The maintenance of rheumatologic diseases is heavily dependent upon pharmacologic interventions that, though effective, pose substantial risks of hepatotoxicity and nephrotoxicity. Though guidelines for monitoring these patients have been established, compliance with these measures in real-world practice is inconsistent. Some studies show that many patients do not get the needed laboratory tests, especially in resource-limited regions. The following editorial points out the shortcomings in the practice of surveillance for these patients, especially in low-income settings including Pakistan.

Introduction. Charcot-Marie-Tooth (CMT) disease is the most common inherited peripheral neuropathy, consisting of hereditary motor and sensory neuropathies traditionally classified as demyelinating (CMT type 1) or axonal (CMT type 2) based on nerve conduction studies, with next-generation sequencing now improving genetic diagnosis. CMT type 1 is more prevalent, accounting for 37.5% to 84% of cases, while CMT type 2 represents 12% to 35.9%, but limited epidemiological data on CMT type 2 make diagnosis and family tracing challenging. Case report. We report the case of a 16-year-old female who presented with a two-year history of progressive bilateral hand deformities and foot drop, with no sensory symptoms or sphincter disturbances. Family history revealed a similarly affected sister. Examination showed distal muscle wasting, clawing of fingers, pes cavus, hammer toes and areflexia in both lower limbs, with preserved upper limb reflexes and normal sensation. Nerve conduction studies (NCS) revealed absent motor responses with preserved sensory function and electromyography (EMG) indicated chronic denervation. These findings were clinically and electrophysiologically consistent with CMT type 2, although genetic studies could not be done due to financial constraints. Multidisciplinary care was planned including physiotherapy, orthotic support for foot drop and genetic counseling, in addition to ongoing neuromuscular follow-up. Conclusion. This adolescent case, clinically and electrophysiologically consistent with CMT type 2, was characterized by early hand deformities, absent sensory symptoms, and a strong family history. It highlights the importance of considering hereditary motor neuropathies in patients with distal muscle wasting, especially in settings where genetic testing is unavailable, and shows that careful clinical and electrophysiological assessment can support a probable diagnosis and appropriate management.

Background: Clinical audits are a well-established tool for ensuring adherence to standards and driving improvements in healthcare delivery. Incomplete documentation in emergency departments (EDs) threatens patient safety and continuity of care. Objective: This study aimed to evaluate and improve documentation completeness through a clinical audit and targeted intervention in a paperbased ED setting. Methods: This audit was conducted at Chaudhary Muhammad Akram Teaching and Research Hospital, Lahore, Pakistan. A clinical audit was conducted over two cycles involving 1140 and 964 emergency notes, respectively. The initial audit reviewed 1,140 emergency files from January 2025 using a standardized checklist. Targeted interventions were implemented in February 2025. A re-audit of 964 files from March 2025 was then conducted using the same checklist. Results: Documentation completeness improved significantly for all measured items following the intervention. Notably, the time of consultation documentation nearly doubled, increasing from 51.8% to 94.2% (difference +42.4%, 95% CI: 39.0%, 45.8%), adjusted p<0.001). Similarly, medication history recording improved by 42.6% (from 47.9% to 90.5%, 95% CI: 39.2%, 46.0%), adjusted p<0.001). Other critical elements, such as the doctor’s full name and signature, also showed substantial gains exceeding 20%. Conclusion: The re-audit reflected a positive trend in completeness of data and time of consultation, physician information, and history documentation, with the checklist items showing improved adherence compared to the original audit. Targeted audit-feedback and visual reminders significantly enhanced documentation completeness in a resource-limited, paper-based ED setting. These findings support the use of structured quality improvement strategies to strengthen clinical documentation in similar contexts.

Objective: This study employed a baseline internal audit design to assess completeness of operative notes documentation at a teaching hospital in Lahore Pakistan. Methods: This observational cross-sectional retrospective audit study utilized a standardized checklist to assess completeness of operative notes, drawing on guidelines from the Islamabad Healthcare Regulatory Authority, Punjab Healthcare Comission and the Royal College of Surgeons, after ethical approval from Institutional Ethical Review Committee of Azra Naheed Medical College, Superior University Lahore Pakistan. The audit reviewed all medical records of Department of Surgery and allied specialties from April to June 2025. A total of 227 records were retrieved; however, 24 records were excluded due to missing or damaged operative notes. The audit was conducted on 203 operative notes. The results were analyzed using SPSS version 23. Results: A total of 203 records were assessed. Key findings included high compliance in date (191, 94.1%) and time of procedure (188, 92.6%) but patient identification was documented in only 28 (13.8%). Names of surgeon and assistant (203, 100%), operative finding (201, 99.0%), doctor signature (197, 97.0%), name of operative procedure (196, 96.6%), operative diagnosis (186, 91.6%) and details of tissue removed, added or altered (183, 90.1%) were reasonably well documented. There were gaps in type of elective/emergency procedure (54, 26.6%), prosthesis use (44, 21.9%), any extra procedure performed with reason (36, 17.7%), anticipated blood loss (32, 15.8%), complications encountered (19, 9.4%) and DVT prophylaxis (07, 3.4%). Conclusions: While some components of operative notes were well-documented, deficiencies persist in areas critical to patient safety and quality care. Continued measures such as revising the operative notes form, training sessions, regular audits and feedback are needed to uphold and enhance documentation practices.

Vasculitis refers to autoimmune inflammatory conditions that damage blood vessel walls, causing diverse symptoms from isolated skin lesions to fatal involvement of the kidneys, lungs, nervous system, or blood vessels themselves. The increasing availability of various non-invasive biomarkers, such as ANCA profiles, complement studies, and radiographic imaging, has improved diagnostic accuracy and helped identify vasculitis at an early stage. However, these biomarkers have limitations in sensitivity and specificity and do not provide direct insight into the extent of tissue damage. Therefore, biopsy and histopathology remain unique in that they demonstrate the underlying inflammatory process within the affected vessels and surrounding tissues. Nevertheless, a biopsy has its own set of constraints. The outcome and diagnostic yield of biopsy for diagnosing vasculitis may be influenced by the appropriate choice of biopsy site, adequate tissue sampling, timing of the procedure, and prior use of corticosteroids or immunosuppressive therapy.

The objective of this study was to assess frequency of erectile dysfunction (ED) and its risk factors among adult men in Lahore Pakistan. This study was conducted from July to August 2025, at Urology Outpatient Department of Chaudhary Muhammad Akram Teaching and Research Hospital, affiliated with Azra Naheed Medical College, Superior University Lahore Pakistan. A total of 136 male participants aged 20-70 years were included using a non-probability consecutive sampling. Patients with any associated urological disease such as urinary tract infection, chronic kidney disease, renal stones or previous urological surgeries were excluded. After informed consent, data was gathered on demographic variables, diabetes mellitus, hypertension, smoking, alcohol use and tea intake. ED was diagnosed according to DSM-5 criteria. Data analysis was performed using SPSS version 23.0. Mean age was 48.0±12.5 years with 110 (80.9%) participants educated ≤ 10 standards and 132 (97.1%) had more than 50,000 PKR family income per month. Diabetes mellitus was present in 28 (20.6%) and hypertension in 38 (27.9%). Sixty (44.1%) patients were smokers, 12 (8.8%) used alcohol and 102 (75.0%) consumed tea >2 cups/day. ED was reported in 10 (7.4%) participants. Stratification of data using Chi-Square tests and Fisher’s exact test revealed no significant statistical association of ED with age (p=0.356), education (p=0.217), employment (p=0.642), family income (p=0.686), diabetes mellitus (p=0.575), hypertension (p=0.681), smoking (p=0.457), alcohol use (p=0.479) or tea intake (p=0.789). In logistic regression analysis, age (p=0.529), education (p=0.492), employment (p=0.411), family income (p=1.000), diabetes mellitus (p=0.999), hypertension (p=0.660), smoking (p=0.363), alcohol use (p=0.999) or tea intake (p=0.748) were not found to be significant predictors of ED. Screening for ED may be considered as part of routine health assessments in men. Further research with a larger and more diverse sample is recommended to better understand the determinants of ED in similar populations.

Background: Lower urinary system symptoms (LUTS) are a group of clinical complaints characterized by irregular urinary patterns. LUTS tremendously affect patient functioning and quality of life (QOL). Despite its impact, many men do not seek medical attention, which can be attributed to the low level of awareness and costs associated with healthcare resources and the stigmatization of urinary symptoms. Objective: To assess the frequency of LUTS, its associated factors, and QOL among men at a urology clinic in Lahore, Pakistan. Methods: This cross-sectional clinic-based study was conducted from May 2025 to July 2025 at the Urology Outpatient Department of Chaudhary Muhammad Akram Teaching and Research Hospital, Lahore, Pakistan, on 165 male participants. To evaluate LUTS and QOL, the International Prostate Symptom Score (IPSS) was used. The QOL item is scored from 0 (“delighted”) to 6 (“terrible”), with scores of 0-2 representing good QOL and 3-6 indicating poor QOL. Data were analyzed using SPSS version 23.0. Results: Mean age was 52.1 ± 14.7 years. Mean IPSS score was 13.6 ± 12.1, with 73.9% of participants reporting LUTS. In univariate analysis, LUTS were associated with age, lower education, lower income, diabetes, and hypertension; however, none of these remained significant in multivariable logistic regression. The mean QOL score was 3.1 ± 1.8, and 2/3 (66.7%) reported poor QOL. In univariate analysis, poor QOL was associated with age, diabetes mellitus, absence of alcohol use, tea intake, and LUTS; however, in multivariable logistic regression, poor QOL was associated with LUTS severity, while alcohol use was inversely associated with poor QOL. Conclusion: LUTS were highly prevalent among adult males presenting to the urology clinic, significantly affecting QOL. Routine screening and early management are essential to reduce symptom burden and improve QOL.

Background: Headache is a common neurological complaint and a major cause of disability. Tension-type headache is common, whereas cluster headache is less common but highly disabling. Local data from Pakistan are limited; therefore, this study assessed the frequency of these headache types among patients presenting to the neurology department in Bahawalpur. Objectives: To assess the frequency of tension-type headache and cluster headache among patients presenting with headache at the neurology department in Bahawalpur, Pakistan. Methods: This cross-sectional study was conducted at the Department of Neurology, Bahawal Victoria Hospital, Quaid-e-Azam Medical College, Bahawalpur, Pakistan, from October 2024 to March 2025. Tension-type headache and cluster headache were diagnosed according to the International Classification of Headache Disorders, 3rd edition (ICHD-3), criteria. A total of 300 patients were recruited using a non-probability consecutive sampling method. The exclusion criteria included altered consciousness, a history of seizures, neurological malignancy, or known psychiatric disorders. Written informed consent was obtained from all participants, and strict confidentiality of their data was maintained. Demographic data, including age and gender, were collected, and participants were assessed for the presence of tension-type headache and cluster headache. All data were entered into SPSS version 23 for analysis. Results: The mean age of the participants was 31.4 ± 16.7 years, and 189 (63.0%) participants were female. Tension-type headache was observed in 88 (29.3%) patients, whereas cluster headache was identified in 26 (8.7%) patients. No statistically significant association was observed between tension-type headache and gender (P = 0.258) or age (P = 0.920). A statistically significant association was found between cluster headache and male gender (P = 0.027) but not with age (P = 0.737). Conclusions: Tension-type headache was more common than cluster headache. Cluster headache was significantly associated with male sex, but not with age, whereas tension-type headache was not significantly associated with either age or sex.

Introduction: Silicosis is an occupational lung condition that can lead to permanent physical disability, primarily due to inflammation, scarring of lung tissue, and breathing difficulties. In regions with high rates of tuberculosis (TB), such as South Asia, the presence of TB accelerates the development of pulmonary fibrosis. Additionally, smoking significantly increases the likelihood of further lung damage. Case Presentation: This case report presents a 65-year-old gentleman who presented to the Department of Pulmonology, Bahawal Victoria Hospital, Bahawalpur, with exertional shortness of breath for 6 months, which worsened in the last month to the extent that he experienced dyspnea at rest. This was associated with a productive cough and yellowish sputum for 3 weeks. He had a past history of pulmonary TB 4 years ago and was an active smoker with a 30-pack-year history. He had worked in a stone-crushing factory for the last 35 years but was unable to work in the last few months due to his illness. His chest X-ray and high-resolution computed tomography (HRCT) demonstrated loss of lung volume bilaterally, diffuse nodularity with ground-glass opacifications, bulky hilum, and a left upper lobe fibro-cavitary lesion. Sputum examination was positive for acid-fast bacilli (AFB) stain, and GeneXpert MTB/RIF PCR confirmed the presence of Mycobacterium TB but showed no drug resistance. Based on clinical and radiographic findings, he was diagnosed with active pulmonary TB (relapse) with underlying chronic silicosis by the pulmonology team and managed with supportive oxygen inhalation therapy, category II anti-TB therapy, smoking cessation counseling, and occupational rehabilitation. Conclusions: This case underscores the significance of coexisting silicosis and TB, especially in individuals with a significant smoking history and occupational exposure to silica. This report emphasizes the importance of early detection, multidisciplinary management, and comprehensive treatment strategies, including anti-TB therapy, smoking cessation counseling, and occupational rehabilitation, to improve patient outcomes in complex cases with overlapping lung diseases.

Objective: To explore and analyze the perception of knee osteoarthritis (KOA) among medical students. Methodology: This observational, cross-sectional study was conducted among medical students at Azra Naheed Medical College, Superior University, Lahore from June 2024 to August 2024. A total of 262 students aged 17 to 26 years from all MBBS classes were included. Knee Osteoarthritis Knowledge Scale (KOAKS), an 11-question Likert-scale questionnaire, was used to assess awareness levels. Data were analyzed using SPSS 26, with descriptive statistics and post-stratification Chi-Square tests used to evaluate associations. Result: The mean age was 21±1.7 years, with 63.7% females. Seventy-six (29.0%) of students reported a family history of knee osteoarthritis. Mean KOAKS score was 35.2±3.9 and 64.1% demonstrated good KOA awareness. The analysis showed no significant association of awareness levels with age (p=0.606), gender (p=0.982), family history (p=0.438) or the year of study (p=0.380). Conclusion: Medical students exhibited a generally good awareness of KOA, with no significant demographic influences. These results highlight a strong foundation of knowledge that can be further enhanced through targeted educational interventions.

Background: Excessive exposure to airborne crystalline Silica can result in irreversible lung inflammation, and fibrosis. Case Report: A 22-year man presented with shortness of breath and persistent cough for 3 days. He was taking oral anti-tuberculous therapy for tuberculous lymphadenitis diagnosed by cervical lymph node biopsy for the last 9 months. He had right sided spontaneous pneumothorax 3 months ago, chest tube thoracostomy and pleurodesis with doxycycline were done. For the last 1 year, he had been working in a cement factory but previously was employed in rice shelling. His chest X-ray demonstrated a right sided pneumothorax, non-homogenous opacifications in middle and lower zones bilaterally. HRCT chest revealed bilateral ground-glass opacifications with nodularities and infiltrates more pronounced peripherally. He was diagnosed as having Acute Silicosis based on radiographic findings and occupational history. He was managed with oxygen inhalation therapy and intravenous steroids. Conclusion: Counseling regarding occupational rehabilitation was done.

Background and Objectives: The present study aimed to assess frequency of carpal tunnel syndrome (CTS) in patients of type 2 diabetes mellitus (T2DM). Methods: This cross-sectional study was conducted at Bahawal Victoria Hospital Pakistan, from January to June 2024. A total of 210 patients with T2DM were included based on specific diagnostic criteria, including HbA1c > 7.0% or random blood glucose levels ≥ 200 mg/dL. The CTS was diagnosed clinically through symptoms such as numbness and pain in the hand, positive Phalen’s and Tinel’s signs, confirmed by nerve conduction studies. Exclusion criteria included patients with chronic kidney disease, coronary artery disease, or other significant health issues. Results: The mean age of participants was 54.7 ± 14.5 years, with a female preponderance (53.8%). Mean duration of diabetes was 6.7 ± 5.7 years, and 71.0% of patients had poor diabetes control (mean HbA1c 10.1 ± 2.4%). The CTS was found in 4.8% (10 patients), with 60.0% having bilateral involvement. The CTS was relatively uncommon in this study population. No significant associations were found between CTS and gender (P = 0.347), age (P = 0.804), duration of diabetes (P = 1.000), or diabetes control (P = 0.727). Conclusions: The CTS was relatively uncommon in our study having no statistical association with patient factors like gender, age, duration of diabetes and diabetes control suggesting that other variables might influence its prevalence in this population. Exploring the possibility of other risk factors or conducting further studies to investigate different demographics or environmental influences could be beneficial.

Objective This study aims to explore key factors influencing hypertension management, including demographic (e.g., age, gender, education level), clinical (e.g., presence of comorbid conditions), and behavioral influences (e.g., medication adherence, lifestyle choices such as diet and exercise). The study seeks to provide specific insights into the gaps in knowledge of hypertension and treatment adherence and identify potential barriers to effective treatment and lifestyle modifications. Methods This study was carried out in the Departments of Medicine and Cardiology at Chaudhary Muhammad Akram Teaching and Research Hospital, Azra Naheed Medical College, Superior University, Lahore, Pakistan, from November 2024 to February 2025. A total of 252 hypertensive patients, diagnosed for at least six months, aged ≥18 years, and of both genders, were enrolled using a nonprobability consecutive sampling technique after informed consent. Patients were excluded if they were unable to complete the questionnaire, had hypertensive emergencies, were critically ill or in the ICU, had an active myocardial infarction or stroke, were undergoing hemodialysis, or had a pre-existing psychiatric illness. A structured questionnaire was completed by the patients, collecting details including demographic and clinical information, the 12-item Hypertension Knowledge Test (HKT), and a 10-item domain regarding practices of hypertension control and treatment adherence. Both these questionnaires have been validated in previous studies. All data were entered into IBM SPSS Statistics for Windows, Version 23 (Released 2015; IBM Corp., Armonk, New York) for statistical analysis. Results The mean age was 47.6±12.9 years, with 133 (52.8%) participants aged ≥45 years. The majority were female (154, 61.1%). Of the 252 patients, 201 (79.8%) were married, 136 (54.0%) had ≤5 years of education, and 152 (60.3%) were employed. The mean duration of hypertension was 7.7±6.0 years, with 146 (57.9%) having hypertension for ≥6 years. Diabetes mellitus was present in 134 (53.2%), ischemic heart disease in 94 (37.3%), and chronic kidney disease in 28 (11.1%). A positive family history of hypertension was reported in 179 (71.0%). The mean HKT score was 7.1±2.0, with the majority (203, 80.6%) having poor knowledge. A significant statistical association of good knowledge was seen with younger age (p <0.001), being unmarried (p = 0.001), being educated (p <0.001), being employed (p <0.001), duration of hypertension ≤5 years (p = 0.039), absence of ischemic heart disease (p = 0.002), absence of chronic kidney disease (p = 0.024), and having a positive family history (p <0.001). No association was seen with gender (p = 0.336) or diabetes mellitus (p = 0.053). Regarding medication adherence, 26 (10.3%) always forget to take their medication, while 65 (25.8%) do so most of the time. In terms of healthcare management, 68 (27.0%) always make their next doctor's appointment before leaving the office, while 99 (39.3%) do so most of the time. However, 21 (8.3%) have missed a scheduled appointment, and 54 (21.4%) do so most of the time. Conclusion This study underscores a significant gap in knowledge of hypertension and suboptimal adherence to treatment among hypertensive patients and highlights the need for educational programs and strategies to promote treatment adherence, especially among older patients and those with lower educational levels.

This study aimed to determine the incidence of acute ischemic stroke in hypertensive individuals in Lahore, Pakistan, and was conducted at the Department of Medicine, Chaudhary Muhammad Akram Teaching and Research Hospital. Hypertension was defined as blood pressure exceeding 140/90 mmHg on two separate occasions, ambulatory readings above 140/90 mmHg recorded at least 15 days apart, or a known history of antihypertensive medication use. Acute ischemic stroke was defined as sudden loss or weakness in function of one or more limbs on clinical examination, confirmed radiologically by a CT scan of the brain. A total of 200 hypertensive patients aged 18 years and older were included using non-probability consecutive sampling. Participants underwent evaluation for blood pressure control, antihypertensive therapy, comorbidities, and acute ischemic stroke. The results showed that acute ischemic stroke was present in 6.5% of patients. Chi-square analysis revealed that prolonged duration of hypertension, poor hypertension control, current treatment regimen, presence of diabetes mellitus, and ischemic heart disease had statistical associations with stroke. However, in logistic regression analysis, no variable was found to be a significant predictor of stroke. It is concluded that acute ischemic stroke is not an uncommon finding in hypertensive patients, being more prevalent in those with prolonged hypertension duration, poor control, and the presence of comorbidities.

Diabetic foot ulcers are moderately severe complications in patients with type 2 Diabetes Mellitus, with peripheral neuropathy and angiopathy often serving as risk factors. This study aimed to examine the clinical characteristics and risk factors linked to diabetic foot ulcers in type 2 diabetes mellitus individuals within the Pakistani demographic. A retrospective cross-sectional design was used, to analyze the medical files of 68 diabetic foot ulcer patients. Data were collected from the Departments of Medicine and Surgery at Chaudhary Muhammad Akram Teaching and Research Hospital, Lahore Pakistan from Sept. to Dec. 2024. Patients’ clinical profiles, including demographic data, diabetes duration, diabetes control, HbA1c levels, and the presence of comorbidities were all evaluated. Out of the 68 patients, 70.6% were male having a mean age of 55.6±11.7 years, and 55.9% had diabetes for seven years or more. With regard to clinical factors, 61.8% had peripheral neuropathy, 58.8% had hypertension, 47.1% had retinopathy, 26.5% had nephropathy, 20.6% had ischemic stroke, 8.8% had ischemic heart disease, and 2.9% had hypothyroidism, with 97.1% showing poor glycemic control. This study identified a high rate of comorbidities in patients with diabetic foot ulcers, with inadequate diabetes control being a major contributing factor. Timely detection and management of diabetes and its complications are crucial to alleviating the impact of diabetic foot ulcers.

Polycystic ovary syndrome (PCOS) is a prevalent endocrine disorder among women of reproductive age, associated with menstrual irregularities, infertility, and long-term metabolic risks. Despite its common occurrence, awareness and understanding of PCOS remain inadequate among young women. This study aimed to assess the level of awareness, common misconceptions, and sources of information about PCOS among young adult female university students. A descriptive cross-sectional study was conducted at Superior University, Lahore, Pakistan. One hundred female students aged 18–25 years were recruited through non-probability consecutive sampling after obtaining informed consent. Participants with a current or past diagnosis of PCOS were excluded. Data on demographics, knowledge and perceptions of PCOS were collected using a structured self-administered questionnaire and analyzed using SPSS version 23. Descriptive statistics were used to summarize the findings. All participants (100%) had heard of PCOS. Knowledge accuracy was limited: 71% recognized irregular menstrual cycles as a common symptom, only 47% correctly identified PCOS as a hormonal disorder, and 38% considered it treatable. Emotional and perception responses were predominantly worry (67%) and fear (24%), with 57% associating PCOS with infertility. The majority perceived lifestyle modification (54%) as the preferred treatment. Main sources of awareness were educational settings (46%) and TV/social media (30%). Notably, just over half (52%) indicated they would seek medical consultation, highlighting a key behavioral implication for campus health education. While awareness of PCOS was high, misconceptions about its hormonal basis and management persist, and emotional responses indicate considerable concern among students. Targeted health education programs are needed to improve knowledge, address misconceptions, and promote timely help-seeking behaviors in university settings.

Background: This study investigates the prevalence of depression and anxiety among type 2 diabetes mellitus (T2DM) patients in Pakistan, focusing on socio-demographic factors and co-morbidities. Understanding these mental health issues is crucial for improving diabetes management and patient outcomes, particularly in a country with limited mental health resources. Objective: To determine the frequencies of anxiety and depression in patients with T2DM presenting in medicine outpatient clinics. Methods: A cross-sectional study was conducted at Chaudhary Muhammad Akram Teaching and Research Hospital, Azra Naheed Medical College, Superior University Lahore, from February to October 2024. The study was performed in outpatient clinics of the medicine department. Atotal of 216 T2DM patients were enrolled using non-probability consecutive sampling. Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale (HADS). Demographic data and diabetes-related variables were also collected. Statistical analysis was performed using SPSS version 23.0, with chi-square tests post-stratification keeping p-value <0.05 as significant. Results: Mean age was 53.7 +/- 13.0 years, with a majority being female (61.1%). Poor diabetes control was reported in 176 (81.5%) patients. Anxiety was seen in 44 (20.4%) patients, with higher levels in females than males (p<0.001). Depression was found in 54 (25.0%) patients, with significantly higher rates in females compared to males (p<0.001), and in those with chronic kidney disease (p=0.007). Conclusion: This study highlights the high frequency of anxiety and depression among T2DM patients, especially in females and those with chronic kidney disease. These findings underscore the need for integrated mental health care in diabetes management, including routine screening and targeted interventions for high-risk groups.

We present the case of a 17-year-old female who developed Janeway lesions as a cutaneous manifestation of infective endocarditis caused by Staphylococcus aureus. The patient presented with a 7-day history of high-grade fever, chills, body aches, palpitations, and exertional shortness of breath. Physical examination revealed multiple purplish-red, non-itchy macules on both hands and left foot, consistent with Janeway lesions. Cardiovascular examination demonstrated a grade 4 pan-systolic murmur at the mitral area and a grade 4 early diastolic murmur at the aortic areaBlood cultures identified Staphylococcus aureus, sensitive to vancomycin and gentamycin. Transthoracic echocardiography revealed vegetations on the mitral valve and moderate-to-severe mitral regurgitation. Fundoscopy did not reveal Roth’s spots, and tests for ANA, HBV, HCV and HIV were negative. The patient was diagnosed with infective endocarditis and started on intravenous vancomycin and gentamycin, showing clinical improvement. She was discharged on vancomycin to complete a 6-week course of treatment. This case underscores the importance of recognizing cutaneous signs, such as Janeway lesions, which can aid in the early diagnosis of infective endocarditis and guide appropriate treatment. Abbreviations: ANA: Antinuclear Antibody, CRP: C-reactive protein, ESR: erythrocyte sedimentation rate, LFTs: liver function tests, PML: posterior mitral leaflet, RFTs: renal function tests, TLC: total leukocyte count, Keywords: Janeway Lesions; Infective Endocarditis; Septic Embolism; Staphylococcus Aureus; Vancomycin Citation: Waris B, Butt NI, Bashir A, Khizar I, Afzal A. Janeway lesions in infective endocarditis: an old clinical sign revisited. Anaesth. pain intensive care 2025;29(4):442-445. DOI: 10.35975/apic.v29i4.2684 Received: February 14, 2025; Revised: June 12, 2025; Accepted: June 25, 2025

Breast self-examination (BSE) is an accessible, self-performed screening method for detecting potential changes or abnormalities in the breast such as breast cancer, allowing individuals to familiarize themselves with their normal breast tissue and identify any unusual signs, but it is not a substitute for other breast cancer screening methods like mammograms or clinical exams. The objective of this research was to assess attitudes towards Breast Cancer and BSE in middle aged females from Lahore Pakistan.This descriptive cross-sectional study was conducted at OPD of Chaudhary Muhammad Akram Teaching and Research Hospital, Azra Naheed Medical College Superior University Lahore Pakistan. Fifty females attending OPD of the hospital, aged 35 to 45 years were enrolled in the study after taking informed consent using non-probability consecutive sampling technique. Females with a present or past diagnosis of breast abnormalities (cysts, mastitis, benign or malignant tumors) were excluded from the study. Demographic information was noted and then the participants filled a structured questionnaire comprising of 3 domains: first domain was regarding attitude towards Breast Cancer; second domain was about attitude towards BSE; while the third domain focused on BSE and mammography practices. All the data was entered and analyzed through SPSS version 26. Majority of the females were aged 35 to 40 years (33, 66.0%). Based on socioeconomic background, 19 (38.0%) females belonged to middle socio-economic status. Majority of the females (17, 34.0%) were undergraduates on educational status followed by 16 (32.0%) illiterate. Forty (80.0%) were married. In the present study, 37 (74.0%) females had heard about Breast Cancer but only 09 (18.0%) were aware about BSE. Only 09 (18.0%) respondents reported performing BSE while 14 (28.0%) had a history of mammographic scan. Advice from friends (04, 8.0%) was the biggest sources of BSE information. Attitude regarding breast cancer and BSE was poor in our study. Our study highlights the need to promote knowledge and awareness regarding breast cancer and BSE by educational programs, public health messages, seminars and through social media. Targeted public health interventions should be done, including educational campaigns and community outreach, to improve awareness and encourage early detection practices such as BSE and mammography, especially among less educated and lower-income women.