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BACKGROUND A large number of the elderly in Indonesia are affected by an increasing number of disabilities, with reduced mobility being one of the causes. Locomotive syndrome may cause decreased mobility, and its progression can impair the activities of daily living. Early screening is essential to halt its progression. The loco-check, a screening tool for locomotive syndrome, is available in English. A cross-cultural adaptation of this tool for an Indonesian version is important to maintain the validity of the questionnaire for its implementation in Indonesia. The aim of this study was to obtain a valid Indonesian version of the loco-check questionnaire that has been adapted as per Indonesian language and cultural conventions (through a cross-cultural adaptation process). METHODS The subjects in the study were community-dwelling geriatrics over 65 years of age who were recruited using consecutive non-probability judgment sampling according to the inclusion criteria. This study, conducted from February to October 2019, was divided into two stages consisting of: (1) language and cultural adaptation; (2) validity and reliability testing. The seven items on the loco-check were translated using forward-backward translation. The final questionnaire was generated through an expert panel discussion. The validity and reliability were evaluated using concurrent validity and Cronbach's alpha using SPSS Version 23.0. RESULTS In the first stage, the first and second trials showed a strong correlation between the English and Indonesian versions of the questionnaire with r = 0.997 (p

Recurrent laryngeal nerve (RLN) injury is one of the main complications of total thyroidectomy. If the injury is bilateral, total airway obstruction, aphonia and hoarseness of voice could be precipitated. Hence, it is wise for the operating surgeon to be guided by neural monitoring during thyroidectomy. We present a valuable experience handling a middle-aged man with a huge papillary thyroid carcinoma . He needed an urgent thyroidectomy due to obstructive symptoms. We highlight our intraoperative dexterity in handling his surgery in the context of continuous monitoring of RLN using electromyography.

Objective: To determine the frequency of place of delivery and person detecting the anomaly among newborn babies presenting with delayed diagnosis of anorectal malformation (ARM). Methods: This is a Descriptive Cross-Sectional Study, conducted at Department of Paediatric Surgery, National Institute of Child Health (NICH) Karachi, from February 19, 2019 to August 18, 2019. All patients with ARM who were diagnosed beyond two hours of life (Delayed diagnosis) were included in the study. Chi square test was applied for comparison of categorical variables. Results: Total 110 patients were enrolled in this study. Nineteen (17.3%) patients were delivered at home, while 91 (82.7%) were delivered at the hospital. The first person detecting the anomaly was grandmother (n=25) or a non-medical person in 58 patients (52.7%), 52 were diagnosed by a medical personal either primarily in 31 cases (28.2%) or secondarily by a neonatologist in 21 cases (19.1%). Conclusion: It is concluded that Non-medical person detected ARM mainly despite the babies being delivered mostly at the hospital, indicating the need for meticulous neonatal examination. doi: https://doi.org/10.12669/pjms.38.1.4156 How to cite this:Perveen S, Ali S, Jabbar A, Fatima B. Place & Person involved in delivery: Factors leading to delay in diagnosis of Anorectal Malformation in Newborns. Pak J Med Sci. 2022;38(1):297-301. doi: https://doi.org/10.12669/pjms.38.1.4156 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: Rheumatoid Arthritis (RA) is a chronic inflammatory disorder that impact daily life activities. The impact on work productivity is critical because of persistent work disability. Aim: To evaluate work productivity in RA patients compared to healthy controls, and to assess the impact of socio-demographic characteristics on work productivity. Methods: This was a case-control study conducted at the Rheumatology Unit of Baghdad Teaching Hospital, Medical City during the period from August 2020 to the end of March 2021. Seventy-two patients with RA were selected and compared with 72 healthy subjects as a control group. All patients were diagnosed according to ACR/EULAR 2010 RA classification criteria. The socio-demographic and clinical features, lifestyle practices, and disease activity of the patients and controls were all recorded during interviews. A standardized Arabic version of the Workplace Activity Limitation Scale (WALS) and the Job Limitations Questionnaire were used to assess the impact of RA on work productivity (WLQ-25). Results: The vast majority of patients were females (58.1%). Positive rheumatoid factor was reported in 94.4% of the patients. The patients showed a significantly lower WALS total score and higher WLQ-25 total score median (IQR) compared with controls. Conclusion: Active RA impairs the work productivity which was influenced by CDAI score and negatively associated with the use of DMARDs.

Purpose: determine any relationship between tanner staging of the patients and transfusion program, iron overload and chelation therapy and study tanner staging of β- thalassemic patients attending Thalassemic Center in Ibn Al-Atheer Teaching Pediatric Hospital. Patients and Methods: A descriptive-analytic study (case series study) was done on β- thalassemic patients attending Thalassemia Center in Ibn Al- Atheer Teaching Hospital in Mosul, during the period from the 1st of January to the 30th of June 2019.Sixty patients with β- thalassemia, 45 of them are β- thalassemia major cases and 15 are β- thalassemia intermedia cases. The patients of the major type were sub-classified into 3 groups according to their ages: Group 1, Patients from the age of ≥ 13 years; Group 2, Patients from the age of 14 years to 16 years and Group 3, Patients from the age of more than 17 years. Results: current study showed male (77.78, 66.67) % more than female (22.22; 33.33) % in both types of thalassemia (Major and Intermedia) respectively.so the most of the patients in this study live in urban areas (58.33%) and (41.67%) in rural areas, mean age at diagnosis of thalassemia major was 7.16 months, Delayed tanner staging was found in 64.44% of patients with thalassemia major, while in thalassemia intermedia only 33.33% were considered to be on a delayed stage. as well as 4(80%) of Tanner Stage (II) for pateints in age group (≥ 13) years compare to 20% for stage (III), so 50% for both stage (II and III) respectively in age group (14-16) years. Conclusion: Two-third of the patients with thalassemia major had delayed puberty (64.44%), while one- third of the patients with thalassemia intermedia had delayed pubertal development (33.33%).

Gallbladder cancer (GBC) is an uncommon but very aggressive malignancy with poor prognosis. Concerns for oncological inferiority related to the technical difficulties in performing laparoscopic portal lymphadenectomy discourage many surgeons to undertake this operation minimally invasively. With wide application of robotic technology to solve limitations of conventional laparoscopy, we describe our initial outcomes of robotic central hepatectomy and portal lymphadenectomy for gallbladder carcinoma in 15 consecutive patients. Data were presented as median (mean ± SD). Patients were 70 (73 ± 10.9) years old with BMI of 26 (26 ± 3.6) kg/m2. Tumor size was 3(4 ± 1.9) cm. Operative duration was 222 (237 ± 85.7) minutes and estimated blood loss was 200 (222 ± 135.4) mL. There were no intraoperative complications and complete resection (R0) was obtained in nearly all patients. Postoperative complications were seen in two patients (bile leak (n = 1) and respiratory failure (n = 1)). Length of stay was 3 (4 ± 4.0) days without 30-day mortality. Robotic approach is safe and effective for the treatment of GBC.

Background Guillain Barre syndrome (GBS) is most common cause of acute flaccid paralysis, affect peripheral nerves with distinctive features clinical, pathological and prognosis. Patient and methods this study is prospective of 60 patients admitted at al-kadymia teaching hospital from first January 2004 to end April 2009. Age includes 1 to ≤11 years. Diagnosis was by clinical examination and confirmed by CSF tests and nerve conduction velocity study. Results It was found that 32 patients were male and 28 were female. Cranial nerves involved in 30% of patients. Sensory symptoms found in 16%. CSF changes was seen in 85.5% patients. Antecedent events were found in 27 patients out of 60, 14 had history of upper respiratory tract infection 45%, 7 had gastroenteritis 11%, 6 patients had history of fever 3 weeks earlier 10% and 15 patients had complicated by respiratory failure managed by mechanical ventilators, During this study 4 patients had been died. Conclusions: Current study conclude about 45% of patients had history antecedent events in as upper respiratory tract infection , gastroenteritis and fever, so cerebrospinal fluid CSF cell in the majority of cases within normal range and mostly lymphocytes, Cranial nerves were affected in most patients without serious sequels so Steroid was not given to most of patients in our study without any significant effect on the course of disease , Hospitalization was range from 2 week to 4 week, Recovery was range from 4 to 12 week and Death rate was 6% .

Objectives: Study was designed to find out the Correlation of serum uric acid with renal function parameters in Preeclampsia. Study Design: Cross Sectional study. Setting: Sir Ganga Ram Hospital Lahore. Period: July 2016 to July 2017. Material & Methods: Level of serum uric acid, serum creatinine and blood urea of 40 Preeclamptic women and 30 gestation-matched normotensive controls were estimated. Their Demographic and clinical characteristics were noted. The blood sample was analyzed for biochemical parameters, blood urea, serum uric acid, serum creatinine and urinary protein. Result: Mean age and gestational age of women was 25 weeks with BMI 29 Kg/m2. Level of serum uric acid and blood urea and serum creatinine were increased, but significant difference only observed with serum uric acid and blood urea with marked proteinuria. An inverse relationship of serum uric acid with urinary protein was observed. A direct relationship, of serum uric acid with serum creatinine was observed. Conclusion: it is concluded that estimation of parameters of renal function of preeclamptic women are important along with hyperuicaemia.

Pyogenic granuloma is a type of inflammatory hyperplasia of the oral mucosa and skin that occurs commonly. Histopathologically, it mimics an angiomatous lesion instead of granulomatous disease. These lesions generally appear as a sessile papule or solitary nodule and may have a smooth or lobulated surface clinically. These granulomas present in a variety of sizes, ranging from a few millimeters to several centimeters. About 75% of the pyogenic granulomas of the oral cavity are associated with the gingiva. In this case report a 31 years old female presented in the department of oral and maxillofacial surgery with the complaint of abnormal growth of gingiva in maxillary anterior region. The patient was diagnosed with the pyogenic granuloma (pregnancy tumor), which had developed in the second trimester of her pregnancy. Surgical excision was done to remove the lesion.

There is a scarcity of data summarizing the clinical picture, laboratory, and imaging findings and outcome in children with malignancy and coronavirus disease 2019 (COVID-19) infection. This study characterizes a detailed comparison of pediatric oncology patients with and without COVID infection. A retrospective study was conducted at The Indus Hospital, Karachi, from March 2020 to June 2020. Clinical presentation, laboratory and imaging findings, disease severity, and outcome were compared between cohorts. The mean age of children with and without COVID was 8.0±4.9 and 7.4±4.1 years, respectively. Hematologic malignancy comprised the largest number of patients, followed by solid tumors. Lymphocytosis and low neutrophil-lymphocyte ratio was observed in the COVID positive group. Cardiac dysfunction (1.4% vs. 0%), acute respiratory distress syndrome (8% vs. 0%) and lower peripheral capillary oxygen saturation/fraction of inspired oxygen ratio (473 vs. 486) found to be associated with severe disease in COVID positive group (P

Background and aims: A high-fat diet increases triglyceride (TG) accumulations in hepatocytes and results in non-alcoholic fatty liver diseases (NAFLDs). In this regard, this study investigated the effect of high-intensity interval training (HIIT), along with a high-fat diet on the serum levels of aminotransferases in male Wistar rats. Methods: Forty male Wistar rats were randomly assigned to the standard diet, high-fat diet, exercise + standard diet, and exercise + high-fat diet groups (each containing 10 animals). HIIT program consisted of 6-12 repetitions of 2-minute highs-intensity exercise (85-90% of the maximum speed) interspersed with 1-minute low-intensity exercise (45-50% peak speed) with the frequency of 5 sessions a week over 12 weeks. High-fat diet groups received a diet regimen including 58% fat, 25% protein, and 17% carbohydrate, ad libitum. The blood samples were taken from the left ventricle 48 hours following the last intervention to assess TG, alanine aminotransferase (ALT), and aspartate amino-transferase (AST) concentrations. Data were analyzed using one-way ANOVA and Tukey’s post-hoc tests. Results: The findings showed the mean of ALT, AST, and TG in the high-fat diet group was significantly greater compared to the standard diet group (P=0.001). Furthermore, the mean of ALT, AST, and TG in the exercise + high-fat diet group was significantly lower in comparison with the high-fat diet group (P=0.01, P=0.017, and P=0.012, respectively). Conclusion: Although HIIT ameliorated high-fat diet-induced elevations in the serum levels of TG, ALT, and AST, they did not reach the baseline levels. Thus, it may indicate that a diet as the underlying cause of NAFLDs is more important than any other interventions such as exercise.

Purpose: To understand the impact of vernal keratoconjunctivitis (VKC), a chronic allergic inflammation of the ocular surface that primarily affects children and young adults, on daily life. Methods: This qualitative study used an interpretative phenomenological analysis approach. Paired interviews with patients and parents were conducted in the participants' homes. Interviews continued until thematic saturation (no new information arising) was obtained. Nine patients and their families were interviewed. The patients were between 5 and 13 years old with disease severity ranging from mild to severe. Results: Several consistent themes emerged from the study, including the significant impact of VKC on schooling and family life. Families of children with VKC experience delays in receiving an accurate diagnosis and a lack of information and emotional support, which led the parents to report living in a constant state of tension about whether they were doing the right thing for their child. Although many children with VKC also have other atopic conditions, there is no cohesive approach to clinical care. Conclusions: VKC poses a significant burden on the lives of patients and their families. Greater awareness among clinicians is essential for early diagnosis and treatment and to prevent potential sight-threatening complications. The chronic nature of VKC necessitates a holistic approach to patient care to address the multiple clinical and emotional needs of the children and their families. [ J Pediatr Ophthalmol Strabismus . 2021;58(5):298–303.]

Objective: The purpose of this study was to find out the association of peripheral neuropathy in hepatitis C infection with and without cryoglobulineamia. Study Design: Cross sectional study Place and Duration: Conducted in Liver Transplant Unit, Gambat Institute of Medical Sciences, Gambat Khairpur Mirs, Sindh for the duration of six months from November 2020 to April 2021. Methods: Total 50 patients who had hepatitis C infection and peripheral neuropathy were included in this study. Patients were aged between 18- 60 years. Detailed demographics of patients including age, sex and body mass index were recorded after taking informed written consent. When symptoms and evidence of peripheral sensory or motor involvement were evident, clinical neuropathy was diagnosed. Sural nerve biopsy was done on patients and the biopsy specimen was evaluated morphologically and morphometrically. Multiple neuropathy, cranial neuropathy, and polyneuropathy are all terms used to describe peripheral nerve involvement. Our research focused on the motor conduction of the median, ulnar, and common peroneal nerves, measuring MCV, CMAP amplitude, and distal latency (DL) in both patients with and without cryoglobulinaemia for each nerve. The SPSS 20.0 version was used to analyze the data. Results: Mean age of the patients was 46.23±9.87 years with mean BMI 29.16±11.27 kg/m2. There were 30 (60%) females and 20 (40%) were males. We found that 35 (70%) patients had CG involvement with peripheral neuropathy and 15 (30%) cases were without CG. Prevalence of polyneuropathy was higher 19 (54.3%) in CG patients as compared to non CG 2 (13.3%). Mononeuropathy or multiple neuropathy was higher in HCV CG patients 13 (37.1%) as compared to HCV non CG patients 4 (26.7%). 25 patients underwent nerve biopsy (20 CG patients and 5 non CG). Prevalence of epineurial vasculitis and fascicular loss of axons was higher in non CG patients while demyelination + axonal degeneration were prevalent in CG patients. MCV of the deep peroneal nerve in patients with CG+ was low as compared to CG. Even though no statistically significant differences were detected, the other neurophysiological measures pointed to a more extensive and severe involvement of peripheral nerve in CG+ patients. Conclusion: We concluded in this study that the association of peripheral neuropathy in HCV patients with cryoglobulinaemia was greater as compared to non-CG HCV patients. It appears that both CG+ and CG patients suffer from peripheral nerve injury via a vasculitic mechanism, as evidenced by clinical and morphological observations. Serum CG levels indicate a more severe and broad neuropathic involvement, however research suggests that cryoglobulins are not the only element in the vasculitic process. Keywords: Cryoglobulinemia, Peripheral Neuropathy, HCV

Background: In recent years, lung cancer is a common cancer across the globe. For the early prediction of lung cancer, medical practitioners and researchers require an efficient predictive model, which will reduce the number of deaths. This paper proposes a lung cancer prediction model by using the Random Forest Classifier, which aims at analyzing symptoms (gender, age, air pollution, weight loss, etc.). Objective: This work addresses the problem of classification of lung cancer data using the Random Forest Algorithm. Random Forest is the most accurate learning algorithm and many researchers in the healthcare domain use it. Method: This paper deals with the prediction of lung cancer by using Random Forest Classifier. Results: Proposed method (Random Forest Classifier) applied on two lung cancer datasets, achieved an accuracy of 100% for the lung cancer dataset-1 and 96.31 on dataset-2. In the prediction of lung cancer, the random forest has shown improved accuracy compared with other methods. Conclusion: This predictive model will help health professionals in predicting lung cancer at an early stage.

To determine the rate and types of musculoskeletal injuries among Taekwondo players from Taekwondo clubs in Malaysia. A total of 490 Taekwondo players from various clubs in Malaysia were involved in a cross-sectional study using a self-response questionnaire adopted from different studies and validated before the commencement of the study. The players were recruited from various clubs in different states of Malaysia. The number of players suffered from injuries was 300 as compared to 190 with no injuries. Males players suffered from musculoskeletal injures more than females (p = 0.019). Also, males complained of multiple injuries more than females (p = 0.019). The rate of the injuries among black belt holders was higher as compared to the colour belt (p < 0.001) and black belt holders more liable for multiple injuries (p

Diabetic patients have a high morbidity and mortality related directly or indirectly to their hyperglycemia. The increase in prevalence of diabetes combined with the aforementioned fact puts an increasing burden on the healthcare system and its budget. Strategies to estimate global and local diabetes complications might offer insights to better allocate budget and resources in the future. Method: This is a cross sectional study performed in a teaching hospital from December 2020- to January 2021. Hospitalized patients in medical and critical care units are collected to estimate the incidence of diabetes related morbidity. Two hundred and twenty patients were admitted in this period, two thirds of the admissions were classified as diabetes related. Conclusion: Diabetes carries a higher burden in our cohort compared to global rates and strategies to minimize their complications is urgent and necessary.

الملخص: أهداف البحث: ينبغي البدء باستعمال مانع بيتا مع المرضى الذين يعانون من فشل القلب الحاد المستقر. وينبغي إجراء معايرة بعد فترة أسبوعين من استعمال مانع بيتا. ولا تزال فوائد معايرة مانع بيتا الدقيقة غير واضحة. تهدف هذه الدراسة إلى التحقيق في نتائج المعايرة لمانع بيتا الدقيقة لدى مرضى فشل القلب الحاد المستقر مع انخفاض كسر طرد البطين الأيسر. طرق البحث: في هذه الدراسة الأترابية الاستعادية، قمنا بتحليل البيانات السريرية من سجل قصور القلب. تم تقسيم مرضى فشل القلب الحاد الذين يعانون من انخفاض كسر طرد البطين الأيسر>٤٠٪ إلى مجموعتين، مجموعة معايرة مانع بيتا الدقيقة ومجموعة موجهة حسب المبادئ التوجيهية. تم تعريف النتائج الأولية على أنها مجموعة من ارتفاع تفاقم قصور القلب، وعدم انتظام ضربات القلب البطينية، والوفيات أثناء دخول المستشفى. وقد اعتبرنا النتائج الثانوية مكونات للنتائج الأولية وكذلك النتائج خلال المتابعة التي تستغرق ٩٠ يوما بعد الخروج من المستشفى، بما في ذلك إعادة التنويم بقصور القلب والوفيات. النتائج: لم تكن النتائج الأولية بين المجموعتين مختلفة بشكل كبير (١٢.٣٪ مقابل ٢٤.٤٪؛ المخاطر النسبية ٠.٥١). ومع ذلك، فإن معايرة مانع بيتا الدقيقة خفضت عدم انتظام ضربات القلب البطينية (٥.٧٪ مقابل ١٧.٨٪؛ ٠.٣٢). ومعدل إعادة التنويم بقصور القلب (٢.٦٪ مقابل ٧.٥٪؛ ٠.٣٥) ومعدل الوفيات (٤.٣٪ مقابل ٥٪؛ ٠.٨٧)، ولم يتم العثور على اختلاف بشكل ملحوظ في الوفيات بين المجموعتين. الاستنتاجات: بالمقارنة مع معايرة مانع بيتا حسب توجيهات المبادئ التوجيهية، كانت معايرة مانع بيتا الدقيقة أكثر أمانا في مرضى فشل القلب الحاد المستقر وانخفاض كسر طرد البطين الأيسر الذين تم تثبيت حالتهم سابقا. بالإضافة إلى ذلك، فإن معايرة مانع بيتا الدقيقة قللت بشكل فاعل من أحداث عدم انتظام ضربات القلب البطينية. Abstract: Objectives: A beta-blocker should be initiated in patients with stable acute heart failure (AHF). Beta-blocker titration should be conducted after a two-week interval. The benefits of aggressive beta-blocker titration are still unclear. This study aimed to investigate the aggressive beta-blocker titration outcomes in stabilized AHF patients with low left ventricular ejection fraction (LVEF). Methods: In this retrospective cohort study, we analysed clinical data from the heart failure (HF) registry. AHF Patients with LVEF

Baek et al.1 investigated the duration of COVID-19 virus shedding in infected patients and demonstrated that even in patients demonstrating prolonged viral clearance, the virus was no longer viable after 15 days post onset of symptoms. Our study aimed to measure whether nitric oxide nasal spray (NONS) further accelerates this reduction in SARS-CoV-2 RNA load versus a control arm with saline spray. Our study recruited 80 participants who were divided into a NONS treatment arm or a placebo arm to test the efficacy of NONS as a treatment for mild COVID-19 infection.

Objectives: The study was designed to find out the association of PCOS with insulin resistance and GLUT4. Study Design: Cross Sectional study. Setting: Outdoor Department of Sir Ganga Ram Hospital Lahore. Period: March 2016 to December 2016. Material & Methods: 37 PCOS women visited Outdoor Department of Sir Ganga Ram Hospital Lahore. Their age range was 25- 36 years. 20 ages matched medical staff of the Sir Ganga Ram Hospital, Lahore with no history of any disease were selected as control. Rotterdam’s criteria were used to confirm PCOS. Levels of circulating insulin, GLUT 4 and fasting glucose were estimated. Results: Mean age of PCOS patients and of controls was 30.55 and 29.00 years respectively. Values of BMI were insignificantly raised in PCOS in comparison to controls. Levels of circulating GLUT-4, fasting glucose, insulin and resistance of insulin were increased significantly in women with PCOS in comparison to the controls. Decreased ratio of glucose to insulin was seen in PCOS women in comparison to their controls. Conclusion: A good association of PCOS was observed with insulin mediated release of glucose transporter GLUT 4 and insulin resistance.

Aim: To compare the mean decrease in hemoglobin levels in fixation of intertrochanteric fractures with or without use of Tranexamic acid. Methods: This study was conducted at Orthopedics Unit II, Mayo Hospital Lahore, Pakistan. Total 78 patients were included in the study. Duration of study was from 15-07-2017 till 15-01-2018.Study was approved by hospital ethical committee. A written informed consent was taken. Diagnosis was made clinically and with help of radiology. Patients were randomly divided into two groups. Patients in intervention Tranexamic acid (TXA) group received 15 mg/kg of Tranexamic acid at the time of induction of anesthesia and repeated after three hours, while those in the control group received placebo which is normal saline, intravenously. Results: There were 16(41%) males and 23(59%) females in group-A. There were 15(38.5%) males and 24(61.5%) females in group-B. Mean age in group A (control) with standard deviation was 44.2051±9.64141. Mean age in group B (TXA) was 45.9744±9.03061. p value 0.0046. Mean BMI in group A was 25.65±5.136. Mean BMI in group B was 24.307±2.153. p value 0.233. In group A 13(33.3%) patients had hypertension and 26(66.67%) did not have hypertension in group-A. In group B 16 (46.2%) patients had hypertension and 21 (53.8%) did not have hypertension in group-B. Mean fall in Hb in Group A was 9.47±1.054. Mean fall in Hb in group B was 9.547±0.9402. p value 0.001. Statistically significant difference was present in Group B (TXA) in term of mean fall in Hb ( p value 0.001). Conclusion: We in our study concluded that the patients in TXA group who were given tranexamic acid 1g intravenously before start of surgery had a lesser fall in mean Hb for the operative treatment of per trochanteric fractures with dynamic hip screw. Hence injecting tranexamic acid intravenously can effectively reduce the blood loss during DHS surgery for the intertrochanteric fractures. Keywords: Interochanteric fracture, tanexamic acid, blood loss

Venlafaxine is a serotonin-norepinephrine reuptake inhibitor used to treat depression. Previous studies demonstrated its anti-nociceptive and anti-inflammatory activities through the suppression of pro-inflammatory cytokines. Present research aimed to explore its anti-arthritic potential. Different in-vitro assays including egg albumin, bovine serum albumin denaturation and human red blood cell (RBC) membrane stabilization assays along with in-vivo models of formaldehyde and complete Freund’s adjuvant-induced arthritis were used to study its anti-arthritic effect. Venlafaxine inhibited egg albumin and bovine serum albumin denaturation and preserve the integrity of red blood cells membrane in concentration-dependent manner. In formaldehyde-induced arthritis venlafaxine significantly (p

The current coronavirus disease (COVID-19) pandemic is showing no signs of abatement and result in significant morbidity and mortality in the infected patients. Many therapeutic agents ranging widely between antivirals and anti-inflammatory drugs have been used to mitigate the disease burden. In the deluge of the drugs being used for COVID-19 infection, glucocorticoids (GCs) stand out by reducing mortality amongst in-hospital severe-to-critically ill patients. Health-care practitioners have seen this as a glimmer of hope and started using these drugs more frequently than ever in clinical practice. The fear of mortality in the short term has overridden the concern of adverse long-term consequences with steroid use. The ease of availability, low cost, and apparent clinical improvement in the short term have led to the unscrupulous use of the steroids even in mild COVID-19 patients including self-medication with steroids. The use of GCs has led to the increasing incidence of hyperglycemia and consequent acute complications of diabetic ketoacidosis and mucormycosis in COVID-19 patients. There is an urgent need to dissipate information about optimum management of hyperglycemia during steroid use. In view of this, the Endocrine Society of India has formulated this position statement about the diagnosis and management of hyperglycemia due to the use of GCs in patients with COVID-19 infection.

Traditionally, Vitamin D has been associated primarily with bone health, while further investigations revealed that a sufficient amount is important for many organ functions. Data of 314 individuals were obtained from Erbil governorate public and private hospitals from patients admitted to there for testing their level of Vitamin D and other tests according to their doctor’s prescription. The variable related to their lifestyle, metabolic syndrome, and hematology evaluations were obtained. The body mass index , number of sleeping hours, number of hours spent with electronic devices, serum lipid level anemia-related tests were measured. The results showed that serum 25(OH) Vitamin D levels in studied individuals were related to hyperlipidemia serum cholesterol measures. The level of Vitamin B12 and Iron status were lower in the Vitamin D deficiency (VDD) individuals. Mean platelet volume was higher in vitamin-deficient patients which induces the risk of cardiovascular (CV) diseases. This finding suggests the relation between VDD and metabolic syndrome, CV, and anemia-related measurement.

Background: The increasing trend in multisystem inflammatory syndrome in children (MIS-C) during Covid-19 pandemic is alarming. Understanding the clinical course and outcome will give the clinical and public health implications of this syndrome. Objectives: This study was conducted to find out the clinical presentation, course of the disease and outcome of the children and adolescents of MIS-C. Methods: This observational study was conducted in the department of Pediatric Nephrology, Dhaka Shishu (Children) Hospital, Dhaka, Bangladesh, from August 2020 to October 2020. Total 12 children of MIS-C diagnosed according to WHO diagnostic criteria of MIS-C were included after taking written informed consent from the parents. Mean, median and standard deviation were calculated for the continuous variables. Results: The age ranged from 17 days to 13 years, 56% were male, 17% were positive for SARS-CoV-2 by RT-PCR and 4(33%) had history of the COVID-19 exposure. Organsystem involvement included bilateral pneumonia in 92%, myocarditis in 78%, swollen hands and feet in 67%, mucocutaneous involvement in 50%, diarrhea in 50%, musculoskeletal involvement in 50%, acute kidney injury (AKI) in 33% patients and acute pancreatitis in 25% patients. The median duration of hospitalization was 11 days and ICU stay was 5 days. Mean duration of fever was 8.66 days. Kawasaki’s diseaselike features were documented in 50% patients and 4 of them had elevated level of procalcitonin and troponin I. Markedly elevated C reactive protein (CRP), Ferritin and D dimer in all patients were present. All patients with cardiac involvement had left ventricular dysfunction and ejection fraction was as low as 38.5%. Coronary-artery dilatation was documented in 33%. About 67% received intensive care with oxygen support by low flow nasal cannula or face mask, 33% received vasoactive support and systemic glucocorticoid, 50% received intravenous immunoglobulin (IVIG) plus methyl prednisolone. Antiplatelet and anticoagulant therapy was given in 75% and 33% patients respectively. Out of 12 patients 2 died, the contributing cause of death included complications like hypotension, shock, myocarditis, coagulopathy and AKI. Conclusion: MIS-C led to serious and life-threatening complications especially when there are cardiac involvement, hypotension and acute kidney injury. DS (Child) H J 2020; 36(2): 87-94

The effect of myeloid leukemia, especially cute myeloid leukemia (AML), has been widely noticed on the parameters of liver and kidney functions and the levels of certain hormones. This study aimed to evaluate a number of biochemical parameters of liver and kidney functions and hormones in Iraqi subjects with newly diagnosed acute myeloid leukemia. Eighty newly diagnosed AML adult patients (40 males and 40 females) and forty healthy individuals (20 males and 20 females) with an age range of 16-75 years were involved in this study during their attendance at the Hematology Department of Baghdad Teaching Hospital/ Medical city in Baghdad province from March 2019 to February 2020. Blood samples were collected from all subjects for the determination of serum levels of the parameters of liver function parameters., kidney function , lactate dehydrogenase (LDH), and Erythropoietin (EPO). The results showed that the serum levels of liver function parameters (alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkaline phosphatase (ALP) had highly significant increases (p< 0.01) in AML patients (85.87±2.49 , 53.93±1.76, 150.87±7.04 U/L, respectively) as compared to the control (30.58 ±2.04, 22.89 ±0.97, 75.51 ±2.12 U/L, respectively ). Also, the level of kidney function parameters (blood urea, creatinine and uric acid) showed highly significant increases (p< 0.01) in AML patients (58.82 ±1.49, 1.831 ±0.05, 8.34 ±0.15 mg/dl, respectively) as compared to the control (31.10 ±1.03, 0.850 ±0.02, 4.81 ±0.14 mg/dl, respectively). In addition, the level of LDH showed a highly significant increase (p< 0.01) in the patients with AML (657.72 ±80.76 U/L) as compared to the control (166.05 ±6.15 U/L). Moreover, the level of EPO showed a highly significant increase (p

Chronic lymphocytic leukemia (CLL) in pediatric age is rare in the literature. It is a common disease of older adults, characterized by clonal proliferation and progressive accumulation of monoclonal B-cell lymphocytes. The diagnosis is established by immunophenotyping and prognosis is defined by staging system (Rai and Binet), as well as by several biological and genetic markers. We report a case of CLL diagnosed in an adolescent girl presented at 16 years of age. The case is being reported to improve awareness regarding this rare entity in children. Case Presentation: A 16 year old female presented with fever, weight loss and cervical lymphadenopathy. After baseline workup, lymph node biopsy, bone marrow biopsy along with immunohistochemistry and flowcytometry on peripheral blood was performed to establish the diagnosis. The clinico-pathologic features including extensive immunophenotyping were consistent with CLL. Discussion: Management guidelines for older adults are very well established but no standardized protocol exists for pediatric age group. We offered her Fludarabine and Cyclophosphamide as first line regimen and she responded well and achieved remission after four cycles. Unfortunately disease relapsed within two years. At this time, determination of optimum therapeutic protocol was a unique challenge as hematopoietic stem cell transplant (HSCT) was not available at our institute. Conclusion: CLL is an extremely rare malignancy in childhood and adolescence. Therefore age specific treatment protocols are not established. Reporting this case will help in eliciting the high index of suspicion among pathologists and oncologists for this exceptionally unusual and life threatening disease so that delays can be avoided.

Background The European Atherosclerosis Society Familial Hypercholesterolaemia Studies Collaboration (FHSC) global registry provides a platform for the global surveillance of familial hypercholesterolaemia through harmonisation and pooling of multinational data. In this study, we aimed to characterise the adult population with heterozygous familial hypercholesterolaemia and described how it is detected and managed globally. Methods Using FHSC global registry data, we did a cross-sectional assessment of adults (aged 18 years or older) with a clinical or genetic diagnosis of probable or definite heterozygous familial hypercholesterolaemia at the time they were entered into the registries. Data were assessed overall and by WHO regions, sex, and index versus non-index cases. Findings Of the 61 612 individuals in the registry, 42 167 adults (21 999 [53.6%] women) from 56 countries were included in the study. Of these, 31 798 (75.4%) were diagnosed with the Dutch Lipid Clinic Network criteria, and 35 490 (84.2%) were from the WHO region of Europe. Median age of participants at entry in the registry was 46.2 years (IQR 34.3-58.0); median age at diagnosis of familial hypercholesterolaemia was 44.4 years (32.5-56.5), with 40.2% of participants younger than 40 years when diagnosed. Prevalence of cardiovascular risk factors increased progressively with age and varied by WHO region. Prevalence of coronary disease was 17.4% (2.1% for stroke and 5.2% for peripheral artery disease), increasing with concentrations of untreated LDL cholesterol, and was about two times lower in women than in men. Among patients receiving lipid-lowering medications, 16 803 (81.1%) were receiving statins and 3691 (21.2%) were on combination therapy, with greater use of more potent lipid-lowering medication in men than in women. Median LDL cholesterol was 5.43 mmol/L (IQR 4.32-6.72) among patients not taking lipid-lowering medications and 4.23 mmol/L (3.20-5.66) among those taking them. Among patients taking lipid-lowering medications, 2.7% had LDL cholesterol lower than 1.8 mmol/L; the use of combination therapy, particularly with three drugs and with proprotein convertase subtilisin-kexin type 9 inhibitors, was associated with a higher proportion and greater odds of having LDL cholesterol lower than 1.8 mmol/L. Compared with index cases, patients who were non-index cases were younger, with lower LDL cholesterol and lower prevalence of cardiovascular risk factors and cardiovascular diseases (all p, Pfizer Independent Grant for Learning Change [16157823]; Amgen; Merck Sharp Dohme; Sanofi-Aventis; Daiichi Sankyo; Regeneron; National Institute for Health Research (NIHR) Imperial Biomedical Research Centre, UK; NIHR; Czech Ministry of Health [NU20-02-00261]; Canadian Institutes of Health Research; Austrian Heart Foundation; Tyrolean Regional Government; Gulf Heart Association, The EAS FHSC is an academic initiative that has received funding from a Pfizer Independent Grant for Learning & Change 2014 (16157823) and from investigator-initiated research grants to the European Atherosclerosis Society-Imperial College London from Amgen, Merck Sharp & Dohme, Sanofi-Aventis, Daiichi Sankyo, and Regeneron. KKR acknowledges support from the National Institute for Health Research (NIHR) Imperial Biomedical Research Centre, UK. KID acknowledges support from a PhD Studentship from NIHR under the Applied Health Research programme for Northwest London, UK (the views expressed in this publication are those of the authors and not necessarily those of the National Health Service, the NIHR, or the Department of Health). TF was supported by a grant from the Czech Ministry of Health (NU20-02-00261). JG receives support from the Canadian Institutes of Health Research. The Austrian Familial Hypercholesterolaemia registry has been supported by funds from the Austrian Heart Foundation and the Tyrolean Regional Government. The Gulf Familial Hypercholesterolaemia registry was done under the auspices of the Gulf Heart Association.

Background: COVID-19 is a disease that started in Wuhan/China in late 2019 and continued through 2020 worldwide.Scientists worldwide continue to research to find vaccines, treatments, and medication for this disease. Studies also conenue to find the pathogenicity and epidemiology mechanisms.Materials and Methods:In this work, we analyzed cases obtained from Alshifaa center in Baghdad/Iraq for 23/2/2020-31/5/2020 with total instances of 797, positive cases of 393, and death cases of 30.Results: Results showed that the highest infection cases were among people aged between 41-45. Also, it was found that males' number of cases was more than females. In contrast, death cases were significantly higher in males than females.It was notable that the number of cases increased over time; here, it grew from April to May from 92 to 238, respectively.Conclusion: It is worth mentioning that by the beginning of Jun, the number of cases has dramatically increased, and now more than 2K points are recorded daily.Also, death cases had the same behavior.

Hamstring muscle (HMS) tightness is known as the impotence of full knee extension while the hip is flexed which creates discomfort or pain along hip to knee in posterior compartment of thigh. The aim of this study is to evaluate thep r e v a l e n c e o f H M S t i g h t n e s s a m o n g administrative staff due to prolonged sitting. Objective: To evaluate the HMS tightness due to prolonged sitting among administrative staff. Methodology: A cross sectional study was conducted among 274 participants from administrative staff of Government College University Faisalabad (GCUF), Faisal Hospital and Commissioner Office Faisalabad (Fsd). To measure the poplitealangle, Active Knee Extension Test (AKE) was performed. Data analysis was done by using SPSS version 17. Results: This study showed that out of 274 participants 152 subjects showed hamstring tightness with prevalence of 55.5%. As the age advances, the HMS tightness also increases. Conclusions: The present study shows that almost more than half participants from administrative staff of GCUF, Faisal Hospital and Commissioner Office Fsd have HMS tightness.

Background: A four trocar laparoscopic cholecystectomy become the standard procedure since the first laparoscopic procedure was reported. But laparoscopic cholecystectomy has gained many steps such as reduction in port number and size. Objective: To compare Clinical results from three ports versus the traditional four ports in laparoscopic cholecystectomy. Patients and Methods: A prospective randomized clinical trial of 100 patients was done on those who were admitted for elective laparoscopic cholecystectomy in Baquba teaching hospital, between April 2014 and March 2015, patients were classified into two groups (A) for three ports and (B) for 4 ports. Variables such as, complications, operative time, postoperative pain, nausea, and vomiting were assessed. Results: One-hundred patients were included in this study, age of them ranged from 18-70 year and a male to female ratio was 1:9. There were no significant differences in demographic data between the two groups. Postoperative pain, analgesic requirements, nausea and vomiting, and hospital stay were slightly more in group B but statistically not significant. Postoperative return to activity was shorter in group A 6.10 versus 7.00 days for group B with (p= 0.021) which is statistically significant. There is no difference in the rate of complications. Conclusion: Three ports laparoscopic cholecystectomy is feasible as an alternative for four ports without any significant complication. Keywords: Laparoscopy; Cholecystectomy; Postoperative complications

Objective To molecularly characterise the relationship between Epstein-Barr virus (EBV) genotypes and Pashtun ethnicity. Methods The cross-sectional study was conducted from November 2018 to December 2019 after approval from the Gomal University, Dera Ismail Khan, Pakistan, and comprised blood samples from transgender sex workers who were seropositive for human immunodeficiency virus-1 and seronegative for human immunodeficiency virus residing in two cities of Khyber Pakhtunkhwa province and Islamabad, the federal capital. Formalin-fixed paraffin-embedded (FFPE). Samples were collected from the partner institute along with the patients data, but without any follow-up from the study subjects which was purely on the basis of physical availability. β-globin gene and EBER-1(EBV encoded small RNA-1) were amplified for qualitative assessment and existence of Epstein-Barr virus. Characterisation of EBNA-2 (EBV Nuclear Antigen-2 was done through nested polymerase chain reaction. Results Of the 80 subjects, 40(50%) each were seropositive and seronegative individuals. The overall mean age was 28±6.917 years. Among the seropositive group, 38(95%) were homosexual and 2(5%) were heterosexual. Among the seropositive group, 16(40%) had Epstein-Barr virus genotype 1 and 6(15%) had genotype 2, while co-infections were found in 2(5%) subjects. In the seronegative group, 36(90%) subjects had Epstein-Barr virus genotype 1, while there was no case of genotype 2 or co-infection. EBV-2 genotypes with HIV seropositivity showed strong association (p=0.005). Amplification for the EBER-1 gene was done in all the 80(100%) samples. Conclusions Epstein-Barr virus EBV genotype 1 was found to be the most frequent type, while genotype 2 and co-infections were detected in only seropositive samples.

Background: Papular mucinosis is a variety of mucinosis characterized by excessive production of mucin by fibroblasts and deposition in the dermis. It manifests itself with fleshy papules or plaques in different sites of the body and taking different clinical morphological cutaneous features. Objective: The objective is to report and evaluate the different clinical and histopathological features of the disease in Iraqi patients. Patients and Methods: This is a case series and a clinical descriptive study in which ten patients with papular mucinosis were reported during the period from 2012 through 2019. The age ranged from 4 to 56 years, with seven females and three males. Clinical evaluation regarding histories of the disease and examination was carried out. General investigation was done and skin biopsy for histopathological assessment was conducted. Results: Nine patients were adults, with their age ranging from 20 to 56 years, a mean of around 35 years, and only one 4-year-old child. It is a disease with a female predominance, as observed in 7 (70%) females. The common sites of involvement were the face but the rash may extend to affect the neck and upper arms. The rash appeared in the form of skin-colored or red fleshy papules and plaques or in diffuse erythematous orange peel-like forms. The rash was asymptomatic in most patients. The pathology of the disease clarified the diffuse deposition of mucin in the dermis, as was demonstrated with H&E staining. Conclusion: Papular mucinosis is a rare disease characterized by mucin deposition in the skin affecting mostly adult females. The face is commonly involved together with other areas such as the neck and upper arms, but the trunk and lower limbs are spared. It manifests itself with different clinical morphological cutaneous features. Papular granuloma annulare must be considered as an important differential diagnosis in all cases of papular mucinosis.

Background: Angiokeratoma is a group of benign vascular telangiectasias in the superficial dermis associated with hyperkeratosis of the epidermis. There are different types of angiokeratoma and the color of the lesions—pink, red, dusky red, blue-red—depends on their age. Materials and Methods: Twenty-four patients with different varieties of angiokeratoma were collected from April 2013 through March 2020 and classified according to well-defined types. Each patient gave their formal consent after the nature of the disease was explained to them. Full medical history taking and clinical examination were performed on all patients. Skin biopsies were taken from 12 cases and processed for histopathology with H&E stain. As for therapy, diathermy was used for the treatment of selected localized cases, especially those on the scrotum. Results: Twenty-four cases with different types of angiokeratoma were evaluated, 19 (79.16%) males and 5 (20.83%) females, with ages ranging from 13 to 25 years and a mean age of 19 years. The age of onset was most commonly around adolescence and early adulthood. The lesions were classified into the following: 11 (45.83%) cases of Fordyce, 5 (20.83%) cases solitary, 4 (16.66%) cases circumscriptum, 3 (12.5%) cases oral (on the tongue), and one (4.16%) corporis diffusum (Fabry disease). All patients displayed warty red, blue, or black papules, nodules, or plaques, with the exception of isolated angiokeratoma. Their histopathology revealed hyperkeratosis of the epidermis, which could have been mild or marked acanthosis, as seen in the form of pseudoepithelial hyperplasia with marked elongation of rete ridges. As a dermal change, markedly dilated blood vessels occupied the papillary and reticular dermis. Diathermy was an effective mode of therapy in selected patients with satisfactory cosmetic and therapeutic results. Conclusion: All types of angiokeratoma were recognized but the most common were angiokeratoma of Fordyce, mainly affecting male genitalia, followed by solitary angiokeratoma, affecting mainly the limbs, and angiokeratoma circumscriptum linearly along the limbs. Oral angiokeratoma of the tongue appeared in three patients. All these types have a characteristic presentation that is easy to recognize: warty dusky-red lesions.

Early in the SARS-CoV-2 pandemic, convalescent plasma (CP) therapy was proposed as a treatment for severely ill patients. We conducted a CP treatment protocol under the Mayo Clinic Extended Access Program at University Hospital Brooklyn (UHB). Potential donors were screened with a lateral flow assay (LFA) for IgM and IgG antibodies against the SARS-CoV-2 S1 receptor-binding domain (RBD). Volunteers that were LFA positive were tested with an ELISA to measure IgG titers against the RBD. Subjects with titers of at least 1:1024 were selected to donate. Most donors with positive LFA had acceptable titers and were eligible to donate. Out of 171 volunteers, only 65 tested positive in the LFA (38.0%), and 55 (32.2%) had titers of at least 1:1024. Before our donation program started, 31 CP units were procured from the New York Blood Center (NYBC). Among the 31 CP units that were obtained from the NYBC, 25 units (80.6%) were positive in the LFA but only 12 units (38.7%) had titers of at least 1:1024. CP was administered to 28 hospitalized COVID-19 patients. Patients who received low titer CP, high titer CP and patients who did not receive CP were followed for 45 days after presentation. Severe adverse events were not associated with CP transfusion. Death was a less frequent outcome for patients that received high titer CP (>1:1024) 38.6% mortality, than patients that received low titer CP (≤1:1024) 77.8% mortality.

To study the genetic effect of gestational diabetes mellitus by study IRS1gene expression in female with Gestational diabetes mellitus. It is characterized high level of blood glucose, especially during first trimester then increased during the 2nd and 3rd trimester of the pregnancy period. The blood samples taken from one hundred twenty healthy women and female with gestational diabetes mellitus in 3rd trimester period of pregnancy, level of fasting blood glucose (FBG) also HbA1c% measured to diagnose GDM, in addition to lipid profile (cholesterol, triglyceride, HDL, LDL, and VLDL), molecular study consist of RNA extraction and qRT- PCR for IRS1gene expression determination. The fasting blood glucose mg/dl and HbA1c% level was increased highly significantly (P

Objectives Hypertension is a very common cardiovascular disease. Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARBs) are widely used to treat hypertension. Many patients with hypertension are vulnerable to the antihypertensive adverse effects, which potentially reduces the adherence rate. Therefore, we conducted this study in order to evaluate the safety profile of both classes (ACEi and ARBs) on respiratory functions. Methods Two main groups of subjects were studied: first group is healthy control subjects and the second group is hypertensive patients, which was subdivided into subgroups in order to investigate the effect of all tested medications (captopril, enalapril, lisinopril, losartan, and valsartan). Respiratory efficiency was evaluated by measuring pulmonary function tests: FEV1, FVC, and FEV1%. Measurements were done using micromedical spirometer. Results We found that ARBs do not impair normal respiratory functions as measured by FEV1, FEV1%, and FVC in hypertensive patients. While ACEi treatments significantly reduced FEV1, FEV1%, and FVC compared to the other groups. Conclusions ARBs are not associated with any harmful effects on respiratory functions in hypertensive patients, unlike ACEi. As such, they could represent a first-choice treatment for hypertensive patients who are at high risk to the respiratory adverse effects.

Study Design: Retrospective cohort study. Objective: The purpose of the study was to compare early complication, morbidity and mortality risks associated with fusion surgery crossing the cervico-thoracic junction in patients aged over 80 years undergoing combined anterior and posterior approach versus a posterior-only approach. Methods: We retrospectively identified octogenarian patients with myelopathy who underwent fusion crossing the cervico-thoracic junction. Patient demographics, Nurick score, surgical characteristics, complications, hospital course, early outcome and 90-day mortality were collected. Comorbidities were classified using the age-adjusted Charlson Comorbidity Index (AACCI). Radiographic measurements for deformity correction included the C2-C7 sagittal Cobb angle, C2-7 sagittal vertical axis and T1 slope pre- and postoperatively. Results: Out of 8,521 surgically treated patients, 12 octogenarian patients had a combined anterior and posterior approach (AP group) and 14 were treated from posterior-only (P group). Mean age was 81.4 ± 1.2 and 82.5 ± 2.7 years, respectively. There was no significant difference in Nurick scores between the groups ( P > 0.05). The major complication risk in the AP group was significantly higher, requiring PEG tube placement due to severe dysphagia in 4 patients (33%) compared to none in the P group. A greater improvement in cervical lordosis could be achieved through a combined approach. The 90-day mortality risk was 8% for the AP group and 0% for the P group. Conclusions: A combined anterior and posterior approach is associated with a significantly higher major complication rate and can result in severe dysphagia requiring PEG tube placement in one-third of patients over 80 years of age.

INTRODUCTION: Mixed gonadal dysgenesis (MGD) or 45,X/46,XY mosaicism is a sex chromosomal disorder of sexual development. We aim to characterize the clinical and reproductive features of 45X/46 XY attending tertiary care center in Kerala. MATERIALS AND METHOD: Retrospective review of clinical records which include clinical presentation, hormonal profile, cytogenetics, psychosexual assessment, and histopathology of gonadectomy specimen of ten cases of 45X/46 XY mosaicism who attended Endocrinology/ OBG out patient department from 2008 to 2020. RESULTS: The mean ages of all the cases were 12 ± 3.79 years (± 2 SD). Short stature was universally seen. Virilisation was the most common manifestation (80%) followed by delayed puberty (20%). Autoimmune thyroid disease was seen in 40% of cases. We noticed a delayed presentation in our clinical study. 45X/46 XY subjects who wished to continue as female underwent gonadectomy and were feminized with hormone replacement therapy. Male 45X/46 XY who retained their undescended testis is planned for periodic surveillance for malignancy. CONCLUSION: 45X/46 XY may present like Turner’s syndrome in clinical practice. Early counseling and gender assignment by a panel of specialists are crucial. Delayed presentation is less commonly encountered now a day and may pose a clinical challenge. Management in 45X/46 XY is multi-disciplinary which includes Turner’s like surveillance, proper sex assignment, timely genital reconstruction surgeries, gonadectomy, gonadal monitoring, and hormonal replacement therapy is needed.

BackgroundThoracic ureteric herniation is an uncommon finding with a varying presentation. Since its first documen-tation in 1958, few case reports have been published, and there is no consensus on its management. This condition is typically asymptomatic, with most cases identified incidentally from cross-sectional imaging or discovered intra-operatively.As a result of differing presentations and a lack of consensus or evidence of best practice, this rare finding’s management is not defined. This can range from adopting a conservative approach to more invasive measures such as ureteric stenting or pyeloplasty to repair the thoracic hernia.The authors present a case of thoracic ureteric herniation in a 74-year-old male presenting with right-sided abdominal pain. This patient was known to have a diaphragmatic hernia following pulmonary fibrosis investigations and chronic obstructive pulmonary disease (COPD). At presentation, there was acute kidney injury (AKI), and subsequent computed topography (CT) demonstrated right-sided hydronephrosis and perinephric fat stranding. This was caused by ureteric obstruction with a transition point at the site of thoracic herniation. The patient was successfully managed with retrograde ureteric stent insertion.This case report aims to highlight variance in the presentation of ureteric thoracic herniation and discuss management options. There is no consensus on management for this condition and choices dependant on specific symptoms and patient factors to the best of our knowledge.

Adverse Drug Reactions are among the major problems that cause mortality and morbidity in patients worldwide. In this study, Adverse Drug Reactions with common medicines were addressed, and the knowledge of pharmacist for prescribed medicine was also evaluated before and after educating the patients by pharmacist. The duration of this study was one year from October 2016 to October 2017. A descriptive cross-sectional study was designed and completed on 150 patients admitted to the hospital's medical ward. Patients whose ages were between 18-60 years, either male or female, who reported chronic diseases and took medication for a long time were selected for the study. Children or patients having < 18 years and taking medicine for a short period were excluded from this study. Selected patients were evaluated, and results were collected. Finally, the collected data was analysed with the 21st version of IBM’s Statistical Package for Service Solutions (SPSS v23). Of 150 selected patients, 61% were male, and 39% were female. Most patients were from the 18-30 age group, i.e., 28%. 60% of the patients hail from rural areas, and 40% from an urban areas. Of the 150 patient studied, 36.7% were illiterate, and only 4.7% of patients were above intermediate. Most of the patients were working in different government and private sectors. 8% of those taking the combination of Amoxicillin+Omeprazole+Salbutamol reported side-effects, whereas minimum side effects (2.0%) with Cholorothiazide+Atenolol+ Paracetamol. Reported adverse drug reactions (ADRs) in patients were Headache (14.9%), nausea (13.8%), vomiting (10.3%), abdominal pain (12.6%), constipation (8.0%), diarrhea (10.3%), skin rashes (5.7%), loss of appetite (4.6%), dizziness (6.9%), tiredness (6.9%) and confusion (5.7%). The knowledge of patients regarding therapy was compared before and after counseling that shows increased awareness in patients after counseling the patients. Before counseling average knowledge of patients was 27.5% that increased to 50.3% after counseling. After analyzing the results, it is concluded that pharmacist counseling and providing education to patients can significantly decrease the ADRs and increase the compliance of drugs that will ultimately enhance patients' quality of life. It was recommended that the hospital should appoint the pharmacist, especially a clinical pharmacist, and Hospital administration should arrange the programs for the awareness of patients on appropriate uses of drugs and their side effects.

Background: Atrial fibrillation (AF) is correlated with a poor biventricular pacing and inadequate response to cardiac resynchronization therapy (CRT). Biventricular pacing improvement can be achieved by conducting the atrioventricular junction ablation (AVJA). We aimed to investigate the benefit of AVJA for permanent AF and heart failure with reduced ejection fraction (HFrEF) patients receiving CRT. Methods: In August 2020, a systematic review and meta-analysis study comparing CRT plus AVJA versus CRT for permanent AF and HFrEF patients was conducted. Relevant articles were identified through the electronic scientific database such as ClinicalTrials.gov, ProQuest, ScienceDirect, PubMed, and Cochrane. The pooled risk ratio (RR) and pooled mean difference (MD) were estimated. Results: A total of 3199 patients from 14 cohort studies were involved in this study. Additional AVJA reduced cardiovascular mortality (RR = 0.75, 95% confidence interval [CI] = 0.61 to 0.93, P

Objective: To explore the burden of drug resistant tuberculosis in Khyber Pakhtunkhwa, Pakistan. Methods: A total of 8220 referred suspected TB patient samples were collected from 1st March 2016 to 28th February 2017 from TB laboratories across all districts of Khyber Pakhtunkhwa province and processed for the detection of drug resistant tuberculosis (DR-TB). Drug Susceptibility testing (DST) on all Mycobacterium tuberculosis complex (MTC) strains was performed at Provincial TB Reference Laboratory, Peshawar. Results: Among the 8220 suspected TB samples, 1351 samples were declared positive on culture. The DST results showed that 525 samples were resistant to at least one of the first and second line anti-TB drugs. Importantly, among these 525 TB resistance cases, XDR-TB were 0.4% (n=5), MDR-TB were 4.6% (n=62), polyresistant were 18% (n=243), monoresistant was 16% (n=215) and 61% (n=826) were reported as pan-sensitive. Gender wise ratio are slightly increased in female (n= 4230; 51.5%) as compared to male (n=3990; 48.5%), while the age group 15-24 were the main target of TB disease (n=1978; 24%). Conclusion: Our data suggests that DR-TB cases especially MDR-TB and XDR-TB in newly diagnosed TB patients are alarmingly increased in Khyber Pakhtunkhwa region. Furthermore, the timely detection of drug resistance is important to optimize treatment and management of MDR-TB as well as XDR-TB. Key words: Tuberculosis; MDR-TB; XDR-TB; Continuous....

Objective: To determine the frequency of high MELD score in cirrhotic patients undergoing liver resection due to hepatocellular carcinoma also compare the frequency of mortality in patients with high or low MELD score. Study Design: Cross sectional study Place and Duration: Department of Gastroenterology, Shaikh Zayed Hospital, Lahore. Duration: 6months i.e. 23 12-2017 to 22-06-2018. Methodology: 75 patients were enrolled. Then blood sample was obtained. Reports assessed and MELD score calculated. Scores were labeled as high or low. Patients underwent liver resection according to BCLC. The mortality was noted. All the collected data was entered and analyzed on SPSS version 22. Results: In this study out of total 75 cases 60 were males and 15 females. The mean age of patients was 39.44±9.76 years, male to female ratio was 4:1. Low MELD class was noted in 45 (60%) cases and high MELD class noted in 30(40%) cases. Mortality occurred in 27(36%) cases. Insignificant difference found between the MELD class with mortality. Conclusion: High MELD score was seen in 40% cirrhotic patients undergoing liver resection due to HCC. Post HCC resection, mortality occurred in 36% patients within three months of surgery. No significant association was found between the mortality and MELD score. Keywords: MELD, Hepatocellular Carcinoma, Mortality, Cirrhosis

Objective: To determine the frequency of fetomaternal morbidity and mortality among obstetric patients referred to tertiary care hospital with history of no antenatal visit. Study Design: Descriptive Case Series Study. Setting: Gambat Institute of Medical Sciences, Sindh Province. Period: June 2018 to December 2018. Material & Methods: About 175 pregnant females aged 18-35 years, having alive singleton pregnancy, gestational age >20-40 week without any history of obtaining antenatal care facility were included and followed-up till delivery and outcome were noted. Results: Mean age of females was 27.49 ± 4.46 years (18-35). Mean gestational age was 34.03 ± 4.07 weeks. About two third women (63%) were referred from rural areas. Maternal mortality rate was 12.6% while perinatal mortality was about 21.7%. Frequency of maternal morbidity of recorded as 34.9% case of hemorrhage, 36.6% case of anemia, 12.6% case of dystocia, 29.7% case of pre-eclampsia, 23.4% case of eclampsia & 19.4% case of sepsis. Maternal age was significant effect modifier for the frequency of pre-eclampsia, sepsis and maternal mortality (p