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BACKGROUND: Astrocytic tumors are the most common primary brain tumors. Glioblastoma is the most common astrocytic tumor representing the highest World Health Organization (WHO) grade (WHO grade IV) with poor prognosis and short survival time. Anaplastic lymphoma kinase (ALK) has a role in embryonic central nervous system development. ALK receptor is thought to contribute to nervous system function, repair, and metabolic homeostasis and is expressed in high-grade tumors like anaplastic large cell lymphoma that makes it a potential target for therapeutic intervention. AIM: This work aimed to examine the immunohistochemical expression of ALK in astrocytic tumors and its correlation with age, sex, clinical presentation, location, laterality, recurrence, and WHO grade to implicate possible therapeutic potential. METHODS: This retrospective study was conducted on sixty cases of archived, formalin-fixed, paraffin-embedded tissue blocks that included different subtypes and grades of astrocytic tumors. Immunohistochemistry using ALK monoclonal antibody was performed using a standard avidin-biotin-peroxidase system. RESULTS: Of the sixty cases, 57 (95%) cases were negative for ALK, while three (5%) cases are positive for ALK; all showed the strong intensity of expression. No statistically significant association was found between ALK expression and astrocytic tumors in addition to other clinical variables of the studied tumors. CONCLUSIONS: Most cases of astrocytic tumors showed negative ALK expression apart from three positive cases seen in higher WHO grades, especially gliosarcoma. The high number of negative cases for ALK in our study group suggests that ALK expression is not associated with a prognostic significance toward astrocytic tumors whatever its grade.

Objective Data on patients requiring a second run of venoarterial extracorporeal membrane oxygenation (VA-ECMO) support in patients affected by postcardiotomy cardiogenic shock (PCS) are very limited. The authors aimed to investigate the effect of a second run of VA-ECMO on PCS patient survival. Design Retrospective analysis of an international registry. Setting Multicenter study, tertiary university hospitals. Participants Data on adult PCS patients receiving a second run of VA-ECMO. Measurements and Main Results A total of 674 patients with a mean age of 62.9 ± 12.7 years were analyzed, and 21 (3.1%) patients had a second run of VA-ECMO. None of them required more than two VA-ECMO runs. The median duration of VA-ECMO therapy was 135 hours (interquartile range [IQR] 61-226) in patients who did not require a VA-ECMO rerun. In the rerun VA-ECMO group the median overall duration of VA-ECMO therapy was 183 hours (IQR 107-344), and the median duration of the first run was 114 hours (IQR 66-169). Nine (42.9%) of the patients who required a second run of VA-ECMO died during VA-ECMO therapy, whereas five (23.8%) survived to hospital discharge. No differences between patients treated with single or second VA-ECMO runs were observed in terms of hospital mortality and late survival. In patients requiring a second VA-ECMO run, the actuarial survival estimates at three and 12 months after VA-ECMO weaning were 23.8% ± 9.3% and 19.6% ± 6.4%, respectively. Conclusions Repeat VA-ECMO therapy is a valid treatment strategy for PCS patients. Early and late survivals are similar between patients who have undergone a single or second run of VA-ECMO.

OBJECTIVES Therapeutic plasma exchange has been reported to be useful in the management of acute liver failure and acute-on-chronic liver failure. This retrospective study evaluated therapeutic plasma exchange as an adjunct to standard supportive care for early allograft dysfunction after living donor liver transplant. MATERIALS AND METHODS All consecutive adult living donor liver transplants performed from January 2015 to February 2019 were included. Patients treated without or with therapeutic plasma exchange for early allograft dysfunction (Olthoff criteria) were compared. RESULTS There were 465 adult transplant recipients, and 67 (14.4%) had early allograft dysfunction, of which 43 (64%) had therapeutic plasma exchange and 24 (36%) did not. Fourteen patients were excluded, as they had both preoperative and immediate postoperative therapeutic plasma exchange (5 patients with acute liver failure and 9 with acute-on-chronic liver failure). The therapeutic plasma exchange group (n = 29) had more preoperative acute kidney injury (55.2% vs 25.0%; P = .009), lower graft-recipient weight ratio (0.96 vs 1.09; P = .043), and slightly higher final portal pressure (11 vs 10 mg/dL; P = .027). Therapeutic plasma exchange was started at a median of postoperative day 9, with median serum bilirubin of 13.6 mg/dL and a median of 3 sessions per patient. There was no 90-day mortality in the group without therapeutic plasma exchange; however, in the therapeutic plasma exchange group, 13 patients (45%) died (P < .001). Patients who received therapeutic plasma exchange had more septic complications (62.1% vs 12.5%; P < .001) and needed more postoperative renal replacement therapy (51.7% vs 8.3%; P < .001). CONCLUSIONS This is the first study to compare patients treated with or without therapeutic plasma exchange for early allograft dysfunction in the living donor liver transplant setting. Within the limitations of this retrospective study, we were unable to confirm whether therapeutic plasma exchange could increase early mortality.

Objective: To determine frequency of vitamin D deficiency in patients presenting with fibromyalgia and its association with various factors. Study Design: Cross sectional study. Place and Duration of Study: Medicine department, Pak Emirates Military Hospital Rawalpindi, from Sep 2018 to Feb 2019. Methodology: Ninety patients of fibromyalgia were included in the study. Diagnosis of fibromyalgia was made by the consultant rheumatologist on the basis of American College of Rheumatology Criteria needed for fibromyalgia diagnosis and classification. Vitamin D levels

Dynamic and static reconstruction procedures are employed for facial reanimation in patients suffering from facial nerve paralysis. Denervation and paralysis of the facial nerves causes considerable psychological and functional damage. Facial paralysis can affect facial expressiveness, communication, smile symmetry, eye protection, and speech competence. Due to their presumed poor prognosis, patients requiring facial nerve repair in a head and neck cancer practice are historically the least likely to receive a nerve graft. Dynamic reconstruction, on the other hand, is the gold standard in neurotology since patients are unlikely to die from their underlying condition. Even with malignant pathology, extended preoperative palsy, proximal nerve injury location, radiation, or long graft length, the current series supports the use of dynamic reconstruction. Dynamic facial reconstruction should be preformed in most cases unless there’s health risk of the method.

Objectives: The objective of this study was to determine the predictive value of GRACE score for predicting obstructive coronary artery disease in patients with non ST-segment elevation myocardial infarction (NSTEMI). Methodology: This cross-sectional study was conducted at the largest public sector cardiac care center of the Pakistan between January 2020 and June 2020. In this study, we included adult patients diagnosed with NSTEMI and correlation of GRACE score was assessed with angiographic finding of obstructive CAD defined as ≥50% stenosis in the left main or ≥70% stenosis in other coronary arteries. Results: A total of 227 patients were included in this study, out of whom 72.2% (164) were male patients and mean age was 55.77 ± 9.15 years. Mean GRACE score was found to be 95.89 ± 21.15. On coronary angiography obstructive CAD was present in 84.6% (192) of the patients. Area under the cure for predicting obstructive CAD was 0.669 [0.552 to 0.785]. The optimal cutoff value of GRACE score was ≥ 84 with sensitivity of 79.7% [73.3% to 85.1%] and specificity of 57.1% [39.3% to 73.7%]. GRACE score of ≥ 84 was found to be an independent predictor of obstructive CAD with odds ratio of 4.33 [1.61 - 11.64; p=0.004] adjusted for gender, age, hypertension, diabetes, family history of CAD, and smoking. Conclusion: GRACE score has a moderate predictive value in predicting obstructive CAD in patients with NSTEMI. The optimal cutoff value of 84 is an independent predictor with good sensitivity but moderate specificity in predicting obstructive CAD.

Background: Conversion disorder (CD) is characterized by neurological symptoms affecting voluntary motor control and incompatible with organic damage to the nervous system. Since novel insights have been gained with the advent of functional magnetic resonance imaging, we aimed to explore potential functional alterations in various areas of the brain in a sample of Egyptian patients suffering from conversion disorder. Methods: This cross-sectional study was carried out on patients who met the DSM-5 criteria for conversion disorder presented with weakness or paralysis aged from 18- 40 years old. Group A (Cases): include 30 patients with motor conversion disorder. Group B (Control): include 30 normal healthy individuals free from any psychiatric disorders. Structured Clinical Interview DSM-IV (SCID-I) and (SCID-II) were applied for psychometric evaluation. Results: The cases had increased activity in the contralateral amygdala of the affected side of patients with CD. Cases also showed decreased activation of contralateral basal ganglia in the affected side as well as a decreased activity of the motor cortex contralateral to the affected side. There was a decrease in activation of SMA contralateral to the side of disability. There was an increase in the activity of the contralateral insula. Conclusions: Functional abnormal alterations in motor and sensory systems are related to the presence of neurological symptoms in conversion disorder.

OBJECTIVES/BACKGROUND Resting coronary blood flow approximates flow with maximal vasodilation in very severe coronary stenosis. We studied the incidence of exhausted vasodilatory reserve by FFR, its clinical characteristics and long-term prognosis after FFR guided percutaneous coronary intervention (PCI). METHODS Consecutive patients undergoing FFR-guided PCI for coronary stenosis with reduced resting blood flow (baseline Pd/Pa

To report the experience of liver transplantation (LT) for tyrosinemia type 1 (TT-1). Clinical data of children with TT-1 who underwent living donor LT between July 2009 and May 2020 were retrospectively analyzed. Data included pre-LT nitisinone therapy, graft type, post-LT complications, HCC incidence, and graft/patient survival. Nine children were diagnosed with TT-1 at a median age of 12 mo (6–54 mo). Nitisinone was started in 6 patients at a median age of 15 mo (6–42 mo), but all had frequent interruption of therapy due to logistics with drug procurement including its cost. Median age at transplantation was 5 y (2–11 y). Explant liver showed HCC in 5 patients (55% of total cohort). The graft and patient survival are 100% with median follow-up of 58 mo (24–84 mo). LT is curative for TT-1 and excellent results can be obtained in experienced centers. This is especially favorable in countries with limited resources where the cost of medical therapy is highly prohibitive, with lifelong diet restrictions and unclear long-term risk of HCC.

BACKGROUND: Paresthesia with intrathecal anesthesia occurs when the entry of the needle causes an uncomfortable pain, burning, or electric sensation that usually radiates to the buttocks or legs. The importance of avoiding paresthesia is to lower the risk of postoperative neurological problems, in addition to reducing the incidence of that unpleasant sensation. The majority of reported occurrences of nerve injury caused by spinal anesthesia were preceded by paresthesia during the spinal anesthesia needle insertion. To the best of our knowledge, no studies have been done to compare the incidence of paresthesia in cesarean sections using median and paramedian routes to provide spinal anesthetic. AIM: Our study aimed to compare the incidence of paresthesia in the median and paramedian approaches of intrathecal anesthesia to predict its association with nerve injury. METHODOLOGY: Two hundred-ninety-six parturients scheduled for elective cesarean sections under spinal anesthesia were in the study from November 2020 to January 2021. They were divided into two groups. The median group (n = 157) and the paramedian group (n = 135) according to the approach used for providing spinal anesthesia. The incidence of paresthesia was compared between both groups. The number of trials in each approach and the occurrence of postoperative neurological complications (for example: nerve injury, paraplegia, or foot drop) were also documented. RESULTS: The sample size was calculated based on a pilot study that was conducted before the original study. The calculated sample size was based on an alpha error of 0.05 and 90% power. The incidence of paresthesia was higher in the median group (10.7%) than the paramedian (3.7) group with statistical significance (p = 0.039). In both groups, no postoperative neurological problems were noted in any groups. CONCLUSION: The median group has significantly more incidence of paresthesia than the paramedian group. The significance of this finding is that the paramedian approach is expected to be less likely to cause neurologic problems during spinal anesthesia.

Gentamicin is an important member of the aminoglycoside class of antibiotics having broader spectrum with extend to ototoxicity and nephrotoxcity. A reliable and accurate high performance liquid chromatography (HPLC) procedure was established using Agilent Zorbax Eclipse plus phenyl hexyl C18 (4.6 × 250 mm, 5 μm) column and UV detection at 330 nm. Recovery of gentamicin from biological and pharmaceutical samples was more than 95-98% after spiking the drug. The sensitivity of method is predicted by calculating a lower level of the limit of detection and lower limit of quantification (0.286 and 0.867 μg/mL, respectively. The procedure was used to quantify gentamicin in biological fluids and pharmaceuticals dosage form.

Background: Polymorphisms of genes encoding the pro-inflammatory and anti-inflammatory cytokines can affect the clinical presentation of the infection. We aimed to assess the role of EGF gene single-nucleotide polymorphism in the outcome of chronic hepatitis B virus (HBV) infection in children. Methods: One hundred HBV-infected children and 75 healthy matched controls were enrolled in this prospective study. Patients included 18 chronic inactive and 82 chronic active carriers. EGF rs4444903 A>G genotypes were determined using allele-specific amplification. Results: Significant differences regarding EGF genotypic frequency (p=0.001) in patients compared to controls (p=0.001). Eighteen percent were inactive, and 82% were active carriers. AA, AG and GG genotypic frequency were 66.7%, 33.3%, 0% and were 3.7%, 37.8% and 58.5% in the inactive and active carriers, respectively, with significant differences regarding AA, AG, GG genotypic frequency (p=0.001 for all). EGF AA, AG, GG genotypes frequency were 1.9%, 33.3%, and 64.8%, respectively, with significant differences between cirrhotic and non-cirrhotic patients regarding AA, AG, GG genotypic frequency (p=0.001 for all). Conclusion: Increased G allele frequency in EGF rs4444903 A > G polymorphism in HBV- Egyptian children is associated with worse outcomes.

Objectives: The authors evaluated the outcome of adult patients with coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome (ARDS) requiring the use of extracorporeal membrane oxygenation (ECMO). Design: Multicenter retrospective, observational study. Setting: Ten tertiary referral university and community hospitals. Participants: Patients with confirmed severe COVID-19-related ARDS. Interventions: Venovenous or venoarterial ECMO. Measurements and Main Results: One hundred thirty-two patients (mean age 51.1 +/- 9.7 years, female 17.4%) were treated with ECMO for confirmed severe COVID-19-related ARDS. Before ECMO, the mean Sequential Organ Failure Assessment score was 10.1 +/- 4.4, mean pH was 7.23 +/- 0.09, and mean PaO2/fraction of inspired oxygen ratio was 77 +/- 50 mmHg. Venovenous ECMO was adopted in 122 patients (92.4%) and venoarterial ECMO in ten patients (7.6%) (mean duration, 14.6 +/- 11.0 days). Sixty-three (47.7%) patients died on ECMO and 70 (53.0%) during the index hospitalization. Six-month all-cause mortality was 53.0%. Advanced age (per year, hazard ratio [HR] 1.026, 95% CI 1.000-1-052) and low arterial pH (per unit, HR 0.006, 95% CI 0.000-0.083) before ECMO were the only baseline variables associated with increased risk of six-month mortality. Conclusions: The present findings suggested that about half of adult patients with severe COVID-19 -related ARDS can be managed successfully with ECMO with sustained results at six months. Decreased arterial pH before ECMO was associated significantly with early mortality. Therefore, the authors hypothesized that initiation of ECMO therapy before severe metabolic derangements subset may improve survival rates significantly in these patients. These results should be viewed in the light of a strict patient selection policy and may not be replicated in patients with advanced age or multiple comorbidities. (C) 2021 The Authors. Published by Elsevier Inc.

Background: Diffuse large B-cell lymphoma (DLBCL) is considered the commonest subtype of non-Hodgkin lymphoma (NHL) in the world. It is a refractory disease with a high mortality rate due to frequent relapses. Several prognostic parameters are now widely studied for risk stratification and achieving a better outcome. Objectives: In this study, we aim to assess the prognostic value of immunohistochemical expression of CD10, BCL6, and MUM1 independently as surrogate markers for cell of origin (COO) classification of DLBCL and their correlation with clinicopathological characters and survival. Patients and methods: This is a retrospective study conducted on 63 cases of DLBCL, NOS. Full-faced sections were constructed and immunostained for CD10, BCL6, and MUM1. Results: CD10 expression was associated with early-stage (P=0.003), normal serum LDH level (P=0.022), absence of B symptoms (P=0.019), low international prognostic index (IPI) and age-adjusted-IPI (P=0.001) and also associated with longer progression free survival (PFS) (P=0.006). BCL6 expression was associated with centroblastic variant (P=0.005), good ECOG performance status (P=0.038) and low IPI (P=0.004) and also associated with better overall survival (OS) (P=0.028) and PFS (P=0.018). MUM1 expression was associated with advanced-stage (P=0.002) while no significant association was detected with other clinicopathological parameters or survival. Conclusion CD10, BCL6, and MUM1 can be used independently as prognostic immunohistochemical markers for DLBCL that may denote the clinical behavior of the disease and further patients' outcomes.

Background: Once preeclampsia is diagnosed, evidence-based interventions may reduce the risk or severity of maternal and infant health outcomes of preeclampsia. Aim of the study: Was to assess nurses knowledge and practices regarding the use of evidence-based for pregnant women with pre-eclampsia. Design: A descriptive study design was utilized to achieve the aim of the study. Setting: The present study was conducted at obstetrical and gynecological department at Benha University Hospital. Sampling: A convenient sample. Tools: Three tools were used for data collection:A self-administered questionnaire, Observational checklist and Modified Likert scale. Result: There were more than one third of studied nurses(41.7%) had average level of total knowledge about EBP and preeclampsia, less than two third of studied nurses (65%) had satisfactory level of total practices regarding preeclampsia and more than half of studied nurses (53.4) had high level of awareness about barriers. Conclusion: There was statistical significance positive correlation between total practices, total knowledge about evidence based practices and total knowledge of preeclampsia. Recommendation: Improving nurse’s awareness regarding EBP through involving them in educational programs to encourage them to utilized EBP into patient daily care.

BACKGROUND Measurement of post-percutaneous coronary intervention (PCI) fractional flow reserve (FFR) demonstrates residual ischemia in a large percentage of cases deemed angiographically successful which, in turn, has been associated with worse long-term outcomes. It has recently been shown that a resting pressure index, Pd/Pa, has prognostic value post stenting, however, its diagnostic value relative to FFR post-PCI has not been evaluated. METHODS The diagnostic accuracy of Pd/Pa in identifying ischemia (FFR≤0.80) pre- and post-PCI was evaluated. Three patient subsets were analyzed. A reference pre-PCI cohort of 1,255 patients (1,560 vessels) was used to measure the accuracy of pre-PCI Pd/Pa vs. FFR. A derivation post-PCI group of 574 patient (664 vessels) was then used to calculate the diagnostic accuracy of post-PCI Pd/Pa vs. FFR. A final prospective validation cohort of 230 patients (255 vessels) was used to test and validate the diagnostic performance of post-PCI Pd/Pa. RESULTS Median Pd/Pa and FFR were 0.90 (IQR 0.90-0.98) and 0.80 (IQR 0.71-0.88) in the reference pre-PCI model, 0.96 (IQR 0.93-1.00) and 0.87 (IQR 0.77-0.90) in the post-PCI derivation model, and 0.94 (IQR 0.89-0.97) and 0.84 (IQR 0.77-0.90) in the post-PCI validation model respectively. There was a strong linear correlation between Pd/Pa and FFR in all three models (p

Background Acute Stanford type A aortic dissection (TAAD) is a life-threatening condition. Surgery is usually performed as a salvage procedure and is associated with significant postoperative early mortality and morbidity. Understanding the patient’s conditions and treatment strategies which are associated with these adverse events is essential for an appropriate management of acute TAAD. Methods Nineteen centers of cardiac surgery from seven European countries have collaborated to create a multicentre observational registry (ERTAAD), which will enroll consecutive patients who underwent surgery for acute TAAD from January 2005 to March 2021. Analysis of the impact of patient’s comorbidities, conditions at referral, surgical strategies and perioperative treatment on the early and late adverse events will be performed. The investigators have developed a classification of the urgency of the procedure based on the severity of preoperative hemodynamic conditions and malperfusion secondary to acute TAAD. The primary clinical outcomes will be in-hospital mortality, late mortality and reoperations on the aorta. Secondary outcomes will be stroke, acute kidney injury, surgical site infection, reoperation for bleeding, blood transfusion and length of stay in the intensive care unit. Discussion The analysis of this multicentre registry will allow conclusive results on the prognostic importance of critical preoperative conditions and the value of different treatment strategies to reduce the risk of early adverse events after surgery for acute TAAD. This registry is expected to provide insights into the long-term durability of different strategies of surgical repair for TAAD. Trial registration ClinicalTrials.gov Identifier: NCT04831073.

Objective: This observational study was done to know the factors responsible and management of suction pneumothorax after trans-hiatal esophagogastrectomy. Materials and Methods: Progressive observational study of 415 patients who underwent trans-hiatal esophagogastrectomy and 35 patients who underwent trans-abdominal esophago-gastrectomy in last five years, for carcinoma esophagus and followed in immediate post-operative period for suction pneumothorax. Results: Ten patients from trans-hiatal group and two patients from trans-abdominal group complicated with suction pneumothorax in immediate post-operative period. It is the corrugated rubber drain site behind the neck incision close to esophago-gastric anastomosis which is responsible for maximum number of cases of suction pneumothorax. Withdrawal of corrugated rubber drain is the first and effective treatment, if diagnosis is made at an earliest point of occurrence of suction pneumothorax. If pneumothorax and air leak is not diagnosed and treated, then other fatal pulmonary complications can occur. Conclusion: Trans-hiatal esophageal dissection is usually associated with mediastinal pleural breach, so bilateral intercostal tube thoracostomy is a rational part of this surgery. Also close observation in immediate post-operative period is necessary to pick-up suction pneumothorax at an earliest point of suspicion. Keywords: Trans- hiatal suction pneumothorax, Esophagogastrectomy suction pneumothorax.

MitraClip (Abbott Vascular, Inc., Santa Clara, California) has emerged as a viable alternative for treatment of symptomatic severe mitral regurgitation. Conduction abnormalities are not a known complication of this procedure. We report a case of complete heart block without a ventricular escape rhythm immediately following MitraClip placement near the medial leaflets (A3-P3) in a patient with underlying trifascicular block. (Level of Difficulty: Intermediate.), Central Illustration

AIM This study aimed to compare the level of interleukin (IL)-10, IL-17, IL-27, IL-35, and IL-37 in the gingival crevicular fluid (GCF) and human plasma of subjects with periodontal disease. MATERIALS AND METHODS In this cross-sectional study conducted over a 3-month period at a primary dental clinic in Malaysia, 45 participants were recruited via consecutive sampling and assigned into three groups, namely healthy periodontium group (n = 15), gingivitis group (n = 15), and periodontitis group (n = 15). Gingival crevicular fluid and plasma samples were collected from each participant. Enzyme-linked immunosorbent assay test was conducted to measure the concentration of IL-10, IL-17, IL-27, IL-35, and IL-37. Kruskal-Wallis H test was used to compare the interleukin levels between patient groups. RESULTS In GCF samples, IL-17 level was the highest in the periodontitis group (p

Background: During coronary artery bypass grafting (CABG), the myocardium is subjected to endure periods of ischemia and reperfusion, which may result in post-ischemic contractile dysfunction. That is a major contributor to early and late morbidity and mortality and increased requirement of pharmacologic and mechanical circulatory support.Glucose insulin potassium (GIK) infusion was thought to provide a cardioprotective effect. Objective: To investigate whether the use of GIK solution in patients undergoing on-pump CABG affects requirements of inotropes. Patients and Method: In this prospective, randomized placebo-controlled trial, 64 patients were assigned into two groups: the GIK group in which glucose-insulin and potassium infusion was given during CABG surgery, and the non-GIK group in which only saline infusion was given during the procedure. Results: In the GIK group, all patient needed not more than two inotropes with mean of 1.28 ± 0.46, while in the non-GIK group there were patients who need up to three inotropes with mean of 1.56 ± 0.56 (P. value of 0.032). Conclusion: GIK infusion during on-pump CABG reduces perioperative inotropic requirements.

The rising episodes of deadly heat waves have intensified the need for a heat protection strategy. The Unani system of medicine offers ways to stay healthy in different climatic conditions. Hence, this article aims to discuss the applicability of health protection measures suggested by Unani scholars for hot weather conditions in the light of current researches. The manual literature survey of classical Unani texts was conducted to collect information on health safety measures for hot weather. A substantial search of scientific databases such as “Google Scholar” and “Medline” for proposed measures in combination with “heat-stroke”, “heat exhaustion” and “heat rash” was also conducted to identify their possible activity in heat-related illnesses. The guidelines for summer seasons in the classical Unani literature are described under the title tadābīr-i-mavsam. Unani scholars have discussed in detail the pathophysiological effects of heat and the measures to stay healthy by regulating the body system through lifestyle, diet and herbs. Most of the measures proposed by them are backed up by evidences. However, some measures have not yet been evaluated for their therapeutic or prophylactic efficacy in heat-related illnesses. On the basis of findings, the authors advocate the adoption of evidence-based measures and propose further investigation of those measures that are not well supported by the evidence or have not yet been evaluated.

Background: Pomegranate belongs to the family of Punicaceae. It has deciduous shrubs. Pomegranate is generally cultivated in Afghanistan, China, Iran, India, Pakistan, USA. Objective: This study aimed to review the pomegranate peels for exploring their importance in the field of health. Results: This review showed that Pomegranate is used as food and plays a vital role in the medicinal field. Because pomegranate fruit and its peel extraction contain various compounds like antioxidants, phenolic Acid, flavonoids, tannins etc., that have been found very effective in the health field. Due to the presence of antioxidants and other active compounds, pomegranates' peel is imperative for the betterment of human health. Besides, various medicines such as antidiarrheal medicine may be prepared from the peel extract of Pomegranate. Peel extract can act against various microbes such as Klebsiella pneumonia and Staphylococcus epidermidis, Bacillus subtilis, Klebsiella pneumoniae, Salmonella typhi, E. coli, S. aureus etc. The pomegranate strip and root remove have been accounted for in creatures to diminish blood glucose activity. Conclusion: It concludes that further research is needed to explore the hidden characteristics of pomegranate peel.

Urban planning is at a turning point The COVID-19 pandemic calls for an alternative approach which focuses on creating healthier built environments This is especially true in Africa given rapid urbanization combined with skill shortages in planning and underinvestment Connecting health and planning is not new across Africa Forty-five per cent of African countries experience at least one epidemic annually, including cholera, measles and malaria This is partly related to the presence of dense informal and unplanned settlements, with minimal access to water, sanitation and hygiene facilities contributing to the rapid transmission of respiratory illnesses Here, Andres et al assess the health impacts of the COVID-19 pandemic across Africa and examine the role of urban planning in such circumstances

Osteoarthritis (OA) is a common degenerative condition leading to significant pain, functional limitation, and economic loss. Generalized OA (GOA) is associated with greater morbidity and accounts for 5-25% of total OA cases depending on definition used. This paper aims to determine the frequency and pattern of GOA, compare clinical and laboratory parameters of GOA and non-GOA subjects, then identify independent associations of GOA among Nigerians with knee OA.A cross-sectional study of 180 knee OA patients with knee and generalized OA defined using ACR criteria. Questionnaire administration was followed by physical examination and appropriate radiographs. Data was summarized using tables and figures. Multivariate regression was done to identify independent GOA associations with statistical significance p0.05. Ethical approval was obtained for the study.There were 180 participants with mean age 59.7±9.1 years. Twenty-eight patients (15.6%) had GOA of which 26 were female. The hip/knee/spine pattern was the commonest while hand OA was rare. Comparisons showed that GOA patients were significantly older with longer pain duration, higher pain score, more Heberden's nodes, and greater fatigue. There were no significant differences between both groups in levels of inflammatory markers and other laboratory parameters. Further analysis identified joint stiffness as the only independent association of GOA (OR 3.34, p=0.01).A 15.6% frequency of GOA was identified among knee OA sufferers with the hip/knee/spine pattern most frequent. Nigerians with GOA are predominantly females with a large joint phenotype. Joint stiffness was the only independent association of GOA observed. Key Points • Generalized osteoarthritis occurs in 15.6% of Nigerian patients with knee osteoarthritis. • Females are predominantly affected with a large joint phenotype involving the hip/knee/spine. • Joint stiffness is an independent association of generalized osteoarthritis.

Purpose Acute hemorrhagic leukoencephalitis (AHLE) is a rare and severe form of acute disseminated encephalomyelitis (ADEM). Only a few reports of AHLE in coronavirus disease 2019 (COVID-19) patients have been described to date. We report a case of COVID-19-related AHLE along with a literature review describing salient clinical and imaging characteristics. Methods A literature search was performed on Medline (2020-present), PubMed, Cochrane Library, CINAHL, and Google scholar on 28 January 2021 for all articles published using MeSH terms “COVID-19” or “SARS-CoV-2” with “Acute hemorrhagic leukoencephalitis” or “Acute hemorrhagic encephalitis.” Relevant case reports and case series describing clinical and imaging features of AHLE associated with SARS-CoV-2 infection were included, data compiled, and critically reviewed. Results Acute onset encephalopathy and rapidly deteriorating neurological status is the common clinical presentation in AHLE. CSF analysis reveals elevated proteins and lymphocytic pleocytosis. Typical neuroimaging features include multifocal, variable-sized, poorly defined cerebral white matter lesions with cortical sparing. Involvement of the brainstem, cerebellar peduncles, and deep grey matter can also occur, although rarely. Lesions are hyperintense on T2-weighted (T2W) and fluid-attenuated inversion recovery (FLAIR) images, hypointense on T1W images, and show microhemorrhages, variable diffusion restriction, and post-contrast enhancement. Extensive microhemorrhages, brainstem involvement, and gross hemorrhage often portend a poor prognosis. Conclusion Heightened awareness about the clinical and imaging presentation of COVID-19-related AHLE can positively alter the outcome in a select few by enabling early diagnosis and aggressive management.

Background: Enterocolitis necrotizing (NEC) is linked to oxidative stress and ischemical necrosis. Ischemia modified albumin (IMA) is an albumin produced by reactive oxygen species that develop during ischemia owing to albumin modifications. Aim: to assess the amount of IMA in NEC-diagnosed preterm babies and to compare their level of healthy control. Methods and Subjects: Group (A) comprised thirty preterm babies with NEC, (B) included a control group of thirty preterm babies. The NEC diagnosis was established by Bell's amended staging criteria and ELISA assessed serum IMA in all subjects. Results: There was a substantial difference between patients and control groups (group A and B) in gestational age, sex and weight. There was a substantial difference in IMA levels between patients and control groups (P

Introduction: Third molar impaction is a common condition associated with a high standard of living. Aim: The main objective of the study was to document the prevalence of mandibular third molar impactions among the Najran populace. Materials and Methods: This is a retrospective study reviewing computerized medical records and panoramic radiographs of patients presenting for the extraction of mandibular third molars. Ethical approval was granted from the General Directorate of Health Affairs, Ministry of Health, Najran region. Data such as demographics, indications for third molar removal, position, and pattern of third molar impaction were collected. Data were stored and analyzed using IBM SPSS software version 25 for IOS (Armonk, NY: IBM Corp). Results and Discussion: Amongst 6205 extractions, 1024 mandibular third molar extractions were carried out with a prevalence rate of 16.5%. There were 609 (59.5%) female and 415 (40.5%) male (F:M = 1.5:1). The age ranged from 17 to 69 years (mean ± standard deviation, 31.4 ± 9.6 years), with the majority (52.1%) in the age group of 21–30 years. One hundred and ninety-one (18.6%) of the pericoronitis cases were associated with vertical impaction, while the majority of the caries were associated with mesioangular impaction (323 [31.5%]). Mesio-angular impactions (40.8%) and Level A depth (477 [46.6%]) were the most common. Class I ramus relationship had the highest distribution (561 [54.8%]). Conclusion: We have reported a prevalence rate of 16.5% of impacted mandibular third molar in mostly 21–30 years of age with female preponderance. Pericoronitis was the main indication for surgical extraction.

Background: Sodi-Pallares and colleagues first time introduced use of glucose-insulin and potassium (GIK) solution for myocardial protection. They used this solution in patients with acute myocardial infarction and concluded that GIK solution limited electrocardiographic changes in these patients. Objective: To investigate the effectiveness of the GIK solution regarding myocardial protection evaluated by postoperative creatine kinase MB (CKMB) and cardiac troponin I levels. Method: In this prospective, randomized clinical trial, sixty-four patients were assigned into two groups: GIK group, in which glucose-insulin and potassium infusion were given during surgery, and non-GIK group in which only saline infusion was given during the procedure. Results: All CK-MB values were lower in the GIK group than the Non-GIK group in the postoperative period (6, 12 and 24 hours’ samples) with statistically significant results. Troponin values were lower in the GIK group versus the Non-GIK group after 6 and 12 hours with statistical significance (P < 0.001 and 0.022 respectively). Conclusion: The addition of GIK infusion throughout the operation to standard myocardial protective techniques in patients undergoing on-pump coronary artery bypass graft (CABG) surgery attenuates myocardial ischemic injury.

Objective The purpose of this study is to assess the use of ultrasound indices to evaluate volume status and fluid responsiveness in patients with septic shock. Patients and methods A total of 40 successive patients aged above 40 years, with septic shock on admission to the ICU, were enrolled in the study, comprising 26 fluid responders and 14 fluid nonresponders. Results Regarding demographic data and other patient characteristics, no statistically significant difference between both the study groups was seen. Regard baseline hemodynamics data, there was no statistically significant difference between both groups. but after fluid bolus, there was a statistically significant difference between both groups. Regarding hemodynamics data. There was no significant difference between both groups regarding maximum inferior vena cava (IVC) diameter, whereas the minimum IVC diameter and internal jugular vein (IJV) area/common carotid artery area were significantly lower in the group of fluid responders compared with the nonresponder group. The caval index was significantly higher in the responder group compared with the nonresponder group, whereas there was no significant difference in the aspect ratio of the IJV between responder and nonresponder groups. Conclusion IVC diameter, caval index, IJV area, and IJV/common carotid artery area ratio are useful methods to predict fluid responsiveness in spontaneously breathing patients in septic shock.

Coronavirus disease 2019 (COVID-19) pandemic has affected health care systems worldwide. Severe presentations of COVID-19 such as severe pneumonia and acute respiratory distress syndrome (ARDS) have been associated with the post-viral activation and release of cytokine/chemokines which leads to a “cytokine storm” causing inflammatory response and destruction, mainly affecting the lungs. COVID-19 activation of transcription factor, NF-kappa B (NF-κB) in various cells such as macrophages of lung, liver, kidney, central nervous system, gastrointestinal system and cardiovascular system leads to production of IL-1, IL-2, IL-6, IL-12, TNF-α, LT-α, LT-β, GM-CSF, and various chemokines. The sensitised NF-κB in elderly and in patients with metabolic syndrome makes this set of population susceptible to COVID-19 and their worse complications, including higher mortality. Immunomodulation at the level of NF-κB activation and inhibitors of NF-κB (IκB) degradation along with TNF-α inhibition will potentially result in a reduction in the cytokine storm and alleviate the severity of COVID-19. Inhibition of NF-κB pathway has a potential therapeutic role in alleviating the severe form of COVID-19.

Objectives: OXP3 is a gene related to regulatory T cells existing on chromosome X. This meta-analysis, based on genetic association studies, was conducted to investigate the association of FOXP3 polymorphisms with susceptibility to multiple sclerosis (MS). Methods: All genetic association studies covering both FOXP3 and multiple sclerosis terms were searched in PubMed, Web of Science and Google Scholar. The information of genotype frequencies was summarized and results were synthesized through odds ratio (OR). Heterogeneity and publication bias were investigated using I2 scale and Begg's funnel plot, respectively. Results: For rs3761548 -3279 C/A polymorphism, AA/AY genotypes were a risk factor in comparison to CC/CY genotypes (P =0.022; OR =1.752; 95% confidence interval [CI] =1.084-2.830; random). AC genotype was a risk factor in comparison to CC/CY genotypes (P =0.004; OR =1.537; 95% CI =1.145-2.062; random) and homozygote genotypes (P =0.016; OR =1.216; 95% CI =1.038-1.426; fixed). For rs2232365 -924 G/A polymorphism, 2 significant associations were found according to a fixed effect model; of course, they did not remain significant in the random effect model. Conclusion: According to the collected populations, susceptibility to and protection from MS are associated with rs3761548 -3279 C/A upstream polymorphism. However, it should be regarded that this association is ethnicity dependent with low effect size.

OBJECTIVES We conducted a systematic review and meta-analysis to evaluate the long-term outcomes of PCI compared to CABG in patients with LMCAD. BACKGROUND Recent data from randomized controlled trials (RCTs) has raised concerns regarding the long-term efficacy and safety of percutaneous coronary intervention (PCI) compared with coronary artery bypass grafting (CABG) in patients with left main coronary artery disease (LMCAD). METHODS We searched MEDLINE and EMBASE databases for published RCTs comparing PCI using stenting with CABG in patients with LMCAD. Preferred reporting items for systematic review and meta-analysis guidelines were used for the present study. End-points of interest were all-cause mortality, cardiovascular (CV) mortality, myocardial infarction (MI), stroke, and repeat revascularization at longest available follow-up. Relevant data were collected and pooled odds ratio (OR) with 95% confidence intervals (CI) was calculated using random-effects model. RESULTS Five RCTs including a total of 4,499 patients were included in the final analysis. Mean duration of follow-up was 96 months. The risks of all-cause mortality [OR 1.09 (95% CI 0.88-1.34)] and cardiovascular mortality [1.14 (0.88-1.47)] were comparable between PCI and CABG. There were no statistically significant differences between PCI and CABG for MI [1.52 (0.98-2.37)] and stroke [0.84 (0.48-1.45)]. Conversely, repeat revascularization was significantly higher with PCI as compared with CABG [1.82 (1.49-2.22)]. CONCLUSION At long-term follow-up, PCI is associated with similar risks of mortality but a higher risk of repeat revascularization compared with CABG in LMCAD. Long-term risk of MI with PCI compared to CABG needs to be further explored in future studies.

Malnutrition during the critical period of pregnancy has significant health outcomes for both the mother and her offspring. Medical nutrition therapy (MNT) by a registered dietitian nutritionist (RDN) may help mitigate negative health effects, although studies that support the role of the RDN have not been comprehensively evaluated. The objective was to explore the health effects of MNT by an RDN on maternal and infant outcomes in pregnant women with malnutrition. A systematic review of studies published between 2000 and 2014 that incorporated MNT by an RDN during pregnancy were retrieved from a PubMed search, using criteria established by the Academy of Nutrition and Dietetics Evidence Analysis Process. Among 94 identified studies, five controlled trials met the inclusion criteria. The initial search was extended to include one study published between 2014 and 2019. Outcomes included maternal gestational weight gain, maternal markers of glycemic control, maternal complications such as hypertension, incidence of caesarean section, infant birth weight both in grams and in clinical categories, infant gestational age, and infant complications. There was good/strong evidence that MNT by an RDN decreased gestational weight gain, although there was no effect on maternal complications, caesarean section deliveries, and gestational age among women with mixed body mass index status or those who were overweight/obese. The evidence was deemed fair in support of an effect on glycemic control, infant birth weight, and infant complications. The heterogeneity in the results are due to the variation among populations studied, types of interventions, and inconsistency among outcomes. In addition, the training and educational requirements of the RDN or the international equivalent may vary widely across the four countries in which studies were conducted. There was good evidence for MNT by an RDN during pregnancy on improving gestational weight gain among overweight/obese women. To better support the role of MNT by an RDN in the health care of pregnant women, research that clearly identifies the role of the RDN in the intervention, includes a control group, and studies more heterogeneous populations is needed.

Salivary gland tumors (SGT) comprise 3% of all head and neck tumors, are mostly benign, and arise frequently in the parotid gland. Pleomorphic adenoma (PA) is the commonest SGT, representing 60-70% of all benign parotid tumors. Clinically, parotid PA presents as irregular, lobulated, asymptomatic, slow-growing preauricular mass, involving both superficial and deep lobes, and could grow to gigantic proportions. Histologically, PA has epithelial and mesenchymal elements in chondromyxoid matrix and is managed surgically. Based on a review of 43 cases reported in English literature since 1995, giant parotid PA is reported as large as 35 cm (diameter) and 7.3 kg (resected weight). Although rare, 10 cases of malignant transformation were reported in the review. Surgical management included extracapsular dissection (ECD), superficial parotidectomy, and total parotidectomy for benign tumors, and adjuvant radiation or chemotherapy for malignant tumors. We further present the case of a 36-year-old healthy male with slow-growing and asymptomatic giant parotid PA, of 4-year duration. The patient presented with firm, lobulated preauricular swelling, provisionally diagnosed as PA based on radiographic and cytological findings. The tumor was resected through ECD, and the patient had uneventful postoperative recovery and a 7-year recurrence-free follow-up period. Histological examination revealed epimyoepithelial proliferation punctuated by chondromyxoid areas, with extensive squamous metaplasia and keratin cysts. To the best of knowledge from indexed literature, giant parotid PA is rarely reported in Saudi Arabia. In addition to its rarity, this case is reported for its benign nature despite atypical histological presentation, successful surgical management without complications, and long-term recurrence-free follow-up. Based on this report, clinicians must be aware of atypical histological presentations associated with PA and plan suitable surgical management and follow-up to avoid morbidity. Nevertheless, attempts must be made to diagnose and manage these lesions at an early stage and before they reach gigantic proportions.

Summary: This study assesses the efficacy of 2 different potentiated ionophores (monensin and narasin) and a chemical (nicarbazin, a shuttle) in program with narasin to control coccidiosis in challenged male broilers through the evaluation of performance and macroscopic lesions of internal organs. A total of 4,400 broiler chicks were housed in 44 floor pens of 100 birds each; birds of the first group were fed a narasin/nicarbazin (NN)–containing diet from 0 to 27 D of age followed by narasin diet until market age, and those of group 2 were fed a monensin/nicarbazin diet followed by narasin ration for the same trial periods. The coccidia challenge was performed at day 1 by the inclusion of a proven Eimeria-infected litter in the bedding of all floor pens followed by an oral challenge using a commercial cocci vaccine at 7 D of age with a concentration of 11 times the vaccine dose. Although results showed that NN and monensin/nicarbazin treatments both demonstrated efficacy at reducing coccidian lesions, NN significantly increased BW and reduced feed conversion ratio (P < 0.05) at 27 (1,405 vs. 1284 g and 1.458 vs. 1.566, respectively) and at 33 D of age (2,178 vs. 2,026 g and 1.549 vs. 1.642, respectively). Weight and weight percentages of the ready-to-cook carcass and carcass cutup parts were significantly improved by NN. Narasin/nicarbazin inclusion in diet for 0 to 27 D followed by narasin until market weight was a successful strategy because, in addition to preventing and controlling coccidiosis, it improved performance of broiler chickens.

Aims/Introduction This study determined the prevalence and risk factors for diabetic peripheral neuropathy (DPN) and painful DPN (pDPN) in patients with type 2 diabetes in primary healthcare (PHC) and secondary healthcare (SHC) in Qatar. Materials and Methods This was a cross‐sectional multicenter study. Adults with type 2 diabetes were randomly enrolled from four PHC centers and two diabetes centers in SHC in Qatar. Participants underwent assessment of clinical and metabolic parameters, DPN and pDPN. Results A total of 1,386 individuals with type 2 diabetes (297 from PHC and 1,089 from SHC) were recruited. The prevalence of DPN (14.8% vs 23.9%, P = 0.001) and pDPN (18.1% vs 37.5%, P, The prevalence of diabetic neuropathy and painful diabetic neuropathy is lower in primary healthcare, and is attributed to better control of risk factors for diabetic peripheral neuropathy. However, approximately 80% of patients with diabetic neuropathy were undiagnosed in both primary and secondary healthcare. Diabetic neuropathy is associated with poor glycemic control, hyperlipidemia and hypertension, whereas painful neuropathy is associated with obesity and reduced physical activity.

Interstitial lung disease (ILD) occurs in 15% of connective tissue disease (CTD) patients causing considerable morbidity and mortality. Data is scarce regarding its clinical characteristics and outcomes in Africa. We aim to study the frequency, clinico-radiological characteristics, and treatment outcomes of African CTD-ILD patients. A retrospective cross-sectional study of ILD among 318 CTD patients diagnosed using relevant ACR criteria at the rheumatology unit of Lagos State University Teaching Hospital (LASUTH), Lagos from 2012 to 2019. Socio-demographics, clinical features, radiological findings, and treatment outcomes were documented. Data was analyzed using SPSS version 21 with p < 0.05. The LASUTH ethics committee approved the study. Interstitial lung disease occurred in 31 (9.7%) of 318 CTD cases. Their mean age was 38.8 ± 13.3 years, range 19-68 years with 28 (90.3%) females. Proportions of CTD-ILD were Sjogren's syndrome (50%), UCTD (50%), systemic sclerosis (46.7%), MCTD (33.3%), PM/DM (25%), SLE (6.5%), and RA (2.6%). Commonest presentations were cough (93.5%) and bibasal inspiratory crackles (83.9%) with a restrictive pattern in 83.9%. Antinuclear antibody occurred in 100% and anti-ENA in 67.7%. Traction bronchiectasis (89.7%) and ground glass opacities (96.6%) were frequent HRCT findings. Treatments included pulse-dose prednisolone, cyclophosphamide, mycophenolate mofetil, pirfenidone, and rituximab. Outcomes were ambulatory oxygen therapy (12.9%) and mortality (16.1%) with 9.7% lost to follow-up. CTD-ILD is a female predominant disease occurring in 9.7% of CTD patients mostly those with Sjogren's syndrome and systemic sclerosis. Due to significant morbidity and mortality, we advocate routine ILD screening for all CTD patients including those with undifferentiated disease. Key Points: • Interstitial lung disease occurs in 9.7% of patients with underlying connective tissue disease. • Females are predominantly affected especially those with Sjogren's syndrome and systemic sclerosis. • Mortality occurs in roughly 1 in every 6 patients with CTD-ILD.

Highlights • Bleeding after transurethral resection of bladder tumor is usually minimal and resolve spontaneously within days or weeks. • Common iliac artery aneurysm is a rare but can cause severe hematuria after cystoscopy with minimal manipulation. • Endovascular graft repair is minimally invasive procedure that showed excellent results in treatment of common iliac artery aneurysm., Introduction Transurethral resection of bladder tumor (TURBT) is an outpatient simple procedure that aims to remove bladder masses. Bleeding post TURBT is usually minimal and resolve completely within days or weeks. Massive bleeding after TURBT for small bladder masses is unusual. In this article we will report a case of unexpected massive hematuria that occurred after simple TURBT. Presentation of case A 69 patient who presented to our clinic complaining of intermittent painless gross hematuria. Ultrasound showed 1 cm bladder mass for which TURBT was done. On the 3rd post operative day the patient presented to ER complaining of massive hematuria and drop in hemoglobin. CT scan showed large left common iliac artery aneurysm which was managed using Endovascular graft repair (EVAR). Discussion Common iliac artery aneurysm is rare entity. Usually it is asymptomatic. However if it is large it can compress the perivesical vessels causing engorgement of these vessels that can manifest as massive hematuria after minimal endoscopic manipulation of the bladder. Conclusion Massive hematuria after simple TURBT is unusual for urologists. If it happens it may indicates iliac aneurysm or vascular malformation.

The presence of the thyroglossal duct cyst (TDC) within the thyroid gland is of rare occurrence as only 16 cases have been documented to date. It is even rare for the intrathyroidal TDC to present as infective thyroiditis as only one case has been reported in the scientific literature. We report a case of intrathyroidal TDC which presented as recurrent episodes of thyroiditis in a 13-year-old female. Diagnostic work-up, management, and review of pertinent scientific literature is also presented. To the best of our knowledge, this is the second case of intrathyroidal TDC which has presented as chronic recurrent thyroiditis. It is the first case of the intrathyroidal TDC with chronic thyroiditis reported in the pediatric age group.

Schistosomiasis is a multifactorial disease that includes environmental, behavioral, parasitic, vector, and host factors. This study aimed to assess the protective effect of single and polyvalent antigens from cercarial antigen preparations (CAPs), soluble worm antigen preparations (SWAPs), and soluble egg antigens (SEAs) which were used as candidate vaccines in an experimental model of Schistosoma mansoni-infected mice. The efficiency of the antigens was tested by determining their effects on fecal egg count, egg viability analysis, and tissue egg counts. Histological and morphometric analyses of granulomas in liver and intestine tissues were performed. In the present study, all immunized groups showed a significant reduction in the average fecal egg count and tissue egg load compared with infected mice. The most substantial reduction in fecal egg count was observed in the combined vaccinated group (23.23 ± 3.2). The group vaccinated with CAP before infection showed the highest reduction in tissue egg load (liver and intestine: 85.22 and 91.70%, respectively). Immunized animals showed a highly significant reduction in the numbers of hepatic granulomas compared with the infected non-immunized group. In conclusion, combining these different antigens (CAP, SWAP, and SEA) augments the protective immunity compared with other immunized groups.

C-peptide is gaining much interest recently due to its well-documented beneficial effects on multiple organ dysfunction induced by diabetes. Our study was designed to investigate the effect of C-peptide on hepatocellular dysfunction in diabetic rats. Wistar male rats were separated into four groups: control, diabetic, diabetic + insulin, and diabetic + C-peptide. Serum levels of glucose, insulin, and liver biomarkers were assessed. Liver sections were collected for histopathological examination and immuno-histochemical assessment of tumor necrosis factor alpha (TNF-α). Oxidative stress markers and gene expression of inducible nitric oxide synthase (iNOS), transforming growth factor beta 1 (TGF-β1), and glucose-6-phosphatase (G6Pase) were also measured in liver tissues. C-peptide administration prevented hepatic dysfunction induced by diabetes to a similar extent as that of insulin which was confirmed microscopically. We concluded that C-peptide could be used as an alternative therapy to insulin to correct hepatocellular dysfunction associated with type 1 diabetes mellitus (T1DM).

Typhoid ileal perforation is the common complication of typhoid fever in third week of its phase of progression. It is the most common cause of mortality in developing countries. Small perforations are dealt with primary repair and the more complicated disease is treated by multiple other options. Prognosis is good with primary repair with least postoperative complications. Objectives: To detect the outcome of typhoid ileal perforation treated by primary repair at tertiary care hospital. Study Design: Cross sectional study. Setting: Surgical Department of PMC Hospital Nawabshah. Period: From August 2017 to December 2018. Material & Methods: This study included total 70 patients. All patients were admitted from surgical OPD and emergency department of PMCH Nawabshah. Out of 70, 45 (64.28%) were females and 25 (35.71%) were male patients. Age ranged from 27 to 52 and 24 to 47 in females and males respectively. The common presentation was pain in whole abdomen along with distention and fever, vomiting. Plain X ray chest/ Abdomen and ultra sonography showed gas under diaphragm. Primary repair was done and also other surgical options but our study included only the postoperative outcomes of primary repair of typhoid ileal perforation. A few complications were detected after primary repair of the gut perforation. Results: Total 70 patients were included in this study. 45 (64.28%) were females and 25 (35.71%) were male patients. In females, 25 (55%) were found single perforations of less than 1cm whereas 7 (15.5%) had size of perforation less than 1.5 cm. In 25 males, 11 (44%) had single perforations of less than 1cm in size. 2 (8%) had < 1.5 cm size perforations and 12 (48%). Over all complication rate in this study was 26%. Conclusion: Primary repair is the best surgical option to treat typhoid ileal perforation in selected patients with least postoperative complications.

Background Uterine fibroids are a common type of solid tumor presenting in women of reproductive age. There are very few alternative treatment available from conventional treatment involving surgeries. Labisia pumila var. alata or locally known as 'Kacip Fatimah' was widely used as traditional medicine in Malaysia. This plant has been used to maintain a healthy female reproductive system. The present study aimed to evaluate anti fibroid potential of L. pumila extracts through in vitro apoptosis activity against uterine leiomyoma cells (SK-UT-1) and in uterine leiomyoma xenograft model. Evaluation of bioactive markers content were also carried out. Methods Apoptotic induction of the extracts was determined by morphological examination of AO/PI dual staining assay by flourescent microscopy and flow cytometry analysis on Annexin V-FITC/PI stained cells. In vivo study was done in immune-compromised mouse xenograft model. HPLC analysis was employed to quantify marker compounds. Results Morphological analysis showed L. pumila induced apoptosis in a dose dependent manner against SK-UT-1 cells. In vivo study indicated that L. pumila significantly suppressed the growth of uterine fibroid tumor. All tested extracts contain bioactive marker of gallic acid and cafeic acid. Conclusion This work provide significant data of the potential of L. pumila in management of uterine fibroids. .

Summary A 19-year-old female presented at 25-weeks gestation with pancreatitis. She was found to have significant hypertriglyceridaemia in context of an unconfirmed history of familial hypertriglyceridaemia. This was initially managed with fasting and insulin infusion and she was commenced on conventional interventions to lower triglycerides, including a fat-restricted diet, heparin, marine oil and gemfibrozil. Despite these measures, the triglyceride levels continued to increase as she progressed through the pregnancy, and it was postulated that she had an underlying lipoprotein lipase defect. Therefore, a multidisciplinary decision was made to commence therapeutic plasma exchange to prevent further episodes of pancreatitis. She underwent a total of 13 sessions of plasma exchange, and labour was induced at 37-weeks gestation in which a healthy female infant was delivered. There was a rapid and significant reduction in triglycerides in the 48 h post-delivery. Subsequent genetic testing of hypertriglyceridaemia genes revealed a missense mutation of the LPL gene. Fenofibrate and rosuvastatin was commenced to manage her hypertriglyceridaemia postpartum and the importance of preconception counselling for future pregnancies was discussed. Hormonal changes in pregnancy lead to an overall increase in plasma lipids to ensure adequate nutrient delivery to the fetus. These physiological changes become problematic, where a genetic abnormality in lipid metabolism exists and severe complications such as pancreatitis can arise. Available therapies for gestational hypertriglyceridaemia rely on augmentation of LPL activity. Where there is an underlying LPL defect, these therapies are ineffective and removal of triglyceride-rich lipoproteins via plasma exchange should be considered. Learning points: Hormonal changes in pregnancy, mediated by progesterone,oestrogen and human placental lactogen, lead to a two- to three-fold increase in serum triglyceride levels. Pharmacological intervention for management of gestational hypertriglyceridaemia rely on the augmentation of lipoprotein lipase (LPL) activity to enhance catabolism of triglyceride-rich lipoproteins. Genetic mutations affecting the LPL gene can lead to severe hypertriglyceridaemia. Therapeutic plasma exchange (TPE) is an effective intervention for the management of severe gestational hypertriglyceridaemia and should be considered in cases where there is an underlying LPL defect. Preconception counselling and discussion regarding contraception is of paramount importance in women with familial hypertriglyceridaemia.

Background and Aim: Brucellosis is a zoonotic disease caused by the bacterium of the genus Brucella. This disease is present worldwide, especially in developing and underdeveloped countries, where it is endemic. This first-of-its-kind study in Lebanon aimed to assess the prevalence of brucellosis across the country and to determine the efficacy of a vaccine for reducing losses in herds so that its toll on public health is reduced. Materials and Methods: Three hundred and fifty-three blood serum and 261 milk samples were obtained from cows in different areas of Lebanon. The samples were analyzed using serological tests (rose Bengal, milk ring, and indirect enzyme-linked immunosorbent assay [ELISA]) and confirmed with competitive ELISA and polymerase chain reaction. Results: The highest rate of Brucellae was found in the Bekaa region (10%). After vaccination of 5 cows and 13 heifers at different times, the results showed that all the vaccinated animals have developed an immune response to brucellosis 60 days after vaccination. This vaccine can be considered as stable and preventative to protect against brucellosis in animals and thus protect the public from this infection. Conclusion: These findings will provide further insight into designing future targeted awareness interventions and adapted policies as efforts toward reducing the prevalence and prevention of brucellosis in cattle in Lebanon.

BACKGROUND Melasma is a common esthetic problem affecting the face with a lot of risk factors being incriminated. Although several treatment options are available, none of them is satisfactory. OBJECTIVE This split face prospective study aimed to compare the efficacy of microneedling with vitamin C versus with PRP in the management of mixed melasma. METHODS Ten females with bilateral mixed facial melasma were treated with six sessions of microneedling. After the needling vitamin C was applied on the right side of the face and PRP was applied on the left side. Clinical, dermoscopic, and histological assessment of the used treatments was done 1 month after the last session. RESULTS The clinical and dermoscopic clearance of melasma was proved significantly on both sides of the face but was more significant with vitamin C (P = 0.005). Reduction of epidermal melanin and dermal melanophages was more observed with vitamin C. Moreover, MART-1 stain revealed a more significant reduction in the epidermal, dermal, and the total MART-1 positive cells with vitamin C (P =0.044, 0.039, and 0.035 respectively). CONCLUSION Microneedling with vitamin C was more efficient in treating mixed melasma than with PRP.

The current research aims to determine the effect of using audit procedures in accordance with the International Auditing Standard (IAS. No.545) in auditing measurement and disclosure on the basis of fair value in assessing audit risk, as the questionnaire was used to identify the opinions of the sample in the statement of the impact of the use of audit procedures in accordance with the IAS 545 in auditing measurement and disclosure on the basis of fair value in the assessment of audit risk. Nevertheless, after analyzing the study variables and testing the hypothesis, the research reached the most important conclusions, which are that most auditors lack the skills necessary to audit fair value accounting estimates because there are no fixed bases for measuring fair value, which creates difficulty for the auditor to understand the models used in preparing fair value estimates by the administration, and this affects in assessing audit risk. The most important recommendations were that work should be done to provide specific bases and clear models for measuring fair value, to reduce dependence on personal judgment for fair value estimates. Therefore, the auditor should use the same measurement models used by management when auditing fair value estimates, which contributes to improving the audit risk assessment.

Objectives: The purpose of the present study is to investigate the prevalence of lower flat ridge among a group of completely edentulous patients in Kashmir population, and to correlate it with age, gender, the presence or absence of a previous denture and the period of complete edentulism. Materials and Methods: 100 patients with lower flat ridge were included in the study. A questionnaire was used to record the data of each patient which include; the gender, the age of the patient, the presence or the absence of a previous denture, and the date of the last tooth extraction (the period of complete edentulism). The patients were informed that the recorded information was required for a research purpose, and it will be used in a survey, and their consents and agreements were taken verbally. All the collected data were checked and assessed by a prosthodontic specialist. The patients age were divided into four groups; (40-50 years), (51-60 years), (61-70 years), (more than 71 years). The period of complete edentulism were divided into two groups; (up to 4 years), and (more than 4 years). The data were correlated and descriptive statistic of tables, numbers and percentages along with Chi-Square, were used to analyze the data. Results: The results of the study showed that; 64 (64%) of the patients were males and 36 (36%) of the patients were females. The majority of the patients were from the age group (51-60) and (40-50) years in male and female respectively. The occurrence of the lower flat ridge was significantly higher in patients with previous dentures 75(75%) than those without dentures 25(25%) in both genders. Finally, the results revealed that patients who were completely edentulous for up to four years had significantly higher numbers of lower flat ridge 55(55%) comparing to those who were completely edentulous for more than four years 45(45%). Conclusions: The presence of a previous denture, the longevity period of complete edentulism, the age, and the gender of the patient has an effect on the resorption of the lower residual ridge, and on the height of the lower residual ridge.