Background: Neck discomfort is a prevalent ailment that affects people of all ages, their families, communities, and healthcare systems globally. It also causes significant disability. The purpose of this study was to evaluate the knowledge of neck pain risk and prevention variables among Ortho OPD patients at Zonal Hospital Dharamshala, Himachal Pradesh. Material and Methods: A convenience sampling technique was used to pick 400 Ortho OPD patients from Zonal Hospital Dharamshala for this cross-sectional study, which was conducted between August 2018 and October 2019. A self-administered, pre-tested, semi-structured questionnaire was used to gather information about their sociodemographic traits and knowledge about neck pain avoidance. Epi info v7 software was used to evaluate the data using the necessary statistical tests. Results: In the present study 37% (148) of the Patients fall were below 40 years of age while 63% (252) were above 40 years. 59.25% (237) of patients were male and 40.75% (163) were female. Among the total study participants, 39 (9.75%%) didn’t know about any risk factor of neck pain. 336(84%) respondents said that Bad posture while working on computer/mobile/reading is the major risk factor for neck pain followed by Hard pillow during sleep 314 (78.5%), Bad posture while sitting, walking & during sleep 223 (55.75%) and over use of computer or smart phone 221 (55.25%). Among the total, maximum 328 (82%) respondents said that the Frequent position change and stretching the neck muscles while working is the major preventive factor for neck pain followed by Maintaining good posture while sitting, walking and sleeping 321 (80.25%), Using a soft pillow during sleeping 313 (78.25%) and adjusting the desk, chair and computer while studying/reading 232 (58%). Still 33 (8.25%) respondents didn’t know any preventive factor for shoulder pain among participants. Conclusion:According to survey findings, the participants had eitherinsufficient or not satisfactory knowledge about the Neck pain. The present study warrants the educational program and awareness campaigns on risk factors and Preventive measures of neck pain.

Introduction: Medical students face significant academic pressure, psychological stress and existential crisis. Personality type refers to psychological classification of different types of individuals. Type D personality is a vulnerability factor for general psychological distress that affects physical health status and people with type D personality are at increased risk of developing psychiatric disorders. A number of determinants influence the occurrence of depression, as biochemical factors, genetic, environmental factors and personality traits. Material and methods: Total 380 undergraduate students from VMMC were enrolled by stratified simple random sampling. A predesigned, pretested, semi structured questionnaire along with DS14 and PHQ9 was used for data collection. Statistical analysis: SPSS licensed Software version 20.0 was used. Simple tables and cross tables were made. For qualitative data analysis Chi-square test was used. Results: Among 380 participants studied, male students were 213 (56%) and females were 167 (44%). Out of 380 students 116 (30.5%) students had Type D personality and 264 (69.5%) students did not have Type D personality. The overall prevalence of depression was found to be 44.5%. It was observed that depression was significantly associated with Type D personality. Conclusion and recommendation: This study reports high prevalence of Type D personality and depression among medical undergraduate students. Timely intervention in the form of diagnosis, treatment and counselling for students having Type D personality, depression and other associated factors can prove to be beneficial.

Central precocious puberty (CPP) is a rare disease. In Spain, the annual incidence in girls ranges from 0.13-2.17 new cases per 100,000. CPP in girls is usually idiopathic. Only 7-15% is related to an intracranial lesion. Intracranial arachnoid cysts are usually congenital account for 1% of intracranial masses in newborns. Intraventricular location is rare, account only 0.3-1.4%. Intracranial arachnoid cysts are usually asymptomatic but can present with CPP in 10-33% of patients. We report a case of a 7-year-old-girl presenting the unusual coexistence of CPP and a neurologically asymptomatic intraventricular arachnoid cyst. The etiopathogenesis of this association is not well recognized. Analysis of LH peaks after GnRH testing is the gold standard for the diagnosis of CPP. Although central nervous system disorders account for a higher percentage of cases in boys with CPP, they must also be excluded in girls. In this patient, brain MRI did not show hypothalamic-pituitary axis alterations or the existence of hydrocephalus, so we cannot prove a causal relationship between the intraventricular arachnoid cyst and CPP. Therefore, this coexistence may be only accidental. However, we emphasize that all girls with CPP should undergo brain MRI as part of their evaluation, as clinical characteristics, including age, do not help to predict underlying pathologies. Cyst surgery does no affect the course of pubertal development. There seems to be a consensus that in pediatric patients the indication for surgery is seizure onset, hydrocephalus, ruptured/hemorrhaged, and mass effect or slow-growing clinical course.

Pregnancy-induced high blood pressure is one of the most common and life-threatening pregnancy complications. This cross-sectional study aimed to investigate the relationship between platelet count and pregnancy-induced hypertension. 20 samples were collected from pregnant women and patients with blood pressure, where the number of platelets was measured by standard methods and all medical examinations and tests were conducted in Al Majar Alkabir Hospital

Introduction: Sleep is the time of the day when the mind and body finally get the well-deserved rest. Medical students, are constantly compromising on their sleep, in order to spare time for increased workload, curricular demands, social expectations, technology for recreation and communication. Medical students are also subjected to potential stressful situations like social responsibility, an overwhelming academic curriculum and having to learn complex clinical skills. Objectives: 1) To study the sleep pattern among undergraduate medical students. 2) To find the prevalence of perceived stress in study participants. 3)To determine the association of sleep pattern with perceived stress in study participants. Design: Cross-Sectional study. Methods: Total 350 undergraduate students from Vardhman Mahavir Medical College, Delhi were enrolled by stratified simple random sampling. A self-designed, pretested, semi structured questionnaire along with PSQI and PSS10 was used. Results: Out of 350 students, 41.7% (146) were females and 58.3% (204) were males. The mean age of the students was 20.22 ±1.63 years. About 57% (199) students had poor sleep quality and 67.7% (237) had moderate stress. Sleep Quality in study participants was significantly associated with Perceived Stress. Conclusion: This study reports high prevalence of poor sleep and perceived stress among medical undergraduate students. 

Background: Swallowed foreign bodies are not uncommon in a typical ORL practice and could be wrought with a lot of challenges in the management. This study is therefore to determine the pattern, presentation and outline their management and challenges encountered. Methodology: A retrospective review of all patients diagnosed of foreign body ingestion seen in the ENT surgery department of UPTH within the period of 2016 to 2020. The patients’ records, clinic, ward and theatre register were the source of the data. The biodata, presenting complaints, management and outcome were collected and analysed. Diagnosis was made on the basis of history, clinical findings, radiological evaluation and confirmed at surgery. Results: There was a total of 32 subjects; 19 males and 13 females. The age 1-10 years were the most affected; 46.9%. Fish bone was the commonest object and was seen both in children and adults while dentures were the second commonest and found only in adults. About 31.3% of the foreign bodies were seen as radiopaque on x-ray while 17.5% were diagnosed based on presence of soft signs. .Most had emergency oesophagoscopy; 87.5%. Failed oesophagoscopy was recorded in 3.1%. Conclusion:Swallowed foreign body is commoner in children and males are more affected. Fish bone and dentures are the objects commonly swallowed. While dentures is seen more in adults, toy parts, button batteries and other small objects are commonly seen in children

Endodontic sealers play an important role in controlling endodontic infection and preventing leakage of nutrients and reinfection of the root canal. A variety of endodontic sealers is available including zinc oxide eugenol, calcium hydroxide, glass ionomer, silicone, resin, and bioceramic based sealers. Bioceramic based sealers are ceramic products that are designed particularly for medical and dental applications. These sealers include alumina, zirconia, bioactive glass, glass ceramics, hydroxyapatite, and calcium phosphates. New generation of endodontic sealers has been produced based on calcium silicate as MTA Fillapex, EndosealMTA, Total Fill BC Sealer, EndoSequence BC Sealer, iRoot SP, Endo CPM sealer, MTA-Angelus and ProRoot Endo Sealer.

Objective: Is to determine the prevalence of anisometropic amblyopia and associated refractive errors in a sample of school-age children in Al Anbar Province, Iraq, who are between 6 to 10 years of age. Design and Settings: This is a population-based cross-section study in Al Anbar, Iraq Moreover, 6,000 school-age children are involved, along with a team consisting of an ophthalmologist and two optometrists; they visit the school and conduct visual acuity examinations, using the E-test and refraction test, which are both auto- and -manual “with cycloplegia” for children suspected of decreased visual acuity. They do a slit lamp exam (with portable lamps), used to assess anterior segment, red reflex and lens opacity with a fundus exam to exclude pathology of the eye. Results: The prevalence rate of anisometropic amblyopia is 2.8%. There is a significant association between errors of refraction and amblyopia (p<0.002). The most common error of refraction is hypermetropia, followed by myopia and astigmatism.

Entry into the healthcare system is fundamentally shaped by individual wants, resources, and needs, with the ability to obtain services influenced by factors such as travel distance, waiting times, financial capacity, and access to regular care. Central to care-seeking behavior is the perceived "cost" of healthcare, which patients often seek to minimize, though cost reduction strategies typically involve either cutting benefits or rationing services. From the perspective of hospital administrators and physicians, healthcare costs refer to the production expenses incurred in delivering patient care, including direct costs and appropriate overhead allocations for administration, personnel, equipment, and facility maintenance. These costs ultimately inform hospital charges, which represent the prices set for services. Healthcare costs are distinguished from health expenditures, with the latter referring to the amounts actually paid or charged for services rendered. Parallel to these economic considerations, surgical technology has advanced significantly, offering alternatives to traditional open surgery. Open surgery, characterized by large incisions and extended recovery periods, remains common but is increasingly complemented by minimally invasive approaches. Laparoscopic surgery utilizes small incisions, video cameras, and specialized instruments to perform procedures with reduced trauma. Robotic-assisted laparoscopic surgery represents a further technological evolution, employing a robotic device controlled by a surgeon from a console to achieve enhanced precision, magnification, and three-dimensional visualization. This approach combines the benefits of minimally invasive techniques with superior instrument maneuverability. Robotic surgery offers patients multiple advantages over open surgery, including smaller incisions, reduced pain, shorter hospital stays, faster recovery times, and improved clinical outcomes, thereby transforming the surgical landscape while introducing new cost considerations for healthcare systems.

Rivaroxaban is a Xa factor inhibitor; it is prescribed for non-valvular atrial fibrillation, deep vein thrombosis and pulmonary embolism. We retrospectively reviewed all our patients treated from June 2012 to February 2016 with rivaroxaban (Xarelto®, Bayer HealthCare AG, Wuppertal, Germany). In our experience we follow more then 500 patient that take Xarelto. Some of these develop anaemia like a conseguence of the treatment, but only few of these presented major or minor bleendings. Among the 505 patients, anaemia was encountered in 21 patients (4%). Of these 21 patients, 10 had a concomitant bleeding (mainly with a gastrointestinal source), while in 11 patients (2%) no source of bleeding was found. Moreover, haemoglobin level drop in these 11 patients compared to the whole population was not attributable to age, sex, creatinine level or duration of treatment. This side effect could be explained by a chemical similarity with hydroxyurea and linezolid.

The behavioral emergencies, in the present scenario are an alarming condition. These conditions if not attended at the earliest can result in the damage to life and property. Thus, the main objective of this article is to highlight the multifactorial aspects which could be the cause of aggression and results in violent behavior of the patient. Detailed evaluation and assessment of the patient can help in prevention of further attacks as well as effective management of the case. De-escalation technique helps minimizing the severity of the attacks. Efficacy of homoeopathic system of medicines in dealing such situations has also been discussed.

Objectives: Cachexia is a dysregulation of fat, protein, and carbohydrate metabolism largely due to cytokine excess; ultimately resulting in severe wasting of the body’s lean body mass (LBM), albumin, and branched-chain amino acids (BCAA) depletion. The aim of this study is to evaluate the clinical differences between two commercially available WP formulas that differ in BCAAs enrichment proportion. Methods: A retrospective analysis was conducted in our institution between Jan 2019 and Jan 2021. Patient who had 2≤ episodes of diarrhea or failed to complete one week of hospital admission were excluded. All patients’ continuous variables were analyzed using Independent Samples and One-Sample T-test while categorical data were expressed as numbers with percentages by using Chi Square test. Results: Group I (%BCAAs≥20%) demonstrated a significantly shorter length of stay (LOS) and lower overall 28-day mortality compared with Group II (%BCAAs≈12%) with Mean±SD of (9.80±1.79 days vs. 12.00±2.33 days) and Mean percentage of (20.97% vs. 13.33%), respectively. Percent changes in albumin level (%∆ALB) were significantly higher in Group I compared with Group II (35.3%±4.64% vs. 28.3%±5.49%). Conclusion: BCAAs enriched WP formula was superior to standard WP formula in stimulating ALB synthesis and LBM anabolism/catabolism ratio in cachexic hospitalized hypoalbuminemic patients. 

Background: Shoulder pain, stiffness or weakness can make it difficult to carry out everyday tasks, like reaching for something on a high shelf, driving a car or brushing your hair This study was undertaken with the objective to assess the knowledge about risk factors and practices for shoulder pain among Ortho OPD patients in civil hospital Rohru. Material and Methods: This cross-sectional study was conducted between Aug- December 2020 among Ortho OPD patients in civil hospital Rohru selected by convenience Sampling Technique.Information regarding their socio-demographic characteristics and knowledge, regarding prevention and practices in case of shoulder pain were obtained using a self-administered, pre-tested, semi-structured questionnaire. Data was analyzed using Epi info v7 software using appropriate statistical tests. Results: In the present study 35% (140) of the Patients fall were below 40 years of age while 65% (260) were above 40 years.  54% (216) of patients were male and 46% (184) were female. Among the total study participants, 38 (9.5%%) didn’t know about any risk factor of shoulder pain. 267(66.75%) respondents said that Bad posture while sitting, walking and during sleep is the major risk factor for shoulder pain followed by Lack of physical activity 206 (51.5%). Maximum 280(70%) respondents said that the Exercise and yoga regularly major preventive factor for shoulder pain followed by, maintaining good posture while sitting, walking and sleeping 278(69.5%). Maximum participants, 312(78%) replied that they take pain killer medications in case of shoulder pain followed by pain relief gels 306(76.5%) and Cold applications/ice application 295(73.75%). Conclusion: By Exercise and yoga regularly, maintaining good posture while sitting, walking and sleeping, proper back support while sitting and avoiding heavy lifting on head, we can prevent shoulder pain. Pain killer medications, pain relief gels Cold and Heat applications and resting the shoulder helps in reliving shoulder pain.

Periodontists may require to provide safe treatments to patients during the Covid 19 pandemic. It is a droplet infection that is rapidly spreading throughout the globe. Hence the clinicians need take all the safety measurements while doing any dental procedures. This article would discuss the association between periodontal disease and SARS-CoV-2 virus and the recommendations for periodontal practice.

Background: Dengue fever is associated with electrolyte disturbances. Hyponatremia and hypokalemia are the commonest electrolyte disturbances. The reason for hyponatremia in classic Dengue fever patients was uncertain. However, it might be the consequence of salt depletion, excess water from increased metabolism, transient inappropriate antidiuretic hormone or the influx of sodium in the cells as a result of dysfunction of sodium potassium pump3. The purpose of the present study was to assess the electrolyte disturbances in Dengue infected patients and to find relation of electrolyte disturbances to complication of Dengue fever. Methods: In this cross sectional study we assessed100 patients admitted with acute stroke in Victoria and Bowring and Lady Curzon hospital during period June 2019 to December 2019. 100 cases of Dengue virus infections were confirmed using Dengue day 1 test kit for detecting dengue antigen. It is a rapid solid phase immune-chromatographic test for the qualitative detection of Dengue NS1 antigen and differential detection of IgM and IgG antibodies to Dengue virus. Serum Sodium and potassium were estimated. Serum electrolyte levels are correlated with Dengue severity. Results: Out of 100 subjects, 3 were having dengue shock syndrome; 28 were having dengue with warning signs and 69 were having dengue without warning signs Majority of patients were males (73) while (27) were female patients. Out of 3 subjects having dengue shock syndrome, all the 3 subjects were females. Fever was found to be the most common clinical presentation in 97 patients (97.9) followed by myalgia in 69 patients (69.6%), headache in 59 patients (59.5%), skin rash in 27 patients (27.27). In the present study, Median sodium levels were high in group having dengue without warning signs (137) followed by dengue with warning signs (131) and dengue shock syndrome (124). Out of 100 subjects, 31 had mild hyponatremia, 7 had moderate hyponatremia and 62 had normal Sodium scores. Chi-square test showed significant association between sodium and dengue severity (c2 = 34.82, p = 0.00). Median Potassium levels were high in group having dengue without warning signs (3.9) followed by dengue with warning signs (3.75) and dengue shock syndrome (3.7). Out of 100 subjects, 35 had mild hypokalemia, 1 had moderate hypkalemia and 84 had normal potassium scores. Chi-square test showed no significant association between potassium and dengue severity. Conclusion: Hyponatremia was the most frequent electrolyte disturbance. Mild hyponatremia and mild hypokalemia were more common among patients of Dengue without warning signs, whereas moderate and severe hyponatremia were more common among Dengue with warning signs and severe Dengue.

Cervical cancer is the most common cancer in women in developing countries and it found three-quarters of the estimated half a million new cases occur each year. Cervical cancer can be prevented by early detection. One of the early detection methods is suitable for developing countries is the Visual Inspection method of Acetic Acid. With a cross-sectional study approach it sought the affecting factors that influence the use of IVA method early cervical cancer screening at Baktiraja Health Center. It involved women of childbearing age 0-50 years, the number of samples is 83 respondents. The data collection was based on the questionnaire. The results showed that there was a relationship between age (p = 0.049), knowledge (p = 0.015), attitude (p = 0.025), availability of facilities and infrastructure (p = 0.031), family support (p = 0.009) and health service providers (p. = 0.049) with the use of the IVA method. Meanwhile, there is no relationship between education (p = 0.141), health-related skills (p = 0.944). The most dominant variable is family support with a value of p = 0.009<p = 0.05, with an Odds Ratio (OR) value of 3,625. Management of the Baktiraja Community Health Center is expected to improve reproductive health services for women of childbearing age with early detection of cancer cervix with the Inspection Method with Visual Acetic Acid (IVA).

Description of neurodevelopmental disorders in infants with low-birth-weight Neonatal Intensive Care Unit of the hospital in Baghdad, Iraq. A descriptive study was conducted on a certain 130 children who were distinguished by low weight. Samples were collected in a hospital in Baghdad, Iraq, where these steps were followed by a descriptive procedure for general evaluation of the motor development of children in addition to the hearing problem. The improvement of the methods of care for premature babies over the past ten years has resulted in a significant reduction in the incidence of diseases associated with prematurity chronic respiratory diseases, severe neurological disorders and cases of severe retinopathy, as well as to improvements in the physical condition and psychological functioning. A newborn's weight is an important indicator of the health of the mother and the newborn and a newborn is considered underweight if his weight is less than 2500 grams. Birth weight is also a means of predicting the probability of death or developing several chronic diseases that affect adults. And that the reasons for this include uterine infections, chronic diseases in mothers, old age of the mother, lack of nutrition and obesity, smoking and environmental factors.

Blue sclera is a bluish discolouration of the white sclera of eye. The blue colour is caused by thinness of collagen layers of the sclera that allows the veins of the choroid layers to be seen. Blue sclerae are characteristic of a number of conditions, particularly connective tissue disorders and musculoskeletal disorders. In this article we have presented a few clinical cases which were diagnosed on the basis of this ‘blue sclera’.

Inappropriate hospital stay increases hospital costs, decrease available resources for patients with critical situation and put patients at risk of nosocomial infections. 

It was observed that 24.3 % cases of hospital stay studied were inappropriate in Medical Side while as 41.38% cases of hospital stay studied were inappropriate in Surgical Side. 

Dental caries remains a multifactorial public health problem in Brazil and is the primary etiological factor for most pulp and periapical pathologies, including apical abscesses. The progression of untreated caries leads to pulp inflammation, necrosis and subsequent bacterial colonization, resulting in purulent infection and abscess formation. Apical abscesses may present as acute or chronic conditions, differing in symptom severity and clinical evolution. Chronic apical abscesses are typically asymptomatic, slow-progressing and often associated with fistula formation as a mechanism for purulent drainage and symptom relief. Accurate diagnosis is fundamental in endodontics and relies on a combination of clinical tests, including percussion, mobility, probing, anesthesia tests and radiographic examinations. While periapical radiographs remain the standard diagnostic tool, panoramic imaging may assist in extensive lesions. Microorganisms play a central role in the initiation and persistence of chronic periapical lesions, making effective root canal decontamination essential for treatment success. Understanding the immunological and pathological mechanisms involved in chronic abscess formation is crucial for proper diagnosis, prognosis and management of endodontic infections.

Background: COVID-19 pandemic has broken the world into fragments and the fear of pandemic in several forms has affected our nation. COVID -19 Pandemic has hard struck the entire nation with spreading of its wings at every nook and corner of the nation. Gleaming amidst darkness with a ray of hope, a small peripheral Armed forces hospital (MH Mhow) tried to tide over the dark horizon by organizing Plasma donation camp. Objectives: The aim of the camp was to make plasma therapy available for  moderate to severe cases of Covid 19 affected Veterans ,serving personnel’s and dependents admitted in the hospital for treatment. Material And Methods: First ever conducted Convalescent plasma donation camp in armed forces and entire nation by Military Hospital Mhow in collaboration with (Model blood bank) MGM medical college, Indore in a single day  with close to 30 healthy Covid Knights who had good antibody titres in their body and had complete resolution of symptoms before donation. Results: A Total of 45 voluntary serving personnel’s, veterans and dependents who had been prior diagnosed with Covid19 lab test positivity by RTPCR were chosen. Screening test was conducted for all the 45 donors previously tested positive 10 days prior to plasma donation event.30 donors were found eligible for plasma donation. There was an inverse correlation found out between the antibody (IgG) titres against SARS COV2 infection and CT values of RTPCR assays. Conclusion: Without a current vaccine to immunize against SARS-CoV-2, the pathway to treatment still dismal, it is clear that COVID-19 will be with us for the foreseeable future. Therefore, a hitherto for COVID-19 treatment and prevention modalities are urgently needed. One such promising treatment was successfully paved for by the use of convalescent plasma from COVID-19 survivors, paved through convalescent Plasma donation for moderate to severe COVID 19 affected patients.

Dreams are a series of thoughts, images and sensations occurring in a person’s mind during sleep especially in REM sleep pattern. As per Sigmund Freud “The interpretation of dreams is the royal road to knowledge of the unconscious activities of the mind”. His book has been the precursor to many hypothesis and concepts and research into dreams and its significance. As per Carl c Jung, He saw dreams as the psyche’s attempt to communicate important things to the individual. His model of psyche an idea of dreams which arise from ego. His many books with different volumes are a vast source of significance and interpretation of dreams. Dreams are influenced by the past and present experiences and sometimes are determinative of future. Different types of dreams have been interpreted based on fear, threat, insecurities, being vulnerable, struggle, frustration, wishes, sexuality, need for change in perception and individuality, etc. though few dreams are forethought to be the admonition sign and may impact personality of the person. Dreams have been found to have strong neurophysiological relationship with mid brain structures dealing with memory and human emotions. In Homoeopathy dreams are considered to be the inner essence of individual in a subconscious level and have an implication to the understanding of the state of mind and concealed will and desires, leading to help in selection of the similimum. In this review article, analysis of dreams and its homoeopathic applicability has been elucidated.

Background: Myopia is a very common eye disease and a common cause Vision loss. Increased muscular proliferation among young adults, including medical students Universities, raises scientific interest in this problem. The aim of the study is to examine the prevalence of refractive errors within the youth Students. Method:  A cross-sectional study that included 598 people (1195 samples). Was checked. Statistically significant differences in qualitative variables were assessed by means of the Pearson Chi-squared test. Statistical analysis was performed by SPSS 20.0. Results: 272 (45.5%) students from all subjects had refractive errors: myopia in 226 (37.7%) and hypermetropia in 46 (7.6%) (p<0.001) (p<0.001). Only 187 (68.8%) of the screened students who had a refractive error used visual corrections. Obligatory to Stretching of the visual apparatus, some students have complaints such as 173 (63.6%) and eye fatigue Redness 132(48.5%).

With interest we read the article by Gogia et al. about a 58yo male who developed polyneuritis cranialis (PNC) four days after onset of a mild infection with SARS-CoV-2 manifesting with nausea, vomiting, shortness of breath, abdominal pain, and fever [1]. PNC involved cranial nerves V (left facial numbness), cranial nerve VII (left facial palsy), and cranial nerves IX and X (reduced gag reflex, dysphagia) [1]. The patient improved under valacyclovir [2]. It was concluded that PNC can be a manifestation of COVID-19 [1]. The report is appealing but raises the following comments and concerns.

The main shortcoming of the study is that the patient did not undergo lumbar puncture. PNC is a subtype of Guillain-Barre syndrome (GBS), why cerebro-spinal fluid (CSF) investigations usually show normal cell count but elevated CSF protein (dissociation cyto-albuminique) [2]. 

Patients with PNC usually profit from steroids or intravenous immunoglobulins (IVIG) [3], why it is surprising that only valacyclovir was administered. Valacyclovir is indicated if there is clinical or serological evidence for herpes zoster infection but this should be confirmed by PCR for varicella zoster DNA in the serum and CSF. Discrepant to the cases description, there is mentioning of valacyclovir and steroids during 7d in the discussion [1].   

Since the patient received remdesivir, convalescent plasma, and dexamethasone for COVID-19 it should be discussed if clinical manifestations improved rather from the COVID-19 therapy than from valacyclovir. 

A further shortcoming is that no follow-up was reported in the case description. Not before the discussion it is mentioned that the patient recovered completely within 3 weeks [1]. 

There is a discrepancy in the description of symptoms. On the one hand the patient reported “mild dysphagia” but on the other hand the patient denied “any other neurological symptoms such as new weakness, numbness in arms, legs, difficulty speaking, dysphagia, and diplopia” [1]. This inconsistency should be clarified.

We do not agree with the notion that the report is the first report about SARS-CoV-associated PNC in the absence of GBS. PCN without affection of peripheral nerves has been reported by others before [4]. Cavalagli et al. reported a 69yo male with affection of cranial nerves IX, X, and XII after an infection with SARS-CoV-2 [4]. 

Missing are nerve conduction studies of the facial nerves. We should know if the facial nerve lesion was demyelinating or axonal in nature.

Overall, the interesting report has several limitations, which should be addressed before drawing final conclusions. Cranial nerve involvement with or without affection of the peripheral nerves is well appreciated in COVID-19. COVID-19 patients with PNC require CSF investigations, nerve conduction studies, and IVIGs in case of dissociation cyto-albuminique.

Venereal warts are a sexually transmitted infection caused by the Human Papillomavirus (HPV) 6 and 11. This study was conducted to assess the demographic pattern, features and factors associated with venereal warts in UPTH, Rivers state. The study was a descriptive cross-sectional study conducted on 118 patients that had viral warts who visited the hospital within an eight-year period. 36 (30.51%) of the patients had venereal warts. 14 (38.95%) had the lesions in the entire genital region while 10 (27.8%) had it on the penis. Other sites involved included the anus, vulva and vagina. Data analysis was performed using the IBM statistical package for Social Sciences (SPSS) version 20. Venereal warts are common.

Massive hyphaema presentation after laser iridotomy is very rare. We report a 65 year old lady who was on traditional medicine for breast cancer and developed massive hyphaema following neodymium doped yttrium aluminium garnet laser iridotomy at our hospital.

Background: This study was conducted to examine the application errors of nurses working in paediatric units regarding parenteral drug administration. Methodology: The study was conducted with 65 paediatric nurses working in the Paediatrics Units of Istanbul Bakırköy Dr Sadi Konuk Training and Research Hospital between June 2015 and September 2015. The data of 38 nurses who were observed out of 50 nurses who accepted the study and got the lowest score on the Malpractice Tendency Scale (MTS) were also evaluated in this study. Results: While the MTS scale total score of paediatric nurses was found to be 229.14 ± 14.64, the highest mean score of the subscales was 'communication' (22.93 ± 2.41), the lowest mean score was obtained from the "hospital monitoring and equipment and equipment safety" (40.57 ± 4.20) subscale. Most of the nurses' medication administration errors, respectively; they stated that the number of patients (77%) and the excessive working hours (75.4%) were due to reasons such as fatigue (70.5%), not having enough information about the drug (63.9%). The positive behaviours observed by the researcher regarding the drug administration process of the nurses; while nurses placed the medicine cabinet in accordance with the characteristics of the medicine (97.3%), sent the drugs to be given as infusion in appropriate liquid and amount (97.3%) and washed their hands before treatment (94.7%), negative behaviours were observed; nurses did not take any measures to prevent noise in the environment (100%), did not make the drug preparation in the treatment room (97.4%), did not consider the dry powder volume when calculating the drug dose (97.3%) and did not use a calculator (97.3%) has been. Conclusion: In order to prevent medication errors, a corporate culture for drug safety should be established, post-graduate training for nurses should be provided and practices should be monitored.

Background: COVID 19 is a deadly pandemic affecting the world during 2020. This prospective study was done to study the variations in clinical presentation in the admitted patients with COVID-19 at ESIC MCH. Methods: This prospective observational study was done from AUGUST 2020 to October 2020. All patients both male and female admitted to covid positive ward at ESIC hospital during this period were studied. Patients below 12 years and pregnant women were excluded from the study. The study was carried out in all patients fulfilling the inclusion and exclusion criteria. Results: A total of 200 patients 80 females and 120 males presented during the study period. Most of the patients presented with dyspnea140[70%], fever 120[60%], sorethroat 100[50%], cough100 [50%], rhinitis 50[25%], myalgia40[20%], diarrhea20[10%], anosmia20[10%], dysguesia20[10%], nausea15[7.5%]. Conclusion: It was observed from the study that most of the patients had fever as the major symptom. dyspnea and cough symptoms followed in many patients. Some patients went into severe respiratory distress.it was observed that patients recovered from the symptoms after symptomatic treatment but persisted with weakened immune system, respiratory disturbances reminiscing the long term sequelae this deadly pandemic could lead to…...

About 50 samples were collected from Al-Ramadi Teaching Hospital and early postoperative complications for diabetes patient were identified as uncontrolled blood glucose could lead to complications for patients with surgery or for diabetics. Slightly high blood sugar can delay healing and can increase your chances of developing an infection from less than 2 percent to more than 10 percent. In general, the higher the blood sugar level, the higher this risk. Checking glucose during surgery is reasonable if the surgery is prolonged or if your glucose levels are unpredictable. Even diabetics who control diet and exercise well can experience high blood glucose levels during the hours and days following surgery. If your glucose fluctuates widely between checks, you may even need to be checked at night if you have symptoms of low or high blood glucose. Features of the flow surgical diseases in patients with diabetes mellitus and complications diabetes itself represent a significant theoretical and practical interest for doctors of various specialties. In developed countries, diabetes mellitus occurs in 5-6% of the population and the need surgical interventions occur in more than half of them, this demonstrates the urgency of the problem of diabetes mellitus in surgery. Based on the previously acquired knowledge of normal and pathological physiology and anatomy, endocrinology to study etiology, pathogenesis, clinic, diagnosis, treatment tactics in complications of diabetes mellitus within the competence of the surgeon, features of surgical pathology in diabetes mellitus. Task (1) to assimilate morphological substrates for the development of surgical complications of diabetes. (2) to study the clinical manifestations of surgical complications diabetes mellitus, learn how to take anamnesis, complaints, examination with this pathology. (3) To get acquainted with modern approaches to the treatment of surgical complications of diabetes. (4) To study the features of the clinic of surgical diseases in diabetes mellitus. (5) become familiar with the surgical approaches to the treatment of sugar diabetes. Test questions from related disciplines: (1) Insulin, its role in metabolism. (2) Violation of metabolism in diabetes mellitus. (3) The structure of the capillary wall and arterial bed. Control questions on the topic of the lesson: (1) Etiology and pathogenesis of diabetes mellitus. (2) Influence of insulin on metabolism. (3) Complications of diabetes mellitus related to the competence of the surgeon. (4) Pseudo-peritonitis in diabetes. (5) Acute gastrointestinal bleeding in diabetes. (6) Purulent-inflammatory diseases of the skin and subcutaneous tissue. (7) Anaerobic non-clostridial soft tissue infection in diabetes. (8) The concept of diabetic foot syndrome. Five (9) syndrome of mutual burdening. (10) Features of performing surgical interventions for diabetes.

We present an unusual case of gastric leak who had sleeve gastrectomy 16 days ago for morbid obesity. 39 years old female with no co-morbid discharged on 2^nd post-operative day from hospital. On 16^th post-operative day, she presented with history of fever. A small leak at esophagogastric junction was seen on CT scan and managed by gastric stenting. Interestingly, after two weeks, she passed the stent through rectum before planned removal.

We read with interest the article by Liu et al. about an optical coherence tomography (OCT) study of five patients (10 eyes) with Leber’s hereditary optic neuropathy (LHON) due to the variant m.11778G>A in MT-ND4 which were compared with 11 clinically unaffected carriers (22 eyes) of the variant and with 20 healthy controls [1]. Thicker foveal thickness, thinner foveal pit depth, and flatter foveal slopes were found in LHON patients and unaffected carriers compared to controls [1]. We have the following comments and concerns.

Missing in this study are the heteroplasmy rates of the m.11778G>A variant [1]. Though most of the primary LHON mutations are found in a homoplasmic state, there are exceptions and even the m.11778G>A variant occurs in the heteroplasmic state and is nonetheless pathogenic [2]. Thus, knowing heteroplasmy rates is crucial as they may strongly influence the OCT results.

We should know how the authors excluded that any of the 20 control subjects was indeed an asymptomatic m.11778G>A carrier. We should know if the 20 healthy subjects had undergone genetic testing to exclude the presence of an asymptomatic m.11778G>A variant.

We also should know the haplogroup of the investigated family since the haplotype may strongly determine the phenotypic expression of primary LHON mutations [3]. 

Missing in the study is the information about who of the affected or unaffected carriers was a smoker. Since smoking is regarded as a putative trigger of LHON in asymptomatic carriers, it is worthwhile to know how many of the included m.11778G>A carriers were smoking or not. 

A further shortcoming of the study is that it was not mentioned how many of the 5 LHON patients received antioxidants, in particular idebenone (900mg/d). The latter is the only approved drug for LHON and may exhibit a significant effect in some of the LHON patients [4]. Since idebenone may strongly influence the test results, it is worthwhile to know how many of the 5 LHON patients received the drug or other antioxidants known to exhibit a beneficial effect.

Since some patients carrying the m.11778G>A variant may recover spontaneously [5], it should be mentioned how many of the 5 LHON patients reported spontaneous remission or improvement over time. Spontaneous recovery may also strongly influence the study results.

In all four sectors total retinal and RNFL thickness were, though not statistically significant, larger in unaffected carriers compared to controls. This finding contradicts thicker foveal thickness, thinner foveal pit depth, and flatter foveal slopes in unaffected carriers compared to controls. This discrepancy requires an explanation.

Overall, the presented study has a number of shortcomings, which need to be solved before final conclusions can be drawn. Considering factors influencing the expressivity of the m.11778G>A variant is crucial for interpretation of the study results. Whether allegedly asymptomatic carriers of the variant m.11778G>A are subclinically affected remains unproven.

Recent studies demonstrated that individuals with Parkinson´s disease (PD) require 1.5 times more likely hospitalization than controls. Additionally, duration of hospitalisation and rate of complications, particularly infections and delirium, are increased in PD patients. Unfortunately, there is evidence that inpatients with PD may have a higher mortality rate than outpatients with PD [1]. Based on these facts, we enjoyed reading the recent article entitled, “Description of multimorbidity clusters of admitted patients in medical departments of a general hospital” by Matesanz-Fernández and colleagues published in the Intern Med J [2]. The authors identified for the first time some clusters of comorbidities among inpatients with PD. Considering the strong clinical relevance of these results, what are the repercussions on cardiac events in PD?

Really, PD is one of the most frequent age-related neurodegenerative disorders, affects millions of people globally, has no cure, and several studies demonstrated that patients with PD have an increased mortality compared to the general population. The predominant causes of death in PD are pneumonia and cardiovascular diseases [3-5]. Besides that, sudden unexpected death in PD (SUDPAR), a rare but fatal event, is increasingly discussed as a contributor to mortality in PD. SUDPAR has been defined as unexpected death of a patient with PD without any satisfactory explanation of death as determined by autopsy [5,6]. So far there are no epidemiological studies that precisely demonstrate the possible distribution of SUDPAR among main research centres for movement disorders, but relevant data that evaluated SUDPAR cases found that an average of 14% of PD patients dies suddenly. Although causes of SUDPAR are not yet entirely identified [5,6], translational studies suggest that cardiac abnormalities and autonomic dysfunction play a possible "direct" role in SUDPAR, even because ~60% of PD patients have cardiovascular comorbidities and because of the frequent autonomic disturbances in PD [5]. Moreover, some determinants may be directly related to SUDPAR, such as age at onset, duration of PD, gender, motor severity and drug treatment (polypharmacy) [5,6]. However, these risk factors of SUDPAR need to be further investigated. Considering these clinical aspects, a current question could be: How to follow the news about SUDPAR?

In fact, a fundamental practical problem in studying SUDPAR risk factors, mechanisms, and prevention is that it is relatively uncommon [5,6]. Thus, crucial questions are whether and when to talk about SUDPAR to individuals and family members. To answer these questions, it would be appropriate to establish a task force that discusses issues related to SUDPAR. Furthermore, a close convergence of clinical research and clinical care (e.g., neurologists, cardiologists, and other multidisciplinary team members) is extremely important to assess and establish the state of knowledge of SUDPAR [6]. Moreover, another point suggested in the literature is the importance of focusing also on dietary habits and food preferences in PD patients, facts related to the prevention of possible cases of SUDPAR [7,8]. In view of the complex needs of people with PD, a very recent study verified the reason for admission, specialist team interventions, length of stay, frequency of readmission, discharge destination, mortality and the bed cost per unplanned emergency department (ED) attendance or hospital admission episode [9]. It was found that the mortality of PDs admitted via the emergency department was twice as much as those of non-PD patients [9].

On the whole, PD is a heterogeneous, multifactorial, and systemic neurodegenerative disorder. To reduce mortality rates in PD individuals, a multidisciplinary team should perform routine cardiovascular screening (ECG, Holter-monitoring, and echocardiography [5,6]. Explanations for increased mortality rates in PD patients and for the occurrence of SUDPAR are warranted.

Acknowledgment

Our studies are supported by the following grants: FAPESP (Fundação de Amparo à Pesquisa do Estado de São Paulo); CNPq (Conselho Nacional de Desenvolvimento Científico e Tecnológico); Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES).

Cardiac complications in SARS-CoV-2 infected patients not only include myocardial injury, myocarditis, Takotsubo cardiomyopathy (TTS), coagulation abnormalities. heart failure, cardiac arrest, arrhythmias, acute myocardial infarction or cardiogenic shock but is more variegated. Additionally considered should be endocarditis due to superinfection, viral or bacterial pericarditis, aortic dissection, pulmonary embolism from the right atrium, ventricle or outflow tract and cardiac autonomic denervation. Cardiac damage due to side effects from the anti-COVID medication should not be neglected.

With interest we read the article by Maruo et al. about a 22yo male in whom Leigh syndrome was diagnosed upon endo-myocardial biopsy (EMB). Causative for Leigh syndrome was the mtDNA variant m.14453 A>G in MT-ND6 [1]. Biochemical investigations of the EMB revealed a complex-I defect. Biochemical investigations of the muscle homogenate were normal [1]. The patient manifested phenotypically with delayed psycho-motor development, seizures, lactic acidosis, hypertrophic cardiomyopathy, and muscle weakness [1]. We have the following comments and concerns. 

Leigh syndrome is usually diagnosed upon the clinical presentation, cerebvral MRI findings (bilateral basal ganglia, midbrain, brain stem, or cerebellar T2 hyperintens lesions), and confirmation of a mutation in one of the >75 currently known genes to cause Leigh syndrome. Since Leigh syndrome was suspected already prior to EMB, we shouold know why the patient nonetheless underwent EMB. Instead of EMB the patient should have undergone sequencing of the mtDNA. 

Phenotypes of pathogenic mtDNA variants may not only be determined by heteroplasmy rates [2] but also by mtDNA copy number, hyplotype, and polymorphisms. Thus, we should know the mtDNA copy number, the haplotype, and which polymorpshism of the mtDNA were detected. 

Biochemical investigations of the myocardial homogenate is unusual why we should know how the authors specified normal limits for respiratory chain complex acitivities. 

Since neuromuscular disorders (NMDs) are frequently associated with noncompaction, also known as left ventricular hypertrabeculation (LVHT), [3] and since mitochondrial disorders (MIDs) are the group of genetic disorders most frequently associated with LVHT [4], it is crucial to know if echocardiography was revised for LVHT. Since LVHT may be missed on echocardiography due to technical issues [5], we should know the results of cardiac magnetic resonance imaging (cMRI). Since LVHT is frequently associated with late gadolinium enhancement (LGE) [6], we should know if the index patient presented with LGE on cMRI.

Since several of the anti-seizure drugs (ASDs) are potentially mitochondriaon-toxic [7], it should be specified which ASDs the index patient particularly received and in which dosage. It is also crucial to know the quality of seizure control, if there were triggers of seizures, and if the ASDs exhibited any side effects. Since it is known that the ketogenic diet may exhibit a beneficial effect on epilepsy in MIDs, we should know if the ketogenic diet was ever tried in the index patient and if it was beneficial. 

Since mtDNA variants frequently manifest with multisystem disease and since the index patient manifested in the brain, heart, and muscle (myo-cardio-encephalopathy), we should know the results of prospective investigations for multisystem disease. Particularly, we should know which organs other than the brian, heart, and muscle were additionally involved. Particularly, we need to know which cells produced lactate in excess. Was it the myocardium, the brain or the muscle?

How do authors explain the discrpancy between normal muscle biposy and normal biochemical investigations of the muscle and muscle weakness on clinical neurologic exam. 

Overall, the study has several limitations which should be addressed before drawing final conclusions. Patients with suspected Leigh syndrome should not undergo EMB but rather sequencing of the mtDNA or whole exome sequencing (WES) for confirming the disgnosis Leigh syndrome. Genetic tests have less side effects than EMB.

With interest we read the article by Sanchez-Morales et al. about a retrospective study of 10 pediatric patients with neurological manifestations of an infection with SARS-CoV-2 (COVID-19) [1]. Three patients had Guillain-Barre syndrome (GBS), two optic neuritis, two acute ischemic stroke, one myositis with rhabdomyolysis, one acute cerebellar ataxia (ACA), and one anti-NMDA-R immune encephalitis [1]. It was concluded that acute neurological compromise during these days suggests an infection with SARS-CoV-2 [1]. The study is appealing but raises comments and concerns. 

We do not agree with the notion that the patient with optic neuritis is the first pediatric case with SARS-CoV-2 associated optic neuritis [1]. In a recent review about cranial nerve involvement in COVID-19, a 15yo male with mild COVID-19 was reported who had optic neuritis and neuromyelitis optica (NMO)-like features [2] [Finsterer, submitted]. This particular patient benefited from steroids. 

There is a discrepancy between table 3 and the information in the text. According to table 3, 5 patients had probable COVID-19 but in the text only 3 patients had probable COVID-19. This discrepancy should be solved. The weak evidence for COVID-19 in the 10 patients argues against a causal relation between the neurological abnormalities and SARS-CoV-2. 

We should be told about the underlying cause of ACA in one patient [1]. Was ACA attributable to cerebellar affection (cerebellitis), to spinal cord affection, or due to neuropathy of peripheral nerves? Were there cerebellar signs other than ataxia (e.g. slurred speech, dysmetria, dysdiadochokinesia, positive rebound)? 

Concerning the two patients with acute ischemic stroke, we should be told if they carried any classical risk factors for ischemic stroke, such as arterial hypertension, diabetes, hyper-lipidemia, or atrial fibrillation. Since venous sinus thrombosis (VST) is an increasingly recognised complication of a SARS-CoV-2 infection [3], we should be told if the two patients had ischemic stroke following VST, particularly if the D-dimer was elevated or if magnetic resonance venography revealed VST. Concerning the treatment of acute ischemic stroke we should be told if the two index patients underwent thrombolysis or if they required mechanical thrombectomy. Did any of the two require oral anticoagulation?

Concerning the three patients with GBS we should be informed about the subtype of GBS (AIDP, AMAN, AMSAN, MFS, Bickerstaff’s brainstem encephalitis (BBE), polyneuritis cranialis, cervico-brachial GBS) that was found in the three patients. It is also of interest which type of treatment the three patients received. Steroids, immunoglobulins, or plasma exchange?

The patient with immune encephalitis is interesting as an increasing body of evidence accumulated showing that SARS-CoV-2 can trigger the development of immune encephalitis or immune myelitis [4]. Single cases with limbic encephalitis, NMDAR-positive immune encephalitis, and BBE have been previously reported [5].

Overall, the interesting study has several limitations. The underlying cause of ACA and of ischemic stroke should be clarified. The subtypes of GBS should be presented and which therapy was applied for ischemic stroke respectively GBS. Immune encephalitis/myelitis should be stressed as a neurological complication of COVID-19. 

With interest we read the article by Sen et al. about a 27yo female with genetically confirmed mitochondrial encephalopathy, lactic acidosis, and stroke-like episode (MELAS) syndrome in whom infection with SARS-CoV-2 was assumed to have triggered a stroke-like episode (SLE) clinically manifesting as non-bilious, non-bloody emesis, inability to tolerate feeds and medications, severe abdominal pain, mental deterioration, and a seizure [1]. The patient’s SLE was managed with L-arginine and unfractionated heparin in a therapeutic dosage [1]. The report is appealing but raises the following comments and concerns.

We do not agree with the notion that the SLE was triggered by SARS-CoV-2 [1]. Due to the gastro-intestinal compromise the patient was not taking her regular antiepileptic drugs (AEDs) since one week prior to admission [1]. Since it is well-known that seizures can trigger SLEs [2], seizures more likely than the infection with SARS-CoV-2 triggered the SLE. Arguments for seizures as the trigger of the SLE are that she was not talking levetirazetam (LEV), oxcarbazepine (OXC), and lamotrigine (LTG) since one week, that she had a seizure one day prior to admission, that electroencephalography recorded sharp waves over the area of the SLE, and that SARS-CoV-2 was not documented in the cerebro-spinal fluid (CSF) [1]. Missing in this respect are serum levels of OXC, LEV, and LTG. Sub-therapeutic levels of the AEDs would further strengthen the seizure theory. 

A shortcoming of the study is that only T2/FLAIR and apparent diffusion coefficient (ADC) MRI modalities were provided. Stroke-like lesions (SLLs), the morphological equivalent of a SLE on MRI, are characterised by hyperintensity not only on T2/FLAIR but also on diffusion weighted imaging (DWI) and perfusion weighted imaging (PWI). Furthermore, a SLL may show up as hypo-intensity on oxygen-extraction fraction (OEF) MRI and as hypo-metabolism on FDG-PET [3]. Additionally, MR-spectroscopy (MRS) may show a lactate peak within the SLL [4]. Since SLLs in the chronic stage can have a similar appearance as the lesion shown in figure 1, it cannot be excluded that the presented lesion does not represent an acute SLL but rather an old regressing lesion. A further argument against an acute SLL in the index case is that she did not present with typical features of a SLE. Isolated vomiting is a rare manifestation of a SLE and mental decline could be simply interpreted as prolonged post-ictal confusion. 

Since COVID-19 frequently manifests with gastro-intestinal compromise, it cannot be excluded that the gastro-intestinal abnormalities were rather due to the infection with SARS-CoV-2 than due to the SLE. Missing in this respect are stool cultures, gastroscopy and colonoscopy, particularly with regard to the dark-coloured stool [1]. 

We should be told if quadruparesis, ataxic gait, intention tremor, generalised wasting, were present already prior to the SARS-CoV-2 infection. Description of her pre-morbid condition is crucial to assess which of the abnormalities could be attributed either to the viral infection and which to MELAS. Delineation of COVID-19 manifestations from MELAS manifestations is crucial as the treatment of both is different. We should be told why AEDs were not increased and the rationale for therapeutic anticoagulation for the SLE. 

Missing in the report is the genetic cause of MELAS. We should be told if MELAS was due to an mtDNA or nDNA variant. In case it was due to an mtDNA variant we should know the heteroplasmy rates in affected tissues. 

Overall, the interesting case has several limitations which challenge the conclusions. Acuteness of the presented SLL must be documented by multimodal MRI and MRS. To proof that SARS-CoV-2 triggered the SLE confirmation of the virus within the CSF should be provided. Exact delineation of MELAS and COVID-19 manifestations is crucial in the index patient. Whether an infection with SARS-CoV-2 truly deteriorates MELAS remains to be proven.

With interest we read the article by Shemer et al. about nine patients who developed unilateral, peripheral facial nerve palsy after vaccination with the mRNA vaccine BNT162b2 [1]. It was concluded that a causal relation between vaccination and the neurological compromise could not be established and that the pathophysiological mechanism remains elusive if a causal relation is assumed [1]. The study is appealing but raises the following comment and concerns.

The main shortcoming of the study is that the nine included patients had not undergone neurological investigations [1]. Since there are indications that SARS-CoV-2 triggers the development of Guillain-Barre syndrome (GBS) [2] and that SARS-CoV-2 vaccination may be occasionally complicated by the occurrence of GBS, it is crucial that all 9 patients were seen by a neurologist. Since various subtypes of GBS may be characterised by affection of a single or multiple cranial nerves [3], it is essential that GBS was excluded in all 9 patients. GBS is usually diagnosed according the Brighton criteria by clinical assessment, nerve conduction studies, cerebro-spinal fluid investigations, and eventually MR imaging with contrast medium [3]. Thus, we should be told how many of the 9 patients had involvement of other cranial nerves or even involvement of peripheral nerves, how many had undergone lumbar puncture, and how many nerve conduction studies to confirm or rule out affection of nerves other than the facial nerve. 

There are several arguments against a causal relation between the vaccination and facial palsy. First in two patients the latency between vaccination and development of facial palsy was long (26, respectively 30 days) [1]. Side effects after such a long latency not necessarily can be attributed to the vaccination. Second, nothing is reported about the exclusions or confirmation of alternative causes of the facial palsy. We should know in how many patients was there a malignoma, borreliosis, or varicella zoster virus (VZV) infection. Third, since publication of this report only four further patients have been reported as per the end of March 2021 who developed facial palsy time-linked to a SARS-CoV-2 vaccination [4,5] suggesting that the prevalence of peripheral facial palsy has not increased since introduction of SARS-CoV-2 vaccines. 

Another shortcoming is that it is unknown how many of the 9 included patients had already developed antibodies against SARS-CoV-2 and how many patients were SARS-CoV-2 positive despite having received the vaccination.

A further shortcoming is that nuclear facial palsy was not considered why none of the 9 patients had undergone cerebral imaging to exclude a lesion of the facial nucleus in the pons or affection of the facial tract radiating from the nucleus to the ventral side of the pons.

Patient-2 of the case series obviously had developed facial palsy plus (Ramsey Hunt syndrome) due to a VZV infection [6]. Since the management of Ramsey Hunt syndrome due to VZV infection is challenging and the outcome often worse as compared to Bell’s palsy, we should be informed about the therapeutic management and outcome of patient-2 after her second admission. 

In patient-3 VZV infection occurred prior to the SARS-Co’V-2 vaccination, why it is more likely that VZV was responsible for facial palsy than the vaccination.

Overall, this interesting study has several limitations which challenge the conclusions. GBS and nuclear facial palsy need to be excluded in all patients, results of nerve conduction studies should be provided, and alternative causes of facial palsy should be excluded. Furthermore, it should be mentioned how many of the vaccinated patients were SARS-CoV-2 positive or had developed antibodies against the virus.

With interest we read the article by Adebiyi et al. about 80 patients with epilepsy who were investigated for cardiac autonomic neuropathy (CAN) by means of 5 tests, the heart rate response to deep breathing, to the Valsalva manoeuvre, and standing, and blood pressure variation during isometric handgrip and after 3min of standing.[1] It was found that 52.5% had CAN, of which 69% had pure parasympathetic dysfunction and only 3% pure sympathetic dysfunction.[1] Patients with >4 seizures per month and those receiving antiepileptic drugs (AEDs) for <10y had higher odds to develop CAN.[1] We have the following comments and concerns.

The main shortcoming of the study is that neuropathy was not confirmed by other means than the five applied tests. Most patients with autonomic neuropathy also develop neuropathy of motor and sensory fibers, which can be documented on nerve conduction studies (NCSs). Thus, it is crucial that patients with suspected CAN undergo NCSs. CAN can also be documented by ¹²³I-metaiodobenzylguanidine (MIBG) single photon emission computed tomography (SPECT).[2] Thus, we should know how many of the included patients had CAN also on NCSs and on MIBG SPECT. 

A further shortcoming is that the type of epilepsy was not specified. Thus, we should know how many of the 80 patients had structural, genetic, infectious, metabolic, immunologic, or kryptogenic epilepsy. Knowing how many had genetic epilepsy is crucial since some of the genetic epilepsies are associated with neuropathy.[3] Genetic epilepsies may also manifest in the heart with ventricular arrhythmias or conduction defects.[4] Additionally, mutations in certain genes, such as KIF1A, may manifest with epilepsy and autonomic neuropathy.[5] 

Autonomic neuropathy usually not only manifests in the autonomic fibers supplying the heart but also in parasympathetic or sympathetic fibers supplying the pupillary muscles, the lacrimal glands, the salivary glands, bronchial smooth muscles, the intestines and pancreas, the liver, the suprarenal gland, the urinary bladder, and sexual organs. Thus, we should know if the 42 patients with CAN, had pupillary dysfunction, hypo/hypersecretion of lacrimal fluid or saliva, bronchospasm, dyspepsia, gastrointestinal dysfunction, urinary voiding dysfunction, or sexual dysfunction. 

Since CAN may be associated with systolic or diastolic dysfunction and heart failure, we should be informed about the results of echocardiography and the pro-brain natriuretic peptide (BNP) values in the 42 patients. We should also know if infectious, immunologic and metabolic causes of epilepsy and autonomic neuropathy were excluded. 

Interesting would be follow-up data to see if any of the 42 patients experienced sudden unexpected death in epilepsy (SUDEP). Since CAN may contribute to the occurrence of SUDEP, it is conceivable that some of those with CAN experienced near-SUDEP or SUDEP during the disease course.

Overall, the appealing study has some shortcomings which should be addressed before drawing conclusion as those presented. The high frequency of CAN in selected epilepsy patients may depend on the methods applied to measure CAN and on the inclusion criteria. Epilepsy should be classified according to etiology to see if there is a correlation between the cause of epilepsy and CAN. 

Fertility preservation is becoming increasingly to improve the personal satisfaction in malignancy survivors. Notwithstanding rules recommending that conversation of richness conservation ought to be done preceding beginning disease treatments, there is an absence of execution around here. A few procedures are accessible for richness safeguarding and they can be utilized exclusively or together in a similar patient to amplify effectiveness. Oocyte and undeveloped organism cryopreservation are currently settled strategies yet have their restrictions. Ovarian tissue cryopreservation however viewed as trial as of now, has a more extensive clinical application and the upside of keeping the richness window open for a more drawn out time. Both chemotherapy and radiotherapy significantly affect regenerative potential and ripeness safeguarding methodology ought to be done preceding these medicines. The requirement for richness protection must be weighed against dreariness and mortality related with malignancy. There is along these lines a requirement for a multidisciplinary coordinated effort among oncologists and conceptive experts to improve mindfulness and accessibility.

As of now, there are numerous individuals on the planet experiencing persistent kidney infections around the world. Because of the a few danger factors like food, climate and expectations for everyday comforts numerous individuals get infections out of nowhere without comprehension of their condition. Diagnosing of persistent kidney infections is for the most part obtrusive, expensive, tedious and frequently hazardous. That is the reason numerous patients arrive at late phases of it without treatment, particularly in those nations where the assets are restricted. Hence, the early recognition procedure of the illness remains significant, especially in non-industrial nations, where the sicknesses are for the most part analyzed in late stages. Finding an answer for previously mentioned issues and braving from impediments turned into a solid intention to lead this examination. In this examination study, the impacts of vector machines calculation are explored. The ongoing kidney infection dataset depends on clinical history, actual assessments, what's more, research facility tests. Exploratory outcomes appeared more than 93% of achievement rate in arranging the patients with kidney infections based on three execution measurements i.e., precision, affectability and explicitness.

The study was done and samples were collected at Hospital, Nineveh, Iraq. Recent studies have demonstrated a high risk of kidney damage and associated cardiovascular complications in patients with rheumatoid arthritis (RA), which generally determines the prognosis of these patients. However, the incidence of chronic kidney disease (CKD) in RA in the Russian cohort of patients has not been precisely established. Goal: To establish the frequency, as well as to evaluate morphological variants and risk factors of renal damage in patients with RA. Materials and Methods: Examined 180 patients with RA, followed up in the Clinic of Nephrology, Internal and Occupational Diseases named after V.I. EAT. Tareeva for the period from 2014 to 2019.The following indicators were assessed: age, sex, duration of the disease, presence of extra-articular appearances, as well as clinical and laboratory indicators of disease activity, including ESR, C-reactive protein (CRP), rheumatoid factor level and activity index DAS28-ESR. From the general population risk factors for CKD, the body mass index, the presence and degree of arterial hypertension (AH), lipid and carbohydrate metabolism parameters were assessed. Results: The incidence of CKD in RA patients was 19.7%. The risk factors for the development of CKD stage III and higher in patients with RA were age, presence and severity of hypertension, lipid metabolism disorders, as well as high indicators of disease activity - ESR, CRP, DAS28-ESR index and duration of RA, in multivariate regression analysis had an independent effect RA, age, hypertension and hypercholesterolemia. Among the morphological variants of kidney damage, the most common was amyloidosis (50.0%), which is associated with a longer duration of the disease and an increased level of CRP. CGN was detected in 30.4% of cases, with the prevalence of mesangial forms of glomerulonephritis. Tubulointerstitial nephritis was detected in 19.6% of cases. In 31 (36.0%) of 86 patients, an isolated decrease in the glomerular filtration rate of less than 60 ml/min was revealed. Conclusion: The risk factors for CKD in RA patients, in addition to the general population factors, are the activity and duration of the disease. The most common form of kidney damage is amyloidosis, which, in contrast to chronic glomerulonephritis, is associated with persistent high levels of inflammatory proteins and a longer duration of the disease.

Background: Acute myeloid leukaemia (AML) is a heterogeneous haematological malignancy characterized by the proliferation of immature myeloid cells in the bone marrow, typically exceeding 20-30% blasts. According to the French-American-British (FAB) classification, AML is divided into eight subtypes (M0-M7) based on morphological and cytochemical features. This study aimed to evaluate alterations in complete blood count (CBC) parameters in adult AML patients and to analyse the distribution patterns of FAB subtypes over time. Materials and Methods: A retrospective review was conducted on 521 adult patients diagnosed with AML and admitted to Baghdad Teaching Hospital, Medical City, between January 2000 and December 2011. After excluding 53 cases due to relapse, age below 15 years, incomplete data, prior haematological disorders or unclassified AML, 468 patients were included in the final analysis. Clinical history, physical examination findings and laboratory investigations were documented. Diagnostic evaluation included CBC, differential white blood cell count, peripheral blood smear, bone marrow examination with blast percentage estimation and special cytochemical stains to confirm AML subtype classification. Results: Among the 468 patients, the most frequent subtype was AML-M3 (28.2%), followed by M2 (26.3%), M1 (19.7%), M5 (15%), M4 (7.9%), M6 (1.9%) and M7 (1%). AML was most prevalent in the 15-24-year age group, with a gradual decline in frequency in older age groups. The male-to-female ratio was approximately 1:1.05, indicating no significant gender predominance. Haematological findings revealed anaemia (haemoglobin <30%) in 95.7% of patients, leukopenia in 59.8% and thrombocytopenia (<150×10⁹/L) in 94.7%. Peripheral blood blasts were detected in 78% of cases, while Auer rods were present in 32.3%. Cytochemical staining (Sudan Black B) was positive in 85.6% of cases. A notable increase in AML incidence was observed in 2011, accounting for 20.5% of total cases during the study period. Conclusion: The findings demonstrate that AML-M3 and AML-M2 were the predominant subtypes in this cohort. Haematological abnormalities, particularly anaemia and thrombocytopenia, were highly prevalent. Not all patients exhibited circulating blasts, highlighting the importance of bone marrow examination for definitive diagnosis. The study underscores the need for advanced diagnostic modalities, including immunophenotyping and molecular genetic analysis, to improve classification accuracy and therapeutic outcomes. Additionally, prompt management of cytopenias and infection risk remains essential due to the high likelihood of severe infections and bleeding complications in AML patients.

SARS CoV-2 often causes respiratory distress and pneumonitis in patients to require ventilatory support in order to maintain oxygenation. Intubation is often discouraged due to high mortality and increased risk of cross infection to the patients and health care workers due to aerosols. Early intervention by Chest physiotherapy can help in improving the respiratory function and prevents the need of intubation. This is a case report of 45 years old male patient with SARS CoV-2 pneumonitis with diabetes as comorbidity who suffered from hypoxemia and was planned for intubation because of falling SPO2 value. Chest physiotherapy in prone positioning, Incentive spirometry exercises, Neurophysiological facilitation of Respiration, Proprioceptive neuromuscular facilitation (PNF) for breathing, acupressure point stimulation and Active cycle of breathing technique (ACBT) were used in this case.  After 14 sessions of Physiotherapy, the overall outcomes of the patient were satisfactory. The SPO2 levels maintained at 94, the level of dyspnoea was grade 1 and the anxiety score decreased from 21 to 13, depression scores from 21 to 09. The RT-PCR was done on date 06-07-2020 and was negative. Thus, chest physiotherapy can help in improving oxygenation and avoiding the need of intubation and ventilation.

Background: Scrub typhus is a serious public health problem in the state of Himachal Pradesh as the climatic and geographical conditions are conducive for spread of vector of this disease. The aim of this study was to find the Lymph-adenopathy among patients with Scrub typhus. Materials and Methods: This cross-sectional Sero-Epidemiological study was conducted in the department of Paediatrics, Indira Gandhi Medical College and Shimla from 1st June 2017 to 30^th Nov 2018. The study participants were newly diagnosed paediatric cases(n-102) of scrub typhus with a positive Scrub typhus IgM ELISA test. Results: In the present study, among 102 newly diagnosed cases of Scrub Typus, 57 (55.9%) were males while 45 (44.1%) were females. 39 (38.2%) were in the age group of 1-10 years while 63 (61.8%) were in the age group of 11-18 years. Lymphadenopathy was present in 16(15.7%) of patients. It was present in axilla 7(43.7%), cervical 4(25.0%), inguinal 2(12.5%) and multiple sites 3(18.8%) patients. Conclusion: The general physicians should be sensitized regarding Lymph-adenopathy associated with Scrub typhus.

Background: Scrub typhus is a disease caused by Orientia tsutsugamushi bacteria, caused by the bite of infected larval mite (chigger), which is mainly found in the shrubs. It is endemic and documented zoonotic disease in the state of Himachal Pradesh as the climatic and geographical conditions are conducive for spread of vector of this disease. This study was done to study the Epidemiological factors associated with new diagnosed cases of scrub typhus and risk factors in paediatric population. Materials and Methods: This cross-sectional Sero-Epidemiological study was conducted in the department of Paediatrics and Microbiology, Indira Gandhi Medical College, Shimla from 1^st June 2017 to 30^th Nov 2018. The study participants were newly diagnosed paediatric scrub typus cases(n-102) and data was analysed using Epi info7 software using appropriate statistical tests Results: In the present study, among 102 newly diagnosed cases of Scrub Typus, 57 (55.9%) were males while 45 (44.1%) were females. 39 (38.2%) were in the age group of 1-10 years while 63 (61.8%) were in the age group of 11-18 years. Children living in the rural area, male gender, lower middle class of socioeconomic status, not taking bath daily, involved in agriculture activities, having contact with rodents, rearing cattle, spending more than one hour time outdoor into agricultural activities, not wearing full sleeve dress and shoes for outdoor activities, were risk factors for acquiring the scrub typhus. Conclusion: general physician, school children and public should be educated, through health education campaigns in hospitals, schools and in media regarding the prevention of risk factors associated with scrub typhus, to reduce the morbidity and mortality associated with this disease.

Diabetic foot is a commonly known complication of diabetes which can lead to amputation causing misery to the patient. It is known to cause increased morbidity and mortality. The burden of diabetic foot is rising both in developed and developing country. If a patient is from lower socioeconomic background, then it will dent him financially once he develops a complication. With such a dangerous scenario seen in most developing countries, prevention of diabetic foot is the best solution and there have been various methods of prevention. Various new terms have been coined in field of diabetic foot. The author in this article introduces 2 new terms namely the diabetic foot delay and the diabetic foot push. These terms will help in raising the awareness of diabetic foot and its problems and assist in interventions that can prevent diabetic foot complications.

A review of the scientific literature on the use of anaesthesia in diabetics. An important task of the anaesthesiologist during anaesthesia for diabetics is to maintain optimal blood sugar levels, glycaemic parameters are selected individually, but one should not seek the complete normalization of blood sugar levels, since hypoglycaemia occurring during Surgery is riskier than high blood sugar. The methodological basis for research was formed by general scientific methods of analysis, synthesis, comparison, and statistical methods of perception. Modern anaesthesia blocks or distorts clinical symptoms of hypoglycaemia. Important clinical signs from the central nervous system, such as agitation, convulsions, coma, etc. The catecholamine reaction, which occurs in response to hypoglycaemia and is characterized by tachycardia, moderate hypertension, and under general anaesthesia, can be associated with cardiovascular depression in the form of hypotension and bradycardia. It is difficult to distinguish hypoglycaemia during surgery from the manifestations of insufficiency of general anaesthesia (the corresponding reactions in both cases may be similar). Low blood sugar levels during surgery are facilitated by the use of large doses of anaesthesia or their prolonged administration due to the length of the surgery. These drugs weaken the mechanisms that mobilize the anti-isolation hormones in hypoglycaemia, so the effect of insulin under anaesthesia is longer than in the state of wakefulness, and a small overdose of it causes hypoglycaemia. In this regard, the blood sugar level of diabetics should be determined during the procedure every 1-2 hours. The methodological basis for research was formed by general scientific methods of analysis, synthesis, comparison, and statistical methods of perception. Modern anaesthesia blocks or distorts clinical symptoms of hypoglycaemia. Important clinical signs from the central nervous system, such as agitation, convulsions, coma, etc. The catecholamine reaction, which occurs in response to hypoglycaemia and is characterized by tachycardia, moderate hypertension, and under general anaesthesia, can be associated with cardiovascular depression in the form of hypotension and bradycardia. It is difficult to distinguish hypoglycaemia during surgery from the manifestations of insufficiency of general anaesthesia (the corresponding reactions in both cases may be similar). Low blood sugar levels during surgery are facilitated by the use of large doses of anaesthesia or their prolonged administration.

Neonatal health is undoubtedly one of the most significant health challenges facing the developing world. Transition from intra uterine to extra uterine environment is a critical period demanding behavioural and physiological newborn adjustment at birth and immediate newborn period. A comparative study was conducted to assess the effectiveness of Mummification and Kangaroo Mother Care with Mummification. A quasi-experimental multiple time series design was used. The study was conducted at Sri Ramakrishna Vivekananda Urban Maternity Centre and Durgabai Deshmuk General Hospital and Research Centre. 60 newborn babies within 24 hours of birth followed by normal delivery were selected as sample. In each experimental group I & II 30 newborn babies were selected. Physiological parameters such as temperature, heart rate, respiratory rate were assessed by observation and behavioural parameters like sleeping pattern was assessed by modified Brazelton behavioural assessment scale (1984). The findings of the study revealed that the Kangaroo mother Care is highly significant at (p <0.001) level than Mummification. The Kangaroo Mother Care can be safely included in routine care of new born babies without any additional resources.

Objectives: Globally, the prevalence of multi-drug-resistant gram negative-bacteria is increasing in an exaggerated manner making the importance of conserving salvaging antibiotics such as Colistin is of our urgent priority. Our objectives in this study are to investigate the clinical impacts of Colistin nebulizer when adjunctively used at dose regimen of 1 MIU TID with Colistin IV. Methods: An observational retrospective study was conducted on eligible 122 adult mechanically ventilated critically ill refractory VAP infected patients admitted to adult ICU of King Hussein Medical Hospital (KHMH) at the Royal Medical Services (RMS) in Jordan between April 2017 and January 2019. All eligible mechanically ventilated critically ill VAP affected patients were allocated into either Group I (Colistin IV + Colistin Neb) or Group II (Colistin IV). Results: The mean age of the whole study cohort was 59.90±10.85 years and Group II cohort were insignificantly older than Group I cohort [60.10±11.65 years vs 59.70±10.05 years, respectively, p>0.05]. Males were significantly distributed in our study at ratio approximately 2:1 compared to females [86 (70.5%) vs 36 (29.5%), respectively, p<0.05] in which 66.7% (40 VAP infected ICU admitted males) were grouped to Group I compared with 25.8% (VAP infected ICU admitted females) were grouped to Group II. The primary outcome of this study (An overall 28-day ICU mortality) was detected in fifty-two (N=52) with an overall incidence of 46.62% during an average of 10.89±5.34 days and 12.66±5.91 days of ICU and overall hospital. Conclusion: Colistin nebulizer at dose regimen of 1 MIU TID has a positive clinical impact when is adjunctively used with renal-adjusted Colistin IV in mechanically ventilated critically ill patients with ventilator associated pneumonia which caused by multi-drug-resistant gram-negative bacteria. Also, this dual Colistin delivery may mitigate the emergence of pan-resistant GNB by conserving Colistin activity via maximizing its PK/PD parameters.

The outbreak of Corona Virus -2019 has taken the involvement of stakeholders in public health sector. It takes a well-prepared management for the participation of Higher Education in socializing the protection of individuals in community. An application of the descriptive analysis procedure was made to collect the right way to handle the Community Service of Health Education participation to help society and local government to socialize, to keep the health protocols for Covid-19. Data obtained shows that during Covid-19, Community Service Programs have made a special orientation which focused on handling Covid 19 pandemic outbreak. They have the directly educating public, creation of the media solicits and medical devices distribution for prevention. It concludes that the Tertiary Education Institutions have provided the concept of handling the Covid-19 pandemic in the community and they offered an integrated and sustainable models.

The study was conducted in Babylon Teaching Hospital, Babylon, Iraq Polycystic Ovary Syndrome. Increased androgen levels in the body lead to the appearance of hirsutism (excessive hair growth on the body and face). At the same time, there may even be baldness or hair loss with bald spots on the sides of the forehead and on the head. Many women develop acne, sebum and the skin becomes oily. One of the main reasons for seeking medical attention in PCOS patients is infertility due to lack of ovulation. PCOS is characterized by an increase in the size of the ovaries and an increase in the levels of male hormones (testosterone) and LH in the blood. Consequently, the normal functioning of the ovaries is disrupted, a failure occurs in the blood supply and energy supply system. The egg matures, but ovulation does not occur, while the level of oestrogen rises and the hormone progesterone decreases, respectively. Polycystic ovary condition is the most widely recognized endocrinological problem in female of regenerative age. It is normally connected with anovulatory subfertility, for which there are a scope of treatment choices accessible to help them imagine.

Three samples that were subjected to postpartum complications were studied out of 22 cases and the main objective of this study was to know the management in the case of death of a twin foetus As these results were subjected to strong monitoring of the blood clotting file, in addition to that, the resulting complications were studied and were found to indicate that in the case of a twin pregnancy with the death of one foetus with good control. A miscarriage is not likely after week 12 or before week 24 (late miscarriage). In twin pregnancies, the cause of a late miscarriage is either an abnormal twin growth, twin transfusion syndrome or a TTTS foetal transfusion. This condition occurs when one identical twin sharing the same placenta receives a lot of blood in the womb, while the other receives too little, which affects its growth and development. Unfortunately, one baby dies while the other continues to grow for the remainder of the pregnancy.

Ergonomics is one of the most important and crucial aspects in dental profession. Its goal being connecting most efficiently and securely people and things at the workplace. In dentistry the postures assumed by dental surgeons during their professional work has an enormous effect on their body. And they are becoming more prone to musculoskeletal disorders. The successful application of ergonomics assures high productivity, avoidance of illnesses and injuries and increased satisfaction among workers. The branch of Periodontics in particular is the one where time consuming ultrasonic scaling and extensively long surgical procedures are performed. Owing to this, the muscles used for this purpose are at risk of becoming fatigued causing discomfort to the practitioner. Thus, this review article focuses on the possible ill effects of incorrect postures and various methods to stabilize the dental operatory to allow the operator to work with comfort, efficiency and ease.

Objectives: To evaluate safety and effectiveness of Percutaneous nephrolithotomy (PCNL) over the last 2 years (from January 2018 to January 2020) in a single center in terms of demographic profile, stone characteristics, stone clearance, requirement of additional procedures and reported complications. Materials and Methods: This is a retrospective study which included all patients who underwent PCNL at King Hamad University Hospital (KHUH), Bahrain from January 2018 to January 2020. Both standard and mini PCNL were used as required. Various lithotripters were used according to preference of the surgeon. Data analysis was performed regarding demographic profile, laboratory investigations, imaging, operative time, stone clearance, complications and hospital stay. Stone analysis was performed in all of our cases to know the nature of stones. Collection of data was performed through standard structured questionnaire and retrieved from KHUH data base system. Statistical analysis was performed with statistical package for the social science (SPSS Inc, Chicago, Illinois, USA) version 25.0. Results: A total of 54 cases were included in the study. The mean age was 45.5 years. Forty-two patients were male and 12 patients were female giving a male: female ratio of 3.5:1. Average size of stone was 2.15cm (as assessed by Non contrast CT scan) with most common location being lower calyx and pelvis (33.3%) followed by pelvis alone (18.5%). Partial and complete staghorn stones were present in 14.8 and 11.1 % respectively. Lower calyx the most common site of puncture (94.4%). Mean hemoglobin drop was 0.57gm/dl. Stone clearance rate was 88.9%. We encountered bleeding as major complication with blood transfusion required in 3 (5.5%) of cases. Mean hospital stay of patients was 3.2 days. Conclusions: PCNL performed at KHUH Urology center remains a safe and effective minimally invasive treatment modality for large renal stones with an acceptable stone clearance rate and minimal morbidity in experienced hands.

Background: Fever represents one of the most important reasons for emergency department visits among young infants aged less than 3 months. In 5 to 15 % of cases, fever is caused by a severe bacterial infection. This study aimed to evaluate the precision of using complete blood count differential (CBCD) for identifying febrile infants aged between 1 and 3 months with Severe Bacterial Infections (SBIs). Materials and Methods: A mono-centric retrospective study was conducted among young febrile infants seen in the Emergency Department (ED) of the Rafic Hariri University Hospital (RHUH) between January 2018 and January 2020. Data were compared using the Chi-square test and one-way analysis of variance (ANOVA) as appropriate and then binary logistic regression was used to identify risk factors of SBI. Results: A total of 200 febrile infants aged between one and three months were included in this study. The prevalence of SBI was 15.5% and the most common bacterial infection was urinary tract infections (UTIs) (65.5% of all SBIs). Pneumonia was the most common diagnosis of the infants in study accounting for 37% of all diagnosis. C - reactive protein (CRP) levels, platelets count and white blood cell (WBC) counts were significantly associated with SBI (p-value <0.05). Binary regression analysis showed that CRP levels (OR = 1.013) and temperature (OR = 3.78) were risk factors for increased bacteremia and UTIs respectively. Conclusion: This study confirmed that complete blood count differential is not sufficiently accurate test for identifying young infants with SBI. Better diagnostic tools are needed to optimize the identification of young febrile infants with SBIs.

To simplify the precautionary measures, protocols have been developed for emergency dental care against the CoV-19 pandemic. From April 14 of 2020 show more than 2 million people have been infected with the virus, causing more than 120,000 deaths in over 210 countries worldwide. Published regarding complications, protocols and other information for the dentistry care during SARS-CoV-2 pandemic. The documents included randomized clinical trials and systematic reviews. The research criteria include the following words and combinations: Randomized study, Systematic review, n-Cov-19-SARS, coronavirus diseases, saliva, epithelial oral mucosa cell, aerosol, spray using the Boolean operators AND or and NOT. Was declared a pandemic by the World Health Organization (WHO) on March 11 of 2020, said SARS, MERS, Cov persist on inanimate surfaces (metal, glass, plastic) for up to 9 days, in stomatology, such as the airborne spread, contact spread and contaminated surface spread, used cetylpyridinium chloride significantly reduced the number of CFU, epithelial cells of tongue, Cov-19 infectious susceptibility. Dentists are directly exposed to inhalation of viral particles in aerosols, where the virus can remain viable for up to 3 hours.

Introduction: AlP is also known as celphos and is one of the most dreaded poisons one can ever encounter in toxicology. Due to non-availability of antidote and high mortality celphos poisoning has always been a big headache and menace for the intensivists throughout the world. Literature is full of different drugs and trials to counter its irreversible toxic effects, but hardly with any concrete success. In literature the usefulness of the gastric ventilation technique had been reported. Further clinical trials are required to assess the usefulness of this technique and this study is one of the attempts towards the same. Materials and Methods: This is a prospective descriptive study of patients of celphos (AlP) poisoning carried out in Oscar super-speciality hospital Sonipat Haryana from January to December 2019. Twenty patients were admitted in ICU of our hospital over the last 1-year period with an alleged history of intake of celphos. Gastric lavage along with gastric ventilation was done in all patients along with other supportive treatment. Results: Mean age of our patients was 22.2 years with male to female ratio of 3:2. Most of the patients presented with non-specific findings. During hospitalisation hypotension, arrythmias and respiratory failure were common. 60% of patients in this study need artificial ventilation while as ionotropic support was needed in 50% of patients. Mortality rate in this study was 65%. Mortality rate was statistically high in cases who had hypotension, multiorgan failure, delayed gastric lavage and where ingestion of poison was greater than 4 grams. Conclusion: AlP poisoning is one of the most dreaded poisons one can ever encounter in toxicology. In India it is commonly used by farmers as pesticide as it is cheap, effective, free from toxic residue and does not affect seed viability. As there is no specific antidote for AIP poisoning so most of the treatment is supportive. Gastric ventilation along with gastric lavage with the aim of removing phosphine gas from stomach before it is absorbed seems to be effective in decreasing mortality in these patients however before it becomes a routine procedure like gastric lavage in these patients further studies with controlled head-to-head trails and minimising confounding factors needs to be done.

Introduction: Antibiotics Intra Venus (IV) to per oral (PO) conversion is one of the key strategies in the antimicrobial stewardship program (ASP). Early switch over from IV to oral therapy has major advantages, such as reduced risk of catheter related infections, less expensive, reduction in the hidden costs and early discharge from a hospital. Materials and Methods: A prospective and observational study was conducted over a period of six month among respiratory tract infection patients who admitted to general medicine and pulmonary department. The necessary data were collected in specially designed format from respective case sheets. Results: 84 patients were enrolled in the present study and 71 patients were subjected to antibiotic conversion whereas 13 patients were not subjected to antibiotic conversion. The patients who were subjected to antibiotic conversion were divided into 2 groups, Group E and Group L. Group E had subjects who were converted early from IV to oral antibiotic within 1-4 days and Group L had subjects who were converted from IV to oral antibiotics within 5-10 days. Out of 71 patients, 39 patients were subjected to early antibiotic switch whereas 32 patients were subjected to late antibiotic switch. The frequently prescribed IV antibiotic was levofloxacin (39.02%) and same is switched to oral (39.1%). The most common type of antibiotic conversion method was step down therapy (68%) and the most frequently converted class of antibiotics was fluoroquinolones. Conclusion: conversion of antibiotics from IV to per oral, especially early conversion reduce the length of hospital stay and reduce the financial burden of a patients and, minimizes the possible IV complications which influence the faster recovery of a patients and improves the better patient compliance.

Background: Chronic kidney disease (CKD) is considered the popular disorder throughout the world. It associates with abnormalities of mineral metabolism such as calcium, phosphorus and parathyroid hormone. Objectives: The study aimed to evaluate the alteration of serum levels of Ca, Ph and PTH in hemodialysis patients in in Zawia Kidney Center, Western Libya and determining the relationship of age with the levels of these parameters. Materials and Methods: One hundred subjects were included in the present study. Out of which 50 cases were dialysis patients collecting from AZ-Zawia kidney center and 50 subjects were health individuals used as control divided into male and female, mean age was 47.03±14.14 years. Five ml of venous blood was collected from each participant for estimating the serum levels of PTH, Ca and Ph. Results: The result showed that the level of PTH was higher than normal, where the mean level of PTH in dialysis patients was 421.64±391.30 and 44.59±12.32 pg/ml in the control. Ca level in dialysis patient was slightly lower than normal while Ph is nearly similar to control subjects. The level of PTH was high in young patient (580.6±440.4) and decreases with increase in age, where recorded its mean level in age group >60 year, was 240.3±321.0 and there was a significant negative correlation between age and the serum level of PTH (r= -0.3 P=0.03). However, the results showed that none significant correlation between age and the serum levels of Ca and Ph, p-value =0.461 and 0.701, respectively. In addition. the percentage of the patients who had a serum iPTH level of <150 pg/mL was 32% while that of patients with iPTH of >300 pg/mL was 46 %. Hypocalcemia and hypophosphatemia were observed in 66% and 46% of the patients, respectively. Moreover, 28%, 22% and 42% of the patients, respectively, reached the K/DOQI target range of Ca, P and iPTH. Conclusion: It can be concluded that hyperparathyroidism is a common disorder in hemodialysis patients and parathyroid hormone is decreasing whenever increase patient age. Percentage of dialysis patients, in Az-Zawia, who their serum of PTH and Ca and Ph in within target range recommending by K/DQOI was lower in comparing with non-target rang. Therefore, it is recommended that patients should consider and have attention about their health by having proper medication to adjust the level of mineral metabolism and parathyroid hormone.

Anterior neck swellings are common in surgical and ENT practice; however, pulsatile anterior neck masses are rare and often indicate underlying vascular anomalies. Failure to recognize such conditions may result in catastrophic hemorrhage during diagnostic or surgical procedures. We report a case of a 65-year-old woman presenting with a painless, slowly progressive, pulsatile anterior neck swelling. Clinical examination and ultrasonography with Doppler suggested a vascular origin. Contrast-enhanced computed tomography confirmed a high-riding brachiocephalic artery ascending anterior to the trachea up to the C7–T1 level before bifurcation. The patient was managed conservatively and counseled regarding potential surgical risks. This case highlights the importance of careful clinical assessment and appropriate imaging in evaluating pulsatile neck swellings to prevent inadvertent injury during invasive procedures.

Objectives: Most mechanically ventilated critically ill patients are mal-nourished and significant portion of them are taking either partial or complete total parenteral nutrition due to exogenously and endogenously multi-factors that impairs there’s enteral nutrition effectiveness. In addition to nutrition support fluids, most if not all intensive care unit admitted patients are taking dextrose saline maintenance fluids which provide approximately 0.17 Cal/ml regardless of saline concentration. This non-nutritional source of calories may have negative clinical and economic impacts if not assess adequately in mechanically ventilated patients who are also taking nutrition support. The aim of this study is to evaluate the clinical impacts of NNCs associated dextrose maintenance fluids in mechanically ventilated critically ill patients who are also taking TPN. Materials and methods: An observational retrospective study was conducted in King Hussein Medical Center Intensive Care Unit. One-Way ANOVA and Chi Square Tests were used analyzed our tested patient’s data followed by Tukey Kramer Post Hoc Test to determine the mean differences of significant dependent variables across the Eucapnic, mild hypercapnic, moderate hypercapnic and severe hypercapnic groups. Results and discussion: Our tested patients had an average age of 57.88±9.01 years in which 72.0% (85 patients) and 28.0% (33 patients) were male and female, respectively. The overall risk of dextrose saline maintenance fluids associated hypercapnia regardless of severity in our tested critically ill patients was 74.58% (88 patients) in which 27.12%, 24.58% and 22.88% of the hypercapnic patients had mild, moderate and severe hypercapnia status, respectively. Conclusion: NNCs associated dextrose saline fluids may increase the risk of hypercapnia associated ventilator weaning failure, if the NNC is not adequately assessed and subtracted from total calories inputs from enteral or parenteral nutrition support formulas.

Periodontal disease is a chronic, multifactorial, inflammatory disease associated with dysbiotic biofilm of the plaque and is characterized by progressive destruction of dental attachment apparatus. The goal of periodontal disease treatment is to achieve complete regeneration of the periodontal tissues (cementum, periodontal ligament and bone). In recent years the advent of Nanotechnology has provided a promising insight into field of Dentistry and in particular Periodontology and Implantology. Due to the small size of nanoparticles, they are able to deliver the drug to particular tissues, cells or pathogens in the periodontal pockets and also act as a regenerative material. This review focuses on the experimental studies of various authors and their usage of nanomaterial in managing periodontal diseases, including diagnosis and treatment.

Pseudo exfoliative glaucoma (PEXG) is a sight-threatening disease that develops resulting from Pseudo-exfoliation syndrome (PEX). The clinical impact of the diagnosis of early glaucomatous change can be understood. About 30-50% of retinal ganglion cells may be lost before any visual field changes are detected due to the deposition of PEX material. Some studies have reported the presence of difference in RNFL thickness measurement between the eyes with the PEX. The purpose of this study was to evaluate the RNFL thickness using SD-OCT system among the patients with PEX in comparison with patients affected with PEXG attending OPD clinic in the department of ophthalmology in IGMC Shimla. Patients having pseudo-exfoliation with glaucoma showed significant visual field defects as compared to their counterparts (p<0.001). The overall mean RNFL Thickness(µm) in the two groups was 89.47±13.52 µm and 72.73±13.54 µm and the difference between the means of RNFL thickness between the two groups was found to be statistically significant (p<0.001). Measurement of RNFL thickness in early stages of Pseudo-exfoliation with glaucoma can help to modify the course of management.

Background: GIT is one of the main causes of human morbidity and mortality especially in developing countries. Aim: To identify the characteristics of patients with gastrointestinal tract infection in emergency unit during the study period. Methods: A retrospective cross-sectional study was conducted in all hospitals which contain the emergency department in eighteen governorates in Iraq. All the cases admitted from the first of January 2018 to the end of December 2019 was enrolled in this study. Semi-structured questionnaire was used to collect the information from the records. The sample size was 3085345 cases. Data was described by using the descriptive statistics such as frequency, percentage, Chi-square and P. value. STATA version 14 statistical package was used to analyze the data. Results: Our finding presented that the higher percentage 52% of them were occur during 2019 and 25.3% of them were occur in the age groups 20 to 44 years old, followed by 25% in the age more than 45 years old; half of them 51.3% were male cases. The frequencies of cases 52% were higher during 2019 more than 48% in 2018. Conclusion: We concluded that the GIT infection had occurred in the age groups 1- 19, 20- more than 45 years old, respectively. The higher rate of disease was higher during 2019 more than in 2018. There are a highly significant association has been found between the age groups, gender by years at the p. value less than 0.05. Recommendation: We need further research on this field to decrease the mortality and morbidity among people in emergency department.

Background: Road traffic accidents are a major cause of unhappiness, disability and death globally, with an inordinate number occurring in developing countries. Aims: To assess the frequency, characteristics of studied samples with RTA and to identify the outcomes of admission to emergency units during the period of this study. Method: A retrospective cross-sectional study was carried out in all the hospitals which are containing the Emergency department. All the road traffic injuries registering from 1^st January 2015 to end of December 2019 were taken irrespective of the place of accident. Total patients registered were approximately 988226 in this time period. Semi-structured questionnaire was used to study socio-demographic variables, site of injury and various risk factors related to RTAs. Results: Our finding found that the majority of cases 61.2% were in the age groups 26-35 years old followed by 27.3% in the 36 to 45 years and the least frequency 1.8% in the ages less than 15 years old. The male cases 59.2% were more than female cases 40.8%. The majority of them had no job. The highest frequency 38.4 %of them had head injury followed by 37.2% had chest and abdomen injury. Conclusion: We concluded that the majority of RTA patients were in the age 26-35 years old. The higher percentage of RTA patients occurs during 2019. The rate of RTA injuries was higher during 2015 and 2019. Majority of them are alive and most of them had permanent disability. There is a significant association has been found between the site of injury and year at the p. value less than 0.05. Recommendation: We need further research on this field to decrease the mortality and morbidity among people with RTA injuries in emergency department.

Background: Previous studies revealed that Neutrophil-to-Lymphocyte Ratio (NLR) is associated with cirrhotic adults’ mortality rate in the liver transplantation waiting list, independent of the cirrhosis stage or the (MELD) score Model for End-Stage Liver Disease. However, there is not enough information available about the usefulness of this ratio among children. Objective: We aimed to evaluate the prognostic value of NLR on the survival of cirrhotic children, candidates for liver transplantation, on the waiting list. Materials and Methods: In the present historical cohort study, cirrhotic children, younger than 18 years of age, listed for first elective single organ liver transplant, were recruited. Results: A total of 103 patients were studied. The median of the patients’ age was 4.5 years and the male to female ratio was 0.94:1. Sixteen patients died during follow-up (mean duration of 9.34±3.98 weeks). The clinic-demographic and laboratory parameters between surviving and non-surviving patients were similar to each other’s except for variceal bleeding, total bilirubin, PELD/MELD score and NLR that was higher among the non-survivor patients. After adjusting for confounding factors in the multiple logistic models, the adjusted odds ratio (OR) for NLR for those who survived was 1.39 (95% CI, 1.04-1.87; P=0.026). The NLR has more specificity but less sensitivity than MELD/PELD score (81% vs. 70%) and (50% vs. 68%) respectively. Conclusion: We observed that a higher NLR was correlated with higher risk of mortality among the children who suffered from liver cirrhosis, on the liver transplantation waiting list.

With interest we read the article by Pergolizzi et al. about a systematic review about the neurological manifestations of patients with COVID-19 [1]. It was concluded that SARS-CoV-2 enters the brain via ACE2-receptors, that neurological disease only rarely precedes the onset of pulmonary manifestations of a SARS-CoV-2 infection, that patients with pre-existing neurological conditions are at an increased risk of experiencing COVID-19 associated neurological abnormalities, that particularly patients with severe COVID-19 are at an increased risk of experiencing neurological disease, that drugs suppressing the immune response against SARS-CoV-2 are contraindicated for treating neurological involvement and that the neurological disease in COVID-19 patients may be easily missed [1]. We have the following comments and concerns.

The main shortcoming of the review is that it is highly speculative. There is no study available which clearly indicates that patients with pre-existing neurological disease are at an increased risk during a SARS-CoV-2 infection of developing additional neurological compromise. Entrance of SARS-CoV-2 2 to the brain via ACE2-receptors also remains unproven. There is no evidence available that particularly patients with severe infection are at an increased risk of experiencing neurological complications.

The authors do not mention a number of potential neurological manifestation of the SARS-CoV-2 infection. Central nervous system (CNS) abnormalities not included were sinus venous thrombosis, intracerebral bleeding, subarachnoid bleeding, acute, haemorrhagic, necrotic encephalopathy (AHNE), acute demyelinating encephalo-myelitis (ADEM), vasoconstriction syndrome, pituitary apoplexies’, psychosis, Parkinson’s disease, myelitis and plexitis [2-4]. Among the peripheral nervous system (PNS) abnormalities associated with SARS-CoV-2 the authors did not discuss dysgeusia, myasthenic syndrome, myositis, rhabdomyolysis and myasthenia [5].

Missing in the review is a discussion about secondary neurological compromise in COVID-19 patients due to side effects of drugs given to treat COVID-19. These drugs include chloroquine, azithromycin, steroids and others.

Overall, the review by Pergolizzi et al. has some limitations which should be met before drawing final conclusions. There is a need for prospective studies on the neurological involvement in SARS-CoV-2 infected patients. Neurological side effects of drugs given to treat COVID-19 should be included in a review about neurological disease in COVID-19.

With interest we read the article by Scheidl et al. about a 54 years-old female with non-symptomatic COVID-19 who experienced Guillain Barre syndrome (GBS), subtype acute, inflammatory, demyelinating neuropathy (AIDP) three weeks after having been tested positive for SARS-CoV-2 and two weeks after onset of typical manifestations of the viral infection [1]. The cerebrospinal fluid (CSF) was negative for SARS-CoV-2 and the patient significantly improved upon administration of intravenous immunoglobulins (IVIG) [1] We have the following comments and concerns.

We do not agree with the notion that CVOID-19 associated GBS is rare [1]. In a recent review 62 patients as per 12^th of August with SARS-CoV-2 associated GBS have been described [2]. As per the end of December 2020 >160 patients with SARS-CoV- associated GBS have been published, suggesting that SARS-CoV-2 associated GBS is not so infrequent as stated in the review.

We do not agree with the statement the SARS-CoV-2 enters the central nervus system (CNS) only via the nose and the olfactory nerve [1]. There is evidence that SARS-CoV-2 can disrupt the blood brain barrier (BBB) and thus enters the brain via the hematogenic pathway [3i]. Whether there are additional routes via which the virus reaches the CNS remains speculative. 

Though we agree that the majority of patients with SARS-CoV-2 associated GBS develops the AIDP subtype, an increasing number of patients with the axonal subtype (acute, motor, axonal neuropathy (AMAN)) has been published [2,4]. There are also a number of patients who developed Miller-Fisher syndrome or isolated mononeuropathy of the oculomotor, trochlear, facial or glossopharyngeal cranial nerves [5].

We do not agree that SARS-CoV-2 associated GBS develops 5-10 days after onset of the viral infection [1]. The range is much broader and there are even cases, in which GBS preceded the onset of the viral infection [2]. Even the patient described by Scheidl et al. developed with a latency of 14d after the first COVID-19 symptoms (loss of smell and taste). In case GBS develops prior to the onset of COVID-19 it is quite likely that patients were only subclinically infected and that GBS was the initial clinical manifestation.

There is a discrepancy between the description of the patient with paraparesis, reduced tendon reflexes and numbness and tingling of all four extremities and the description that “the general physical examination was normal” [1]. We should know if there were progressive muscle weakness and sensory disturbances or not.   

In conclusion, the case of a patient with SARS-CoV-2 associated GBS described by Scheidl et al. is quite usual. Contrary to what is stated in the review, the frequency of SARS-CoV-2 associated GBS is higher than anticipated, the virus enters the CNS via the hematogenic route, the latency between onset of COVID-19 and onset of GBS is highly variable and several subtypes of GBS are increasingly acknowledged. Missing is the investigation for virus-RNA in the CSF but there are indications that in most of the cases of SARS-CoV-2 associated GBS the CSF is free of virus RNA, suggesting that SARS-CoV-2 associated GBS is indeed due to the immune reaction against the virus but not due to a direct viral attack.

With interest we read the article by Scopelliti et al. about a 46yo male with upper respiratory tract infection followed by three episodes of dyspnoea and exercise intolerance being attributed to an infection with SARS-CoV-2 despite repeatedly negative PCR-tests [1]. The patient was lastly diagnosed with sero-negative myasthenia gravis (MG) and responded favourably to appropriate treatments [1]. We have the following comments and concerns.

Why was the patient diagnosed with COVID-19 pneumonia despite a negative swab PCR test for SARS-CoV-2? Interstitial pneumonia may not only occur in the context of a SARS-CoV-2 infection but due to a number of other causes [2]. 

If the patient was diagnosed with COVID-19 at his first admission, why was he discharged already after three days? It is unclear why the diagnosis of COVID-19 was confirmed despite a second negative PCR test for the virus. We admit that the naso-pharyngeal swab test can be negative but nonetheless a patient may be infected with SARS-CoV-2 [3]. However, in this case, SARS-CoV-2 should have been documented in a compartment other than the naso-pharynx or by determination of antibodies. Since there are cases with negative swab test but positive PCR in the bronchi, it would have been an option to initiate a bronchoscopy. Why was no treatment initiated for bilateral basal infiltrates during the second hospitalisation? 

The index patient was diagnosed with MG upon the clinical presentation, the results of the repetitive nerve stimulation (RNS) and the beneficial response to pyridostigmine and steroids. Missing for the diagnosis of MG is a single fiber electromyographic (SF-EMG) examination, which should show an increased jitter and an increase in blockings. We should also be told about the results of high-frequency repetitive nerve stimulation.

The patient was initially treated with azithromycin from which it is known that it may trigger myopathy or rhabdomyolysis [4]. Since azithromycin may trigger the development of myopathy [5] it is conceivable that the “myasthenic” symptoms rather reflect myopathy than myasthenia. Patients with COVID-19 frequently receive drugs which are potentially myotoxic, such as chloroquine, azithromycin, remdesivir/lopinavir or tacilizumab. We should be told if any of these compounds were administered to the index patient and if relapses of dyspnoea were attributable to myotoxic side effects of these drugs.

An O₂ saturation of 91-97% is normal. This is no indication for oxygen supplementation. More meaningful would have been lung function tests to see if there was truly muscular respiratory dysfunction. 

The results of RNS are not convincing. The decrement was mild and may be also recorded in other neuromuscular disorders, why a false positive result of RNS cannot be excluded. Missing in this respect is the family history. We should be informed if the family history was positive for neuromuscular disorders or for multisystem disease additionally affecting the muscles. 

Overall, the report about and the management of the index patient has a number of shortcomings, which should be addressed before attributing the clinical presentation truly to MG. Thorough work-up is particularly required for patients with sero-negative MG.

With interest we read the article by Sriwastava et al. about a systematic review following the PRISMA guidelines about patients with polyradiculitis (polyradiculoneuritis, Guillain-Barre syndrome (GBS)) with/without cranial nerve involvement in association with a SARS-CoV-2 infection (COVID-19) (SC2-GBS) [1]. Among 50 patients with SC2-GBS collected until July 2020, 33 had acute, inflammatory, demyelinating polyneuropathy (AIDP) and the remainder acute, motor axonal neuropathy (AMAN), acute, motor and sensory axonal neuropathy (AMSAN), Miller-Fisher syndrome (MFS), Bickerstaff encephalitis (BFE) or polyneuritis cranialis (PNC) [1]. It was recommended to carry out long-term follow-up investigations to assess the outcome of these patients [1]. We have the following comments and concerns.

We do not agree that only 50 patients with SARS-CoV-2 associated GBS have been reported in the first half of 2020. In addition to the 50 patients included in the review, at least 18 other patients were published during this period. These additional patients were reported by “Ghosh et al.”, “Juliao-Caamano et al.”, “Marta-Enguita et al.”, “Galan et al.”, “Oguz-Akarsu et al.”, “Esteban Molina et al.”, “Farzi et al.”, “Paybast et al.”, “Khalifa et al.”, “Frank et al.”, “Manganotti et al.”, “Wada et al.”, “Garcia-Manzanedo et al.” and “Naddaf et al.”. By the end of December 2020, >200 SC2-GBS cases have been reported. 

Though there is evidence that SARS-CoV-2 can trigger GBS, there are conflicting results concerning a suspected increase of the prevalence of GBS since onset of the pandemic. In a study of 47 SC2-GBS patients from the UK, the prevalence of GBS did not increase between March and May 2020 as compared to the years 2016-2019 [2]. However, in a retrospective, multicentre study from northern Italy of 34 SC2-GBS patients, the estimated incidence of GBS during March and April 2020 increased from 0.93/100000/y in 2019 to 2.43/100000/y in 2020 [3].

A further limitation refers to the discrepancy between the method and results section. In the method section it is stated that only patients with PCR-confirmed COVID-19 were included [1]. However, in the results section and in table 2 it is mentioned that 3 AIDP patients and 3 non-AIDP patients were negative by PCR. The discrepancy should be explained. According to the inclusion criteria, these six patients should have been excluded. Furthermore, it is unclear why age <18y was an exclusion criterion. GBS in paediatric patients is not at variance from GBS in adults.

Two thirds of the patients required artificial ventilation [1]. It should be discussed if respiratory insufficiency in these patients was due to involvement of the respiratory muscles in GBS, due to brainstem encephalitis, due to viral pneumonia with acute, respiratory distress syndrome (ARDS) or due to a mixture of the three. 

Missing is the treatment patients received for COVID-19. Since some of the drugs applied are potentially neurotoxic (e.g. lopinavir, tocilizumab, chloroquine) [4-6], it is crucial to know if any of these compounds were given.

GBS has to be delineated from critical ill neuropathy, from toxic neuropathy and from any pre-existing neuropathy. We should know if these differentials were excluded in all 50 cases. 

In a recent review about 62 patients with SC2-GBS, four patients developed GBS prior to clinical manifestations of COVID-19 [7]. These patients were reported by “Zhao et al.”, “Coen et al.” and “Chao et al.”. Why were these patients classified as GBS developing after onset of COVID-19 in the present review? SC2-GBS prior to onset of non-neurological manifestations of COVID-19 has been also reported by others [8] and is explained by subclinical infection with the virus prior to onset of GBS or the incubation time of SARS-CoV-2, which is up to 14 days [3]. 

Not discussed in the review were cases in which GBS developed during artificial ventilation on an ICU. Diagnosing GBS during artificial ventilation is challenging [3] but if the neurological exam indicates neuropathy and if patients cannot be weaned successfully from the respirator,

GBS should be considered. Early diagnosis of GBS is crucial as the outcome improves with early application of appropriate treatment [9]. 

We do not agree with the statement that ischemic stroke is among the most frequent manifestations of COVID-19. SARS-CoV-2 associated ischemic stroke is rare and the prevalence of ischemic stroke apparently did not increase since onset of the pandemic [10]. 

In table 1 of the review a paper by “Solomon et al.” is cited as reference 28, which cannot be found in the reference list. There is also no hit for this paper on a PubMed search. When searching the paper by “Ebrahimzadeh et al.”, no entry could be found. The paper by “Mozhdehipanah et al.”, cited in table 1, is not accessible either. The reference “Augustina et al,” listed in table 1, could neither be found in the reference list nor by a PubMed search. However, the paper indexed as reference 45 is erroneously mentioned in table 1 by the given name instead of the surname. 

According to the flow-chart of figure 1 of the review, 37 studies were included in the discussion [1]. However, in the first paragraph of the discussion, 39 studies are mentioned. This inconsistency should be solved. 

Overall, SARS-CoV-2 triggers the development of GBS but cannot be found in the CSF. SC2-GBS occurs in each age group and is not at variance with regard to clinical presentation and treatment compared to non-COVID-19 GBS. Outcome of SC2-GBS, however, appears to be worse compared to non-CS2-GBS. Whether the prevalence/ incidence of GBS increased since outbreak of the pandemic is under debate but an increasing number of SC2-GBS cases are reported. Alertness for SC2-GBS in non-symptomatic, symptomatic and ventilated COVID-19 patients is warranted.

Introduction: Fissure-in-Ano is a frequently encountered proctologic problem in daily surgical practice. Morphologically, it is a vertical tear in anal mucosa distal to dentate line mostly found in the posterior midline. Sphincter hypertonia and local ischemia is supposed to be the pathology behind causation of anal fissures consequent upon passage of hard stool. Aim: The aim of the present study is to determine the prevalence and clinical presentation of patients of fissure-in-Ano in a teaching government hospital. Materials and Methods: This study is a prospective study conducted at Patna Medical College Hospital, an 1800 bedded government hospital of Bihar India. Patients with Fissure in Ano admitted or examined as outpatient were randomly selected in this study. The diagnosis was made on the basis of Anorectal examination which included inspection, digital rectal examination and proctoscopic examination. Results: Our study found out that out of the 680 patients with Anorectal ailments, 190 patients (27.9%) were having anal fissures. Out of them, 125 were males and 65 were females, majority were under 40 years age. Pain during defecation, bleeding and constipation were reported as the common clinical symptoms. 77.3% of patients with fissure-in-Ano had an acute presentation and the most common location was reported to be posterior midline (90.5%). Conclusion: Our study reveals that fissure-in-Ano is a common proctologic disease attending government hospital’s surgery department. Main presentation is pain and burning Lifestyle modification plays a major role in prevention of this disease but results in early cure of this condition. Avoiding constipation, consuming high fifer diet are the principal methods to keep this painful condition away.

Background: Heart failure is one of the major causes of mortality & morbidity in Bangladeshi cardiac patients.  Combination of heart failure (HF) and depression may worsen the symptoms. There may be bad prognosis. However, there are limited data on the psychological correlation with heart failure in Bangladeshi patients. Materials and Methods: This was an observational & cross-sectional study. The study enrolled 90 patients with heart failure admitted in university cardiac center of Bangabandhu Sheikh Mujib Medical University; Shahbag, Dhaka, Bangladesh from March, 2019 to February, 2020. History taking and complete medical records were reviewed carefully. The structured questionnaire used in this study gathered information on respondent demographic and disease characteristics and information obtained from the Depression Questionnaire.  Results: The prevalence of depression among heart failure patients was 41.11%. Those who had sleep disturbances, followed no regular exercise regimen, had family disharmony were higher risk of depression. Conclusion: Prevalence of depression in HF patients should be kept in mind of healthcare providers. Early identification of HF patients with depression, healthcare providers may prevent worse prognosis and ensure the provision of appropriate rehabilitation to this population.

Cervical cancer remains a major public health problem accounting for about 12% of all female cancer (and 80% of all new cases) in developing countries and it is the second most common cancer in women globally with an estimated number of 500,000 new cases of cervical cancer and 273,000 mortality annually, of which 85% of the recorded deaths occur in developing countries like Nigeria, despite the awareness that cervical cancer is a preventable disease, the utilization of cervical cancer screening is still poor. This study assessed the perception and acceptance of cervical cancer screening among child bearing age women attending postnatal clinic in Ifako-Ijaiye General Hospital, Lagos state, Nigeria. A non-experimental descriptive study of 87 women of child bearing age was conducted using convenience sampling method. A self-structured questionnaire was used to gather data from 87 women that attends postnatal clinics and analyzed with statistical package for the social science and results were presented using frequency tables and percentage. The result shows that majority of the respondents (40%) are between the age range of 25 -34 years, 55% are Christian, 70% of them are married and also from Yoruba tribe, 70% of them have a form of formal education. Women perception of cervical cancer screening reveals that there is a good perception towards the screening services 86% claimed that cervical cancer is preventable while 88% agreed that screening exercise help to prevent cervical cancer, 44% of the respondents claimed they have undergone cervical cancer screening exercise and 38% claimed they had it once, 37.5% of the respondents associated their lack of screening to fear of result (unknown outcome). Majority of the respondents strongly agreed that to improve acceptance, pain relief should be given after the procedure (70%), Privacy and confidentiality should be paramount (67%) and screening should be made free in Government hospitals (66%).Cervical cancer screening test has been proven effective in detecting cervical abnormalities and thus allow for early treatment, this study identified that these women had good perception towards the use of screening services but uptake of screening still remains low. Hence the need to intensify sensitization programs on the benefits of cervical cancer screening, screening services should be made available, accessible and affordable to the women while sustaining awareness campaigns.