Consensus guidelines for the management of adult high-grade gliomas for low and middle-income countries.

High-grade glioma (HGG), a formidable and often incurable disease, presents an even greater challenge in low- and middle-income countries (LMICs) where resources and medical expertise are scarce. This scarcity not only exacerbates the suffering of patients but also contributes to poorer clinical outcomes. Particularly in LMICs, the underrepresentation of the population in clinical trials and the additional hurdles posed by financial constraints underscore an urgent need for contextspecific management strategies. In response, we have rigorously evaluated recent guidelines from leading medical societies, adapting them to suit the specific needs and limitations of the local context in Pakistan. This effort, undertaken in collaboration with local physicians, aims to provide a comprehensive, standardised approach to diagnose, treat, and follow-up with HGG patients. By focussing on the best available clinical evidence and judicious use of limited resources, we strive to improve patient care and outcomes in these challenging settings.

Role of neurosurgeons In strengthening paediatric neuro-oncology In low- and middle-income countries: a narrative review with case examples.

Paediatric neuro-oncology in low- and middle-income countries (LMICs) accounts for a significant proportion of cancer-related mortalities in this age group. The current dearth of structured paediatric neurosurgery training programmes in LMICs requires multidisciplinary coordination; neurosurgeons play certain key roles, as discussed in this article, in ensuring safe and effective care for paediatric neuro-oncology patients. This document intends to elaborate through illustrative cases of the technical and structural nuances required by neurosurgeons in LMICs to provide appropriate surgical care.

Trends and in-hospital cardiac complications in patients with atrial fibrillation undergoing allogeneic stem cell transplant: A National Inpatient Sample analysis (2002-2019).

BACKGROUND: Cardiovascular comorbidities increase the risk of transplant-associated complications. However, the impact of atrial fibrillation (AF) as an independent risk factor remains limited. METHODS: The National Inpatient Sample (NIS) database was queried using the International Classification of Diseases codes to identify patients admitted for allogeneic stem cell transplant (ASCT). The patients were then subclassified into with and without AF. Subsequently, a multivariate logistic regression model was constructed to account for patient demographics, comorbidities, and hospital characteristics to evaluate the impact of AF on the primary outcome of interest: all-cause mortality, and secondary outcomes of interest that included common hospitalization complications. RESULTS: The data for 77 157 cases of ASCT were collected between 2002 and 2019. Among these 5086 (6.6%) cases had concurrent AF. Multivariate logistic regression revealed patients undergoing ASCT with AF had almost a three times higher risk of all-cause mortality (odds ratio = 2.99 [95% confidence interval: 2.73-3.28]; p < .01). AF patients also had a higher risk for cardiac arrest, cardiogenic shock, acute kidney injury, and need for hemodialysis (all p < .01). CONCLUSION: AF causes a higher risk of death and cardiovascular complications among patients undergoing ASCT. This signifies the importance of pretransplant consultation and optimization for cardiovascular comorbidities to improve hospitalization outcomes.

Correlation Of Medial Longitudinal Arch Height With Postural Stability, Sensory Integration, Balance And Fall Risk Among Healthy Young Adults.

A cross-sectional analytical study was conducted on 165 healthy young adults. With pes rectus and pes planus to correlate the medial longitudinal arch height with postural stability, sensory integration of balance and fall risk. Persons with pes cavus, congenital foot anomalies other than pes planus, leg length discrepancies, recent history of trauma, lower limb amputations, history of serious foot injury, ligamentous laxity, or an active inflammatory disorder were excluded. Outcome measurements included normalised truncated navicular height (NTNH), Chippaux Smirak index (CSI), athletic single leg stability (ASLS) index, fall risk (FR) index, postural stability (PS), clinical test of sensory integration of balance (CTSIB), and balance error scoring system (BESS). Spearman correlation and Mann Whitney U test were used for data analysis. CSI and NTNH were noted to have no significant correlation (p<0.05) with PS, FR, CTSIB, ASLS and BESS among healthy young adults. Males were observed to have poorer balance and fall risk as compared to females.

Effect of Ramadan Fasting on Body Weight and Body Mass Index (BMI) in Public Sector Undergraduate Medical Students of Peshawar.

Objective: To determine the effects of fasting on weight and eventually on Body Mass Index (BMI) in medical students of a Public Sector Medical College. Methods: It was a prospective analytical study conducted in a Public Sector Medical College in Peshawar City from 28th March to 20th May 2022 (1443 Hijri). Convenience Sampling was used and 115 students (58 male and 57 female) of 1st Year MBBS to Final Year MBBS were enrolled. Four readings of weight were taken, one before, two during, and one after Ramadan. A well-structured self-administered questionnaire was used to inquire about basic demographic characteristics, sleep patterns during Ramadan and normal routine, and family history of obesity. The collected data were analyzed through SPSS software and a repeated measures ANOVA test was used for drawing statistical conclusions. Results: A slight increase in the mean weight was observed during the second week of Ramadan while a loss of 0.4 kg occurred during the fourth week of Ramadan, F (1, 81) = 1777.55; p < 0.0001. The same pattern was observed for BMI, F (1, 81) = 2705.18; p < 0.0001. However, the weight and the BMI were regained in two to three weeks following Ramadan. Conclusion: Ramadan offers a non-hazardous way of weight loss. Further studies across different geographical locations with larger sample sizes should be conducted to identify and quantify the association between weight and fasting and also to identify potential confounders.

Prevalence of urinary incontinence among young female adults.

A cross sectional survey was conducted in 2018-2019 to determine the prevalence of urinary incontinence among university going nulligravid young female adults in Rawalpindi/Islamabad, Pakistan. A total of 608 participants were included in the study via convenience sampling. Data was collected regarding demographic and personal information, in addition to Medical, Epidemiologic, and Social Aspects of Aging (MESA) Urinary Incontinence Questionnaire (UIQ). Independent t-test and One-way ANOVA were used for inter-group comparisons. Pearson and Spearman correlation was used to determine the relationship between variables. The overall prevalence of urinary incontinence was observed to be 193(31.7%) and of stress, urge and mixed incontinence was found to be 64(10.5%), 56(9.2%) and 73(12%) respectively. A significant difference (p<0.05) was observed in terms of MESA-UIQ stress incontinence and urge incontinence scores based on tobacco use, menstrual disorders, eating disorders and marital status.

Effects of glucosamine and chondroitin sulfate supplementation in addition to resistance exercise training and manual therapy in patients with knee osteoarthritis: A randomized controlled trial.

OBJECTIVE: To determine the added benefits of short-term glucosamine and chondroitin sulfate supplementation in combination with manual therapy and resistance exercise training in the management of knee osteoarthritis. METHODS: A parallel-design, double-blind randomised controlled trial was conducted from January to September 2020 at the Foundation University Institute of Rehabilitation Sciences and Fauji Foundation Hospital, Rawalpindi, Pakistan, and comprised of knee osteoarthritis patients of either gender having radiological evidence of grade III or less on Kellgren classification. The subjects were randomly allocated to active comparator group A and experimental group B. Both the groups received manual therapy and resistance exercise training, while group B additionally received glucosamine and chondroitin sulfate supplementation for 4 weeks. Study outcomes included pain, function, quality of life, range of motion, strength, fall risk, skeletal muscle mass, visceral fat area, body fat, intracellular water ratio, and segmental lean and fat mass. Data was analysed using SPSS 21. RESULTS: Of the 24 subjects, there were 12(50%) in each of the two groups. Each groups had 9(75%) males and 3(25%) females. In terms knee osteoarthritis grade, there was no significant difference between the groups (p=1.00). No significant differences were observed in any of the outcome measures neither at 2 weeks, nor at 4 weeks post-intervention between the groups (p>0.05) except for percentage change in segmental lean mass of the right leg at 2nd week and of the left leg at 4th week (p<0.05). CONCLUSIONS: Manual therapy and resistance exercise training are effective in the management of knee osteoarthritis, however, glucosamine and chondroitin sulfate supplementation for 4 weeks showed no additional benefits. Clinical Trial Number: NCT04654871. https://www.clinicaltrials.gov/ct2/show/NCT04654871.

Occurrence of paralytic scoliosis in patients with poliomyelitis reporting at Fauji Foundation Hospital, Rawalpindi.

Pakistan is one of the only three countries in the world with an enduring poliovirus transmission, making poliomyelitis an important health concern for Pakistan. Paralytic scoliosis is a common musculoskeletal dysfunction associated with poliomyelitis. To determine the occurrence of paralytic scoliosis a cross-sectional study was conducted at Fauji Foundation Hospital, Rawalpindi from 2015 to 2018. All patients with poliomyelitis reporting to the hospital were included, whereas patients with scoliosis but no poliomyelitis were excluded. Cobb's angle was used to determine the severity of scoliotic curves. Pearson correlation was used to determine the correlation of Cobb's angle with age and Independent T-test was used to determine the difference in terms of gender. Confidence interval was kept at 95%. A total of 51 patients with poliomyelitis were included in the study with a mean age of 28.58±15.07 years. The overall occurrence of scoliosis was found to be 60.8% with mean Cobb's angle of 23.35o±7.40o, and risk of developing paralytic scoliosis in males was 0.90 times the risk in females. No significant correlation (p=0.833) was observed between age and Cobb's angle. No significant difference (p=0.72) was observed among males and females in relation to Cobb's angle.

The UN Incheon strategy Implementation and the Pakistani quagmire; ground realities.

The Economic and Social Commission for Asia and the Pacific is the regional developmental arm of the United Nations. There are over 650 million persons with disabilities living in the region. In 2012, member countries, including Pakistan, launched the new decade of persons with disabilities from 2013 to 2022, adopting the Incheon Strategy to 'Make the Right Real', based on the Put Convention on the rights of Persons with Disabilities" and aimed at accelerating the disability inclusive development with 10 measurable goals and targets. The year 2017 marked the mid-point of that decade at which point member countries were to submit the Government Members Report on the Implementation of Incheon Strategy. The ambiguity in usage of terms, variable definition of disability, and use of impairment screens in population census of Pakistan has resulted in flawed data and underreporting of persons with disabilities. Pakistan provided data on only 13 of the 30 core indicators as part of its midpoint review. There is lack of awareness among ministries regarding the Incheon Strategy implementation.

Rising trend of Nutraceuticals: Evaluation of lyophilized beetroot powder at different doses for its hypolipidemic effects.

A diet comprising of nutrients that would control hypertension as well as hyperlipidemia would be very beneficial over all. This study aimed to assess the effect of lyophilized beet root powder at different doses on lipid profile and hyperlipidemia model. Albino rabbits weighing 1500-2000gms were taken for both studies. Beetroot powder was administered to animals at 500mg/kg and 1000mg/kg doses and after two month dosing the blood samples were withdrawn and lipid profile was assessed. Next a model of hyperlipidemia was created comprising of albino rabbits that were divided into five groups each containing n=6. Group I was considered as control, Group II was marked as Negative control, Group III was taken as standard, whereas Group IV and V were considered as treated and given different doses of beetroot. Blood samples were drawn at baseline, 45th day and at day 60th of study. Highly significant decrease in lipid profile (Cholesterol, LDL and TGS) and significant increase in HDL was observed by both doses after one month. HDL was increased more at 1000mg/kg dose. The presence of flavonoids and saponins in beetroot is responsible for hypolipidemic effect. From our research we came to the conclusion that beetroot powder reduced the lipid profile and could be beneficial in treatment of cardiovascular disease due to atherosclerosis and obesity.

Four-Factor Prothrombin Complex Concentrate: An Indispensable Adjunct in Coagulopathy of Trauma Management - A Comparative Review of the Literature over 2 Decades.

BACKGROUND: Damage control resuscitation forms the cornerstone of management in trauma surgery. Several blood products have been widely used for preoperative transfusions prior to emergency surgeries and for hemorrhage control in trauma. Prothrombin complex concentrate (PCC) is now being introduced as an essential component of damage control resuscitation. SUMMARY: We did a comparative descriptive analysis of several single and multi-institutional clinical trials and retrospective cohort studies. The primary focus of these studies was a comparison between PCC and other transfusion modalities including recombinant factor VIIa, fresh-frozen plasma, and fibrinogen based on several vital parameters. The parameters included rapid international normalized ratio reversal, hospital length of stay, cost-effectiveness, mortality rate, and rate of thromboembolic complications. KEY POINTS: Although still awaiting its approval from the FDA for use in traumatic coagulopathy, 4-factor PCC has shown far more convincing results in contrast to former transfusion modalities, even 3-factor PCC. However, more prospective extensive clinical trials on national levels are needed to compare its effectiveness to 3-factor PCC and gather promising recognition in the trauma care fraternity.

Efficacy and safety of middle meningeal artery embolization in the management of refractory or chronic subdural hematomas: a systematic review and meta-analysis.

INTRODUCTION: Refractory or chronic subdural hematomas (cSDH) constitute a challenging entity that neurosurgeons face frequently nowadays. Middle meningeal artery embolization (MMAE) has emerged in the recent years as a promising treatment option. However, solid evidence that can dictate management guidelines is still lacking. METHODS: We conducted a systematic review and meta-analysis (MA) in compliance with the PRISMA guidelines to evaluate the efficacy and safety of MMAE compared with conventional treatments for refractory or cSDH. Databases were searched up to March 2019. Using a random-effects model, meta-analyses of proportions and risk difference were conducted recurrence, need for surgical rescue, and complications. RESULTS: Eleven studies (177 patients) were included. Majority (116, 69%) were males with a weighted mean age of 71 + -19.5 years. Meta-analysis of proportions showed treatment failure to be 2.8%, need for surgical rescue 2.7%, and embolization-related complications 1.2%. Meta-analysis of risk-difference between embolized and non-embolized patients showed a 26% (p < 0.001, 95% CI 21%-31%, I2 = 0) lower risk of hematoma recurrence in MMAE. Similarly, in the embolized group, the need for surgical rescue was 20% less (p < 0.001, 95% CI = 12%-27%, I2 = 12.4), and complications were 3.6% less (p = 0.008, 95% CI 1%-6%, I2 = 0) compared to conventional groups. CONCLUSIONS: Although MMAE appears to be a promising treatment for refractory or cSDH, drawing definitive conclusions remains limited by paucity of data and small sample sizes. Multicenter, randomized, prospective trials are needed to compare embolization to conventional treatments like watchful waiting, medical management, or surgical evacuation. More extensive research on MMAE could begin a new era in the minimally invasive management of cSDH.

Emotiv EPOC+ fed electrical muscle stimulation system; an inexpensive brain-computer interface for rehabilitation of neuro muscular disorders.

Advancements in the Neuro-rehabilitation across Pakistan is warranted to effectively and efficiently deal with the disease burden of neurological conditions. Being a developing country, an in-expensive treatment approach is required to culminate the rise in the disease occurrence in Pakistan. Brain-Computer Interfaces (BCIs) have come up as a new channel for communication and control, eliminating the need of physical input, opening doors to a wide array of applications in terms of assistive and rehabilitative devices for paralyzed patients and those with neuromuscular disorders. Even with a promising prospect, BCIs and electroencephalograms (EEG) can be very expensive and therefore, they are not practically applicable. For this reason, the purpose of the current study was to come up with a possibility of an inexpensive BCI for rehabilitation of patients with neuro-muscular disorders in Pakistan by using a low-cost and readily available equipment like Emotiv EPOC+ EEG headset and electrical muscle stimulator.

Effects of static stretching as compared to autogenic inhibition and reciprocal inhibition muscle energy techniques in the management of mechanical neck pain: a randomized controlled trial.

OBJECTIVE: To compare the effects of static stretching with autogenic inhibition and reciprocal inhibition muscle energy techniques on pain, disability and range of motion in patients with mechanical neck pain. METHODS: A parallel design randomised controlled trial was conducted at Fauji Foundation Hospital and Railway-General Hospital, Rawalpindi, Pakistan, from April to November, 2017, and comprised of patients aged 18-70 years with neck pain of moderate intensity scoring 4-8 on numeric pain rating scale with limited or painful range of motion. The patients were randomly allocated via lottery method into static stretching group, autogenic inhibition muscle energy technique group and reciprocal inhibition muscle energy technique group. All the subjects received five consecutive treatments sessions. Outcome measurements included numeric pain rating scale score, neck disability index score and goniometry for cervical range of motion. Data was collected at baseline and after first and fifth sessions, and was analysed using SPSS 21. RESULTS: Of the 78 subjects, there were 26(33.3%) in each of the three groups. Of them 7 were lost to follow-up and the study was completed by 71(91%) subjects. The overall mean age was 41.55±11.89 years (p>0.05). There was no significant difference between the groups at baseline (p>0.05). However, at first and second follow-up, there was a significant difference (p<0.05) between the groups in terms of immediate and short-term relief, except for immediate effects related to range of motion (p=0.056). CONCLUSIONS: Significant difference existed among static stretching, autogenic inhibition and reciprocal inhibition groups in terms of pain, disability and range of motion in patients with mechanical neck pain.

Effect of muscle energy techniques and facet joint mobilization on spinal curvature in patients with mechanical neck pain: A pilot study.

Neck is one of the most common site of musculoskeletal symptom manifestations. An impaired spinal curvature is a common finding in patients with mechanical neck pain. A pre-post quasi experimental pilot study was conducted at Fauji Foundation Hospital from January- March 2017,in which 12 patients with mechanical neck pain and straightening of the cervical spine were included and treated for 7 consecutive sessions consisting of muscle energy techniques (MET) in combination with facet joint mobilization. The objective of this study was to determine the effects of MET and facet joint mobilization on spinal curvature and functional outcomes in patients with neck pain. Outcome measurement tools that were included comprised of pain severity, neck disability index (NDI), cervical lordosis which was measured via x-ray based posterior tangential method, goniometry for cervical range of motion (ROM) and modified sphygmomanometer dynamometry (MSD) for isometric muscle strength. A significant difference was observed in pre and post treatment scores for all outcomes (p<0.05); demonstrating an effective combination therapy in terms of improved spinal curvature, pain, disability, ROM and isometric muscle strength.

Effect of different doses of lyophilized beetroot on fertility and reproductive hormones.

Infertility has recently been a common issue for which multiple medicinal as well as surgical treatments are available. Beta vulgaris commonly referred to as garden beet is one of the most utilized vegetable especially in salad dressings. The Present study was conducted to evaluate the effect of lyophilized beet root on fertility and reproductive hormones. The study was carried out in January 2017 on two different animal models. For fertility purpose albino mice of both genders weighing 20-25gm were divided into 5 pairs for each group, First group was control given distilled water, next was treated I being given beetroot 500mg/kg and last one was given 1000mg/kg beetroot. Similarly 5 pairs were made of buck and doe's weighing 1.75gm-2.5gm and labelled as Control, Treated I and Treated II and were administered distilled water, 500mg/kg and 1000mg/kg beetroot respectively. The pups were again mated after they grew up and in this way F1 generation was also observed. The kits were observed for presence of anomaly. The estrogen, progesterone and testosterone levels were evaluated at baseline, during pregnancy and post pregnancy in rabbit model. Improved fertility with no anomalies in the pups and kits were observed. The reproductive hormones were also highly significantly increased (p<0.001) as compared to baseline values. The study suggests that beetroot would be very beneficial in improving fertility and maintaining hormonal level during fertility hence it would prove to be very beneficial in maintaining pregnancy as well as treating infertility.

Screening of water distilled Rosa damascena Mill. flowers as hematopoietic agent in an animal model.

Pancytopenia is classified as low blood cell count. Low levels of hemoglobin, red blood cells, white blood cells and platelets are indicative of pancytopenic state. This pancytopenic state can be treatment (drug) or disease induced. Conventional approaches available to treat pancytopenia are usually associated with many undesirable adverse effects, are costly and parenterally administered. Interest in natural products has significantly increased due to their ability to stimulate cellular components of immune system. This study is designed to investigate the hematopoietic i.e. erythropoeitic, leucopoietic and thrombopoeitic potential of water distilled flowers of Rosa damascena Mill.

Salat (Muslim prayer) as a therapeutic exercise.

'Salat' is a Muslim prayer mandatory for all Muslims five times a day. It is comparable to performing a mildintensity exercise, because most of the joints and musclesundergo exercise during different positions and movements adopted in Salat. Though Salat is practised by all Muslims, evidence is very limited regarding the biomechanics and therapeutic effects of Salat as an exercise. However, literature shows activation of biceps brachii, triceps brachii, pectoralis major, scapular musculature, rectus femoris, biceps femoris, tibialis anterior and gastrocnemius during different postures of Salat. Moreover, Salat is also found to improve balance in healthy individuals as well as stroke patients, decreases the chances of development of knee osteoarthritis, and provide cardiovascular and compositional benefits. The current literature review was planned to look into the current evidence and discuss what is known regarding the effects of Salat and how it can be used as an exercise.

Common balance measures and fall risk scores among older adults in Pakistan: Normative values and correlation.

The objective of this study was to assess the balance and fall risk among the community dwelling healthy older adults in Pakistan and to determine the correlation between balance measures and fall risk, for which a crosssectional correlation study was conducted at Foundation University Islamabad and Fauji Foundation Hospital from March 2016 to February 2017. A total of 77 individuals over 50 years were included via convenience sampling. I n di vi d u al s w i t h he a r i ng /v is ua l an d c o gn it ive impairments, infections, and orthopaedic and severe comorbid conditions were excluded. Data collection tools included Berg Balance Scale (BBS), Timed Up and Go (TUG) test, Functional Reach Test (FRT) and Fall Risk Score (FRS). Independent t-test and Bivariate Pearson Correlation (CI=95%, P<0.05) were used for analysis. Mean value of the BBS, FRS, TUG and FRT was 41.36±2.96, 3.40±1.47, 15.90±2.68 and 13.34±3.45 respectively. Age had a significant (p<0.05) positive correlation with FRS and negative correlation with BBS. A significant correlation (P<0.05) was found only between FRT & TUG and TUG & BBS.