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Background: In Yemen; initial surveillance of COVID-19 focused primarily on patients with symptoms or severe disease, and, as such, the full spectrum of the disease, are not clear that make the epidemiology of COVID-19 is uncertain. To the best of our knowledge, this is the first seroprevalence study done in Yemen to measure the seroprevalence of anti-SARS-CoV-2 antibodies in the general population by sex and age group in Aden, Yemen. Methods: It is a one-time cross-sectional investigation among 2000 participants from all age groups from four districts in Aden at southern Yemen. A multi-stage sampling method used. Data collected by using a well-structured questionnaire and blood sample were collected. Healgen COVID-19 IgG/IgM Rapid Test Cassette was used in all participants. All positive RDT and 14% of the negative RDTs underwent ELISA test (WANTAI SARS-CoV-2 Ab Elisa Kit). Results: A 549 out of 2001 participants were RDT positive and proved by ELISA giving the prevalence of COVID-19 infection to 27·4% and specifically the prevalence of IgG was 25%. The prevalence of asymptomatic COVID-19 infection in all the study group was 7·9%. The highest prevalence was observed in Al-Mansurah district (33·4%). Regarding socio-demographic factors females, housewives and history of contact with COVID-19 patients have significant higher prevalence rates (32%, 31% and 39% respectively). Interpretation: high prevalence of SARS-CoV-2 antibodies was reported. Household contacts are the main factors for transmission. Enhancing population immunity is recommended by introducing COVID-19 vaccine. Funding: The study was funded from WHO/ EMRO. Aden Office Declaration of Interest: None to declare. Ethical Approval: This study was approved by the University of Yemen.

The association between Subclinical hypothyroidism and Depression is recognised. It is found that patients with Thyroid disorders are more prone to develop depressive symptoms and depression may be accompanied by various subtle thyroid abnormalities. The most commonly documented abnormalities are elevated T4 levels, Low T3, elevated rT3, a blunted TSH response to TSH, Positive anti thyroid autoantibodies and elevated CSF TRH concentrations. It is also found that thyroid hormone supplements appear to accelerate and enhance the clinical response to antidepressants. It is found out that Depression is associated with changes in Hypothalamic-pituitary axis as thyroid hormones act on the central nervous system. Mild thyroid dysfunction causes depression in younger patients (

Patient preference for a healthcare professional is mediated by physician gender. The primary aim of this study was to assess gender preference for an endoscopist in a cohort of Muslim patients. The secondary aim was to identify factors that influence gender preference.This was a multicenter cross-sectional study conducted at 3 tertiary care hospitals in Pakistan. Consecutive patients scheduled for elective outpatient upper endoscopy or colonoscopy were asked to complete a questionnaire immediately before and after the procedure. Data collected included patient demographics, occupation, education level, procedure type, gender preference, and reason for preference.A total of 1078 patients completed the questionnaire (age 43.5 ± 15.8 years; 53.2% men). Upper endoscopy was the most frequent procedure, performed in 84% of patients. Gender preference was expressed by 707 patients (65.6%), of which 511 (72.3%) were willing to wait for an average of 7 days for an endoscopist of the preferred gender. Male patients' preferences (45.1% male endoscopist, 17.1% female endoscopist, 37.8% no preference) differed from female participants' (16.9% male endoscopist, 52.6% female endoscopist, and 30.5% no preference; P .00001). No education was associated with having a gender preference (odds ratio, .55; 95% confidence interval, .37-.81; P = .003). Reasons for gender preference included religious values and family pressure, which were more frequently expressed by women (P .0001).Most Muslims in Pakistan expressed a gender preference, and both female and male patients showed a preference for a same-gender endoscopist. No education was associated with having a gender preference.

Background We determined the burden of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in air and on surfaces in rooms of patients hospitalized with coronavirus disease 2019 (COVID-19) and investigated patient characteristics associated with SARS-CoV-2 environmental contamination. Methods Nasopharyngeal swabs, surface, and air samples were collected from the rooms of 78 inpatients with COVID-19 at 6 acute care hospitals in Toronto from March to May 2020. Samples were tested for SARS-CoV-2 ribonucleic acid (RNA), cultured to determine potential infectivity, and whole viral genomes were sequenced. Association between patient factors and detection of SARS-CoV-2 RNA in surface samples were investigated. Results Severe acute respiratory syndrome coronavirus 2 RNA was detected from surfaces (125 of 474 samples; 42 of 78 patients) and air (3 of 146 samples; 3 of 45 patients); 17% (6 of 36) of surface samples from 3 patients yielded viable virus. Viral sequences from nasopharyngeal and surface samples clustered by patient. Multivariable analysis indicated hypoxia at admission, polymerase chain reaction-positive nasopharyngeal swab (cycle threshold of ≤30) on or after surface sampling date, higher Charlson comorbidity score, and shorter time from onset of illness to sampling date were significantly associated with detection of SARS-CoV-2 RNA in surface samples. Conclusions The infrequent recovery of infectious SARS-CoV-2 virus from the environment suggests that the risk to healthcare workers from air and near-patient surfaces in acute care hospital wards is likely limited.

Background: Polio is reported as reemerging disease in Malaysia after 27 years of being free from it. It is important to identify the awareness towards polio vaccine among the medical students who are the future and the pillars of the nation, to develop a country. Aims and Objectives: This study aims to assess the knowledge, attitude, and barriers toward polio immunization among pre-clinical medical students. Materials and Methods: A cross-sectional study was conducted among 190 pre-clinical students from a private university after obtaining informed consent and institutional ethical clearance. Data collected from Google Forms questionnaire were analyzed using SPSS version 20. Results: Insufficient knowledge, especially on disease nature, transmission, and correct dosage of vaccine, was noticed. Findings revealed that 79.5% of the students showed unfavorable attitude toward polio immunization. Year 2 students are more positive toward the vaccination compared to year 1. Main barriers toward polio immunization selected by the respondents are disagreement from the spouse, insecure about vaccine safety, and distance of the health center. Conclusion: Pre-clinical students should enhance their knowledge to be able to recognize the various barriers of polio immunization in our country and be part of the effort in solving these barriers as polio eradication is critical to ensuring a healthier future for children.

Objectives This study sought to identify predictors of major clinically important atrial fibrillation endpoints in hypertrophic cardiomyopathy. Background Atrial fibrillation (AF) is a common morbidity associated with hypertrophic cardiomyopathy (HCM). The HCMR (Hypertrophic Cardiomyopathy Registry) trial is a prospective natural history study of 2,755 patients with HCM with comprehensive phenotyping. Methods All patients received yearly telephone follow-up. Major AF endpoints were defined as requiring electrical cardioversion, catheter ablation, hospitalization for >24 h, or clinical decisions to accept permanent AF. Penalized regression via elastic-net methodology identified the most important predictors of major AF endpoints from 46 variables. This was applied to 10 datasets, and the variables were ranked. Predictors that appeared in all 10 sets were then used in a Cox model for competing risks and analyzed as time to first event. Results Data from 2,631 (95.5%) patients were available for analysis after exclusions. A total of 127 major AF endpoints events occurred in 96 patients over 33.3 ± 12.4 months. In the final model, age, body mass index (BMI), left atrial (LA) volume index, LA contractile percent (active contraction), moderate or severe mitral regurgitation (MR), and history of arrhythmia the most important. BMI, LA volume index, and LA contractile percent were age-dependent. Obesity was a stronger risk factor in younger patients. Increased LA volume, reduced LA contractile percent, and moderate or severe MR put middle-aged and older adult patients at increased risk. Conclusions The major predictors of major AF endpoints in HCM include older age, high BMI, moderate or severe MR, history of arrhythmia, increased LA volume, and reduced LA contractile percent. Prospective testing of a risk score based on these parameters may be warranted.

OBJECTIVE To examine the prevalent understanding of and management approaches to chronic endometritis among obstetricians/gynecologists. METHODS In a cross-sectional observational study, 262 members of national and international professional obstetrician/gynecologist societies were surveyed via anonymous electronic survey that investigated knowledge of the pathophysiology, diagnostic criteria, clinical implications, and treatment strategies for chronic endometritis. Statistical analyses of results were performed using Fisher's exact tests, chi square tests and odds ratios with 95% confidence intervals. A two-sided P

Antiviral treatment is recommended for all hospitalized children with suspected or confirmed influenza, regardless of their risk profile. Few data exist on adherence to these recommendations, so we sought to determine factors associated with influenza testing and antiviral treatment in children.Hospitalized children18 years of age with acute respiratory illness (ARI) were enrolled through active surveillance at pediatric medical centers in seven cities between 11/1/2015 and 6/30/2016; clinical information was obtained from parent interview and chart review. We used generalized linear mixed-effects models to identify factors associated with influenza testing and antiviral treatment.Of the 2299 hospitalized children with ARI enrolled during one influenza season, 51% (n = 1183) were tested clinically for influenza. Clinicians provided antiviral treatment for 61 of 117 (52%) patients with a positive influenza test versus 66 of 1066 (6%) with a negative or unknown test result. In multivariable analyses, factors associated with testing included neuromuscular disease (aOR = 5.35, 95% CI [3.58-8.01]), immunocompromised status (aOR = 2.88, 95% CI [1.66-5.01]), age (aOR = 0.93, 95% CI [0.91-0.96]), private only versus public only insurance (aOR = 0.78, 95% CI [0.63-0.98]), and chronic lung disease (aOR = 0.64, 95% CI [0.51-0.81]). Factors associated with antiviral treatment included neuromuscular disease (aOR = 1.86, 95% CI [1.04, 3.31]), immunocompromised state (aOR = 2.63, 95% CI [1.38, 4.99]), duration of illness (aOR = 0.92, 95% CI [0.84, 0.99]), and chronic lung disease (aOR = 0.60, 95% CI [0.38, 0.95]).Approximately half of children hospitalized with influenza during the 2015-2016 influenza season were treated with antivirals. Because antiviral treatment for influenza is associated with better health outcomes, further studies of subsequent seasons would help evaluate current use of antivirals among children and better understand barriers for treatment.

Retropharyngeal abscess is a relatively uncommon midline deep neck space infection that extends from the base of the skull to the posterior mediastinum, situated between the buccopharyngeal and alar fascias. In this case report, we present a 14-month-old previously healthy female patient who had a high-grade fever for 7 days, associated with neck stiffness and restriction of neck movements to the right side. Her parents noticed decreased oral intake associated with dysphagia, muffled quality of voice, and obstructive sleep apnea. However, the patient had no clinical signs of mechanical obstruction on examination. A contrast-enhanced computed tomography scan of the neck showed a large retropharyngeal septated fluid collection measuring 8 × 3 × 6 cm, which was categorized as a large retropharyngeal abscess that was complicated by descending mediastinitis. The patient was taken immediately to the operation theater for incision and drainage under general anesthesia, after which she was started on intravenous antibiotics.

BACKGROUND: The declaration of Coronavirus disease 2019 (COVID-19) as a Public Health Emergency of International Concern (PHEIC) on 30 January 2020 required rapid implementation of early investigations to inform appropriate national and global public health actions. METHODS: The suite of existing pandemic preparedness generic epidemiological early investigation protocols was rapidly adapted for COVID-19, branded the 'UNITY studies' and promoted globally for the implementation of standardized and quality studies. Ten protocols were developed investigating household (HH) transmission, the first few cases (FFX), population seroprevalence (SEROPREV), health facilities transmission (n = 2), vaccine effectiveness (n = 2), pregnancy outcomes and transmission, school transmission, and surface contamination. Implementation was supported by WHO and its partners globally, with emphasis to support building surveillance and research capacities in low- and middle-income countries (LMIC). RESULTS: WHO generic protocols were rapidly developed and published on the WHO website, 5/10 protocols within the first 3 months of the response. As of 30 June 2021, 172 investigations were implemented by 97 countries, of which 62 (64%) were LMIC. The majority of countries implemented population seroprevalence (71 countries) and first few cases/household transmission (37 countries) studies. CONCLUSION: The widespread adoption of UNITY protocols across all WHO regions indicates that they addressed subnational and national needs to support local public health decision-making to prevent and control the pandemic.

Objective: To observe the outcome of single burr hole evacuation of EDH in a pediatric population. Material and Methods: We included 52 children who had had a head injury and were diagnosed with EDH on a CT scan. Over three months, they were all admitted to the pediatric neurosurgery ward. Serial CT scans and neurological evaluations were performed on all of the youngsters regularly to monitor their progress. Results: 52 pediatric and adolescent patients were included. The age range was 6 months to 18 years. There were 30 male and 22 female patients. All of the children have EDH as a result of head injuries sustained in various accidents. All of the youngsters underwent surgery to remove EDH through a single burr hole. On the second postoperative day, five infants underwent reoperation owing to neurological deterioration, and two children died. The result was good (mRS 0) in 44/52 (84.6%) instances, mild deficits (mRS 1–2) in 4/52 (7.6%), and severe impairments (mRS 3–5) in 2/52 (3.84%) cases six months after the event. Conclusion: Although, EDH is a life-threatening surgical disease if not treated promptly, EDH evacuation by a single burr hole has a satisfactory prognosis in the juvenile population, with fewer complications and recurrences.

Introduction: Corona virus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2), has become global pandemic. Proinûammatory mediator, serum ferritin is reported to be elevated significantly by different studies in COVID-19. Our study was aimed to find whether serum ferritin level can be employed as a biomarker to assess the disease severity in COVID-19 cases. Methods: This cross sectional observational study was carried out at Armed Forces Institute of Pathology (AFIP), a tertiary referral laboratory between 15 March 2020 and 15 June 2020. Total 2418 hospitalized RT-PCR confirmed COVID- 19 patients from Combined Military Hospital (CMH) were included in our study. Serum ferritin was measured by electrochemiluminescence immunoassay and was compared between the severe and non-severe groups. P-value < 0.05 was considered statistically significant. Results: Total patients were 2418, among them 337 (13.9%) from intensive care unit (ICU) and 2081 (86.1%) from non- ICU. Median age and IQR were 60.5 (51.5–68.0) years in ICU patients versus 38.0 (28-46.1) years in non-ICU patients (p

PURPOSE: Women who utilize assisted-reproductive technology (ART) to achieve pregnancy experience unique circumstances before and during their pregnancy. This study aims to examine the progression of mental health in pregnant women who conceived via various methods of ART to understand gestational time periods of emotional stability or risk specific to these populations. METHODS: Secondary analysis of the Yale Pink and Blue Study - a prospective cohort involving women from 137 obstetrical practices in the northeastern United States between 2005–2009. Depressive and anxiety symptoms among spontaneous, planned pregnancies were compared to ART pregnancies using the Edinburgh Postnatal Depression Scale (EPDS) and its anxiety subscale (EPDS-3A), respectively. Generalized Estimating Equations were used to compare group changes (EPDS and EPDS-3A score threshold ≥10) at timepoints of

Purpose Changes occur in the expression of oestrogen-regulated and proliferation-associated genes in oestrogen receptor (ER)-positive breast tumours during the menstrual cycle. We investigated if Oncotype® DX recurrence score (RS), Prosigna® (ROR) and EndoPredict® (EP/EPclin) prognostic tests, which include some of these genes, vary according to the time in the menstrual cycle when they are measured. Methods Pairs of test scores were derived from 30 ER-positive/human epidermal growth factor receptor-2-negative tumours sampled at two different points of the menstrual cycle. Menstrual cycle windows were prospectively defined as either W1 (days 1–6 and 27–35; low oestrogen and low progesterone) or W2 (days 7–26; high oestrogen and high or low progesterone). Results The invasion module score of RS was lower (− 10.9%; p = 0.098), whereas the ER (+ 16.6%; p = 0.046) and proliferation (+ 7.3%; p = 0.13) module scores were higher in W2. PGR expression was significantly increased in W2 (+ 81.4%; p = 0.0029). Despite this, mean scores were not significantly different between W1 and W2 for any of the tests and the two measurements showed high correlation (r = 0.72–0.93). However, variability between the two measurements led to tumours being assigned to different risk categories in the following proportion of cases: RS 22.7%, ROR 27.3%, EP 13.6% and EPclin 13.6%. Conclusion There are significant changes during the menstrual cycle in the expression of some of the genes and gene module scores comprising the RS, ROR and EP/EPclin scores. These did not affect any of the prognostic scores in a systematic fashion, but there was substantial variability in paired measurements.

Background Convalescent plasma(CP) was utilized as potential therapy during COVID-19 pandemic in Pakistan. The study aimed at appraisal of CP transfusion safety and usefulness in COVID pneumonia. Methods Single arm, MEURI study design of non-randomized open label trial was conducted in five centers. Patients werecategorized as moderately severe, severe, and critical. The primary endpoint was a) improvement in clinical status and change in category of disease severity; secondary endpoint was b) CP ability to halt disease progression to invasive ventilation. CP transfused to hospitalized patients. Statistical tests including median (interquartile ranges), Mann-Whitney U test, Fisher’s exact test using SPSS ver. 23, ANOVA and Chi-square test were applied for the analysis of results parameters before and after CP treatment. SOFA score was applied for multiorgan failure in severe and critical cases. Results A total of 50 adult patients; median age 58.5 years (range: 29–92 years) received CP with infusion titers; median 1:320 U/mL (Interquartile range 1:80–1:320) between April 4 to May 5, 2020. The median time from onset of symptoms to enrollment in trial was 3 to 7 days with shortness of breath and lung infiltration as severity criterion. In 35 (70%) recipients, oxygen saturation improved from 80 to 95% within 72h, with resolution of lung infiltrates. Primary endpoint was achieved in 44 (88%) recipients whereas secondary endpoint was achieved in 42 (84%). No patient experienced severe adverse events. A high SOFA score (> 7) correlated with deaths in severe and critical patients. Eight (16%) patients expired due to comorbidities; cardiac arrest in 2 (4%), multiorgan failure secondary to cytokine storm in 5 (10%) and ventilator associated complications in 1 (2%). Conclusion CP transfusion can be used as a safe and useful treatment in moderately severe and severe patients. Trial registration The trial registration number is NCT04352751 (https://www.irct.ir/search/result?query=IRCT20200414047072N1). Trial Registration date is 28th April 2020.

Background Stroke is the second leading cause of death in the world and a major cause of disability, with ischemic stroke contributing to 87% of all strokes. Platelets are central in the formation of thrombus, and in the process, they enlarge in size, become active, and secrete prothrombotic factors. This is supported by the presence of large platelets in ischemic stroke, where they may be implicated in the pathogenesis of vessel occlusion, leading to stroke. The mean platelet volume (MPV) is an important laboratory marker of platelet function and activation. Materials and Methods The present study was conducted to assess the role of MPV in the pathogenesis, severity, and outcome of ischemic stroke. It was an observational study in 100 acute ischemic stroke (AIS) patients (excluding cardioembolic stroke) admitted to the Medicine wards, Department of Medicine, Jawaharlal Nehru Medical College, a tertiary care hospital at Aligarh. The MPV was correlated with the conventional risk factors of ischemic stroke and outcome (using modified Rankin scale [mRS]). The study revealed statistically significant correlation between MPV and hypertension, type 2 diabetes mellitus, and carotid intima media thickness (CIMT). Also, the MPV at presentation positively correlated with mRS (correlation coefficient 0.818); thus, high MPV was associated with more severe disability. Conclusion The MPV at the time of presentation of ischemic stroke may be useful in predicting the severity of stroke and neurological recovery. However, a larger study including diverse population is required to endorse its predictive value in AIS.

BACKGROUND: Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain. METHODS: We randomly assigned 5179 patients with moderate or severe ischemia to an initial invasive strategy (angiography and revascularization when feasible) and medical therapy or to an initial conservative strategy of medical therapy alone and angiography if medical therapy failed. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was death from cardiovascular causes or myocardial infarction. RESULTS: Over a median of 3.2 years, 318 primary outcome events occurred in the invasive-strategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, -1.8 percentage points; 95% CI, -4.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32). CONCLUSIONS: Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used. (Funded by the National Heart, Lung, and Blood Institute and others; ISCHEMIA ClinicalTrials.gov number, NCT01471522.).

Objective: The aim of this study was to assess the incidence of tricuspid valve involvement in rheumatic mitral stenosis among Pakistani patients that helps in the medical decisions and special consideration for the management of disease. Study Design: Prospective Study. Setting: National Institute of Cardiovascular Disease (NICVD), Karachi. Period: February 2018 to November 2019. Material & Methods: As per the study inclusion criteria, Three fifty eight (358) Pakistani patients' diagnosed with Rheumatic Mitral stenosis. The study was compiled as per international standards (ICH-GCP-E6), prior to initiation, the ethics review committee approved the study and informed consent was taken from all recruited subjects. Results: The study prospectively assessed the echocardiographic profile of rheumatic heart disease patients and recruited 358 patients with chronic Rheumatic Mitral Stenosis. Out of these patients, 93.9% (336) had tricuspid regurgitation and 7% (25) had triscuspid stenosis. Their ages ranged from 14 to 85 years (mean 40.3 years). Of these, 73.6% (263) were females and 26.5% (95) were males. On the basis of severity, in case of tricuspid stenosis, 3.9% (14) were mild, 1.1% (4) were moderate and 2% (7) were progress from mild to moderate. In case of Tricuspid regurgitation, 39.9% (143) were mild, 29% (105) moderate and 88% (24.6) were severe. Conclusion: The study concluded that in the local population, the patients with chronic Rheumatic Mitral Stenosis had common involvement of Triscuspid valvular disease, more come in female and affected all age groups. Hence, before management of Rheumatic Mitral Stenosis with other lesions, especially the Triscuspid valve involvement, detailed assessment is required in order to achieve the best outcome in patients with the Mitral valve disease.

Introduction: The final adult height (FAH) of patients with congenital adrenal hyperplasia (CAH) is often lower than the predicted adult height (PAH) using the Bayley-Pinneau (B&P) method. The aim of the current work was to test the validity of B&P in predicting FAH from a bone age (BA) measurement performed at onset of puberty. Material and ethods: This was a retrospective longitudinal observational convenience single-centre study. The study included 54 patients (male and female) with classic CAH, whether salt-wasting (SW) or simple virilising (SV), who had reached FAH. The results of auxological measurements and hormonal data around the time of puberty were retrieved from files. Predicted adult height (PAH) was calculated from a BA taken at onset of puberty and compared with FAH. Results: The median PAH SDS at the onset of puberty (–1.5) was significantly greater than the median FAH SDS (–2.2) (p < 0.001). The median target height SDS (–0.8) was significantly higher than the median FAH SDS (–2.2) (p < 0.001). FAH and FAH SDS were significantly worse in females (150.36 ± 7.23; –2.05 ± 1.13) than in their male counterparts (162.86 ± 3.30; –1.53 ± 0.51) (p value < 0.001; 0.048). In patients with good control, there was no difference between PAH SDS (–1.7) and FAH SDS (–1.5) (p value = 0.37). In patients with poor control (over- or under-treated) FAH SDS (–2.1) was significantly lower than PAH SDS (–1.4) (p value < 0.001). Conclusion: The B&P method was able to accurately predict FAH in children with classic CAH, who were medically well controlled (based on 17-hydroxyprogesterone levels), but overestimated it by a significant 0.7 SD in poorly-controlled patients.

The Pre-IVF Treatment with a GnRH Antagonist in Women with Endometriosis (PREGnant) Trial (clinicaltrials.gov no. NCT04173169) was designed to test the hypothesis that 60-day pre-treatment with an oral GnRH antagonist in women with documented endometriosis and planning an IVF cycle will result in a superior live birth rate to placebo. Eight hundred fourteen women are required from 4 national sites. To determine the feasibility of using an electronic medical record (EMR)-based strategy to recruit 204 participants at the Colorado site, we conducted a survey of women within the UCHealth system. Eligible women, identified using relevant ICD-10 codes, were invited to complete a 6-question survey to assess planned utilization of IVF, potential interest in participation, and whether delays in treatment due to COVID-19 would influence their decision to participate. Of 6354 age-eligible women with an endometriosis diagnosis, 421 had a concurrent infertility diagnosis. After eliminating duplicates, 212 were emailed a survey; 76 (36%) responded, 6 of whom reported no endometriosis diagnosis. Of the remaining 70, 29 (41%) were planning fertility treatment; only 19 planned IVF. All 19 expressed interest in participation. COVID-19 delays in treatment were not considered as a factor affecting participation by 8/19; the remaining 11 felt that it would "somewhat" affect their decision. None reported that they would not consider participation because of COVID-19. EMR-based recruitment for an endometriosis clinical trial is feasible although the overall yield of participants is low. Delays in treatment due to COVID-19 did not appear to overly influence potential recruitment.

The efficacy of chemotherapy in cancer therapy is limited due to resistance, treatment selectivity, and severe adverse effects. Immunotherapy, chemotherapy, targeted therapy, radiation, and surgery are the most common therapeutic strategies for treatment, with chemotherapy being the most successful. Nonetheless, these treatments exhibit poor effectiveness due to toxicity and resistance. Therefore, combination therapies of natural products may be used as an effective and novel strategy to overcome such barriers. Cisplatin is a platinum-based chemotherapy agent, and when administered alone, it can lead to severe adverse effects and resistance mechanism resulting in therapeutic failure. Curcumin is a polyphenolic compound extracted from turmeric (Curcuma longa) exhibiting anticancer potential with minimal adverse effects. The combination therapy of curcumin and cisplatin is a novel strategy to mitigate/attenuate cisplatin-related adverse effects and improve the barrier of resistance reducing unwanted effects. However, there are uncertainties on the efficacy of curcumin, and more in depth and high-quality studies are needed. This review aims to explain the adverse effects related to individual cisplatin delivery, the positive outcome of individual curcumin delivery, and the combination therapy of curcumin and cisplatin from nano platform as a novel strategy for cancer therapy.

الملخص: أهداف البحث: يهدف هذا البحث إلى تقييم الآثار قبل السريرية المضادة للسرطان للميتفورمين في نموذج طُعم أجنبي لسرطان الثدي. طرق البحث: أجريت هذه التجربة التداخلية خلال فترة محددة مدتها خمسة أشهر (أغسطس ٢٠١٦ - يناير ٢٠١٧). حيث استخدمنا نموذج طُعم أجنبي من الفئران بلب/ج عارية. وكان حجم العينة ٥٠ فأرا، وُزعت لمجموعتين المجموعة أ والمجموعة ب لمجموعتي الميتفورمين والتحكم السلبية، على التوالي. وتم تقييم النشاط السرطاني للميتفورمين من خلال مقارنة حجم الورم، ووزن الورم، ونسبة تراجع الورم، ونسبة التراجع المئوية ومعدل البقاء على قيد الحياة. النتائج: بالمقارنة مع مجموعة التحكم، خفض الميتفورمين بشكل كبير تطور الورم في نموذج الطُعم الأجنبي لسرطان الثدي الناجم حسب مؤسسة ميتشغان للسرطان-٧. وقد انعكس ذلك من خلال اختلافات كبيرة في حجم الورم في المتابعة النهائية. وقد تم دعم النتائج التي توصلنا إليها من خلال انخفاض كبير في معدل نمو الورم ووزن الورم في مجموعة الميتفورمين مقارنة بمجموعة التحكم. وبالمثل، كان معدل البقاء الكلي وتراجع الورم مرتبطين بشكل أكبر في مجموعة الميتفورمين. الاستنتاجات: أثبتت هذه الدراسة أن الميتفورمين يمكن أن يقلل بشكل كبير من نمو الورم ويمكن أن يزيد من معدل البقاء على قيد الحياة في نموذج الطُعم الأجنبي لسرطان الثدي. Abstract: Objective: This research aims to evaluate the preclinical meritorious and anticancer effects of Metformin in a Xenograft model of breast cancer. Methods: This interventional trial was conducted during a defined period of 5 months (August 2016 January 2017). We used a Xenograft model of nude BALB/c mice. A sample size of 50 mice, allocated into two groups and designated as Group A and Group B for Metformin and negative control groups, respectively. The anticancer activity of Metformin has been evaluated by comparing the tumour volume, tumour weight, tumour regression ratio, percentage regression, and survival rate. Results: Compared with the control group, Metformin can significantly reduce the progression of tumour in the Xenograft model of breast cancer induced by MCF-7. This is reflected by significant differences in tumour volume at the final follow-up (p =

Objectives: The purpose of this study was to determine the number of physiotherapists who interrupted their services because of the COVID-19 pandemic and to verify the procedures adopted by the physiotherapists who are still working. Methods: It was a Cross sectional study. Study Setting was University of South Asia, Lahore. Data was collected through self-administered questionnaire. Physiotherapists working in Government and Private Hospitals in Lahore were recruited. Data was collected from October 2020 to November 2020. Non-probability Convenient sampling technique was used to recruit participants in study. Sample size of 241 Participants was calculated by using an online calculator (Raosoft,Inc.2004) with 5% margin of error, 95% confidence level and population of 462 physiotherapists working in Lahore in various Government and Private Hospitals Results: Out of 210 participants, males were 154 (73%) while females were 56 (27%). 37 (18%) were working in government hospitals while 173 (82%) were working in private setups. 14 (7%) were holding only undergraduate degree while 196 (93%) were post graduate. 28 (13%) were having up to 4 years of clinical experience working as physiotherapist, 65 (31%) were having up to 8 years of experience while 117 (56%) were having up to 12 years of clinical experience. When asked about Source of information on COVID-19, 16 (8%) chose Official international health organization sites and media, 18 (9%) chose Official government sites and media e.g. Ministry of Health Pakistan, 121 (58%) chose News Media e.g. TVs, radios, Magazines, Newspapers, 52 (25%) chose Social Media e.g. WhatsApp, Facebook, Twitter, Instagram while 2 (1%) chose journals and only 1 participant (.5%) chose others source of information. Conclusion: The distribution of Attitude, Knowledge, and Practice is the same across categories of source of information on COVID-19. Keywords: COVID-19, Coronavirus disease, Knowledge, Attitude, Practice

Objectives: In depth exploration of perceptions of physiotherapist regarding the prevalent conspiracy theories about the COVID-19 and its vaccine and assess their willingness to get vaccinated. Methods: A qualitative research method was adapted to gain a keen insight into vaccine hesitancy in physiotherapist. Ground theory was used as a framework to develop a semi- structured questionnaire guided to conduct in-depth interviews. Results: Most participants believed that SARS-CoV-2 is a natural virus that causes a disease just like other viruses and it is absurd to believe that the vaccine is being used by foreign powers for the implantation of microchips just to control humans. Many physiotherapist believed that pharmaceutical companies might be hiding some important information on coronavirus to promote the sale of their product. Majority of participants believed that the government should enforce everyone to get coronavirus vaccine. All the participants showed some doubts on the reliability and trust worthiness on the COVID-19 vaccine safety and efficacy data. All but one participant showed willingness to get coronavirus vaccine if it is to be provided free of cost. Majority of participants considered adverse reaction, cost of vaccine, and limited data on safety and efficacy profile of coronavirus Vaccine an important hindrance to their final decision on getting vaccine. Conclusion: COVID-19 vaccine hesitancy is a major hindrance to our current fight against coronavirus pandemic. Stakeholders must consider this ongoing vaccination campaign as an unprecedented opportunity to formulate required interventions that will help reduce vaccine hesitancy among Pakistani physiotherapist. Key terms: COVID-19, Vaccine, Hesitancy, Pakistan, Physiotherapist

Purpose We estimated penetrance of actionable genetic variants and assessed near-term outcomes following return of results (RoR). Methods Participants (n = 2,535) with hypercholesterolemia and/or colon polyps underwent targeted sequencing of 68 genes and 14 single-nucleotide variants. Penetrance was estimated based on presence of relevant traits in the electronic health record (EHR). Outcomes occurring within 1-year of RoR were ascertained by EHR review. Analyses were stratified by tier 1 and non–tier 1 disorders. Results Actionable findings were present in 122 individuals and results were disclosed to 98. The average penetrance for tier 1 disorder variants (67%; n = 58 individuals) was higher than in non–tier 1 variants (46.5%; n = 58 individuals). After excluding 45 individuals (decedents, nonresponders, known genetic diagnoses, mosaicism), ≥1 outcomes were noted in 83% of 77 participants following RoR; 78% had a process outcome (referral to a specialist, new testing, surveillance initiated); 68% had an intermediate outcome (new test finding or diagnosis); 19% had a clinical outcome (therapy modified, risk reduction surgery). Risk reduction surgery occurred more often in participants with tier 1 than those with non–tier 1 variants. Conclusion Relevant phenotypic traits were observed in 57% whereas a clinical outcome occurred in 19% of participants with actionable genomic variants in the year following RoR.

Background: COVID-19 is an emerging respiratory virus which was initially reported to the WHO on December 31, 2019 and declared as a public health emergency by the WHO on March 11, 2020. Aim: The aim of the study was to investigate the public knowledge, attitudes, and practice toward COVID-19. Method: This is an online cross-sectional study. The questionnaire was in both Arabic and English languages and consisted of 4 segments (demographic, knowledge, attitude, and practice). The results were collected anonymously. The data were entered in Excel sheets and then exported and analyzed using SPSS software. Results: A total of 1,602 UAE residents completed the questionnaire. The mean knowledge score is 71%, which reflects good knowledge. The mean attitude score is 78%, which reflects a positive attitude. The mean practice score is 76%, which reflects good practice. Ninety-four percent of the population avoid handshakes, 93.3% wear face masks regularly, 85.5% use hand sanitizers, and 66% wash their hands, 22.7% drink honey with ginger, 13% still prefer to take garlic, and 82% chose to constantly update themselves with information about COVID-19; however, only 10% relied on purely medical sources. Conclusions: This study showed that UAE residents have satisfactory knowledge and favorable practice, with an overall high positive attitude. However, it is still encouraged to continue efforts in spreading awareness and public health education across all platforms, as well as increase awareness campaigns and correct misconceptions circulating on nonmedical platforms since they are a major source of information for the public.

Metabolism of progesterone (P4) by the enzyme 20α hydroxysteroid dehydrogenase (20α‐HSD) in myometrial cells is postulated to be a mechanism for P4 withdrawal, which occurs concomitant to uterine inflammation (physiologic or infection‐induced) and associated activation of transcription factors: NF‐кB and AP‐1, common to term and preterm labour. We found that 20α‐HSD protein is significantly increased in human myometrium during term labour, and in mouse uterus during term and preterm labour. Treatment of human myometrial cells with the pro‐inflammatory mediators, lipopolysaccharide (LPS, mimicking infection) and 12‐O‐tetradecanoylphorbol‐13‐acetate (TPA, mimicking inflammation), induced 20α‐HSD gene expression and increased 20α‐HSD protein abundance. LPS treatment decreased P4 release into the culture medium and resulted in up‐regulation of GJA1 in the hTERT‐HM cells. The NF‐кB /AP‐1 transcription factors mediated effects of LPS and TPA on 20α‐HSD gene transcription. Both pro‐inflammatory stimuli induced 20α‐HSD promoter activity in LPS/TPA‐treated cells which was significantly attenuated by inhibition of NF‐кB (JSH: 20 µM) or AP‐1 signalling (T5224: 10 µM). Deletion of NF‐кB consensus sites abrogated LPS‐mediated promoter induction, while removal of AP‐1 sites reversed the TPA‐mediated induction of 20α‐HSD promoter. We conclude that inflammatory stimuli (physiologic or pathologic) that activate NF‐кB or AP‐1 induce 20α‐HSD transcription and subsequent local P4 withdrawal resulting in up‐regulation of GJA1 and activation of myometrium that precedes labour.

BACKGROUND Obstetric practitioners routinely deal with antenatal patients who have high risk of developing established coagulopathy, which leads to a very high incidence of maternal morbidity and mortality. We wanted to assess the role of blood components in preventing disseminated intravascular coagulation (DIC) in highrisk patients and determine the amount of blood components required along with the rate of improvement in the DIC score, during treatment of high-risk obstetric patients of DIC and in patients with established DIC. METHODS This is an interventional study. 274 obstetric patients who were at high risk for developing DIC and / or with established DIC admitted during the 20 months study duration were included in the study. Patients were categorized in to three groups based on the DIC score according to ISTH scoring system in to non-overt and overt DIC groups. Those with DIC score < 5 were grouped as IA and IB randomly and those with DIC score > / = 5 were grouped as II. Software used was ANOVA using variance ratio F test for testing the significance between groups and chisquare test was used to find out the association between the groups or parameter. RESULTS Prophylactic transfusion of blood components showed faster rate of improvement than control group. Average consumption of blood components was more in patients of established coagulopathy as compared to non-overt group. CONCLUSIONS Transfusion of blood components can prevent overt DIC in high-risk patients. KEYWORDS DIC - Disseminated Intravascular Coagulation, PPH - Post Partum Haemorrhage, Coagulopathy, Component Therapy

Objective: To compare steroids with other treatment options like NSAIDS and other analgesics for management of postchikungunya arthritis based on visual analogue scale (VAS). Study Design: Comparative cross-sectional study. Place and Duration of Study: Department of Rheumatology, Liaquat National Hospital, Karachi, from Jan to Jul 2018. Methodology: A total of 112 patients were included in this study, of both genders. Patients with history of fever >38.5°C and polyarthralgia who had positive chikungunya IgM serology or PCR were included in this study. Patients fulfilling inclusion criteria and who were treatment naïve were given NSAIDs or other analgesics if contraindication to NSAIDs was present. Those who had received 2 weeks of NSAIDs were given a single dose of intramuscular steroids. Response to treatment was characterized by clinical examination according to visual analogue scale (VAS) taken at baseline, 2 weeks and 4 weeks. All analyses will be conducted by using SPSS-20. Results: Overall, 66 (58.9%) received steroids, 37 (33%) patients were given NSAIDs, and other forms of analgesics were prescribed to 9 (8%) patients. In nearly half of the patients, i.e. 57 (50.89%) partial response was seen, 13 (11.6%) showed complete response, while 42 (37.5%) had persistent arthralgia, which was statistically significant p-value

Hormone therapy (HT) is an effective treatment for menopausal symptoms, including vasomotor symptoms and genitourinary syndrome of menopause. Randomized trials also demonstrate positive effects on bone health, and age-stratified analyses indicate more favorable effects on coronary heart disease and all-cause mortality in younger women (close proximity to menopause) than in women more than a decade past menopause. In the absence of contraindications or other major comorbidities, recently menopausal women with moderate or severe symptoms are appropriate candidates for HT. The Women’s Health Initiative (WHI) hormone therapy trials—estrogen and progestin trial and the estrogen-alone trial—clarified the benefits and risks of HT, including how the results differed by age. A key lesson from the WHI trials, which was unfortunately lost in the posttrial cacophony, was that the risk:benefit ratio and safety profile of HT differed markedly by clinical characteristics of the participants, especially age, time since menopause, and comorbidity status. In the present review of the WHI and other recent HT trials, we aim to provide readers with an improved understanding of the importance of the timing of HT initiation, type and route of administration, and of patient-specific considerations that should be weighed when prescribing HT.

Biosimilars have the potential to increase patient access and significantly reduce healthcare costs in the US. However, uptake in the US has been slower than anticipated, limiting the benefits of biosimilar competition. Understanding the factors that affect uptake is critically important to realize the benefits of biosimilars. A US national survey study was conducted electronically from December 11, 2019 to January 8, 2020. The survey was administered to 507 US healthcare professionals practicing in dermatology, gastroenterology, hematology, oncology, nephrology, or rheumatology. The survey evaluated prescriber attitudes toward biosimilars in general, as well as prescriber decision making, using a series of hypothetical scenarios with fictional biological products. Fewer than half had a baseline understanding of key elements of biosimilarity, even among respondents who had previously prescribed a biosimilar. Regardless of previous experience, all respondents benefited from receiving additional information about biosimilarity, indicating the potential benefits of educational efforts for prescribers across all specialties and levels of experience. Prescriber choice was driven primarily by formulary status; however, respondents identified a variety of factors that would influence their willingness to prescribe a biosimilar, including financial savings to the patient, pharmacovigilance, patient experience, and education on the FDA approval process. Over one-third of participants indicated a preference for reference products and nearly half indicated a hesitancy to try biosimilars until they have been on the market longer. Naming conventions for biosimilars did not affect prescribers’ willingness to prescribe biosimilars. Gaps in prescriber knowledge and hesitancy toward biosimilars remain significant challenges for biosimilar uptake. While formulary status of a biosimilar product strongly influences prescriber choice, additional prescriber education on biosimilarity is needed.

Background: Nonischemic cardiomyopathy is a leading cause of reduced left ventricular ejection fraction (LVEF) and is associated with high mortality risk from progressive heart failure and arrhythmias. Myocardial scar on cardiovascular magnetic resonance imaging is increasingly recognized as a risk marker for adverse outcomes; however, left ventricular dysfunction remains the basis for determining a patient’s eligibility for primary prophylaxis with implantable cardioverter-defibrillator. We investigated the relationship of LVEF and scar with long-term mortality and mode of death in a large cohort of patients with nonischemic cardiomyopathy. Methods: This study is a prospective, longitudinal outcomes registry of 1020 consecutive patients with nonischemic cardiomyopathy who underwent clinical cardiovascular magnetic resonance imaging for the assessment of LVEF and scar at 3 centers. Results: During a median follow-up of 5.2 (interquartile range, 3.8, 6.6) years, 277 (27%) patients died. On survival analysis, LVEF ≤35% and scar were strongly associated with all-cause (log-rank test P =0.002 and P P =0.001 and P P =0.001), there was no significant association between LVEF ≤35% and SCD risk ( P =0.57). On multivariable analysis including established clinical factors, LVEF and scar are independent risk markers of all-cause and cardiac death. The addition of LVEF provided incremental prognostic value but insignificant discrimination improvement by C-statistic for all-cause and cardiac death, but no incremental prognostic value for SCD. Conversely, scar extent demonstrated significant incremental prognostic value and discrimination improvement for all 3 end points. On net reclassification analysis, the addition of LVEF resulted in no significant improvement for all-cause death (11.0%; 95% CI, −6.2% to 25.9%), cardiac death (9.8%; 95% CI, −5.7% to 29.3%), or SCD (7.5%; 95% CI, −41.2% to 42.9%). Conversely, the addition of scar extent resulted in significant reclassification improvement of 25.5% (95% CI, 11.7% to 41.0%) for all-cause death, 27.0% (95% CI, 11.6% to 45.2%) for cardiac death, and 40.6% (95% CI, 10.5% to 71.8%) for SCD. Conclusions: Myocardial scar and LVEF are both risk markers for all-cause and cardiac death in patients with nonischemic cardiomyopathy. However, whereas myocardial scar has strong and incremental prognostic value for SCD risk stratification, LVEF has no incremental prognostic value over clinical measures. Scar assessment should be incorporated into patient selection criteria for primary prevention implantable cardioverter-defibrillator placement.

Background Guillain-Barre syndrome (GBS) is an acute polyradiculoneuropathy, often preceded by an infection. Rarely, it is preceded by a surgical procedure. Most of the postsurgical GBS cases are reported with the neurosurgical, gastrointestinal, orthopedic, and cardiac procedures. GBS is rarely reported after a coronary artery bypass grafting (CABG). To date, only 12 cases have been reported in the literature. Our case is 13th in number and the first case from Pakistan. Case presentation We report a case of a 54-year-old man presented with acute flaccid quadriparesis and areflexia after a CABG procedure. He was subsequently diagnosed with an acute inflammatory demyelinating polyneuropathy (AIDP) variant of GBS and underwent five sessions of plasmapheresis. His weakness improved and could ambulate unassisted on follow-up visits. Conclusion GBS is a potentially treatable condition if timely diagnosed and managed. It should be considered in every patient presenting with an acute-onset weakness after surgery.

Objective: To investigate whether extreme of body mass index (BMI) is associated with pregnancy outcomes. Study Design: Retrospective cohort study. Place and Duration of Study: Hamdard University Hospital, Karachi, Pakistan, from Feb 2019 to Jan 2020. Methodology: We conducted a retrospective cohort study of 1000 women delivered in between February 2019 to January 2020. BMI is categorized into four groups according to the Asian-Pacific cutoff points as underweight (25 kg/m2). Maternal outcomes measured were pre-eclampsia, gestational diabetes, delivery by cesarean section, instrumental delivery, anemia, postpartum hemorrhage and fetal outcome included small for gestational age and large for gestational age. Logistic regression model was used to adjust the confounder. Maternal outcomes were evaluated with relative risks and 95% confidence intervals. Results: In results, 13%, 54%, 22%, 9% and 2% were underweight, normal body mass index, overweight, obese and morbidly obese categories respectively. The gestational diabetes, pre-eclampsia, labour induction, frequency of cesarean section, post-partum hemorrhage increased linearly with increasing body mass index and expressed as adjusted odds ratio (95% confidence interval) respectively: 10.0 (95% CI 3.5, 28.7), 5.3 (95% CI 2.0, 14.1), 2.7 (95% CI 1.1, 6.8), 4.9 (95% CI 2.8–8.8), 2.5 (95% CI 0.31–20.6). The anemia and small for gestational age were found in underweight group with adjusted odd ratio2.47 (95% CI 1.6–3.6), 4.6 (95% CI 2.6, 8.1) respectively. Conclusion: Obese women are more prone to have maternal and fetal complication which includes preeclampsia, gestational diabetes, caesarean section rate, labor induction and macrosomic babies. Underweight women are not risk free for complica-tion as they are associated with anemia and small for gestational age.

We report a case of a 65-year-old man who presented to the Endocrine service for hypercalcemia. He had painful joints, muscle aches, joint stiffness, and incidentally discovered elevated calcium levels on two separate occasions. A lab evaluation indicated non-parathyroid mediated hypercalcemia with calcium levels in the range of 10.1-10.5mg/dl. Parathyroid hormone related peptide (PTHrP) level was undetectable. His PTH and 25-OH Vitamin D levels were normal. But his 1, 25 Dihydroxy Vitamin D levels were low. Initial imaging revealed a heterogeneously enhancing mass on the posterolateral left kidney. Our patient underwent a left nephrectomy, and the mass was identified as RCC on surgical pathology. We illustrated the differential diagnosis of hypercalcemia and the evaluation of hypercalcemia occurring with RCC. This case explains that we need to carefully evaluate, interpret, and review all the data, especially when the patient has borderline elevated calcium levels and does not have a typical presentation of malignancy.

Background: Child Pugh classification is an easy-to-use method that allows Physicians to assess malnutrition in patients suffering from CLD. Objective: To determine the frequency of malnutrition at different stages of chronic liver disease in accordance with Child Pugh classification. Study Design: The type of study is a cross-sectional study. Settings: Medical Unit III Civil Hospital, Karachi Pakistan. Duration: Six months from 31st May 2016 to 30th November 2016. Methodology: All the patients between the age 30 to 60 years who are known cases of CLD secondary to hepatitis B, C or both, with active signs of CLD were included. All the patients having debilitating co-morbidities likes malignancy, TB, psychiatric, etc. were excluded. Anthropometric evaluation and lab investigation at the time of admission were performed for all the patients. Results: The average age was 48.12±8.521 years and duration of disease was 5.48±3.792 months. There were 61.54% male and 38.46% females. Hepatitis-B was observed in 19.91% (n=44) cases, Hepatitis-C was 62.44% (n=62.44) and both hepatitis B and C was observed in 17.65% (n=39) cases. According to Child Pugh score, 9.5% cases were in class A, 32.58% were in class B and 57.92% were in class C. Frequency of malnutrition in chronic liver disease patients was 62.44% (138/221). Rate of malnutrition was significantly high in class B and C (p=0.002). Rate of malnutrition was also observed to be significantly high in those cases who were positive for both hepatitis like B and C (p=0.001). Effect of duration of cirrhosis was also not statistically significant with malnutrition. Conclusion: Malnutrition was significantly common among chronic liver disease patients regardless of viral etiology. Child Pugh B & C patients were found to have more significant malnourished states.

Objective: To determine the frequency of various Inherited Metabolic Diseases (IMDs) in clinically suspected neonates and children in relation to age, gender, and distribution in rural and urban areas.Materials and Methods: A total of 275 symptomatic neonates and children were enrolled for IMDs. A complete medical history, baseline biochemical tests, cerebrospinal fluid analysis, arterial blood gases, anion gap, serum ammonia, lactate, and urinary ketones were assessed. Any significant microbiological cause for the presenting symptom was excluded. For screening of Inborn Metabolic Error simple Heel prick test was done on PerkinElmer 226 filter paper in newborns and infants. Samples were sent to Jordan for analysis. High-performance liquid chromatography combined with tandem mass spectrometry (LC-MS/MS) was the technique used in the screening of a variety of IMDs. The frequency of Inherited Metabolic Diseases and their relation with age, gender, and location was determined using the chi-square goodness of fit test. A p-value ≤ of 0.05 was considered statistically significant. Results: Of the 275 subjects screened, 47(17%) had an inherited metabolic disorder, of which 27 were male and 20 were female with a Male to Female ratio of 1.35:1. The difference in metabolic disorders was significantly different between age (p=0.01) and gender (p=0.04). Of the diagnosed cases G6PD disorder was found to be the most frequent disorder 14 (29.79%) of the total diagnosed cases, followed by Aminoaciduria in 9 (19.15%) and Carnitine Uptake Defect in 7 (14.8). Conclusion: The cases detected to have IMDs revealed a significant prevalence. G6PD was detected as the most frequent disorder. A simple Heel prick test on PerkinElmer 226 filter paper is a useful method to detect IMDs, though confirmation is usually required by other tests.

Background: Otomycosis may be refractory to the treatment prescribed and challenges the clinicions to determine whether the external ear disease is an isolated entity or related to any other systemic disorder or the result of underlying immune deficiency disorder. Aim & Objective: The aim of the study was to identify the causative organism associated with otomycosis with special reference to aspergillus and candida species. On the basis of finding of this study, treatment of otomycosis due to aspergillus/ candida species can be better when a particular species is isolated and its antifungal sensitivity pattern is known. Materials and Methods: The present study “CHANGING TRENDS OF ANTIFUNGAL SUSCEPTIBLITY IN ISOLATES FROM CASES OF OTOMYCOSIS” was undertaken in the Department of microbiology at Ayaan Institute of Medical Sciences, Hyderabad & KIMS Narketpally. The study was conducted over a period of 1 year from April 2019 to April 2020.The study group comprised of 100 patients presenting with complaints of itching and ear ache to the ENT outpatient department at Ayaan Institute of Medical Sciences & KIMS. Patients were evaluated as per the study protocol ear swabs were collected and processed as per the standard microbiological techniques for the isolation and identification of the organism. Different etiological agents were identified with special reference to aspergillus and candida species. Results: In the present study maximum number of patients was in the age group of 21-30 years (30%) from low socio-economic status presenting with itching, ear ache and decrease hearing. Prevalence of otomycosis was high in females mostly due to injury to the ear canal with hairpin followed by use of antibiotic ear drops. Out of 100 study group, 61% had fungal infection by aspergillus species followed by candida species 17% and normal floro or no growth was seen in 24% cases. Among the aspergillus species 4 species were identified. A.Niger(36%) A.Flavus(15

Uterovaginal prolapse is the downward descent of the pelvic organ, resulting in protrusion of the vagina, uterus, bladder or rectum. The association between POP and hydronephrosis has been shown by various studies, but severe hydronephrosis leads to renal dysfunction are rarely seen. We report a case of 70 years old female with massive vaginal prolapse and chronic renal impairement. She presented with urinary tract infection (UTI) and raised creatinine levels of 4.5mg/dl. After correction of UTI, she surgically managed to relieve her obstructive symptoms. After surgery her creatinine levels drop to 2.0mg/dl but chronic renal failure persisted. Advance stage prolapsed may damage renal function if left untreated. Timely diagnosis and management may prevent irreversible damage to kidneys Continuous...

During the Covid-19 pandemic, it was postulated that there might be a delay in cancer patients` presentation, stage migration, changes in management leading to excess cancer mortality [1]. However, there is a paucity of real-time objective data to support this, particularly in HNC. In our HNC multidisciplinary team (MDT), approximately 300 new patients present annually. The purpose of this observational study was to assess the impact of Covid-19 on the presentation, stage and management pattern on newly presented HNC patients during the pandemic era.

Objective: The objective of study was to explore the relationship of breathing and pain during endodontic therapy. Materials and methods: 500 patients who presented in the department of operative dentistry were included in the study. Numeric pain scale was used to document the pain perceived during endodontic therapy. Results were analysed using SPSS version 23. Results: Among the 500 cases, 250 cases presented with mild pain, 158 presented with moderate pain while 92 presented with severe pain. 55.4% cases were of nasal breathers while 44.6% cases were of oral breathers. Conclusion: Patients presenting with nasal breathing pattern reported with mild pain perception during endodontic therapy when compared to patients who were oral breathers. Considering life style modifications like breathing patterns, body hydration and sleep impact the patient’s life and pain management during endodontic therapy. Educating patients on proper breathing and its benefits will have positive outcome on endodontic therapy. Keywords: Oral breathing, nasal breathing, pain perception, endodontics.

Background: The CALGB 40603 and BrighTNess studies found that adding high dose carboplatin every 3 weeks to the standard neoadjuvant DD AC - paclitaxel regimen in TNBC increased the pathologic complete response (pCR) rate to 54-58% but with the cost of increased treatment related toxicities resulting in decreased completion of the full course of treatment. Our hypothesis is by changing the high dose carboplatin every 3 weeks to low dose weekly carboplatin, it will retain the same benefit in pathologic response rate and minimize the treatment related toxicities, which in turn permits the full course of neoadjuvant treatment given to patients. Patients and Methods: This multi-center study was conducted through the WON (NCT03301350). Eligible TNBC patients for neoadjuvant chemotherapy received weekly carboplatin (AUC=2) and paclitaxel 80 mg/m2 for 12 doses, followed by dose dense doxorubicin 60 mg/m2 and cyclophosphamide 600 mg/m2 every 2 weeks with granulocyte growth factor support for 4 cycles. A one-week break was added before DD AC after the first 22 patients in order to minimize prolonged cytopenia. Primary end point was pCR. Secondary endpoints were frequency of dose modification and treatment related toxicities. Results: Accrual target was 50 with 80% power to detect a 20% difference using a one-sided binomial test at an alpha significance level of 0.025, but study was terminated earlier. Twenty-nine eligible patients consented for the study from November 2017 to February 2020. Median age was 52 year-old (range, 33-80). Twenty-eight patients received the study regimen. Three were removed due to early study termination and one (3.8%) died from grade 5 neutropenic sepsis after the last cycle of DD AC before surgery. Thus, 24 patients were evaluable for the primary outcome and 26 were evaluable for dose modification and toxicity outcomes. Eight patients (33%) achieved pCR and another 4 patients (17%) had minimal (ypT1aN0) residual disease. Of 26 patients, 24 (92%) were able to receive the full course of treatment +/- dose modification. One patient required the discontinuation of weekly carboplatin/paclitaxel completely due to severe infusion reaction and one did not finish the treatment before the study was terminated. Eight patients (31%) required dose delay with 5 of them during the weekly carboplatin/paclitaxel treatment. Seven patients (27%) also required dose reduction with 5 of them during the weekly carboplatin/paclitaxel treatment. Seventeen patients (65%) experienced severe adverse event (grade 3 or 4) with the majority of events (12/17) relating to grade 3-4 neutropenia or neutropenic fever. Conclusion: Although our study showed a lower pCR rate of 33% in compare to the previous CALGB 40603 (54%) and BrighTNess (58%) studies, we demonstrated that the majority of patients (92%) were able to receive the full course of study treatment. This weekly carboplatin with paclitaxel - AC regimen was used in the recent Keynote 522 study as the backbone chemotherapy to combine with check-point inhibitor immunotherapy in TNBC. However, any dosing schedules of carboplatin, weekly or every 3 weeks, add substantially to grade 3 or 4 toxicity of paclitaxel - AC. Aggressive supportive care management is needed when carboplatin is used. Citation Format: Yee Chung Cheng, Ruth O'Regan, Lubna N Chaudhary, Sailaja Kamaraju, Harvey Einhorn, Emmanuel Sampene, Marialane Pigsley, Mark E Burkard, Christopher R Chitambar, Kari B Wisinski. A phase II study of neoadjuvant weekly carboplatin/paclitaxel followed by dose-dense doxorubicin/cyclophosphamide (DD AC)in patients with triple negative breast cancer (TNBC): Wisconsin oncology network (WON) study [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS13-51.

Highlights • Diagnosis and management of giant juvenile fibroadenoma can be challenging. • Maintaining symmetry after complete excision is tougher in developing breasts. • Periareolar approach for subareolar fibroadenomas provides good cosmetic results. • Benign tumor to breast size ratio up to 70% provides excellent cosmetic outcome., Introduction Fibroadenoma is the most common benign lesion of breast in young women, characterized by an aberrant proliferation of both epithelial and mesenchymal elements. It is termed giant fibroadenoma when it is larger than 5 cm or weighs more than 500 g with an incidence of 0.5–2% of all fibroadenomas. Presentation of case In this report, we discuss a case of a 13-year-old Pakistani girl who presented with a giant juvenile fibroadenoma in left breast and was treated by a subareolar lump excision through a periareolar incision with excellent cosmetic outcome. To the best of our literature search, this is the first case of giant juvenile fibroadenoma in an adolescent being reported from Pakistan. Discussion Surgical management of giant juvenile fibroadenoma in immature breast is challenging as it may either result in asymmetric defect or damage to developing breast tissue resulting in long term poor outcomes. Surgical decision should be carefully undertaken and reported for future reference in such cases. Conclusion The diagnosis and management of giant juvenile fibroadenoma can be challenging because these tumors clinically and histologically mimic phyllodes tumor due to their rapid growth and large size. Excision through a periareolar approach for fibroadenomas located in subareolar region provides good cosmetic results in these patients with minimal scar visibility.

To noninvasively assess left atrial (LA) kinetic energy (KE) in hypertrophic cardiomyopathy (HCM) patients using 4D flow MRI and evaluate coupling associations with mitral regurgitation (MR) and left ventricular outflow tract (LVOT) obstruction. Twenty-nine retrospectively identified patients with HCM underwent 4D flow MRI. MRI-estimated peak LVOT pressure gradient (∆PMRI) was used to classify patients into non-obstructive and obstructive HCM. Time-resolved volumetric LA kinetic energy (KELA) was computed throughout systole. Average systolic (KELA-avg) and peak systolic (KELA-peak) KELA were compared between non-obstructive and obstructive HCM groups, and associations to MR severity and LVOT ∆PMRI were tested.The study included 15 patients with non-obstructive HCM (58.6 [45.9, 65.2] years, 7 females) and 14 patients with obstructive HCM (51.9 [47.6, 62.6] years, 6 females). Obstructive HCM patients demonstrated significantly elevated instantaneous KELA over all systolic time-points compared to non-obstructive HCM (P

Juvenile polyposis syndrome (JPS) is a clinically diagnosed hamartomatous polyposis syndrome that increases the risk of gastrointestinal cancer. Approximately 40%–50% of JPS is caused by a germline disease-causing variant (DCV) in the SMAD4 or BMPR1A genes. The aim of this study was to characterize the phenotype of DCV-negative JPS and compare it with DCV-positive JPS. Herein, we analyzed a cohort of 145 individuals with JPS from nine institutions, including both pediatric and adult centers. Data analyzed included age at diagnosis, family history, cancer history, need for colectomy/gastrectomy, and polyp number and location. Compared with DCV-positive JPS, DCV-negative JPS was associated with younger age at diagnosis (P < 0.001), lower likelihood of having a family history of JPS (P < 0.001), and a lower risk of colectomy (P = 0.032). None of the DCV-negative individuals had gastric or duodenal polyps, and polyp burden decreased after the first decade compared with DCV-positive JPS. Subgroup analysis between SMAD4 and BMPR1A carriers showed that SMAD4 carriers were more likely to have a family history of JPS and required gastrectomy. Taken together, these data provide the largest phenotypic characterization of individuals with DCV-negative JPS to date, showing that this group has distinct differences compared with JPS due to a SMAD4 or BMPR1A variant. Better understanding of phenotype and cancer risk associated with JPS both with and without a DCV may ultimately allow for individualized management of polyposis and cancer risk. Prevention Relevance: Juvenile Polyposis Syndrome (JPS) is a gastrointestinal cancer predisposition syndrome requiring lifelong surveillance, however there is limited data comparing individuals with and without a germline disease-causing variant in SMAD4 or BMPR1A. Herein we show that individuals with JPS without an underlying disease-causing variant have distinct phenotypic differences including lack of upper gastrointestinal polyps and lower rates of a family history of JPS, suggesting that a different approach to management may be appropriate in this population.

BACKGROUND Every blood transfusion is associated with 1 % chance of transfusion associated problems including transfusion transmitted blood-borne infections to its recipient. The major globally prevalent transfusion transmitted infections are human immunodeficiency virus, hepatitis B virus, hepatitis C virus, syphilis and malaria parasite. We wanted to compare safety of blood among replacement and voluntary donations by comparing the prevalence of transfusion-transmissible infections among them. METHODS All donors were screened by enzyme-linked immunoassay for five transfusion transmissible infectious agents - human immunodeficiency virus, hepatitis B virus, hepatitis C virus and syphilis by collecting plasma from the pilot tube attached to the blood bag. Malaria was tested from whole blood sample. RESULTS A total of 24,491 donors was included in the study. Among them 21,090 (86.11 %) were replacement and 3,401 (13.89 %) were voluntary donors. Out of 24,491 donors, 560 (2.29 %) units tested positive. Hepatitis B virus (hepatitis B surface antigen) is found to be the most prevalent transfusion transmitted infection among both replacement donations and voluntary donations. CONCLUSIONS There should be more voluntary donations to achieve safer blood transfusion practices as self-deferral by donors with high risk condition is the most effective way to reduce prevalence of transfusion transmitted infections. KEYWORDS Enzyme-Linked Immunoassay, Hepatitis C Virus, Hepatitis, Replacement Donors, Transfusion Transmitted Infections, Voluntary Donors