Here we present a fusiform, partially thrombosed, previously ruptured aneurysm in the posterior cerebral artery that was treated with parent vessel sacrifice after a micro-WADA and micro-balloon test occlusion (video 1). These aneurysms pose treatment challenges due to their deep location, morphology, and potentially eloquent distal supply.1 2 Primary coiling, stent assisted coiling, or microsurgical clipping are often not viable options, whereas flow diversion, parent vessel sacrifice,3 or trapping with bypass are usually employed. Pharmacological provocative testing via a micro-WADA4 5 with or without a micro-balloon test occlusion is critical to establish whether the territory at risk has functional eloquence, although specific reports for using these techniques are limited. We describe the patient presentation, initial treatment attempt and failure, and our protocol for performing a micro-WADA/balloon test occlusion test. Video 1 Micro wada for PCA aneurysm.

Background: While it is often presumed that undergoing breast reconstruction (BR) after mastectomy has positive psychosocial effects, a comprehensive review of current knowledge on the topic is to date absent. The aim of this systematic review is to summarize the available literature on the effects of BR on postoperative psychological distress. Methods: A systematic review of the literature was performed using PubMed, Google Scholar, EMBASE, PSYCinfo, and Web of Science. Inclusion criteria included clinical studies of patients who underwent BR post-mastectomy with psychological distress assessments as primary outcomes. Articles were independently reviewed and assessed for bias and evidence quality. Analyses were performed among patients receiving mastectomy alone (MA) versus mastectomy with breast reconstruction (MBR), immediate versus delayed mastectomy, and implant-based versus autologous reconstruction. Results: Ninety-nine studies published from 1980-2021 met inclusion criteria and were reviewed. Twentysix (26.3%) studies compared patients who underwent MBR to those who underwent MA. Of these, 18 (69.2%) found that MBR had superior effects on psychologic outcomes, 6 (23.1%) found no differences, and 2 (7.7%) found negative psychologic effects relative to MA. Fourteen (14.1%) studies compared immediate versus delayed BR, of which 4 (28.6%) found that immediate BR had superior psychologic outcomes while 10 (71.4%) found no significant differences. Sixteen (16.2%) studies compared autologous versus implant-based reconstruction. Eight (50.0%) of these reported patients with autologous BR were more satisfied with breast appearance. Conclusions: While findings are not uniform, the majority of studies found that BR following mastectomy improves psychologic outcomes, with a possible benefit of immediate over delayed BR. Future studies should determine if BR type has an effect on psychological distress.

Purpose Lumbar degenerative diseases impose a substantial health burden, prompting the exploration of advanced surgical approaches such as Oblique Lumbar Interbody Fusion (OLIF). This meta-analysis aims to evaluate the comparative efficacy of OLIF with anterior screw fixation (OLIF-AF) against OLIF with posterior pedicle fixation (OLIF-PF) in addressing these conditions. Methods A systematic search across multiple databases identified five studies meeting inclusion criteria, incorporating a total of 271 patients. Comparative analysis encompasses primary and secondary outcomes related to fusion rates, intraoperative parameters, patient-reported measures, and radiographic assessments. Results Primary outcome analysis demonstrated no statistically significant difference in total fusion rates between OLIF-AF and OLIF-PF. However, secondary outcomes revealed distinct advantages in OLIF-AF, showcasing lower intraoperative blood loss and reduced operative times compared to OLIF-PF. Nonetheless, patient-reported outcomes, encompassing measures such as pain scores and functional assessments, as well as radiographic parameters, exhibited no significant variations between the two techniques. Conclusion While OLIF-AF displayed favorable results in intraoperative parameters, such as reduced blood loss and shorter operative times, it did not significantly differ in patient-reported outcomes and radiographic assessments compared to OLIF-PF. Interpretation of findings must consider limitations in sample sizes and study heterogeneity. Future investigations with larger, more diverse cohorts and extended follow-ups are imperative to confirm these preliminary findings and comprehend the actual clinical impact of these OLIF techniques in managing lumbar degenerative diseas.

BACKGROUNDː Transposition of the Great Arteries (TGA) is one of the most common types of congenital heart defects (CHD). Recent advances in computed tomography angiography (CTA) have helped in the detection of this condition. However, the scientific literature remains scarce with regards to a comparison between Iran and Pakistan, hence this study was conducted. METHODSː A cross-sectional study was conducted comparing patient cohorts from Pakistan and Iran. Patients diagnosed with CHD as confirmed by CTA, aged less than 18-year-old were included in this study. Data regarding demographics, nationality, and any CHDs was extracted via patient interviews which were further supplemented by screening of the hospital records. Data analysis was conducted using SPSS version 21 (Chicago, IL: IBM SPSS Statistics) where a p-value <0.05 was statistically significant. RESULTSː Levocardia was the most common cardiac axis in both of our populations (n=119, 70.0% for Pakistan and n=31, 100.0% for Iran). Ventricular septal defect (VSD) was noted in 154 (90.6%) and 15 (48.4%) of the patients from the Pakistani and Iranian cohort, respectively. Prevalence of patent ductus arteriosus (PDA) was found to be significantly associated between the populations with an increased odds of PDA observed in the Iranian population (n=27, 87.1%) compared to the Pakistani population (n=92, 54.1%) (p <0.001). CONCLUSIONSː Our study highlights an important association of PDA between Pakistan and Iran, with increased odds of PDA in the Iranian population. Moreover, the prevalence of various CHDs in both populations raises concerns that warrant investigation to study the possible contributory factors.

This book chapter presents a concise overview of SARS-CoV-2, the virus responsible for the COVID-19 pandemic. It explores viral classification based on morphology and nucleic acid composition with a focus on DNA and RNA viruses, the SARS-CoV-2 structure including the structural as well as nonstructural proteins in detail, and the viral replication mechanisms. The chapter then delves into the characteristics and diversity of coronaviruses, particularly SARS-CoV-2, highlighting its similarities with other beta-coronaviruses. The replication and transcription complex, RNA elongation, and capping, as well as the role of accessory proteins in viral replication and modulation of the host immune response is discussed extensively.

Objective: Vitamin D deficiency in Chronic Kidney Disease is a known fact, but the data regarding the prevalence and extent of vitamin D deficiency in different stages of Chronic Kidney Disease is scarce. This leads to a delay in addressing this issue. We conducted this study to assess vitamin-D deficiency in different stages of Chronic Kidney Disease to improve the evidence available to Physicians and Nephrologists which can help them better address this common finding in Chronic Kidney Disease. Methods: This retrospective study from a tertiary care hospital in Karachi, Pakistan, included adult Chronic Kidney Disease patients who had their serum 25 Hydroxy vitamin D levels done. The patients were classified according to stages of Chronic Kidney Disease using Estimated Glomerular Filtration Rate values. Appropriate statistical tests were performed to find a correlation between the severity of vitamin D deficiency in different stages of Chronic Kidney Disease with a statistically significant p value of <0.05 and a 95% confidence interval. Results: In total, 148 patients were included in the study. All patients had serum 25 Hydroxy vitamin D levels less than 30 ng/ml. The severity of vitamin D deficiency was observed to increase progressively from stage 3A Chronic Kidney Disease through stage 5. Vitamin D levels in Chronic Kidney Disease stage 3 were significantly greater than in Chronic Kidney Disease stages 4 and 5 ( p value < 0.001), and stage 5 patients had the lowest vitamin D levels in our study. Similar, statistically significant findings were observed for serum phosphate levels, too, with stage 5 Chronic Kidney Disease patients having a greater serum phosphate concentration than stages 3A and 3B ( p value = 0.002, 0.006). Conclusion: All Chronic Kidney Disease patients in our study either had vitamin D insufficiency or deficiency. In addition, we observed a significant decrease in vitamin D levels from Chronic Kidney Disease stage 3 to stage 5. Greater serum phosphate levels were detected in stage 5 compared to stages 3A and 3B.

Introduction: Benzodiazepines are a class of sedative-hypnotic drugs often used by people suffering from anxiety, sleep disorders, stress reactions, panic disorders, obsessive-compulsive disorders, and mania due to their anticonvulsant, anxiolytic, and muscle relaxant properties [1,2]. Between the year 1996 to 2013, the percentage of US adults filling benzodiazepine prescriptions rose from 8.1 million to 13.5 million (67% increase), and the cumulative quantity of benzodiazepines served over the years surged by 140% [3]. However, this rise in treatment using benzodiazepines heavily contributed to an increase in the number of cases of benzodiazepine overdose-related deaths, from 0.58 to 3.07 per 100,000 adults. This value soon reached a plateau in early 2010 but continued to increase among the elderly and the Hispanic and African American communities [3]. It is worth noting that nearly 75% of these deaths were not caused by benzodiazepines alone but by the added effects of alcohol, opioids, or amphetamines [3].In mention to its relation with age, the use and misuse of benzodiazepines vary, with individuals between the ages of 50 to 64 years having the highest prescription-based use, whereas young adults of ages 18 to 25 years presented with the highest statistics for non-prescription based use, highlighting the misuse and abuse of benzodiazepines, according to a study conducted in the United States [4].Overdoses induced by benzodiazepines rarely present as an emergency and are often aggravated further by additional ingestion of other drugs [5]. In people with long-term benzodiazepine use, immediate retirement from the drug may induce a severe withdrawal syndrome, resulting in anxiety, confusion, sleep disorders, and in extreme cases, seizures [6]. The most widely used benzodiazepine, Alprazolam, has much greater side effects from withdrawal, including mania, psychosis, delirium, and hyperadrenergic states [7]. Furthermore, tapering of benzodiazepines has been linked to Takotsubo cardiomyopathy [8].This article reports a case regarding a Pakistani patient with no previous history of drug abuse that voluntarily overdosed on benzodiazepines (Alprazolam) alone and was later diagnosed with hypoxic-ischemic (anoxic) encephalopathy.Case Presentation:A 32-year-old Pakistani male was presented to the emergency department in an unconscious and gasping condition. His mother had found him in an unresponsive, comatose state. The patient had a history of epilepsy, anxiety, and depression. The remainder of his past medical history was unremarkable, and any admissions made during childhood had no recrudesce in adulthood.At the emergency department, the patient suffered multiple seizure episodes, and remained unconscious, maintaining a GCS of 3/15. Upon physical examination, unresponsive bilateral pinpoint pupils were noted; the neck of the patient was found to be supple, and the bilateral plantar reflexes were normal, suggesting active involuntary movement. His abdomen was soft and nontender, and his chest was found to be unremarkable.On the first day of admission, a complete blood count revealed a low hemoglobin count of 12.9 g/dl, leukocytosis (white blood cell count of 14.0 x 10^9/L), neutrophilia (neutrophil at 93%), hyperglycemia (glucose concentration at 93 mg/dl) and hyperproteinemia (proteins: 66.1 mg/dl), while displaying a minor decrease in the hematocrit levels. The test for plasma lactate levels was normal, resting at 15.5; however, lactate dehydrogenase levels produced a low result of 21 U/L (the normal range is 135 – 225 U/L). The above-mentioned laboratory investigations have been summarized in Table 1. Arterial blood gases revealed high anion gap metabolic acidosis. On the second day of admission, a urine test revealed a positive result for benzodiazepine overdose (>200 ng/ml) while testing negative for amphetamines, cannabinoids, barbiturates, and cocaine metabolites, as mentioned in Table 2. Enzyme-linked immunosorbent assay for human immunodeficiency virus (HIV) antibodies and tests for the presence of Hepatitis B and C virus revealed negative results. The gram stain showed no organisms. On the fifth day, a test for C-reactive protein (CRP) revealed a CRP of 15.62 mg/l (normal range is less than 6), suggesting the presence of an inflammation reaction. His respiratory examination displayed acute hypercapnic respiratory failure (type II).A CT scan, which was also conducted on the first day, revealed no intraparenchymal hemorrhage, cerebral edema, or midline shift. Grey and white matter differentiation were intact, and the basal ganglia and thalami showed normal density. This was viewed through multiple axial images obtained from the base up to the vertex of the skull without intravascular contrast.Initial treatment for hypercapnic respiratory failure and seizures was initiated, as these were the presenting symptoms when our patient had arrived in the ER. He was intubated, aided by a pressure-synchronized intermittent mandatory ventilation (P-SIMV) mode ventilator, and transferred to the ICU for intensive care and monitoring. The patient was administered anti-inflammatory glucocorticoids, intravenous lactam antibiotics (meropenem, and tazobactam with piperacillin), levetiracetam for the treatment of seizures, and half normal saline with 2 amps of KCL at 75 ml/hr via a nasogastric tube as an immediate course of treatment.On the third day, the patient had self-extubated but maintained an oxygen saturation of 99% and was supplied with 5 L/min oxygen via facemask at a respiratory rate of 22/min. The patient’s GCS topped 15/15, and reintubation was considered unnecessary. The patient was drowsy, but was physically responsive and fully capable of conversing with the consultant. On this day the patient was diagnosed with benzodiazepine poisoning. The patient admitted to intentionally overdosing on Alprazolam, a type of benzodiazepine, with suicidal intentions, despite not having any history of using the drug or any other illicit substances previously. He was later diagnosed with major depressive disorder by the neurologist that overlooked the case.Further in regards to the patient’s condition, anion gaps returned to normal, and no further seizures occurred. The patient remained fatigued, but mobilization out of bed was prescribed. The patient had a physiotherapy session in which chest physiotherapy was conducted. The patient was kept in an ICU setting for another day before being transferred to a normal monitoring setup.In regards to the radiological tests taken following the initial CT scan, an echocardiography, electroencephalography (EEG) and a general abdomen ultrasound were taken on the third day. Echocardiography revealed atypical septal motion and an ejection fraction of 55%; however, all other findings were normal, with an absence of thrombi or pericardial effusions. EEG reported fast beta activity of 15-18 Hz in the background rhythm and muscle stiffness due to ventilation; however, photic stimulation was normal, and no focal or generalized epileptic discharges were noted. Since idiopathic epilepsy appears normal on an interictal EEG, the technician had advised that a diagnosis be made after clinical correlation. The abdominal ultrasound showed a slightly altered texture with raised echogenicity of the liver; however, the rest of the abdomen was unremarkable. On the fifth and sixth days of admission, a brain MRV/DWI and MRA were conducted to accurately view the condition of the brain. MRA revealed a comparatively attenuated right vertebral artery with normal hyperintensity within the right and left vertebral, basilar, and bilateral posterior cerebral arteries. No evidence of stenosis or abnormal dilation of the hyperintense arteries was seen. The MRV presented evidence of bilateral symmetrical abnormal signal intensity areas seen in the basal ganglia, predominantly in the globus pallidus, which appears hyperintense on T2/FLAIR images while showing restriction on the DWI images. The superior sagittal, inferior sagittal, transverse, and straight sinuses appeared unremarkable, and no venous segment filling was detected to show signs of thrombosis. Another MRV, which was taken 24 hours after the first one, presented the Dural sinuses as normal. The MRI, MRA, and MRV imaging, with DWI protocol, demonstrates ischemic hypoxic insult involving bilateral globus pallidus, which was later understood to be linked to the benzodiazepine intoxication.Upon gaining consciousness, the patient admitted to intentionally overdosing on Alprazolam with suicidal intentions, despite not having any history of using the drug or any other illicit substances previously. He was later diagnosed with major depressive disorder by the neurologist that overlooked the case.On the final day, the patient possessed the following vitals: blood pressure of 130/80, a pulse of 76/min, respiratory rate of 21/min, and oxygen saturation of 99% in the absence of oxygen support. The abdomen, respiratory and cardiovascular examinations were completely normal. The patient had fully gained consciousness, was well-oriented in time, place, and person, and held a GCS of 15/15, with an attenuated right vertebral artery under CNS findings. He was discharged after staying at the hospital for 6 days and was instructed to return for a follow-up after 1 week.During the follow-up, the patient presented with no cognitive deterioration and was completely responsive and healthy. The patient presented with no personality changes and sustained a GCS of 15/15.

About 40% of the people with the obsessive-compulsive-disorder do not experience the desired outcome after the existing treatment, and its several side effects were reported. This systematic review was conducted to evaluate the efficacy and tolerability of alternative drugs and assess the possibility of their use as treatment options for obsessive-compulsive-disorder. The Scientific databases PubMed, Science Direct, Google Scholar, Cochrane, Directory of Open Access Journals, MedRxiv and BioRxiv, were searched from inception to March 2022, using appropriate search strategies for each drug and following the Prisma guidelines 2020. Studies were selected according to the already set criteria and assessed for bias. Data were extracted, and descriptive and continuous data were analyzed and presented as frequency/percentage and mean. A total of 16 observational and interventional studies were included for data extraction. The studies focused on four drugs, Psilocybin (n=4), Cannabis (n=7), Nicotine (n=3), and Morphine (n=2), that were used to test out their effect on OCD symptoms. Overall, the majority of the studies showed promising results by documenting a reduction in Y-BOCS scores. However, few subjects, specifically those using nicotine or Cannabis, did not affect their condition or self-reported worsening symptoms. Few side effects were also noticed. This systematic review found that the drugs mostly showed a positive response. All Psilocybin and morphine users, 88.2% and 74.1% of the nicotine and Cannabis users, respectively, reported experiencing the positive effect of these drugs, indicating that these drugs have the potential to be used in the management of OCD. However, further research is required in this arena to thoroughly understand the mechanism of action by which these drugs produce their therapeutic effect. Policies to destigmatize and encourage clinical trials with these drugs are crucial for exploring the use of these drugs as a treatment option for OCD.

Glioblastomas (GBM) are the most prevalent malignant CNS tumors globally, affecting about 3.19 per 100,000 people. The standard of care of GBM management includes surgical resection followed by radiotherapy and/or chemotherapy owing to the high recurrent rates. Despite the advances in neurosurgical practice and brain cancer research, low- and middle-income countries (LMICs) did not benefit greatly from these advances compared to high-income countries (HICs). First, the case ascertainment is low in LMICs, which contributes to a lower than actual disease burden and delayed presentation of the tumors with a worse prognosis. Second, GBM treatment is expensive; unregulated radiation and chemotherapy costs can expose the patients to financial hardships and lead to treatment discontinuation. Third, the lack of trained neurosurgical workforce in poor resource settings in LMICs further complicates the situation. Fourth, radiation therapy and chemotherapies are expensive and unavailable in many poor-resource settings in LMICs. Fifth, LMICs suffer from a weak infrastructure especially with low numbers of prepared ORs, laboratories, and advanced imaging techniques. In the present article, we highlight the major challenges of GBM management and further propose solutions for governments and health policy makers to improve GBM care in LMICs.

Proboscis lateralis (PL) is an uncommon congenital facial deformity marked by the protrusion of a primitive tubular structure made up of skin and soft tissue that generally emerges from the eye's medial canthus and is associated with some craniofacial deformities. We report the first case of PL with multiple craniofacial, neurological, cardiac, and spinal anomalies. A full-term female baby delivered by cesarean section cried immediately at birth. The mother reported having a normal pregnancy but has a history of x-ray during her first trimester. The baby was born with a rare presentation of proboscis lateralis which was accompanied by multiple anomalies, including but not limited to bilateral colpocephaly, corpus callosum agenesis, complex cyanotic congenital heart disease, and hemivertebra of the T10 body. PL is an uncommon congenital condition that causes a variety of craniofacial abnormalities. Multiple additional defects affecting various organ systems should also be evaluated in a person diagnosed with PL.

BACKGROUND:Intramedullary spinal cord ependymomas (IMSCEs) are rare tumors that mostly occur in adults. Management strategies and related outcomes are heterogeneously reported across the literature, demanding a comprehensive analysis to standardize guidelines. We performed a systematic review of the literature on IMSCEs.METHODS:A literature search was conducted using 6 databases from inception up to July 28, 2022. Studies with data on clinical characteristics, management strategies, and related outcomes in adult patients with histopathologically confirmed IMSCEs were pooled and analyzed.RESULTS:The analysis included 69 studies comprising 457 patients (52.7% males). Mean age was 42.4 ± 7.4 years. Sensory deficit (58.0%) was the most prevalent symptom, followed by radicular pain (50.5%). Tumors mostly involved the cervical (64.4%) or thoracic (18.8%) spinal cord and were mostly World Health Organization grade II (80.5%) and classic subtype (72.4%). Gross total resection was performed in most cases (83.4%), with adjuvant radiotherapy delivered in 10.5% of cases. Progression-free survival ≥2 years was reported in 61.1% of cases, and tumor recurrence or progression was reported in only 7.0% of the patients. At last follow-up, 97.4% of patients were alive.CONCLUSIONS:IMSCEs are uncommon tumors that frequently manifest with debilitating symptoms that require surgical treatment. When feasible, gross total resection may be pursued to improve the patient's functional status and prevent tumor progression, with adjuvant radiotherapy required only in some more aggressive grade III lesions. Future studies should investigate different growth patterns and prognoses based on different IMSCE subtypes.

Objectives:Multifocal fibrosclerosis is a rare disorder causing progressive fibrosis of multiple organ systems. Existing data on the disease show that there are multiple manifestations of the disease, with different outcomes. However, quantitative data are scarce, prompting the need for our investigation. Method:A comprehensive systematic review was performed from inception to November 16, 2022, with the restriction of English language, not including review articles. Article screening and extraction was performed independently, and shortlisted articles were assessed for bias. Analysis was performed using SPSS Version 25 (IBM® SPSS® Statistics; Chicago, IL, USA). Data were presented as frequencies and percentages, with a confidence interval of 95%. Result:This review included 134 patients, with 78 (58.2%) males. Mean age was 53.6 years and included two pediatric patients. The most common comorbidity was diabetes (9.7%). Prevalent presenting symptoms included pain (47.8%) and swelling (35.1%). A mean of 2.51 organs or anatomical sites was affected, retroperitoneum (64.2%) being most affected. The pancreas (30.0%) and digestive system (47.0%) were the organs/organ systems most affected. Patients had favorable outcomes in 79.1% of cases, 87.3% had no relapse, and 91.8% of patients survived the condition. Conclusion:The findings in this study provide a quantitative measurement of the demographics, presentations, organ manifestations, and outcomes of multifocal fibrosclerosis. We found the disease to be prevalent in males in Japan or the United States, with the abdomen and its organs being commonly involved.

Introduction: The renal system manifestations of coronavirus disease-2019 have been documented extensively; however, scientific literature remains scarce regarding collapsing glomerulopathy hence the need for this investigation. Methods: A comprehensive review was conducted covering a timeline from 1 January 2020 to 5 February 2022 without any restrictions. The data extraction was conducted independently, and articles were assessed for the risk of bias. Data analysis was conducted using Comprehensive Meta-Analysis version 3.3.070 and RevMan version 5.4 for pooled proportions and risk ratio (RR) between dialysis-dependent and independent treatment groups with a P-value less than 0.05 considered significant. Results: A total of 38 studies were included in this review, including 74 (65.9%) males. The mean age was 54.2 years old. The most common symptoms reported were related to the respiratory system (59.6%, 95% CI: 50.4–68.2%) and hematuria (34.2%, 95% CI: 26.1–43.4). Antibiotics (25.9%, 95% CI: 12.9–45.3%) was the commonest management used. Proteinuria was the most reported laboratory finding at 89.5% (95% CI: 82.4–93.9%), while the commonest microscopic finding was acute tubular injury (77.2%, 95% CI: 68.6–84.0%). An increased risk of the presence of symptoms (P=0.005) and microscopic findings (P=0.0003) related to collapsing glomerulopathy in dialysis-dependent group was noted with increased management (P=0.01) used in this group for coronavirus disease-2019 infection. Conclusion: The findings of this study portray the prognostic value of the variables (symptoms and microscopic findings, etc.) reported in the analysis. Hence this study serves as a foundation for future investigations that minimize the study’s limitations to provide a more robust conclusion.

AbstractBackgroundAwareness of rights is a precondition to establishing rule of law in society. Sexual and Reproductive Health and Rights (SRHR) are closely knitted in the human rights framework as they overlap with other human rights such as the right to health and life. However, awareness about these rights remains a challenge. Considering the importance of these rights this study has measured the awareness of adolescents about SRHR in Bahawalpur (Division) of Pakistan.MethodologyWe conducted a cross‐sectional study in the Divison of Bahawalpur, Pakistan from October 2019 to December 2019. The study included a sample size of 500 respondents which included 250 young females of age 15–19 and 250 their parents (mother). The reasoning behind including only females in this study was the increased vulnerability and greater impact of SRHR in their life compared to males. The age range 15–19 was primarily selected as females this age will better understand and respond to the questionnaire compared to females in their early adolescent years. The quantitative research was conducted using two‐stage cluster sampling. Detailed structured questionnaires were distributed among the respondents to obtain their points of view on the awareness of SRHR. The population was divided into multi‐clusters with 25 households comprising 250 households for the division of Bahawalpur. The information was also gathered from the doctors and the teachers through interviews. The data were analyzed using SPSS version 21.ResultsThe study explored the knowledge and understanding of adolescent SRHR thereby highlighting the key restrictions in Bahawalpur, Pakistan, which prohibit adolescents from gaining access to SRHR and exercising it. There is a significant portion of adolescents who strongly agreed with the importance and awareness level and think they should be more aware of information regarding SRHR. However, they are of the view that they are less independent in practicing them.ConclusionThe study found a low level of awareness about SRHR among young female and their parents in Bahawalpur, Pakistan. It is a need of time and responsibility of the local government of the Bahawalpur region to devise clear and proper policies which give access to these rights. This can be done by including the information on these rights in the course curriculum and teachers keeping in view the cultural and regional restrictions that guide the young female about SRHR.

BACKGROUND:After introducing Covid-19 vaccines, a few side effects were reported, pityriasis rosea being one of them. Therefore, this study will systematically review its manifestation afteradministration. METHODS:Databases were searched, covering a timeline from December 1, 2019 to February 28, 2022. Data were independently extracted and accessed for bias. SPSS statistical software version 25 was used for appropriate inferential statistics. RESULTS:Thirty-one studies were included for data extraction after screening following the eligibility criteria. A total of 111 people were identified to have developed pityriasis rosea or pityriasis rosea-like eruptions after vaccination, out of which 36 (55.38%) were female. The average age of incidence was calculated to be 44.92 years, and 63 (62.37%) people presented after administration of the first dose. It was found popularly in the trunk area, either asymptomatically or with mild symptoms. Meantime the onset, was 8.58 days, and meantime it took to recover, was 6.44 weeks. CONCLUSION:The association between pityriasis rosea and pityriasis rosea-like eruptions after Covid-19 vaccines was established, but given the scarcity of studies, there is a need to conduct different clinical trials to confirm this association further and study the etiology and mechanism of the disease.

The embryonal subtype of rhabdomyosarcoma is the most frequent, commonly seen in children. However, it is uncommon to discover this subtype in adults, especially in the larynx. We presented a rare case of a 63 years old man who presented with worsening hoarseness, dysphagia for solids, and dyspnea and was later diagnosed with embryonal rhabdomyosarcoma of the larynx.

Objectives Paediatric cancer is a leading cause of death for children. Children in low-income and middle-income countries (LMICs) were four times more likely to die than children in high-income countries (HICs). This study aimed to test the hypothesis that the COVID-19 pandemic had affected the delivery of healthcare services worldwide, and exacerbated the disparity in paediatric cancer outcomes between LMICs and HICs. Design A multicentre, international, collaborative cohort study. Setting 91 hospitals and cancer centres in 39 countries providing cancer treatment to paediatric patients between March and December 2020. Participants Patients were included if they were under the age of 18 years, and newly diagnosed with or undergoing active cancer treatment for Acute lymphoblastic leukaemia, non-Hodgkin’s lymphoma, Hodgkin lymphoma, Wilms’ tumour, sarcoma, retinoblastoma, gliomas, medulloblastomas or neuroblastomas, in keeping with the WHO Global Initiative for Childhood Cancer. Main outcome measure All-cause mortality at 30 days and 90 days. Results 1660 patients were recruited. 219 children had changes to their treatment due to the pandemic. Patients in LMICs were primarily affected (n=182/219, 83.1%). Relative to patients with paediatric cancer in HICs, patients with paediatric cancer in LMICs had 12.1 (95% CI 2.93 to 50.3) and 7.9 (95% CI 3.2 to 19.7) times the odds of death at 30 days and 90 days, respectively, after presentation during the COVID-19 pandemic (p<0.001). After adjusting for confounders, patients with paediatric cancer in LMICs had 15.6 (95% CI 3.7 to 65.8) times the odds of death at 30 days (p<0.001). Conclusions The COVID-19 pandemic has affected paediatric oncology service provision. It has disproportionately affected patients in LMICs, highlighting and compounding existing disparities in healthcare systems globally that need addressing urgently. However, many patients with paediatric cancer continued to receive their normal standard of care. This speaks to the adaptability and resilience of healthcare systems and healthcare workers globally.

OBJECTIVE:Coronavirus disease 2019 is caused by severe acute respiratory syndrome coronavirus-2. The coronavirus disease 2019 pandemic has imparted an extraordinary burden on the intensive care services, which is likely to echo in pandemic and critical care management glob- ally. We aim to meta-analyze mortality outcomes in cardiovascular disease patients and groups receiving corticosteroids therapy, intensive care admission status during coronavirus disease 2019 hospitalization and groups receiving corticosteroid therapy, and lastly, mortality outcomes in mechanically ventilated patients. Finally, we collate a coronavirus disease 2019 field algorithm for ST-elevation myocardial infarction critical care. METHODS:PubMed databases were searched for relevant observational studies with MeSH terms including, "cardiovascular disease," "COVID-19," "intensive care," "mortality," and "mechanical ventilation." A random-effect model was used to calculate the risk ratio, using RevMan V5.3. RESULTS:A total of 67 622 patients were included with 10 076 participants in the cardiovascular disease group. Overall, the mean age of the participants in the studies was 60 ± 1.6 years and 52.1% were female. A higher death risk was found in cardiovascular disease patients during and after coronavirus disease 2019 infection (risk ratio = 2.43, 95% CI = 1.74 to 3.41, P < .0001). Mechanical ventilation was likened to worsen mortality rates at any time during the hospital stay (risk ratio = 5.32, 95% CI = 3.89 to 7.29, P < .0001). Publication bias was not observed and high methodological qualities were included. CONCLUSIONS:Cardiovascular disease imparts a high burden on intensive care leading to high mortality among coronavirus disease 2019 patients. It is essential that myocardial infarctions in the acute care setting, and conditions such as hypertension and coronary artery diseases, are closely monitored while leading coronavirus disease 2019 hospitalization protocols.

Abstract Rationale: Expanded dengue syndrome (EDS) is the phenomenon coined by the World Health Organization for cases of dengue fever (DF) with rare but dangerous consequences. EDS mainly leads to complications involving the vital organs, thus is also associated with a higher mortality rate. This case report presents the first-ever case where a patient developed EDS with both rhabdomyolysis-induced acute kidney injury and compartment syndrome of the limbs. Patient concerns: Our patient, an 18-year-old Pakistani male, presented with fever, colicky abdominal pain, vomiting, diarrhea, dark-colored urine, and oliguria. Diagnoses: Dengue rapid NS-1 test came back positive. Along with myoglobinuria both serum creatine phosphokinase and creatine levels were abnormal. Hence, the patient was diagnosed with rhabdomyolysis-induced acute kidney injury. On physical examination, his right arm was painful and tender with restricted movement at the elbow. A Doppler ultrasound of the arm revealed thickening of the skin and underlying muscles, as well as edematous abnormalities affecting the entire right upper limb, both of which are indications of compartment syndrome. Interventions and outcome: The management included rehydration, administration of dextrose and bicarbonate (bicarbonate infusion) prepared by adding 150 mEq sodium bicarbonate in 850 mL dextrose 5%, pain killers, along with platelet, and packed red cell transfusions. Additionally, right upper limb was kept elevated at 90° for 30 minutes every 2 hours to reduce edema and crept bandages were applied. The patient was discharged after 11 days and the follow-up was uneventful. Lesson: Physicians should be aware that rhabdomyolysis-induced acute kidney damage and limb compartment syndrome are also possible DF consequences, and they should be on the lookout for any indications pointing to these complications in DF. A prompt diagnosis can prevent further complications and fatality.

Background: Pediatric Cardiac Intensive Care Units (PCICU) stays have been associated with adverse outcomes as documented in the literature. However, data remain scarce on the factors which influence the length of such stays in the developing world. Objective: To find out predictors of short versus prolonged PCICU stay after primary repair of tetralogy of Fallot (ToF). Methods: A prospective study was conducted at the Department of Pediatric Cardiology, National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan, from March 2021 to August 2021. A total of 93 patients of any age undergoing primary ToF repair were included. Patients having a PCICU stay < 48 h were labeled as short PCICU stay, while those with a PCICU stay & GE;48 h were termed as prolonged PCICU stay. Multivariate binary logistic regression analysis was performed to identify factors predicting prolonged PCICU stay. Results: Overall, the mean age was noted to be 10.75 +/- 4.54 years. The mean duration of PCICU was calculated to be 74.1 +/- 50.2 h (Range: 24-340 h). There were 57 (61.3%) patients with prolonged PCICU, while 36 (38.7%) had a short duration of PCICU stay. In multivariate binary logistic regression analysis, significantly low SpO(2) at the time of presentation, intraoperative tricuspid regurgitation, high postoperative inotropic score, postoperative pulmonary embolism, and postoperative bleeding from a wound were found to be significant predictors of prolonged PCICU stay after primary repair of ToF. Conclusions: The findings of this study are paramount given the identification of factors associated with the prolonged stay, which will help in the future prediction of the prognosis of treated patients.