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Introduction Anthracosis is black discoloration of the bronchi, which can sometimes cause anthracofibrosis. Usually, exposure to biomass fuel, air pollution, or smoke at the workplace causes it. The objective of the current study was to determine the association between tuberculosis and anthracosis. Methods Patients with chronic dyspnea, dry cough, and infiltrates or mass lesions on chest X-rays underwent bronchoscopic lavage and biopsy where needed. Patients were divided into two groups on the basis of anthracosis on bronchoscopy. Diagnosis of tuberculosis was made on bronchial wash acid-fast bacilli smear, mycobacterial culture, or Xpert Mycobacterium tuberculosis (MTB) rifampicin (RIF) assay. Results Tuberculosis was diagnosed by bronchoscopy in 68/173 (39.30%) patients with anthracosis which was significantly higher (p-value 0.020) than the control group (43/159, 27.04%). Most of the cases (54/68, 79.41%) had positive Xpert assay. The male-to-female ratio was 3:1, and all the females with anthracosis were homemakers and used biomass fuel. Conclusion Patients with exposure to smoke are prone to develop anthracosis. The presence of anthracosis is associated with the development of tuberculosis. Appropriate investigations for tuberculosis must be done in subjects undergoing bronchoscopy who are found to have anthracosis. Expanding understanding among the masses regarding the hazards of using biomass fuel in closed spaces can be a crucial measure toward diminishing the chance of developing anthracosis and the concomitant risk of tuberculosis., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Institutional Review Board Committee, Jinnah Postgraduate Medical Centre, Karachi issued approval F.2-81/2015-GEN/9820/JPMC. 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, Ahmed et al.)

Background: Small bowel imaging presents significant challenges due to the bowel's length, narrow caliber, and complex looping. Accurate diagnosis of gastrointestinal disorders often requires detailed imaging to differentiate various pathologies, such as inflammatory bowel disease (IBD), infections, ischemic conditions, and neoplasms., Introduction: The small bowel plays a crucial role in digestion and absorption and is susceptible to various pathologies. CT imaging is essential for diagnosing bowel wall thickening, which can indicate a range of conditions. Dual-energy CT (DECT) and CT enterography offer advanced imaging capabilities to address these diagnostic challenges. This study aims to evaluate the efficacy of CT in staging malignant lesions by correlating imaging findings with histopathology to enhance non-invasive diagnosis and treatment strategies., Methodology: This cross-sectional study was conducted over two years at Era's Medical College and Hospital, Lucknow, India, with 60 subjects. Patients with abnormal bowel wall thickening (>5 mm) on ultrasound were included, while those with renal dysfunction or pregnancy were excluded. After informed consent, subjects consumed a mannitol solution before undergoing CT scans using a 384-slice Dual Energy CT scanner (Somatom Force, Siemens Healthcare, Erlangen, Germany). All images were post-processed on a workstation using Synovia software (Synovia Solution, Fort Worth, Texas), which allows for image analysis using three-material decomposition. Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 26 (Released 2019; IBM Corp., Armonk, New York)., Results: The majority of patients were young adults aged 20-39 years (63.33%), with a slight male predominance (53.33%). Abdominal pain was the most common complaint (35.00%). Mild wall thickening (<10 mm) was associated with IBD (48.28%), while marked thickening (>10 mm) was linked to neoplastic lesions (48.39%). Symmetrical thickening was common in infective and inflammatory conditions, whereas asymmetrical thickening was typical of neoplastic lesions. CT scans demonstrated high diagnostic accuracy, with 83.33% sensitivity, 95.24% specificity, 88.24% positive predictive value, and 93.02% negative predictive value, resulting in an overall accuracy of 91.67%., Conclusion: The study highlights that neoplastic lesions are associated with marked bowel wall thickening, while inflammatory conditions present with mild thickening. CT scans proved highly effective in diagnosing gastrointestinal disorders, with significant accuracy in distinguishing between benign and malignant lesions. This underscores the importance of advanced imaging techniques in clinical practice for improved patient outcomes., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Institutional Ethics Committee, Era's Lucknow Medical College and Hospital issued approval ELMC and H/RCELL/2023/115. Ethical approval was granted by the Institutional Ethics Committee of Era's Lucknow Medical College and Hospital (Approval number: ELMC and H/RCELL/2023/115, dated December 28, 2023), in compliance with international and university standards, and written approval is preserved by the authors. 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, LNU et al.)

Background Coronary artery disease (CAD) is one of the major causes of death all over the world. Its severity evaluation through the Gensini scoring system is quite a complex process as these score systems require complex investigations and cardiologists. Therefore, this study aimed to determine the predictive capacity of neutrophil-to-lymphocyte ratio (NLR) for the severity of CAD in patients with myocardial infarction. Methods This cross-sectional study was performed on 208 patients with acute myocardial infarction whose coronary angiography was performed in the Department of Cardiology of Benazir Bhutto Hospital (BBH), Rawalpindi, Pakistan during the period of one year from January 2022 to March 2023. The enrollment of patients was made through purposive sampling and established inclusion and exclusion criteria. Ethical approval and informed consent were acquired before the data collection. Data was collected through a self-structured form. Vessel score and Gensini score were applied for the assessment of the severity of CAD. Patients were divided into two groups based on the Gensini score system. Data analysis was carried out in the Statistical Package for the Social Sciences (SPSS) version 25 (Released 2017; IBM Corp., Armonk, New York, United States). Both descriptive and inferential statistics were used to compare the study variables between the patients with non-severe CAD and patients with severe CAD. Pearson's correlation was used to determine the correlation between the NLR and the severity of CAD. A linear regression model was applied to evaluate the predictive capacity of the NLR for the severity of CAD. A p-value less than 0.05 was set as statistically significant. Results Out of 208 patients, 128 (61.53%) patients had non-severe CAD while 80 (38.47%) patients had severe CAD. Significant differences were observed in the Gensini mean scores, NLR values, and in the frequencies of hypertension, diabetes mellitus, dyslipidemia, and history of smoking, with p≤0.05 for all these variables, between the non-severe CAD group and severe CAD group. NLR was significantly correlated with the severity of CAD (p-value=0.001). Pearson's correlation coefficient was 0.71 for NLR with the Gensini scores. The simple linear regression model was valid (the p-value of the F test was <0.000), with beta coefficients of 2.60 (p=0.002) for NLR. The R 2 value was 0.80 (80%). Conclusions In the current study, a significant percentage of patients had severe CAD. Furthermore, a positive and significant association was noted between the NLR with the severity of CAD. This present study suggests that NLR is a reliable predictor of CAD severity; therefore, it could be used for risk stratification of cardiac patients with CAD., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Ethical Review Board of Benazir Bhutto Hospital issued approval BBH.ERB.283/288. 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, Ahmad et al.)

Background Ischemic stroke (IS) is a fatal complication of acute coronary syndrome (ACS). Factors that speed up IS development after ACS are understudied, especially in developing countries like Pakistan. Thus, this study was designed to identify the potential risk factors of IS in patients with a preceding episode of ACS. Methodology This retrospective study was performed on 208 patients whose ACS and its consequent complications such as IS were managed in the cardiac and neurology units of Benazir Bhutto Hospital, Rawalpindi, from January 2022 to March 2023. Patients were enrolled via consecutive sampling and pre-defined inclusion and exclusion criteria. Before data collection, informed consent and ethical approval were obtained. Data were retrieved from the medical records of the patients. A self-structured proforma was applied to collect data. SPSS version 25 (IBM Corp., Armonk, NY, USA) was used for data analysis. The study variables between patients with and without IS were compared using descriptive and inferential statistics. The association between IS and its possible risk factors in patients who had previously experienced ACS was determined using multivariate logistic regression. Results Of the 208 enrolled patients, 24 (11.54%) had IS following ACS. Sedentary lifestyle (odds ratio (OR) = 3.099, 95% confidence interval (CI) = 1.025~4.219, p = 0.009), hypertension (OR = 3.060, 95% CI = 1.798~4.876, p = 0.002), diabetes mellitus (OR = 2.899, 95% CI = 1.126~4.112, p = 0.009), dyslipidemia (OR = 2.907, 95% CI = 1.332~4.254, p = 0.007), history of smoking (OR = 2.760, 95% CI = 1.234~4.122, p = 0.018), and non-adherence to ACS medication (OR = 2.966, 95% CI = 1.300~4.266, p = 0.030), were the risk factors of IS among patients with preceding ACS. Conclusions In the study population, the incidence of IS following ACS was significant. Sedentary lifestyle, hypertension, diabetes mellitus, dyslipidemia, smoking history, and non-compliance with ACS therapy all played a significant role in the development of IS in patients with prior ACS. Proper management of ACS and associated risk factors could lead to the prevention of serious complications such as IS., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Ethical Review Board (ERB) of Benazir Bhutto Hospital, Rawalpindi issued approval BBH.ERB.283/101. 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, Riaz et al.)

Background Due to their potential to carry a wide range of bacteria, pigeon feces may contribute to the spreading of infectious diseases in urban settings.  Objective This study analyzed the presence of enteric bacteria from pigeon feces in Jeddah and their antimicrobial susceptibility and described the molecular characteristics of the carbapenem resistance genes it produced. Method Two hundred twenty-five pigeon feces specimens were collected from eight parks in Jeddah. Conventional microbiology techniques were employed to identify the isolated bacteria, and the automated Vitek2® system (bioMérieux, Marcy-l'Étoile, Lyon, France) provided additional confirmation. Kirby-Bauer disk diffusion method was utilized to screen for antimicrobial resistance. Only 50 antibiotic-resistance isolates further underwent molecular diagnosis for testing groups of carbapenems-encoding genes (blaNDM, blaSIM, and blaAIM), using multiplex polymerase chain reaction (PCR).  Result Of the 50 antibiotic-resistant isolates, 28% (14/50) were Klebsiella pneumoniae , 24% (12/50) were Enterobacter cloacae , and 48% (24/50) were Escherichia coli . Ninety percent (90%) of the isolates showed resistance to cefuroxime, 56% to gentamicin, 52% to amoxicillin/clavulanic acid, and 100% to meropenem. NDM beta-lactamase was the most often discovered gene (26%) and was followed by AIM beta-lactamase (5%) Conclusion According to this study, there may be a chance for resistant K. pneumoniae, E. cloacae , and E. coli to spread amongst several hosts within the same area. Consequently, to prevent the continued occurrence and dissemination of resistant strains among other hosts in the same location, it is essential to monitor the AMR (antimicrobial resistance) of E. coli, E. cloacae , and K. pneumoniae from pigeons., Competing Interests: Human subjects: All authors have confirmed that this study did not involve human participants or tissue. 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, Elsheikh et al.)

Background Postoperative acute heart failure (AHF) in elderly patients after hip fracture surgery is a common complication. Therefore, this study aimed to identify the risk factor of AHF after hip fracture surgery among the older population. Methods This retrospective cohort study was performed on 88 admitted patients whose hip fractures were fixed via internal fixation surgery in a tertiary care hospital in Rawalpindi, Pakistan, from January 2022 to March 2023. Recruitment of patients was made through established inclusion and exclusion criteria. Ethical approval and informed consent were also gained before the data collection. A self-designed form was used to collect data. Data analysis was carried out in the IBM SPSS Statistics for Windows, Version 25 (Released 2017; IBM Corp., Armonk, New York, United States). Both descriptive and inferential statistics were applied to compare the attributes of the patients with AHF and patients without AHF. Multivariate logistic regression was used to evaluate the association between the postoperative AHF and its potential risk factors. Results Out of 88 enrolled patients, 12 (13.64%) had developed postoperative AHF. Age ≥ 65 years (OR = 2.606, 95% CI = 1.035~4.160, p = 0.010), anemia (OR = 3.178, 95% CI = 1.847~5.990, p = 0.029), hypertension (OR = 2.019, 95% CI = 1.110~4.034, p = 0.012), diabetes mellitus (OR = 2.003, 95% CI = 1.115~4.012, p = 0.015), hypoalbuminemia (OR = 2.486, 95% CI = 1.218~4.619, p = 0.030), and operation time ≥ 120 minutes (OR = 1.702, 95% CI = 1.099~2.880, p = 0.018), were the risk factors of postoperative AHF in elderly patients after hip fracture surgery. Conclusions In the study population, the incidence of postoperative heart failure was significant and age ≥ 65 years, anemia, hypertension, diabetes mellitus, hypoalbuminemia, and operation time ≥ 120 were significantly involved in the development of it. Preoperative identification and management of AHF risk factors could lead to the prevention of postoperative complications., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Riaz et al.)

Introduction: Knowledge of anatomical landmarks is crucial for effective dental treatments, especially in surgical procedures. The mental nerve (MN), a branch of the inferior alveolar nerve, features a critical landmark known as the anterior loop (AL), often overlooked by surgeons. This study aims to assess the occurrence of the MN AL, its type, and its length within a sample of the Jordanian population by utilizing cone beam computed tomography (CBCT) scans., Methods: This retrospective observational study included the acquisition of CBCT images from a total of randomly selected 268 patients who sought treatment for a range of dental conditions (such as tooth extraction, orthodontic therapy, and dental implants) at hospitals affiliated with the Jordanian Royal Medical Services. Reformatted images were utilized to detect the AL type, length, and the association between the nerve type and mental foramen (MF) position., Results: This study involved 268 patients. The distribution of MF positions and the characteristics of the inferior dental nerve were evaluated, with no significant gender differences observed. The predominant location for the MF in both males and females in both sides was position IV, with 52% of females and 56-59% (left-right sides) of males presenting this trait. The inferior dental nerve types also showed no significant gender variation, with 42-43% (left-right sides) of females having type III and a similar distribution among males. Measurements of the midline-mental foramen and inter-foramen distances revealed slight variations between genders, with significant differences noted in the right AL length for type III nerves, favoring males (p=0.034). A notable correlation was found between the type of inferior dental nerve and the MF position, particularly with type I nerves predominantly associating with position IV mental foramina (p≤0.004)., Conclusion: CBCT scans are essential in the precise evaluation of the AL, aiding in the prevention of nerve injuries during dental procedures. Our results highlight the diversity of the AL in the Jordanian population and the importance of individualized treatment plans. Future research with larger cohorts is advised to refine these insights, aiming to improve treatment outcomes and patient care., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Royal Medical Services Ethical Committee issued approval 20.8/2023. The study was performed in accordance with the principles of the Declaration of Helsinki, 1975. 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, Al dalalah et al.)

Background Radiology reports are important medico-legal documents facilitating communication between radiologists and referring doctors. Language clarity and precision are crucial for effective communication in these reports. Radiology reporting has changed with the evolution of imaging technology, prompting the adoption of precise terminology. Diagnostic certainty phrases (DCPs) play an important role in communicating diagnostic confidence in radiology reports. Objective The aim of this study was to evaluate the use of DCPs in radiology reports, before and after targeted educational interventions. Materials and methods The study was approved by the Aga Khan University Hospital's Ethical Review Committee and includes cross-sectional radiology reports. It involved three cycles of retrospective evaluation, with educational interventions in between to improve the use of DCPs. Results The study found a dynamic shift in the use of DCPs during the three cycles. Initially, intermediate-certainty phrases prevailed, followed by an increase in high-certainty phrases and a drop in low-certainty phrases. Later cycles showed a significant decline in DCPs and an increase in the use of definitive language. Across all subspecialties, there was a consistent decrease in intermediate- and low-certainty DCPs. Conclusion The study validates the transformative impact of educational interventions on the use of DCPs in radiology reports. The radiology reports frequently used DCPs with intermediate to low diagnostic certainty with improvement in the subsequent cycles of the study after educational interventions. It emphasizes the significance of continuing education to ensure the use of precise nomenclature., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Zafar et al.)

Introduction Non-alcoholic fatty liver disease (NAFLD) is the most prevalent liver condition worldwide. NAFLD has been associated with metabolic syndrome and its symptoms, such as type 2 diabetes, hypertension, dyslipidemia, and obesity. Ultrasound is widely used to grade hepatic steatosis, being the most cost-effective, non-invasive, and readily available modality without radiation exposure. The study aimed to assess the correlation of NAFLD grade as seen on ultrasound with blood parameters in a Pakistani population. Materials and methods The included patients were those who were diagnosed with fatty liver disease on ultrasound and whose laboratory tests were available within two weeks of the ultrasound. Two seasoned radiologists rated the severity of NAFLD after looking over ultrasound scans. Consecutive sampling technique was used to minimize selection bias. The degree and direction of the linear relationship between the NAFLD grade and each biochemical parameter were measured using the Pearson correlation coefficient. Results There were 207 patients in all who had been identified with NAFLD on ultrasound, the majority of whom had grade II NAFLD and were in their sixth decade of life. According to Pearson's analysis, the grade of NAFLD had larger positive associations with triglycerides, total cholesterol, low-density lipoprotein, and fasting blood sugar. High density lipoprotein and C-reactive protein were found to have a negative correlation with the grade of NAFLD. Conclusion The findings of the study highlight the correlation between NAFLD grade on ultrasonography and specific blood parameters, implying that managing these biochemical indicators may help to improve hepatic steatosis., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Zafar et al.)

Background: One of the greatest benefits of contemporary restorative dentistry is the creation of fixed partial dentures. The retention and durability of the fixed partial dentures may be improved by using a variety of tooth preparation methods, surface treatments, and luting resins., Aim: To measure the shear binding strength of resin cement to saliva-contaminated lithium disilicate (LDS) ceramic after being exposed to various cleaning treatments., Methodology: Over 30 LDS samples were examined. In Group 1, a cleansing solution comprising 15% zirconium oxide (Ivoclean) was employed for a duration of 20 s. This was succeeded by a rinsing phase lasting 15 s utilizing deionized water, followed by a 15-s period for drying. Subsequently, a final stage of air drying was conducted over a span of 15 s. In contrast, Group 2 underwent a washing procedure of 20 s involving a cleansing solution containing 30% sodium silicate. This was then ensued by a rinsing interval of 15 s with deionized water, succeeded by an air-drying process spanning 15 s. After applying cleaning solutions to the surface and adhering the specimens to the composite blocks using resin cement Multilink Automix (Ivoclar Vivadent, Schaan, Liechtenstein), the shear bond strength was assessed., Results: Using a 30% sodium silicate solution (Group 2), we were able to get the highest mean shear bond strength value after saliva-contaminated LDS. Group 1, 15% zirconium oxide (Ivoclean) had the weakest decontamination agents as measured by mean shear bond strengths. The shear bond strength values of the two groups were found to vary significantly between individuals using the independent sample t -test. LDs ceramic cleaned with a 30% sodium silicate solution had a higher shear bond strength than ceramic cleaned with Ivoclean (p<0.05)., Conclusion: The application of a 30% sodium silicate solution rendered the highest shear bond strength for saliva-contaminated LDS ceramic. In comparison, ceramic cleaned with Ivoclean exhibited notably lower shear bond strength values. The outcome of this investigation highlights the potential of diverse cleaning agents in influencing the adhesive qualities of resin cement, thereby contributing to the enhancement of fixed partial denture durability and efficacy., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, RK et al.)

Introduction: Ventral hernia is one of the common surgical conditions that can significantly impact a patient's quality of life (QoL). Open ventral hernia repair using the Rives-Stoppa (RS) and Transversus Abdominis Release (TAR) procedures has gained recognition for its effectiveness in achieving hernia repair and reducing the risk of further recurrence. However, limited research has been performed to explore the short-term outcomes and QoL assessment following these two surgical techniques. The aim of this study was to know the result after RS and TAR methods of hernia repair in terms of short-term recurrences, pain, postoperative complications, and QoL., Methods: This was a prospective, interventional study, which included 30 patients fulfilling the inclusion criteria. The study group was subjected to posterior component separation (PCS)-TAR and RS repair as per surgical indication (RS if defect size 4-10cm; PCS-TAR if defect size >10cm and

Background and objective Due in part to its effect on intraocular pressure (IOP) measurements, the assessment of central corneal thickness (CCT) is recognized as an essential part of the initial glaucoma assessment. The most widely utilized clinical technique to measure CCT is ultrasound pachymetry (USP). In recent years, many dedicated anterior-segment optical coherence tomography scanners (AS-OCTs) have been developed. Previous studies have compared CCT measurements between USP and various AS-OCTs. This study aimed to assess the degree of agreement between USP and CASIA2 (Tomey Corporation, Nagoya, Japan), a second-generation swept-source AS-OCT developed in Japan. Methodology The data on CCT screening measurements of 156 eyes (88 patients) performed over a period of three months, from January to March 2020, on glaucoma patients attending the Royal Hallamshire Hospital (RHH) in Sheffield, UK were collected retrospectively and statistically analyzed. Results The average age of the 88 patients included in the study was 66 years (range: 20-86 years). Our findings show that when compared to CASIA2 measurements, USP measurement of the CCT resulted in significantly thicker values (paired t-test: t=23.15,p<2.2 x 10 -16 ). The average difference between the two methods was 19.98 ± 10.78 μm. It is hypothesized that this difference may be due in part to inaccurate probe placement during ultrasound probe measurement, resulting in thicker CCT values. Conclusion The observed difference may be clinically significant as it could induce clinical discrepancy in terms of perceived glaucoma risk in patients. Therefore, USP and CASIA2 should not be used interchangeably, and clinicians should take into account the significant difference between these methods., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Baxter et al.)

Background: Coronary artery disease (CAD) is the leading cause of mortality and morbidity globally. Percutaneous coronary intervention (PCI) is a minimally-invasive lifesaving intervention for these patients; however, acute kidney injury (AKI) is a serious complication of the procedure commonly occurring due to radiocontrast-induced nephropathy., Methods: A retrospective cross-sectional analytical study was carried out at the Aga Khan Hospital, Dar es Salaam (AKH,D), Tanzania. A total of 227 adults who underwent a percutaneous coronary intervention from August 2014 to December 2020 were enrolled. The AKI was defined based on an increase in absolute and rise in percentage creatinine using the Acute Kidney Injury Network (AKIN), and contrast-induced acute kidney injury (CI-AKI) by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Bivariable and multivariable logistic regression was utilized to analyze factors associated with AKI and the outcomes of these patients., Results: Twenty-two of the 227 (9.7%) participants sustained AKI. The majority of the study population was male and of Asian ethnicity. No statistically significant factors were associated with AKI. The in-hospital mortality rate was 9% for the AKI versus 2% for non-AKI groups. The AKI group had a longer hospital stay and required ICU care and organ support including hemodialysis., Conclusions: Nearly 1-in-10 patients undergoing PCI are likely to develop AKI. The in-hospital mortality rate is x4.5 times higher for patients with AKI post-PCI compared to those without AKI. Further larger studies are recommended to determine factors associated with AKI in this population., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Hooda et al.)

Acute intermittent porphyria (AIP) is an autosomal dominant disorder of heme biosynthesis in the liver that is caused by the accumulation of toxic heme metabolites aminolevulinic acid (ALA) and porphobilinogen (PBG) due to a deficiency in the enzyme hydroxymethylbilane synthase (HMBS). The prevalence of AIP is found to commonly affect females of reproductive age (ages 15-50) and people of Northern European descent. The clinical manifestations of AIP include acute and chronic symptoms that can be outlined into three phases: the prodromal phase, the visceral symptom phase, and the neurological phase. Major clinical symptoms involve severe abdominal pain, peripheral neuropathy, autonomic neuropathies, and psychiatric manifestations. Symptoms are often heterogeneous and vague, which can lead to life-threatening signs if not treated and managed appropriately. Whether treating AIP in its acute or chronic form, the cornerstone of treatment consists of the suppression of the production of ALA and PBG. The mainstay of managing acute attacks continues to comprise discontinuing porphyrogenic agents, adequate caloric support, heme treatment, and the treatment of symptoms. In recurrent attacks and chronic management, prevention is key with the consideration of liver transplantation and/or renal transplantation. In recent years, there has been great interest in emerging treatments that focus on a molecular level such as enzyme replacement therapy, ALAS1 gene inhibition, and even liver gene therapy (GT), which has changed the way of traditionally managing this disease and will pave the way for innovative therapies to come., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Kizilaslan et al.)

Background: Skin and soft tissue infections are one of the most common diseases presenting to the emergency department (ED). There is no study available on the management of Community-Acquired Skin and Soft Tissue Infections (CA-SSTIs) in our population recently. This study aims to describe the frequency and distribution of CA-SSTIs as well as their medical and surgical management among patients presenting to our ED., Methods: We conducted a descriptive cross-sectional study on patients presenting with CA-SSTIs to the ED of a tertiary care hospital in Peshawar, Pakistan. The primary objective was to estimate the frequency of common CA-SSTIs presenting to the ED and to assess the management of these infections in terms of diagnostic workup and treatment modalities used. The secondary objectives were to study the association of different baseline variables, diagnostic modalities, treatment modalities, and improvement with the surgical procedure performance for these infections. Descriptive statistics were obtained for quantitative variables like age. Frequencies and percentages were derived for categorical variables. The chi-square test was used to compare different CA-SSTIs in terms of categorical variables like diagnostic and treatment modalities. We divided the data into two groups based on the surgical procedure. A chi-square analysis was conducted to compare these two groups in terms of categorical variables., Results: Out of the 241 patients, 51.9% were males and the mean age was 34.2 years. The most common CA-SSTIs were abscesses, infected ulcers, and cellulitis. Antibiotics were prescribed to 84.2% of patients. Amoxicillin + Clavulanate was the most frequently prescribed antibiotic. Out of the total, 128 (53.11%) patients received some type of surgical intervention. Surgical procedures were significantly associated with diabetes mellitus, heart disease, limitation of mobility, or recent antibiotic use. There was a significantly higher rate of prescription of any antibiotic and anti-methicillin-resistant Staphylococcus aureus (anti-MRSA) agents in the surgical procedure group. This group also saw a higher rate of oral antibiotics prescription, hospitalization, wound culture, and complete blood count., Conclusion: This study shows a higher frequency of purulent infections in our ED. Antibiotics were prescribed more frequently for all infections. Surgical procedures like incision and drainage were much lower even in purulent infections. Furthermore, beta-lactam antibiotics like Amoxicillin-Clavulanate were commonly prescribed. Linezolid was the only systemic anti-MRSA agent prescribed. We suggest physicians should prescribe antibiotics appropriate to the local antibiograms and the latest guidelines., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Alizai et al.)

Objectives:  The coronavirus disease 2019 (COVID-19) pandemic has resulted in an increase in the number of patients necessitating prolonged mechanical ventilation. Data on patients with COVID-19 undergoing tracheostomy indicating timing and outcomes are very limited. Our study illustrates--- outcomes for surgical tracheotomies performed on COVID-19 patients in Tanzania., Methods:  This was a retrospective observational study conducted at the Aga Khan Hospital in Dar es Salaam, Tanzania., Results:  Nineteen patients with COVID-19 underwent surgical tracheotomy between 16 th March and 31 st December 2021. All surgical tracheostomies were performed in the operating theatre. The average duration of intubation prior to tracheotomy and tracheostomy to ventilator liberation was 16 days and 27 days respectively. Only five patients were successfully liberated from the ventilator, decannulated, and discharged successfully., Conclusions:  This is the first and largest study describing tracheotomy outcomes in COVID-19 patients in Tanzania. Our results revealed a high mortality rate. Multicenter studies in the private and public sectors are needed in Tanzania to determine optimal timing, identification of patients, and risk factors predictive of improved outcomes., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Kassam et al.)

Introduction Pneumothorax is a common medical emergency and has potentially life-threatening consequences, so it is important for radiology residents and consultants to know its radiographic appearance so that timely diagnosis and appropriate management can be done. Patients with pneumothorax have nonspecific complaints, and clinical examinations are not confirmatory. The chest X-ray is easily available and has high accuracy in the detection of pneumothorax. The aim of this study is to determine the agreement between the on-call radiology resident and the attending radiologist in the diagnosis of pneumothorax on chest radiographs. Materials and methods This cross-sectional study was performed in the Department of Radiology at Aga Khan University Hospital, Karachi. After approval from the ethical review committee (ERC), the study was carried out. A total of 174 patients were included in the study. The resident interpreting the radiograph commented on the pneumothorax and recorded it on the "Comments" section of the picture archiving and communication system (PACS). Further entries were made in the department's "Panic Logbook." Subsequently, the final report by the attending radiologist was tallied, and the decision of both the resident and the attending radiologist regarding the presence or absence of pneumothorax was compared for interobserver agreement. Results Of the 174 patients, 139 (79.9%) were male and 35 (20.1%) were female. The mean age of the patients was 45.6 ± 12.4 years. Pneumothorax was reported by the resident in 164 (94.25%) cases, while the attending radiologist reported it in 167 (96%) cases. The remaining 4% of cases were ultimately diagnosed on a CT scan of the chest performed at the request of the primary team; they were too small to be detected on a chest radiograph. The most common side involved was the right side, with 112 (64.4%) cases, followed by the left side with 55 (31.6%) and both sides with five (2.9%), while in two cases, pneumothorax was not reported by the resident and the attending radiologist. The position of the pneumothorax was as follows: apex in 80 (46%), base in 56 (32.2%), and along the lateral border of the lung in 93 (53.4%). Concordance between the resident and the radiologist was found to be 92.5% (kappa = 0.20; p = 0.008). Stratification for age, gender, the position of pneumothorax, and the level of residency was also carried out. Conclusion In our setting, there was a high level of agreement (92.5%) between the resident and the attending radiologist in reporting pneumothorax on chest radiographs (kappa = 0.20; p = 0.008)., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Hafeez et al.)

Introduction: The advent of laparoscopic techniques in repairing inguinal hernia has significantly improved outcomes of inguinal hernia surgery. However, acute and chronic postoperative pain after fixation of mesh with tacks and the cost of tacking devices are major hindrances to the widespread use of laparoscopic transabdominal preperitoneal (TAPP) repair in resource-poor settings. This study sought to introduce a method of mesh fixation that will reduce the cost of laparoscopic TAPP repair and might help reduce postoperative pain., Objective: To compare outcomes in the early postoperative period like pain, seroma, hematoma, urinary retention, and neuralgia after fixation with suture versus the tack fixation of mesh in laparoscopic TAPP repair of inguinal hernia.  Subjects and methods: This study was conducted from 1 st  June 2019 to 31 st May 2020. A total of 144 patients between ages 18 and 60 years with an inguinal hernia on any side and having an American Society of Anaesthesiologists (ASA) score of I/II were included in this study. Patients with a recurrent hernia, large scrotal hernia, strangulated and obstructed hernias, ASA III and ASA IV, prostatism, and chronic cough were excluded. Seventy-two patients were in Group A (tack fixation group) while 72 were in Group B (suture fixation group). Separate investigators were assigned to collect pre-operative and post-operative data from both groups, recorded on specially designed proforma., Results:  The age range was 18 to 60 years with a mean age of 46.53 years ±10.01 S.D in Group A and 46.19 ±9.58 S.D in Group B. In Group A 98.6% of patients were male, and 1.4% were females while in Group B 100% of patients were male. It was found that mean pain in Group A was 4.88 ±0.887 and 5.29± 0.777 at 6 hours and 24 hours respectively. Mean pain in group B was 3.43 ±0.962 and 4.11±0.703 at 6 hours and 24 hours respectively. Moreover, mean pain in Group B was significantly less than mean pain in Group A both at 6 hours and 24 hours intervals with a p-value < 0.001. The early postoperative complications were not significantly different in both groups.  Conclusion: In TAPP repair, suture fixation of mesh is less painful than tack fixation. However, there is no significant difference in the rate of other early postoperative outcomes like seroma, hematoma, urinary retention, and neuralgia. Further multicentric studies with a longer duration of follow-up are needed to validate our results., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Aziz et al.)

Formative assessments are an essential yet often overlooked aspect of postgraduate surgical training. This report explores the strategies by which formative assessments are integrated into postgraduate surgical training in Pakistan (using urology as an example), by comparing the regional recommendations and infrastructures offered by local governing bodies to that of a more structured system, as offered by the General Medical Council (GMC). The College of Physicians and Surgeons Pakistan (CPSP) serves as the de facto local accrediting body for postgraduate surgical training and makes a conscious effort in maintaining the standard of training throughout the country. However, although formative assessment activities are encouraged in its roster, they are rarely monitored as strictly as summative outcomes. This is a far cry from how the structured format is exemplified by the GMC's various guidelines and protocols. It must be emphasized that in order to improve the overall quality of training, measures need to be made to improve the ways in which feedback and formative activities are implemented and monitored., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Khan et al.)

Background: Online oral assessments have been poorly studied in medical education. This study aims to assess the perception of the online oral assessment strategy for formative purposes., Objective: To explore the perception of trainees and examiners on their experience of online oral assessment., Methods: Online oral assessments were conducted using the Zoom platform (Zoom Video Communications, Inc., San Jose, California, United States) over a period of six days. Each candidate was examined by two examiners and formative feedback was provided at the same time. At the end of the course, participants were asked to fill out an online questionnaire regarding their perception of this online platform for oral assessment.  Results: A total of 192 participants were included in this study as examiners (n=48), candidates (n=53), and observers (n=91). The overall impression of the organization and accessibility of the model was found favorable with a generally lower degree of perceived anxiety in this format. Major limitations faced by participants included technical difficulties (n=84), linguistic issues (n=37), and failure to observe body language (n=38). Using the Joughin matrix, this model of online oral assessment was found as a fair and valid assessment tool with relatively low reliability., Conclusions: The online oral assessment model has been found to be a reliable and valid method of formative assessment. Further work could be done on this model to assess its potential for summative purposes., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Siddiqui et al.)

Background: One of the most important causes of neonatal deaths in developing nations is birth asphyxia. Though the probability of a complete recovery is very low, hypoxic-ischemic encephalopathy (HIE) associated with asphyxia can be managed with multiple treatment options. The study evaluated the efficacy of the addition of magnesium sulfate (MgSO 4 ) to melatonin therapy in neonates with HIE., Methodology: A prospective, observational study was conducted in the department of neonatal intensive care, Pakistan Institute of Medical Sciences Hospital, Islamabad, Pakistan from October 2020 to March 2021. All neonates with an Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) score of less than five at five minutes, umbilical blood pH of less than 7.0, and moderate neonatal encephalopathy as detected on the modified Sarnat score which is a clinical tool used for the assessment of the severity of HIE were included in the study. Neonates with congenital abnormalities, intrauterine growth retardation, neonatal sepsis, and infants born to mothers with diabetes mellitus type 2 were excluded from the study. The infants were randomly assigned to either of the groups, i.e., i) group 1 included neonates who were administered at least three doses of magnesium sulfate (MgSO 4 ) infusion in addition to melatonin, or ii) group 2 included neonates who were administered melatonin only. Blood samples of all neonates were evaluated and compared between the two groups., Results: A total of 90 neonates with HIE were included in the study. There was a predominance of female neonates. The mean ages of babies in group 1 and group 2 were 37.2 ± 0.43 and 37.3 ± 0.59 weeks, respectively. The mean weight on the term was 2.88 ± 0.11 and 2.89 ± 0.10, respectively. The Apgar score at 5 mins in group 1 was 1.73 ± 0.81 while in group 2, 1.82 ± 0.94. It was found that there was a more significant improvement in pH after 3 days and after one week of treatment in group 1 as compared to group 2. The mean pH in babies after three days of intervention was 7.23 ± 0.03 in group 1 which was significantly better than group 2 (p<0.0001). After seven days, the mean normalized to 7.39 ± 0.04 in group 1 (p < 0.0001). It was found that in patients in group 1, the mortality was lower than in group 2 (p < 0.0001)., Conclusion: HIE patients who were administered melatonin in combination with magnesium sulfate yielded better patient outcomes. Thus, it was concluded that the use of magnesium sulfate as dual therapy with melatonin improved patient outcomes for HIE. However, it is recommended that similar studies are conducted with a wider range of parameters, such as duration of hospital stay and assessment of the neurological outcomes of the patients., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Khan et al.)

Background:  In adults, lymph nodes are not normally palpable. A number of patients with asymptomatic lymphadenopathy never visit physicians for the condition, and thus, this important sign is often missed by the medical practitioner if it is not the presenting complaint. The incidence of lymphadenopathy is suggested to be increasing. While lymphadenopathy is benign and self-limiting in most patients, the underlying disease may range from treatable infectious etiology to malignant neoplasms. In most cases clinical examination and history guide towards the cause of lymphadenopathy. In recent years, fine needle aspiration cytology (FNAC) has become an easy clinical tool (with or without the assistance of CT, MRI, and ultrasound) for the diagnosis of the underlying cause of lymphadenopathy., Aims and Objectives:  To find out the cytomorphological pattern in superficial lymphadenopathy with the help of FNAC., Materials and Methods:  This descriptive cross-sectional study was conducted at HBS General Hospital, Islamabad from January 2017 to June 2019. Patients presenting with superficial lymphadenopathy were included in the study. FNAC was performed by the pathologist, histopathological reports were examined and analyzed using Statistical Package for the Social Sciences (SPSS) version 22 (IBM Corp., Armonk, NY).  Results: Six hundred and thirty-two patients underwent FNAC. Tuberculous lymphadenitis was the most common diagnosis (56.1%) followed by reactive hyperplasia (28.29%). The sample showed metastatic malignancy 3.36% and lymphoma 2.05%. Cervical lymphadenopathy was the most common site for TB (49.36%). Metastatic cancer observed in cervical lymph nodes was 3.16% and lymphoma was 1.74%., Conclusion:  FNAC is recognized as a simple and safe diagnostic technique that can diagnose cases of superficial and deep lymphadenopathy easily. The most common cause of superficial lymphadenopathy in our study was tuberculosis with cervical lymph nodes., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Islam Sheikh et al.)

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has led to an outbreak of a pandemic worldwide. The spike (S) protein of SARS-CoV-2, which plays a key role in the receptor recognition and cell membrane fusion process, is composed of two subunits, S1 and S2. The S1 subunit contains a receptor-binding domain that recognizes and binds to the host receptor angiotensin-converting enzyme 2 (ACE2), while the S2 subunit mediates viral cell membrane fusion with the cell membrane and subsequent entry into cells. Mutations in the spike protein (S) are of particular interest due to their potential for reduced susceptibility to neutralizing antibodies or increasing the viral transmissibility and infectivity. Recently, many mutations in the spike protein released new variants, including the Delta and Kappa ones (known as the Indian variants). The variants Delta and Kappa are now of most recent concern because of their well-increased infectivity, both a spin-off of the B.1.617 lineage, which was first identified in India in October 2020. This study employed homology modeling to probe the potential structural effects of the mutations. It was found that the mutations, Leu452Arg, Thr478Lys, and Glu484Gln in the spike protein increase the affinity for the hACE2 receptor, which explains the greater infectivity of the SARS-Cov-2 B.1.617 (Indian Variant)., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Hajj-Hassan et al.)

Background In Pakistan, the neonatal mortality rate is 41 per 1,000 live births and birth asphyxia is one of the leading causes of neonatal mortality and morbidity. The goal of this study was to determine whether postnatal magnesium sulfate therapy can improve short- and long-term neurological outcomes in term or near-term neonates with moderate-to-severe birth asphyxia. Methodology This prospective double-blind randomized controlled trial was conducted in the Neonatology Department of the Children's Hospital & The Institute of Child Health, Lahore. A total of 62 neonates (31 in each group) were randomized to receive either three doses of magnesium sulfate infusion at 250 mg/kg per dose, 24 hours apart (treatment group), or three doses of injection 10% distilled water infusion at 3 mL/kg, 24 hours apart (placebo group). Both groups received similar supportive care. The neurodevelopmental assessment was done at six months of age using the ShaMaq Developmental Inventory. Results Demographic data such as gestational age, mean weight, age at presentation, gender, hypoxic-ischemic encephalopathy grade, mode of delivery, and the presence of seizures at presentation were comparable between both groups. In the magnesium sulfate group, statistically significant results were seen in terms of early seizure control (p = 0.001), early initiation of feed (p = 0.002), and shorter duration of hospital stay (p = 0.003). Moreover, the magnesium sulfate group had lower mortality compared to the control group, though it was not statistically significant (p = 0.390). There was no significant difference in terms of cranial ultrasound findings between the two groups (p = 0.783) at the time of discharge. Regarding the neurodevelopmental delay, there was no significant difference between the magnesium sulfate and control groups (p = 0.535). Conclusions Postnatal magnesium sulfate treatment improves short-term neurologic outcomes at discharge in term or near-term neonates with moderate-to-severe perinatal asphyxia. However, no difference was noted in the neurodevelopmental outcome at six months., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Iqbal et al.)

Introduction Open and closed nailing are the two reduction methods used for the fixation of femoral shaft fractures. The study aims to assess the clinical and functional outcomes of open and closed nailing for closed femoral shaft fractures. Methodology A total of 398 patients who underwent intramedullary nailing fixation of nonpathological femoral shaft fracture between January 2016 to December 2019 were reviewed retrospectively. Two hundred seventy-four underwent closed nailing, and 124 were considered for open nailing. Results The primary outcome reviewed was the union rate of fracture. Other outcomes analyzed were complications, intraoperative blood loss, time to union, and the duration of the procedure. Patients in the open group had a union of fracture in 15.71 weeks, closed nailing group had a union in 15.53 weeks (p-value 0.495). Patients with open nailing had a mean Radiological union scale in tibial (RUST) fracture score of 11.435, whereas the closed nailing group had a mean of 11.664 (p-value 0.187). Operative time was higher in the open group when compared to the closed nailing group (p-value 0.000). However, intraoperative blood loss was more in open nailing in comparison to closed nailing. Furthermore, 15 patients with closed nailing had non-union, whereas 11 had non-union after open nailing (p-0.204). Superficial infection and deep infection requiring debridement were equally observed among the two treatment groups. Conclusion Fixation of femoral shaft fractures with open nailing has similar outcomes in union rates, time to union, and rates of significant complication similar to those of close nailing., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Tahir et al.)

Background The aim of this study was to evaluate the safety and efficacy of transcatheter aortic valve implantation (TAVI) program in a Tertiary care hospital in Karachi, Pakistan. Methodology This study was conducted by interventional cardiology department of the National Institute of Cardiovascular Diseases (NICVD), Karachi from July 2015 to February 2020. All patients of severe aortic stenosis (AS) who underwent TAVI were included. Baseline characteristics, in-hospital course and one-month follow-up data were collected. Results This study included 100 consecutive patients with severe AS undergoing TAVI. Sixty-three (63.0%) patients were males and the mean age was 67.38 ± 10.73 years. Eighty-five (85%) patients were in the New York Heart Association (NYHA) class III-IV. Aortic valve mean gradient was 51.33±10.47 mmHg and 50% of patients had bicuspid aortic valves. Core valve was implanted in 86 (86%) and evolute-R aortic valve was implanted in 14 (14%) patients. TAVI was successfully done in 94% of patients. Post-deployment aortic valve mean gradient was 5.33±4.13 mmHg. Major vascular access site complications were noted in 14% and atrioventricular (AV) blocks were seen in 22% of cases. There was a significant difference in symptoms of patients before and after the procedure. Overall, eight (8%) patients expired during hospital stay. At one-month follow-up, 76% of patients were found to have no limitation of physical activities. Conclusions Results of this study showed that TAVI is a safe procedure in these high-risk patients and is an alternative to surgery for AS patients in the region., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Ammar et al.)

Background In the current coronavirus disease-2019 (COVID-19) pandemic, the pattern of hospital admissions for acute ST-elevation myocardial infarction (STEMI) is changing, and increased mortality and morbidity is being noted in these patients. Cardiac manifestations of COVID-19 are complex and include STEMI, myocarditis, myocardial injury, and cardiomyopathy. The objective of our study was to compare the data of patients with STEMI presenting in COVID-19 versus the non-COVID-19 era.  Methods We analyzed the clinical and angiographic characteristics of STEMI patients undergoing primary percutaneous coronary intervention (PCI) at our center. The primary outcome variables were admission rate for STEMI, mean total ischemic time (TIT), coronary artery disease burden, mean ejection fraction, and in-hospital mortality for three defined groups. Group A consisted of patients who underwent primary PCI from March through April 2020. Group B included patients who underwent primary PCI from January to February 2020. Group C consisted of patients who underwent primary PCI from March to April 2019. We then compared the data among the three groups and calculated any significant p-value (p<.001). Results In Group A, 1139 patients were admitted for primary PCI. The mean admission rate was 18.6 ± 4.36 admissions per day. There were 1535 patients in Group B and an admission rate of 26.01 ± 4.90 (p<.001 compared to Group A). In Group C, there were 1537 patients and an admission rate of 24.8 ± 4.55 (p<.001, compared to Group A). The mean TIT was 429.25±272.16 minutes for Group A, 359.78±148.04 minutes for Group B, and 346.75±207.31 minutes for Group C (p<.001). A higher mortality rate was noted in Group A (COVID-19 era) versus Group C (non-COVID-19 era; p<.001). Conclusions A lower admission rate, higher TIT, and higher mortality rates were noted in patients with acute STEMI during the COVID-19 pandemic compared to the pre-COVID era. During the COVID-19 pandemic, physicians should bear in mind that patients with STEMI have increased mortality and morbidity. Where possible, efforts should be made for timely management of these critical patients to decrease mortality., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Mengal et al.)

Introduction A clear picture of the prevalence of Fanconi anemia is not known due to limited studies and research of the subject. This study will detect the frequency of positive chromosomal breakage in pediatric aplastic patients and provide the evidence-based guidelines which help in consideration of appropriate treatment and awareness to the society. Methods A total of 104 aplastic anemia patients were recruited of age <18 years whose samples were tested for chromosomal breakage with mitomycin C (MMC). History of consanguinity between parents were documented for all the patients referred to us. Result Out of 104 diagnosed aplastic anemia patients, 35 (33.7%) patients were found to be Fanconi positive. Mean age of all hypoplastic patients for aplastic anemia and Fanconi anemia was 10.7 ± 4.5 and 10.6 ± 3.5, respectively. Male preponderance was found to be higher (64, 61.5%) as compared to females (40, 38.5%) in aplastic patients. The male to female ratio was observed as 2.5:1 in Fanconi patients while 1.3:1 in non-Fanconi aplastic patients. Parental consanguinity was observed in 33 (94.2%) with Fanconi anemia. Conclusion Fanconi anemia accounts for significant number of patients with hypoplastic bone marrow, therefore consanguineous marriages should be avoided through mass education in Pakistan., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Siddiqui et al.)

Introduction Primary percutaneous coronary intervention (PPCI) is now a well-established treatment of acute ST-elevation myocardial infarction (STEMI). For the first time in Pakistan, various off-site satellite centers are established to perform PPCI 24-hours. Our population mainly resides in the rural area with low literacy rate and poor socioeconomic conditions. The majority of the patients who are presented in the satellite center had either never received any long-term treatment plan or were non-compliant to their medication. The objective of this study was to determine the outcome of patients at six months who underwent primary PCI at a rural satellite center of Sindh, Pakistan. Methods This study was conducted at Larkana satellite center of National Institute of Cardiovascular Diseases, Karachi. Patients who underwent PPCI for STEMI from October 2017 to March 2018 were enrolled in the study. In case of death of the patient, data were obtained from the attendant of the deceased. Patients, on follow-up visits, were interrogated for post-procedure symptoms. Results A total of 271 patients were enrolled in the study. The mean age ± standard deviation of patients was 54.84 ± 10.64 years. The most common culprit artery was left anterior descending (LAD) artery with 161 (59.4%) patients, followed by right coronary artery (RCA) with 98 (36.2%) patients. Only 41 (15%) patients had a three-vessel disease, while 141 (52%) patients had single-vessel disease. On follow-up, 70 (25.8%) patients complained of chest pain grade II, 20 (7.4%) complained of shortness of breath (SOB) grade II, 44 (16.2%) complained of vertigo, and 16 (5.9%) complained of nonspecific weakness. The mortality rate of 6.3% (17) was observed after six months of PPCI. The mortality rate was found to be lower for patients with LAD disease (p = 0.036) and higher among patients with RCA as the culprit artery (p = 0.045). The mortality rate was significantly associated with the number of diseased vessels and the type of stent deployed. Conclusion Primary PCI, at a rural satellite center, has an overall positive outcome. Steps should be taken to provide free medication along with encouragement towards compliance of dual antiplatelet medication. Furthermore, the facility for subsequent procedures should be provided at the same set-up., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Mujtaba et al.)

Introduction Overexpression of survivin, an anti-apoptotic protein, has been associated with the progression of cancer, resistance to drugs, and a poor prognosis. The expression level of survivin indicates the progression of the disease, early recurrence, and a failure to respond to therapy. Our study was a retrospective analysis performed on archival specimens. Materials and methods The study included a total of 50 histopathologically proven cases of potentially malignant lesions and squamous cell carcinoma. Immunohistochemical staining was carried out using primary rabbit monoclonal antibodies to survivin (PathnSitu, Telangana, India) along with a horseradish peroxidase detection kit (Leica Biosystems, Maharashtra, India). The intensity of staining of survivin in the epithelium was determined, and the data obtained from potentially malignant lesions, oral squamous cell carcinoma, fetal tissue, and normal oral mucosa were compared. Results The expression of survivin was positive in 70% of the samples of oral squamous cell carcinoma followed by 50% from cases of leukoplakia, 20% of oral submucous fibrosis samples, and 10% of lichen planus samples (P < 0.05). Conclusion Malignant transformation of these potentially malignant lesions increases with increased expression of survivin. This expression of the anti-apoptotic protein might be an early phenomenon in the initiation and advancement of oral squamous cell carcinoma. The prognosis of oral squamous cell carcinomas becomes poorer with increased expression of survivin. Therefore, survivin might be helpful as an important therapeutic target because it is expressed more in tumor cells and absent in most adult tissues., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Sakthivel et al.)

Introduction Native veins are an ideal option for dialysis in a patient with chronic kidney disease (CKD) as compared to a prosthetic graft. Femoral vein (FV) translocation to the upper arm is also an alternative to a prosthetic graft as reported in the literature when all options of using the native veins of the arms are exhausted. Thus, we aimed to compare the patency of the upper limb translocated FV arteriovenous fistula (AVF) with a prosthetic arteriovenous bridge graft (AVBG). Methods It is a retrospective cohort study that was conducted in the Department of Vascular Surgery, Aga Khan University Hospital. It included adult patients who underwent either upper arm translocation of FV or prosthetic AVBG using the consecutive purposive sampling technique. There were a total of 10 patients who underwent FV translocation AVF and 20 patients who had AVBG in the upper arms. Results A total of 30 patients were included in the study. Of these 30 patients, 10 underwent FV translocation AVF and the remaining 20 had AVBG. There was a significant difference in the mean operating time of the two surgeries. The mean operating time in FV translocation was 223 (± 41.5) minutes and in those with AVBG, the mean operating time was 100 (±26.5) (p= <0.001). There was no significant difference in the total length of hospital stay in both procedures performed. The primary patency rate for FV translocation was 90% and 95% in AVBG (p=1.00). Ten percent of FV translocation had a primary failure rate compared with that of AVBG, which was 5% (p=1.00). The mean follow-up period was 61 weeks in the FV translocation group and 64 weeks in the AVG group. Conclusion There was no significant difference in both groups in terms of patency, length of hospital stay, and fewer complications were observed in the FV translocation group as compared with the AVBG group., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2019, Moosa et al.)

Up to 10% of patients suffer from various degrees of dialysis access-associated steal syndrome (DASS) after surgery for hemodialysis access. This systematic review was conducted to find out optimal intra-operative techniques to prevent DASS in high-risk patients. This systematic review is registered with PROSPERO (2017:CRD42017060804). It was conducted at Department of Surgery, Aga Khan University Hospital, Karachi. All types of studies conducted on intra-operative techniques to prevent DASS in high-risk population (Age > 60 years, female gender, diabetes mellitus, peripheral arterial disease and previous DASS) undergoing access creation from January 1990 till April 2019 were included in the systematic review. Thorough search was conducted on Pubmed, Google Scholar and Cochrane databases to identify relevant articles. Included studies reviewed for success of various techniques to prevent dialysis access steal syndrome are summarized. Out of 125 studies in the initial search, six met the inclusion criteria. Five were retrospective case series while one was a case report. The largest study sample size was 32. All but one study had arterio-venous access creation on an arm. "Proximalization of arterial inflow" was described in three and "prophylactic distal revascularization and interval ligation (DRIL) procedure" in two studies to prevent DASS. Only one patient out of these studies developed DASS at an overall follow-up of 7-42 months. Proximalization of inflow has been reported as the most common procedure performed to prevent DASS followed by extension technique and DRIL procedure. All three procedures have satisfactory outcome with no clear superiority of one over the other., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2019, Shaikh et al.)

Chondromyxoid fibroma (CMF) is a rare, benign neoplasm of the chondroid, myxoid, and fibrous tissue. It characteristically affects the lower extremity long bones, although it may rarely arise within the craniofacial skeleton. We report the diagnosis and management of a 31-year-old male with a large, incidentally discovered CMF originating from the sphenoid sinus. A subsequent review of the literature reveals the need to differentiate from more aggressive neoplasms, such as chondrosarcoma and chondroma, which share radiographic features. A histopathologic examination is crucial for proper diagnosis and treatment. We discuss clinical sequelae, highlight the importance of a thorough pre-operative evaluation, and summarize previously suggested treatment paradigms., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2019, El-Kouri et al.)

Introduction Transthoracic echocardiography (TTE) is the primary noninvasive imaging modality for quantitative and qualitative evaluation of cardiac anatomy and function. The Hyderabad satellite center of National Institute of Cardiovascular Diseases (NICVD), Pakistan has recently started its operations, including TTE; therefore, it is imperative to assess the initial experience for the process improvement of the center. Therefore, the aim of this clinical audit was to review our initial experience of TTE at this newly operational satellite center. Methods In this clinical audit, we reviewed the records of patient undergone TTE at the echocardiography department of NICVD Hyderabad satellite center from May 2018 to October 2018. Demographic characteristics, clinical history, indications for the TTE, and echocardiographic diagnoses were reviewed. Results A total of 2,177 TTE procedures were performed during the study period of six months out of which 68.7% (1,496) were performed in male patients. Mean age of the patients was 50.83 ± 12.44 years with 48.2% (1,050) patients above 50 years of age. The most frequent indication for the procedure was cardiomyopathy, 54.1% (1,177), among other indications, native valve regurgitation was in 49.8% (1,085), ischemic heart disease in 23.2% (504), heart murmurs in 17.3% (377), cardiac masses in 14.3% (312), pericardial disease in 8.5% (184), pulmonary disease in 7.3% (160), infective endocarditis in 6.4% (139), aortic and major disease in 6.3% (138), and native valve stenosis in 5.4% (177) of the patients. Procedures were performed before coronary artery revascularization in 2.2% (47) and for prosthetic valve assessment in 1.7% (38) patients. The TTE was normal in 36.6% (796) patients, while the most frequent diagnosis was cardiomyopathy, 53.8% (1,172), among the other TTE findings valvular heart disease was in 21.8% (475), ischemic heart disease (IHD) in 21.6% (470), pericardial disease in 8.0% (175), and congenital heart disease (CHD) in 1.4% (30) patients. Conclusion This clinical audit showed the effective use of TTE as a noninvasive imaging modality for quantitative and qualitative evaluation of cardiac anatomy and function at a newly operational satellite center of a resource-limited country with normal TTE findings in only 36.6% of the patients., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2019, Balouch et al.)

Objective The aim of this study was to observe the weight change in a patient with type 2 diabetes initiated on insulin therapy and the relation of weight gain with caloric intake. Methods This retrospective longitudinal follow-up study was conducted at the Baqai Institute of Diabetology and Endocrinology (BIDE), a tertiary care hospital of Karachi, Pakistan. Records of 917 patients attending the tertiary care diabetic clinic were retrieved from January 2009 to May 2016 from the Hospital Management System (HMS). Subjects were divided into two groups: group A consisted of subjects on oral hypoglycemic agents (OHA), while group B consisted of subjects on insulin therapy with OHA. Change in weight, change in HbA1c, and change in calories intake were calculated by examining data at baseline and end-line visit of the study. Results Group B showed significantly higher weight gain than group A (48.3% vs 24.8%). Insulin therapy with OHA (OR (95% CI = 1.78(1.05-3.02)), increased caloric intake (OR [95% CI = 1.98(1.093.60)]) and decreased HbA1c (OR [95% CI = 0.44(0.24-0.79)]) were the only factors identified as significant predictors of weight gain. Conclusion It is concluded that type 2 diabetic subjects, especially on insulin treatment, gain weight due to increase or unadvised caloric intake. Long-term multicenter studies are needed to ascertain the findings of this study., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2019, Naeem et al.)