The 100 most-cited articles in Cureus, 2019

Micro-learning is an educational teaching method used to train users on multiple platforms. This article will provide a brief introduction to the concepts of short-term and long-term memory, and explain how micro-learning can be used to increase retention in learners. Micro-lessons can aid in negating the Ebbinghaus forgetting curve and can use reintroduction to keep retention at significantly higher levels. This process also speeds up the learning process overall because students avoid the phenomenon of mental fatigue. The article cites studies suggesting mental fatigue can cause serious cognitive decline in individual performance. By breaking complex courses into manageable smaller lessons, micro-learning preserves the neurotransmitter cascade for steady neurochemical performance. By using mobile devices, students can pause and continue their micro-lessons with ease. The mobile application also gives them the opportunity to continually check on their performance, and adjust their learning accordingly. Micro-learning on mobile devices also keeps engagement levels high because it…

INTRODUCTION: Adequate sleep has a crucial role in enhancing cognitive skills especially memory retention. Poor night time sleep quality and the consequent daytime sleepiness affect physical and cognitive health of students and their academic performance. The aim of this study is to find whether or not poor academic performance is a consequence of poor sleep quality among Pakistani medical students. METHODS: It was an observational, cross-sectional study conducted with undergraduate medical students. Pittsburgh Sleep Quality Index (PSQI) was used to assess the sleep quality. Academic performance was assessed by mean grade point average (GPA) of the students. The data were analyzed using the Statistical Package for the Social Sciences (SPSS) 22.0 (IBM Corp., Armonk, NY, USA). RESULTS: There were 512 (64.24%) students with global PSQI score ≥5 indicating poor sleep quality. The mean GPA of poor sleepers was 2.92 ± 1.09 which was significantly lower than that of good sleepers (p < 0.0001). In the group of students who scored lower GPA (2.0-2.7), 28.2% had very bad subjective sleep…

INTRODUCTION: Erector spinae plane block (ESPB) is a novel regional anesthesia technique used in postoperative pain and chronic neuropathic pain of the thoracoabdominal region. There are no previously published large case series. This retrospective review aimed to report the indications, levels of block, success of block and complications, and also to evaluate the effect of ESPB on postoperative/chronic pain. METHODS: We retrospectively evaluated the charts and medical records of 182 patients who had ESPB in the last one year. All records were collected in the postoperative recovery room, ward, and pain unit. RESULTS: ESPB performed at several different levels and for several different indications led to effective postoperative analgesia when part of a multimodal analgesia plan. Few complications were noted. CONCLUSION: ESPB is an interfascial plane block with many indications. The possibility of complications must be considered.

We review the epidemiology, etiology, symptomatology, clinical presentation, anatomy, pathophysiology, workup, diagnosis, non-surgical and surgical management, postoperative care, outcomes, long-term management, and morbidity of lumbar radiculopathy. We review when outpatient conservative management is appropriate and "red flag" warning symptoms that would necessitate an emergency evaluation. Diagnostic modalities, including magnetic resonance imaging (MRI), computerized tomography (CT), contrast myelogram, electromyogram (EMG), and nerve conduction velocity (NCV), are involved in the diagnosis and decision-making are discussed. Treatment of lumbar radiculopathy requires a multimodal and multispecialty team. We review indications for the involvement of other professionals, including physical therapy (PT), occupational therapy (OT), physical and rehabilitation medicine (PMR), and pain management.

Physician burnout is an emerging condition that can adversely affect the performance of modern-day medicine. Its three domains are emotional exhaustion, depersonalization, and a sense of reduced accomplishment among physicians, with the Maslach Burnout Inventory (MBI) being the gold standard questionnaire used to scale physician burnout. This concern not only impacts physicians but the entire healthcare system in general. There is growing awareness regarding the mental health of physicians and the consequences faced by the healthcare system as a result of burnout. According to a recent study, more than 50% of physicians reported suffering from at least one burnout symptom. In this review article, we aim to identify the causes leading to burnout, its impact on physicians, and hospital management as well as interventions to reduce this work-related syndrome. Some contributing factors leading to burnout are poor working conditions with long work shifts, stressful on-call duties, lack of appreciation, and poor social interactions. Burnout can lead to adverse consequences, such as…

Background Stress, anxiety and impeded sleep are a frequent feature of life in modern societies. Across socio-economic strata, stress, anxiety and ineffective sleep detract from healthful living and serve as precursors of various ailments. The use of herbs to offset these antecedents and outcomes has greatly increased in recent years. Ashwagandha, an adaptogenic Ayurvedic herb, has been often used to combat and reduce stress and thereby enhance general wellbeing. While there have been other studies documenting the use of Ashwagandha for stress resistance, this is the first study to use a high-concentration root extract while also varying the dosage substantially. Therefore, this is the first study to offer insight into dose-response of a high concentration root extract. Material and methods In this eight-week, prospective, randomized, double-blind, placebo-controlled study, the stress-relieving effect of Ashwagandha root extract was investigated in stressed healthy adults. Sixty male and female participants with a baseline perceived stress scale (PSS) score >20 were randomized to…

Objective To show the recent trends in thyroid cancer in the United States, elucidate the characteristics of stage IV thyroid cancer, and consider the effects of diagnostic testing on the rising incidence of thyroid cancer. Design A retrospective population-based study conducted using the National Cancer Database from 2000-2013 (NCDB). Demographics of patients presenting with stage IV thyroid cancer were compared to patients presenting with all other stages using the chi-square testing. The incidence rates were examined with the trend graphs. Results When compared to stages I-III, there was an increased incidence of stage IV thyroid cancer in: Medicare, lower level of education, lower income, advanced age, male sex, increased number of comorbidities, further distance from a treatment facility, and medullary/anaplastic histology. The incidence of thyroid cancer increased from 7.1 per 100,000 in 2000 to 17.6 per 100,000 in 2013. During this same time period, stage IV disease increased 1 per 100,000. The increase in the incidence of thyroid cancer was almost entirely due to an increase…

Chronic obstructive pulmonary disease or COPD is one of the conditions that physicians frequently see in both the hospital and outpatient setting. In order to improve diagnostic and treatment outcomes, the Global Strategy for the Diagnosis, Management and Prevention of COPD, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) was created in 2001. Every year, a new report is generated based on an analysis of published studies which attempts to improve the way physicians handle COPD. GOLD reports are considered to be essential evidence-based reference tools for the implementation of effective management plans, and represent the current best practices for the care of patients with COPD. The 2017 report greatly revised the guidelines and added a few components that changed the system of COPD diagnosis and treatment. This review article addresses those changes, explains the current guidelines, and draws attention to areas that still require improvement.

Introduction Insomnia is a prevalent sleep disorder that can profoundly impact a person's physical health and mental wellbeing. Most of the currently available drugs for insomnia exert adverse effects. Hence, alternative herbal therapies could be effective in treating insomnia. Ashwagandha, a proven "Rasayana" from ancient Ayurveda is having the required potential to treat insomnia. Objective To determine the efficacy and safety of Ashwagandha root extract in patients with insomnia and anxiety. Methods This was a randomized, double-blind, placebo-controlled study conducted at Prakruti Hospital, Kalwa, Maharashtra, India. A total of 60 patients were randomly divided into two groups: test (n = 40) and placebo (n = 20) in a randomization ratio of 2:1. Test product was a capsule containing highest concentration full-spectrum Ashwagandha root extract 300 mg, and the placebo was an identical capsule containing starch. Both treatments were given twice daily with milk or water for 10 weeks. Sleep actigraphy (Respironics Philips) was used for assessment of sleep onset latency (SOL), total…

Background In the 1960s, less than 10% of medical school graduates were women. Today, almost half of all medical school graduates are women. Despite the significant rise in female medical school graduates, there continues to be a large gender gap in most subspecialties, particularly surgical subspecialties such as neurosurgery. Objective The purpose of our study was to assess the factors contributing to differences in the academic ranks of male and female staff in academic neurosurgery programs in Canada and the United States (US). Methods Data about women in academic neurosurgery was collected from a number of sources, including Fellowship and Residency Electronic Interactive Database (FREIDA), Accreditation Council for Graduate Medical Education (ACGME), Canadian Resident Matching Service (CaRMS) FRIEDA, ACGME, CaRMS, Pubmed, and Scopus, to create a database of all neurosurgeons in the US and Canada. The analysis included neurosurgeons in academic and leadership ranks and also the H index, citations, publications, citations per year, and publications per year. Results Women…

Introduction The overall environment of the medical school is often considered very stressful. It projects negative effects not only on the academic performances of medical students but also deteriorate their physical health and psychosocial wellbeing. The aim of this study was to determine the frequency of depression, stress, and anxiety among final year medical students. Methods This observational study was conducted in public and private medical colleges in February 2019. The instrument utilized in this study was Depression, Anxiety, and Stress Scale (DASS-21). Factors predisposing to depression, stress, and anxiety were also recorded. Data were entered and analyzed using SPSS v. 21. Results The mean scores of depression, anxiety, and stress were 18.00 ± 11.5, 19.15 ± 11.2, and 20.92 ± 11.2, respectively. The mean score of anxiety and stress was higher in private college students, while that of depression was higher in public college students. Overall, 57.6% of the students suffered from moderate to extremely severe depression, 74% of the students suffered from moderate to…

Every eleventh adult has diabetes, and every third has prediabetes. Over 95% of diabetics are of type 2. It is well established that diabetes doubles the risk of heart disease and stroke apart from increasing the risk of microvascular complications. Hence, strict glycemic control is necessary. However, it increases the risk of hypoglycemia, especially in patients with longstanding diabetes. Continuous glucose monitors (CGM) use a sensor to continuously measure the glucose levels in the interstitial fluid every 10 seconds and gives out mean values every five minutes. CGMs are emerging tools in the management of type 2 diabetes. The prime objective of this review is to find out if there is enough supporting evidence, suggesting that continuous glucose monitoring is more effective than self-monitoring of blood glucose (SMBG) in type 2 diabetes. We conducted a systematic literature search in Medline (PubMed) looking for any studies addressing our objective. It is observed that there is a varying level of evidence supporting that employing a CGM can reduce glycated hemoglobin (HbA1c),…

Mounting evidence suggests that radiation stimulates the immune system and this contributes to the abscopal effect, which is defined as "response at a distance from the irradiated volume." Though identified more than 50 years ago, the abscopal effect is revisited today. One rationale is that the abscopal effect is often observed with efficient immunotherapy. Here, we give an overview of the clinical data on the abscopal effect, generated by a combination of immunotherapy and radiotherapy (RT). Only papers that included RT in combination with immunotherapy were evaluated according to four main categories including RT parameters, sequencing of therapies, the definition of the abscopal effect, and patient selection. Twenty-four cases in 15 reports were reviewed. The results varied. Patient ages ranged from 24 to 74. RT dose (median total dose 18-58 Gy) varied. Biologically effective dose (BED) 10 was calculated to be a median 49.65 Gy (28-151 Gy). The time to a documented abscopal response ranged from less than a month to 12 months. The large variation concerning fractionation and…

Introduction Cholangiocarcinoma is an aggressive and rare cancer of the bile duct with a very poor prognosis. It accounts for approximately three percent of gastrointestinal cancers but nearly 20 percent of deaths are from hepatobiliary cancers. Cholangiocarcinoma is also a clinically silent disease that presents at advanced stages. In this study, we wanted to identify subpopulations at the greatest risk of developing cholangiocarcinoma such that we can improve diagnosis and ultimately reduce the cancer mortality rate. Methods The United States Cancer Registry (USCS) was used to obtain data for cholangiocarcinoma from 2001 to 2015. Incidence analysis was done for sex, race, stage, primary location (intrahepatic bile duct or extrahepatic bile duct), and US regional location. Results The overall incidence of cholangiocarcinoma from 2001 to 2015 was 1.26 per 100,000 people per year. The overall incidence rates were greatest for each stratification in males, Asian and Pacific Islanders (API), distant disease, intrahepatic bile duct cholangiocarcinoma (ICC), and in the Northeast.…

Objective The aim of this bibliometric analysis is to evaluate the importance and impact of the articles that have been published with the title gestational diabetes mellitus (GDM) in the specialty of obstetrics & gynecology and endocrinology during the period 1946-2019. It also reveals that the area of GDM has received increased attention and interest by researchers, research funding institutions, and practitioners. Material and methods A thorough database search of Scopus and Web of Science was performed and the articles pertaining to gestational diabetes mellitus that were published between 1946 and 2019 were reviewed by two reviewers, Iftikhar PM and Ali F, with respect to their year of publication, authors, country of origin, journal of publication, and the affiliated institutions of the authors as well as journals. Institutional review board approval was not required for this study, as the data being analyzed were already available electronically, and otherwise, in libraries and databases. Results The 30 most-cited articles on gestational diabetes mellitus were thoroughly…

Background There is increasing concern among healthcare communities about the misinformation online about using cannabis to cure cancer. We have characterized this online interest in using cannabis as a cancer treatment and the propagation of this information on social media. Materials & methods We compared search activity over time for cannabis and cancer versus standard cancer therapies using Google Trends' relative search volume (RSV) tool and determined the impact of cannabis legalization. We classified news on social media about cannabis use in cancer as false, accurate, or irrelevant. We evaluated the cannabis-related social media activities of cancer organizations. Results The online search volume for cannabis and cancer increased at 10 times the rate of standard therapies (RSV 0.10/month versus 0.01/month, p<0.001), more so in states where medical or recreational cannabis is legal. The use of cannabis as a cancer cure represented the largest category (23.5%) of social media content on alternative cancer treatments. The top false news story claiming cannabis as a cancer cure…

The use of a central line or central venous catheterization was brought to attention in 1929 when Dr. Werner Forssmann self-inserted a ureteric catheter through his cubital vein and into the right side of his heart. Since that time the central line technique has developed further and has become essential for the treatment of decompensating patients. Central lines are widely used for anything from rapid fluid resuscitation, to drug administration, to parenteral nutrition, and even for administering hemodialysis. Central lines come in different sizes, types, and sites of administration. Sometimes their use can be associated with complications as well. The following review article addresses these parameters of central lines and goes into detail regarding their complications.

Objective Lattice radiotherapy (LRT) is a novel technique of delivering heterogeneous doses of radiation to voluminous tumors not amenable to surgery. Built from the conventional two-dimensional grid, LRT utilizes the power of new technology, three-dimensional radiation allowing the delivery of higher doses of radiation to small spheres, also called vertices, inside bulky tumors while limiting exposure to surrounding healthy tissue. The main goals of the study were the evaluation of tumor response and the overall safety of LRT in this cohort of patients with bulky non-small cell lung cancer. Materials and methods During a seven-year period, 10 patients with non-small cell lung cancer (NSCLC), who presented with bulky, unresectable tumors, were treated using a single fraction of LRT followed by conventionally fractionated radiation. Patients received one initial LRT fraction of 18 Gy in the vertices and 3 Gy in the periphery. After the LRT, all patients continued with conventional radiation: 25 to 29 daily fractions of 1.8 Gy to 2 Gy. Results With a median follow-up of six months…

Global warming is a phenomenon that is affecting society in sundry ways. As of 2017, Earth's global surface temperature increased 0.9°C compared to the average temperature in the mid-1900s. Beyond this change in temperature lies significant threats to human health in the form of natural disasters and extreme temperatures. One natural disaster that has been receiving much more attention as of 2010 is the ignition and spread of wildfires. Warmer climates lead to drier conditions, providing ideal kindling for the rapid spread of these infernos. The dangers that these intense fires pose are twofold: first, the fire causes mass property damage, physical harm, or death to the people unfortunate enough to be caught in the blaze; second, the health hazards of smoke inhalation and the emotional strain of losing one's possessions cause immense physical and emotional harm to the fire's victims. Another health hazard that is becoming more common due to global warming is heatwave exposure. The heat provides an ideal environment for certain pathogens to thrive, increases people's risk of…

Medical errors are the eighth leading cause of mortality in the United States and contribute to over one million preventable injuries. In an effort to prevent medical errors, reporting systems serve as invaluable tools to detect patient safety events and quality problems longitudinally. Historically, trainees (i.e., students and residents) rarely submit incident reports for encountered patient safety threats. The authors propose an immersive learning experience utilizing gamification theory and leveraging the increasingly popular ‘escape room’ to help resident trainees identify reportable patient safety priorities. All 130 incoming intern physicians at the Thomas Jefferson University (Jefferson) were enrolled in the Patient Safety Escape Room study as part of their residency orientation (June 2018). The residents were randomly divided into 16 teams. Each team was immersed in a simulated escape room, tasked with identifying a predetermined set of serious patient safety hazards, and successfully manually entering them into the Jefferson Event Reporting System within the time allotted…

Dravet syndrome (DS), also known as severe myoclonic epilepsy of infancy (SMEI), is one of the rare early childhood intractable epileptic encephalopathies associated with pleomorphic seizure activity, cognitive decline, motor, and behavioral abnormalities. The convulsive seizure is the most common type seen in DS. After the first episode of seizure-like activity, behavioral disorders and cognitive decline are progressive and long-lasting. The most common etiology identified in patients with DS is a de-novo genetic mutation alpha-1 subunit of voltage-gated calcium channel gene (SCN1A). DS is diagnosed clinically and if unclear, genetic testing is recommended. DS treatment options include anti-epileptic drugs and cannabinoids; ketogenic diet therapy and surgical options such as the deep brain and vagal nerve stimulation. Due to drug-refractory epilepsy in DS, many more therapies are being investigated to increase the longevity of patients.

Implementing an electronic health record (EHR) can be a difficult task to take on and planning the process is of utmost importance to minimize errors. Evaluating the selection criteria and implementation plan of an EHR system, intending interoperability, confidentiality, availability, and integrity of the patient health information data, while ensuring timely, accurate, and regulatory compliant generation of reports is a critical task. This article discusses the selection and implementation plan that will primarily consist of assessing existing institutional workflows for each department, and it outlines the necessities and inclinations of the institution to include in the EHR system for the organization to function properly. Resources and tools are included to assist in the selection of the product as well as ideas on how to train staff and evaluate staff readiness. Regulatory requirements are also included for consideration during the initial process. EHR increases the logistic productivity of workflows and offers a safer way to care for patients. To ensure efficiency, there is a…

Cancer of unknown primary (CUP) is a malignant widespread metastatic disease without an identifiable primary site after extensive clinical investigation. Recently, a decline is observed in the diagnosis of CUP, mainly due to improvement in detection of the primary tumors, thus decreasing the unknown primaries. Worldwide, CUP is the sixth to eighth most common malignancy, accounting for 2.3% to 5% of a new cancer diagnosis. CUP is third to fourth most common cause of death due to cancer-related mortality. The prognosis of CUP is depressing with the median survival of three to six months in the previous studies, but according to recent studies, median survival is less than one year. High risk for developing CUP is seen in heavy smokers (26 or more cigarettes/day) and individuals with the lowest quartiles of waist circumference. A weak association is observed with the use of alcohol consumption and low level of education. Human papillomavirus DNA plays a role in those with squamous cell carcinoma of unknown primaries in head and neck regions. In the diagnosis of CUP, comprehensive…

Introduction Diabetes mellitus (DM) is a chronic, progressive metabolic illness which is commonly complicated by coexistence of depression and anxiety. This study aimed to assess the prevalence of anxiety and depression among diabetic patients and the factors predicting this coexistence. Methods It was a cross-sectional, observational study which included patients of type 2 DM admitted in the hospital due to diabetes-related condition - diabetic foot infections/ulcers, hyperosmotic hyperglycaemic state (HHS), and hypoglycaemic coma/seizure. Anxiety and depression were measured by using the Hospital Anxiety and Depression Scale (HADS). Data was entered and analysed using SPSS version 22.0 (IBM Corp., Armonk, NY, USA). Results Mean anxiety score of the participants was 10.88 ± 4.075 and mean depression score was 11.82 ± 4.049. There were 72 (50.7%) patients who had anxiety and 70 (49.2%) patients who had depression. Higher scores of anxiety and depression were statistically significant in female gender, older participants, individuals with longer duration of diabetes, those taking…

In rural and underserved areas, there are restrictions in healthcare due to the lack of availability of neurologists; patients have to travel long distances to receive the required care. Considering the fact that neurological conditions have large mortality and disability rates, there is a need for innovative services like tele-neurology. It is an important tool in improving the health and quality of life by using different ways of communication between neurologists and patients, or neurologists and other providers. We examine the current types of facilities available in tele-neurology, as well as outcomes, barriers, limitations, legal litigations, and the multidisciplinary nature based on prior studies. We have also suggested recommendations for the future of tele-neurology including effective-accessibility and inexpensive-utilization in developing countries. There are various tele-health programs created by The Veterans Health Administration including a clinical video tele-health (CVT) system. This system allows direct patient care of veterans by neurologists. The University of…

Introduction Gastrointestinal stromal tumor (GIST) was once a mislabeled cancer with inaccurate incidence data in the United States (US). Since the discovery of a gain of function mutation in kit, the proper identification of GIST has greatly improved. Given this inaccuracy in prior GIST incidence, our goal in this study was to evaluate the true incidence of GIST in at-risk populations in all 50 states. Methods The United States Cancer Statistics (USCS) was used to obtain data for GISTs from 2001 to 2015. Incidence analysis was done for sex, race, stage, primary location, and US regional location. Results The overall incidence of GISTs from 2001-2015 was 0.70 per 100,000 people per year. Overall incidence rates were greatest for each stratification of males, blacks, localized disease, primary location in the stomach, and the Northeast. The incidence in blacks increased with an annual percent change (APC) of 6.27 between 2001 and 2015. Between 2001 and 2015, the incidence of localized disease and GISTs with a primary location in the stomach increased with APCs of 8.90 and 6.25,…

Introduction Over the past few years, there have been drastic advancements in the management of type 1 and 2 diabetes mellitus (DM). Prevention of complications is a prime concern of all physicians dealing with DM. However, whether or not these interventions have helped in reducing the incidence of diabetic ketoacidosis (DKA) in patients with type 1 DM, is still an unanswered question. The aim of this study is to assess the clinical pattern of DKA, evaluate its outcomes, and study the predictors of outcome. Methods The study was conducted as a prospective, observational one in the department of medicine of a tertiary care hospital from July-December 2018. Patients of type 1 DM presenting in the emergency department with DKA were evaluated for their predisposing factors, clinical presentation, biochemical parameters, rate of mortality, and predictors of mortality. Data was processed through and analyzed using IBM SPSS Statistics for Windows, version 22.0 (IBM Corp., Armonk, NY). Results The common clinical presentations include severe vomiting (32.2%), abdominal pain (27.9%), and…

The most important thing about autism spectrum disorder (ASD) is that there is, in fact, no cure for this disorder; however, currently, there are many claims of pharmacological and dietary therapies and behavioral interventions that are said to improve outcome or even lead to "cure" or "recovery." It continues to remain a challenging condition for children and their families. Research conducted on many of these treatment modalities is limited and, consequently, sufficient evidence does not exist to support their use. The primary aim of this paper was to search for the evidence of the efficacy of each treatment for autism till now. We reviewed different treatment modalities and randomized clinical trials on each treatment to look for the evidence. Although there are interventions that may be effective in alleviating some symptoms and improving skills that help autistic persons lead more productive lives, proven benefits were observed only with applied behavioral analysis (ABA) and some psychopharmacologic agents.

Major adverse cardiovascular events (MACE) remain the major cause of mortality and morbidity in patients with STEMI (ST-elevation myocardial infarction). The current literature is aimed to analyze the occurrence of MACE following STEMI irrespective of treatment provided, and follow up after the first diagnosis of STEMI. A PubMed search for Studies of STEMI identified 24,244 articles. After applying our inclusion/exclusion criteria, we found out 75 articles of relevance wherein MACE and its components were considered to be the primary endpoint. These 75 articles included eight Cohort Studies, 13 clinical trials including five randomized controlled trials (RCT), one case-control Study, one cross-sectional study, one review article, and 51 other observational studies. Our analysis shows that MACE remains one of the strongest adverse outcomes among STEMI patients. The current literature review found out the incidence of MACE was 4.2 % to 51% irrespective of the mode of treatment, and follow-ups lasting up to 10 years from the time of STEMI diagnosis.

The abscopal effect is mediated by a systemic anti-tumor immune response and reflects the regression of non-irradiated metastatic lesions at a distance from the primary site of irradiation. This review will focus on understanding the biological rationale behind the abscopal effect of radiotherapy (RT), which has a recently renewed interest as a result of the successes achieved with immunotherapy and RT in combination. Both RT and immunotherapy are standard components of modern treatment regimens. Combination of these two modalities results in an increased response in the irradiated lesions themselves and the metastatic regions distant from the site of irradiation. We will summarize the abscopal effect of radiotherapy, in particular, the synergistic effect of RT and immunotherapy.

Thermal osteonecrosis is the in situ death of bone tissue as a result of excessively high temperatures. While the exact temperature at which thermal osteonecrosis occurs has not yet been determined, 50°C is the accepted critical value, as bone regeneration is almost completely impaired from this point on. Thermal osteonecrosis is a significant concern in orthopedic surgery, as it can compromise the bone-implant interface in fracture fixation, which, by definition, is a complication. A literature review was undertaken of the pertinent literature concerning heat generation from bone drilling and how this heat affects bone tissue. The Pubmed, ScienceDirect, and secondary (Cochrane Library) databases were searched up to December 2017 using keywords with the appropriate use of Boolean operators. Both simple text word searching and thesaurus searching were used to maximize the number of relevant articles retrieved. Reference tracking was performed via the retrieved articles to further extend the boundaries of the search. The level of evidence was Level V. It was identified that factors…

Background Despite the number of female medical-school applicants reaching an all-time high and the increasing number of females in surgical training, males retain an overwhelming majority in senior surgical academic positions and formal leadership positions. This study aims to better understand the extent of and influences for gender disparity in general surgical societies throughout North America, Europe, and Oceania. Methods Data collection for this retrospective cross-sectional study took place between June and December 2017. Committee and subcommittee members from the eight selected general surgical societies that met the inclusion criteria (n = 311) were compiled into an Excel spreadsheet in which the data was recorded. Analyzed metrics included university academic ranking, surgical society leadership position, h-index, number of citations, and total publications. SCOPUS database (Elsevier, Amsterdam, Netherlands) was used to generate author metrics, and STATA version 14.0 (StataCorp, College Station, TX) was used for statistical analysis. Results Overall, 83.28% of members of…

Academic clinicians have high expectations to meet in their academic institutions. Accomplishments are to be expected in multiple domains for their positions' sustainability and promotions. In addition to excelling in their clinical practice, they are expected to maintain productive scholarly activities and meet the required educational and administrative responsibilities. Striking a balance between clinical, educational, research, and administrative duties is highly challenging and could lead to emotional exhaustion and burnout. Lately, the ever-growing patient population, competitive academic environment, and resident work hour restrictions have led to increased strain and demand on academic physicians and predisposing them to burnout. Despite the numerous studies looking at burnout in various professions, fewer studies have looked at burnout, specifically in clinical faculty members. Little is known about academic job satisfaction, stress, and rates of burnout, or how these factors affect scholarly success and productivity. Clinician faculty educators may be at significant risk…

Alzheimer's disease (AD) is the most common cause of dementia in elderly patients, affecting individuals older than 60 years. It is a complex degenerative brain disease characterized by progressive cognitive impairment. AD constitutes a major global health concern. A central role for inflammation has been implicated in the pathogenesis of AD. Despite the understanding of multiple molecular pathways in the pathophysiology of AD, novel treatment agents with a possible role in modifying the disease activity are still lacking. Our article provides a comprehensive review of various observational studies and randomized trials encompassing the use of anti-inflammatory agents in the management of AD patients and utilizes the conclusions derived therefrom to give recommendations in this regard.

The prevalence of pruritus in chronic kidney disease (CKD) patients has varied over the years, and some studies suggest the prevalence may be coming down with more effective dialysis. Chronic kidney disease-associated pruritus (CKD-aP), previously called uremic pruritus, is a distressing symptom experienced by patients with mainly advanced chronic kidney disease. CKD-aP is associated with poor quality of life, depression, anxiety, sleep disturbance, and increased mortality. The incidence of CKD-aP is decreasing given improvements in dialysis treatments, but approximately 40% of patients with end-stage renal disease experience CKD-aP. While the pathogenesis of CKD-aP is not well understood, the interaction between non-myelinated C fibers and dermal mast cells plays an important role in precipitation and sensory stimulation. Other causes of CKD-aP include metabolic abnormalities such as abnormal serum calcium, parathyroid, and phosphate levels; an imbalance in opiate receptors is also an important factor. CKD-aP usually presents as large symmetric reddened areas of skin, often at…

Clostridium difficile is a gram-positive bacterium notorious for causing epidemic diarrhea globally with a significant health burden. The pathogen is clinically challenging with increasing antibiotic resistance and recurrence rate. We provide here an in-depth review of one particular strain/ribotype 027, commonly known as NAP1/B1/027 or North American pulsed-field gel electrophoresis type 1, restriction endonuclease analysis type B1, polymerase chain reaction ribotype 027, which has shown a much higher recurrence rate than other strains.

Introduction Any infection occurring at the site of a surgical incision superficially or deep within the fascia, within 30 days of a surgical procedure is termed as a surgical site infection (SSI). Due to limited resources, non-adherence to infection control guidelines and substandard sterilization practices, the incidence is higher in developing countries. The aim of this study is to estimate the incidence of surgical site infections in general surgeries at a tertiary care hospital in Pakistan and identify the predisposing risk factors. Methods This was a retrospective analysis that included all surgical records from June 1, 2018, to December 31, 2018. After exclusion, 882 records were included. The incidence of SSI and predisposing risk factors were noted. Data were entered and analyzed using SPSS v. 22.0 (IBM Corp, Armonk, NY, US). Results The incidence of SSI was 8.84% (n=78). SSIs were more common in older participants (11.4% vs. 6.4%; p=0.009), in patients with more than 24 hour of preoperative hospital stay (11.2% vs. 64%; p=0.013), in procedures of longer duration (1.53 ±…

The objective of this study was to conduct a review of the benefits and adverse effects of cannabis (or marijuana) legalization in various states across the US. The current study offers a preliminary evaluation of the problems concerning marijuana legalization in several states, with the primary goal being the assessment of the impact of laws and policies governing the legalization and use of marijuana for medical purposes. A comprehensive search on cannabis and its derivatives was performed using multiple resource databases: PubMed, MEDLINE, Embase, PsycINFO, CENTRAL (Cochrane Controlled Register of Trials), government web sources, and the Department of Public Health databases. A total of 47 reports that evaluated the effects of cannabis legalization were included in this review. All review stages were conducted independently by two reviewers. Data were extracted in standardized tables by one reviewer and adjusted by a second, which were verified by the third author. We examined the use of cannabis before and after the changes in policy and the impact of marijuana legalization on…

Primary spinal astrocytoma is a subtype of glioma, the most common spinal cord tumor found in the intradural intramedullary compartment. Spinal astrocytomas account for 6-8% of all spinal cord tumors and are primarily low grade (World Health Organization grade I (WHO I) or WHO II). They are seen in both the adult and pediatric population with the most common presenting symptoms being back pain, sensory dysfunction, or motor dysfunction. Magnetic Resonance Imaging (MRI) with and without gadolinium is the imaging of choice, which usually reveals a hypointense T1 weighted and hyperintense T2 weighted lesion with a heterogeneous pattern of contrast enhancement. Further imaging which may aid in surgical planning includes computerized tomography, diffusion tensor imaging, and tractography. Median survival in spinal cord astrocytomas ranges widely. The factors most significantly associated with poor prognosis and shorter median survival are older age at initial diagnosis, higher grade lesion based on histology, and extent of resection. The mainstay of treatment for primary spinal cord…

Background Any infection occurring in a wound after a surgical procedure is called a post-operative surgical wound infection. Surgical wound infection is a type of nosocomial infection that is acquired in hospitals when a person is admitted for reasons other than the infection. Surgical site infections (SSIs) are the second most common nosocomial (hospital-acquired) infections after urinary tract infections. SSIs contribute to a significant rate of morbidity and mortality in patients and has become a major public health problem worldwide. The increase in antibiotic resistance associated with SSIs has also become a therapeutic challenge for physicians worldwide. Methods This cross-sectional study was carried out among the patients admitted in various surgical wards of the Ayub Teaching Hospital. A total of 95 patients were enrolled for the study using a non-probability convenient sampling technique. Data were collected using a structured questionnaire by students carrying out the research for a time period of one month. SSIs were assessed by: 1. Pus or purulent discharge from the…

Efficacy and tolerance of pharmacological medications in chronic pain are limited. Therefore, repetitive transcranial magnetic stimulation (rTMS) is regarded as a secure therapeutic option for pain relief, and it was proven to produce an analgesic effect. A wide variety of stimulation parameters can influence its long-lasting antalgic effect. Defining the best stimulation protocol can afford greater uniformity and consistency for considering rTMS as a promising effective tool. We aimed to systematically review and evaluate the current literature on transcranial magnetic stimulation for patients suffering from chronic pain, assess its efficacy, and estimate the best stimulation protocol. The Screened and tested electronic databases comprised PubMed, Ovid Medline, Cochrane database library, and Google scholar from the year 2000 till 2018. The keywords utilizing search terms "Transcranial magnetic stimulation", "chronic pain", "neuropathic pain" were used to study all possible randomized clinical trials about the impact of transcranial magnetic stimulation on long-lasting pain. All…

Background Anemia is one of the most common conditions that affect pregnancies, with dietary iron deficiency being its most common cause. Maternal anemia has been associated with increased risks of both maternal and neonatal adverse outcomes. This study aimed to analyze the maternal and neonatal outcomes in women with third-trimester anemia. Methods This was a retrospective report from a Pakistani public hospital. It included data records of the childbirths in the hospital, with at least one record that documented the hemoglobin (Hb) level in women in the first or second trimester and one in the third trimester. The duration of the study was from January 1, 2019 to June 30, 2019. Women with Hb level of <10mg/dL in the third trimester were categorized as anemic, and those with Hb level of >10mg/dL were categorized as non-anemic. Pregnancy outcomes were assessed for both mothers and babies. All data were processed through SPSS version 21.0 for Windows (IBM Corp., Armonk, NY). Results The study evaluated 235 (37.8%) anemic and 387 (62.2%) non-anemic women. Adverse maternal outcomes…

Iron deficiency anemia (IDA) is the most common type of anemia. Impaired iron absorption can be caused by a decrease in trace elements as zinc, which is found in the structure of enzymes that coordinate or catalyst iron metabolism. The aim of this study is to detect if zinc deficiency is associated with IDA and to determine the effect of associated zinc deficiency on symptoms of IDA in adult IDA patients. This case-control study included 30 IDA patients with matched healthy control group (n = 30) for age and sex. For each subject, the parameters were evaluated: hemoglobin (Hb); mean corpuscular volume (MCV), total iron binding capacity (TIBC), serum iron, serum ferritin (SF). Serum zinc levels were measured by atomic absorption method with the PerkinElmer Analyst. Symptoms attributed to iron deficiency or depletion, defined as fatigue, cardiopulmonary symptoms, mental manifestations, epithelial manifestations, and neuromuscular symptoms were recorded. Serum zinc levels were lower in IDA patients (43.4 ± 7.9 mg/dL) than in the control subjects (94.7 ± 16.75 mg/dL; p < 0.0001). Zinc…

Objectives The clinical outcomes of patients treated with spatially fractionated GRID radiotherapy (SFGRT) for bulky tumors of the head and neck at a single institution were evaluated retrospectively. Endpoints of interest included tumor response, symptom improvement, treatment tolerance, and adverse events. Methods Institutional review board approval was obtained prior to study initiation. The institutional database was queried for patients with tumors of the head and neck treated with SFGRT between August 2007 and April 2015. Medical records of identified patients were reviewed for treatment details and clinical endpoints of interest. SFGRT was delivered in one fraction of 15 gray (Gy) or 20 Gy; 6 megavolt (MV) or 18 MV photon beams were passed through a multileaf collimator (MLC)-based or brass GRID template. All patients had a planned course of conventionally-fractionated external beam radiotherapy (EBRT) to begin on the day following SFGRT delivery. Results Twenty-one consecutive patients meeting study criteria were identified. The most common tumor histology was squamous cell…

Introduction Ocular involvement in leukemia may occur because of direct leukemic infiltration or because of secondary ophthalmic involvement as a result of abnormalities related to blood like anemia, thrombocytopenia, and leukocytosis. In some patients with leukemia, ophthalmic signs can precede the systemic features and can help in early diagnosis of systemic leukemia. Due to the scarcity of data on this topic from Pakistan, we conducted this study to determine the pattern of ocular involvement in patients with leukemia presenting in our settings. Methods This cross-sectional study was conducted in a tertiary care hospital of Pakistan over a period of one year. The study comprised of both newly diagnosed and follow-up patients of acute leukemia of age more than 15 years. Patients underwent detailed ophthalmic anterior and dilated posterior segment examination. Patient's demographic profile, type of leukemia, chemotherapy status, and hematologic findings were also documented. Results There were 97 leukemic patients in the study with 55 (56.7%) males and 42 (43.3%) females. Various…

The United States Federal Centers for Disease Control and Prevention (CDC) has been working with state investigators on reported cases of lung illnesses linked to e-cigarette or vaping products. Symptoms of difficulty breathing, shortness of breath, chest pains, gastrointestinal sickness leading to serious lung damage and death has been linked to the risk behavior of using vaping products bought on the streets in healthy young people. CDC has detected vitamin E acetate as a chemical of concern among people with the lung injury. Vitamin E acetate is a condensing agent in vaping products, and all injured lung fluid samples appear to harbor this agent. The mysterious outbreak is identified in individuals vaping within the 90 days, ranging over a few days to developing over several weeks. There is growing evidence that vaping is hazardous to your health including immediate health dangers such as death from respiratory causes, long term health effects, cardiovascular events, depression which increases the risk of suicidal thoughts and suicide. This review article summarizes the growing…

Pericarditis is a common cardiac manifestation in systemic lupus erythematosus (SLE). Serositis is recognized in the ACR, SLICC, and EULAR/ACR classification criteria. We reviewed the prior research regarding the epidemiology, risk factors, presentation, and treatment of pericarditis in SLE.

Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality and morbidity in low- and middle-income countries (LMICs) including Bangladesh. But no systematic review has been carried out in Bangladesh, which portraits the burden of COPD and its risk factors. Therefore, this systematic review was conducted to find out the prevalence and risk factors of COPD in Bangladesh. We searched PubMed, Google Scholar, Popline, and Banglajol from January 1, 1972 to April 30, 2017. We included studies that reported the prevalence and/or risk factors of COPD among Bangladeshi people. Two researchers independently searched and screened all the articles and extracted data from nine eligible studies. The whole process was verified by another researcher. Quality assessment was performed using a checklist adopted from published articles on quality assessment guidelines of observational studies. Discrepancies were resolved by consensus. Data analysis was done thematically. The pooled COPD prevalence among Bangladeshi adult was 12.5% (95% CI, 10.9-14.1) using the Global Initiative for…

Mindfulness is being used increasingly in various aspects of cancer management. Benefits of mindfulness practices are being observed to manage the adverse effects of treatment, symptoms from cancer progression, and the cost-effectiveness compared to conventional contemporary management strategies. In this review article, we present clinical trial data showing the benefits of mindfulness in various aspects of cancer management as well as techniques that have been commonly used in this practice.

Anal fistula, or fistula-in-ano, is a condition involving the anal region that is common yet debilitating. Surgery is the mainstay of treatment for an anal fistula and the chances of recurrence are quite high even after corrective surgical procedures. The risk factors for recurrence can be broadly classified into four categories: 1) risk factors related to the fundamental anatomy of the fistula and presence of comorbidities, 2) lack of proper preoperative assessment of the fistula, which includes failure to recognize the internal opening and overall structure of the fistula and not supplementing the proctologic examination with sufficient imaging, 3) intraoperative loopholes that include improper procedure selection, inexperience of the surgeon, and failure to get rid of the entire tract along with its ramifications, and 4) lack of proper postoperative care in the early and late periods following the surgery. The aim of this paper, therefore, is to highlight the factors that could increase the risk of recurrence in different types of anal fistulae. Once surgeons know these risk…

Immune thrombocytopenic purpura (ITP) is an autoimmune condition that affects nearly 1:10,000 people in the world. It is traditionally defined by a platelet count of less than 100 x 109L, but treatment typically depends on symptomology rather than on the platelet count itself. For primary idiopathic ITP, corticosteroids have been the standard first-line of treatment for symptomatic patients, with the addition of intravenous immune globulin (IVIG) or Rho(D) immune globulin (anti-RhD) for steroid-resistant cases. In cases of refractory or non-responsive ITP, second-line therapy includes splenectomy or rituximab, a monoclonal antibody against the CD20 antigen (anti-CD20). In patients who continue to have severe thrombocytopenia and symptomatic bleeding despite first- and second-line treatments, the diagnosis of “chronic refractory ITP” is appropriate, and third-line treatments are evaluated. This manuscript describes the efficacy of different treatment options for primary ITP and introduces the reader to various third-line options that are emerging as a means of treating chronic…

Simulation-based education has been shown to be an effective tool to mitigate skill decay. However, many of the strategies reported in the literature have overlapping terminology with little consensus on the timing of the strategy to prevent skill decay. In this review, we propose and provide a standardized nomenclature and framework for simulation strategies used to obtain, maintain, or regain skills that are decaying. This framework delineates four types of training: initial, maintenance, booster, and refresher. The framework differentiates these training types based on the learner competency at the time of the training, as well as the frequency and intensity of the training. Initial training is aimed at "novice" learners with the goal to achieve competency. Once competency is achieved, maintenance training prevents skill deterioration through low-dose high-frequency (LDHF) training. Booster training is used when the learner is still proficient, but competency begins to wane. Booster training occurs less frequently than maintenance training but with greater intensity to overcome…

Introduction Undergraduate medical research is very important not only for scientific learning but also for career progress. However, there are barriers, especially in developing countries, that restrict undergraduate research. This study aims to evaluate the barriers experienced by medical students in conducting research at undergraduate level. Methods It was an observational, cross-sectional survey conducted with 687 clinical students of two public medical universities of Pakistan. A self-structured questionnaire consisting of seven items was administered to assess the barriers in conducting research at undergraduate level. Data was processed and analysed through SPSS v 22.0 (IBM Corp., Armonk, NY, USA). Results Lack of knowledge as a barrier was identified by 90.68% (n = 623) students. The second most common barrier identified by the students was lack of time (88.79%; n = 610), followed by lack of mentoring as the third most common barrier (85.74%; n = 572). Sub-group analysis showed that lack of knowledge, lack of mentoring, limited data base access, lack of time, and lack of…

This review article aims to provide insight into the mechanisms of action, pharmacokinetics, clinical efficacy, safety and tolerability of four novel antidepressants including desvenlafaxine, vortioxetine, vilazodone, and levomilnacipran. Following keywords are used in PubMed and Scopus to search for relevant articles: (depression) AND (psychopharmacology OR desvenlafaxine OR levomilnacipran OR vortioxetine OR vilazodone). Patients with a lack of effectiveness or tolerability to certain antidepressants may get benefit from selecting a new antidepressant with different mechanism of action. These medications can be an option in the selection of newer antidepressants. Depression may not be caused by the simple deficiency of serotonin in the brain, but rather a complex interplay of various neurotransmitters including serotonin, norepinephrine, glutamate, and histamine at certain brain areas. The above-mentioned novel antidepressants exert their therapeutic benefits by acting on multiple neurotransmitters. The complexity of underlying the neurobiological mechanism should be considered…

Background Occupational burnout is an unwanted outcome of chronic workplace stressors which may be emotional or interpersonal. Chronic exposure to human suffering and long working hours have contributed to greater job stress and early burnout among healthcare providers. This study utilized the abbreviated Maslach Burnout Inventory (aMBI) to gauge the extent of overall burnout and on three subscales - perspective taking, compassionate care, and walking in patients' shoes - among interns, postgraduate trainees, and physicians of internal medicine. Materials and methods In this cross-sectional study, 71 internal medicine doctors - 40 interns, 22 postgraduate trainees, and nine physicians - completed aMBI with informed consent. It is a nine-item scale with three subscales - emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). Each subscale has three items that are marked on a seven-point Likert scale. Higher scores of EE and DP indicate higher burnout, and a higher score of PA indicates lower burnout. Overall burnout was taken as the sum of EE and DP.…

Allergic bronchopulmonary aspergillosis (ABPA) is a pulmonary disorder that results from a hypersensitivity reaction to the fungi Aspergillus fumigatus (Af). It presents with pulmonary infiltrates and bronchiectasis. Past research studies on ABPA have led to the conclusion that it is both underdiagnosed and much more prevalent than previously assumed. The underdiagnosing of ABPA is due to a lack of consensus regarding diagnosis and treatment. Complications that result from delay in treatment for ABPA are pulmonary fibrosis, bronchiectasis with chronic sputum production, and severe persistent asthma with loss of lung function. Because of this, it becomes imperative that ABPA treatment guidelines are reviewed and more thoroughly evaluated regarding their efficacy. The following article addresses the epidemiology, the pathophysiology, and the treatment of ABPA. The treatment is studied in detail regarding the types of medications used and their proven clinical impact on patients according to past research studies. The aim of this article is to address the current need for larger…

Background Stereotactic body radiation therapy (SBRT) is a proven and effective modality for treatment of hepatic primary and metastatic tumors. However, these lesions are challenging for planning and treatment execution due to natural anatomic changes associated with respiration. Magnetic resonance imaging (MRI) offers superior soft tissue contrast resolution and the ability for real-time image-guided treatment delivery and lesion tracking. Objective To evaluate the plan quality, treatment delivery, and tumor response of a set of liver SBRT cancer treatments delivered with magnetic resonance (MR)-guided radiotherapy on a MR-linear accelerator (MR-linac). Methods Treatment data from 29 consecutive patients treated with SBRT were reviewed. All treatments were performed using a step and shoot technique to one or more liver lesions on an MR-linac platform. Patients received 45 to 50 Gy prescribed to at least 95% of the planning target volume (PTV) in five fractions except for two patients who received 27-30 Gy in three fractions. Computed tomography and MRI simulation were performed in…

INTRODUCTION: Since 2016, the province of Sindh is in the limelight because of its association with the emergence and spread of extensively drug-resistant Salmonella typhi (XDR S. typhi). Although its global spread has been proven in several studies, our information regarding its countrywide existence is still insufficient. In the last four years, few cases of XDR S. typhi were identified at the Shifa International Hospital (SIH), Islamabad, Pakistan. This article aims to report demographic patterns, clinical presentations, and treatment outcome of these cases. MATERIALS AND METHODS: This study was conducted at SIH, Islamabad, on blood culture-proven XDR S. typhi cases from January 2015 to December 2018. The data were retrieved from the hospital's record system. Patient demographic details, clinical presentations, management, and disease outcomes were evaluated and statistical analysis was performed through IBM SPSS Statistics for Windows, version 23.0 (IBM Corp., Armonk, NY). RESULTS: A total of 30 blood culture-proven XDR S. typhi cases were identified and 80% (24) of them were…

Background End-stage renal disease (ESRD) is a major public health problem with many associated symptoms. Uremic pruritus (UP) develops in 40% of patients on hemodialysis and has major effects on the patient's life. It is also an independent risk factor for increased mortality, and its psychiatric implications remain poorly characterized in our local setup, where it tends to be underdiagnosed and undertreated. Objectives and rationale The study aims to report the prevalence of uremic pruritus in our study population and associate it with various patient parameters, which may define a subset of patients at high risk for this pruritus. We also assess the effects of uremic pruritus on the patient's quality of life (by using the Dermatology Life Quality Index; DLQI) and depressive symptoms (by using the Public Health Questionnaire; PHQ-9). Materials and methods It was a descriptive, cross-sectional study conducted in the nephrology unit of the multi-organ failure (MOF) center of the Holy Family Hospital (HFH), Rawalpindi, Pakistan, from February 2019 to June 2019, during which 173 male…

Dual-plating of the distal femur is required in some cases to achieve stable fixation. The indications of a medial plate in addition to the lateral plate are medial supracondylar bone loss, low trans-condylar bicondylar fractures, medial Hoffa fracture, peri-prosthetic distal femur fractures, non-union after failed fixation with single lateral plate, poor bone quality and comminuted distal femur fractures (AO type C3). We recommend orthogonal plate configuration with locked plates by a single incision or dual incision approach as per surgeon choice.

Pain and joint dysfunction of the upper limb following treatment for mammary carcinoma are defined as the most frequent side effects of surgery for mammary carcinoma by calculating a prevalence range in the USA that varies between 12% and 51% with regard to pain and between 1.5% and 50% for joint dysfunction. This objective of this study was to describe physiotherapy interventions that demonstrate efficacy based on the type of pain present in patients with shoulder pain who have been treated for breast cancer. We conducted a search for relevant publications in the last 10 years (2009-2019) on the PubMed, Medline, CINAHL, and Cochrane databases. The articles obtained were selected on the basis of correlation criteria, with themes concerning shoulder pain after mammary carcinoma and physiotherapy performed to treat this pain. Studies suggest treating musculoskeletal pain through active exercises, joint and tissue mobilization techniques, with accessory joint mobilization and neurodynamics performed by experienced physiotherapists. In order to treat radio-induced and drug-induced…

Background Major depressive disorder (MDD) is a disabling health problem with a very high global prevalence and burden. Alteration of inflammatory markers in depression is of growing interest to many psychiatry researchers. This study aimed to examine the serum levels of interleukin-6 (IL-6) and C-reactive protein (CRP) in MDD patients to find out their association with depression. Materials and methods The present study recruited 88 MDD patients and 86 control subjects matched by age, gender, and body mass index (BMI). The Hamilton depression rating scale (Ham-D) was used on all patients to measure their severity of depression. Serum levels of IL-6 and CRP were analyzed by commercially available enzyme-linked immunosorbent assay (ELISA) kits (Abcam, Cambridge, MA, USA). Results The mean values of serum levels of IL-6 and CRP were 2.94 ± 0.12 pg/mL and 0.99 ± 0.02 mg/L for the patient group and 2.42 ± 0.21 pg/mL and 1.09 ± 0.06 mg/L for the control group, respectively. We found significantly elevated concentrations of serum IL-6 in MDD patients compared with control subjects (p <…

Introduction: Burn wounds are commonly infected by organisms which delay wound healing. Therefore, it is necessary to evaluate the flora obtained from wounds of burn patients in order to determine the most effective treatment. The aim of this study was to determine the frequencies of various bacteria isolated from burn wounds and to determine their antimicrobial susceptibility. Materials and methods: This descriptive cross-sectional study was conducted from January 2018 to November 2018 which included consecutive samples of burn wounds from patients admitted to the burn ward of a tertiary care hospital. Bacteria and their antimicrobial susceptibility were determined by swab cultures and sensitivity tests by standard aseptic techniques. Data were analysed via the Statistical Package for Social Sciences (SPSS), v23.0 (IBM SPSS Statistics, Armonk, NY). Chi-square tests were applied between qualitative variables, while the Kruskal-Wallis test was applied to compare the means of asymmetrical data. Bacterial isolates and their susceptibility pattern were represented as frequencies and pie…

Over the last decades several studies among the adult population have attempted to establish a correlation between the risk of stroke incidence and serum uric acid (SUA) concentration, and how these levels influence the patient's neurological outcome after a stroke. But, to date, the results are conflicting. In this review, an extensive literature search was performed through PubMed for articles published until May 2019 to review the association. The study selection was narrowed by searching PubMed database using the Medical Subject Headings (MesH) and associated keywords. Only articles conducted in English and on human subjects were included. We considered an article for this review if it had statistics on either the incidence, stroke mortality or post-stroke functional outcomes along with serum uric acid levels in adults. This review includes 21 articles with data of 33,580 cases of stroke and 1,100,888 participants. We can divide the articles reviewed into two separate cohorts of studies. One relates serum uric acid levels to stroke frequency and mortality, while the other is…

Insomnia can be defined as difficulty falling asleep or maintaining sleep, waking up earlier than expected, or having non-restorative sleep. It is one of the most common sleep disorders in the world. Insomnia is a common symptom of many neurodegenerative diseases but only recently has it been found that it is a risk factor for neurodegenerative disorders such as Alzheimer's disease and Parkinson's disease. We did a traditional review to analyze the relationship between insomnia and neurodegenerative diseases. We analyzed all the relevant articles on Pubmed and included studies done on humans over the last 10 years with full text available. After reviewing the available literature on Pubmed, we conclude that insomnia is an important risk factor for neurodegenerative diseases. In addition, insomnia and neurodegenerative disorders have a complex and bi-directional relationship. We think it requires further study to understand the sole contribution of insomnia to the development of various neurodegenerative diseases when different factors like mood problems, genetic factors, and…

Background Hashimoto's thyroiditis (HT), also known as chronic lymphocytic thyroiditis, is an autoimmune disorder affecting the thyroid gland and is the most common cause of hypothyroidism in the US. Despite medical management with thyroid hormone replacement, many individuals with HT continue to experience symptoms and impaired quality of life. Given the limited number of efficacious treatments outside of hormone replacement and the overall burden of continued symptomatic disease, this pilot study was designed to determine the efficacy of a multi-disciplinary diet and lifestyle intervention for improving the quality of life, clinical symptom burden, and thyroid function in a population of middle-aged women with HT. Materials and methods The study recruited 17 normal or overweight (body mass index (BMI) <29.9) female subjects between the ages of 20 and 45 with a prior diagnosis of HT. The 17 women participated in a 10-week online health coaching program focused on the implementation of a phased elimination diet known as the Autoimmune Protocol (AIP). The 36-Item Short Form Health…

Introduction This third study in the Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) series examined potential relationships between point-of-care ultrasound (PoCUS) use and the length of resuscitation, the frequency of interventions, and clinical outcomes during cardiac arrest. Methods A health records review was completed for adult patients (>19 years, without a do not resuscitate (DNR) order) who presented to a tertiary emergency department in cardiac arrest between 2010 and 2014. Patients were grouped based on PoCUS use and findings for cardiac activity. Data were analyzed for length of resuscitation, frequency of interventions, return of spontaneous circulation (ROSC), survival to hospital admission (SHA), and survival to hospital discharge (SHD). Results Of the 223 patients who met inclusion criteria, 180 (80.7%) received assessment by PoCUS during cardiac arrest management in the emergency department (ED). In the PoCUS group, 21 (11.6%) demonstrated cardiac activity and 159 (88.4%) did not. Patients with activity on PoCUS had longer mean…

Introduction Contraception is regarded as an important preventive measure of unintended pregnancies and sexually transmitted diseases, including human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS), among youths. This study aimed to assess the knowledge, attitude, and practice of contraception among female undergraduates in Dodoma, Tanzania. Methodology A cross-sectional study was conducted among 347 female undergraduates of St John's University, Dodoma. Descriptive statistics were used for data analysis. Statistical analysis was done using Epi-Info version 7.2.2.6 (Centers for Disease Control and Prevention, Atlanta, Georgia. A p-value of less than 0.05 was considered statistically significant. Results The mean (±SD) age of participants was 27.4 (± 5.7). The majority (96%) of the participants were aware of contraception. Awareness of contraception was significantly associated with the age (p<0.0001), marital status (p<0.00001), and religion of the participating students (p=0.02). Slightly less than half (47.4%) of the students reported having…

This technical report highlights how one mental health chatbot, or psychological artificial intelligence service named Tess, has been customized to deliver on-demand support for caregiving professionals, patients, and family caregivers at a non-profit organization. This low-cost, user friendly, and highly customizable service allows emotional support to be scaled to thousands of people at a single time. The following report describes the phased approach to implementing Tess in order to reach staff, caregivers, and patients across Canada and the United States.

Transcranial magnetic stimulation (TMS), a research tool with various effects on brain cells, can depolarize cerebral neurons noninvasively. This method offers temporal and spatial resolution and can be combined with other neurocognitive and neuro-experimental techniques. Prefrontal TMS therapy repeated daily for four to six weeks is a neuromodulation technique approved by the US Food and Drug Administration for the treatment of major depressive disorder (MDD) in patients resistant to medications. This technique utilizes electromagnetic induction to excite neuronal cells. Several recent studies have enhanced our understanding of this novel treatment intervention. This report reviews recent studies on the mechanism of action, patient eligibility, effectiveness, and safety of TMS in treating depression.

Introduction Metabolic syndrome (MetS) has been recognized as one of the most important clinical challenges and global health issues of today. Growing evidence suggests that mechanisms of energy metabolism may also play a key role in mediating aspects of cognitive function. Brain-derived neurotrophic factor (BDNF) is one such factor well known for its critical role in neuronal plasticity, including memory and learning, and more recently metabolic processes. BDNF levels have been shown separately to be dependent on diet and exercise programming. Purpose The purpose of this study was to investigate the effect of diet and exercise on BDNF levels and cognitive functioning with any metabolic association in individuals characterized with MetS. Methods Twelve subjects with MetS followed a randomized crossover design with two four-week interventions, including a carbohydrate (CHO)-restricted Paleolithic-based diet (CRPD; <50gCHO) with sedentary activity (CRPD-Sed) and CRPD with high intensity interval training (HIIT; CRPD-Sed), separated by a four-week washout period. The HIIT exercise…

Background Point-of-care ultrasound (POCUS) has many applications in emergency medicine, which have been proven to improve patient outcomes. Training programs and well-established guidelines for its use are available, but Canadian adoption rates and attitudes toward this technology have not been recently assessed. Objectives This study aimed to provide a national assessment of the current use of POCUS in Canadian emergency departments (ED) including patterns of use, attitudes towards its role, descriptors of training experience, as well as barriers to increased utilization. Methods An electronic survey was sent to physician members of the Canadian Association of Emergency Physicians. The survey included questions related to demographics, attitudes towards POCUS, POCUS utilization, and barriers to POCUS use. Responses were statistically analyzed to identify significant associations. Results Responses demonstrated a strong association between POCUS training and amount of POCUS usage. Neither hospital type nor community type was associated with the degree of POCUS usage. POCUS was most…

Introduction Hyperuricemia (HU) does not only predispose to gouty arthritis but also increases the risk of major cardiovascular events and chronic kidney disease and decreases the overall quality of life. Although the incidence of hyperuricemia is increasing in the Asian population, prevalence studies from healthy asymptomatic adults are still scarce. The aim of this study was to determine the frequency of HU in the general population of Karachi, Pakistan. Methods A cross-sectional study was conducted in various out-patient clinics across Karachi in January 2019. Serum uric acid (SUA) levels were recorded using UASure Blood Uric Acid Monitoring System. Age, gender, body mass index (BMI), the frequency of activity, the frequency of meat consumption, and the presence of hypertension were noted. For hypertensives, the use of thiazide diuretics was noted. Data were entered and analyzed using SPSS v. 22. Results This study was completed by 375 individuals including 208 (55.5%) men and 167 (44.5%) women. Their mean age was 48.78 ± 13.399 years and the mean SUA level was 5.92 ± 1.73 mg/dl.…

Objectives To evaluate the effect of social media, TV shows, plastic surgeons' self-advertisement, and before-and-after cosmetic surgery photos of patients who actually visited the clinic to seek a consultation or intervention. Methods This is a cross-sectional study; institutional review board approval was granted in 2018. This study was conducted among patients attending cosmetic clinics at King Abdulaziz University Hospital in Riyadh, Saudi Arabia. The questionnaire is composed of socio-demographic data and about the reason for the trending of plastic surgeries. Results Three hundred and ninety-nine patients participated in the study. Of all participants, 60.4% agreed on the impact of the surgeon's self-advertisement in the trending of plastic surgeries; 53.4% said yes to cosmetic television programs having an effect on the trend of plastic surgeries; 65.7% of the participants answered yes to before-and-after pictures of social media having an effect on the trend of cosmetic procedures; and 54.1% of the participants answered yes to wanting to look better in selfies as a reason…

While immune checkpoint inhibitors have been groundbreaking for cancer treatment, there are many reported cases of patients undergoing immunotherapy who have discontinued or temporarily interrupted treatment due to the development of autoimmune-related adverse effects. Here, we present a 63-year-old female with a history of psoriasis (in spontaneous remission) and newly diagnosed poorly differentiated lung adenocarcinoma (pTXN3M1a) who experienced a severe flare-up of her psoriasis three months after initiating single-agent pembrolizumab. The patient was initially treated with topical clobetasol propionate ointment, however, due to minimal response to this regimen, the patient was commenced on secukinumab; an IL-17 inhibitor. To our knowledge, this is the first case of the successful use of secukinumab for the treatment of immunotherapy-induced psoriasis. More importantly, immunotherapy with pembrolizumab was continued successfully with the co-administration of secukinumab without complications or the recurrence of non-small cell lung cancer (NSCLC).

Introduction There is widespread public interest when celebrities are diagnosed with cancer. We sought to assess how this interest impacts awareness of prevalent cancers. Methods We reviewed common cancer-related search terms using Google Trends (Google LLC, Mountain View, CA) between the years 2004 and 2017 and retrospectively correlated these findings with media or celebrity-related events. The Google Trends application was used to obtain the "search volume index" (SVI), defined as the number of searches for a specific term standardized to the total number of searches over that time period. Data were presented in a graphical format. Isolated peaks of greater than 25% from the baseline SVI were identified. Using the date of the peaks, a further search was performed to determine if any event in the media triggered the peak. Results "Lung Cancer," "Pancreas Cancer," "Endometrial Cancer," "Cervical Cancer," "Brain Cancer," and "Glioblastoma" each had the highest peak correspond with a celebrity-related event covered in the media. These search terms displayed several additional…

OBJECTIVES: Multiple myeloma (MM) is a malignant disorder characterized by proliferation of a single clone of plasma cells derived from β-cells in the bone marrow. It is the second most common adult hematological malignancy, and it is the most common cancer with skeletal components as its primary site. The purpose of the retrospective study was to assess the hematological profile, different biochemical parameters, and the serum electrophoresis patterns of patients consistent with clinical symptoms of multiple myeloma. MATERIALS AND METHODS: A retrospective study of 99 patients diagnosed with multiple myeloma (MM) was carried out at the Hematology Department of Benghazi Medical Center (BMC) in Benghazi, Libya from January 2010 to March 2017. Information on the laboratory features was obtained at presentation (before treatment) and analyzed. RESULTS: Of the 99 study detected cases of multiple myeloma at diagnosis, 14% were younger than 45 years and 35% were 70 years or older. The mean age was 61 years, of which 42 (42.4%) were males and 57 (57.6%) were females. Anemia was seen in…

Aim The primary aim of this study was to evaluate the indications, effectiveness, application levels, and local anesthetic (LA) dosages used in erector spinae plane block (ESPB) in pediatric patients based on our clinical data. The secondary aim was to compare previously reported pediatric ESPBs with our data and to prepare a mini-guide for future clinical applications. Materials and methods One hundred and forty-one pediatric patients who received ESPB and were operated by the Department of Pediatric Surgery were included in this retrospective observational study. ESPB is routinely performed with 0.5 ml/kg 0.25% bupivacaine (max 20 ml). Demographic data and the type of surgery were recorded. Face, Legs, Activity, Cry, and Consolability (FLACC) or Numeric Rating Scale (NRS) scores, analgesic requirements, and the type of analgesic administered at postoperative period were recorded. Results ESPB was applied using three different techniques, the classic approach, the transverse approach, and the Aksu approach. Unilateral ESPB was performed on 112 patients, while 29 received a…

The purpose of this article is to investigate and characterize from a physics perspective the Zap-X (ZAP Surgical Systems, Inc., San Carlos, CA), a new, dedicated self-contained and self-shielded radiosurgery system, focusing on beam energy and performance, leakage, radiation safety, dose delivery accuracy, regulations, quality assurance, and treatment planning. This investigation is required to establish the mechanical and overall performance specifications of the system and to establish baseline parameters for future clinical usage. The applied methods include measurements of energy, focal spot size, beam performance, dosimetry, beam data, treatment planning system, leakage radiation, acceptance testing, and commissioning. The results of the characterization reveal a 3 megavolt (MV) linear accelerator (linac) with a focal spot size of 2 mm, a dose rate of 1,500 MU/min at the isocenter with a dose linearity of 3%, a beam penumbra of less than 3 mm, and beam symmetry of less than 2%. Beam performance, as well as dosimetry characteristics, are suitable for intracranial radiosurgery.…

OBJECTIVE: We aimed to study the role of ultrasound in the diagnosis of chronic kidney disease (CKD) and its correlation with serum creatinine level. MATERIALS AND METHODS: This was a retrospective cross sectional study conducted in the ultrasound department of Dr. Ziauddin Hospital Clifton campus, Karachi from April 6, 2017 to October 6, 2017 for a period of six months. A total of 200 patients with CKD and glomerular filtration rate (GFR) determined to be < 60 ml/min were included in this study. Blood tests were gathered from the chosen patients, serum creatinine estimation was done for those patients and they underwent ultrasonography on the same day to assess echogenicity, parenchymal thickness, cortical thickness, and longitudinal length. This information was noted in the pro forma. RESULTS: The average age of the patients was 54.62±13.3 years. Mean serum creatinine was significant among echogenicity grades [p=0.0005]. Mean parenchymal thickness was also significant among echogenicity grades (p=0.0005). Mean longitudinal length was also significant among echogenicity grades…

PURPOSE: Mobile health (mHealth) has promise to improve patient access to disease prevention and health promotion services; however, historically underserved populations may have poor access to mobile phones or may not be aware of or comfortable using phone features. Our objectives were to assess mobile phone ownership and mobile phone literacy among low-income, predominately racial and ethnic minority patients. MATERIALS AND METHODS: We conducted a cross-sectional survey of a convenience sample of primary care patients in a publicly-funded clinic in Houston, TX. RESULTS: Of 285 participants, 240 owned a mobile phone and 129 owned a smartphone. The most common uses of phones were talk (89%) and text messaging (65%). Only 28% of smartphone owners had health apps. Younger age was significantly associated with smartphone ownership and use of smartphones for Internet browsing, social media, and apps. CONCLUSION: Our findings from a safety-net patient population represent trends in mobile phone ownership and literacy. Despite the single-site location of our study, the findings could be…

Objectives Improved soft-tissue visualization, afforded by magnetic resonance imaging integrated into a radiation therapy linear accelerator-based radiation delivery system (MR-linac) promises improved image-guidance. The availability of MR-imaging can facilitate on-table adaptive radiation planning and enable real-time intra-fraction imaging with beam gating without additional exposure to radiation. However, the novel use of magnetic resonance-guided radiation therapy (MRgRT) in the field of radiation oncology also potentially poses challenges for routine clinical implementation. Herein the early experience of a single institution, implementing the first MRgRT system in the country is reported. We aim to describe the workflow and to characterize the clinical utility and feasibility of routine use of an MR-linac system. Methods The ViewRay MRIdian MR-linac system consists of a split-magnet 0.35 T MR-imaging scanner with a double focused multi-leaf collimator (MLC) equipped 6MV linear accelerator. Unique to the system are the control console integrated on-table adaptive radiation…

Heterotopic pregnancy is defined as the simultaneous presence of intrauterine and ectopic pregnancies. It is a rare condition, but due to the increasing use of artificial reproductive techniques, the incidence of heterotopic pregnancy is increasing. Most of the patients with heterotopic pregnancy have a previous history of infertility or tubal diseases. In this case series, we are presenting six cases of heterotopic pregnancy. Three of them had a history of assisted reproductive technique: one patient had in vitro fertilization with three embryos transferred, and two patients received follicular stimulating hormone therapy. In one of the cases, heterotopic pregnancy was missed on an initial transabdominal scan, and in the following weeks, it was diagnosed on transvaginal ultrasound. Five patients underwent laparoscopic salpingectomy, and one patient had laparotomy and then a salpingectomy was done. Follow-up ultrasound scans for intrauterine pregnancy (IUP) showed abortion of the IUP, except in one patient who delivered a healthy full-term baby via spontaneous vaginal delivery.…

Introduction The currently available literature suggests a wide range of conversion (4.9-20%) from laparoscopic cholecystectomy (LC) to open cholecystectomy (OC) despite the increase in surgical expertise. Open cholecystectomy is important as the last resort for safe surgical practice in complicated cases. Increased number of pre-operative and perioperative risk factors need to be identified to pre-empt conversion. However, there has been a significant decrease in conversion rates over the past few decades. This study was conducted to determine conversion rates in our population and to identify any significant risks for conversion. Methods This prospective study was conducted at the Shifa International Hospital, Islamabad, Pakistan, including 1081 cholecystectomies, performed over a two-year period from January 2017 to January 2019. Comparison of risk factors between the two groups; laparoscopic cholecystectomy (LC) group and conversion to open cholecystectomy (OC) group was done. Statistical analysis was done using SPSS 24.0.1. P<0.05 were considered significant. Results In our…

A rare complication of cervical spine decompression is acute paralysis following the procedure. This neurologic deficit is thought to be due to reperfusion injury of a chronically ischemic spinal cord and is referred to as "white cord syndrome" given the pathognomonic finding of hyperintensity on T2-weighted MRI. Three prior cases have been reported. We present a case of transient quadriplegia following posterior cervical decompression. A 41-year-old male with cervical spondylotic myelopathy presented with bilateral progressive upper extremity weakness, hyperreflexia, and cervical spine MRI showing severe cord compression at C1 and partial hyperintense signal. Intraoperatively, after C1 bony decompression and without perceptible technical cause, the patient experienced a complete loss of both somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) with an eventual return to baseline prior to completing the operation. The patient awoke from surgery with acute quadriplegia without perceptible technical cause (intraoperative compression or evident anatomic…

Background We examined the biomechanical performance of a three-dimensional (3D)-printed vertebra on pedicle screw insertional torque (IT), axial pullout (APO), and stiffness (ST) testing. Materials and methods Seventy-three anatomically identical L5 vertebral body models (146 pedicles) were printed and tested for IT, APO, and ST using single-threaded pedicle screws of equivalent diameter (6.5 mm), length (40.0 mm), and thread pitch (2.6 mm). Print properties (material, cortical thickness [number of shells], cancellous density [in-fill], in-fill pattern, print orientation) varied among models. One-way analysis of variance was performed to evaluate the effects of variables on outcomes. Results The type of material significantly affected IT, APO, and ST (P < 0.001, all comparisons). For acrylonitrile butadiene styrene (ABS) models, in-fill density (25-35%) had a positive linear association with APO (P = 0.002), ST (P = 0.008), and IT (P = 0.10); similarly for the polylactic acid (PLA) models, APO (P = 0.001), IT (P < 0.001), and ST (P = 0.14). For the nylon material type, in-fill…

This review focuses on factors contributing to sleep quality among pregnant women with low socioeconomic statuses during the third trimester of their pregnancy. Electronic searches were conducted, following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We searched for published, peer reviewed, English language primary research articles using electronic databases including PubMed, EMBASE, Ovid, MEDLINE and Google Scholar ending June 2019. All references were reviewed manually and independently by authors. After applying the inclusion criteria, 56 articles were selected; 38 of which are full-text and included in this review. All articles related to the analysis of poor sleep quality among uncomplicated pregnant women were included. Pregnant women with a specific pathology were excluded. We found poor sleep quality among pregnant women is correlated with low socioeconomic levels. Pregnant women with lower incomes tend to have inadequate diets, which further complicates the health of the mother and the baby. External factors including low…

Aesthetic procedures represent one of the most commonly performed procedures in the medical field. Such procedures have been growing in popularity. Social media is a term used to describe electronic platforms that promote the dissemination of information to targeted users. These platforms play a critical role in promoting aesthetic procedures. Objective The objective of this study was to assess the impact of social media on aesthetic procedures among the female population in Riyadh, Saudi Arabia. Methods A cross-sectional study was performed. A validated online questionnaire, consisting of 26 questions, was distributed among females visiting the facial plastic clinic at King Abdulaziz Medical City, in Riyadh, Saudi Arabia. Results Out of 1449 participants, 81% were aged between 25 and 34 years. The majority (78.8%) were aware of the complications that may follow aesthetic procedures. The decision to undergo such procedures was affected by the price in 77%. Overall, 97% thought that cosmetic specialized accounts on social media are helpful, yet 77.8% believed that such accounts do…

Introduction Our study was meant to assess the knowledge, attitude, and barriers towards research in medical students of Pakistan. By assessing the factors, we aim to increase the role of medical students in research, which will eventually help developing countries like Pakistan to achieve self-reliance in health care. Methods Undergraduate and postgraduate students of medicine, dentistry, and pharmacy schools of Dow University of Health Sciences, Karachi, were enrolled from February-March 2018 in a cross-sectional, descriptive study using questionnaires to provide details of the parameters of attitude to the knowledge of and barriers towards research for each individual. All data were coded for each of the parameters. Data analyses were performed by one-way analysis of variance (ANOVA)/Tukey and Student's t-test, Pearson's correlation, and Chi-squared tests. Results A total of 850 questionnaires were received. The overall mean scores of students on attitude, knowledge, and barriers were 69.27 ± 13.44, 70.39 ± 15.67, and 72.46 ± 13.46, respectively; 81.8% of students' scores fell…

INTRODUCTION: Deep brain stimulation has emerged as an effective treatment for movement disorders such as Parkinson's disease, dystonia, and essential tremor with estimates of >100,000 deep brain stimulators (DBSs) implanted worldwide since 1980s. Infections rates vary widely in the literature with rates as high as 25%. Traditional management of infection after deep brain stimulation is systemic antibiotic therapy with wound incision and debridement (I&D) and removal of implanted DBS hardware. The aim of this study is to evaluate the infections occurring after DBS placement and implantable generator (IPG) placement in order to better prevent and manage these infections. MATERIALS/METHODS: We conducted a retrospective review of 203 patients who underwent implantation of a DBS at a single institution. For initial electrode placement, patients underwent either unilateral or bilateral electrode placement with implantation of the IPG at the same surgery and IPG replacements occurred as necessary. For patients with unilateral electrodes, repeat surgery for placement of contralateral…

Introduction Laparoscopic appendectomy for nonperforated appendicitis is associated with improved outcomes. This study compares laparoscopic appendectomy and open appendectomy in cases of a perforated appendix by assessing surgical site infection, mean operating time, and length of hospital stay. Materials and methods This study was a prospective randomized study conducted at the Department of Surgery, Holy Family Hospital, Rawalpindi, Pakistan, from January 2016 to January 2017, by randomly allotting the laparoscopic or the open appendectomy technique to 130 patients by the lottery method. Patients having a perforated appendix were included after they provided informed consent. Data were entered and analyzed using IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY, US). Results The frequency of wound site infection was significantly higher in open appendectomy (27.69%) than in the laparoscopic approach (10.77%; p=0.01). Mean hospital stay was slightly longer in the laparoscopic approach (4.38 ± 1.09 days) than in open appendectomy (4.18 ± 0.77 days; p=0.23). Mean…

Background Cardiac arrests may occur anytime, anywhere and to anyone including learners at schools. Teachers have a moral obligation to care for learners while on the school premises. Outcomes after cardiac arrest are better when the first-responder possesses adequate knowledge and skill in basic life support (BLS) and cardiopulmonary resuscitation (CPR). The aim of this study was to assess the knowledge, attitudes and perceptions of student-teachers pertaining to BLS. Methods This was a self-administered, questionnaire based, prospective and cross-sectional study of senior undergraduate student-teachers enrolled at a South African university. The study was conducted between 04 November 2017 and 18 February 2018. Results A total of 316 student-teachers, with a mean age of 21.8 ± 2.6 years completed the survey. Trauma-related emergencies, allergic reactions and breathing difficulties were witnessed during practice teaching sessions at various schools by 52.5% (n = 166), 36.4% (n = 115) and 32.9% (n = 104) of participants, respectively. The mean knowledge score pertaining to BLS was…

This article reviews the use of thoracic ultrasound in the intensive care unit (ICU). The focus of this article is to review the basic terminology and clinical applications of thoracic ultrasound. The diagnostic approach to a breathless patient, the blue protocol, is presented in a simplified flow chart. The diagnostic application of thoracic ultrasound in lung parenchymal and pleural diseases, role in bedside procedures, diaphragmatic assessment, and lung recruitment are described. Recent updates discussed in this review help support its increasingly indispensable role in the emergent and critical care setting.

Ralstonia species are Gram-negative bacilli that have increasingly been recognized as emerging nosocomial pathogens, particularly in immunocompromised hosts. Ralstonia pickettii is the most clinically important pathogen from the Ralstonia genus. Nosocomial outbreaks of Ralstonia pickettii infections brought about by the use of contaminated medical solutions, including saline, sterile water, as well as disinfectants, have been reported. There have been case reports of invasive infections with variable presentations. Here, we describe three cases of Ralstonia pickettii bacteremia during a period of one year in a tertiary care hospital in Karachi, Pakistan. The first case was a 76-year-old male, known case of type 2 diabetes mellitus (DM), hypertension, and amyotrophic lateral sclerosis, who presented with complaints of burning micturition, hematuria, and fever. The patient had a history of multiple hospital admissions in the recent past. His blood culture was found to be positive for Ralstonia pickettii. A computed tomography scan of the kidneys, ureter, and bladder (CT KUB) was…

Colorectal cancer is a leading cause of cancer mortality in the United States, and metastasis to the liver is a frequent sequela. Currently, surgical resection is the best option for curative treatment and/or long-term survival after colorectal liver metastasis (CRLM), but unfortunately, not all patients are surgical candidates. Alternative and adjunct therapies commonly used in the treatment of CRLM include chemotherapy, biologic therapy, radio-embolization, and radiofrequency ablation. The aim of this review was to report the various treatment modalities and outcomes currently used in the treatment of CRLM.

BACKGROUND: Paediatric intubations are a relatively rare but critical procedure that requires adequate practice to achieve skillful performance. Simulation is a method to teach intubation skills in a safe environment. Rapid Cycle Deliberate Practice (RCDP), as a method of simulation debriefing, has been shown to improve pediatric resident resuscitation skills. It has not been demonstrated if RCDP can be effectively used in procedural skills training. The objective of this study was to determine if RCDP with feedback in real-time, as well as an opportunity to repeat the action, is superior to a simulation where no feedback is provided during the simulation and is instead provided after the simulation. MATERIALS AND METHODS: This was a randomized controlled single-blinded study. All participants were videotaped during a simulated pre-assessment intubation, then received either the intervention (RCDP) or the control teaching (feedback after the simulation), followed by a post-assessment intubation. These videos were scored by two independent raters on an intubation checklist. The…

Introduction Complementary and alternative medicine (CAM) is becoming popular among individuals affected by chronic diseases, such as diabetes mellitus. We aimed to determine the knowledge, attitude, and practices of complementary and alternative medicine use among type 2 diabetes patients in Karachi, Pakistan. Methods An observational, prospective, cross-sectional study was conducted in the institute of diabetology in a tertiary care hospital in Pakistan from 1st March 2018 till 31st August 2018. All patients of type 2 diabetes mellitus attending the clinic for routine follow-up visits during the study period were interviewed. Their demographic characteristics, clinical data, and knowledge, attitude, practices towards use of CAM products were assessed. Data was managed using SPSS for Windows version 16.0 (SPSS Inc, Chicago, IL). Results CAM therapies were being used by 151 (57.8%) individuals. Herbs (n = 121; 80.1%), specific diets (n = 98; 64.9%), and cupping (n = 68; 45.0%) were the most readily utilized CAM practices. CAM practices were associated with diabetes-related…

Introduction Telepsychiatry is becoming an increasingly appealing option for mental health treatment due to its ability to overcome barriers which prevent certain demographics from having access to mental health services. There is a surprising lack of research being done on this promising mode of health care delivery. The aim of this study is to evaluate the existing literature in order to determine the clinical effectiveness and cost-effectiveness of telepsychiatry in resource-constrained environments. Methods Literature searches were performed in PsychINFO, PubMed, Medline, EMBASE, Centre for Reviews and Dissemination, and the Cochrane Library Controlled Trial Registry databases (2000 - May 2017). A search of the following terms was used: telemedicine; telemedical; telepsychiatry; telepsychiatric; teleconsultation; e-health; video conference; and telecare. Type of mental disorder and intervention, along with the clinical outcome or patient satisfaction, were all identified. Exclusion criteria included studies with a sample size of fewer than 10 cases, as well as studies which…

Introduction Gastroesophageal reflux disease (GERD) influences patients' general health, daily and social functioning, and physical and emotional activities. It strongly affects the health-related quality of life with frequent interruptions during sleep, work, and social activities. GERD is defined as a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications. GERD symptoms are a major concern for many patients, as they cause a disturbance in physical, social and emotional health. In this study, we determine the prevalence of anxiety and depression in patients with GERD with and without chest pain. Methods In this cross-sectional study, a total of 258 consecutive patients with a diagnosis of GERD were included in this study. Of 258 participants, 112 had concerns about chest pain. Clinical presentations and comorbid disorders were evaluated by a previously validated gastroesophageal reflux symptom questionnaire. Depressive and anxious symptoms were assessed using a Hospital Anxiety/Depression Scale. Results A total of 107 (41.4%)…

INTRODUCTION: It is well-known in the field of endodontics that the presence of a smear layer in the root canals can harbor bacteria and limit the penetration of irrigating solutions and intracanal medications into the dentinal tubules which, in turn, causes the failure of endodontic treatment. Removing the entire smear layer throughout the root canal is essential for the success of endodontic treatment and these chemical agents that facilitate the removal of the smear layer are called chelating agents. Ethylenediaminetetraacetic acid (EDTA), being the most widely used chelating agent, brings about increased reduction in the microhardness of the root dentin, thereby making it friable. N-acetyl cysteine (NAC) is naturally occurring antioxidant that has various beneficial properties for the human being. Several studies have been done in determining the antimicrobial efficacy of NAC against various endodontic pathogens and concluded NAC to be advantageous. The chelating property of NAC has been utilized in heavy metal detoxification, where it binds to the metal ion and removes them…