The role of angiotensin receptor blockers in treating epilepsy: a review.

Epilepsy is a chronic brain disease with a global prevalence of 70 million people. According to the World Health Organization, roughly 5 million new cases are diagnosed every year. Anti-seizure drugs are the treatment of choice. However, in roughly one third of the patients, these drugs fail to produce the desired effect. As a result, finding novel treatments for epilepsy becomes inevitable. Recently, angiotensin receptor blockers have been proposed as a treatment to reduce the over-excitation of neurons in epilepsy. For this purpose, we conducted a review using Medline/PubMed and Google Scholar using the relevant search terms and extracted the relevant data in a table. Our review suggests that this novel approach has a very high potential to treat epilepsy, especially in those patients who fail to respond to conventional treatment options. However, more extensive and human-based trials should be conducted to reach a decisive conclusion. Nevertheless, the use of ARBs in patients with epilepsy should be carefully monitored keeping the adverse effects in mind.

Association of neutrophil-to-lymphocyte ratio with clinical, pathological, radiological, laboratory features and disease outcomes of invasive breast cancer patients: A retrospective observational cohort study.

Inflammatory conditions play part in the progression of malignancies, and markers signifying growth of these factors can indicate prognosis. Neutrophil-to-lymphocyte (NLR) is used as a marker of subclinical inflammation that may become an integral part of workup to indicate prognosis and associated pathology. This study aims to explore the association of NLR ratio with clinical characteristics, radiological assessment and staging, histopathology, and disease outcomes of breast cancer. A retrospective cohort study was conducted in a tertiary care center to include breast cancer patients that were diagnosed between January 2001 and December 2020. Data including tumor size, lymph nodes, metastasis, histological grading, ER/PR/HER2-neu status, molecular subtypes, clinical staging); nodal findings (sentinel and axillary); pathology from frozen section; and disease outcomes were assessed. Multivariable regression and Kaplan-Meier survival curves were employed to indicate the association of NLR with breast cancer features and disease-free survival. A total of 2050 patients had a median age of 50 years, median NLR levels of 2.14, most common pathology ductal followed by lobular, and most common site of metastasis being lungs followed by bones. Disease-free rate was 7.6%, and a recurrence rate of 1.8%, while 1.6% deaths were reported. NLR was found associated with age, treatment outcomes, tumor size, lymph nodes, metastasis and clinical staging. Other positive correlations were with Ki67 proliferation index, molecular subtypes, and tumor size on frozen section (at transverse and craniocaudal dimensions). Negative correlations were seen with estrogen and progesterone receptors. However, NLR was not found predictable of disease-free survival (P = .160). Significant predictors of disease-free survival were histological grading, ER, PR status, molecular subtype, and Ki67 proliferation index. NLR being a readily available marker has shown novel findings in its association with tumor staging, disease outcomes and characteristics of breast malignancy.

Managing and treating Sydenham chorea: A systematic review.

INTRODUCTION: Sydenham's chorea (SC), prevalent in developing countries and occasionally affecting developed ones, poses a clinical challenge due to the lack of systematic guidelines for diagnosis and treatment. Resulting from Group A Beta-Hemolytic Streptococcus infection, SC presents various symptoms. This review aims to collect and evaluate available data on SC management to propose a cohesive treatment plan. METHODS: We searched PubMed, the Cochrane Library, Google Scholar, and ClinicalTrials.gov for literature on SC management from inception until 24th July 2022. Studies were screened by titles and abstracts. Cochrane Collaboration's Risk of Bias tool (RoB-1) assessed Randomized Controlled Trials, while the Risk of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool evaluated nonrandomized studies. RESULTS: The review includes 11 articles assessing 579 patients. Excluding one study with 229 patients, of the remaining 550 patients, 338 (61.5%) were females. Treatments used were dopamine antagonists in 118 patients, antiepileptics in 198, corticosteroids in 134, IVIG in 7, and PE in 8 patients. Dopamine antagonists, particularly haloperidol, were the primary treatment choice, while valproic acid (VPA) was favored among antiepileptics. Prednisolone, a corticosteroid, showed promising results with weight gain as the only side-effect. Our review emphasizes the importance of immunomodulators in SC, contrasting previous literature. CONCLUSION: Despite limitations, dopamine antagonists can serve as first-line agents in SC management, followed by antiepileptics. The role of immunomodulators warrants further investigation for conclusive recommendations.

Comparative efficacy and safety of lemborexant 5 mg versus 10 mg for the treatment of insomnia: a systematic review.

INTRODUCTION: Insomnia is a common condition that may be caused by or coexist with other medical or psychological illnesses. Nearly a quarter of a billion people across the globe suffer from insomnia frequently. Lemborexant, a dual orexin receptor antagonist, is a recently authorized hypnotic-based medication for insomnia. The purpose of this systematic review is to further investigate its efficacy and safety profile, with the primary goal of comparing the effects of two FDA-approved doses of lemborexant, 5 mg and 10 mg (LEM5 and LEM10, respectively). MATERIALS AND METHODS: PubMed, Google Scholar, ClinicalTrials.gov, and Cochrane Central were searched for relevant literature, and studies were considered if they compared the efficacy and safety of lemborexant 5 mg to lemborexant 10 mg. This study comprised clinical trials. RESULTS: A total of 6 studies were evaluated for efficacy and safety of lemborexant therapy. They reported a significant betterment in values pertaining to sleep efficacy, sleep onset latency, wake after sleep onset, total sleep time, sleep quality, ISI score, and morning alertness. The results presented a dose-dependent pattern and showed slight variation with the different dosages. The most prevalent side effects noted were somnolence, headaches, and dizziness, with infections like UTIs and upper respiratory tract infections also being commonly reported. The incidence is rather ambiguous and not sincerely dose-dependent. The differences between results for LEM5 and LEM10 do not exhibit a wide variation, although slight dose-dependent alterations are noted. CONCLUSION: Lemborexant is well integrated with the amelioration of sleep disturbances in insomniac patients, as shown by a decrease in eSOL and sWASO and a rise in sSE, sTST, quality of sleep, and morning alertness. Effects last 12 months after therapy.

Efficacy and Safety of Vericiguat for Treatment of Heart Failure: A Systematic Review.

Heart failure is a growing global health concern with high mortality and morbidity. Beta-blockers, mineralocorticoid receptor antagonists, and angiotensin-converting-enzyme inhibitors are the treatments of choice for worsening clinical symptoms. In early 2021, the FDA approved a new oral soluble guanylate cyclase stimulator, Vericiguat, for the treatment of chronic heart failure. To evaluate the efficacy and safety of this approved drug, we conducted a systematic review of the available randomized controlled trials (RCTs). A literature search was conducted using PubMed, The Cochrane Library, and Clinicaltrials.gov from inception to June 6, 2022, without any language restriction. The systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The quality of the included studies was checked using the Cochrane Risk-of-Bias tool. After a thorough literature search, 7 studies met our pre-defined criteria and were therefore included in this review. Our review suggests that vericiguat was better in preventing all causes of death, cardiovascular death, and hospitalizations due to heart failure irrespective of the atrial fibrillation status of the patients and was even beneficial for patients with NT-proBNP levels up to 8000 pg/ml. The safety of the vericiguat, according to our review, is not up to the standards, especially with a higher dosage of vericiguat. Despite all of this, vericiguat can be a breakthrough in the treatment of heart failure as it has great potential to improve the disease severity.

The battle against Thalassemia in Pakistan: Way to move forward.

Thalassemia, one of the most common genetic hemoglobinopathy, is yet still an economy-depriving disorder, prevalent throughout the world. Specifically in Pakistan, numerous factors have led to the ever-increasing numbers of the affected masses. Amidst its battle with other diseases, it is worthy to highlight that the country did not overlook this disorder and hence, significant work has been done to change the thalassemia status of the country. From the establishment of reforms to private philanthropic organizations, Pakistan is actively fighting against the disorder. However, some more practical working and well-devised planning can help the country, attain a thalassemic-free status.

SARS-CoV-2 Vaccination and Chilblain-like Lesions: What Do We Know so Far?

Introduction: The coronavirus pandemic has caused massive damage to global health care and the economy. The vaccination program has been paced around the globe to return as soon as possible to pre-COVID time. Although all the vaccines have been approved after the rigorous clinical and safety trials, some adverse effects have surfaced and are being reported from different parts of the world. One such side effect is chilblain-like lesions following the COVID vaccination. Chilblain lesions, also known as pernio, are an inflammatory condition usually affecting the acral regions of the body. It is mostly reported from cold and damp areas and has multiple causes associated with it. Objective: This study aims to review the publicly available data and to provide concise and comprehensive information as well as evaluate the potential pathology, clinical approach, and management of CLL post-vaccination. Methods: An extensive literature search over PubMed, Cochrane library, Google Scholar, and Clinicaltrails. gov from inception till 5th October 2021, without any restriction of language was carried out. All the recruited articles were reviewed, and their bibliographies were also screened for any relevant information. Results: 12 studies (10 case reports and 2 case series) were retrieved reporting the incidence of CLL post-vaccination. 8 studies reported incidence in female patients while 5 reported in males, with one study mentioning no gender. Moreover, most of them were either from Europe or the United States of America, except for two cases, reported from Turkey. Conclusions: Although the overall incidence of Chilblains following COVID-19 vaccination is low, there is still a strong need to find out the exact mechanism behind this to redefine the safety and administration criteria of the vaccines and to formulate a proper management protocol.

Postoperative cardiac troponin I as an indicator of surgical outcomes: A systematic review.

INTRODUCTION: Cardiac surgeries are generally associated with high morbidity and mortality. To prevent any adverse outcomes, it is crucial to identify patients at risk of developing postoperative complications and initiate relevant therapeutic interventions. Several biomarkers are used to determine postoperative myocardial injury but they either lack sensitivity and specificity or are elevated for a short time. In this systematic review, we evaluate postoperative troponin I as a predictor of postoperative myocardial infarction, mortality, and hospital and Intensive Care Unit stay. METHODS: This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. A thorough literature search was conducted over PubMed, clinicaltrials. gov, and the Cochrane library from inception till May 24, 2022 using relevant keywords, and only articles that met the pre-defined criteria were recruited. RESULTS: Following a comprehensive literature search, a total of 359 articles were obtained. Following a rigid screening and full-length review, only 13 studies met our inclusion criteria and were included. The recruited studies evaluated data from a total of 12,483 individuals and assessed troponin I as a predictor of at least one outcome. CONCLUSION: Troponin I has the potential to be used as a stand-alone predictor of surgical outcomes following coronary artery bypass grafting and valvular surgeries. However, supplementing it with other markers and scores offers the best chance at timely diagnosing any complications.

SARS-CoV-2 vaccination and uveitis: Are they linked?

In 2019, the discovery of a new strain of Coronavirus, later referred to as SARS-CoV2 took the world by storm, leading to a pandemic and shutting down all global activities. Several measures were taken adequately to combat the viral havoc, including developing numerous vaccines. All the vaccines currently available for the general population went through rigorous screenings and trials to ensure maximum safety and were only approved after that. However, once they were rolled out in the markets and administered to the population, some adverse reactions were reported, one of which included uveitis. It is an ocular inflammatory condition of the uveal tract, choroid, or iris. If untreated, it can lead to severe consequences, including blindness. It is further divided into four categories based on its anatomical location. Despite the rare incidence of uveitis following COVID-19 vaccination, it may contribute to vaccine hesitancy; hence addressing and digging into the pathophysiological cause is crucial. This study evaluates all the pathophysiological and demographical links between COVID-19 vaccination and uveitis, suggesting appropriate management plans.

Infectious disease surveillance system in Pakistan: challenges and way forward.

Infectious Disease Surveillance (IDS) in the community is essential to prevent, control, and detect outbreaks. A strong surveillance system is a need of time for low to middle-income countries like Pakistan where around half of the reported deaths are due to infections that can be easily prevented in the presence of a surveillance system. Although Pakistan has IDS which monitors and collects the data on several infectious diseases, the system is unreliable, inadequate, and substandard. As a result, dengue, tuberculosis, malaria, hepatitis B and C, and many other infectious diseases are still prevalent in Pakistan and unfortunately, the numbers are still rising. In this commentary, we have tried to highlight the problems the country is facing to establish a proper and self-sustainable surveillance system and have recommended some steps the relevant stakeholders should consider taking to make healthcare better in Pakistan.

Mysterious dengue-like virus: A case report from Pakistan.

Recently, in Pakistan, several cases of mysterious dengue-like illness are being reported, which has concerned the authorities and requires prompt action. We present a case of a 52-year-old female patient presenting with a history of continuous fever, documented up to 104 F, for 5 days. The symptoms were associated with headache, nausea, retro-orbital headache, arthralgia, and myalgia. Currently, to the best of our knowledge, this is the first reported case in the literature for the endemic mysterious virus and may serve as the groundwork for future studies.

The association between SARS-CoV-2 vaccines and transverse myelitis: A review.

In late 2019, the emergence of a new viral strain, later referred to as Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) took the shape of a global pandemic, affecting millions of lives and deteriorating economies around the globe. Vaccines were developed at an exceptional rate to combat the viral desolation, all of them being rolled out once they displayed sufficient safety and efficacy. However, assorted adverse events came into attention, one of them being Transverse Myelitis (TM), an infrequent, immune-mediated, focal disease of the spinal cord. This disorder can lead to severe neurological complications including autonomic, sensory, and motor deficits. The literature aims to shed light on TM and its various etiologies, specifically in line with the vaccine, and a comprehensive treatment plan. Discussing and reducing the number of vaccines related adverse events can help succor in bringing down the vaccine hesitancy and ultimately combatting the pandemic.

West Nile virus outbreak in Pakistan: Another potential public health threat in the pipeline?

West Nile virus (WNV), a single-stranded RNA virus belonging to the family of Flaviviridae, is an arbovirus transmitted to humans predominantly by mosquito bites. It exhibits a wide range of clinical findings ranging from asymptomatic presentation to severe several neurological disorders. WNV has afflicted several countries around the globe including Pakistan. News of yet another outbreak in the country by WNV is circulating again. Concerned authorities should act vigilantly before the endemic takes over completely and bring down the already bereaving healthcare of Pakistan.

Efficacy of Remimazolam for Procedural Sedation in American Society of Anesthesiologists (ASA) I to IV Patients Undergoing Colonoscopy: A Systematic Review and Meta-Analysis.

Remimazolam is made by combining midazolam and remifentanil as an alternative to conventional sedatives. To evaluate the efficacy of remimazolam for sedation in patients undergoing colonoscopy, we conducted a systematic review and meta-analysis of the available randomized controlled trials (RCTs) comparing remimazolam and midazolam. A search was conducted using PubMed, Cochrane Library, and clinicaltrial.gov from inception till December 26, 2021, for RCTs that investigated the efficacy of remimazolam during the above-mentioned procedure. There was no restriction of language. A quality assessment was performed using the Cochrane Risk-of-Bias tool. The data were pooled, and a meta-analysis was completed. The systemic review was conducted in accordance with the Preferred Reporting Items for Systemic Reviews and Meta-Analysis (PRISMA) guideline statement. Three randomized controlled trials involving 539 patients were included in the meta-analysis. Compared with midazolam during colonoscopy, remimazolam results in reduced need for top-up doses (RR= 3.45, 95% CI=1.07 to 11.14; P=0.04, I2=84%). The need for rescue medication was reduced with remimazolam as compared to midazolam (RR=2.42, 95%CI=1.04 to 5.61; P=0.04, I2=96%). There was no significant difference observed between the two drugs on completion of colonoscopy and the overall procedural sedation, but the sensitivity analysis favored remimazolam over midazolam for procedural sedation (RR=4.08, 95%CI=2.35 to 7.09; P<0.00001, I2=39%). This analysis demonstrates the advantages of remimazolam over other agents and sets a platform for relevant future studies.

SARS-CoV-2 vaccine-associated-tinnitus: A review.

The global vaccination drive against severe acute respiratory syndrome coronavirus-2 is being pursued at a historic pace. Unexpected adverse effects have been reported following vaccination, including thrombotic thrombocytopenia, myocarditis, amongst others. More recently, some cases of tinnitus are reported post-vaccination. According to the Vaccine Adverse Events Reporting System (VAERS), 12,247 cases of coronavirus post-vaccination tinnitus have been reported till September 14, 2021. To the best of our knowledge, this is the first review evaluating any otologic manifestation following vaccine administration and aims to evaluate the potential pathophysiology, clinical approach, and treatment. Although the incidence is infrequent, there is a need to understand the precise mechanisms and treatment for vaccine-associated-tinnitus.