Intraoperative Neuromonitoring during Peripheral Arteriovenous Malformation Embolization.

PURPOSE: To evaluate whether intraoperative neuromonitoring (IONM), including pre-embolization lidocaine injection challenge ("provocative testing") is associated with reduced risk of irreversible nerve injury during embolization of peripheral arteriovenous malformations (AVMs). MATERIALS AND METHODS: Medical records of patients with peripheral AVMs who underwent embolotherapy with IONM with provocative testing between 2012 and 2021 were reviewed retrospectively. Data collected included patient demographic characteristics, AVM location and size, embolic agent used, IONM signal changes after lidocaine and embolic agent injections, postprocedural adverse events, and clinical outcomes. Decisions regarding whether embolization would proceed at specific locations were based on IONM findings after the lidocaine challenge and as embolization proceeded. RESULTS: A cohort of 17 patients (mean age, 27 years ± 19; 5 women) who underwent 59 image-guided embolization procedures with adequate IONM data was identified. No permanent neurologic deficits occurred. Transient neurologic deficits were observed in 3 patients (4 sessions), comprising skin numbness (2 patients), extremity weakness (1 patient), and extremity weakness and numbness (1 patient). All neurologic deficits resolved by postoperative day 4 without additional treatment. CONCLUSIONS: IONM, including provocative testing, during AVM embolization may minimize potential nerve injury.

Clinical manifestations of patients with GDF2 mutations associated with hereditary hemorrhagic telangiectasia type 5.

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant fibrovascular dysplasia caused by mutations in ENG, ACVRL1, and SMAD4. Increasingly, there has been an appreciation for vascular conditions with phenotypic overlap to HHT but which have distinct clinical manifestations and arise from novel or uncharacterized gene variants. This study reported on a cohort of four unrelated probands who were diagnosed with a rare form of GDF2-related HHT5, for which only five prior cases have been described. Two patients harbored heterozygous missense variants not previously annotated as pathogenic (p.Val403Ile; p.Glu355Gln). Clinically, these patients had features resembling HHT1, including cerebrovascular involvement of their disease (first report documenting cerebral involvement of HHT5), but with earlier onset of epistaxis and a unique anatomic distribution of dermal capillary lesions that involved the upper forelimbs, trunk, and head. The other two patients harbored interstitial deletions larger than five megabases between 10q11.22 and 10q11.23 that included GDF2. To our knowledge, this is the first report detailing large genomic deletions leading to HHT5. These patients also demonstrated mucocutaneous capillary dysplasias, including intranasal vascular lesions complicated by childhood-onset epistasis, with a number of extravascular findings related to their 10q11.21q11.23 deletion. In conclusion, patients with GDF2-related HHT may present with a number of unique characteristics that differ from classically reported features of HHT.

Clinical Outcomes following Percutaneous Urinary Diversion for Hemorrhagic Cystitis.

Hemorrhagic cystitis (HC) can lead to severe morbidity in treatment-refractory cases. Percutaneous nephrostomy (PCN) drainage was first described in 1993 as a safe, nonoperative procedure to achieve supravesical urinary diversion and treat severe HC. Despite its early success, subsequent studies in the adult population have been limited. This retrospective case series describes long-term outcomes following PCN placement in 24 patients with refractory HC. The overall technical success of the procedure was 100%. Seventeen of 24 (71%) patients experienced resolution of hematuria. The median time for hematuria resolution after the procedure was 12 days (interquartile range, 7-28 days). Postprocedural HC severity grade significantly decreased from a median Grade 3 to Grade 1 (P < .01). The complications included catheter obstruction, dislodgement, and associated urinary tract infections occurring at rates of 1.0, 1.6, and 1.7 per 1,000 catheter days, respectively. This study of PCN placement demonstrated and further confirmed the effectiveness of urinary diversion in treating refractory HC.

University students' behavioral intention and gender differences toward the acceptance of shifting regular field training courses to e-training courses.

During the COVID-19 lockdown, all the courses at Imam Abdulrahman Bin Faisal University (IAU) were delivered fully online, including field-training courses. Since there was no previous experience in offering field-training courses in a distance format, the current study aims to identify factors that could impact students' behavioral intention to accept the e-training approach in teaching field training courses at IAU. In order to gather the data, the researchers designed a questionnaire based on the UTAUT model and they ensured the face, content, and construct validity of the questionnaire by sending it to five experts in the relevant field and by using exploratory factor analysis. Also, all the questionnaire's items were reliable since the Cronbach's alpha values were above 0.77 for all the items. A total of 397 participants provided valid responses. The result of this study indicated that Effort Expectancy (EE), Facilitating Condition (FC), Performance Expectancy (PE), and Social Influence (SI), respectively were the primary predictors for students' intention to use e-training. These factors explained 32.1% of the variance in students' behavioral intentions. As far as students' gender is concerned, there were significant differences between students' PE, FC, and SI. Based on these results, policymakers at IAU will have a clear image of the most essential factors that colleges should target to increase students' acceptance of e-training.

Green synthesis, in vivo and in vitro pharmacological studies of Tamarindus indica based gold nanoparticles.

The current investigation aims to synthesize gold nanoparticles (AuNPs) from aqueous extract of Tamarindus indica and to evaluate the in vitro anti-bacterial and in vivo sedative and anelgescic activities of crude extract as well as synthesized AuNPs. Several methods have been reported to synthesize AuNPs; however, most of them were not ecofriendly. In the present study, the green synthesis of AuNPs has been carried out. Using the green synthesis method, AuNPs of T. indica were synthesized at room temperature (25 °C) by mixing 5 mL of HAuCl4 (1 mM) with 1 mL of T. indica seed extract solution. This extract solution was prepared by taking 5 gm dry seeds in 100 mL of double deionized water with continuous stirring for up to 24 h at 80 °C. The stability of AuNPs was confirmed with the help of relevant experimental techniques including ultraviolet-visible (UV/Vis) showing maximum absorbance at 535-540 nm, Fourier transform infrared showing a broad signal at 3464 cm-1 which can be attributed to either amide or hydroxyl functionalities and atomic force microscopy analysis showed that the biomaterial surrounding AuNPs was agglomerated which proves the formation of discrete nanostructutres. These AuNPs have been evaluated for their antibacterial potential. The results revealed good antibacterial activity of the samples against. Klebsiella pneumonia, Bacillus subtilis and Staphylococcus epidermidis with 10-12 mm zone of inhibition range. The AuNPs were also found stable at high temperature, over a range of pH and in 1 mM salt solution. Moreover, the crude extract and respective AuNPs also exhibited interesting sedative and analgesic activities. Hence, we focused on phytochemicals-mediated synthesis of AuNPs considered as greatest attention in the treatment of anti-bacterial, analgesic, and sedative.

Video assisted thoracoscopic management of primary spontaneous pneumothorax.

OBJECTIVE: To analyze the outcome of Video assisted Thoracoscopy (Vats) in Primary Spontaneous Pneumothorax (PSP). METHODS: This case series was carried out from Jan 2010 to Jan 2017 in Department of Thoracic Surgery CMH Rawalpindi and Lahore. A total of 98 patients underwent Video-assisted thoracoscopic for PSP. Inclusion criteria were physiologically fit patients with PSP for recurrent attacks, occupational hazards and prolonged air leak. Exclusion criteria included secondary spontaneous pneumothorax, previous pleurodesis and physiologically unfit patient for general anaesthesia. Vanderschueren's thoracoscopic classification was used for macroscopic staging. A 3-port technique was used for apical stapling with partial pleurectomy up to 6th rib. Parietal pleura and diaphragm was also abraded. RESULTS: Occupational hazard was the commonest indication for surgery, n= 39 (39.7%). This was followed by recurrent pneumothorax 37 (37.7%), persistent air leak 19 (19.38%) and contra lateral pneumothorax n=4 (4.08%). Mean age was 22.8 ± 6.5 years. Majority of the cases , 69(70.4%) were in stage 3 of Vanderschueren's classification. Stage 4 were (18.5%) and stage 2 were 7 (7.14%). Mean operative time was 51 ± 14. 4 minutes. Postoperative prolonged air leak occurred in 3 patients and post-operative neuralgia occurred in 8 patients. Mean follow-up was 22 ±5.5 months, range 5-24 months for all patients. One had generalized recurrence and 2 patients had subpulmonic trapping of air. CONCLUSION: Video-assisted thoracoscopic stapling and pleurectomy is an effective definitive treatment for primary spontaneous pneumothorax when indicated with minimal recurrence.

Preparation and characterization of co-processed starch/MCC/chitin hydrophilic polymers onto magnesium silicate.

It was aimed to investigate the compressibility, compactibility, powder flow and tablet disintegration of a new excipient comprising magnesium (Mg) silicate co-processed (5%-85% w/w) onto chitin, microcrystalline cellulose (MCC) and starch as the hydrophilic polymers of interest. Initially, the mechanism of tablet disintegration was studied by measuring water infiltration rate, moisture sorption, swelling capacity and hydration ability. Moreover, the powders compression behavior was carried out by applying Kawakita model of compression analysis in addition to porosity and radial tensile strength measurements. In vitro drug release of compacts made of 400 mg ibuprofen and 300 mg of the hydrophilic polymers containing 30% w/w Mg silicate co-precipitate was investigated in phosphate buffer (pH 7.8). This work demonstrated that the incorporation of Mg silicate to the hydrophilic polymers lead to the improvement of powder flowability, compactibility, stability (with regard to storage conditions), compacts crushing strength, and disintegration time in addition to faster drug release. The overall findings are practically advantageous in the context of finding a low cost and multifunctional co-processed excipient of natural origins.

Lung cancer in Pakistan, where do we stand?

Lung cancer is the most common cancer in males and second most common in females after breast cancer. We have compared our data with the international statistics to see where do we stand. In Pakistan, we do not have a valid central cancer registry at present which can provide a true picture of lung cancer. Therefore, we used statistics of GLOBOCON 2012, in order to evaluate the true burden of lung cancer in our population through the recently established data by PHRC (Pakistan Health and Research council). Our analysis showed that data depicting true incidence and mortality of lung cancer in Pakistan are lacking. GLOBOCON 2012 placed lung cancer as the 3rd most common cancer in Pakistan while PHRC 2016 placed it as the 10th most common cancer irrespective of the rise in smoking incidence in Pakistan over the past one decade. This calls for an urgent need to formulate a valid central cancer registry in the country in association with the local bodies.

Depression In Type-2 Diabetic Patients Presenting To A Tertiary Care Hospital In Pakistan.

BACKGROUND: Diabetes affects almost every system including mental health. When depression and diabetes coexist, the outcome is even worse. This study was conducted to find the prevalence of comorbid depression in diabetic patients and its association with diabetic control. METHODS: This was a descriptive cross sectional observational study conducted in the department of general medicine of Pakistan Institute of Medical Sciences, Islamabad from March to September 2014. A total of 223 adult diabetic patients 30-60 years of age were enrolled. Becks Depression score (BDI) and HDRS (Hamilton Depression Rating Score) of each patient was calculated. Patients were stratified into various categories based on their demographics, depressions scores and diabetic control (by means of HbA1C). Percentages, frequencies and means were calculated accordingly using SPSS-16. RESULTS: Out of a total of 223 patients, 55.6% were females while the rest (44.4%) were males. The mean age of the patients was 51 years. Majority of the patients were uneducated (35.9%). Eighty-seven% were married, Mean BMI, duration of diabetes and HbA1C were 27 Kg/m2, 8.3 years±6.1 years and 8.15±2.13% respectively. Mean BDI and HDRS were 9.97±9.42 and 6.27±6.74 respectively. 25.6% and 21.1% of the patients had at least some degree of depression when assessed by BDI and HDRS score respectively.. CONCLUSIONS: Depression is common in diabetic patients especially females, uneducated, have social issues like widows, those having long standing diabetes and those who have uncontrolled blood sugars.

The forgotten disease - Lemierres syndrome.

Lemierre's syndrome refers to septic thrombosis of deep veins of the neck, is a rare and often life threatening complication following upper respiratory tract infections. We present here a case of Lemierre's syndrome in a previously healthy 30 years old female who had a febrile illness for two weeks with associated dysphagia, hoarse voice and right sided neck swelling. She was investigated for retropharyngeal and parapharyngeal abscess, granulomatosis with polyangiitis, tuberculosis and thyroiditis but finally concluded as Lemierre's syndrome based on the findings of thrombosis of the deep neck veins following respiratory tract infection, septic pulmonary emboli and clinical recovery with antibiotics and supportive care. Lemierres syndrome can be fatal if diagnosis and treatment is delayed. Strong clinical suspicion leads to early diagnosis and may prevent life threatening organ dysfunction.

PHARMACOLOGICAL ASSESSMENT OF HISPIDULIN - A NATURAL BIOACTIVE FLAVONE.

Hispidulin is well-known natural bioactive flavone on behalf of its pharmacological aspects. This review contains data on isolation, synthetic methodology, pharmacokinetics and bioactivities of hispidulin. The article provides a critical assessment of present knowledge about hispidulin with some clear conclusions, perspectives and directions for future research in potential applications.

Role Of Clamping Tube Thoracostomy Prior To Removal In Non-Cardiac Thoracic Trauma.

BACKGROUND: The frequently encountered thoracic trauma in surgical emergencies is a major cause of mortality and morbidity. Eighty percent of thoracic trauma can be managed by simple insertion of tube thoracostomy. Though guidelines for insertion are comprehensively explained in literature, an ideal algorithm for discontinuation is not available. A standard and safe defined protocol would eliminate hesitancy in confident removal among general surgeons. The objective of this study was to determine role of clamping trial prior to removal in terms of frequency of recurrent pneumothorax. METHODS: This study was conducted in department of Surgery Combined military hospital/Military Hospital Rawalpindi from April 2013 to March 2014. Total 180 patients with blunt or penetrating thoracic trauma were included in the study. Chest tube (28-36 Fr) was inserted in Trauma centre under strict asepsis. Tubes were then connected to under water seal for minimum six hours. Patients were randomly divided in two equal groups (90 in each). In Group A, Clamping trial was given before attempting removal while in Group B, tube was removed immediately without clamping trial. Patients of both groups were observed two hourly for development of recurrent pneumothorax. Data was analysed using SPSS-18. RESULTS: The comparison of frequency of recurrent pneumothorax in Group A (9 patients, 10%) and in Group B (4 patients, 4.5%) was not found to be statistically significant. (p-value 2.073). CONCLUSIONS: Clamping trial is unnecessary prior to removal of tube thoracostomy in blunt and penetrating non-cardiac thoracic trauma in terms of recurrent pneumothorax.

PHARMACOLOGICAL ASSESSMENT OF HISPIDULIN--A NATURAL BIOACTIVE FLAVONE.

Hispidulin is well-known natural bioactive flavone on behalf of its pharmacological aspects. This review contains data on isolation, synthetic methodology, pharmacokinetics and bioactivities of hispidulin. The article provides a critical assessment of present knowledge about hispidulin with some clear conclusions, perspectives and directions for future research in potential applications.

AN EXPERIENCE OF BRONCHOTOMY AND RESECTIONAL PROCEDURES AFTER FAILED BRONCHOSCOPIC FOERIGN BODY RETRIEVAL.

BACKGROUND: Foreign body bronchus is a surgical emergency and is associated with a high mortality if neglected or complicated. The objective of this study was to analyse the outcome of bronchotomy and resectional procedures after failed bronchoscopic foreign body retrieval. METHODS: This study of 24 cases of bronchotomy and resectional procedures after failed bronchoscopic foreign body retrieval was done from June 2008 to June 2009 and March 2010 to Sep 2013. Patients after failed retrieval of foreign body by bronchoscopy either by ENT specialists or thoracic surgeons underwent bronchotomy or resectional procedures were included in the study. We used the posterolateral thoracotomy approach for the surgical procedures. RESULTS: Bronchotomy and resectional procedures were done in 24 cases. Age of patients ranged from 2 years to 51 years. Most patients were children and right side was mostly involved. Bronchotomy procedures were 10 (41%) and resectional surgeries were 13 (58%). Emergency lobectonies were 3 out of 13 resectional surgeries. Right intermedius bronchus was opened up and incision was extended in the direction of foreign body in 6 cases and left bronchus intermedius was opened in 4 cases. Haemoptysis was the main symptom in late presenters. Range of objects retrieved in our study was from pins, needles to whistles. CONCLUSION: Retention causes endobronchial obstruction with stasis leading to irreversible damaged parenchyma. Foreign body with structural changes require resection, others can be offered bronchotomy which is a safe procedure for retained non retrievable foreign bodies.

Recent pharmacological advancements in schiff bases: a review.

Schiff bases are the biologically privileged scaffolds in organic chemistry, commonly synthesized from the condensation reaction of carbonyl functional group with amines. Naturally occurring and synthetically prepared Schiff bases are active molecules with many pharmacological activities like antibacterial, anti-cancer, anti-fungal, anti-malarial, antioxidant and many more. This review article summarizes pharmacological developments in the recent few years and gives a brief overview of their therapeutic potential.

Percutaneous mesocaval shunt creation for portal thrombosis in a patient with a JAK2V617F mutation.

Myeloproliferative neoplasms (MPN) are the most common cause of noncirrhotic, nontumoral portal vein thrombosis (PVT). Over 90 % of MPN patients with PVT carry the JAK2V617F mutation. Compared to other etiologies of PVT, patients with JAK2V617F MPNs are at increased risk of developing significant portal hypertension. However, when these patients develop refractory portal hypertensive complications requiring portosystemic shunt placement, they have limited options. Transjugular intrahepatic portosystemic shunt (TIPS) insertion is often not feasible, as these patients tend to have extensive, occlusive portal thrombus with cavernous transformation. Surgical portosystemic shunt creation can be an alternative; however, this is associated with significant mortality. In this report, we describe the novel use of a percutaneous mesocaval shunt for successful portomesenteric decompression in a patient with portal hypertension from PVT associated with JAK2V617F positive essential thrombocythemia.

Enzyme-triggered approach to reduce water bodies' contamination using peroxidase-immobilized ZnO/SnO2/alginate nanocomposite.

Enzyme immobilization on solid support offers advantages over free enzymes by overcoming characteristic limitations. To synthesize new stable and hyperactive nano-biocatalysts (co-precipitation method), ginger peroxidase (GP) was surface immobilized (adsorption) on ZnO/SnO2 and ZnO/SnO2/SA nanocomposite with immobilization efficacy of 94 % and 99 %, respectively. Thereafter, catalytic and biochemical characteristics of free and immobilized GP were investigated by deploying various techniques, i.e., FTIR, PXRD, SEM, and PL. Diffraction peaks emerged at 2θ values of 26°, 33°, 37°, 51°, 31°, 34°, 36°, 56°, indicating the formation of SnO2 and ZnO. The OH stretching of the H2O molecules was attributed to broad peaks between 3200 and 3500 cm-1, whereas ZnO/SnO2 spikes occurred in the 1626-1637 cm-1 range. SnO stretching mode and ZnO terminal vibrational patterns have been verified at corresponding wavelengths of 625 cm-1 and 560 cm-1. Enzyme entrapment onto substrate was verified via interactions between GP and ZnO/SnO2/SA as corroborated by signals beneath 1100 cm-1. GP-immobilized fractions were optimally active at pH 5, 50 °C, and retained maximum activity after storage of 4 weeks at -4 °C. Kinetic parameters were determined by using a Lineweaver-Burk plot and Vmax for free GP, ZnO/SnO2/GP and ZnO/SnO2/SA/GP with guaiacol as a substrate, were found to be 322.58, 49.01 and 11.45 (µM/min) respectively. A decrease in values of Vmax and KM indicates strong adsorption of peroxidase on support and maximum affinity between nano support and enzyme, respectively. For environmental remediation, free ginger peroxidase (GP), ZnO/SnO2/GP and ZnO/SnO2/SA/GP fractions effectively eradicated highly intricate dye. Multiple scavengers had a significant impact on the depletion of the dye. In conclusion, ZnO/SnO2 and ZnO/SnO2/SA nanostructures comprise an ecologically acceptable and intriguing carrier for enzyme immobilization.

Characteristics of Stroke-related Seizures and their Predictive Factors: A Tertiary Care Center Experience.

BACKGROUND AND PURPOSE: Various risk factors have been described in the literature that increase the risk of seizures associated with stroke. This study was aimed to determine the occurrence rate of poststroke seizures (PSSs) and the associated risk factors in Arab population. MATERIALS AND METHODS: Study included all stroke patients aged >18 years with a minimum follow-up of 24 months following stroke to identify seizure occurrence. Patient's hospital records for all admissions and clinic visits were reviewed. Seizures were classified into early PSS if they occur within 1 week of stroke, and late PSS if they occur after 1 week of stroke. RESULTS: Out of 594 patients, 380 were males. Seizure occurrence was higher in anterior circulation infarctions (94.8%, P < 0.05), cortical location (80.5%, P < 0.05), large artery atherosclerosis (63.8%, P < 0.05), lower activated partial thromboplastin time (APTT) (P = 0.0007), patients with ischemic heart disease (IHD) (P = 0.01), and those who underwent craniotomy (P = 0.001). Nonhigh-density lipoprotein cholesterol was inversely related to PSS (P = 0.01). Higher stroke severity (89%) and confusion (67%) at the time of presentation were independently related to PSS. CONCLUSIONS: Eighty-two (13.8%) patients had PSS. Greater stroke severity at presentation with altered sensorium was independent risk factors for the development of PSS. Patients with underlying IHD, lower APTT, and undergoing neurosurgical intervention require vigilant monitoring for PSS.

Résumé Ontexte et objectif:Divers facteurs de risque ont été décrits dans la littérature qui augmentent le risque de convulsions associées à un AVC. Cette étude visait à déterminer le taux d'occurrence des crises post-AVC (PSS) et les facteurs de risque associés dans la population arabe.Matériels et Méthodes:L'étude a inclus tous les patients victimes d'AVC âgés de plus de 18 ans avec un suivi minimum de 24 mois après l'AVC pour identifier la survenue d'une crise. Les dossiers hospitaliers des patients pour toutes les admissions et visites à la clinique ont été examinés. Les saisies ont été classées en premiers PSS s'ils surviennent dans la semaine suivant l'AVC, et PSS tardif s'ils surviennent après 1 semaine de l'AVC.Résultats:Sur 594 patients, 380 étaient des hommes. Crise d'épilepsie la fréquence était plus élevée dans les infarctus de la circulation antérieure (94,8 %, P < 0,05), la localisation corticale (80,5 %, P < 0,05), l'athérosclérose des grandes artères (63,8 %, P < 0,05), un temps de thromboplastine partielle activé (APTT) inférieur (P = 0,0007), les patients atteints de cardiopathie ischémique (IHD) (P = 0,01) et ceux ayant subi une craniotomie (P = 0,001). Le cholestérol des lipoprotéines non de haute densité était inversement lié au PSS (P = 0,01). Course supérieure la gravité (89 %) et la confusion (67 %) au moment de la présentation étaient indépendamment liées au PSS.Conclusions:Quatre-vingt-deux (13,8 %) patients avait PSS. Une plus grande gravité de l'AVC lors de la présentation avec un sensorium altéré était un facteur de risque indépendant pour le développement du PSS. Les patients avec une IHD sous-jacente, un APTT inférieur et une intervention neurochirurgicale nécessitent une surveillance vigilante du PSS.

Pulmonary arteriovenous malformation (PAVM): rare cause of hemoptysis.

Pulmonary arterio-venous malformation is an abnormal communication between pulmonary arteries and pulmonary veins. These lesions are rare and are an important part of the differential diagnosis of common pulmonary problems such as hypoxemia and pulmonary nodules. Pulmonary arterio-venous malformation was diagnosed in a 33 year old man who presented with recurrent episodes of haemoptysis and also had taken anti-tuberculous treatment (ATT) before. Pulmonary angiography revealed fistulous communication between right bronchial artery and right pulmonary vein. He was treated by lobectomy.

Paget's Disease of Bone: A Rare Incidence in Early Adult Life in Pakistan, Southeast Asia.

Paget's disease of bone (PDB) is a focal disorder of skeletal remodeling leading to alteration of bony structures and properties, uncommonly reported in people under the age of 40 years, particularly in the Southeast Asia region. In the literature, PDB has been well reported in regions of Europe, in contrast to Asia where there has been limited records of prevalence of PDM especially in the younger age population. Here, we report a 21-year-old male patient presenting with an advanced disease with complaints of auditory impairment, bone pain, and neurological signs due to compression of the interverbal disc developed progressively over two months, having an elevated serum alkaline phosphatase level of 601 IU/L. The patient was administered zoledronic acid that brought significant improvement in his health. We aim to signify the advanced presentation of PDB in our region to create awareness about the condition among physicians and aid in the prompt diagnosis and prevention of the most dreaded complications of the disease, such as osteosarcoma, secondary osteoarthritis, and fractures.