The interplay between diabetes and non-alcoholic fatty liver disease: a cross-sectional study from Pakistan

Background and objectives

Non-alcoholic fatty liver disease (NAFLD) is characterized by ectopic deposition of fat in the liver, in the absence of other secondary causes of fat buildup. The relationship between NAFLD, including alanine aminotransferase (ALT), and glycated haemoglobin (HbA1c), is important for predicting the severity of disease and prognosis. This study aims to investigate the association of HbA1c in type 2 diabetes mellitus (T2DM) patients with NAFLD via measuring the ALT levels.

Materials and methods

This retrospective cross-sectional study enroled 130 patients with T2DM and NAFLD. The association between levels of HbA1c and ALT in patients of NAFLD with controlled and uncontrolled T2DM, respectively, was investigated. Stratification was done based on gender and diabetic control, using HbA1c levels as a marker of glycemic control. Serum ALT levels were also compared in both groups.

Results

The mean age of the participants was 50.2±5.7 years. The total participants were 130, of which 77 (59.3%) were females and 53 (40.7%) were males. The numbers of patients having uncontrolled T2DM (HbA1c>7%), and controlled T2DM (HbA1c <7%) were 78 (60%) and 52 (40%), respectively. Moreover, 46 (35.3%) females and 32 (24.7%) males had uncontrolled T2DM, and 31 (23.8%) females and 21 (16.2%) males had controlled T2DM. The mean ALT level for uncontrolled and controlled T2DM in female patients was found to be 24.6±3.4 and 13.5±2.4, respectively, (P <0.05). For male patients, it was found to be 54.0±4.9 and 29.1±5.4, respectively (P=0.008).

Conclusion

There is a positive association between elevated HbA1c and ALT levels in T2DM patients with NAFLD.

Digital eye strain and its associated factors among radiology physicians in Pakistan: a cross-sectional survey using logistic regression analysis

Background and aims

Increased use of digital devices in the modern era has led to the development of digital eye strain (DES) or computer vision syndrome in their users. This can result in the development of various ocular and visual symptoms among them. In this study, the authors aimed to view the prevalence of digital eye strain among radiology physicians in Pakistan and their associated risk factors.

Materials and methods

A cross-sectional study was conducted to evaluate occupational DES among radiology physicians in Pakistan. The data collection was done using the convenience sampling technique, and the data were analyzed using IBM SPSS for Windows, Version 25.0.

Results

Out of the 247 respondents, 33.6% were males and 66.4% were females. 41.7% of them were between 30 and 40 years of age and 51.8% of them were radiology residents. 52.2% of the participants had a refractive error and were using a corrective lens. The majority of the radiologists in our study (84.2%) preferred picture archiving and communication system (PACS) over films and 82.2% of them reported having breaks of less than 15 min. Major symptoms reported by the participants were tired or heavy eyes (69.6%) and headache (69.3%). The proportion of developing DES was higher in females [P=0.001, adjusted odds ratio (aOR)=2.94], radiology residents (P=0.031, aOR=3.29), and working hours of more than 4 h per day (P<0.001, aOR=0.04).

Conclusion

With recent advances in the field of radiology in Pakistan, the frequency of developing DES among radiologists is increasing. Being a female, having long working hours, and having noticeable flickers on the digital screens were among the significant factors in developing DES among radiologists.

Cardiac contractility modulation: A new horizon in the management of heart failure with preserved ejection fraction (HFpEF)

Cardiac contractility modulation (CCM) is a new therapy that has shown promising results in heart failure with preserved ejection fraction (HFpEF) management. This therapy involves the use of a device that delivers electrical signals to the heart during the refractory period, enhancing cardiac contractility without changing heart rate or rhythm. This short article explores the potential of CCM as a new horizon in the management of HFpEF, highlighting its mechanism of action, clinical trials, and future directions for research. Overall, CCM has emerged as a promising therapy for improving the outcomes of patients with HFpEF and provides hope for the development of more effective treatments in the future.

Diabetes mellitus: Is Pakistan the epicenter of the next pandemic?

Estimated age-adjusted comparative diabetes prevalence in adults (20-79 years) in Pakistan from the year 2011 to 2021.

Molecular Targets of Valeric Acid: A Bioactive Natural Product for Endocrine, Metabolic, and Immunological Disorders

BACKGROUNDS

Postbiotics produced by gut microbiota have exhibited diverse pharmacological activities. Valeric acid, a postbiotic material produced by gut microbiota and some plant species like valerian, has been explored to have diverse pharmacological activities.

METHODS

This narrative review aims to summarise the beneficial role of valeric acid for different health conditions along with its underlying mechanism. In order to get ample scientific evidence, various databases like Science Direct, PubMed, Scopus, Google Scholar and Google were exhaustively explored to collect relevant information. Collected data were arranged and analyzed to reach meaningful a conclusion regarding the bioactivity profiling of valeric acid, its mechanism, and future prospects.

RESULTS

Valeric acid belongs to short-chain fatty acids (SCFAs) compounds like acetate, propionate, butyrate, pentanoic (valeric) acid, and hexanoic (caproic) acid. Valeric acid has been identified as one of the potent histone deacetylase (HDAC) inhibitors. In different preclinical in -vitro and in-vivo studies, valeric acid has been found to have anti-cancer, anti-diabetic, antihypertensive, anti-inflammatory, and immunomodulatory activity and affects molecular pathways of different diseases like Alzheimer's, Parkinson's, and epilepsy.

CONCLUSION

These findings highlight the role of valeric acid as a potential novel therapeutic agent for endocrine, metabolic and immunity-related health conditions, and it must be tested under clinical conditions to develop as a promising drug.

An Investigation of Contrast-Induced Acute Kidney Injury in Patients Undergoing Percutaneous Coronary Intervention: A Cross-Sectional Study From Pakistan

Background and objective Contrast-induced acute kidney injury (CIAKI) is a complication observed among individuals undergoing primary percutaneous coronary intervention (PCI) and is associated with high morbidity and mortality rates. It is characterized by an elevation in serum creatinine (SCr) levels >0.5 mg/dl or a 50% relative increase in SCr from the baseline value following exposure to contrast within a 48- to 72-hour timeframe, in the absence of any alternative causes for acute kidney injury (AKI). This study aimed to assess the incidence of CIAKI in patients following PCI. Methods This prospective study was conducted from July to December 2022, after obtaining ethical approval from the institutional ethics committee (reference no: 147/LRH/MTI). A total of 159 consecutive patients who met the selection criteria were enrolled. A detailed patient and family history was obtained, and a thorough physical examination was conducted. Baseline tests, including SCr, were performed, with SCr repeated 72 hours post-PCI. All investigations were performed in the affiliated hospital's main laboratory and conducted by the same biochemist. Results The study included 159 patients presenting with myocardial infarction, angina pectoris, or ischemic features on EKG, exercise tolerance test (ETT), or echocardiogram and underwent PCI. The patients had a mean age of 51 ± 9 years, baseline SCr of 0.77 ± 0.41 mg/dl, SCr 72 hours post-procedure of 0.83 ± 0.41 mg/dl, and an average contrast volume of 128.6 ± 63 ml; 87 (55%) patients were male, and 72 (45%) were female. CIAKI was observed in 15 (9.4%) patients. Hypertension and diabetes mellitus were the most prevalent comorbidities. Male gender, diabetes mellitus, and hypertension had a clinically significant association with the development of CIAKI (p<0.05). ST-elevation myocardial infarction (STEMI) was the predominant clinical presentation in 81 (50.9%) cases. Conclusions This study examines the frequency, risk factors, and associations of CIAKI following PCI at a tertiary care hospital in a low-middle-income country. We believe our findings provide future directions for identifying and minimizing the risk of CIAKI in this patient population.

Brain herniation and subsequent complications following partial resection of high-grade glioma: A case report

Key Clinical Message

This case highlights the need for tailored strategies to address issues like brain herniation, subdural hygroma, and cerebrospinal fluid leak, which, if not managed promptly, can lead to long-term neurological deficits. Additionally, the role of specialized facilities in delivering highly specialized care for managing such intricate cases cannot be understated.

Abstract

Decompressive craniectomy-induced subdural hygroma (SDH) frequently coexists with external cerebral herniation, resulting in neurological impairments. The incidence of brain herniation through a craniectomy defect postoperatively is 25%. Brain herniation (BH), SDH, and cerebrospinal fluid leak require urgent neurosurgical management as they can lead to irreversible long-term neurological deficits. We report a case of a 42-year-old male who presented with headache and grand mal seizures. He was diagnosed with herniation of brain parenchyma through the surgical defect with a displacement of the bone flap by a heterogeneously enhancing lesion in the left parietal lobe along with SDH in the left frontoparietal region post partial resection of high-grade glioma. In this report, we discuss the pathogenesis and management strategies of brain herniation, wound infection, cerebrospinal fluid (CSF) leak, ipsilateral SDH, floating bone flap, and communicating hydrocephalus in an adult patient following partial resection of high-grade glioma. This particular case emphasizes the value of an individualized patient-centered surgical approach to minimize the risk of postoperative complications.

Alterations in certain immunological parameters in the skin mucus of the carp, Cirrhinus mrigala, infected with the bacteria, Edwardsiella tarda

The bacterial fish pathogen Edwardsiella tarda causes heavy stock mortality, severely hampering fish production, resulting in great economic loss to the farming industry. The first biological barriers that confer immune protection against pathogen entry are the fish mucosal surfaces. The present study was undertaken to investigate the influence of E. tarda on certain enzymatic and non-enzymatic parameters in the skin mucous secretions of the fish Cirrhinus mrigala using spectrophotometry and zymography. Fish were randomly divided into three groups: control, vehicle control, and infected. A sublethal dose of E. tarda (2.2 × 106 CFU/fish) suspended in 50 μL of PBS was injected intra-peritoneally at 0 day (d). Subsequently, mucus samples were collected at 2 d, 4 d, 6 d and 8 d post-infection. The activities of lysozyme (LYZ), protease (PROT), alkaline phosphatase (ALP), acid phosphatase (ACP), catalase (CAT), peroxidase (PER), superoxide dismutase (SOD), and glutathione S-transferase (GST) decreased significantly in the skin mucus of the challenged fish, indicating the suppressed immune system and decreased antioxidant capacity of C. mrigala to E. tarda infection. Lipid peroxidation (LPO) and total nitrate-nitrite were significantly higher at several time points post-infection, suggesting that physiological functions have been impaired following pathogen challenge. The present findings could be relevant for fish aquaculture and underline the importance of skin mucus not only for assessing fish immune status but also for identifying early warning signals of disease caused by pathogens.

Clinical Utility of S.T.O.N.E, Guy's Scoring System, and Renal Stone Complexity Scoring in Predicting Outcome of Single-Tract Percutaneous Nephrolithotomy

BACKGROUND

Several imaging-based scores have been developed to predict postoperative stone-free state (SFS) and complications. This study aimed to assess the accuracy of the S.T.O.N.E., Guy Scoring System (GSS), and Seoul National University Renal Stone Complexity (S-ReSCS) scores in predicting the outcomes of single-tract percutaneous nephrolithotomy (ST-PCNL). This scoring system holds paramount importance for low-income and low-middle-income countries (LMICs), as it is inexpensive and cost-effective for the healthcare system.

METHODOLOGY

This retrospective study was carried out with 147 participants. Based on the preoperative computerized tomographic (CT) scan, each patient's S.T.O.N.E. score, GSS, and S-ReSCS were recorded. The modified Clavien grading system was used to document intra- and postoperative complications.

RESULTS

The mean age of the sample population was 45 years. SFS was achieved in 110 (74.8%) patients. The number of calyces involved (p = 0.008), S.T.O.N.E. scoring (p = 0.001), GSS (p = 0.008), and S-ReSCS (0.001) correlated well with the SFS. Forty-nine (33.33%) patients developed complications. The most common complications fell within Clavien grade II. No statistical significance was noted between the S.T.O.N.E. score, GSS, and S-ReSCS with the modified Clavien grading system.

CONCLUSION

The S.T.O.N.E. scoring, GSS, and S-ReSCS have a high predictive value for achieving SFS in ST-PCNL. In addition, findings from LMICs are comparable with those from the rest of the world.

The tendency of segmental distribution of hepatic metastasis according to couinaud classification: a comparison of portal versus systemic route of metastatis due to primary colorectal and breast tumors

Objective

The liver is the commonest site of metastatic disease for patients with colorectal cancer (CRC), with at least 25% of patients developing liver metastasis (LM) during their illness. About 50% of patients diagnosed with metastatic breast cancer develop LM, and 5-12% of these patients develop LM as the main site of breast cancer recurrence. This study aims to determine the frequency of segmental distribution of LM seeding from portal versus systemic routes of dissemination due to primary CRC and breast carcinoma, respectively.

Material and methods

This retrospective study was conducted in a tertiary care teaching hospital in Pakistan. Ethical approval was taken from the institutional review board. A total of 587 patients were included in the study with 297 CRC patients with LM and 300 breast carcinoma patients with LM. Segment I involvement was excluded from the calculation because of the dual blood supply. Patients' detailed demographics and other information were collected on a predesigned proforma. The authors evaluated axial and multiplanar reformatted computed tomography images for LM and CRC metastasis. Data analysis was done using SPSS version 25. P value less than or equal to 0.05 was considered statistically significant.

Results

A study population of 587 patients was employed that comprised 287 CRC and 300 breast carcinoma patients. There were 179 (30.5%) male and 408 (69.5%) female patients. The mean age of patients was 54.9±13.3. The study revealed that 204 (34.8%) CRC patients showed right lobe (V, VI, VII, VIII) and 83 (14.1%) CRC patients showed left lobe involvement of metastasis while 192 (32.7%) breast carcinoma patients showed right lobe involvement and 108 (18.4%) breast carcinoma patients showed left lobe involvement in metastasis (P=0.02). We also found 40 (6.8%) colorectal and 55 (9.4%) breast carcinoma patients showed left lateral segment (II, III) involvement. Medial segment involvement (IV) was seen in 43 (7.3%) CRC patients and 53 (9%) breast carcinoma patients (P=0.03).

Conclusion

The right hepatic lobe is the predominant site of metastasis independent of the portal or systemic route of dissemination in primary carcinoma. Moreover, in left lobe metastasis medial segment (IV) is more affected in CRC while the lateral segment (II, III) is more affected in breast carcinoma.

Degradation of co-applied Atrazine and Fipronil in Phanerochaete Chrysosporium Augmented Biobeds

White rot fungi possess an enzymatic system that is non-specific to any pesticide and can be used for pesticide detoxification in biobeds. The present study evaluated potential of Phanerochaete chrysosporium to degrade co-applied atrazine and fipronil in ash or biochar biomixtures. Five biomixtures were prepared by partially replacing compost in rice straw-compost biomixture (BM) with 10% rice husk ash (RHA), 10% sugarcane bagasse ash (SBA), and 1 and 5% wheat straw biochar (WBC). Results suggested that after 30 days P. chrysosporium augmented biobeds resulted in 60.52-72.72% atrazine and 69.57-72.52% fipronil degradation. Hydroxyatrazine and fipronil sulfone were detected as the only metabolite of atrazine and fipronil, respectively, and were further degraded. Although, SBA significantly enhanced atrazine degradation, RHA or SBA had no significant effect on fipronil degradation. WBC (5%) slowed down degradation of both pesticides.

White Matter Stroke Masquerading as Subarachnoid Hemorrhage After High-Risk Percutaneous Coronary Intervention: A Case Report

Considering the context of percutaneous coronary artery angiography (PCI), stroke is a rare but severe complication and is associated with high morbidity and mortality. A computed tomography (CT) scan of the brain is an indispensable imaging modality to diagnose ischemic stroke changes following PCI. A 75-year-old female who presented with sudden onset chest pain was diagnosed with anterior-wall myocardial infarction which required primary PCI. However, an hour following the procedure, she suddenly developed drowsiness, confusion, and hemiparesis. Non-contrast CT showed hyperdense signals in posterior falx and tentorium cerebelli suggesting subarachnoid hemorrhage (SAH) as well as low attenuation signals in bilateral periventricular region suggestive of microvascular ischemic changes. It was critical to decide about the continuation of dual antiplatelet therapy (DAPT), aspirin and P2Y12 inhibitor, as soon as possible. Based on the clinical presentation and mixed picture on the CT scan, a second opinion was sought by a multidisciplinary team, which concluded that the findings were consistent with white matter stroke and DAPT was resumed. The hemiparesis improved gradually with the reversal of CT scan findings. There is a lack of reported literature about ischemic stroke and SAH following high-risk PCI and what should be the best approach in ambiguous cases. The management of white matter stroke and SAH is contrasting, particularly in deciding whether to continue the DAPT after PCI; hence it is critical to diagnose them promptly. Thus, this case highlights the importance of differentiating SAH from white matter stroke for prompt treatment of post-PCI complications to ensure positive outcomes.

Epidermal modifications in a hill stream catfish, Hara hara in relation to its natural habitat: A scanning electron microscope and histochemical investigation

In the present study, the epidermis of the hill stream fish Hara hara has been investigated employing scanning electron microscope, histology, histochemistry and immunofluorescence techniques. The epidermis is characteristically differentiated into plaques separated from each other by deep furrows. In plaques, the epidermis is keratinized. In contrast, in furrows, it is mucogenic. Surface epithelial cells in plaques get modified into characteristic spine-like unculi. At the distal ends of these unculi, we find tree-like branched dendritic structures. The keratinized epithelial cells in plaques together with unculi frequently exfoliate at the surface. The epidermis in furrows is equipped with secretory glandular cells, that is, mucous goblet cells, sacciform cells and club cells; and sensory structures, that is, the taste buds. These glandular cells are involved in the elaboration of different types of carbohydrate and protein moieties. Further, in the epidermis of both, plaques and furrows, melanophores are frequently interspersed between the epithelial cells. In the plaque epidermis, in addition to melanophores, melanin granules are observed in epithelial cells undergoing keratinization as well as in those sloughing at the surface. Sloughing of keratinized epithelial cells together with spine-like unculi at the surface of the plaques; the secretions of the glandular cells, the distribution of melanophore and the taste buds interspersed between the epithelial cells and the presence of melanin granules in the keratinized epithelial cells have been associated with different functional roles. These include hydrodynamic advantage, protection from mechanical stress, pathogens, UV radiation, localization of food accurately and so on in relation to the natural habitat of the fish.

Home health care and cardiac rehabilitation following major cardiac surgeries in Pakistan

Cardiovascular disorders are a leading cause of morbidity and mortality globally, and coronary artery bypass graft surgery is one of the most effective procedures for coronary artery disease. Cardiac rehabilitation (CR) has been shown to offer benefits beyond reducing mortality and morbidity rates, including enhancing patients' quality of life and reducing healthcare costs. Home-based CR programs offer personalized plans tailored to individual needs and availability and have been shown to be more effective in sustaining improvements than center-based CR programs. However, there are challenges associated with providing home care services in developing countries, including personnel shortages, lack of financing and policies, and limited access to end-of-life or hospice services. The use of multidisciplinary telehealth and telecare homecare programs that make use of web-based technologies to monitor postoperative outcomes in patients undergoing cardiac surgery may provide a solution to some of these challenges. This manuscript emphasizes the potential of home health care and CR in improving postoperative outcomes in Pakistan and identifies some of the challenges and potential solutions associated with providing home care services.

Knowledge assessment of radiologists, radiology residents, and radiographers regarding contrast materials and management of adverse drug reactions occurring due to contrast materials: a cross-sectional study

The purpose of this study was to assess the knowledge of the radiology personnel regarding contrast media used in radiology and the management of associated adverse drug reactions.

Methods

A questionnaire-based cross-sectional study was conducted from 21 February to 31 March 2019 in five major hospitals of Peshawar, Pakistan. A 30-item questionnaire was adopted from the existing literature containing both open and closed-ended questions and the authors conducted a pilot study among 25 participants to assess the face validity of the tool. A universal sampling technique was adopted. Descriptive statistics were used to summarize the findings of the study.

Results

Less than half of the participants could correctly classify iodinated contrast media used in radiology on the basis of ionicity and osmolaity. Sixty-three percent chose severe contrast material-induced allergic reaction as type I hypersensitivity reaction while almost half of them correctly identified the features of iodinated contrast media associated with lesser side effects. Very few of them (6.7%) had read the ACR 2018 manual on contrast media. Regarding the risk factors for acute adverse reactions and signs/symptoms of anaphylaxis few could answer satisfactorily. Twenty-eight percent of participants correctly identified epinephrine as the initial medication in an anaphylactic reaction. Regarding the preferred route of administration, concentration and dose of epinephrine, the participants' correct response was quite poor (43.8%, 6.7%, and 8.6%, respectively). More than 65% of participants could name a single intravenous corticosteroid and antihistamine.

Conclusion

Radiology personnel's knowledge regarding contrast material and management of severe contrast material-induced allergic reactions is unsatisfactory.

Characterization of Genetic Mutations in Multi-Drug-Resistant Isolates of Mycobacterium tuberculosis Bacilli Conferring Resistance to a Second-Line Anti-tuberculosis Drug

INTRODUCTION

Multi-drug-resistant tuberculosis (MDR-TB) has become a major public health concern globally. Mutations in first- and second-line drug targets such as katG, inhA, rpoB, rrs, eis, gyrA, and gyrB have been associated with drug resistance. Monitoring predominant mutations in the MDR-TB patient population is essential to monitor and devise future therapeutic regimes. The present study is aimed to characterize genetic mutations in MDR isolates of Mycobacterium tuberculosis (MTB) bacilli conferring resistance to a second-line anti-tuberculosis drug in the Eastern Indian population.

METHODS

This cross-sectional study was conducted in the Department of Microbiology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, and in the Tuberculosis Demonstration & Training Centre, Agamkuan, Patna. A total of 3270 patients suspected to have MDR-TB were recruited in the study. Two sputum samples, one on the spot, and the other in the morning were collected from each patient and the diagnosis of rifampicin-sensitive (RS)/rifampicin-resistant (RR/MDR) TB was done by Gene-Xpert test. One hundred fifty RS-TB samples and 150 RR/MDR-TB samples were considered for line probe assay (LPA). RS samples were subjected to first-line LPA using Genotype^® MTBDR Plus ver 2.0 and RR/MDR samples were considered for second-line LPA using Genotype^® MTBDRsl ver 2.0. All sputum samples were subjected to sputum smear microscopy using the Ziehl-Neelsen staining method. Statistical analysis was done using Statistical Package for Social Sciences (SPSS) version 26.0 (IBM Corp. Armonk, NY) and R (version 4.1; R Core Team 2021).

RESULTS

In the present study, out of 3270 patients, we detected RR/MDR-TB in 235 patients (7.19%), RS-TB in 812 patients (24.83%), the rest of the patients negative for MTB (2223, 67.98%). Out of 150 RR/MDR-TB sputum samples tested, resistance to fluoroquinolone (FQ) was observed in 41 samples. The selected patients had predominantly FQ resistance due to the gyrA gene mutations (97.56%, n=40) compared to the gyrB gene mutations (2.44%, n=1). We observed >60% of the mutations in the gyrA gene in codon 94 (MUT3C (D94G), MUT3A (D94A), and MUT3D (D94H). In addition, we found the mutations MUT1 (A90V) and MUT2 (S91P) in the codons 90 and 91 of the gyrA gene in the considered MTB patient population.

CONCLUSION

The identified genes can be further validated to be considered as therapeutic targets, but more therapeutics and advanced strategies should be applied in the management of MTB.

Ecotoxicological impacts of environmentally relevant concentrations of aspirin in the liver of Labeo rohita: Biochemical and histopathological investigation

Aspirin is one of the emerging pharmaceutical contaminants in the aquatic environment and thus it could impart toxicity to non-target organisms including fish. The present study aims to investigate the biochemical and histopathological alterations in the liver of the fish, Labeo rohita exposed to environmentally relevant concentrations of aspirin (1, 10, and 100 μg/L) for 7, 14, 21, and 28 days. The biochemical investigation revealed a significant (p < 0.05) decrease in the activity of antioxidant enzymes such as catalase, glutathione peroxidase, glutathione reductase; and reduced glutathione content in a concentration and duration dependent manner. Further, the decrease in the activity of superoxide dismutase was in a dose dependent manner. The activity of glutathione-s-transferase, however, increased significantly (p < 0.05) in a dose dependent manner. The lipid peroxidation and total nitrate content showed a significant (p < 0.05) increase in a dose and duration dependent manner. The metabolic enzymes such as acid phosphatase, alkaline phosphatase, and lactate dehydrogenase showed a significant (p < 0.05) increase in all three exposure concentrations and durations. The histopathological alterations in the liver such as vacuolization, hypertrophy of the hepatocytes, nuclear degenerative changes, and bile stagnosis increased in a dose and duration dependent manner. Hence, the present study concludes aspirin has a toxic impact on fish, which is evidenced by its profound effect on biochemical parameters and histopathological analysis. These can be employed as potential indicators of pharmaceutical toxicity in the field of environmental biomonitoring.

Scrotal trichilemmal cysts: a case report

Trichilemmal cyst (TC), commonly known as the pilar cyst of the scrotum wall, is an uncommon disease. It is a type of epidermoid cyst (EC) with a benign course, and malignant change is quite rare. This disease is unusual in the scrotum; therefore, multiple cysts in the scrotum are much more unusual. There have been reports of TCs in other parts of the body, but this is the first instance of scrotal TCs in Pakistan.

Case presentation

We discuss the case of a 60-year-old male patient who presented to the clinic with a right-sided scrotal swelling, which was identified as a right-sided inguinal hernia on examination, and multiple small swellings on the scrotal skin identified as TCs. The patient had scrotoplasty after hernia surgery to remove the cysts and reconstruct the excised scrotum. Following scrotoplasty, the patient's discomfort was resolved, and cosmetic satisfaction was achieved.

Clinical discussion

Excision is required if TCs become infected or for esthetic reasons. In the event of big cysts, full scrotal wall resection followed by scrotoplasty is necessary. The thigh fasciocutaneous flap is used to cover the denuded testes after scrotoplasty. The procedure's advantages include a good outcome, low morbidity, early discharge, and great esthetic outcomes.

Conclusion

We present a literature review about multiple TCs in the scrotum and their surgical management. This case will guide surgeons and future researchers in dealing with similar cases in the future.

Environmental Exposure: Effect on Maternal Morbidity and Mortality and Neonatal Health

Environmental factors are important causes that impair global pregnancy outcomes and are, importantly, responsible for maternal morbidity and mortality. However, apart from the direct reasons for maternal deaths, mainly obstetric and neonatal complications, such factors are ignored or given less importance. The recent surge in research on the impact of various environmental factors on pregnancy outcomes suggests the need for immediate attention to such factors and device-specific policies to counter the situation. Moreover, the recent coronavirus disease of 2019 (COVID-19) pandemic, global warming, and climate change showed a lack of preparedness to counter the impact of such events on maternal survival and safe and successful pregnancy outcomes. In the present review, we have emphasized the specific factors responsible for increased maternal and neonatal deaths and their association with specific environmental factors. Increased attention on maternal healthcare, preparedness to counter sudden environmental challenges and improvement of the conventional requirement for better maternal healthcare access and nutrition at a global level may improve the scenario.

Impact of COVID-19 Vaccination on Women During Pregnancy and Breastfeeding

Rapid development of anti-SARS-CoV-2 vaccinations in the late 2020s has significantly altered the trajectory in which the virus affects various patient demographics, especially the most susceptible ones. In light of ethical and conceptual safety considerations, pregnant women were initially barred from participating in clinical studies for the coronavirus disease 2019 (COVID-19) vaccination programs. However, the steady accumulation of reliable observational data from cohorts of pregnant women who received vaccinations enabled the research establishments to quickly address a number of open questions. Still, more than a year after vaccines were widely available, the safety concerns of expectant or nursing mothers are cited as the primary justification for refusing COVID-19 vaccination, and notably, the rate of vaccination in the said populations is known to be consistently lower than those of the general populace. In light of such a scenario, we have made an attempt to garner relevant studies that evaluated the effect of COVID-19 vaccination on pregnant and lactating mothers which may prove to be supporting evidence for its wide usage among the said population.

Concomitant Coronary Artery Disease and Persistent Left Superior Vena Cava in a Patient Presenting With Symptomatic Sinus Bradycardia: A Case Report

Persistent left superior vena cava (PLSVC) is a congenital venous anomaly. It is frequently associated with other cardiac anomalies. The presence of dual superior vena cava is due to the lack of development of the left cardinal vein in utero. The coronary sinus gets dilated as a result of increased blood flow to the right heart and may be seen on echocardiography. This case describes a 50-year-old lady who presented to the emergency department with lightheadedness, nausea, and vomiting for one day, and her electrocardiogram showed a heart rate of 30 beats per minute. A temporary pacemaker was placed. She had a history of asymptomatic PLSVC diagnosed six months ago through percutaneous coronary intervention. A permanent pacemaker was passed through PLSVC to access the right ventricle and she was discharged home after five days of an uneventful hospital course. Clinicians should be aware of this rare congenital anomaly and its potential complications, particularly in patients with unexplained syncope or bradycardia. Further research is needed to better comprehend the clinical presentation, diagnostic evaluation, and management of PLSVC-related cardiac abnormalities.

Giant Sinoatrial Nodal Artery Aneurysm with Fistula into the Right Atrium Treated by Partial Resection and Plication: A Case Report

Coronary artery aneurysms (CAAs) occur when an artery dilates 1.5 times the reference vessel. They occur most commonly because of atherosclerosis. CAAs are a rare phenomenon, and it is even rarer to find a giant CAA, which is roughly defined as a size 400% above the reference vessel. Giant CAAs are commonly found in the right coronary artery. The sinoatrial nodal artery (SNA) is among the least common sites for CAA involvement. Sometimes, communication exists between the aneurysm and a chamber of the heart or a great vessel. The consequences of the fistula depend on its size. Because of the rarity of the condition, guidelines are not well developed. However, small CAAs can be managed conservatively, whereas giant CAAs require resection, ligation, and bypass grafting. CAAs have a predilection for males and the elderly. We describe a 40-year-old South Asian woman presenting with mild dyspnea on exertion of 1 year's duration. Echocardiography showed a 60×60 mm cystic sac, subsequently confirmed by computerized tomography, which showed 3 large aneurysms (70×61 mm) and 3 small aneurysms in the SNA. Coronary angiography illustrated that the SNA branched off the left main coronary artery, and the aneurysm communicated with the right coronary artery. The aneurysm was partially resected and plicated.

Prevalence of Workplace Bullying Among Healthcare Professionals in Tertiary Care Hospitals in Pakistan

Workplace bullying (WPB) in the healthcare system (HCS), whether perpetrated by healthcare professionals (HCPs) or patients, is a serious problem. The goal of this research study was to find out how common WPB is among HCPs. We conducted a questionnaire-based cross-sectional study in the three public tertiary care hospitals of Karachi, Pakistan from May to October 2020. A validated Negative Acts Questionnaire-Revised (NAQ-R) was used to measure WPB prevalence. The final sample size was 449, out of which 72.4% were females and 27.6% were males. The majority of respondents were house officers or 1st-year trainees who had completed their MBBS (n = 252, 56.1%). Residents (n = 197, 43.9%) who were pursuing specialty training made up the remainder of the respondents. As per NAQ-R cut-offs, the prevalence of bullied, being bullied, and not bullied was 41, 29, and 30%, respectively. WPB prevalence was higher in males (53%) than females (38%), whereas it occurred more often in residents (48%) than house officers (36%). We found similar findings while using the self-reported definition for WPB. Based on our findings, we conclude that WPB is pervasive among HCPs, particularly for males and residents in tertiary care hospitals in Pakistan.

Immunoprotective role of aloin and disease resistance in Labeo rohita, infected with bacterial fish pathogen, Aeromonas hydrophila

The effect of aloin on mucosal immune response and disease resistance was elucidated in Labeo rohita infected with the bacterial fish pathogen, Aeromonas hydrophila. Fishes were divided into four groups: (i) control, (ii) vehicle control, (iii) bacteria infected and (iv) bacteria infected and aloin treated. Fish were intraperitoneally injected with A. hydrophila suspension at the dose of 2 × 10⁶ CFU/fish at 0 day (d). Following bacterial injection at 0 d, fish were treated with aloin at a dose of 1 mg/kg body weight intraperitoneally at an interval of 24 h for 4 consecutive days. Mucus collected from fish of each group was analyzed at 2 d, 4 d, 6 d, 8 d and 10 d. In bacteria-infected fish, a significant decrease (P < 0.05) in the activity of certain enzymatic and non-enzymatic immune parameters was observed. The activity of these immune parameters showed a gradual recovery on administration of aloin in bacteria-infected fish. Cumulative mortality was also found to be low in the aloin-treated group as compared to that in the infected group. Thus, aloin could act as an immunostimulant and play a protective role against disease caused by bacteria.

Two Rare Diseases, One Patient: A Case Report of Mucormycosis and Granulomatous Polyangiitis

Mucormycosis is a rare but fatal disease caused by a filamentous fungus involving the nose, paranasal sinuses, and brain. These organisms usually cause severe infections in immunocompromised individuals. Granulomatous polyangiitis (GPA), also known as Wegner's granulomatosis, is a rare, aseptic necrotizing granulomatous vasculitis involving small and medium-sized vessels commonly affecting the nose, ears, lungs, and kidneys. The simultaneous occurrence of mucormycosis and GPA, two rare diseases, in the same patient is exceedingly rare. In this case study, we describe a 40-year-old woman who presented with manifestations of both GPA and mucormycosis. She was started with steroids and antifungal agents and achieved significant improvement.

Accidental Penetrating Thoracic Injury with a Screwdriver in a Child: A Case Report

Accidental penetrating injuries are common among children, either with a sharp or a blunt object. The screwdriver is an uncommon weapon; therefore, injuries caused by it represent an even rarer subset. Inadvertent injuries in the chest with a screwdriver as a stabbing weapon are extremely unusual. Penetrating chest injuries can be fatal if they cause wounds in the cardiac chambers or major thoracic vessels. We describe a 9-year-old child with an unintentional penetrating thoracic injury caused by a screwdriver. An explorative left anterior thoracotomy showed that the tip of the implanted screwdriver was lying near the left subclavian vessels and the apex of the lung, but it did not perforate any of those. The screwdriver was dislodged, and the wound was closed. The patient had an event-free 1-week hospital stay.

Shellac as a multifunctional biopolymer: A review on properties, applications and future potential

Shellac is a physically refined form of lac resin, a natural biopolymer of animal origin obtained from tiny insects feeding on the sap of specific host trees. Shellac, in its basic form, is a polyester macromolecule composed of inter and intra esters of polyhydroxy aliphatic and sesquiterpene acids. It has been used in several industries for ages due to its exceptional properties such as film-forming, adhering, bonding, thermoplasticity, water-resistance and easy solubility in spirit and aqueous alkali solvents. From the beginning of the 21^st century, due to increasing demand for natural products, a paradigm shift in the scope and applications of shellac has been witnessed, especially in green electronics, 3D printing, stealth technology, intelligent sensors, food and pharmaceutical industries. Shellac offers enormous potential for greener technologies as a natural and environmentally friendly material. This review provides an insight into the lac in detail, covering various forms of the lac, structure, properties, different applications of shellac and its future potential. This article would benefit the researchers involved in shellac research and others looking for natural and greener alternatives to synthetic polymers in various applications.

Time to Reconsider the Inhaled Drugs for<br /> Tuberculosis

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A Rare Case of a Type IV Dual Left Anterior Descending Artery and Ectopic Left Anterior Descending and Circumflex Arteries Requiring Surgery

Congenital anomalous coronary arteries (CACAs) comprise an important variant of the coronary vasculature. They are benign in the vast majority of cases, whereas a small minority may be affected by serious consequences such as myocardial infarction, arrhythmia, cardiac arrest, and even death. We herein describe a 62-year-old man with sudden and severe substernal chest pain; Q waves in electrocardiographic leads II, III, and aVF; and positive serum troponin I enzyme. Left heart cardiac catheterization revealed triple coronary vessel disease with a 60% to 70% occlusion in the left main coronary artery (LMCA). The left anterior descending (LAD) and the left circumflex artery arose from the ostium of the right coronary artery. Additionally, a rudimentary type IV dual LAD originated from the LMCA. A coronary artery bypass graft surgery was performed using a left internal mammary artery graft for the LAD and a saphenous vein graft for the diagonal branches (I & II) of the LAD and the posterior descending artery. The patient was discharged after an uneventful 1-week hospital course.

Safety and Adequacy of Ultrasound-Guided Percutaneous Renal Biopsy in Children: A Single-Center Experience

Background Ultrasound-guided percutaneous renal biopsy (PCRB) is a commonly used technique to obtain renal tissue for histopathological diagnosis in children and adolescents. The objectives of this study include determining the indications for renal biopsy, documenting the safety and efficacy of ultrasound-guided PCRB, and documenting its complications along with histopathological findings in children. Methodology The Ethical Review Committee approved this cross-sectional study. Data of all children with either nephrotic or nephritic syndrome from January 2017 to September 2020 (at The Kidney Center Post Graduate Training Institute Karachi) who underwent ultrasound-guided PCRB were collected and analyzed. An ultrasonic examination was performed both before and after the biopsy. Results During the research period, 104 individuals underwent PCRB. The average age of the children biopsied was 7.44 ± 4.12 years (range = 1-17 years). The most prevalent reason for biopsy was nephrotic syndrome. Almost 94% of PCRBs were effective. Post-biopsy complications were detected in 16 cases, with peri-nephric hematoma being the most prevalent. Conclusions In children, ultrasound-guided PCRB can safely be performed under sedation in experienced hands with an automated biopsy gun needle. The use of real-time ultrasound guidance as well as the automated biopsy gun ensures good outcomes.

Establishing Atrial Fibrillation Clinics: If not now, When?

BACKGROUND AND OBJECTIVES

Atrial Fibrillation (AFib) is the most common arrhythmia, associated with considerable morbidity and mortality. It affects 8% population and its incidence rises with age. The consequences of untreated or poorly treated Afib are grave, therefore, appropriate management of this condition should occupy high priority.

DISCUSSION

AFib clinic provides a prompt, well-organized, and conclusive approach to managing affected patients. The essence of such a set-up lays in providing frequent monitoring to the patient in well-equipped centres with specialized doctors and trained staff. Worldwide AFib clinics have shown evidence of morbidity, mortality, and cost-benefits.

CONCLUSION

In developing countries such as Pakistan with less budget granted to health care, specialized AFib clinics could save cost, besides providing better health care outcomes to the patients. It is crucial to establish such focused AFib care centres urgently.

Mental health risk among children during COVID-19 lockdown

The COVID‐19 pandemic has created a hugely detrimental impact on the psychological health of people around the world. Children are extremely vulnerable; therefore, it is of utmost importance to discuss the prevalence of the symptoms, their associated risk factors, and the strategies to identify and understand their deteriorating mental health (MH) before it leads to disastrous outcomes. Hence, parents and schools should come together in devising modes to create an environment in which children can easily tackle the lockdown periods which have become the new reality. Negative effects on MH have long‐term consequences, therefore necessary interventions must take place.

Evaluation of Antitumor Efficacy of Chitosan-Tamarind Gum Polysaccharide Polyelectrolyte Complex Stabilized Nanoparticles of Simvastatin

PURPOSE

The present study was intended to fabricate chitosan (Ch)-tamarind gum polysaccharide (TGP) polyelectrolyte complex stabilized cubic nanoparticles of simvastatin and evaluate their potential against human breast cancer cell lines.

MATERIALS AND METHODS

The antisolvent precipitation method was used for formulation of nanoparticles. Factorial design (32) was utilized as a tool to analyze the effect of Ch and TGP concentration on particle size and entrapment efficiency of nanoparticles.

RESULTS

Formulated nanoparticles showed high entrapment efficiency (67.19±0.42-83.36±0.23%) and small size (53.3-383.1 nm). The present investigation involved utilization of two biological membranes (egg and tomato) as biological barriers for drug release. The study revealed that drug release from tomato membranes was retarded (as compared to egg membranes) but the release pattern matched that of egg membranes. All formulations followed the Baker-Lansdale model of drug release irrespective of the two different biological barriers. Stability studies were carried out for 45 days and exhibited less variation in particle size as well as a reduction in entrapment efficiency. Simvastatin loaded PEC stabilized nanoparticles exhibited better control on growth of human breast cancer cell lines than simple simvastatin. An unusual anticancer effect of simvastatin nanoparticles is also supported by several other research studies.

CONCLUSION

The present study involves first-time synthesis of Ch-TGP polyelectrolyte complex stabilized nanoparticles of simvastatin against MCF-7 cells. It recommends that, in future, theoretical modeling and IVIVC should be carried out for perfect designing of delivery systems.

Determination of Temperature-Dependent Coefficients of Viscosity and Surface Tension of Tamarind Seeds (Tamarindus indica L.) Polymer

The rheological properties of tamarind seed polymer are characterized for its possible commercialization in the food and pharmaceutical industry. Seed polymer was extracted using water as a solvent and ethyl alcohol as a precipitating agent. The temperature’s effect on the rheological behavior of the polymeric solution was studied. In addition to this, the temperature coefficient, viscosity, surface tension, activation energy, Gibbs free energy, Reynolds number, and entropy of fusion were calculated by using the Arrhenius, Gibbs–Helmholtz, Frenkel–Eyring, and Eotvos equations, respectively. The activation energy of the gum was found to be 20.46 ± 1.06 kJ/mol. Changes in entropy and enthalpy were found to be 23.66 ± 0.97 and −0.10 ± 0.01 kJ/mol, respectively. The calculated amount of entropy of fusion was found to be 0.88 kJ/mol. A considerable decrease in apparent viscosity and surface tension was produced when the temperature was raised. The present study concludes that the tamarind seed polymer solution is less sensitive to temperature change in comparison to Albzia lebbac gum, Ficus glumosa gum and A. marcocarpa gum. This study also concludes that the attainment of the transition state of viscous flow for tamarind seed gum is accompanied by bond breaking. The excellent physicochemical properties of tamarind seed polymers make them promising excipients for future drug formulation and make their application in the food and cosmetics industry possible.

A Comprehensive Review on Source, Types, Effects, Nanotechnology, Detection, and Therapeutic Management of Reactive Carbonyl Species Associated with Various Chronic Diseases

Continuous oxidation of carbohydrates, lipids, and amino acids generate extremely reactive carbonyl species (RCS). Human body comprises some important RCS namely hexanal, acrolein, 4-hydroxy-2-nonenal, methylglyoxal, malondialdehyde, isolevuglandins, and 4-oxo-2- nonenal etc. These RCS damage important cellular components including proteins, nucleic acids, and lipids, which manifests cytotoxicity, mutagenicity, multitude of adducts and crosslinks that are connected to ageing and various chronic diseases like inflammatory disease, atherosclerosis, cerebral ischemia, diabetes, cancer, neurodegenerative diseases and cardiovascular disease. The constant prevalence of RCS in living cells suggests their importance in signal transduction and gene expression. Extensive knowledge of RCS properties, metabolism and relation with metabolic diseases would assist in development of effective approach to prevent numerous chronic diseases. Treatment approaches for RCS associated diseases involve endogenous RCS metabolizers, carbonyl metabolizing enzyme inducers, and RCS scavengers. Limited bioavailability and bio efficacy of RCS sequesters suggest importance of nanoparticles and nanocarriers. Identification of RCS and screening of compounds ability to sequester RCS employ several bioassays and analytical techniques. Present review describes in-depth study of RCS sources, types, properties, identification techniques, therapeutic approaches, nanocarriers, and their role in various diseases. This study will give an idea for therapeutic development to combat the RCS associated chronic diseases.

Morbidity and health seeking behavior among the rural Population, Malaysia

Background: Health seeking behavior is defined as any deed that an individual tackles to perceive themselves to have a health issue or to be sick for the endeavor of discovering a suitable countermeasure. Delays in seeking health care are usually associated with an increase in the mortality rate and the perk of early treatment and control are also acknowledged. Aims and Objective: The present study aimed at finding the morbidity and health seeking behavior among the rural population, Malaysia. Materials and Methods: A community survey was carried out in the rural area of Kedah State and the sample size was 114. A structured questionnaire was used and the data were collected by face to face interview method. Results: Majority of the residents (71.9%) were apparently healthy while 28.1% were diagnosed with illness. Top three common diseases were hypertension (53.1%), diabetes (34.4%) and heart disease (6.3%). About 81.3% of them were taking their medications regularly whereas18.7% were not compliant. Among those with illnesses,31.3% of the respondents were using traditional medicine. About half of the respondents felt that they need not get check-ups and this becomes the major barrier to health care. It was followed by long wait,lack of doctors and mass media. The source of health information was mainly from health staff followed by mass media, friends and campaigns. Conclusion: Based on the study we can conclude that improving health literacy through intensive awareness campaigns and mass media and providing access to technology may create more health awareness and healthconsciousness in individuals and encourage them to lead a healthy lifestyle. Increasing the number of health care professionals and health care centers will motivate the individuals to monitor their diseases and treatment to improve the quality of life.

Sorption and leaching of flucetosulfuron in soil

The adsorption-desorption and leaching of flucetosulfuron, a sulfonylurea herbicide, was investigated in three Indian soils. Freundlich adsorption isotherm described the sorption mechanism of herbicide with adsorption coefficients (K_f) ranging from 17.13 to 27.99 and followed the order: Clayey loam > Loam > Sandy loam. The K_f showed positive correlation with organic carbon (OC) (r = 0.910) and clay content (r = 0.746); but, negative correlation with soil pH (r = -0.635). The adsorption isotherms were S-type suggesting that herbicide adsorption was concentration dependent and increased with increase in concentration. Desorption followed the sequence: sandy loam > clayey loam > loam . Hysteresis (H) was observed in all the three soils with H < 1. Leaching of flucetosulfuron correlated positively with the soil pH; but, negatively with the OC content. Sandy loam soil (OC- 0.40%, pH -7.25) registered lowest adsorption and highest leaching of flucetosulfuron while lowest leaching was found in the loam soil (pH - 7.89, OC - 0.65%). The leaching losses of herbicide increased with increase in the rainfall intensity. This study suggested that the soil OC content, pH and clay content played important roles in deciding the adsorption-desorption and leaching behavior of flucetosulfuron in soils.

Facile method to synthesize efficient adsorbent from alumina by nitric acid activation: Batch scale defluoridation, kinetics, isotherm studies and implementation on industrial wastewater treatment

The excess amount of fluoride contamination in the groundwater or industrial effluents fosters various health problems. Considering the advantages of adsorption, the current research reports the synthesis of a novel adsorbent (HNAA) by simple and convenient process of nitric acid activation of alumina. The physiochemical characterization (SEM, EDX, XRF, FTIR, BET, and pH_ZPC) results exhibited successful activation of alumina and adsorption of fluoride ions. The effect of process parameters (contact time, initial pH, adsorbent dose, initial fluoride concentration and presence of coexisting ions) on adsorption of fluoride ions on HNAA were investigated in batch scale. The adsorption of fluoride ion on HNAA followed the Freundlich isotherm and pseudo second order kinetic model. The Q_max of HNAA adsorbent was 45.75 mg/g at 45 °C. The fluoride ion adsorption was revealed to be endothermic and spontaneous. The experimentation of the HNAA adsorbent on industrial wastewater, with fluoride concentration of 17.5 mg/L, inferred the significant defluoridation potential at the optimized adsorbent dose and pH. The nitric acid activation of alumina resulted in improvement of defluoridation efficiency from 74.18% to 97.43%. The HNAA also exhibited the better regeneration and reusability features which distinguish it as a promising adsorbent to be applied for real field wastewater.

Modifications in the gills of hill stream Moth catfish, Hara hara (Erethistidae, Siluriformes): A light and scanning electron microscope investigation

Present study reports significant modifications in surface ultrastructure, histological organization, and histochemical localization of glycoproteins (GPs) in the gills of a hill stream catfish, Hara hara. Punctate microridges on free surface of epithelial cells covering gill arches, gill rakers, gill filaments and secondary lamellae are considered to provide adaptive plasticity to gills in relation to the environment inhabited by fish. Short and stout gill rakers are considered to prevent food particles to pass in opercular chamber along with respiratory current that could damage delicate gill filaments. Mucous goblet cells show presence of different classes of glycoproteins. GPs with oxidizable vicinal diols are considered to control acidity of acidic GPs. GPs with carboxyl groups have been implicated with defensive mechanism against microorganisms. GPs with O-sulphate esters are associated to trap and to lubricate food particles for easy swallowing. Taste buds on gill arches and gill rakers function to select palatable food particles. Occurrence of taste buds on the gill filaments is regarded significant adaptation to analyse the chemical nature of water. This study could play a significant role to understand adjustment of gills in the hill stream fish.