primary endpoint was any stroke or death occurring within 30 days of enrollment, or an ischemic stroke in the territory of the symptomatic intracranial artery from day 31 after study entry to completion of follow-up. Results A total of 31 (7%) among 451 recruited patients met the "on label" criteria. The relative risk of primary endpoint was lower in "on label" patients treated with stent placement compared with best medical treatment (relative risk .61, 95% confidence interval .2-1.7) but higher in "off label" patients (relative risk 1.81, 95% confidence interval 1.2-2.6). Primary endpoint was seen in 20% and 23.4% of patients treated with stent placement in "on label" and "off label" patients, respectively. Primary endpoint was seen in 25% and 14.2% of patients treated with best medical treatment in "on label" and "off label" patients, respectively. Conclusion The new FDA "on label" criteria may identify a small group of people, who may benefit from intracranial stent placement due to higher risk of primary endpoint in those treated with best medical treatment.

Background: In clinical practice, Total Parenteral Nutrition (TPN) is standard of care for patients of gastrointestinal tract disorders. TPN therapy is associated with a number of adverse effects like hepatobiliary dysfunction, dyslipidemia, and oxidative stress. Different vegetable oils are used by every individual daily in routine life. Objective: This study assessed the magnitude of TPN-associated adverse effects in animals fed on different vegetable oils. Methods: Healthy adult rabbits of local strain were divided into 5 groups (n= 8). The study was divided into 2 phases. Phase I: oil feeding; the first set of rabbits served as control and fed on a normal rabbit diet. Four sets of rabbits were treated for 16 weeks with 1 ml/kg/day of single time heated olive (STH-OO), canola (STH-CO), sunflower oils (STH-SO) or a mixture of these oils (STH-MVO). In phase II: TPN was given to each group, including the control group, for 2 weeks. Before and after TPN therapy, body and liver weights were measured. Plasma lipid profile [triglycerides, total cholesterol, high-density lipoproteins, low-density lipoproteins, very-low-density lipoproteins], liver function marker [total-protein, albumin, total and direct bilirubin, serum glutamic pyruvic transaminase, serum glutamic-oxaloacetic transaminase, gamma-glutamyl transferase, and alkaline phosphatase], oxidative stress and tissue damage parameters [malondialdehyde, C-reactive protein, lactate dehydrogenase, and creatine phosphokinase] of all the groups weremeasured at the end of TPN therapy. Results: Significantly (p Conclusion: This study recommends that high monounsaturated fatty acids containing oils like olive and canola oils, are found to have strong resistance against the hepatic injury and lipid peroxidation. The study also recommends taking the history of oil use by an individual before the initiation of therapeutic agents with known side effects of hepatic toxicity and dyslipidemia.

Objectives: To determine the frequency of uterine rupture after one successful vaginal birth after caesarean section. Study Design: Cross Sectional Study. Setting: Department of Obstetrics and Gynecology of Nishtar Hospital Multan. Period: From12-May-2017 to 11-May-2018. Material & Methods: Total number of 135 patients of 16-45 years with singleton pregnancies were admitted for 2nd Vagina Birth after cesarean Section at gestational age ≥ 28 weeks of gestation. Data in shape of parity, gestational age and BMI was taken. These patients were assessed for frequency of uterine rupture after one successful vaginal birth after caesarean section. Data was analyzed with statistical analysis program (SPSS version 21). Frequency and percentage was calculated for qualitative variables like parity and uterine rupture. Mean ± SD was calculated for quantitative variables like age, BMI and gestational age. Results: Mean age of patients was 29.88+5.34 years. Mean body mass index (BMI) of study patients was 25.17+4.88 kg/m2. Mean gestational age at the time of delivery was 39.01+2.54 weeks. Uterine rupture after vaginal birth occurred in 2 (1.48%) patients. There was no association of gestational age, parity and gestational age with the frequency of uterine rupture. Conclusion: Women with prior successful VBAC are at low risk of maternal and neonatal complications during subsequent trail of VBAC with lower risk of uterine rupture and perinatal complications.

Trans-oral robotic surgery (TORS) was approved by the FDA in 2009 and over the past decade head and neck surgeons have adopted the technology for the benefit of their patients. Whilst the surgical methods have evolved, there has been little consideration about the pathological assessment of the specimens and a lack of understanding around the oncological principles that underpin minimally invasive surgical techniques in the head and neck region. This article will highlight the issues encountered during the reporting of TORS specimens. The challenges include identifying anatomical boundaries, block selection, assessment of resection margins, the use of intra-operative frozen sections, the assessment of tongue base mucosectomies for patients with head and neck cancer of unknown primary, and TORS for recurrent disease. The article will conclude with emerging innovations, including i-Knife, narrow band imaging and the potential of step serial sections to identify sub-clinical HPV-related oropharyngeal squamous cell carcinomas.

Background and purpose Drug-eluting balloons (DEBs) have been proposed as an option for the treatment of in-stent restenosis (ISR) following carotid artery stent placement. We report our experience and review of literature to provide additional data. Methods For literature review, PubMed search was conducted to identify studies published between 2005 and 2019, reporting data on management of carotid ISR with DEBs. Two cases with carotid ISR, which were successfully treated with DEB at our facility, were also included in the final compilation of results RESULTS: A total of seven studies demonstrating the use of the DEBs for treatment of carotid ISR were identified. They encompassed 31 patients, 11 (35.5%) of whom presented with symptomatic ISR, with the remaining 20 patients (64.5%) asymptomatic. DEB angioplasty followed by stent placement was performed in 3 patients, whereas DEB alone was utilized in 28 patients. Periprocedural complications included asymptomatic dissection from DEB inflation in 1 patient and transient neurological deficits in another patient. Follow-up period was variable and ranged from 1 month to 5 years. Three patients were noted to develop recurrent asymptomatic stenosis, whereas 1 patient developed an episode of symptomatic restenosis post procedural on follow-up. In our two cases, both patients were noted to have protracted period of hypotension postprocedure without any new or recurrent neurological symptoms. Conclusion The use of DEBs is a promising development and a viable alternative for management of severe and recurrent carotid ISR.

Advancement in smartphone technology has brought about a steady rise in the global mobile phone usage. Smartphone addiction has been widely studied among adolescent and adult population, and little is known regarding its impact on patients who are diagnosed with major depressive disorder. This study examined the prevalence of smartphone addiction among depressed patients and the association between smartphone addiction and the severity of depression. A cross-sectional study was conducted on 140 patients who were diagnosed with major depressive disorder in the psychiatry department of University Malaya Medical Centre, Kuala Lumpur, Malaysia. Smartphone addiction was assessed with the smartphone addiction scale (SAS). The severity of depression was assessed using the clinician-rated Montgomery-Asberg Depression Rating Scale (MADRS). The prevalence of smartphone addiction was 58.6% (n = 82). This study found that (a) participants who spent more time on their smartphones were found to be at higher risk for smartphone addiction “overuse” subscale (p

Background: Epiretinal membranes are avascular, fibrocellular membranes which develop on the inner most layer of the retina. These membranes can be idiopathic or secondary to the silicone oil injection after pars plana vitrectomy in patients with rhegmatogenous retinal detachment. When symptomatic, such membranes can cause decreased vision, visual distortion and sometimes diplopia. The purpose of this study was to compare the idiopathic epiretinal membranes versus silicone oil filled eyes epiretinal membranes in terms of their diagnostic and surgical features. Material and methods: The study was conducted at the Department of Ophthalmology, Services Hospital Lahore where 13 eyes with idiopathic epiretinal membranes (ERMs) and 13 eyes with silicone oil filled eyes epiretinal membranes (SOERMs) were evaluated from August 2017 to April 2019. The main diagnostic outcome was the preoperative Optical Coherence Tomographic (OCT) findings and main surgical outcome was peroperative time required for removal of epiretinal membranes. Results: Mean central retinal thickness of patients with SOERMs on OCT was 530.30µm, which was recorded one day before surgery. It was greater as compared to the central retinal thickness in patients with idiopathic ERMs which was 391.92 µm. The mean time required for the removal of SOERMs was 466.38 seconds. It was longer as compared to the time required to remove idiopathic ERMs which was 385.69 seconds. Conclusion: The SOERMs are relatively difficult to remove due to increased thickness and more adherent nature as compared to idiopathic ERMs which were single layer and relatively easy to remove.

Background: Cesarean section (CS) has become a frequent practice in the recent years while this increase has been seen in developing as well as developed countries. The aim of current study was to determine the frequency of lower segment cesarean section (LSCS) along with indications of LSCS in multiparous women with previous normal deliveries. Methods: This was a cross sectional study, done at the Department of Gynaecology & Obstetrics, Nishtar Hospital, Multan, from 20th July 2018 to 20th January 2019. A total of 222 pregnant women with live singleton pregnancy at term with gestational age between 37 to 41weeks and multipara with no previous LSCS were included in the study. The decision to undertake LSCS if indicated was made in every case after complete assessment. Data was collected for frequency of LSCS and its indications in shape of fetal distress, antepartum hemorrhage and malpresentation. Results: Mean age was 32.720±1.96 years, mean height 1.551±0.11 meters and mean BMI was 27.855±3.14 Kg/m2. Most women were 31-35 years (90.5%) of age and 2-4 parity (89.2%). Primary caesearen section was seen in 43 patients (19.4%). Indications for primary caesarean section were malpresentation 27.9%, fetal distress 41.9% and antepartum hemorrhage 30.2%. Conclusion: The frequency of LSCS in multiparous women with previous normal deliveries was noted to be 19.4%. Fetal distress turned out to be commonest indication for primary caesarean followed by antepartum hemorrhage and malpresentation.

SummaryThis systematic review and meta-analysis evaluated the clinical outcomes of COVID-19 disease in the ethnic minorities of the UK in comparison to the White ethnic group. Medline, Embase, Cochrane, MedRxiv, and Prospero were searched for articles published between May 2020 to April 2021. PROSPERO ID: CRD42021248117. Fourteen studies (767177 participants) were included in the review. In the adjusted analysis, the pooled Odds Ratio (OR) for the mortality outcome was higher for the Black (1.83, 95% CI: 1.21-2.76), Asian (1.16, 95% CI: 0.85-1.57), and Mixed and Other (MO) groups (1.12, 95% CI: 1.04-1.20) compared to the White group. The adjusted and unadjusted ORs of intensive care admission were more than double for all ethnicities (OR Black 2.32, 95% CI: 1.73-3.11, Asian 2.34, 95% CI: 1.89-2.90, MO group 2.26, 95% CI: 1.64-3.11). In the adjusted analysis of mechanical ventilation need the ORs were similarly significantly raised (Black group 2.03, 95% CI: 1.80-2.29, Asian group 1.84, 95% CI: 1.20-2.80, MO 2.09, 95% CI: 1.35-3.22). This review confirmed that all ethnic groups in the UK suffered from increased disease severity and mortality with regards to COVID-19. This has urgent public health and policy implications to reduce the health disparities.

Supplemental Digital Content is available in the text., Background: To determine the exposure risk for coronavirus 2019 (COVID-19) during neurology practice. Neurological manifestations of COVID-19 are increasingly being recognized mandating high level of participation by neurologists. Methods: An American Academy of Neurology survey inquiring about various aspects of COVID-19 exposure was sent to a random sample of 800 active American Academy of Neurology members who work in the United States. Use of second tier protection (1 or more including sterile gloves, surgical gown, protective goggles/face shield but not N95 mask) or maximum protection (N95 mask in addition to second tier protection) during clinical encounter with suspected/confirmed COVID-19 patients was inquired. Results: Of the 81 respondents, 38% indicated exposure to COVID-19 at work, 1% at home, and none outside of work/home. Of the 28 respondents who did experience at least 1 symptom of COVID-19, tiredness (32%) or diarrhea (8%) were reported. One respondent tested positive out of 12 (17%) of respondents who were tested for COVID-19 within the last 2 weeks. One respondent received health care at an emergency department/urgent care or was hospitalized related to COVID-19. When seeing patients, maximum protection personal protective equipment was used either always or most of the times by 16% of respondents in outpatient setting and 56% of respondents in inpatient settings, respectively. Conclusions: The data could enhance our knowledge of the factors that contribute to COVID-19 exposure during neurology practice in United States, and inform education and advocacy efforts to neurology providers, trainees, and patients in this unprecedented pandemic.

ObjectiveTo determine whether whole genome sequencing can be used to define the molecular basis of suspected mitochondrial disease.DesignCohort study.SettingNational Health Service, England, including secondary and tertiary care.Participants345 patients with suspected mitochondrial disorders recruited to the 100 000 Genomes Project in England between 2015 and 2018.InterventionShort read whole genome sequencing was performed. Nuclear variants were prioritised on the basis of gene panels chosen according to phenotypes, ClinVar pathogenic/likely pathogenic variants, and the top 10 prioritised variants from Exomiser. Mitochondrial DNA variants were called using an in-house pipeline and compared with a list of pathogenic variants. Copy number variants and short tandem repeats for 13 neurological disorders were also analysed. American College of Medical Genetics guidelines were followed for classification of variants.Main outcome measureDefinite or probable genetic diagnosis.ResultsA definite or probable genetic diagnosis was identified in 98/319 (31%) families, with an additional 6 (2%) possible diagnoses. Fourteen of the diagnoses (4% of the 319 families) explained only part of the clinical features. A total of 95 different genes were implicated. Of 104 families given a diagnosis, 39 (38%) had a mitochondrial diagnosis and 65 (63%) had a non-mitochondrial diagnosis.ConclusionWhole genome sequencing is a useful diagnostic test in patients with suspected mitochondrial disorders, yielding a diagnosis in a further 31% after exclusion of common causes. Most diagnoses were non-mitochondrial disorders and included developmental disorders with intellectual disability, epileptic encephalopathies, other metabolic disorders, cardiomyopathies, and leukodystrophies. These would have been missed if a targeted approach was taken, and some have specific treatments.

Introduction The most efficacious treatment for obstructive sleep apnoea (OSA) is Continuous Positive Airway Pressure (CPAP). CPAP’s benefit is curtailed however, because many patients do not adhere to treatment, estimated from trials at 17-85%.1 Since the Covid-19 pandemic, US and French CPAP adherence rates have been reported to have changed.2 We sought to determine CPAP adherence rates of NHS patients pre-and post-pandemic. Methods 5 sleep centres were recruited. To detect an 18% difference [US Philips Respironics survey% adherent 36% (2019) vs 18% (2020)], 80% power, p 0.05%, 2-tailed test, n =92. Average use at Night 3, 7, 14, 1 and 3 months and clinical data collected from 100 patients starting CPAP for first time in i) April 2019 and ii) September 2020, using Resmed Airview and clinical records. Adherence defined as CPAP use ≥4 hrs/night for ≥70% of nights, or at Night 3 median use ≥4 hrs. Results See table 1 for patient characteristics. In 2019, in all centres,% of adherent patients fell from Night 3 to 3 months, with 3-month adherence rates between 29%-50% (p=0.025, figure 1). Similar was seen in 2020 in Conquest (CH) and Musgrove Park hospitals (MSH); in CH, higher% seen up to 1 month compared to 2019. In 2020, at Manchester (MH), Derriford (DH) and Guys and St Thomas’s hospitals (GSTT) the% of adherent patients did not fall between Night 3 and 3 months; MH and DH maintained similar% to 2019, in GSTT, there was a smaller% starting at Night 3 compared to 2019 (30% vs 55%, p Discussion 3 month adherence rates are low -at best 50%. Rates have changed at some centres since the pandemic, with change varying depending on the treatment pathway modifications implemented. References Weaver TE & Sawyer AM. Adherence to continuous positive airway pressure treatment for obstructive sleep apnoea: implications for future interventions. The Indian Journal of Medical Research 2010;131:245-258. Attias D, Pepin JL & Pathak A. Impact of COVID-19 lockdown on adherence to continuous positive airway pressure by obstructive sleep apnoea patients. The European Respiratory Journal 2020;56: doi:10.1183/13993003.01607-2020

Introduction Button battery ingestion (BBI) carries a significant risk of morbidity and mortality. We conducted a regional analysis following an NHS England national patient safety alert to evaluate the knowledge base in the emergency management of BBI amongst emergency practitioners. Methods A ten-point questionnaire was distributed electronically and in hardcopy formats to emergency departments across 15 hospitals within the West Midlands, United Kingdom. The questionnaire assessed participants' knowledge of emergency management of BBI. The effect of clinician grade and previous otorhinolaryngology experience on knowledge scores was evaluated. Results A total of 176 responses were received from 11 hospitals. A small proportion (18%) were aware of a local department protocol. The majority of participants (70%) routinely screened for a button battery in their history taking. Our findings highlighted a lack of awareness of the timeframe for mucosal injury, potential complications, radiological signs, and the necessity for immediate retrieval. The median knowledge score was 18.8% (IQR=12.5-31.3%). Both registrars and consultants scored the highest (median 25%). Previous otorhinolaryngology experience was associated with a higher median score (P=0.002). Conclusion Our multi-center regional emergency medicine analysis demonstrated knowledge deficiency in the initial assessment and management of BBI. A high index of suspicion for button battery ingestion is needed. In view of the time-critical nature of button battery impaction in the esophagus, a "golden hour" concept should be integrated into acute management pathways with the early involvement of otorhinolaryngologists.

Kidney function is affected in COVID-19, while kidney itself modulates the immune response. Here, hypothesize if COVID-19 urine biomarkers level can assess immune activation vs. clinical trajectory. Considering the kidney’s critical role in modulating the immune response, we sought to analyze activation markers in patients with pre-existing dysfunction. This was a cross-sectional study of 68 patients. Blood and urine were collected within 48 h of hospital admission (H1), followed by 96 h (H2), seven days (H3), and up to 25 days (H4) from admission. Serum level ferritin, procalcitonin, IL-6 assessed immune activation overall, while the response to viral burden was gauged with serum level of spike protein and αspike IgM and IgG. 39 markers correlated highly between urine and blood. Age and race, and to a lesser extend gender, differentiated several urine markers. The burden of pre-existing conditions correlated with urine DCN, CAIX and PTN, but inversely with IL-5 or MCP-4. Higher urinary IL-12 and lower CAIX, CCL23, IL-15, IL-18, MCP-1, MCP-3, MUC-16, PD-L1, TNFRS12A, and TNFRS21 signified non-survivors. APACHE correlated with urine TNFRS12, PGF, CAIX, DCN, CXCL6, and EGF. Admission urine LAG-3 and IL-2 predicted death. Pre-existing kidney disease had a unique pattern of urinary inflammatory markers. Acute kidney injury was associated, and to a certain degree, predicted by IFNg, TWEAK, MMP7, and MUC-16. Remdesavir had a more profound effect on the urine biomarkers than steroids. Urinary biomarkers correlated with clinical status, kidney function, markers of the immune system activation, and probability of demise in COVID-19.

Objectives Acute ischemic stroke patients with severe acute respiratory syndrome coronavirus maybe candidates for acute revascularization treatments (intravenous thrombolysis and/or mechanical thrombectomy). Materials and Methods We analyzed the data from 62 healthcare facilities to determine the odds of receiving acute revascularization treatments in severe acute respiratory syndrome coronavirus infected patients and determined the odds of composite of death and non-routine discharge with severe acute respiratory syndrome coronavirus infected and non-infected patients undergoing acute revascularization treatments after adjusting for potential confounders. Results Acute ischemic stroke patients with severe acute respiratory syndrome coronavirus infection were significantly less likely to receive acute revascularization treatments (odds ratio 0.6, 95% confidence interval 0.5–0.8, p = 0.0001). Among ischemic stroke patients who received acute revascularization treatments, severe acute respiratory syndrome coronavirus infection was associated with increased odds of death or non-routine discharge (odds ratio 3.0, 95% confidence interval 1.8–5.1). The higher odds death or non-routine discharge (odds ratio 2.1, 95% confidence interval 1.9–2.3) with severe acute respiratory syndrome coronavirus infection were observed in all ischemic stroke patients without any modifying effect of acute revascularization treatments (interaction term for death (p = 0.9) or death or non-routine discharge (p = 0.2). Conclusions Patients with acute ischemic stroke with severe acute respiratory syndrome coronavirus infection were significantly less likely to receive acute revascularization treatments. Severe acute respiratory syndrome coronavirus infection was associated with a significantly higher rate of death or non-routine discharge among acute ischemic stroke patients receiving revascularization treatments.