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Objectives: This study aimed to determine the dimensions and differences in distances from several anatomical structures to the mental foramen (MtF) in Pakistani participants using cone beam computed tomography (CBCT)., Methods: For this cross-sectional study, retrospective CBCT data of Pakistani individuals from both genders were assessed using the Mimics software (Materialise NV, Leuven, Belgium). The participants were selected from the Mahajir and Pukhtoon ethnic groups in Pakistan. The dimensions of the MtF, which included vertical and horizontal diameter and area of foramen, were measured. The distance of the foramen to various anatomical structures was measured, which included the alveolar crest, inferior border of the mandible, and anterior mandible. Data were assessed using SPSS version 28 (IBM Corp., Armonk, NY). Statistical analysis was performed using an independent sample t-test and a paired t-test. P-values greater than 0.05 and 0.001 were considered significant., Results: Greater measurements had been recorded for the Pukhtoon ethnicity with respect to the vertical, horizontal, and area of the foramen. In relation to the dimensions, males showed larger measurements than females. MtF's distance to the alveolar crest, inferior border of the mandible, and anterior mandible (p < 0.001) was greater in Pukhtoon ethnicity. Males displayed longer measurements., Conclusion: CBCT proved to be a highly accurate and useful tool for the analysis of the dimensions and distances from the MtF in both ethnicities. The Pukhtoon ethnicity exhibited overall greater measurements with respect to the dimensions, highlighting a significant difference between the two ethnicities. Analysis of MtF distance to various landmarks resulted in longer measurements being observed in males and Pukhtoon ethnicity., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Jawatankuasa Etika Penyelidikan Manusia Universiti Sains Malaysia (JEPeM-USM) issued approval JEPeM-USM/21120828. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Alam et al.)

A 75-year-old woman with multiple comorbidities presented with altered mental status, bradycardia, and hypotension following the ingestion of tizanidine. Emergency medical services (EMS) promptly initiated pacing and administered vasopressors, leading to the patient's recovery to her baseline condition after receiving supportive care. ECG findings indicated pre-existing cardiac abnormalities. She was admitted to the intensive care unit for further observation and management and was later discharged in stable condition. This case underscores the potential for severe adverse effects of tizanidine and highlights the critical need for timely recognition and intervention., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Morgom et al.)

Autoimmune encephalitis (AE) is a rare yet critical neurological disorder characterized by inflammation of the brain, typically triggered by an abnormal immune response. The early detection and diagnosis of AE are crucial for effective treatment and improved patient outcomes. However, the diagnostic process is often complicated by the diverse clinical presentations of AE, which can mimic other neurological and psychiatric conditions. Currently, diagnosis relies on a combination of clinical evaluation, neuroimaging, cerebrospinal fluid analysis, and the detection of specific autoantibodies. Despite advances in these areas, challenges remain, particularly in cases where patients are seronegative or present with nonspecific symptoms. This narrative review provides a comprehensive overview of emerging biomarkers for the early detection of AE, highlighting their potential to enhance diagnostic accuracy and speed. We explore a variety of biomarkers, including novel autoantibodies, inflammatory markers, cytokines, and neuronal damage indicators, and discuss their clinical implications. This review emphasizes the need for biomarkers that are not only sensitive and specific but also accessible and rapid to facilitate earlier diagnosis and treatment. By synthesizing current research, this review aims to contribute to the ongoing efforts to refine the diagnostic approach to AE, ultimately improving outcomes for patients affected by this challenging condition., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Bokhari et al.)

Background Rheumatoid arthritis and psoriatic arthritis patients have dysregulated immune system parameters that may increase infection risk at baseline. In addition, treatment of these conditions with immunosuppressive medications may lead to the development of secondary immunodeficiency (SID). Our objective was to assess SID in a cohort on immunosuppressive medications. We hypothesized that SID is clinically detectable by assessing immune parameters and polysaccharide and protein-based vaccination responses. Methodology A prospective cohort study of 42 subjects on immunosuppressive medications was assessed. Analysis included immunoglobulin levels, lymphocyte subsets, and two-step response to diphtheria, tetanus, and 23-valent Streptococcus pneumoniae vaccinations. Exclusions included primary immunodeficiency, malignancy, pregnancy, neutropenia, immunoglobulin replacement, prior B-cell-depleting medication or chemotherapy, use of non-immunosuppressive medication, or recent use of glucocorticoids. Suboptimal vaccine response was defined as an abnormal response based on standard criteria for each vaccine. Results Low IgM levels (below 50 mg/dL) occurred in seven (17%) subjects and IgG (below 650 mg/dL) in three (7%) subjects. Impaired lymphocyte subsets were uncommon. In total, 33 (78%) subjects completed the two-step vaccination assessment. Overall, 29 of 33 (88%) subjects demonstrated suboptimal response to pneumococcal vaccination, 10 (30%) demonstrated suboptimal response to diphtheria, and four (12%) to tetanus. Two (6%) subjects demonstrated suboptimal response to all vaccinations. Finally, 31 (94%) subjects demonstrated suboptimal response to at least one vaccination. Conclusions SID may develop, is clinically detectable, and most notably demonstrated in suboptimal responses to polysaccharide vaccinations, especially against S. pneumoniae ., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Rochester Regional Health Institutional Review Board issued approval 2150 B. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: Shahzad Mustafa declare(s) a grant from Takeda. The grant is not related to the current manuscript. Shahzad Mustafa declare(s) personal fees from Genentech, Astra Zeneca, GSK, Regeneron, CL Behring. Speakers bureau. Allison Ramsey declare(s) personal fees from GSK, Sanofi/Regeneron, AstraZeneca. Speakers bureau. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Ocon et al.)

Cirrhosis is a common liver condition caused by several etiologies including alcohol use disorder, infectious hepatitis, and metabolic dysfunction associated with liver disease. Although common symptomatic complications of cirrhosis include malaise, gastrointestinal bleeding, and abdominal distension, shortness of breath is a less common phenomenon that may occur. Hepatic hydrothorax (HH) is an uncommon cause of shortness of breath that is believed to be caused by the accumulation of ascitic fluid in the pleural space. While most cases of HH occur with ascites and the right side, we hereby present a case of a 70-year-old female with left-sided HH without ascites., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Trivedi et al.)

Tuberculosis (TB), which is predominantly caused by Mycobacterium tuberculosis (MTB), poses severe diagnostic hurdles, especially with pulmonary tuberculosis (PTB), which spreads by aerosols. Sputum culture, the gold standard for MTB diagnosis, is time-consuming, expensive, and easily contaminated. The GeneXpert MTB/RIF (Xpert) assay, a molecular diagnostic tool, can quickly detect MTB and rifampicin (RIF) resistance. However, the ability to identify both live and non-viable MTB DNA, for example, in patients with a previous history of pulmonary tuberculosis or sampling from a contaminated bronchoscope, can result in false positives, as demonstrated in this case series. We present three cases of PTB diagnosed with Xpert, each with no conventional TB symptoms., Competing Interests: Human subjects: All authors have confirmed that this study did not involve human participants or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Bagrecha et al.)

Microbial detection and antimicrobial resistance (AMR) surveillance are critical components of public health efforts to combat infectious diseases and preserve the efficacy of antimicrobial agents. While foundational in microbial identification, traditional cultural methods are often laborious, time-consuming, and limited in their ability to detect AMR markers. In response to these challenges, innovative paradigms have emerged, leveraging advances in molecular biology, genomics, proteomics, nanotechnology, and bioinformatics. This comprehensive review provides an overview of innovative approaches beyond traditional cultural methods for microbial detection and AMR surveillance. Molecular-based techniques such as polymerase chain reaction (PCR) and next-generation sequencing (NGS) offer enhanced sensitivity and specificity, enabling the rapid identification of microbial pathogens and AMR determinants. Mass spectrometry-based methods provide rapid and accurate detection of microbial biomarkers, including matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) and biosensor technologies. Nanotechnology approaches, such as nanoparticle-based assays and nanopore sequencing, offer novel platforms for sensitive and label-free detection of pathogens and AMR markers. Embracing these innovative paradigms holds immense promise for improving disease diagnosis, antibiotic stewardship, and AMR containment efforts. However, challenges such as cost, standardization, and integration with existing healthcare systems must be addressed to realize the full potential of these technologies. By fostering interdisciplinary collaboration and innovation, we can strengthen our ability to detect, monitor, and combat AMR, safeguarding public health for generations., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Ahmad et al.)

Adrenal insufficiency (AI) is a rare but potentially life-threatening endocrine disorder characterized by inadequate production or impaired response to adrenal hormones. Symptoms may range from acute emergent crisis presenting as hemodynamic shock or may be more chronic in presentation with a gradual onset of nonspecific symptoms. These vague symptoms are often accompanied by typical laboratory findings, such as hyponatremia, hypotension, and hyperkalemia, and point toward a diagnosis of chronic AI. In this case presentation, we demonstrate chronic AI presenting with severe hyponatremia, which was revealed after return to an euvolemic baseline. Because of an insidious presentation, AI can be both an incidental finding and easily missed. This case highlights the importance of evaluating suspected cases of AI at a baseline metabolic and hemodynamic state, including volume status. High clinical suspicion is warranted in these patients to avoid potential emergent adrenal crisis and to provide appropriate replacement therapy once etiology is established., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Bathla et al.)

Background Helicobacter pylori ( H. pylori ) is one of the most prevalent causes of chronic gastritis that can lead to gastric cancer if left untreated. Currently, endoscopy and histology are the gold standard tests for the diagnosis of H. pylori gastritis. Recently, studies have shown the utility of narrow-band imaging (NBI) in predicting H. pylori gastritis. Therefore, we aimed to determine the diagnostic accuracy of NBI in predicting H. pylori gastritis in patients with dyspepsia. Methodology After obtaining approval from the Ethical Review Committee, Sindh Institute of Urology and Transplantation, this cross-sectional study was conducted in the outpatient Clinic of Hepatogastroenterology of the institute. Inclusion criteria involved all patients of either gender aged 18 to 65 years with dyspeptic symptoms. We excluded patients with a history of proton pump inhibitor use within two weeks before endoscopy, heart failure, previous gastrectomy, portal gastropathy, cirrhosis, use of antiplatelet medications, non-steroidal anti-inflammatory drugs or anticoagulant medication, and hemorrhagic or thrombophilia disorders. Each patient underwent endoscopy-guided NBI studies followed by biopsies from the antrum and body of the stomach. Multivariate logistic regression analysis was performed for the type of NBI pattern predicting H. pylori infection. The diagnostic accuracy was obtained individually for each NBI type and then for the presence of either two or all three NBI types in predicting H. pylori gastritis. Results Out of the total 775 patients enrolled in the study, abnormal NBI patterns were observed in 401 (51.7%) patients. The presence of abnormal NBI antral mucosal pattern on endoscopy was significantly associated with H. pylori infection (p < 0.001) with excellent diagnostic accuracy. Among the three NBI types, individually, NBI type III had excellent specificity and better diagnostic accuracy in predicting H. pylori gastritis than the other two types. Furthermore, the presence of all three abnormal NBI patterns (I+II+III) together was significantly associated with the presence of H. pylori gastritis with a sensitivity of 94.54%, specificity of 86.55%, and diagnostic accuracy of 90.32%. Conclusions NBI on endoscopy shows excellent diagnostic accuracy in identifying H. pylori gastritis in patients with dyspepsia. However, multicenter studies are required not only to validate our results but also to predict the pre-cancerous lesions on NBI in patients with H. pylori gastritis., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Liaquat Memon et al.)

Background Teeth clenching in weightlifters is a common finding that may result in temporomandibular disorders (TMDs). This study aimed to evaluate the severity and frequency of TMDs among weightlifters at fitness centers in Saudi Arabia. Methods A cross-sectional study was designed to collect data from weightlifters at fitness centers. A non-probability convenient sampling technique was applied using a valid and reliable Fonseca's questionnaire on a Google Sheet (Google, Mountain View, CA) to collect participant data. The survey was conducted from November 2022 to April 2023. Epi Info software (CDC, Atlanta, Georgia) was used to calculate the sample size, and a minimum sample of 278 was required. The data underwent analysis using SPSS version 20 (IBM Corp., Armonk, NY). Results Data analyzed from 375 participants revealed that 192 (51.2%) had mild signs of TMD, whereas 128 (34.13%) of the respondents had no symptoms of TMD. A significant difference was observed among female participants in all the temporomandibular joint severity categories. A statistically significant difference was observed between both genders concerning frequent headaches, earache, and nervousness. Conclusion The prevalence of TMD is high worldwide. Unsupervised athletic activity may result in the occurrence of TMD. Fonseca's questionnaire findings reveal a mild prevalence of TMD in weightlifters., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Mansour Ibrahim Alrowdan et al.)

Despite the extensive research conducted on the relationship between transforming growth factor-beta 1 (TGF-β1) polymorphisms and levels and the onset and development of liver disease, there are still certain gaps that need to be addressed. To address these gaps and provide a comprehensive overview of the current knowledge, this review aimed to identify relevant published research on TGF-β1/TGF-β1 polymorphism, TGF-β1/TGF-β1 levels, and their associations with cirrhosis and hepatitis C. The synthesis of available data was performed to further enhance our understanding in this area. Adopting the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, a search strategy was implemented across several online databases to search for relevant articles as per the defined selection criterion. Eight studies were selected after the completion of the search strategy. Of the eight studies, five revealed a considerably high level of TGF-β1 in patients who had hepatitis C virus (HCV) and liver cirrhosis caused by hepatocellular carcinoma (HCC). The forest plot analysis showed a statistically significant impact of TGF-β1 polymorphism and levels on the incidence of hepatic cirrhosis and hepatitis C, with an odds ratio (OR) of 0.65 and a risk ratio (RR) of 0.76. The heterogeneity test showed a high level of heterogeneity at 94% and 95% for OR and RR, respectively, but the overall effect was significant with P  < 0.01 for both measures. According to the results obtained, the authors concluded that TGF-β1 polymorphism and its associated levels should be taken into account while developing preventive and therapeutic approaches for hepatic cirrhosis and hepatitis C., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Punia et al.)

Introduction: The model for end stage liver disease (MELD), model for end stage liver disease-sodium (MELD Na), and Child-Turcotte-Pugh (CTP) score are independent predictors of mortality in cirrhotic patients. Approximately 43% of cirrhotic patients with advanced disease are frail and can have detrimental effects on the disease prognosis and survival including delisting from the transplant list and increased risk of post-transplant complications. Therefore, our aim was to determine the correlation of MELD, MELD-Na, and CTP score with frailty in patients with hepatitis C virus (HCV) related cirrhosis., Methods:  This cross-sectional study was conducted at the Department of Hepato-gastroenterology, Sindh Institute of Urology and Transplantation from 1 st  January 2022 to 30 th  June 2022. All the patients of either gender aged between 18 and 70 years with serological evidence of HCV and features of cirrhosis on ultrasound abdomen were included in the study. Patients with conditions over estimating frailty were excluded from the study. Liver Frailty Index (LFI) was calculated using grip strength measured in kilograms, timed chair stands, and balance testing. CTP and MELD-Na scores for each patient were also recorded. All the data were analyzed using SPSS version 22.0 (IBM Corp., Armonk, NY). The correlation of MELD, MELD-Na, and CTP with LFI was analyzed using the Pearson correlation coefficient and a p-value < 0.05 was considered statistically significant., Results:  A total of 274 patients were included in the study. Out of them, 185 (67.5%) were males. The mean CTP score was 8.1 + 2.1, MELD score of 13.6 + 7.1, MELD-Na score of 15 + 6.6, and LFI of 4.1 + 0.83. LFI was found to be weakly correlated with MELD (r = 0.278) (p < 0.001), MELD-Na score (r = 0.41) (p < 0.001), and CTP score (r = 0.325) (p < 0.001)., Conclusion:  Weak correlation was noted between LFI, CTP, MELD, and MELD-Na scores in HCV-associated chronic liver disease. Therefore, frailty along with MELD, MELD-Na, and CTP must be assessed before considering the patients for liver transplantation., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Panezai et al.)

Background Venous thromboembolism (VTE) is a condition that occurs when a blood clot forms in veins. Hospitalization increases the risk of VTE so timely risk assessment and adequate prophylaxis for VTE should be done to prevent this potentially fatal complication. Local problem Data from developing countries regarding VTE prophylaxis is scarce. VTE is a neglected area of research in Pakistan. So this closed-loop clinical audit was conducted to evaluate the VTE risk assessment and prophylaxis practices and to analyze the importance of educational intervention in improving the standard of care. Patients and methods We adopted the National Institute for Health and Care Excellence (NICE) guidelines for VTE prophylaxis as an audit standard. We collected data on a specially designed proforma by prospectively reviewing the hospital notes of patients in the Medical Ward of Northwest General Hospital and Research Center, Peshawar, Pakistan. Phase A included 60 patients and after educational intervention, Phase B was conducted with 90 patients. Intervention The results of Phase A were presented in the Clinicopathological Conference (CPC) meetings of the hospital. Healthcare workers were educated regarding the risks of VTE and the importance of timely prophylaxis. Posters were also displayed in the ward for highlighting the importance of VTE prophylaxis. Results In Phase A, only 5% of patients were risk assessed for VTE and of those eligible for prophylaxis only 22.2% received the prescription. Phase B showed a significant adherence to standard practices. In Phase B, 100% of patients were risk assessed for VTE and 75% received the prophylaxis. Conclusion There was poor compliance with standard VTE risk assessment and prophylaxis prescribing practices. However, a simple and effective educational intervention markedly improved patient care in terms of VTE strengthening the impact of clinical audits in the improvement of care., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Shah et al.)

Objectives To evaluate the antibiotic antibiogram in patients with complicated urinary tract infections (cUTIs) presenting to a Nephrology unit of South Waziristan. Methods A cross-sectional study was conducted at the Department of Nephrology, Sholam, South Waziristan. The study included all patients who presented with cUTIs and the symptoms included urinary urgency, hematuria, dysuria, suprapubic discomfort, and increased frequency. Those patients with clinical manifestations but are on antibiotics within the past five days were excluded. Results A total of 158 patients were included in the study with 113 (71.5%) females and 45 (28.5%) males. A total of 95 (60%) cases had gram-negative microbes, 47 (30%) had gram-positive cocci, and 16 (10%) had candida infection. In our study, the highly prevalent uropathogenic gram-positive bacteria showed the highest sensitivity to Linezolid, Rifampicin, and Vancomycin. Methicillin-resistant staph aureus was detected in 25% of isolates. All isolates of candida were sensitive to fluconazole. Gram-negative bacteria were highly resistant to ceftazidime, cefepime, ceftriaxone, and ciprofloxacin. Conclusion The development of bacterial resistance against multiple antibiotics is a global crisis that restricts the drug of choice for the treatment of cUTIs. In our study, we showed that overall, E.coli (gram negative) and S. Aureus (gram-positive) showed variable resistance to many antibiotics including ceftazidime, cefepime, piperacillin-tazobactam, ceftriaxone, and clindamycin., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Kaleem Baloch et al.)

Background This study aimed to assess the bacterial profile of diabetes patients with an infected foot and their antimicrobial susceptibility pattern in a tertiary care hospital. Methodology We conducted a six-month prospective study at a hospital in Peshawar, Pakistan. Demographics and clinical characteristics such as age, sex, type and duration of diabetes, glycemic control, presence of retinopathy, nephropathy, neuropathy, peripheral vascular disease, ulcer size, outcomes, and the number of admitted days at the facility were collected. Pus or discharges from the ulcer base and debrided necrotic tissue were obtained. Gram staining was performed on the samples which were isolated on chocolate agar and MacConkey agar. Incubation was done for 24 hours at a temperature of 37°C, and isolates were identified using standard bacteriological methods. The Kirby-Bauer testing method was used to assess antibiotic susceptibility. Results A total of 200 patients received a diagnosis of diabetic foot ulcer at the hospital during the study period. The age of the patients ranged from 24 to 92 years, with a mean age of 58.12 years (standard deviation (SD) = 12.494). The mean HbA1c level was 9.33% (SD = 2.050). The mean duration of diabetes mellitus was 12.3 years (SD = 6.181). In total, 96 (66.2%) isolates were gram-negative bacteria, while 49 (33.8%) were gram-positive bacteria. Among the gram-negative bacteria, Pseudomonas spp. was the most reported (15.9%), whereas methicillin-resistant Staphylococcus aureus was the most reported gram-positive bacteria (20.7%). Amikacin was found to be the most effective (45%) in treating diabetic foot ulcers, followed by tineam and meropenem being equally effective at a susceptibility of 44%. The highest resistance of the microbes was to the drug trimethoprim (44.5%). Conclusions The pathogens causing diabetic foot ulcers show sensitivity to many of the routinely used medications. However, resistance is being developed to some of the antibiotics such as trimethoprim. Therefore, the culture of the specimen to identify the causative agent and adequate knowledge of the susceptibility pattern are critical for the appropriate management of diabetic foot ulcers., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Ahmad et al.)

Background No scoring system is available to predict the extent of resection of giant pituitary adenomas (GPAs) based on magnetic resonance imaging (MRI) parameters. We developed a novel AKU Giant Pituitary Adenoma (AGPA) score and assessed the predictive ability of the scoring system concerning the extent of resection of GPAs. Methodology We retrospectively collected data of patients presenting with GPAs and used our scoring system to assess the surgical resection of these tumors. The Lundin-Pederson (ABC/2) method was used to calculate the pre- and post-resection tumor volume. The relationship between the extent of resection and the AGPA score was assessed using linear regression. The AGPA score considered the tumor's extension into various planes. The maximum total score was 9. Results The scoring system was applied to 45 patients with GPA who underwent surgical resection. The mean resected tumor volume (%) was 82.0 ± 16.7, and the overall mean AGPA score was 4.2 ± 0.8. The pairwise correlation between the resected tumor volume and the overall AGPA scores showed a strong inverse association (r = -0.633, p < 0.001). A significant difference was detected between the estimated scores of 3 and 5 and 4 and 5 (p < 0.001). Conclusions AGPA score is inversely related to the extent of the tumor to be resected, which would help surgeons predict the amount of tumor resection possible as well as predict the difficulty of surgery and plan optimal preoperative patient counseling. In addition, it can predict if staging and a transcranial approach are required., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Enam et al.)

Coronavirus disease 2019 (COVID-19) has various neuropsychiatric manifestations, including psychotic, mood, anxiety disorders, trauma-related disorders, and cognitive disorders, such as delirium. Although the psychosocial effects of the COVID-19 pandemic contribute to an increase in psychiatric comorbidities, the COVID-19 virus is also an independent risk factor. Previous studies have revealed that the virus can invade the neural tissue, which causes an imbalance of neurotransmitters that cause neuropsychiatric symptoms. The aim of this article is to conduct a systematic review to determine the patterns of neuropsychiatric manifestations of COVID-19, discussing the frequency and its impact on pre-existing psychiatric disorders. Thirty-nine case reports were collected and analyzed for a systematic review. They were full-text, peer-reviewed journal publications from November 2020 to February 2021. Fifty-three patients were included in our study. The most frequent symptom was abnormal/bizarre behavior (50.9%), followed by agitation/aggression (49.1%), and the third most common was altered mental status and delirium (47.2%). Only 48% of our patients had a pre-existing psychiatric disorder, including three not formally diagnosed but displayed psychiatric symptoms prior to the COVID-19 infection. Findings suggest a positive correlation of new-onset psychiatric symptoms with the SARS-CoV-2 virus. However, the exact pathophysiology of the virus itself causing neuropsychiatric manifestations needs to be investigated further., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Idehen et al.)

Vertebrobasilar angioplasty and stenting or mechanical thrombectomy (MT) using a stent retriever or suction thrombectomy are effective interventions in managing acute ischemic stroke caused by vertebrobasilar artery occlusion (VBAO). This study aims to investigate the safety and efficacy of self-expanding stents and balloon angioplasty in managing ischemic stroke. We reviewed the literature for relevant clinical trials and included those reporting the following primary outcomes: successful recanalization, favorable clinical outcome, and stenosis degree change. We included 24 studies (858 patients). In the subgroup analysis, participants were divided into three main subgroups based on the type of intervention: mechanical thrombectomy (MT), percutaneous transluminal angioplasty and stenting (PTAS), and MT+PTAS. Regarding overall mortality, the incidence was 34.5%, 9.9%, and 28.9% in the MT, PTAS, and MT+PTAS groups, respectively. The incidence of arterial dissection was 3.6% in the MT group, 3.1% in the PTAS group, and 16.7% in the MT+PTAS group. Incidence of distal embolization, MT, PTAS, and MT+PTAS groups had 3.4%, 5.8%, and 9.5% incidence rates, respectively. Favorable clinical outcomes were reported in 42.8% of subjects in the MT+PTAS group, 64.7% in the PTAS group, and 39.2% in the MT group. The incidence of intracranial hemorrhage was 5.2%, 4.5%, and 15.3% in the MT, PTAS, MT + PTAS groups, respectively. The incidence of successful recanalization was 85.3% in the MT group, 99.4% in the PTAS group, and 92.7% in the MT+PTAS group. Our analysis concludes that PTAS is the most effective intervention for VBAO and is associated with a lower rate of mortality compared to mechanical thrombectomy alone., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Nso et al.)

Renal dysfunction is a common comorbidity in patients with advanced heart failure who may benefit from mechanical circulatory support (MCS). Unfortunately, renal function may result after left ventricular assist device (LVAD) implantation. The purpose of this study is to examine the outcomes of advanced heart failure patients with end-stage renal disease (ESRD) requiring mechanical circulatory support as a bridge to transplant (BTT) or destination therapy (DT). We searched Medline, Embase, and Cochrane in September 2021. The following keywords were used: left ventricular assist device or LVAD and end-stage renal disease or ESRD. Our study included case reports, case series, descriptive studies, and randomized control trials. Review articles, guidelines, systematic reviews, and meta-analyses were excluded. We also excluded pediatric cases. We identified 278 articles; 92 were duplicated, 186 articles entered the screening phase, and 133 articles were excluded by title and abstract. After the full-text screening, 40 articles were excluded. This systematic review included 13 articles. Among the contraindications to LVAD implantation, a general contraindication is for patients found to have stage 4 chronic kidney disease (CKD) (estimated glomerular filtration rate (eGFR): <30 mL/minute/1.73 m 2 ), while those on dialysis are an absolute contraindication LVAD implantation. Despite the limited data and publications on LVADs in patients with ESRD, LVAD implantation as a bridge to transplantation or destination therapy may be considered in selected patients without increasing morbidity and mortality. Therefore, shared decision-making around the treatment of advanced heart failure with these patients and the care team is essential., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Lakhdar et al.)

Stent thrombosis (ST) is a frequently reported complication in cardiac patients with percutaneous coronary intervention (PCI) that adversely impacts their prognostic outcomes. Medical literature reveals several baseline characteristics of PCI patients that may predict their predisposition to ST and its potential complications. Our systematic review and meta-analysis aimed to determine the diagnostic significance of these baseline parameters in terms of determining the risk of ST among adult patients with PCI.  We statistically evaluated 18 baseline characteristics of more than 15,500 PCI patients to delineate their stent thrombosis attribution. We included a number of articles focusing on baseline parameters in-stent thrombosis-related PCI scenarios. We explored the articles of interest based on inclusion/exclusion parameters across PubMed, JSTOR, Cochrane library, Google Scholar, and Embase. Medical subject headings (MeSH) words included "stent thrombosis," "percutaneous coronary intervention," and "coronary stenting." We extracted the research articles published between 2005 and 2021 on April 20, 2021. The included studies also focused on procedures and clinical factors concerning their association with PCI-related ST. Our findings ruled out the progression of abnormal left ventricular ejection fraction (LVEF)-related stent thrombosis in PCI patients (odds ratio {OR}: 9.68, 95% CI: 1.88-49.90, p=0.007). We found an insignificant clinical correlation between stent thrombosis and PCI in the setting of acute coronary syndrome (ACS). Our study outcomes further revealed the absence of stent thrombosis in PCI patients with antiplatelet prescription (OR: 32.42, 95% CI: 21.28-49.39). The findings affirmed the absence of ST in PCI patients receiving aspirin therapy (OR: 32.77, 95% CI: 18.73-57.34; OR: 4.59, 95% CI: 1.97-10.73). The majority of the included studies negated the clinical correlation of stent thrombosis with diabetes mellitus in the setting of PCI (OR: 0.49, 95% CI: 0.06-3.78). Our study did not reveal statistically significant results based on stent thrombosis in PCI patients with drug-eluting stents (OR: 2.91, 95% CI: 0.35-24.49). The findings also did not reveal the impact of cardiac biomarker elevation on stent thrombosis in PCI patients (OR: 8.42, 95% CI: 2.54-27.98, p=0.0005). Eight studies revealed a statistically insignificant correlation between myocardial infarction and stent thrombosis in PCI scenarios (OR: 2.69, 95% CI: 0.89-8.11, p=0.08). The clinical correlation between PCI and stent thrombosis/major bleeding in the setting of hypertension also proved statistically insignificant at 0.67 (OR: 1.31, 95% CI: 0.38-4.51, p=0.97). The study findings did not correlate mean body mass index and multivessel coronary artery disease with ST in PCI scenarios (OR: 1.98, 95% CI: 0.02-239.58, p=0.78; OR: 1.09, 95% CI: 0.58-2.04, p=0.80). Only two studies revealed statistically significant results confirming stent thrombosis in PCI patients with a prior history of PCI (OR: 0.49, 95% CI: 0.23-1.06; OR: 0.33, 95% CI: 0.02-5.59; p=0.03). Our findings question the clinical significance of baseline characteristics in terms of predicting stent thrombosis in PCI patients. The results support the requirement of future studies to investigate complex interactions between procedural, medicinal, genetic, and patient-related factors contributing to the development of stent thrombosis in PCI patients., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Nso et al.)

Cardiac rehabilitation programs support the health, wellness, and recovery of patients with cardiovascular conditions. This systematic review attempts to expand these findings while analyzing the latest randomized controlled trials (RCTs) focusing on the long-term advantages of home/center-based cardiac rehabilitation interventions. This study also comparatively analyzes the benefits of opting for home-based cardiac rehabilitation instead of center-based measures to improve the long-term clinical outcomes of cardiac patients. We extracted and analyzed 10 studies (based on 1,549 cardiac patients) concerning the therapeutic efficacy of center/home-based cardiac rehabilitation interventions. The included studies complied with the year range of 2000-2021. The risk of bias assessment was undertaken using the Cochrane Risk-of-Bias tool to evaluate random sequence generation, allocation concealment, blinding of subjects, outcome data completeness, and selective reporting patterns concerning the included RCTs. The findings of our systematic review confirmed the capacity of a home-based cardiac rehabilitation program to effectively improve left ventricular ejection fraction, health-related quality of life, physical fitness, recovery rate, self-efficacy, sedentary lifestyle, physical activity, satisfaction level, functional capacity, social support, and hemodynamic parameters of patients with cardiovascular diseases. Home-based cardiac rehabilitation had the potential to minimize the levels of triglycerides, anxiety, depression, waist circumference, and body mass index/weight of cardiac patients. The results of our systematic review affirmed the long-term therapeutic efficacy of a home-based cardiac rehabilitation program compared to a center-based cardiac rehabilitation program for adult cardiac patients., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Nso et al.)

Background: Emergency Medicine didactic teaching has traditionally been delivered through face-to-face (F2F) lectures. However, during the pandemic of COVID-19, the didactic teaching was switched to online through using Microsoft Teams. The aim of this study was to assess the impact of online learning in the knowledge and skills acquisition of millennial learners based within emergency medicine., Methodology: This was a retrospective review of assessment data. Over a period of 10 months (August 2019 to June 2020), each resident was exposed to traditional F2F teaching for a period of four months and then online teaching in a crossover manner. After each method, there were two types of assessments, multiple-choice questions (MCQs) and computer-based objective structured clinical examination (OSCE). A total of 20 MCQs with one correct answer, totaling 20 marks, and 20 OSCEs consisting of an image or a video with five options, each option carrying one mark, totaling 100 marks were used at each assessment point. A student t-test was used to compare the two groups of results., Results: The total number of participants was 49 (n=49). All residents belonged to the millennial generation. Fourteen were female and 35 were male. The mean MCQ 1 score after F2F teaching was 12.16 (SD=1.688), whilst the mean MCQ 2 score after online teaching was 13.40 (SD=1.861). The mean computer-based OSCE 1 score after F2F teaching was 64.45 (SD=5.895), whilst the mean OSCE 2 score after online teaching was 65.57 (SD=5.969). Ten out of 49 students (20.4%) failed the MCQ exam after F2F teaching, whilst 6/49 students (12.2%) failed the MCQ test after online teaching. Seven out of 49 students (14.3%) failed the OSCE exam after F2F teaching, while six out of 49 students (12.2%) failed the OSCE exam after online teaching. There was a statistically significant improvement in the MCQ score after online teaching as compared to F2F teaching (P-value 0.0003), whilst there was no statistically significant change in the OSCE between the two-teaching methods (P-value 0.3513)., Conclusion: Both F2F and online teaching methods resulted in a significant improvement in the knowledge and skills of emergency medicine residents. Online education resulted in a statistically significant improvement of MCQ score as compared to F2F teaching. The difference in MCQ score may be due to millennial learners, who traditionally benefit proportionately more from self-learning that is primarily online., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Bashir et al.)

Over the past decade, several trials have questioned the efficacy of vasodilator therapy in acute heart failure (AHF) in the absence of uncontrolled hypertension. In this article, we provide a unique review of the most valuable four trials that present the role of vasodilator therapy in the management of patients with AHF. These four trials have evaluated the efficacy of different types of vasodilators such as nesiritide, ulatritide, and serelaxin in the setting of AHF. Also, we compared comprehensive vasodilator therapy versus standard therapy to see if there is any effect on mortality and re-hospitalization., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Batool et al.)

Background : 3,4-methylenedioxymethamphetamine (MDMA), known recreationally as "Molly" or "Ecstasy", is a triple monoamine reuptake inhibitor. MDMA specifically acts as a weak 5-HT1 and 5-HT2 receptor agonist, targeting 5-HT 2A , 5-HT 2B , and 5-HT 2C  receptors. Its potential use for therapeutic purposes with these pharmacological profiles remains a controversial subject. Studies have shown the potential benefits in clinical trials for post-traumatic stress disorder (PTSD). A larger amount of data has been provided for the push in support of MDMA-assisted psychotherapy in these patients.  Objective : The aim of this article is to compute a meta-analysis and conduct a systematic review of the effects of MDMA on PTSD, discussing the potential benefits and adverse events relative to dosing and stability of treatment. Methods : Articles were collected and analyzed for systematic review: 16 articles were included in the systematic review that met the criteria for the use of MDMA in the treatment of PTSD as well as assessing the safety and efficacy of the drug in human participants. Ten studies were used for the meta-analysis, with a cumulative sample size of 168 patients. The significance of the findings on dosing and efficacy of MDMA in healthy human participants was quantified based on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and PTSD symptom scores. Results : The disorders for which MDMA demonstrated a net positive or net negative effect on symptoms are presented separately. Adverse events in patients across all disease classes are presented. The therapeutic index for patients who demonstrated a benefit is also presented. An odds ratio for beneficial and adverse events is used to determine treatment-resistant patients who may benefit from clinical trials of MDMA. Discussion : Findings show promising evidence for the potential therapeutic use of MDMA alongside psychotherapy in the treatment of PTSD. The pharmacological profile of MDMA may provide direction for future drug developments to treat patients with treatment-resistant psychiatric disorders., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Tedesco et al.)

Background This study aimed to evaluate the role of disturbed circadian rhythm in potentiating intensive care unit (ICU)-acquired delirium.Previous studies have demonstrated bright light therapy (BLT) as an effective modality to improve sleeping patterns and cognitive function in non-critically ill patients. However, its benefit in the ICU has not been clearly established. In this study, we aimed to evaluate the application of daily high-intensity phototherapy at the bedside to deter ICU delirium incidence and duration. Methodology This was a single center, prospective study conducted in ICUs at the Carilion Roanoke Memorial Hospital in Roanoke, VA. Adults patients admitted to the ICU from July 9, 2018 to March 20, 2020 were included in the study. The patients were subjected to 30-minute BLT session (10,000 lux) at the bedside starting at 0700 while in the ICU. Patients were randomized into either the control group (standard hospital lighting) or phototherapy group. Data were analyzed using Wilcoxon rank sum test for continuous variables, Pearson chi-square test for categorical variables, and logistic regression for multivariable analysis that examined significant risk factors for ICU delirium. Results Delirium incidence between BLT (18%) and control (17.5%) groups was non-significant. Total number of delirium-free, coma-free days, as determined by Confusion Assessment Method for the ICU, demonstrated no differences between groups with a median of 28 days (p = 0.516). In multivariable analysis, patients with a Sequential Organ Failure Assessment Score >3 also showed no significant change in ICU delirium incidence when provided bedside BLT compared to those with standard hospital lighting (odds ratio: 0.08; 95% confidence interval: 0.002-1.40; p = 0.867). Conclusions In this randomized control pilot study, daily morning 10,000 lux BLT of 30-minute duration alone was not associated with a significant decrease in ICU-acquired delirium incidence or duration compared to standard hospital lighting. Future studies should consider a nuanced approach to better elucidate the role of disturbed circadian rhythm in influencing ICU-acquired delirium by not only undertaking BLT during the day but also minimizing nighttime light exposure., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Zhang et al.)

Introduction Alzheimer's disease is associated with low bone mineral density. Various studies have linked early-onset Alzheimer's disease with bone health. In this study, we will determine the association between bone health and recently diagnosed Alzheimer's disease in the local population. Methods This case-control study was conducted at the neurology unit from April 2019 to Sept 2019. One hundred and fifty (150) Alzheimer's patients with recently (within the last six months) confirmed diagnoses, based on clinical symptoms, mental status, and computed tomography (CT) scan, were included from the neurology outpatient department. The gender and age-matched 150 healthy participants were included in the study as the reference group. Various parameters of bone health and mental status were measured. Results Participants with Alzheimer's had a significantly lower level of serum vitamin D (15.2 ± 4.2 ng/mL vs. 27.5 ± 8.1 ng/mL, p-value: < 0.0001) and lower level of serum osteocalcin (4.3 ± 1.7 ng/L vs. 5.6 ± 2.0 ng/L, p-value: < 0.0001). Participants with Alzheimer's disease had more people with T-score ≤ -2.5 as compared to the general population (52.0% vs. 16.6%, p-value <0.0001). Conclusion Alzheimer's disease is associated with poor bone health as compared to the general population of the same age. Bone health can be an important parameter to screen patients at risk of Alzheimer's disease. The management of Alzheimer's disease should include a regular assessment of bone health, and the treatment plan should include therapies to improve bone health., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Kumar et al.)

Introduction The prolonged fluoroscopic time during coronary angiography results in a higher radiation dose delivered to patients. Similarly, a higher contrast volume used is associated with higher rates of contrast-induced nephropathy. This study was designed to identify the better technique in terms of lesser fluoroscopic time and volume of contrast used during the procedure. Objective To compare mean fluoroscopic time and mean contrast volume used in patients undergoing coronary angiography through the transfemoral versus transradial route. Methods A randomized controlled trial (RCT) was conducted at the department of cardiology, Pakistan Institute of Medical Sciences (PIMS) Islamabad between June 2017 and December 2017. Ninety (n=90) patients planned for coronary angiography between 30 and 70 years of age were enrolled. Patients were randomly allocated to Group A (transfemoral route group) and Group B (transradial route group). Fluoroscopic time (minutes) and contrast volume (milliliters) used were measured in each patient. Results The mean contrast volume used in Group A was 70.4 ml (SD=8.7) and in Group B, it was 90.1 ml (SD=9.8) (P<0.001). The mean fluoroscopic time in Group A was 5.1 min (SD=1.2), and in group B, it was 8.6 min (SD=1.2) (P<0.001). Similar trends were noted when data were stratified with respect to age and gender. Conclusion The mean fluoroscopic time and the mean contrast volume were significantly less in patients where coronary angiography was performed through the transfemoral route than through the transradial route in this study., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Hasrat et al.)

Introduction Acute myocardial infarction (AMI) is a devastating medical emergency that requires immediate pharmacological and radiological intervention. With the advent of techniques such as percutaneous coronary intervention (PCI), pacemakers, and percussion pacing, survival rates have improved significantly. However, there are certain factors and complications associated with AMI that still lead to a high mortality rate, such as old age, advanced heart disease, diabetes mellitus (DM), and arrhythmias. Factors such as the type of arrhythmia, the heart rate, and the level at which dissociation occurs between atrial and ventricular rhythm all influence mortality and morbidity rates. Outcomes are further influenced by the sex of the patient, the type of AMI [ST-elevation myocardial infarction (STEMI) or non-ST-elevation myocardial infarction (NSTEMI)], history of smoking, arrival times at the hospital, presence of hyperglycemia, previous history of cardiac surgery, and the need for a temporary pacemaker or a permanent pacemaker. As with most scientific studies, local data from Pakistan is hard to find on this topic as well. With this study, we hope to contribute valuable information and updates to the study of a developing problem from the developing world. Objective We aimed to analyze the frequency and outcomes of different types of arrhythmia in AMI. Methods This study involved a retrospective observational cohort. It was conducted at the National Institute of Cardiovascular Diseases (NICVD), Karachi from January 2019 to July 2019 (six months). All data were retrieved from the online database at the NICVD. Written consent was obtained from all patients. Patient confidentiality was ensured at all times. Results A total of 500 patients were included in the study. The mean age of our cohort was 56.17 ±14.01 years. NSTEMI was more prevalent than STEMI. Sinus arrhythmia (SA) was the most frequently recorded arrhythmia and had the best survival rates. Atrioventricular (AV) nodal blocks and ventricular tachycardia (VT) had the worst outcomes. The overall mortality rate was 11.4%, and the mean in-hospital length of stay was 2.07 ±1.54 days. Smoking increased mortality in all cases. Conclusions AMI is complicated by several types of arrhythmia. SA is the most common arrhythmia in AMI. Mortality in AMI is largely due to AV nodal blocks and VT. Smoking increases mortality in all cases., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Mueed et al.)