Diagnostic accuracy of ultrasonography in diagnosis of Carpal Tunnel Syndrome.

Objective: This study aimed to assess the diagnostic accuracy of Ultrasonography, considering nerve conduction study (NCS) as the gold standard diagnostic modality for carpal tunnel syndrome (CTS). Methods: A cross-sectional study was conducted at the Neurology Department of Allied Hospital, Faisalabad from August, 2020 to January, 2021. NCS and Ultrasonography of wrist were performed for diagnosis of CTS. The sensitivity, specificity, predictive value (NPV), positive predictive value (PPV), and diagnostic accuracy (DA) were calculated for the screening test (Ultrasonography of the wrist), taking NCS as the gold standard. Results: The mean age of the study population was 41.53 ± 8.80 years, with female pre-dominance (71.66%). The right hand was involved in 24(40%) patients, left hand was involved in 4(6.66%) patients, and both hands were involved in 32(53.33%) patients. Among 60 patients, ultrasonography diagnosed 56 (TP+FN) as having CTS, confirmed via nerve conduction study. Sensitivity, specificity, NPV, PPV, and DA of Ultrasonography of the wrist for CTS were 92.8%, 75%, 42.8%, 98.1%, and 91.6%, respectively. Conclusion: Based on the sensitivity and specificity, Ultrasonography may assist in diagnosing CTS.

Neutrophil/lymphocyte ratio-A marker of COVID-19 pneumonia severity.

AIM: To determine the efficacy of neutrophil/lymphocyte ratio (NLR) as a marker of the severity of COVID-19 pneumonia in the South-Asian population. METHODS: This was a prospective, cross-sectional, analytic study conducted at HDU/ICU of District Headquarter Hospital, Faisalabad, Pakistan, from May through July 2020. Sixty-three eligible patients, admitted to the HDU/ICU, were prospectively enrolled in the study. Their NLR, C-reactive protein, serum albumin and serum fibrinogen were measured. Patients' demographic characteristics, comorbidities, clinical manifestations of COVID-19 infection, medication use and history of lung malignancy were retrieved from their medical history. Patients were categorised into either a general group (with mild COVID-19) or a heavy group (with moderate to severe COVID-19). RESULTS: There were significant differences between the two groups in diabetes prevalence, NLR, C-reactive protein and serum albumin. NLR and C-reactive protein were positively correlated (P < .001, P = .04, respectively) whereas serum albumin was negatively correlated (P = .009) with severe COVID-19. NLR was found to be an independent risk factor for severe COVID-19 pneumonia in the heavy group (OR = 1.264, 95% CI: 1.046~1.526, P = .015). The calculated AUC using ROC for NLR was 0.831, with an optimal limit of 4.795, sensitivity of 0.83 and specificity of 0.75, which is highly suggestive of NLR being a marker for the early detection of deteriorating severe COVID-19 infection. CONCLUSION: NLR can be used as an early warning signal for deteriorating severe COVID-19 infection and can provide an objective basis for early identification and management of severe COVID-19 pneumonia.

Implementation of a telemedicine service during COVID-19 pandemic in Pakistan.

AIM: In this feasibility study, we aimed to implement a pilot telemedicine service at our healthcare facility in Faisalabad, Pakistan, and describe our experience. METHODS: Telemedicine service was established by Faisalabad Medical University at two of its affiliated locations: (i) a 24-hour COVID-19 Telephone Helpline was established at the Director Emergency Office, Allied Hospital, and District Headquarter (DHQ) Hospital. (ii) A Telemedicine Clinic comprising consultants and postgraduate residents from different specialties was established at Chief Office, Allied Hospital. The data related to the number and categories of calls and advice provided were collected from 27th March 2020 to 31st July 2020. RESULTS: A total of 4582 calls were received, at both locations, during the study period, out of which 2325 callers (51%) were male, and 2257 (49%) were females. At Allied Hospital, 172 patients were advised accordingly for their complaints, whereas, at DHQ Hospital, 320 patients were advised accordingly for their complaints. At the Telemedicine Clinic only, a total of 2436 calls were received during the study period, 1474 (60%) callers were male, and 962 (40%) were female. The majority of the calls were received by medicine (43%), dermatology (21%), and paediatrics (11%) specialties, respectively. CONCLUSION: Despite some limitations, the benefits of telemedicine in this COVID-19 era are enormous and it is feasible to implement telemedicine services in developing countries. The developing countries must invest in the internet and technology access to facilitate telemedicine and other e-health services for not only curbing this pandemic but also to promote a more efficient healthcare system after the pandemic.

Comparative effectiveness of routine physical therapy with and without instrument assisted soft tissue mobilization in patients with neck pain due to upper crossed syndrome.

OBJECTIVES: To determine the effectiveness of routine physical therapy with and without instrument-assisted soft tissue mobilisation on pain intensity and range of motion in patients with neck pain due to upper crossed syndrome. METHODS: The randomised controlled trial was conducted from January to March 2020, and comprised diagnosed male patients aged 18-40 years of upper crossed syndrome complaining of neck pain visiting the Agile Physical Therapy and Rehabilitation Complex and the National Orthopaedic Hospital, Bahawalpur, Pakistan. The subjects were randomised into control group A which received routine physical therapy and experimental group B which received instrument-assisted soft tissue mobilization along with routine physical therapy. The inclinometer was used to measure range of motion and the numeric pain rating scale for pain measurement. Data was analysed using SPSS 22. RESULTS: Of the 60 subjects, there were 30(50%) in group A with a mean age of 31.50±6.388 years and 30(50%) in group B with a mean age of 32.60±5.55 years. Pain rating at baseline in group B compared to group A show significant difference (p=0.01). Neck range of motion, including flexion, neck right bending, and neck left bending showed significant differences between the groups (p<0.05). The results for neck extension showed that both techniques were equally effective (p>0.05). CONCLUSIONS: Instrument-assisted soft tissue mobilisation with combination of stretching exercises was found to be more effective in the management of neck pain in upper crossed syndrome compared to routine physical therapy. REGISTRATION NUMBER: IRCT20190912044754N1.

Interventional Heart Failure and Hemodynamic Monitoring.

Convergence of the fields of heart failure (HF) and interventional cardiology has led to the formation of a discipline referred to as interventional HF. Although the term may be applied to essentially any invasive procedure performed in patients with HF (eg, coronary angiography, percutaneous coronary intervention, invasive assessment of hemodynamics), it is more commonly reserved for the application of invasive diagnostic or therapeutic procedures to improve the clinical decision-making, functional status, and outcomes of HF patients. This article reviews developing modalities.

Pre-transplant left ventricular diastolic dysfunction is associated with post transplant acute graft rejection and graft failure.

INTRODUCTION: Acute cellular rejection (ACR) is a significant cause of morbidity and graft failure in liver transplant recipients (LTR). Diastolic dysfunction (DD) is frequently present in patients with cirrhosis undergoing liver transplantation. However, it is unclear if DD leads to ACR. METHODS: Data was collected retrospectively for consecutive LTR between January 2000 and December 2010. Demographic data and mortality related data was obtained from social security index. Primary outcome was biopsy proven ACR. Graft failure and all-cause mortality were also evaluated. DD was evaluated as a predictor of these outcomes. Other echocardiographic indices were also assessed as predictors of ACR by using Cox proportional hazard modeling adjusted for covariates. RESULTS: A total of 970 LTR (mean age 53.2 ± 10 years, women 34.6 % and white 64.5 %) were followed for 5.3 ± 3.4 years. Patients with DD (n = 145, 14.9 %) were significantly more likely to develop ACRs (HR 10.56; 95 % CI 6.78-16.45, p value = 0.0001) as well as graft failure (HR 2.09; 95 % CI 1.22-3.59, p value = 0.007) and all-cause mortality (HR 1.52; 95 % CI 1.08-2.13, p = 0.01). There was an increase in the risk of these outcomes with worsening of DD, when adjusted for various risk factors such as donor and recipient age, gender, race, Framingham risk score, pre-transplant MELD, transplant etiology and cold ischemia time. CONCLUSION: Pre-transplant DD is significantly associated with increased risk of allograft rejection, graft failure and mortality. This signifies the importance of cardiac evaluation during the pre-transplant period.

Clinical predictors of post-liver transplant new-onset heart failure.

Objectives of this study were (1) to evaluate preoperative predictors of systolic and diastolic heart failure in patients undergoing liver transplantation (LT) and (2) to describe the prognostic implications of systolic and diastolic heart failure in these patients. The onset of heart failure after orthotopic LT remains poorly understood. Data were obtained for all LT recipients between January 2000 and December 2010. The primary outcome was post-LT heart failure: systolic (ejection fraction ≤ 50%), diastolic, or mixed heart failure. Patients underwent echocardiographic evaluation before and after LT. Pretransplant variables were evaluated as predictors of heart failure with Cox proportional hazards model. 970 LT recipients were followed for 5.3 ± 3.4 years. Ninety-eight patients (10.1%) developed heart failure in the posttransplant period. There were 67 systolic (6.9%), 24 diastolic (2.5%), and 7 mixed systolic/diastolic (0.7%) heart failures. Etiology was ischemic in 18 (18.4%), tachycardia-induced in 8 (8.2%), valvular in 7 (7.1%), alcohol-related in 4 (4.1%), hypertensive heart disease in 3 (3.1%), and nonischemic in majority of patients (59.2%). Pretransplant grade 3 diastolic dysfunction, diabetes, hypertension, mean arterial pressure ≤ 65 mm Hg, mean pulmonary artery pressure ≥ 30 mm Hg, mean pulmonary capillary wedge pressure ≥ 15 mm Hg, hemodialysis, brain natriuretic peptide level and QT interval > 450 ms were found to be predictive for the development of new-onset systolic heart failure. However beta-blocker use before LT and tacrolimus after LT were associated with reduced development of new-onset systolic heart failure. In conclusion, pretransplant risk factors, hemodynamic variables, and echocardiographic variables are important predictors of post-LT heart failure. In patients undergoing LT, postoperative onset of systolic or diastolic heart failure was found to be an independent predictor of mortality.

Atypical stress-induced cardiomyopathy: a case series.

Stress-induced cardiomyopathy (SIC) is characterized by reversible left ventricular (LV) systolic dysfunction, which appears to be triggered by an intense, stressful event in the absence of significant coronary artery disease. It manifests typically with transient left ventricular wall motion abnormalities (WMA) involving the apical and/or mid-ventricular myocardial segments, associated with minimal troponin rise (<5 ng/ml), and typical EGG changes. Described are 3 cases of stress-induced cardiomyopathy with atypical distribution of wall motion abnormalities. Possible contributing mechanisms to the pathogenesis and the variability in WMA are discussed.

Atypical Presentation of Sjogren's Syndrome With Chronic Urticaria: A Case Report and Literature Review.

We present a case of a 26-year-old female with a history of 6-8 months of recurrent severe allergic reactions with anaphylaxis who presented with bilateral shoulder arthralgia and inflammatory arthritis of the right hand involving metacarpophalangeal joints (MCP). Physical examination was significant for tenderness in shoulder and knee joints, swelling, warmth, and tenderness involving MCP joints of the right hand. Schirmer's test was positive in both eyes. Further workup revealed positive antinuclear antibody (ANA) (speckled pattern), anti-Ro antibodies, and elevated inflammatory markers including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). The patient was diagnosed with Sjogren's syndrome and was started on methotrexate once weekly and hydroxychloroquine with significant improvement in the symptoms. Also, we review the literature describing the association between chronic urticaria and rheumatological diseases. This case highlights the varied presentation of rheumatological diseases.

Phasic Diastolic Coronary Artery Compression: A Rare Cause of Chest Pain at Rest.

Phasic diastolic coronary artery compression (PDCAC) is a rare phenomenon caused by the compression of a coronary artery between expanding myocardium and a non-compliant overlying structure. We report a unique case of an elderly female who presented with recurrent paradoxical substernal chest pain at rest caused by PDCAC of the proximal left circumflex artery (LCx). Her chest pain likely occurred at rest due to longer diastolic compression time at slower heart rates. Pericardial adhesion secondary to past breast radiation was the likely cause of PDCAC. She was treated successfully with oral anti-hypertensive and anti-anginal medical therapy. PDCAC is a rare phenomenon but should be on the differential for chest pain occurring at rest, especially if there is a history of mediastinal or cardiac radiation or inflammation. PDCAC treatment depends on the underlying cause but can be treated successfully with medical therapy alone.

RIPASA versus Alvarado score in the assessment of acute appendicitis: A prospective study.

Objectives: This study aimed to compare Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) and Alvarado scoring to accurately identify acute appendicitis. Material and Methods: A cross-sectional prospective study was carried out in the department of surgery. Patients were enrolled and scored using RIPASA and Alvarado scoring systems. Appendectomy was done, and the specimen was sent for histopathology examination, which was used as the gold standard for diagnosis. Among 400 recruits, 11 patients were lost to follow-up, giving us a sample size of 389 patients. The cut-off value for RIPASA and Alvarado scores was 7.5 and 7.0, respectively. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy in diagnosing acute appendicitis of both scores were analyzed using SPSS. Results: Among 389 patients, 256 (66%) were males, and 277 (71%) were under the age of 40 years. RIPASA was more than 7.5 in 345 cases, while Alvarado was more than 7.0 in 261 patients. RIPASA score had a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 95.8%, 87.9%, 98.9%, and 65.9%, respectively. In contrast, the ALVARADO score was 71.1% sensitive and 75.8% specific. RIPASA had a diagnostic accuracy of 95.12%, while Alvarado was only 71.46% accurate in diagnosing acute appendicitis. Conclusion: Compared to the Alvarado scoring system, RIPASA is a better tool in terms of accuracy, sensitivity, and specificity for diagnosing acute appendicitis.

The 21st century disaster: The COVID-19 epidemiology, risk factors and control.

The 21st century will be indelible in the world as ruin of the outbreak of COVID-19 was arose in Wuhan, China has now spread all over the world, up to August 2020. This study was based on the factors affecting the epidemiology of this virus in human societies of global concern. We studied the articles published in journals on various aspects of nCoVID19. The Wikipedia and WHO situation reports have also been searched out for related information. Outcomes were followed up until 2020. The COVID-19 is a virus with pandemic potential which may continue to cause regular infection in human. The pandemic outbreak of COVID-19 threatened public health across the globe in form of system as reflected in the shape of emergency. Approximately 21 million humans are infected and 759,400 have lost their lives till 2020 in all over the world. We have described epidemiological features, reservoirs, transmission, incubation period, rate of fatality, management including recent clinical chemotherapeutic approach and preventive measurements and masses which are at risk of COVID19. This virus causes viral pneumonia when it attacks on respiratory system and multiple failure which can leads to life threatening complications. It is believed to be zoonotic importance although it is not clear from which animal and how it is transmitted. Zoonotic transmission of COVID-19 has not yet known by science. The current study will help to establish a baseline for early effective control of this rapidly spreading severe viral illness. The available data on COVID-19 indicates that older males with comorbidities would have been more infected, which can result in severe respiratory complications. Implementation of preventive measurements, investigation of proper chemotherapeutics and detection of cross species transmission agents must be ensured.

Co-creation on Redefining Consumer Well-Being Needs Among Youth Through Self-Potential Development Model.

A co-creation values consumers' input as its primary crust in informing businesses on current consumer needs. More importantly, it would be the next shape in future demands of consumers in business sustainability. This paper addressed this context, narrowing its scope in investigating the voices of stakeholders on what would be the essential aspects of the present and future youth qualities in achieving sustainable well-being in the present trend. The findings would be essentially helpful for the youth and the business world to understand the aspects of good youth development, which would shape the next fabric of consumerism. Self-potential development of the youth is vital in achieving excellent life quality and the youth's well-being in Malaysia. However, the increase in challenges faced by today's youth is inconsistent with a decline of the group's well-being. There are various studies and interventions implemented to overcome the youth situation. However, there is still in need for a model that can guide the holistic development of youth self-potential. The purpose of this study is to build a sustainable and comprehensive model of the self-potential development of the youth, which can be integrated with all of the self-potential indicators of the youth via a co-creation process. This study used the Fuzzy Delphi Method (FDM) on the proposed elements in the development model and systematically analyzed them using Interpretive Structural Modeling (ISM) to create the development model. The method capitalized 10 stakeholders from various youth development backgrounds in developing the model. The model consists of 25 sub-indicators (SIs, elements) that are divided into five indicators. The model findings show that one of the most driving indicators is an entrepreneurial mindset among youth, followed by the other indicators of youth self-potential development. The model also shows that the civic-mindedness indicator is the output of youth self-potential that will surface at an end of the development. The model will guide the authorized body on the priority elements that can systematically and strategically improve youth self-potential to meet future challenges with youth aspirations.

Ophthalmic Timolol and Hospitalization for Symptomatic Bradycardia and Syncope: A Case Series.

Topical beta-blockers are commonly used for the management of primary open angle glaucoma (POAG). One of the rare but serious side effects of the topical beta-blockers is bradycardia, defined as a heart rate below 60 beats per minute. In few cases, the heart rate drops to much lower level resulting in syncope or symptomatic bradycardia. Topical beta-blockers are still widely used for POAG even though there are much better medications available. We present a series of four cases of symptomatic bradycardia resulting from the use of timolol eye drops and after discontinuation of the eye drops, heart rate improved to normal range (60-100 beats per minute).

Pain Intervention for Cancer and Non-cancer Pain: A Retrospective Analysis of Tertiary Care Hospital Experience.

Background With the recent advancement in medicine there has been a great emphasis on the management of chronic pain which remains as one of the major contributing factors for functional limitation in patients as well as a financial burden on healthcare. Newer treatment modalities are aimed at terminating the vicious pain cycles and in this regard peripheral nerve blocks have proven to be very effective. Objectives The aim of this study is to evaluate the effectiveness of interventions for both cancer and non-cancer patients by objective assessment of the patients before and after the procedure. Materials and methods The study included 252 patients who underwent nerve block procedures in Shaukat Khanum Memorial Cancer Hospital from December 2016 to December 2018. The patients were evaluated using numerical rating scale (NRS) for pain, reduction in analgesic doses and patient satisfaction after one and four weeks post procedure. The data was analyzed using mean values and calculating percentages. Results In cancer group, 168 patients were included; mean age 50.49 ± 15.39 with 46.43% females and 53.57% males, the average pain score was 2.62 ± 1.87 post procedure compared with 6.30 ± 1.87 post procedure. 48.21% of the patients reported a reduction in analgesia while 51.79% of the patients kept on using the same analgesics doses. 74.40% of the patients were satisfied and 25.60% patients remained unsatisfied after one week whereas 66.07% were satisfied, 23.81% were not satisfied and 10.12% loss to follow up after four weeks. In non-cancer group 84 patients were included; mean age 56.49 ± 15.79 with 41.67% females and 58.33% males, the average pain score before intervention was 5.99 ± 1.21 and after intervention it was 2.43 ± 1.62. In 73.81% non-cancer patients the analgesics doses were reduced and 70.24% patients were satisfied while 29.76% were unsatisfied after one week. After four weeks 55.95% were satisfied, 22.62% were not satisfied and 21.43% loss to follow up. Conclusion The study showed decrease in pain scores in both group of patients and the importance of nerve blocks as an effective method for chronic pain management. The reduction in the use of other analgesics was also commendable in both the groups.

Component Alignment in Simultaneous Bilateral versus Unilateral Total Knee Arthroplasty.

PURPOSE: The purpose of this study was to investigate differences in component alignment between first and second knees in simultaneous bilateral total knee arthroplasty (SBTKA) and unilateral TKA (UTKA). MATERIALS AND METHODS: 274 SBTKAs and 198 UTKAs were included in study. Patients were divided into three groups as SBTKA on the right knee (group A), SBTKA on the left knee (group B) and UTKA (group C). Femoral and tibial component alignment was checked in both coronal plane (alpha [α] and beta [ß] angles) and sagittal plane (gamma [γ] and delta [δ] angles) radiographs. RESULTS: There were no statistically significant differences among groups in the preoperative anatomical varus angle and Kellgren-Lawrence gonarthrosis classification grade (p=0.139 and p=0.329, respectively). In the coronal plane, the alignment of femoral component (α angle) and tibial component (ß angle) was similar in all three groups (α angle, 95.01 vs. 95.14 vs. 94.9, p=0.945; ß angle, 90.03 vs. 89.67 vs. 89.98, p=0.483). The sagittal plane alignment of femoral component (γ angle) and tibial component (δ angle) did not show significant differences (γ angle, 7.04 vs. 6.98 vs. 7.00, p=0.132; δ angle, 86.56 vs. 87.41 vs. 86.73, p=0.610). CONCLUSIONS: The angular alignment of components was similar between SBTKA and UTKA.

Association of Genetic Polymorphisms in the Beta-1 Adrenergic Receptor with Recovery of Left Ventricular Ejection Fraction in Patients with Heart Failure.

Two common genetic polymorphisms in the beta-1 adrenergic receptor (ADRB1 Ser49Gly [rs1801252] and Arg389Gly [rs1801253]) significantly affect receptor function in vitro. The objective of this study was to determine whether ADRB1 Ser49Gly and Arg389Gly are associated with recovery of left ventricular ejection fraction (LVEF) in patients with heart failure. Patients with heart failure and baseline LVEF ≤ 40% were genotyped (n = 98), and retrospective chart review assessed the primary outcome of LVEF recovery to ≥ 40%. Un/adjusted logistic regression models revealed that Ser49Gly, but not Arg389Gly, was significantly associated with LVEF recovery in a dominant genetic model. The adjusted odds ratio for Ser49 was 8.2 (95% CI = 2.1-32.9; p = 0.003), and it was the strongest predictor of LVEF recovery among multiple clinical variables. In conclusion, patients with heart failure and reduced ejection fraction that are homozygous for ADRB1 Ser49 were significantly more likely to experience LVEF recovery than Gly49 carriers.

Chitosan based thermosensitive injectable hydrogels for controlled delivery of loxoprofen: development, characterization and in-vivo evaluation.

Oral drug delivery is natural, most acceptable and desirable route for nearly all drugs, but many drugs like NSAIDs when delivered by this route cause gastrointestinal irritation, gastric bleeding, ulcers, and many undesirable effects which limits their usage by oral delivery. Moreover, it is almost impossible to control the release of a drug in a targeted location in body. We developed thermo-responsive chitosan-co-poly(N-isopropyl-acrylamide) injectable hydrogel as an alternative for the gastro-protective and controlled delivery of loxoprofen sodium as a model drug. A free radical polymerization technique was used to synthesize thermo-responsive hydrogel by cross-linking chitosan HCl with NIPAAM using glutaraldehyde as cross-linker. Confirmation of crosslinked hydrogel structure was done by Fourier transform infrared spectra (FTIR). The thermal stability of hydrogel was confirmed through thermogravimetric analysis (TGA) and differential scanning calorimetry (DSC). The scanning electron microscopy (SEM) was performed to evaluate the structural morphology of cross-linked hydrogel. To evaluate the rheological behavior of hydrogel with increasing temperature, rheological study was performed. Swelling and in vitro drug release studies were carried out under various temperature and pH conditions. The swelling study revealed that maximum swelling was observed at low pH (pH 1.2) and low temperature (25 °C) compared to the high range of pH and temperature and it resulted in quick release of the drug. The high range of pH (7.4) and temperature (37 °C) however caused controlled release of the drug. The in vivo evaluation of the developed hydrogel in rabbits demonstrated the controlled release behavior of fabricated system.