Ultrasound Neuromodulation of an Anti-Inflammatory Pathway at the Spleen Improves Experimental Pulmonary Hypertension.

BACKGROUND: Inflammation is pathogenically implicated in pulmonary arterial hypertension; however, it has not been adequately targeted therapeutically. We investigated whether neuromodulation of an anti-inflammatory neuroimmune pathway involving the splenic nerve using noninvasive, focused ultrasound stimulation of the spleen (sFUS) can improve experimental pulmonary hypertension. METHODS: Pulmonary hypertension was induced in rats either by Sugen 5416 (20 mg/kg SQ) injection, followed by 21 (or 35) days of hypoxia (sugen/hypoxia model), or by monocrotaline (60 mg/kg IP) injection (monocrotaline model). Animals were randomized to receive either 12-minute-long sessions of sFUS daily or sham stimulation for 14 days. Catheterizations, echocardiography, indices of autonomic function, lung and heart histology and immunohistochemistry, spleen flow cytometry, and lung single-cell RNA sequencing were performed after treatment to assess the effects of sFUS. RESULTS: Splenic denervation right before induction of pulmonary hypertension results in a more severe disease phenotype. In both sugen/hypoxia and monocrotaline models, sFUS treatment reduces right ventricular systolic pressure by 25% to 30% compared with sham treatment, without affecting systemic pressure, and improves right ventricular function and autonomic indices. sFUS reduces wall thickness, apoptosis, and proliferation in small pulmonary arterioles, suppresses CD3+ and CD68+ cell infiltration in lungs and right ventricular fibrosis and hypertrophy and lowers BNP (brain natriuretic peptide). Beneficial effects persist for weeks after sFUS discontinuation and are more robust with early and longer treatment. Splenic denervation abolishes sFUS therapeutic benefits. sFUS partially normalizes CD68+ and CD8+ T-cell counts in the spleen and downregulates several inflammatory genes and pathways in nonclassical and classical monocytes and macrophages in the lung. Differentially expressed genes in those cell types are significantly enriched for human pulmonary arterial hypertension-associated genes. CONCLUSIONS: sFUS causes dose-dependent, sustained improvement of hemodynamic, autonomic, laboratory, and pathological manifestations in 2 models of experimental pulmonary hypertension. Mechanistically, sFUS normalizes immune cell populations in the spleen and downregulates inflammatory genes and pathways in the lung, many of which are relevant in human disease.

A Case of Intracranial Vertebral Artery Stenosis Treated with Percutaneous Transluminal Angioplasty and Stenting Guided by Brain Oximetry.

Surgical treatment should be considered for patients with severe vertebrobasilar artery (VBA) stenosis or progressive symptoms, but there is currently no clear treatment algorithm. We report a case of symptomatic intracranial vertebral artery stenosis with repeated cerebral infarction treated by percutaneous transluminal angioplasty (PTA) and stenting and monitoring of oxygen saturation by a brain oximeter. The patient was a 76-year-old man referred to our hospital due to infarction in the right cerebellum. Angiography showed 60% stenosis in the right vertebral artery and 90% stenosis in the left vertebral artery with progressive stenosis in the left. The patient was treated with intravenous and oral triple antiplatelet therapy but had dizziness again with new cerebral infarctions in the left cerebellum and right pontine. We shaved the patient's hair up to the superior nuchal line and placed left and right oximeter probes on each cerebellar hemisphere (2 cm lateral and 2 cm caudal from the external occipital protuberance). Under evaluation of blood flow in the posterior circulation with INVOS Cerebral/Somatic Oximeter, PTA and stent placement were performed for left vertebral artery stenosis. Postoperatively, the dizziness disappeared, and the patient was discharged on his own with good outcome. He has not had a recurrent stroke in over 6 years. Although medical treatment is generally considered the first choice for VBA stenosis, recurrent cerebral infarction occurs at a high rate in symptomatic lesions, and the prognosis is poor. In addition, the perioperative complication rate is not low, and there is no established method for evaluating perfusion of posterior circulation. The brain oximeter is already known to be useful in carotid artery (CA) revascularisation. In this report, we were able to perform a minimally invasive evaluation of blood flow in the posterior circulation using the brain oximeter which might be useful for surgical revascularisation not only in CA but also in VBA.

Translation and validation of stroke impact scale-16 in Urdu for Pakistan.

Objective: To translate and validate the Urdu version of stroke impact scale-16 for Pakistani society. METHODS: The prospective cohort study was conducted from February 2018 to February 2020 after approval from the ethics review board of The University of Lahore, Lahore, Pakistan, and copmprised patients with mild to moderate stroke who were recruited from five public and two private hospitals of the Punjab province. Established guidelines were followed to translate the Stroke Impact Scale-16. The patients were concurrently evaluated on Barthel Index, Stroke Rehabilitation Assessment of Movement, Modified Rivermead Mobility Index, Modified Rankin Scale, Short Form 36 Health Survey Questionnaire and the Hospital Anxiety and Depression Scale to assess the validity of Stroke Impact Scale-16, and spearmen correlation coefficient was used to determine the correlation among the scales. Analysis of variance was employed to determine the discriminant validity. Intraclass correlation coefficient, weighted kappa, Cronbach's alpha and item-total correlation were calculated to establish the stability and consistency of Stroke Impact Scale-16. Data was analysed using SPSS 25. RESULTS: Of the 90 patients, 50(55.5%) were females and 40(45.5%) were males. The subjects were aged 50-80 years. The correlation of Stroke Impact Scale-16 was strong with the established tools and ranged from 0.78 to 0.91. The discriminant validity was also significant (p<.001) across all Modified Rankin Scale levels. The Intraclass correlation coefficient was 0.94 and Cronbach's alpha was 0.91 for test-retest reliability and internal consistency, respectively. All corrected item-total correlation values exceeded the priori minimum standard (>0.40) and ranged from 0.51 to 0.68. The weighted kappa for item reliability also achieved priori criteria (>0.40) and ranged from 0.53 to 0.88. Conclusion: With slight modifications, the Urdu version of Stroke Impact Scale-16 was found to have satisfactory psychometric properties and can be used in clinical and research settings for stroke survivors in Pakistan.

Entropy Generation during Head-On Interaction of Premixed Flames with Inert Walls within Turbulent Boundary Layers.

The statistical behaviours of different entropy generation mechanisms in the head-on interaction of turbulent premixed flames with a chemically inert wall within turbulent boundary layers have been analysed using Direct Numerical Simulation data. The entropy generation characteristics in the case of head-on premixed flame interaction with an isothermal wall is compared to that for an adiabatic wall. It has been found that entropy generation due to chemical reaction, thermal diffusion and molecular mixing remain comparable when the flame is away from the wall for both wall boundary conditions. However, the wall boundary condition affects the entropy generation during flame-wall interaction. In the case of isothermal wall, the entropy generation due to chemical reaction vanishes because of flame quenching and the entropy generation due to thermal diffusion becomes the leading entropy generator at the wall. By contrast, the entropy generation due to thermal diffusion and molecular mixing decrease at the adiabatic wall because of the vanishing wall-normal components of the gradients of temperature and species mass/mole fractions. These differences have significant effects on the overall entropy generation rate during flame-wall interaction, which suggest that combustor wall cooling needs to be optimized from the point of view of structural integrity and thermodynamic irreversibility.

Clinical characteristics and outcomes of patients with COVID-19 pneumonia admitted to an intensive care unit in Faisalabad, Pakistan.

AIM: To describe the clinical characteristics and outcomes of adult patients with severe COVID-19, with the exploration of risk factors for mortality in the hospital. METHODS: This study included 20 adult patients diagnosed with COVID-19 admitted to the ICU of DHQ Hospital, Faisalabad (Pakistan). Patients were categorised into the survival group and the death group according to the outcome. We retrieved demographics, clinical manifestations and signs, laboratory indicators, treatment measures and clinical outcomes from the medical record, and summarised the clinical characteristics and outcomes of these patients. RESULTS: The average age of patients was 70 ± 12 years, of which 40% were male. They were admitted to the ICU 11 days after the onset of symptoms. The most common symptoms on admission were cough (19 cases, 95%), fatigue or myalgia (18 cases, 90%), fever (17 cases, 85%) and dyspnoea (16 cases, 80%). Eleven (55%) patients had underlying diseases, of which hypertension was the most common (11 cases, 55%), followed by cardiovascular disease (4 cases, 20%) and diabetes (3 cases, 15%). Six patients (30%) received invasive mechanical ventilation and continuous renal replacement therapy and eventually died. Acute heart injury was the most common complication (19 cases, 95%). Ten (50%) patients died between 2 and 19 days after admission to the ICU. Compared with dead patients, the average body weight of surviving patients was lower (61.70 ± 2.36 vs 68.60 ± 7.15, P = .01), Glasgow Coma Scale score was higher (14.69 ± 0.70 vs 12.70 ± 2.45, P = .03), with fewer concurrent shocks (2 vs 10, P = .001) and acute respiratory distress syndrome (2 vs 10, P = .001). CONCLUSION: The mortality rate is high in critically ill patients with COVID-19. Lower Glasgow Coma Scale, higher body weight and decreased lymphocyte count appear to be potential risk factors for the death of patients with COVID-19 in the ICU.

Expression Profiling of Flavonoid Biosynthesis Genes and Secondary Metabolites Accumulation in Populus under Drought Stress.

Flavonoids are key secondary metabolites that are biologically active and perform diverse functions in plants such as stress defense against abiotic and biotic stress. In addition to its importance, no comprehensive information has been available about the secondary metabolic response of Populus tree, especially the genes that encode key enzymes involved in flavonoid biosynthesis under drought stress. In this study, the quantitative real-time polymerase chain reaction (qRT-PCR) analysis revealed that the expression of flavonoid biosynthesis genes (PtPAL, Pt4-CL, PtCHS, PtFLS-1, PtF3H, PtDFR, and PtANS) gradually increased in the leaves of hybrid poplar (P. tremula × P. alba), corresponding to the drought stress duration. In addition, the activity and capacity of antioxidants have also increased, which is positively correlated with the increment of phenolic, flavonoid, anthocyanin, and carotenoid compounds under drought stress. As the drought stress prolonged, the level of reactive oxygen species such as hydrogen peroxide (H2O2) and singlet oxygen (O2-) too increased. The concentration of phytohormone salicylic acid (SA) also increased significantly in the stressed poplar leaves. Our research concluded that drought stress significantly induced the expression of flavonoid biosynthesis genes in hybrid poplar plants and enhanced the accumulation of phenolic and flavonoid compounds with resilient antioxidant activity.

Perceived stress score among doctors serving at various government and private hospitals in Faisalabad.

OBJECTIVE: To analyse the prevalence of stress among doctors serving at various public and private hospitals. METHODS: The cross-sectional study was conducted at four public and private hospitals in Faisalabad, Pakistan, from July to December 2019, and comprised doctors with at least one year of professional service. Data was collected using the Perceived Stress Scale Questionnaire and was analysed using SPSS 20. RESULTS: Of the 162 respondents, 87(53.7%) were males and 75(46.3%) were females. The females had significantly higher (p<0.05) perceived stress scores compared to the males. Age, number of years in job, and number of children had negative correlation with stress scores (p<0.05). Stress was significantly low in doctors who managed to usually get time-out for relaxation (p<0.01) and in those doing private practice (p<0.05). The effect of doctor's marital status, type of specialty and residence was not significant (p>0.05). CONCLUSIONS: Younger doctors, particularly females, in their early career were found to have higher perceived stress scores compared to their senior colleagues with more children and well-established private practice.

Comparison of functional outcome of simultaneous and staged bilateral total knee arthroplasty : systematic review of literature.

Safety of simultaneous bilateral TKA (simBTKA) and staged BTKA (staBTKA) have been compared in previous systematic reviews but functional outcome remains neglected aspect of the debate. We performed a systematic review of contemporary literature to compare the functional outcome of simBTKA and staBTKA. We searched PubMed/MEDLINE, EMBASE and Cochrane Central Database to identify all articles published between 2000 and July 2020 that evaluated the outcome of patients undergoing BTKA either in simultaneous or staged manner. Ten articles were identified which met the inclusion criteria. Functional outcome was reported in terms of Knee Society score (KSS), range of motion (ROM), Oxford Knee Score (OKS) and Western Ontario and McMaster University score (WOMAC) in seven, five, four and two studies respectively. KSS gained on average 66.6 points (47.5-95.3) for simBTKA and 65.1 points (44.4-97.2) for staBTKA without significant difference between two groups. There was no difference in post-operative ROM (maximum post-operative flexion being 124.4 and 125.1 for simBTKA and staBTKA groups respectively). Mean improvement in OKS ranged from 20 to 32.6 for simBTKA and 21.6 to 33.1 for staBTKA. There was moderate evidence to suggest that both simultaneous BTKA and staged BTKA produce equivalent improvement in functional scores.

An overview of self-medication: A major cause of antibiotic resistance and a threat to global public health.

Self-medication is the use of medicines by people on the basis of their own experience without consulting a doctor. People use medicines for pain management or to cure a disease and sometime this may be unnecessary. There are a lot of public and professional health concerns about misuse of medicines and globally physicians agree upon this rising issue that leads to antibiotic resistance. In developing countries, medicines without prescription are easily available which results in many adverse outcomes, especially bacterial resistance. Insufficient healthcare services and socioeconomic factors result in increased proportion of self-medication compared to drugs prescribed by physicians. The current narrative review was planned to focus on indicating prevalence rate of self-medication in different developed and under-developed countries, major risk factors and control of self-medication due to which antibiotic resistance rate can be minimised. The issue needs urgent attention of representative authorities for taking serious actions. Furthermore, arranging awareness seminars and implementing new policies/regulations to prevent the sale of any drug/antibiotic without prescription could play a vital role in bringing this alarming issue under control.

Review of Hyperkalemia in End Stage Renal Disease.

Potassium balance is maintained in the body by balancing the intake with the excretion and the transcellular shifts of potassium. Excretion of potassium is mainly renal as the contribution of the colon to the net potassium secretion of the colon to the net potassium secretion is trivial in patients with normal renal function. As the majority of potassium excretion is renal, it is not surprising to note that patients with end stage renal disease (ESRD) are at an increased risk of developing hyperkalemia in ESRD patients has been estimated to be 3-5%. Maintenance of a stable serum potassium level in patients with ESRD is crucial. We will review the various measures for the management and prevention of hyperkalemia in ESRD patients such as dietary restrictions, dialysis and drugs enhancing extra renal elimination of potassium.

Association of periodontal pathogenesis and cardiovascular diseases: a literature review.

PURPOSE: To present a short review of recent literature available on the association of periodontal and cardiovascular diseases (CVD) and the role of peridontal disease as a risk factor to exacerbate CVD. MATERIALS AND METHODS: A thorough search of articles was carried out on the databases PUBMED and MEDLINE on the association of periodontal and cardiovascular diseases (CVD). The selected literature included review articles, observational and case-control studies as well as randomised control trials. While selecting articles, priority was placed on papers published within the last 12 years. A brief description of periodontal diseases, atherosclerosis, underlying pathophysiology and oral bacteria has been included. RESULTS AND CONCLUSION: There is growing evidence of the association of periodontal diseases and CVD, as reviewed by the epidemiological studies. The in vitro studies also highlight a potential link between oral bacteria and atherosclerosis. Thus, there is urgent need for proper case controls and efficient interventional trials to analyse how such interventions can produce a positive outcome on cardiovascular diseases. Some recent interventional trials have shown that periodontal treatment can decrease markers of systemic inflammation. The relationship between periodontal diseases and CVD deserves further research because of its consequences for public health.

Effects of routine physical therapy with and without kinesio taping in improving gross motor function in sitting and standing in spastic diplegic cerebral palsy children.

OBJECTIVE: To determine the effectiveness of Kinesio taping along with routine physical therapy on improving gross motor function in sitting and standing among spastic diplegic Cerebral Palsy children. DESIGN: Randomized controlled trial. SETTINGS: University Teaching Hospital University of Lahore, Lahore. PARTICIPANTS: 53 participants with diagnosed spastic diplegic cerebral palsy were randomly allocated in control and experimental groups. INTERVENTION: 26 Participants were treated by kinesio taping which was applied in a criss-cross manner along with routine physical therapy program while the control group (n = 27) received NDT exercise program that comprises of stretching, functional reaching, weight-bearing exercises and walking. OUTCOME MEASURE: Gross motor function was assessed using 2 components of Gross Motor Function Classification System (GMFCS-88), i.e., sitting as well as standing at the base line and after every 3rd week for 12 weeks follow up. RESULTS: In study and control group the mean score of gross motor function for sitting at baseline was 33.96 ± 3.11 and 31.50 ± 3.32 respectively. After intervention, it changed to 47.70 ± 5.46 and 43.46 ± 1.81 respectively. Mean score for Gross Motor Function calculated at base line in study and control group for standing was 27.37 ± 1.14 and 26 ± 3.01 respectively. At the end of intervention, the score improved to 36.55 ± 4.27 and 33.69 ± 2.46 respectively. CONCLUSION: In comparison to control group, significant increase in gross motor function of intervention group was seen after the 12 weeks of intervention. In this way, over back muscles the application of kinesio tape in a Criss-Cross manner may be helpful. Also it can be used as an additional approach along with routine physical therapy to improve standing and sitting in spastic diplegic children.

Acoustic monitoring of an aircraft auxiliary power unit.

In this paper, the development and implementation of a novel approach for fault detection of an aircraft auxiliary power unit (APU) has been demonstrated. The developed approach aims to target the proactive identification of faults, in order to streamline the required maintenance and maximize the aircraft's operational availability. The existing techniques rely heavily on the installation of multiple types of intrusive sensors throughout the APU and therefore present a limited potential for deployment on an actual aircraft due to space constraints, accessibility issues as well as associated development and certification requirements. To overcome these challenges, an innovative approach based on non-intrusive sensors i.e., microphones in conjunction with appropriate feature extraction, classification, and regression techniques, has been successfully demonstrated for online fault detection of an APU. The overall approach has been implemented and validated based on the experimental test data acquired from Cranfield University's Boeing 737-400 aircraft, including the quantification of sensor location sensitivities on the efficacy of the acquired models. The findings of the overall analysis suggest that the acoustic-based models can accurately enable near real-time detection of faulty conditions i.e., Inlet Guide Vane malfunction, reduced mass flows through the Load Compressor and Bleed Valve malfunction, using only two microphones installed in the periphery of the APU. This study constitutes an enabling technology for robust, cost-effective, and efficient in-situ monitoring of an aircraft APU and potentially other associated thermal systems i.e., environmental control system, fuel system, and engines.

A deviant anterior portal vein in the hepatoduodenal ligament with aberrant origin of hepatic arteries directly from the celiac trunk: A case report of two patients underwent pylorus preserving pancreatoduodenectomy (PPPD).

INTRODUCTION: The portal vein (PV) originates behind the neck of the pancreas, where it is formed classically by the union of the superior mesenteric vein (SMV) and the splenic vein (SV) [1]. It courses upwards towards the liver in the free margin of the lesser omentum, the hepatoduodenal ligament, along with other structures of the portal triad, i.e. proper hepatic artery (PHA) and common bile duct (CBD) anterior to it [1]. The PV is found posterior to the PHA and CBD. The abdominal aorta perfuses abdominal viscera via three ventral branches celiac trunk (CA), superior mesenteric artery (SMA), and inferior mesenteric artery (IMA). The celiac trunk supplies the derivates of the foregut and is divided into the left gastric artery (LGA), splenic artery (SA), and common hepatic artery (CHA). The CHA, after its origin, is divided into the gastroduodenal artery (GDA) and PHA. After giving off the right gastric artery (RGA), the PHA bifurcates into the right and left hepatic arteries (RHA, LHA) [2]. IMPORTANCE: This case report aims to share the rare variations in the anatomy of hepatoduodenal ligament structures to increase awareness and understanding among fellow surgeons which may reduce complications. CASE PRESENTATION: We are reporting 2 cases in which during pancreaticoduodenectomy Portal vein was present anteriorly in the portal triad and the common hepatic artery was absent; instead, both the right and left hepatic arteries originated directly from the CA posterior to PV. This retro-portal origin of hepatic arteries directly from CA is not reported in Michel's classification of hepatic artery variations [3]. CLINICAL DISCUSSION: The confluence of SMV and SV posterior to the neck of the pancreas forms the PV. The portal vein runs upwards in the free edge of the lesser omentum. Anteriorly it is related to the CBD laterally and CHA anteromedially. Posteriorly it is related to the inferior vena cava (IVC), and PV is separated from IVC by epiploic foramen [4]. The overall reported incidence in the variation of the portal vein anatomy is 25%. Among all the variations seen, the anterior PV with posteriorly bifurcating hepatic artery is present in only 10 % of the cases [5]. There is an increased risk of hepatic artery anatomical variation in the presence of portal vein variants. Michel's classification [6] classified variations in the hepatic artery anatomy. In our cases, the hepatic artery anatomy was standard and was classified as Type 1. The bile duct was normal anatomic (lateral to the PV). Hence our cases are unique in describing isolated variant locations and courses. Detailed information about the anatomy of the portal triad and all possible variants can help reduce the incidence of iatrogenic complications during surgeries like liver transplants and pancreatoduodenectomies. Before the advancement of modern imaging techniques, the variations in the anatomy of the portal triad were clinically irrelevant and considered less significant. However, recent literature supports that variant anatomy of the hepatic portal triad can prolong the time of surgery and increase the risk of iatrogenic complications. The clinical relevance of variable hepatic artery anatomy has immense importance in hepatobiliary surgeries, including liver transplants where the viability of the graft depends on adequate arterial perfusion. In addition to that, in pancreatoduodenectomies, aberrant arterial anatomy with a reteroportal course is associated with an increased number of reconstructions [7] and bilio-enteric anastomosis disruptions since the CBD derives its blood supply from the hepatic arteries. Therefore, the imaging must be carefully interpreted with radiologists' help before surgical planning. As surgeons preoperative imaging is usually seen for the abnormal origin of hepatic arteries and vascular involvement in case of malignancies. "Eyes don't see what mind doesn't know", the anterior portal vein is a rare entity and should be considered while reviewing preoperative imaging for operative planning. In our cases, EUS and CT scans, both were done but we determined resectability on scans and abnormal origin (replaced or accessory arteries) only. Above mentioned findings were noted during surgery but now in every preoperative scan, we try to determine the presence of all possible variations including the reported ones. CONCLUSION: Detailed knowledge about the anatomy of the portal triad and all possible variants can help reduce the incidence of iatrogenic complications during surgeries like liver transplants and pancreatoduodenectomies. It also reduces the time of surgery. A careful review of all possible variations in preoperative scans with appropriate knowledge all anatomical variations helps avoid unpleasant events and hence, reduce morbidity and mortality.

Vagus nerve stimulation for cardiovascular diseases: Is there light at the end of the tunnel?

Autonomic dysfunction and chronic inflammation contribute to the pathogenesis and progression of several cardiovascular diseases (CVD), such as heart failure with preserved ejection fraction, atherosclerotic CVD, pulmonary arterial hypertension, and atrial fibrillation. The vagus nerve provides parasympathetic innervation to the heart, vessels, and lungs, and is also implicated in the neural control of inflammation through a neuroimmune pathway involving the spleen. Stimulation of the vagus nerve (VNS) can in principle restore autonomic balance and suppress inflammation, with potential therapeutic benefits in these diseases. Although VNS ameliorated CVD in several animal models, early human studies have demonstrated variable efficacy. The purpose of this review is to discuss the rationale behind the use of VNS in the treatment of CVD, to critically review animal and human studies of VNS in CVD, and to propose possible means to overcome the challenges in the clinical translation of VNS in CVD.

The efficacy of antifibrinolytic therapy in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis.

Aim: The efficacy of antifibrinolytics in subarachnoid hemorrhage remains unclear due to conflicting evidence from studies. Materials & methods: Online databases were queried to include randomized controlled trials and propensity matched observational studies. We used Review Manager for the statistical analysis, presenting results as odds ratios with 95% CI. Results: The 12 shortlisted studies included 3359 patients, of which 1550 (46%) were in the intervention (tranexamic acid) group and 1809 (54%) in the control group. Antifibrinolytic therapy significantly reduced the risk of rebleeding (OR: 0.55; 95% CI: 0.40-0.75; p = 0.0002) with no significant decrease in poor clinical outcome (OR: 1.02; 95% CI: 0.86-1.20; p = 0.85) and all-cause mortality (OR: 0.92; CI: 0.72-1.17; p = 0.50). Conclusion: In patients with subarachnoid hemorrhage, antifibrinolytics reduce the risk of rebleeding without significantly affecting mortality or clinical outcomes.

Functional Outcome Of Bristow-Latarjet Procedure In Post-Traumatic Recurrent Anterior Shoulder Instability.

BACKGROUND: Due to its lack of bony support, the shoulder joint has the broadest range of motion out of all the joints in the body. Instead, one of the joints that dislocate most frequently is the shoulder joint. Multiple pathologic abnormalities, including the traumatic separation of the anterior-inferior capsule-labral complex from the glenoid rim, are caused by repeated anterior glenohumeral dislocation. The objective of the study is to ascertain the Bristow-LATARJET procedure's efficacy in situations of recurrent post-traumatic anterior shoulder instability. METHODS: From 31 January 2020 to 31 July 2020, a descriptive case series was undertaken in the orthopaedic surgery department of the Lahore General Hospital. For this study, 71 patients who met the inclusion and exclusion criteria were recruited, and all interventions were conducted while the patients were lying in a beach chair while under general anaesthesia. The Delto-pectoral incision surgical technique was applied. For 12 weeks, all patients underwent clinical follow-up, and the results were documented. RESULTS: There were 50(70.4%) males and 21(29.6%) females in this study & the mean age of the patients were 34.64±10.73. There were 37(52.1%) patients among them the outcome of treatment (Rowe Scale at 12th week) was excellent, among 21(29.6%) it was good, among 8(11.3%) it was fair and among 5 (7.0%) it was poor. There was a significant association between the outcome of treatment (Rowe scale at 12th week) and age groups (p-value: 0.000). CONCLUSIONS: The Bristow-LATARJET procedure is deemed to be a very productive, safe, and problem-free procedure for curing post-traumatic reoccurring traumatic anterior shoulder instability.

Strategic Attributes and Organizational Performance: Toward an Understanding of the Mechanism Applied to the Banking Sector.

The study examines and theorizes the importance of strategic attribute constructs (strategic orientation, organizational culture, and organizational internal market orientation) as applied to Pakistan's banking sector by identifying their roles in enhancing organizational performance and the mediating effect of organizational commitment. The current study adopted quantitative research designs and methods to determine structural relationships between the proposed constructs. A total of 10 hypotheses were tested underpinned by the Resource-Based View of the Firm and Social Exchange theories. The strategic attributes studied were significantly and positively related to, and enhance, organizational performance if the banks: (1) focus on strategic positioning, (2) fostering a strong organizational culture, (3) strategize internal marketing practices, and (4) boost organizational commitment. The findings supported the mediating role of organizational commitment between strategic attributes and organizational performance. This study contributes to existing literature and supports prior research while filling in gaps in the literature concerning developing countries.

Follicular Lymphoma of Breast: A Case Report from Pakistan.

Introduction: Breast lymphoma (BL) is a rare breast tumour and accounts for <1% of all breast malignancies. It is further categorised into primary BL and secondary BL. This manuscript presents a case report of a patient diagnosed with secondary BL. Case Description: A 51-year-old female presented in the one-stop breast clinic with 6-month history of having a static and painless left breast lump. Mass was firm, non-tender and 2 cm in size. It was not adherent to skin or muscle and it was present in the upper outer quadrant of the left breast. Mammo-sonography revealed a circumscribed mass of 17 mm in the outer quadrant of the left breast. There were enlarged ipsilateral lymph nodes. Core biopsy suggested atypical lymphoid infiltrates. She underwent wide local excision of breast and axillary nodal mass. The definitive histological diagnosis revealed non-Hodgkin's follicular lymphoma grade 2/3. Staging computed tomography scan features were suggestive of cervical lymphadenopathy. Hence, staging workup proved this to be a case of secondary BL. Practical Implication: The early diagnosis of BL is highly relevant. Its diagnosis is challenging due to non-specific clinical presentation and imaging features. Commonly FL is diagnosed on excisional biopsy or after wide local breast mass excision. Primary and secondary lymphomas, though rare, should be considered in the differential diagnosis of breast malignancies.

Strategies for precision vagus neuromodulation.

The vagus nerve is involved in the autonomic regulation of physiological homeostasis, through vast innervation of cervical, thoracic and abdominal visceral organs. Stimulation of the vagus with bioelectronic devices represents a therapeutic opportunity for several disorders implicating the autonomic nervous system and affecting different organs. During clinical translation, vagus stimulation therapies may benefit from a precision medicine approach, in which stimulation accommodates individual variability due to nerve anatomy, nerve-electrode interface or disease state and aims at eliciting therapeutic effects in targeted organs, while minimally affecting non-targeted organs. In this review, we discuss the anatomical and physiological basis for precision neuromodulation of the vagus at the level of nerve fibers, fascicles, branches and innervated organs. We then discuss different strategies for precision vagus neuromodulation, including fascicle- or fiber-selective cervical vagus nerve stimulation, stimulation of vagal branches near the end-organs, and ultrasound stimulation of vagus terminals at the end-organs themselves. Finally, we summarize targets for vagus neuromodulation in neurological, cardiovascular and gastrointestinal disorders and suggest potential precision neuromodulation strategies that could form the basis for effective and safe therapies.