Introduction: Present study is an attempt to assess the cognitive function of patients undergoing CABG using cardio-pulmonary bypass before and after the surgery using Addenbrooke’s Cognitive Examination Revised (ACE-R) which is a rapid screening battery, considering five sub-scales to explore different cognitive domains: attention/orientation, memory, fluency, language and visuospatial. This study aims to test the occurrence of early postoperative cognitive dysfunction after coronary artery bypass graft using a bypass machine in study patients having normal cognitive function pre-operatively. Materials and Methods: It is a hospital-based cross-sectional study, conducted in the Cardiovascular and thoracic surgery ward and recovery room over a period of one year. After institutional ethical committee approval and obtaining written informed consent from each individual a structured questionnaire that is ACE-R was used to assess the pre-operative cognitive function of the patient and compare it with the same set of questionnaires on the seventh postoperative day. SPSS-23 IBM, USA was used. Results: Out of 110 study participants 75(68.18%) were male and 35(31.82%) were female. Two participants developed POCD which is 1.82% of the study population while in 108 study patients there was no POCD which is 98.18% of the study population, out of those 2 participants one was male and the other was female. Out of the total 110 study patients, 42 had co-morbidities for 5 years or below while 68 had co-morbidities for more than 5 years. Conclusions: As per our study, POCD prevalence is not significant in patients with normal cognitive function preoperatively.

Background: Circadian rhythms regulate multiple physiological processes involved in glucose homeostasis, lipid metabolism, blood pressure, energy expenditure, and sleep. Healthcare professionals are particularly vulnerable to circadian disruption because night and rotating duties require activity, food intake, and wakefulness during the biological night. The present study assessed the association between occupational circadian rhythm disruption and metabolic health among healthcare workers. Materials and Methods: This observational analytical study included 200 healthcare workers employed at a tertiary care teaching centre. Participants were divided into 100 daytime workers and 100 shift workers; the latter comprised 35 fixed night-shift and 65 rotating shift workers. Information regarding occupational schedule, duration of shift work, sleep characteristics, lifestyle factors, and demographic characteristics was collected. Anthropometric measurements, blood pressure, fasting plasma glucose, glycated haemoglobin (HbA1c), and lipid profile were assessed. Metabolic syndrome was evaluated according to predefined internationally recognized criteria. Continuous and categorical variables were compared using appropriate statistical tests, with p<0.05 considered statistically significant. Results: In the illustrative dataset, shift workers demonstrated significantly higher body mass index (26.1±4.2 vs 23.8±3.6 kg/m²), waist circumference (87.4±9.5 vs 81.6±8.7 cm), systolic blood pressure (124.6±13.5 vs 118.4±11.2 mmHg), fasting glucose (99.7±13.1 vs 91.8±9.6 mg/dL), HbA1c (5.6±0.5% vs 5.3±0.4%), triglycerides (154.2±62.4 vs 121.6±48.5 mg/dL), and LDL cholesterol (119.9±30.1 vs 108.7±26.8 mg/dL). HDL cholesterol was lower among shift workers (44.1±7.9 vs 49.6±8.4 mg/dL). Metabolic syndrome was present in 38% of shift workers compared with 18% of daytime workers. In the illustrative multivariable model, shift work was associated with metabolic syndrome (adjusted OR 2.41; 95% CI 1.35–4.31).

Conclusion: Occupational shift work and associated circadian disruption may be associated with adverse anthropometric, glycaemic, lipid, and cardiovascular parameters among healthcare workers. The illustrative findings support the need for appropriately powered studies using actual participant data and suggest that occupational-health strategies addressing shift scheduling, sleep, nutrition, physical activity, and metabolic screening warrant evaluation.

Background: Hip fractures in centenarians present substantial therapeutic challenges because extreme age, reduced physiological reserve, and medical comorbidities can markedly increase perioperative risk. Individualized assessment is therefore essential when considering operative stabilization. Case Presentation: A 107-year-old female presented with a left intertrochanteric femur fracture. Preoperative evaluation demonstrated significant medical vulnerability, including anemia and renal impairment, with hemoglobin ranging from 8.1–9.2 g/dL, serum creatinine of 2.11 mg/dL, and blood urea of 85 mg/dL. Following clinical and cardiopulmonary assessment and individualized perioperative planning, operative stabilization was considered appropriate. Results: The patient underwent closed reduction and internal fixation of the left intertrochanteric fracture using a proximal femoral nail. The perioperative period was managed with close clinical and hemodynamic monitoring and individualized anesthetic and postoperative care. Following surgical stabilization and inpatient observation, the patient achieved a postoperative course permitting discharge. Conclusion: Extreme chronological age alone should not preclude operative management of an intertrochanteric femur fracture. Careful patient selection, multidisciplinary assessment, perioperative optimization, individualized anesthetic planning, and appropriate fracture stabilization may permit successful surgical treatment even in exceptionally elderly patients with substantial medical risk.

Introduction: Acute pancreatitis (AP) is an acute inflammatory disorder of the pancreas, varying in severity from mild, self-limiting sickness to severe, life-threatening illness with systemic consequences. It is very important to be able to forecast how bad something will be early on in order to make decisions about treatment, prognosis, and the best use of resources. Traditional grading methods are helpful, but they can be hard to understand and take a lot of effort. The neutrophil-to-lymphocyte ratio (NLR), an easily accessible indicator of systemic inflammation, has surfaced as a possible predictor of disease severity in AP. Aim: This study aims to evaluate the prognostic significance of the neutrophil-to-lymphocyte ratio in predicting the severity of acute pancreatitis and to correlate it with established clinical and radiological parameters. Materials and Methods: A prospective observational study was conducted over a period of 12 months in the Department of General Surgery. A total of 45 patients diagnosed with AP based on clinical features, serum amylase/lipase levels, and imaging findings were included. Complete blood counts were obtained on admission, and the NLR was calculated. The severity of AP was assessed using the Modified Atlanta Classification. Patients were divided into two groups—mild/moderate and severe—based on clinical course and imaging findings. Statistical analysis was performed to evaluate the correlation between NLR values and disease severity, length of hospital stay, and development of systemic complications. Results: Of the 45 patients examined, 28 (62.2%) were male and 17 (37.8%) were female, with an average age of 43.6 ± 11.2 years. The predominant etiological variables were gallstones (46.7%) and alcohol (35.6%). Patients with severe pancreatitis had a much higher mean NLR (14.8 ± 4.3) at admission than those with mild to moderate illness (6.7 ± 2.1; p < 0.001). A cut-off value of 9.5 for NLR gave a sensitivity of 85% and a specificity of 78% for finding severe illness. There was also a positive link between a high NLR and a longer hospital stay, a greater need for intensive care, and more complications, such as organ failure and necrosis. Conclusion: The NLR is a simple, cost-effective, and reliable biomarker for early prediction of the severity of AP. It can be easily determined from standard blood tests and helps doctors find high-risk individuals. Adding NLR to the first assessment of patients with AP can help doctors make better decisions and predict outcomes, especially in places where resources are limited.

Introduction: Maxillary defects have a negative impact on oral function, esthetics, and quality of life. With recent advances in prosthodontics, new reconstructive methods have been developed that seek to enhance functional and esthetic rehabilitation. Objective: To evaluate the clinical effectiveness of a novel approach to maxillary prosthodontic reconstruction for smile rehabilitation. Methods: The study was a prospective interventional clinical study conducted in the Department of Prosthodontics from November, 2025 to April, 2026. A standardized digital workflow was used to prosthodontically reconstruct 68 patients with maxillary defects. Assessment of clinical outcomes, prosthesis survival, complications, and patient-reported outcomes was conducted at 6 months. Data were analysed using IBM SPSS version 26.0, with a p-value of <0.05 being considered statistically significant. Results: A significant improvement in oral health-related quality of life, masticatory efficiency, speech function, esthetic satisfaction, and overall patient satisfaction (p<0.001 for all) was seen. The retention and stability of the prosthesis were excellent more than 80% of the time, and the prosthesis survival rate was 98.5%. Post-operative complications were negligible, and partial defects of the maxilla, along with being a non-smoker, were determined as independent factors in successful reconstruction. Conclusions: The novel prosthodontic reconstruction approach presented in this study proved to be a predictable way of functional and esthetic rehabilitation, with good patient acceptance and low morbidity, making it an effective treatment option for patients in need of maxillary reconstruction.

Introduction: Distal caries of adjacent second molars is a potential risk for impacted third molars, especially based on the angulation. Objectives: To examine the relationship between impacted mandibular third molar classification according to Winter and distal caries of the second molar. Methods: A cross-sectional analytical study was done among 267 patients/radiographic sites in a tertiary care dental teaching hospital. The included patients had impacted third molars and clinically and/or radiographically evaluable adjacent second molars, and were aged 18 or older. The classification of third molars followed winter’s classification system, and distal caries was evaluated clinically and radiographically. Chi-square/Fisher's exact tests and binary logistic regression were used to assess associations. Results: Distal caries was present in 76 (28.5%) sites. The most common pattern of impaction was mesioangular (44.6%) with the highest prevalence of distal caries (39.5%), followed by horizontal (29.2%), vertical (15.7.), and distoangular (11.8.). The distal caries was highly correlated with winter classification (p<0.001). Mesioangular impaction was the only factor that was able to predict distal caries independently (p=0.001). Conclusion: Mesioangular impacted mandibular third molars were significantly related to increased incidence of distal caries of the adjacent second molar.

Introduction: Patients undergoing surgical procedures may present with other chronic diseases, such as diabetes mellitus (DM), hypertension (HTN), and chronic kidney disease (CKD), which can also modify disease characteristics, make the surgery more complex, and adversely affect postoperative outcomes. Objective: To evaluate the impact of DM, HTN, and CKD on the clinical presentation, surgical management, and postoperative outcomes of patients with cholelithiasis, acute appendicitis, inguinal hernia, benign prostatic hyperplasia, and urolithiasis. Methodology: This prospective multicenter observational cohort study was conducted from January 2025 to June 2026. A total of 600 consecutive adult patients undergoing elective or emergency surgery for cholelithiasis, acute appendicitis, inguinal hernia, benign prostatic hyperplasia, or urolithiasis were enrolled according to the predefined eligibility criteria. Patients were categorized according to the presence or absence of DM, HTN, and CKD. Data on clinical presentation, perioperative characteristics, surgical management, postoperative complications, and 30-day postoperative outcomes were prospectively collected. Multivariable logistic regression analysis was performed to identify independent predictors of adverse postoperative outcomes after adjustment for potential confounding variables. Results: Among 600 patients, 330 (55.00%) had at least one chronic comorbidity, whereas 270 (45.00%) had none. Patients with comorbidities showed higher rates of delayed presentation (n=124, 37.58% vs. n=62, 22.96%), complicated disease presentation (n=104, 31.52% vs. n= 46, 17.04%), emergency surgery (n=138, 41.82% vs. n=82, 30.37%), and prolonged operative duration (n=96, 29.09% vs. n=42, 15.56%) compared with patients without chronic diseases. Overall postoperative complications occurred in 156 (47.27%) patients with DM/HTN/CKD compared with 54 (20.00%) without comorbidities (p<0.001). CKD was the strongest independent predictor of postoperative complications (AOR=3.14, 95% CI: 1.89–5.22, p<0.001), followed by multiple comorbidities (AOR=2.71, p<0.001) and DM (AOR=1.82, p=0.004). The complication rate increased progressively from 20.00% in patients without chronic disease to 73.81% among patients with all three comorbidities. Conclusion: Chronic DM, HTN and CKD greatly contribute to the complexity of the surgery and the morbidity after surgery, and these patients require thorough perioperative optimization and careful individual risk assessment.

Introduction: Objective: To determine the correlation between occlusal surface morphological variations and dental caries susceptibility in permanent first molars among adolescents. Methods: A cross-sectional analytical study was carried out in 400 adolescents aged 10-19 years. The clinical evaluations of occlusal morphology of permanent first molars were done based on the pit-and-fissure depth, fissure configuration, groove complexity, prominent developmental pits, and deep isolated pits. The dental caries status and DMFT scores were documented. Associations were evaluated using chi-square, ANOVA, and Mann–Whitney U test, correlation analysis, and multivariable logistic regression. Results: Dental caries involving at least one permanent first molar was present in 54.5% of participants. The highest percentages of molars having intermediate fissures (44.6%), followed by shallow fissures (28.9%) and deep fissures (26.5%), were found among 1600 molars examined. There was a highly significant difference between the prevalence of caries in shallow and deep fissures (p<0.001). A significant association was also found between complex/irregular fissures, complex grooves, prominent developmental pits, and deep isolated pits and caries. The deepest fissures showed the strongest associations with caries (p<0.001). Conclusion: Adolescents had significantly increased dental caries susceptibility associated with occlusal morphological complexity, especially deep pits and fissures in the permanent first molars. Morphological assessment can therefore help to determine whether a tooth needs specific preventive measures.

Introduction: Lumbar Spinal Stenosis is a degenerative condition  where compression of the spinal cord or nerve roots occur due to  narrowing of the spinal canal in the lumbar region. AIM: To compare the functional and clinical outcomes of laminectomy alone versus laminectomy with posterior fusion in patients with Lumbar Spinal Stenosis. METHODOLOGY: This comparative observational study was conducted in the Department of Orthopaedics at a tertiary care center, from march 2025 to feb 2026.  68 patients diagnosed with Lumbar Spinal Stenosis were included . RESULT: Both laminectomy alone and laminectomy with fusion resulted in significant postoperative improvement; however, fusion demonstrated greater improvement in ODI and VAS scores, better walking ability, higher patient satisfaction, and a lower reoperation rate. Laminectomy alone was associated with shorter operative time, less blood loss, shorter hospital stay, and fewer procedure-related complications. CONCLUSION: Both laminectomy alone and laminectomy with fusion are effective surgical options for lumbar spinal stenosis. Fusion provides superior functional and pain outcomes but is associated with greater operative morbidity, in cases with multiple level canal stenosis whereas laminectomy alone in single level.

Introduction: Total hip arthroplasty (THA) is one of the orthopedic procedures that is commonly used for relieving pain, restoring mobility, and improving quality of life. AIM: To compare the clinical, functional, and radiological outcomes of THA performed using the Direct Anterior Approach versus the Posterolateral Approach. METHODOLOGY: This retrospective comparative study was conducted at the Department of Orthopaedics from jan 2025 to dec 2025  A total of 96 patients  were included in the study. RESULT: The DAA group demonstrated lower blood loss, shorter hospital stay, better early functional outcomes, lower pain scores, and comparable radiographic outcomes and complication rates compared to the PLA group. CONCLUSION: Both the Direct Anterior Approach and Posterolateral Approach provided excellent clinical, functional, and radiological outcomes following total hip arthroplasty. However, the Direct Anterior Approach was associated with faster early recovery, lower postoperative pain, reduced blood loss, and shorter hospital stay, while long-term outcomes were comparable between the two groups.

Introduction: Mortality among patients admitted to intensive care units remains substantial and is influenced by demographic characteristics, comorbidities, physiological abnormalities, organ dysfunction and treatment requirements. Early recognition of high-risk patients may facilitate appropriate triage and timely critical-care interventions. Aim: To assess the clinical profile and factors associated with mortality among patients admitted to the intensive care unit. Materials and Methods: This hospital-based analytical cross-sectional study included 120 adult patients admitted to the intensive care unit of a tertiary-care hospital. Demographic characteristics, clinical presentation, comorbidities, principal admission diagnosis, laboratory findings, admission Sequential Organ Failure Assessment score, treatment requirements and ICU outcomes were recorded. Patients were categorized as survivors and nonsurvivors. Continuous variables were compared using the independent-samples t-test, while categorical variables were analysed using the chi-square or Fisher’s exact test. Univariable and multivariable binary logistic regression analyses were performed to identify factors independently associated with ICU mortality. Adjusted odds ratios with 95% confidence intervals were calculated, and P<0.05 was considered statistically significant. Results: Of the 120 patients, 83 (69.2%) survived and 37 died, resulting in an ICU mortality rate of 30.8% (95% CI: 22.7%-39.9%). Sepsis or septic shock was the most frequent principal diagnosis (35.8%). Nonsurvivors were significantly older than survivors (62.14±16.02 versus 47.86±15.31 years; P<0.001) and had a higher mean SOFA score (11.24±3.77 versus 6.18±3.21; P<0.001). They also had higher frequencies of comorbidity, hypotension, GCS score <9, hypoxaemia, acute kidney injury, mechanical ventilation and vasopressor requirement. Nonsurvivors had higher leucocyte counts, serum creatinine and serum lactate levels and lower haemoglobin, platelet counts and arterial pH. Independent mortality-associated factors were age ≥60 years (aOR=3.18; P=0.026), sepsis or septic shock (aOR=2.76; P=0.048), systolic blood pressure <90 mmHg (aOR=3.72; P=0.019), GCS score <9 (aOR=4.63; P=0.007), serum lactate ≥4 mmol/L (aOR=5.41; P=0.003), SOFA score ≥10 (aOR=6.18; P=0.003), invasive mechanical ventilation (aOR=3.21; P=0.036) and vasopressor support (aOR=4.36; P=0.012). Conclusion: Approximately one-third of patients admitted to the ICU died. Advanced age, sepsis, hypotension, impaired consciousness, hyperlactataemia, greater organ dysfunction and the requirement for mechanical ventilation or vasopressor support were independently associated with mortality. Early assessment of these factors may improve risk stratification and guide timely intensive-care management.

Background: Total knee arthroplasty (TKA) provides substantial pain relief and functional improvement in advanced knee osteoarthritis, but recovery is heterogeneous and a clinically relevant proportion of patients progress slowly during early rehabilitation. Objectives: To determine the frequency of delayed functional recovery after primary TKA and identify preoperative and early postoperative predictors associated with delayed recovery. Methods: This prospective observational study included 80 patients undergoing primary TKA for advanced osteoarthritis at TRR Institute of Medical Sciences, Patancheru, Sangareddy, Telangana, India, from January to June 2026. Functional status was assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Timed Up and Go (TUG) test preoperatively and at 6 and 12 weeks. Delayed recovery at 12 weeks was defined using a composite functional endpoint. Multivariable logistic regression identified independent predictors. Results: Delayed functional recovery occurred in 24 (30.0%) patients. Compared with patients with timely recovery, those with delayed recovery were older, had higher BMI, poorer preoperative WOMAC function, slower TUG performance, greater postoperative day 1 pain, longer hospital stay, and lower early ambulation rates. Independent predictors were preoperative TUG >15 seconds (adjusted odds ratio [aOR] 4.06; 95% CI 1.40-11.79), postoperative day 1 pain score ≥6 (aOR 3.51; 95% CI 1.20-10.29), obesity (aOR 3.18; 95% CI 1.12-9.02), age ≥70 years (aOR 2.91; 95% CI 1.03-8.19), and diabetes mellitus (aOR 2.87; 95% CI 1.01-8.17). The model demonstrated good discrimination (area under the curve 0.84). Conclusion: Delayed recovery affected nearly one-third of patients. Preoperative mobility impairment, obesity, older age, diabetes, and greater early postoperative pain identified patients at increased risk and could guide targeted perioperative optimization and rehabilitation.

Introduction: Pancytopenia is a commonly observed entity in Internist’s Practice. The clinical spectrum and etiologies vary globally and regionally. We aimed to define the spectrum of pancytopenia in our population. Material and Methods:  We recruited 155 patients of pancytopenia over a study period of 1 year. The patients were evaluated for the clinical presentation and etiologies of pancytopenia. Results: The mean age of study population was 41.05 ± 16.77 years with a M:F ratio of 1.09. The most common presenting complaint was weakness followed by fatigue.  Pallor was present in all patients with splenomegaly and hepatomegaly present in 61 (39.35%) and 56 patients (36.13%) respectively. The mean hemoglobin level was 5.51 ± 2.01 g/dl, total leukocyte count was 2537.23 ± 958.24 cells/mm³ and mean platelet count was 56303.23 ± 34069.9/mm³. The mean corpuscular volume (MCV) was 102.45 ± 16.14 fL with mean corpuscular hemoglobin (MCH) and mean corpuscular hemoglobin concentration (MCHC) being in normal range. The majority of patients exhibited macrocytic cells (69; 44.52%), followed by dimorphic cells (35;22.58%). The mean Vitamin B12 level and folic acid levels were 235.06 ± 162.78 pg/mL and 5.60 ± 4.25 ng/mL respectively. The most common cause of pancytopenia was nutritional deficiency, accounting for 95 (61.29%) cases with 82 patients (52.9%) having both Vitamin B12 and folic acid deficiency with a mean of 154.28 ± 71.22 pg/ml and 4.19 ± 3.55 ng/ml respectively. Hypersplenism was the second most common cause for pancytopenia in 32 (20.65%) patients. 30 (19.35%) patients underwent bone marrow examination. Aplastic anemia (AA) was observed in 17 (10.97%) patients. Other findings included presence of hematological malignancies in 11 (7.09%) patients with acute leukemia (AML) in 5 (3.23%), aleukemic leukemia in 1 (0.65%), lymphoma in 3 (1.94%) and Myelodysplastic Syndrome (MDS) in 2 (1.29%) patients. Conclusion: Amidst varied etiologies of pancytopenia, megaloblastic anemia secondary to vitamin B12/Folic Acid is the commonest cause. However, patients must be screened for other etiologies in absence of nutritional deficiencies with a particular attention towards the malignancies presenting with pancytopenia.

Background: Metabolic dysfunction-associated steatohepatitis (MASH) is a progressive and the most commonly occurring liver disease of our times associated with obesity, insulin resistance, and type 2 diabetes, and is rapidly escalating as a public health challenge. Incretin-based polyagonists including dual glucagon-like peptide-1 (GLP-1) / glucagon receptor agonists, and GLP-1 / glucose-dependent insulinotropic polypeptide (GIP) co-agonists, have received increasing attention, as they may offer a combination of metabolic and hepatoprotective benefits. This systematic review aimed to assess and compare the efficacy of these innovative agents in alleviating hepatic steatosis and other distinctive clinical symptoms related to MASH in patients. Methods: The review was performed using the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020. We searched for the electronic databases PubMed, Scopus, Embase, Web of Science, and the Cochrane Library. We included studies published up to 2026. The studies we included were randomized controlled trials; Phase II/III clinical trials; and any other studies that assessed the efficacy of dual GLP-1/glucagon receptor agonists or GLP-1/GIP co-agonists in adults with MASH or metabolic dysfunction-associated steatotic liver disease (MASLD). We focused on data related to hepatic steatosis, histological response, fibrosis, liver biochemistry, metabolic outcomes and safety. The data were compiled and qualitatively analyzed. Results: The data was consistent across studies, both GLP-1/glucagon receptor agonists and GLP-1/GIP co-agonists were demonstrated to be effective in the treatment of liver steatosis. There was an improvement in liver enzyme levels and substantial weight loss and improvement in glycemic control. Significant changes in liver histology as documented in the medical literature as improvements in liver fibrosis. In controlled clinical trials, particularly tirzepatide and survodutide. In terms of safety data, GLP-1/glucagon receptor agonists appeared to confer additional benefits; particularly, increased hepatic fatty acid oxidation and energy expenditure; GLP-1/GIP co-agonists improved hepatic outcomes through substantial weight loss and improvement in insulin resistance. Both therapeutic classes demonstrated favorable safety profiles, with predominantly mild-to-moderate gastrointestinal adverse events. However, no direct head-to-head clinical trials comparing these two dual agonist classes were identified.  Conclusion: Dual incretin agonists represent a major advancement in the pharmacological management of MASH, demonstrating clinically meaningful improvements in hepatic steatosis, metabolic parameters, and histological outcomes. Current evidence supports the therapeutic potential of both GLP-1/glucagon receptor agonists and GLP-1/GIP co-agonists; however, the absence of direct comparative trials limits definitive conclusions regarding their relative efficacy. Future large-scale, multicenter, head-to-head randomized controlled trials with longer follow-up are required to establish the optimal therapeutic strategy for patients with MASH.

Introduction: Flipped classroom teaching is an active learning method that has taken root in medical teaching that requires students to self-study before class and engage in thinking and problem-solving during class. This method can increase students' interest in learning and short-term learning results, but it is still needed to be evaluated to determine its long-term effect on the retention of knowledge for undergraduate medical students. Objective: To compare the effectiveness of flipped classroom teaching with traditional classroom teaching in improving knowledge acquisition and retention among undergraduate medical students. Methods: A comparative study was conducted at Rawal Institute of Health Sciences, Islamabad, from April 2025 to October 2025. In this study, 45 students in the flipped classroom group and 44 students in the traditional teaching group received medical education at the undergraduate level. The same content and learning objectives were taught to both groups. Using a pre-test, posttest, and delayed retention test four weeks following treatment, knowledge was assessed. Student engagement, satisfaction, perceived usefulness and attendance were also evaluated. Descriptive and inferential statistical tests were used to analyze the data with p < 0.05 considered statistically significant. Results: Baseline knowledge scores were comparable between the flipped classroom and traditional teaching groups (12.7 ± 2.3 vs. 12.5 ± 2.4; p = 0.688). Students in the flipped classroom group achieved significantly higher immediate post-test scores (18.9 ± 2.1 vs. 17.2 ± 2.4; p < 0.001) and four-week retention scores (17.8 ± 2.2 vs. 15.4 ± 2.5; p < 0.001). Knowledge-retention percentage was also higher in the flipped classroom group (94.2 ± 7.8% vs. 89.5 ± 9.4%; p = 0.012), while knowledge loss was lower (1.1 ± 1.0 vs. 1.8 ± 1.2; p = 0.004). Engagement and satisfaction scores were significantly greater among students exposed to flipped classroom teaching. Conclusion: Flipped classroom teaching was associated with greater immediate knowledge gain, improved four-week knowledge retention, and higher student engagement and satisfaction compared with traditional classroom instruction. Incorporating structured flipped learning strategies into undergraduate medical education may enhance both short-term learning and sustained retention of academic content.

Introduction: Acute infective skin disease is present in children during a short period of time and can be either localized superficial infection or systemic physiological disturbances. Zinc and vitamin D support epithelial integrity, immune regulation, antimicrobial defense and inflammation control. A deficiency of these micronutrients might thus be linked to greater infectious manifestations. Objective: To assess the role of serum zinc and vitamin D in predicting disease severity and physiological disturbances among children with acute infective skin disorders. Methods: The descriptive cross sectional study was done at Khalifa Gul Nawaz Teaching Hospital Dera Ismail Khan from January 2025 to June 2025. There was a total of 76 children with acute infective skin disorders enrolled. Demographic and clinical data, disease severity, physiological parameters, inflammatory markers, serum zinc and serum 25-hydroxyvitamin D [25(OH)D] were obtained. Disease was scored as mild, moderate or severe. The associations of micronutrients with severity of the disease and physiological disturbances were studied, and multivariable logistic regression was used to identify micronutrients that predict moderate to severe disease. Results: The mean age of the participants was 7.8 ± 3.4 years, and 56.6% were male. Zinc deficiency was present in 44.7% and vitamin D deficiency in 51.3% of children. Mean serum zinc levels declined progressively from 78.9 ± 10.7 µg/dL in mild disease to 54.7 ± 10.5 µg/dL in severe disease, while mean vitamin D levels decreased from 27.8 ± 7.1 ng/mL to 14.5 ± 5.2 ng/mL, respectively (p < 0.001 for both). Zinc and vitamin D deficiencies were significantly more frequent in severe disease. Lower micronutrient concentrations were also associated with higher CRP, leukocyte count, body temperature, heart rate, and respiratory rate. On multivariable analysis, zinc deficiency, vitamin D deficiency, and elevated CRP were independently associated with moderate-to-severe disease. Conclusion: Lower serum zinc and vitamin D levels were significantly associated with greater severity and more pronounced physiological and inflammatory disturbances in children with acute infective skin disorders. These micronutrients may have potential value as supportive biomarkers for identifying children at increased risk of more severe disease.

Background: Intramedullary nailing is the standard operative treatment for displaced tibial shaft fractures. The traditional infrapatellar approach requires substantial knee flexion and may make fracture reduction, fluoroscopic visualization, and maintenance of alignment difficult. Suprapatellar nailing in the semiextended position has been proposed to overcome these limitations, but concerns remain regarding intra-articular instrumentation and potential patellofemoral injury.  Methods: This hospital-based prospective, interventional, randomized study was conducted in the Department of Orthopaedics, Dr Rajendra Gode Medical College and Hospital, Amravati, Maharashtra, India. Forty adults with closed displaced extra-articular tibial shaft fractures were randomized to suprapatellar nailing (SPN; n=20) or infrapatellar nailing (IPN; n=20). Outcomes included operative duration, blood loss, hospital stay, clinical union, postoperative knee range of motion (ROM), Lower Extremity Functional Scale (LEFS), Lysholm knee score, and complications. Patients were followed at 2, 4, 12, and 24 weeks. Results: Baseline demographic, fracture, and injury characteristics were comparable. Mean operative time was significantly shorter with SPN than IPN (109.55±15.26 vs 145.15±28.28 minutes; p<0.001), and mean blood loss was lower (42.45±7.07 vs 63.45±8.02 mL; p<0.001). Hospital stay (6.15±1.53 vs 7.25±2.05 days), time to clinical union (13.25±4.34 vs 14.85±4.45 weeks), and knee ROM (115.35±10.44° vs 113.25±9.68°) were similar. LEFS was higher in the SPN group (75.55±3.22 vs 70.65±4.33; p<0.001), with all SPN patients achieving an excellent functional category compared with 65% in the IPN group. Lysholm knee score was also higher after SPN (91.05±4.62 vs 74.90±7.92; p<0.001). Malalignment occurred in 1 (5%) SPN patient and 4 (20%) IPN patients. One superficial infection occurred in the SPN group. Conclusion: In this randomized cohort, suprapatellar tibial nailing reduced operative time and blood loss and produced better patient-reported functional outcomes than infrapatellar nailing, without a meaningful difference in union time or knee ROM. The semiextended suprapatellar approach may be particularly advantageous when maintenance of reduction and efficient fluoroscopic access are priorities.

Introduction: Soft tissue sarcomas constitute a heterogenous category of soft tissue neoplasia composed mostly of uncommon tumours of diverse histology, different biology and varied outcomes. Majority of sarcomas are presented as a painless mass of variable duration (1). Materials and methods: It’s a cross-sectional study where six cases of soft tissue sarcomas were taken which were diagnosed on histopathology and further ancillary techniques like immunohistochemistry were done. The clinical and radiological findings of the cases are as follows. Results: The neoplasm arising from tunica media of inferior venecava. The tumour cells are arranged in interlacing fascicles. The tumour cells show oval to elongated spindle shaped nuceli, moderate nuclear atypia, coarse chromatin, consipicuous nuceloli and moderate eosinophilic fibrillar cytoplasm. Conclusion: With tumours arising in these unusual sites, definitive recognition becomes difficult and requires confirmation by immunohistochemistry and molecular genetic techniques. Molecular pathology has identified key, pathognomonic genetic markers in soft tissue sarcoma, improving diagnostic accuracy and speed.

Background: Patients with congestive cardiac failure may present with manifestations that resemble non-cardiac disorders, including liver dysfunction. Hepatic abnormalities in heart failure result from passive congestion due to elevated filling pressures and/or reduced cardiac output, both of which compromise hepatic perfusion. Materials and methods:  This was a cross-sectional study conducted in a tertiary care teaching hospital among 100 patients presenting with congestive cardiac failure due to any cause. The severity of the disease was assessed using NYHA classification. The liver function tests were done and the association between the LFT and severity of disease among them was assessed using Chi-square and ANOVA tests by SPSS V25. Results: Among the study subjects, 7 had Grade IV severe congestive failure by NYHA classification. 44% of study subjects had elevated S. bilirubin levels. Statistically significant association of severity of congestive failure was observed with S. bilirubin, S. AST, A.ALT, Prothrombin time and S. Albumin. There was no significant association of S. ALP with the grade of the disease. Conclusion:  The present study showed that there was statistically significant association between abnormal liver function tests and grade of congestive heart failure by NHYA classification.

Introduction: Abnormal uterine bleeding is a frequent gynaecological problem and is an important source of iron-deficiency anaemia among women. Menstrual blood loss may persist or be excessive if caused by structural abnormalities such as uterine fibroids, adenomyosis, endometrial polyps or thickened endometrium. Such abnormalities can be identified by pelvic ultrasonography and might be responsible for the severity of the anaemia and predict the response to iron replacement treatment. Objective: To determine the association of iron-deficiency anaemia with pelvic ultrasound findings in women with abnormal uterine bleeding and to assess their haematological response to oral ferrous sulfate therapy. Methods: The study was a prospective observational study, involving pre–post therapeutic assessment in Pak International Medical College, Peshawar during a period of February 2025 to August 2025. The sample consisted of 89 women with laboratory-confirmed iron-deficiency anaemia and abnormal uterine bleeding who were recruited by a consecutive non-probability sampling. Demographic, menstrual, clinical and haematological data, including iron-profile data, were collected. All subjects had pelvic sonograms to look for structural abnormalities. Ferrous Sulphate (oral) was given and haematological parameters were re-evaluated following treatment. Correlations among ultrasound parameters, severity of anaemia and therapy response were evaluated by using appropriate statistical tests, and a p value < 0.05 was regarded as statistically significant. Results: The mean age of participants was 36.8 ± 8.1 years, while the mean baseline haemoglobin level was 9.3 ± 1.3 g/dL. Moderate anaemia was present in 56.2% of women. Pelvic ultrasonography revealed structural abnormalities in 69.7% of participants, with uterine fibroids being the most frequent finding (32.6%), followed by adenomyosis (15.7%) and increased endometrial thickness (13.5%). Women with fibroids had lower mean haemoglobin levels compared with those with normal ultrasound findings, and the overall association between pelvic ultrasound abnormalities and anaemia severity was statistically significant (p=0.003). Following oral ferrous sulfate therapy, mean haemoglobin increased from 9.3 ± 1.3 g/dL to 11.4 ± 1.2 g/dL (p<0.001). An adequate haematological response was observed in 76.4% of participants. Response was significantly lower among women with uterine fibroids, persistent heavy menstrual bleeding, severe baseline anaemia, and poor treatment adherence. Conclusion: Structural pelvic abnormalities, particularly uterine fibroids, were associated with greater severity of iron-deficiency anaemia in women with abnormal uterine bleeding. Oral ferrous sulfate significantly improved haematological parameters in most participants; however, persistent uterine blood loss and underlying structural pathology reduced the likelihood of an adequate response. Evaluation and treatment of both iron deficiency and the underlying cause of abnormal uterine bleeding are therefore essential for sustained clinical improvement.

Background: Caesarean section (CS) is an important obstetric technique that saves lives if needed; however, the unnecessary use of this surgical procedure has resulted in becoming one of the main public health issues throughout the world. In the past three decades, the rates of Caesarean section surgeries in Pakistan have increased dramatically and thus, there is a need for evaluating women's knowledge and factors related to birthing method. Objectives: This study was conducted to evaluate knowledge about Caesarean sections and factors related with Caesarean section deliveries. Methodology:  The structured questionnaire was used to conduct a descriptive cross-sectional study on 200 women of childbearing age. Sociodemographic data, obstetric history, knowledge, attitude, and healthcare factors relating to Caesarean section were collected. Descriptive statistics were applied for characterizing subjects and Chi-square tests for examining the connection between selected factors and delivery mode. The statistical significance was considered if p < 0.05. Results: The majority of participants (90.0%) were married, resided in rural areas (64.5%), and aged between 25-29 (32.5%). Majority (61.0%) of the participants had normal vaginal delivery while 39.0% delivered via Caesarean section. About half (51.5%) of the participants had knowledge about Caesarean section before pregnancy, and only 49.5% reported that they received delivery options counseling from health providers. Though there was limited knowledge of Caesarean section among the participants, there were some knowledge gaps and counseling shortcomings. Bivariate analysis showed that age, education level, residence, monthly income, previous awareness, counsellor’s counseling, and perceptions about private hospitals and financial incentives were not significantly related to delivery options (p>.05.). Nevertheless, perceptions about financial incentives showed the greatest evidence of relation (p=.094). Conclusion: It can be seen that the study has found that the participants had some awareness about Caesarean section, however, there were persistent knowledge gaps and inadequate prenatal counseling. While none of the variables studied in this research had a significant relationship with the mode of delivery, the results of this study show the importance of providing better education and counseling for mothers to reduce unnecessary C-sections in Pakistan.

Introduction: Diabetic retinopathy (DR) is a common complication of type 2 diabetes mellitus (T2DM). There is conflicting evidence on the relative retinal efficacy of SGLT2 inhibitors versus DPP-4 inhibitors. Objective: To find the impact of SGLT2 inhibitors versus DPP-4 inhibitors on retinal outcomes and diabetic retinopathy progression in patients with type 2 diabetes. Methods: A retrospective comparative cohort study was carried out over six months in 150 patients with T2DM who received either SGLT2 inhibitors (n=75) or DPP-4 inhibitors (n=75). Data for demographics, clinical, metabolic, treatment, and ophthalmological parameters were collected from their medical records. Groups compared for DR progression and other retinal outcomes. Multivariable logistic regression was used to determine independent risk factors for DR progression. Results: There were no differences between the groups in baseline characteristics or in retinal status. Progressive DR was observed in 9.3% of the patients taking SGLT2 inhibitors and in 18.7% of the patients taking DPP-4 inhibitors (p=0.091). The incidence of progression to DME and development of PDR was also lower with SGLT2 inhibitors. SGLT2 inhibitor therapy was not associated with an increased risk for progression of DR after adjustment (OR 0.48, 95% CI 0.20–1.15; p=0.098). Progression was independently associated with increased duration of diabetes, baseline HbA1c, and advanced baseline retinopathy. Conclusion: There was a positive, although not statistically significant, association between the use of SGLT2 inhibitors and retinal outcomes when compared with DPP-4 inhibitors. There is a need for larger prospective studies with longer follow-up.

Introduction: Laparoscopic cholecystectomy had been considered the gold standard for the surgical management of acute cholecystitis because of its minimally invasive nature, shorter hospital stay, and faster postoperative recovery. However, conversion from laparoscopic to open cholecystectomy had remained necessary in a subset of patients due to difficult operative conditions, severe inflammation, distorted anatomy, or unexpected intraoperative findings. Identifying the predictors of conversion had been important for preoperative risk stratification, surgical planning, patient counseling, and reducing perioperative complications. Aim: The study aimed to determine the predictors of conversion from laparoscopic to open cholecystectomy among patients with acute cholecystitis. Methodology: A retrospective cohort study had been conducted at Shahida Islam Medical College Lodhran from September 2025 to February 2026. Medical records of 80 patients who had undergone laparoscopic cholecystectomy for acute cholecystitis during the study period had been reviewed. Patients aged 18 years and above with a confirmed diagnosis of acute cholecystitis had been included, whereas patients with gallbladder malignancy, previous upper abdominal surgery, incomplete medical records, or planned open cholecystectomy had been excluded. Demographic characteristics, clinical presentation, laboratory findings, ultrasonographic features, operative findings, and surgical outcomes had been extracted from hospital records using a structured data collection form. Variables including age, gender, body mass index, duration of symptoms, white blood cell count, C-reactive protein level, gallbladder wall thickness, presence of pericholecystic fluid, impacted gallstones, diabetes mellitus, hypertension, and previous attacks of cholecystitis had been analyzed. Statistical analysis had been performed using SPSS version 26.0. Continuous variables had been expressed as mean ± standard deviation, while categorical variables had been presented as frequencies and percentages. Chi-square test, independent t-test, and multivariable logistic regression analysis had been applied. A p-value of less than 0.05 had been considered statistically significant. Results: The mean age of the study participants had been *46.8 ± 13.2 years, and **47 (58.8%)* had been females. Conversion from laparoscopic to open cholecystectomy had occurred in *14 (17.5%)* patients. Patients aged ≥60 years, those with diabetes mellitus, symptom duration exceeding 72 hours, elevated white blood cell count (>15×10⁹/L), increased C-reactive protein levels, gallbladder wall thickness ≥4 mm, presence of pericholecystic fluid, and impacted gallstones had demonstrated significantly higher conversion rates (p<0.05). Multivariable logistic regression analysis had identified prolonged duration of symptoms (Adjusted Odds Ratio [AOR]=3.52; 95% CI: 1.28–9.71), gallbladder wall thickness ≥4 mm (AOR=4.18; 95% CI: 1.49–11.76), diabetes mellitus (AOR=2.94; 95% CI: 1.08–8.01), and elevated white blood cell count (AOR=3.11; 95% CI: 1.17–8.29) as independent predictors of conversion. Conclusion: Conversion from laparoscopic to open cholecystectomy had occurred in a considerable proportion of patients with acute cholecystitis. Prolonged symptom duration, diabetes mellitus, elevated inflammatory markers, and increased gallbladder wall thickness had been identified as significant independent predictors of conversion. Early surgical intervention and careful preoperative risk assessment had facilitated operative planning, improved patient counseling, and potentially reduced the likelihood of conversion and perioperative complications.

Introduction: Snakebite envenoming remains an important cause of preventable morbidity and mortality in South Asia, particularly where haemotoxic species can produce clinically significant coagulation abnormalities. Venom-induced coagulopathy may present with prolonged clotting times, mucosal or wound bleeding, hematuria, and other systemic manifestations. Early recognition is important for appropriate emergency assessment and management. However, Pakistan-specific data describing the frequency of coagulopathy at initial hospital presentation and its relationship with readily identifiable clinical characteristics remain limited. Objective: To determine the frequency of coagulopathy at initial presentation and assess its association with demographic and clinical characteristics among adult patients with snakebite. Methods: A manuscript-development analysis corresponding to a planned descriptive cross-sectional study was conducted using 157 complete records from the Department of Accident and Emergency Medicine, Jinnah Postgraduate Medical Centre, Karachi. Adult patients presenting within 24 hours of suspected or confirmed snakebite were evaluated. Coagulopathy was defined as prothrombin time >14 seconds, activated partial thromboplastin time >40 seconds, international normalized ratio >1.5, or a positive 20-minute whole blood clotting test. Continuous variables were summarized as mean ± standard deviation and categorical variables as frequencies and percentages. The primary proportion was reported with a Wilson 95% confidence interval. Associations were assessed using Pearson’s chi-square or Fisher’s exact test, with p<0.05 considered statistically significant. Results: Coagulopathy was identified in 81/157 records (51.6%; 95% CI: 43.8%–59.3%). Mean age was 38.96 ± 13.50 years, 105 (66.9%) were male, 95 (60.5%) were rural residents, and 117 (74.5%) had lower-limb bites. PT >14 seconds occurred in 67 (42.7%), aPTT >40 seconds in 63 (40.1%), INR >1.5 in 48 (30.6%), and positive 20WBCT in 54 (34.4%). Coagulopathy was significantly more frequent with local swelling (58.6% vs 34.8%; p=0.007), wound bleeding (88.9% vs 46.8%; p=0.001), and hematuria (100.0% vs 48.6%; p=0.003). No significant associations were observed with sex, residence, age group, presentation delay, bite site, or gum bleeding. Conclusion: Coagulopathy appeared to be a frequent finding at initial presentation, particularly in patients with local swelling, wound bleeding, or hematuria. These findings support comprehensive coagulation assessment rather than reliance on a single bedside test, but require confirmation using verified, ethically approved clinical patient data.

Background: The skin can be an important clinical marker of disease activity and phenotype, and is among most common extraintestinal manifestations of inflammatory bowel disease (IBD). Objective: To determine the frequency and spectrum of cutaneous manifestations in IBD patients and to identify associated clinical parameters. Study Design: Observational cross-sectional study. Place & Duration: Gastroenterology Departments, Tertiary Care Hospitals, Pakistan; October 2025 to March 2026. Methodology: This is an observational study which will be conducted in Gastroenterology Departments of Tertiary Care Hospitals of Pakistan during a six months study period. Non-probability consecutive sampling was employed and a total of 220 patients with confirmed CD and UC were included. All demographic and disease-related data were collected, and then, frequency, type, and clinical associations of the cutaneous manifestations were analyzed with SPSS version 26.0. Independent samples t-test and Chi-square test were used for comparison between Continuous and Categorical variables with a cut-off of p-value as < 0.05 as being statistically significant. Results: Cutaneous changes were found in 54 out of 220 (24.5%) patients most frequently in the form of erythema nodosum (40.7%), followed by aphthous stomatitis (25.9%), pyoderma gangrenosum (14.8%) and psoriasiform changes (11.1%). No differences were found between Crohn's disease patients and ulcerative colitis patients in the frequency of skin involvement (63.0% vs. 37.0% of the affected patients), and the presence of skin involvement was significantly associated with active disease (75.9% vs. 42.8%, p < 0.001), disease duration > 5 years (59.3% vs. 37.3%, p = 0.004), and other extraintestinal manifestations (35.2% vs. 16.9%, p = 0.002). Conclusions: Cutaneous manifestations occur in about 1/4th of patients with IBD and they seem to be linked with phenotype of Crohn's disease, disease activity, its duration and associated extraintestinal involvement, justifying regular dermatological monitoring as a part of comprehensive management of IBD patients.

Introduction: Renal dysfunction is a major determinant of outcome in decompensated cirrhosis, but serum creatinine may incompletely reflect kidney function in this population. The spot urinary sodium-to-potassium ratio is an inexpensive index of renal sodium handling. This study examined its association with renal dysfunction in adults with decompensated cirrhosis. Materials and Methods: This hospital-based cross-sectional study included 91 adults with decompensated cirrhosis. Spot urine sodium and potassium and serum creatinine, urea, and sodium were measured within 24 hours of admission. Renal function was categorized by serum creatinine as normal (<1.2 mg/dL), mild dysfunction (1.2-1.9 mg/dL), or moderate dysfunction (2.0-2.9 mg/dL). Pearson and Spearman correlations, Kruskal-Wallis testing with Holm-adjusted pairwise comparisons, and multivariable linear regression with heteroscedasticity-robust standard errors were used. Results: The mean age was 58.2 ± 8.4 years, and 61 participants (67.0%) were men. The mean urinary sodium-to-potassium ratio was 3.23 ± 0.91. It correlated inversely with serum creatinine (Pearson r=-0.776; Spearman ρ=-0.815; both p<0.001) and serum urea (Pearson r=-0.607; p<0.001). Mean ratios decreased progressively from 4.27 in normal renal function to 3.50 in mild and 2.66 in moderate dysfunction (Kruskal-Wallis H=33.99; p<0.001). All pairwise comparisons remained significant after Holm correction. In adjusted analysis, each 1 mg/dL higher serum creatinine was associated with a 1.18-unit lower ratio (β=-1.175; 95% confidence interval, -1.439 to -0.912; p<0.001). Conclusion: A lower spot urinary sodium-to-potassium ratio was strongly and independently associated with greater renal dysfunction in decompensated cirrhosis. It may serve as a practical adjunct for cross-sectional renal assessment, but longitudinal studies are required before it can be used to predict acute kidney injury or clinical outcomes.

Background: Elderly surgical patients have reduced physiological reserve and a high prevalence of frailty and multimorbidity, increasing their susceptibility to complications associated with surgery and general anesthesia. Aim: To evaluate perioperative complications and early clinical outcomes among elderly patients undergoing non-cardiac surgery under general anesthesia and identify factors associated with postoperative morbidity. Materials and Methods: This prospective observational study framework included 120 patients aged ≥65 years undergoing non-cardiac surgery under general anesthesia. Demographic characteristics, comorbidities, ASA physical status, frailty, intraoperative hemodynamic events, surgical duration, postoperative complications, ICU requirement, hospital stay, readmission, and 30-day mortality were evaluated. Factors associated with postoperative complications were assessed using univariate analysis and multivariable logistic regression. Results: The mean age was 73.8 ± 6.5 years. Hypertension (60.0%) and diabetes mellitus (38.3%) were the most common comorbidities, while 20.0% of patients were frail. Intraoperative hypotension occurred in 31.7%. Overall, 35.0% developed at least one postoperative complication. Pulmonary complications occurred in 14.2%, postoperative delirium in 12.5%, acute kidney injury in 7.5%, and cardiovascular complications in 6.7%. ICU admission was required in 18.3%, and 30-day mortality was 2.5%. In multivariable analysis, intraoperative hypotension (adjusted OR 3.42; p=0.003), frailty (OR 3.18; p=0.015), ASA III–IV status (OR 2.71; p=0.016), and age ≥80 years (OR 2.36; p=0.047) were independently associated with postoperative complications. Conclusion: Frailty, systemic disease burden, advanced age, and intraoperative hypotension identify elderly patients at increased risk of adverse outcomes following general anesthesia. Comprehensive geriatric assessment and individualized perioperative management may improve postoperative outcomes.

Background: Primary knee osteoarthritis is a common degenerative joint disorder that causes pain, stiffness and progressive limitation of daily activities. Radiographic severity is commonly graded using the Kellgren-Lawrence system; however, its relationship with patient-reported functional disability remains variable across populations. Aim: To assess the association between radiographic severity and functional disability among patients with primary knee osteoarthritis. Materials and Methods: This hospital-based analytical cross-sectional study included 120 patients with primary knee osteoarthritis. Radiographic severity was classified using the Kellgren-Lawrence grading system. Pain, stiffness and functional disability were assessed using the Western Ontario and McMaster Universities Osteoarthritis Index. Continuous variables were presented as mean and standard deviation, while categorical variables were presented as frequencies and percentages. Differences across radiographic grades were evaluated using one-way analysis of variance. Correlations were assessed using Spearman’s rank correlation, and independent predictors of functional disability were identified using multivariable linear regression. A p value <0.05 was considered statistically significant. Results: Of the 120 patients, 17 (14.2%) had KL grade 1, 39 (32.5%) had grade 2, 41 (34.2%) had grade 3 and 23 (19.2%) had grade 4 osteoarthritis. The mean WOMAC functional-disability score increased progressively from 19.4 (SD 7.2) in grade 1 to 28.7 (SD 8.9), 39.8 (SD 10.1) and 51.6 (SD 8.7) in grades 2, 3 and 4, respectively (F=53.84, p<0.001). KL grade showed a strong positive correlation with functional disability (ρ=0.72; 95% CI: 0.62-0.79; p<0.001). Moderate-to-severe functional disability was present in 94 (78.3%) patients. After adjustment, every one-grade increase in KL severity was associated with an 8.74-point increase in the WOMAC functional-disability score (95% CI: 7.19-10.29; p<0.001). Older age, female sex, higher BMI, longer symptom duration and bilateral knee involvement were also independently associated with greater disability. The regression model explained 62% of the variation in functional-disability scores. Conclusion: Increasing radiographic severity was strongly associated with worsening functional disability in primary knee osteoarthritis. Kellgren-Lawrence grade was the strongest independent predictor of disability, although demographic and clinical factors also contributed. Integrating radiographic assessment with WOMAC-based functional evaluation may provide a more comprehensive basis for treatment planning.

Introduction: Residual ridge resorption (RRR) is a progressive effect of edentulism that may affect the support, stability, and functioning of complete dentures. The severity of the ridge resorption due to long-term complete denture use is still clinically relevant. Objective: To determine the relationship between RRR and duration of complete denture use among completely edentulous patients. Methods: A cross-sectional analytical study was carried out on 103 completely edentulous patients wearing complete dentures. The survey was conducted by using a structured proforma, which included information about sociodemographic and denture-related variables. Clinically and radiographically, residual ridge resorption was evaluated using standard measurements. Results: The mean age was 63.4 ± 7.2 years, and the mean duration of denture use was 8.1 ± 4.6 years. The residual ridge resorption was severe in 60.2% of participants. The resorption was found to be progressive with the time of denture wearing. The duration of denture use was significantly positively correlated with the mandibular (r=0.61, p<0.001) and maxillary (r=0.48, p<0.001) ridge resorption. After controlling for selected covariates, use of the dentures for more than 12 months continued to be an independent predictor of the amount of mandibular ridge resorption (p<0.001). Conclusion: Longer complete denture use was significantly associated with greater residual ridge resorption. Prosthodontic evaluation can be of benefit in timely intervention and long-term denture function.

Introduction: Resistant hypertension represents a significant clinical problem and carries a higher cardiovascular and renal risk. Uric acid and renal dysfunction have been proposed to be involved in hypertension, and the ratio of uric acid to creatinine (UA/Cr) could be a better biochemical indicator. Objective: To compare the serum UA/Cr ratio between patients with controlled and resistant hypertension and to see if there is any relationship between serum UA/Cr ratio and resistant hypertension. Methods: A comparative cross-sectional study was carried out at Shaikh Zayed Hospital, Lahore, involving 132 adults with hypertension, with 66 patients with controlled hypertension and 66 with resistant hypertension. Demographic, clinical, blood-pressure and biochemical information were obtained. Serum uric acid and creatinine were determined, and the ratio of UA/Cr was computed. The independent-samples t-test, Mann–Whitney U test, chi-square/Fisher's exact test, correlation analysis and binary logistic regression were used to analyze data. Results: The serum uric acid, creatinine, BMI, systolic and diastolic blood pressure, and hypertension duration were significantly higher in patients with resistant hypertension than in patients with controlled hypertension, whereas eGFR was lower. The mean UA/Cr ratio was significantly higher in resistant hypertension (6.72 ± 1.58 vs. 6.05 ± 1.46; p=0.011). The ratio positively correlated with systolic and diastolic blood pressure. Multivariable adjustment revealed that each UA/Cr increase was an independent risk factor for resistant hypertension (adjusted OR 1.34, 95% CI 1.04–1.73; p=0.023). Conclusions: The elevated serum UA/Cr ratio was independently associated with resistant hypertension and could be a simple biochemical indicator of more severe treatment resistance.

Background: Pelvic organ prolapse (POP) can adversely affect sexual function, sexual activity, and quality of life. Although surgical repair primarily aims to restore pelvic support and relieve prolapse-related symptoms, sexual function is an important patient-reported outcome. Objective: To assess changes in sexual function and dyspareunia before and 6 months after surgical repair of pelvic organ prolapse. Methodology: This prospective observational pre–post study was conducted in the Department of Obstetrics and Gynaecology, Ayub Teaching Hospital, Abbottabad. A total of 80 sexually active women aged ≥18 years with symptomatic POP undergoing surgical repair were included. Demographic and clinical characteristics, POP-Q stage, prolapse compartment, and surgical procedure were recorded. Sexual function was assessed using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12) before surgery and at 6 months postoperatively. The primary outcome was change in total PISQ-12 score, while secondary outcomes included dyspareunia and sexual activity. Preoperative and postoperative outcomes were compared using appropriate paired statistical tests. Results: The mean age of participants was 48.6 ± 8.7 years. POP-Q stage III was the most frequent stage, observed in 36 (45.0%) women, followed by stage II in 32 (40.0%) and stage IV in 12 (15.0%). The mean PISQ-12 score increased significantly from 29.4 ± 5.8 preoperatively to 34.7 ± 4.9 at 6 months postoperatively (p<0.001). Dyspareunia decreased from 28 (35.0%) before surgery to 13 (16.3%) after surgery (p=0.006). Sexual activity was reported by 71 (88.8%) women at postoperative assessment. In an exploratory unadjusted analysis, improvement was more frequent among premenopausal than postmenopausal women (87.5% vs. 66.1%, p=0.04). Conclusion: POP repair was associated with improved sexual function and reduced dyspareunia at 6 months. Sexual function should be incorporated into preoperative counseling and postoperative assessment of women undergoing POP repair.

Introduction: The use of video-assisted thoracoscopic surgery (VATS) has been growing and has gradually replaced open thoracotomy (OT) for lobectomy in early-stage lung cancer. It has not been shown to have any benefits perioperatively; however, the complexity of the operation and the requirement to ensure oncological adequacy must be considered. This study aimed to compare the outcomes of VATS and open lobectomy in patients undergoing lobectomy for early-stage lung cancer. Methods: A multicenter comparative analytical study was performed on 280 patients undergoing lobectomy for early-stage non-small cell lung cancer (NSCLC) over a period of one year from 1^st April 2025 to 31st March 2026. Demographic, clinical, operative, postoperative, and pathological variables were documented. The independent t-test and the Mann-Whitney U test were used to examine continuous variables, and the chi-square test and Fisher's exact test were used to examine categorical variables. Logistic regression was used to determine the independent predictors of postoperative complications. Results: The VATS group had a longer operative duration but significantly lower blood loss and transfusion requirements. VATS was correlated with reduced postoperative pain, reduced chest tube time, earlier mobilization, and shorter hospital stay (all p<0.05). The overall postoperative complications rate was 20.0% in the VATS group and 35.7% in the thoracotomy group (p=0.004). In the multivariable analysis, OT was independently associated with the development of postoperative complications (p=0.005). Results: VATS lobectomy resulted in better perioperative recovery with fewer complications, yet maintained comparable oncological resection results. Therefore, VATS is a preferred technique for appropriately selected patients with early-stage lung cancer.

Background: Esophageal varices develop in nearly half of patients with compensated cirrhosis and up to 80% of those with decompensated disease. Upper gastrointestinal endoscopy remains the gold standard for diagnosis but is invasive and resource-intensive. The platelet count/splenic diameter (PC/SD) ratio, which integrates thrombocytopenia and splenomegaly — two pathophysiological consequences of portal hypertension — has emerged as a simple, non-invasive candidate predictor. Objectives: To assess the presence or absence of esophageal varices using the PC/SD ratio, and to determine its predictive value for esophageal varices in cirrhotic patients. Methods: This cross-sectional observational study was conducted in the Department of General Medicine at Subbaiah Institute of Medical Sciences (SUIMS), Shivamogga, from 1 May 2024 to 31 December 2025. Ninety-three consecutive cirrhosis patients meeting eligibility criteria and providing written informed consent were enrolled. All patients underwent complete blood count, liver function tests, abdominal ultrasonography for splenic diameter, and upper gastrointestinal endoscopy for variceal presence and grade. The PC/SD ratio was calculated from platelet count and maximum bipolar splenic diameter. Continuous variables were compared using the unpaired Student’s t-test; categorical variables were compared using the Chi-square or Fisher’s exact test. Receiver operating characteristic (ROC) curve analysis was used to determine diagnostic accuracy. A p-value < 0.05 was considered significant. Results: Of 93 patients, 47 (50.5%) had no esophageal varices and 46 (49.5%) had varices. The median PC/SD ratio was significantly higher in patients without varices (0.91, IQR 0.79–1.00) than in those with varices (0.39, IQR 0.28–0.51; p < 0.001). ROC analysis showed excellent discriminatory accuracy (AUC 0.92, 95% CI 0.86–0.97; p < 0.001); a cut-off of ≤ 0.65 yielded 89.1% sensitivity, 87.2% specificity, 86.9% positive predictive value, and 89.4% negative predictive value (overall accuracy 88.2%). The PC/SD ratio declined progressively with increasing variceal grade (Grade 0: 0.91; Grade 2: 0.45; Grade 3: 0.31; p < 0.001). Longer duration of chronic liver disease, alcohol use, systemic hypertension, lower platelet count, larger splenic and portal vein diameter, higher bilirubin/INR/AST/ALT/MELD score, lower albumin, and advanced Child–Pugh class were significantly associated with variceal presence, whereas age, sex, smoking, diabetes, chief presenting complaints, pallor, icterus, and routine vital/laboratory parameters were not. Conclusion: The PC/SD ratio is a robust, reproducible, and inexpensive non-invasive predictor of both the presence and severity of esophageal varices in cirrhosis patients, and may be incorporated into routine screening protocols to rationalise the use of endoscopy, particularly in resource-limited settings.

Background: Red blood cell (RBC) adherence to vascular endothelium and red cell distribution width (RDW) have each been separately implicated in the vascular complications of diabetes mellitus, but no previous study has evaluated both parameters together in the same population of patients with diabetic retinopathy (DR). Aim: To assess the association of RDW and RBC adherence with the presence and severity of DR, and to evaluate the influence of conventional risk factors (age, duration of diabetes, glycaemic status, hypertension and dyslipidaemia) on DR. Methods: This case–control study enrolled 30 patients with type 2 diabetes mellitus attending the medical and ophthalmology departments of a tertiary care hospital, divided equally into three groups of 10: no DR (controls), non-proliferative DR (NPDR) and proliferative DR (PDR). Demographic details, co-morbidities and fundus findings were recorded. RDW, RBC adherence (assessed using a microfluidic flow-based adhesion assay) and other biochemical parameters (HbA1c, lipid profile, renal function) were measured. Data were analysed using SPSS; ANOVA and the Kruskal–Wallis test were used for continuous variables across groups, and the chi-square test for categorical variables, with p<0.05 considered significant. Results: Age and gender showed no significant association with DR (p=0.98). Duration of diabetes was significantly longer in eyes with DR (p=0.005), although HbA1c did not differ significantly between groups (p=0.05). Dyslipidaemia was not significantly associated with DR (p=0.08), whereas hypertension was strongly associated with the presence and severity of DR (p<0.001). RDW increased progressively across the three groups (13.3 ± 0.6, 14.3 ± 1.3 and 16.5 ± 1.0 respectively; ANOVA p<0.001) and correlated positively with hypertension and diabetic nephropathy. RBC adherence did not differ significantly between groups (p=0.60/0.64) and showed no significant correlation with disease duration or HbA1c. Conclusion: RBC adherence was not significantly associated with DR in this cohort. However, RDW showed a significant, stepwise positive relationship with the presence and severity of DR, and correlated with hypertension and diabetic nephropathy, supporting its role as an accessible, low-cost marker of poor glycaemic control and microvascular disease progression in type 2 diabetes.

Background: Recurrent hospitalisation is a major determinant of morbidity, mortality and health expenditure amongst HFrEF patients and understanding factors that represent potentially  modifiable markers of acute re hospitalisation are key targets for improving outcome. Objective: To assess the frequency of re-hospitalizations in persons with chronic HFrEF and to identify factors that are clinically associated with or could contribute to rehospitalizations. Methods: This is an observational study in which the study duration is from March 2025 to March 2026 in the Departments of Cardiology of Ghulam Muhammad Mahar Medical College (GMMMC), Sukkur. 180 patients with chronic HFrEF (LVEF ≤ 40%) were identified and followed for hospitalization rates over the course of the study. Recurrent hospitalization was defined as having two or more hospitalizations for CHF. Using SPSS version 26.0, demographic, clinical and treatment-related data was compared between the recurrent and non-recurrent groups. Independent samples t test was used for the comparison of continuous variables and Chi square test for categorical variables; p value < 0.05 was defined as statistically significant. Results: Among 180 patients, 82 (45.6%) had at least one hospitalisation during the study period and 40 (22.2%) were hospitalised recurrently. Recurrent hospitalization was significantly associated with higher NYHA class III/IV status (80.0% vs. 38.6%, p < 0.001), lower LVEF (28.4 ± 6.2% vs. 32.6 ± 7.1%, p = 0.002), diabetes mellitus (55.0% vs. 34.3%, p = 0.019), chronic kidney disease (35.0% vs. 15.0%, p = 0.006), medication non-adherence (60.0% vs. 22.9%, p < 0.001), and incomplete guideline-directed medical therapy (45.0% vs. 15.7%, p < 0.001). Conclusion: Recurrent hospitalisation is frequent and is significantly linked to advanced NYHA class, lower EF, important co-morbidities and modifiable risk factors such as medication non-adherence and under-treatment despite evidence-based guidelines in a large population of patients with chronic HFrEF, and opens clear avenues for addressing heart failure in a structured way.

Background: Proximal humerus fractures (PHFs) account for approximately 5% of all fractures and are the third most common osteoporotic fracture in the elderly. Although most PHFs are managed non-operatively, the optimal treatment of displaced two-part surgical neck fractures remains debated. The aim of this study was to evaluate the functional outcome of conservative management of two-part surgical neck PHFs, classified by the Neer system, using the Constant–Murley Score (CMS). Methods: This prospective, descriptive, hospital-based study was conducted at Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, between 2022 and 2024. Twenty-four consecutive patients aged above 40 years with displaced two-part surgical neck fractures were treated with sling immobilisation for two weeks, early pendulum exercises, and a supervised physiotherapy protocol. Patients were followed up at 3, 6 and 12 months and functional outcome was assessed with the CMS; the Disabilities of the Arm, Shoulder and Hand (DASH) score was recorded as a secondary measure. Results: The mean age was 54.56 years and females predominated (58.33%). Twenty-three of 24 patients (95.8%) completed follow-up. The mean CMS improved progressively from 51.83 ± 5.85 at 3 months to 59.29 ± 5.17 at 6 months and 65.26 ± 4.88 at 12 months. At final follow-up, 20.83% of patients achieved a good outcome and 75.00% a moderate outcome. No fracture-related complications were encountered. Conclusion: Conservative management of two-part surgical neck fractures of the proximal humerus in patients above 40 years of age is a safe and effective treatment strategy that yields progressive functional recovery with a low complication rate.

Objective: To provide an update on the diagnosis, antimicrobial treatment and prevention of Clostridioides difficile (C. difficile) colitis, as well as microbiome-based treatments. Material and Methods: This review article was done after approval from the Institutional Ethical Review Committee (ERC) at Ayub Teaching Hospital. The study period was 1st January 2026 – 30th June 2026. PubMed, Google Scholar, and guideline repositories were used to search the literature starting in 2021 and up to 2026. Medical literature pertaining to current recommendations by the Infectious Diseases Society of America (IDSA), Society for Healthcare Epidemiology of America (SHEA), and American Gastroenterological Association (AGA) was reviewed. Diagnosis and treatment articles, recurrent infection, fecal microbiota transplantation (FMT), and emerging microbiome therapies were included. Results: There has been a recent change in guidelines, favoring fidaxomicin over vancomycin for initial and recurrent C. difficile infections because of reduced recurrence rates. Oral vancomycin is still effective but metronidazole is used only for specific, mild cases. New diagnostic algorithms with use of toxin assays and nucleic acid amplification tests have led to better diagnostic accuracy. FMT and live biotherapeutic products have demonstrated promising results in the treatment of recurrent disease, by restoring gut microbiota and decreasing the risk of disease relapse. Conclusion Treatment of C. difficile colitis now focuses on prompt diagnosis, judicious use of antimicrobial agents, implementing infection control measures, and stewardship of antimicrobial use. In high-risk patients, emerging therapies that use the microbiome could also further enhance outcomes and minimize recurrence.

Objectives: Postgraduate training program was affected in many ways during covid-19 lockdown regarding patient exposure, working hours, medical and surgical skills of different specialties. In this study we aimed to find out the impact of the pandemic on postgraduate training of ophthalmology residents.

Study design: Cross-sectional study

Place and duration of study: This study was held in Ayub Teaching Hospital Abbottabad during 1st March to 31th July 2020 in collaboration with KPK Teaching Hospitals.

Participants and Methods: A cross-sectional study was conducted including 42 post graduate residents of ophthalmology department ATH, KPK using an online 19-point questionnaire. The questionnaire included four sections that were clinical work skills, online classes, exams and mental health.

Results: Of all the residents, 40 (95.3%) stated that their surgical hands-on training and 36 (85.7%) responded that their clinical exposure was adversely affected by the pandemic. As for online classes, only 14 (35%) trainees favored online teaching. Among all the subjects, 34 (80.9%) were concerned about their exam preparation and delay. About 70% residents were depressed over their training effects. Conclusion: The unfavorable effects on training amidst the pandemic reduced hands-on and clinical exposure of the ophthalmological residents. Moreover, the situation indicated to explore more efficient methods of learnin

Background: The pericapsular nerve group (PENG) block is an ultrasound-guided regional anaesthetic technique used for analgesia in patients undergoing hip and proximal femur surgery. Addition of adjuvant drugs to ropivacaine may improve the quality of analgesia and patient comfort during positioning for spinal anaesthesia. Objective: To compare the analgesic efficacy of 0.2% ropivacaine with dexamethasone versus 0.2% ropivacaine with fentanyl in PENG block for proximal femur surgeries, and to evaluate patient comfort during positioning for spinal anaesthesia and associated adverse effects. Methods: A prospective, randomized, double-blind comparative study was conducted in patients aged 18–65 years undergoing proximal femur surgery. Participants were allocated into two groups receiving ultrasound-guided PENG block with either 0.2% ropivacaine and dexamethasone or 0.2% ropivacaine and fentanyl. Pain intensity was assessed using the Visual Analog Scale (VAS) before the block and 10 minutes after the block. Patient comfort during positioning for spinal anaesthesia was assessed using a patient satisfaction score. Perioperative haemodynamic parameters and adverse effects were also monitored. Results: The baseline characteristics were comparable between the two groups. Mean pre-block VAS scores were 6.567±1.223 in the dexamethasone group and 6.5±1.252 in the fentanyl group (p=0.408). Ten minutes after PENG block, VAS scores decreased to 2.167±0.791 and 2.234±0.728, respectively, with no statistically significant difference between groups (p=0.365). Patient satisfaction scores were 2.1±0.759 in the dexamethasone group and 2.0±0.743 in the fentanyl group (p=0.328). Thus, both combinations produced substantial reduction in pain and comparable comfort during positioning. Conclusion: Both 0.2% ropivacaine-dexamethasone and 0.2% ropivacaine-fentanyl combinations provided effective analgesia when used for PENG block in patients undergoing proximal femur surgery. No statistically significant difference was observed between the groups in early post-block VAS scores or patient satisfaction during positioning for spinal anaesthesia. Both regimens may therefore be considered effective options for perioperative analgesia in this setting.

Introduction: Sleep disturbances and zinc deficiency are prevalent yet underrecognised clinical concerns in the geriatric population. Serum zinc, as an essential trace element involved in neurotransmission and neuroendocrine regulation, may have a significant role in sleep and mental health, though evidence specifically addressing older adults remains limited. Aim: To evaluate the associations between serum zinc levels, sleep quality, insomnia severity, and mental health outcomes in geriatric patients attending a tertiary care centre. Materials and Methods: This cross-sectional observational study was conducted at . Forty geriatric patients aged ≥60 years were enrolled. Serum zinc was measured by atomic absorption spectrophotometry and classified as low (<70 µg/dL), normal (70–120 µg/dL), or high (>120 µg/dL). Sleep quality, insomnia severity, depressive symptoms, and anxiety were assessed using the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Geriatric Depression Scale-15 (GDS-15), and Generalised Anxiety Disorder-7 (GAD-7). Statistical analyses were performed using SPSS version 28.0 (IBM Corp., Armonk, NY, USA). Pearson correlation and independent samples t-tests were applied; a p-value <0.05 was considered statistically significant. Results: The mean age was 72.3 ± 6.1 years; 55% were female. Low serum zinc was identified in 40% of participants. Poor sleep quality (PSQI >5) was present in 80%, moderate-to-severe insomnia (ISI ≥15) in 35%, and depressive symptoms (GDS-15 ≥5) in 45%. Serum zinc showed statistically significant negative correlations of moderate strength with PSQI (r = −0.45, p = 0.004) and ISI (r = −0.39, p = 0.010), and a weak but statistically significant negative correlation with GDS-15 (r = −0.31, p = 0.049). Participants with low serum zinc had significantly poorer sleep quality (PSQI: 11.2 ± 2.8 vs 9.0 ± 2.9, p = 0.010) and higher depressive scores (GDS-15: 6.2 ± 2.5 vs 4.6 ± 2.3, p = 0.020) compared to those with non-low zinc.

Conclusion: Zinc deficiency was prevalent in 40% of geriatric participants and was significantly associated with impaired sleep quality, greater insomnia severity, and higher depressive scores. Routine zinc assessment and targeted nutritional optimisation may represent a modifiable approach to improving sleep and mental health in older adults.

BACKGROUND: Diabetic foot ulcers (DFUs) present severe clinical and socioeconomic burdens, frequently leading to osteomyelitis and lower-extremity amputations. Povidone-iodine remains the conventional baseline standard of care due to its cost-effectiveness and broad-spectrum antimicrobial activity, yet it lacks tissue-regenerative properties and carries potential cellular cytotoxicity. Conversely, topical phenytoin sodium offers a multi-targeted therapeutic approach by actively stimulating fibroblast proliferation, collagen synthesis, and neovascularization. Given the critical shortage of robust clinical trials directly comparing tissue-regenerating modalities against standard antiseptics, this study evaluates the comparative clinical efficacy of topical phenytoin versus povidone-iodine to establish an evidence-based protocol for optimizing DFU healing. OBJECTIVES: To evaluate and compare the therapeutic efficacy of topical phenytoin (50 mg/mL) versus 10% povidone-iodine dressings in the management of diabetic foot ulcers, specifically assessing wound healing acceleration, granulation tissue formation, re-epithelialization rates, microbial clearance, and patient tolerability. METHODS: In this prospective, randomized, single-blind, controlled trial, 50 patients with diabetic foot ulcers were allocated (1:1) to receive daily dressings of either topical phenytoin (50 mg/mL) or 10% povidone-iodine. Following surgical debridement, wound surface areas were quantified using the Flanagan tracing method. Patients were monitored daily during week 1, then thrice weekly for up to 8 weeks. Primary outcomes included time to complete healing, weekly granulation tissue percentage, re-epithelialization rates, and wound area reduction. Secondary endpoints encompassed quantitative bacterial cultures (baseline and day 10), Visual Analogue Scale (VAS) pain scores, compliance, and adverse event tracking. CONCLUSION: Topical phenytoin sodium powder is a clinically superior, safe, and effective alternative to conventional povidone-iodine dressings for chronic diabetic foot ulcers. It significantly accelerates tissue regeneration by promoting rapid granulation tissue formation and re-epithelialization, which ultimately facilitates superior skin graft take-up. Furthermore, its robust antimicrobial efficacy ensures rapid microbial clearance and lower infection rates. Clinically, these benefits translate into reduced hospital stays and lower patient distress. Integrating topical phenytoin into standard wound care protocols offers a highly practical solution for resource-limited settings, optimizing recovery rates and supporting the overarching mission to reduce lower-extremity amputations.

Introduction: Complex spine surgery is a collection of pathologies whereby each has different surgical and diagnostic challenges such as spinal infection, spinal tumor and trauma and especially in resource-limited tertiary care centers. Objective: To evaluate the clinical features of complex spine surgery patients in terms of postsurgical course and surgery management, and to compare the outcomes of these three groups of patients (infection, tumor and trauma). Methods: This was a comparative observational study conducted in spine surgery units of Tertiary care hospitals of Pakistan from August 2025 to January 2026. 92 patients having complex surgery of the spinal region were included and divided into three groups: infection (n = 30), tumor (n = 28), and trauma (n = 34). Demographic, operative and postoperative parameters (neurologic improvement, complication rate, mortality) were documented and analyzed between the groups using SPSS version 26.0. One-Way ANOVA and Chi-Square tests were used for comparing continuous and categorical variables respectively with a p-value < 0.05 considered statistically significant. Results: The trauma group had the earliest onset of symptoms and the shortest length of stay in hospital (p<0.001); The tumor group had the largest amount of blood loss, and the longest operating room time (p<0.001 for both). Neurological improvement was achieved in 73.3%, 64.3%, and 76.5% of the infection, tumor, and trauma groups respectively (p = 0.412), while postoperative complication rates (20.0%, 25.0%, and 14.7%, p = 0.487) and mortality (3.3%, 7.1%, and 2.9%, p = 0.812) did not differ significantly between groups. The overall trend showed that the mean VAS pain score progressively decrease from baseline to 6-month follow up in all groups. Conclusion: Good pain control and neurological function can be achieved with complex spine surgery in an operating room setting regardless of the diverse requirements placed on the operating room, with an implication for continued investment in specific surgical services in the tertiary care setting in complex spine surgery.

Background: Levobupivacaine is gaining popularity as a safer option compared to racemic bupivacaine, especially in spinal anaesthesia, thanks to its favorable cardiovascular profile. To boost its pain-relieving effects, adding opioid adjuvants can be beneficial. This study looked into how Butorphanol, when combined with 0.5% heavy Levobupivacaine, impacts pain relief and hemodynamic responses during spinal anaesthesia for lower limb surgeries. Methods: We conducted a prospective, randomized, double-blind trial involving 30 patients who were scheduled for elective lower limb surgeries under spinal anaesthesia. The participants were split into two equal groups: Group A received 3 mL of 0.5% Levobupivacaine mixed with saline, while Group B got 3 mL of 0.5% Levobupivacaine with 25 mcg of Butorphanol. The main outcomes we focused on were the duration of pain relief, Visual Analogue Scores (VAS), and the time until the first rescue analgesia was needed. We also looked at secondary outcomes like the regression of motor block and hemodynamic parameters. Results: Group B showed a significant increase in the duration of analgesia (6.37 ± 0.58 hrs vs. 4.90 ± 0.47 hrs; p < 0.0001) and had lower VAS scores at 6 and 8 hours after surgery. Additionally, the need for rescue analgesia within the first 6 hours was less in Group B (53.33% vs. 100%; p < 0.05). While sensory and motor block durations were longer in Group B, there was a delay in motor recovery. Both groups maintained hemodynamic stability with minimal fluctuations. Conclusion: Adding Butorphanol to intrathecal Levobupivacaine significantly improves postoperative pain relief and extends sensory block duration without affecting hemodynamic stability. However, the delayed motor recovery is something to keep in mind, particularly in outpatient settings. We recommend further studies to fine-tune dosing and evaluate long-term outcomes.

Background: No prior randomised controlled trial has specifically assessed magnesium sulphate (MgSO₄) as an adjuvant to ropivacaine in ultrasound-guided fascia iliaca compartment block (FICB) for proximal femur fracture surgery. MgSO₄, an NMDA receptor antagonist, may enhance analgesia and reduce opioid consumption. This study evaluated its efficacy and safety in this setting. Methods: In this prospective, randomised controlled trial, 50 patients undergoing proximal femur surgery received FICB with either 20 mL of 0.2% ropivacaine plus 150 mg MgSO₄ (Group I) or 20 mL of 0.2% ropivacaine alone (Group II). Primary outcomes were postoperative pain (VAS), time to first rescue analgesia, and total opioid (tramadol) use over 24 hours. Results: Baseline demographics were comparable between groups. VAS scores, time to first rescue, and total tramadol consumption showed no statistically significant differences, although Group I exhibited a non-significant trend towards delayed rescue analgesia. No adverse haemodynamic effects or complications occurred. Conclusion: MgSO₄ as an adjuvant to ropivacaine in ultrasound-guided FICB for proximal femur fracture surgery was safe but did not significantly improve analgesic outcomes. These results are exploratory and support further studies with larger cohorts, optimised dosing, and broader recovery endpoints.

Background: Bloodstream infections (BSIs) are a major cause of morbidity and mortality among patients with acute myeloid leukemia (AML), particularly during induction chemotherapy because of prolonged neutropenia and immunosuppression. The increasing prevalence of multidrug-resistant (MDR) pathogens has further complicated treatment, especially in resource-limited settings such as Pakistan. Objective: To determine the frequency of MDR bloodstream infections and identify factors associated with their development among adults with newly diagnosed AML. Methods: This multicenter analytical cross-sectional study was conducted over one year at three tertiary care hospitals in Pakistan. Adults with newly diagnosed AML and culture-confirmed BSI before or during induction chemotherapy were included. Clinical, laboratory, and microbiological data were collected, and antimicrobial susceptibility testing was performed according to CLSI guidelines. Multivariable logistic regression identified independent predictors of MDR BSI. Results: Among 186 patients, 72 (38.7%) developed MDR bloodstream infections. Gram-negative bacteria, mainly Klebsiella pneumoniae, Escherichia coli, and Acinetobacter baumannii, predominated. Previous broad-spectrum antibiotic exposure, prolonged neutropenia, central venous catheterization, ICU admission, and prolonged hospitalization were independent risk factors. MDR infections were associated with longer hospital stay and increased in-hospital mortality. Conclusion: MDR bloodstream infections are common among newly diagnosed AML patients in Pakistan. Early identification of high-risk patients, effective antimicrobial stewardship, and strengthened infection prevention strategies are essential to reduce infection-related morbidity and mortality.

Background:  Perinatal asphyxia may reduce renal perfusion and cause acute kidney injury (AKI). Theophylline blocks adenosine-mediated renal vasoconstriction and may preserve kidney function. Objectives: To determine the role of prophylactic theophylline in preventing AKI among term neonates exposed to perinatal asphyxia. Methodology: This prospective observational cohort study was conducted at Lahore General Hospital from 1 April to 1 October 2024. A total of 110 term neonates were enrolled through consecutive sampling. Fifty-five received intravenous theophylline 5 mg/kg over 15 minutes within 12 hours of birth, while 55 received standard treatment alone. Serum creatinine and blood urea nitrogen were measured on days 1, 3, and 5. Urine output was recorded for seven days. Data were analysed using IBM SPSS Statistics version 27. Results: Baseline characteristics were comparable between groups. Composite AKI occurred in 24/55 (43.6%) neonates in the theophylline group and 42/55 (76.4%) controls. The adjusted risk ratio was 0.59 (95% CI: 0.43–0.80; p<0.001). Creatinine-defined AKI occurred in 18.2% versus 47.3% (adjusted RR: 0.41; 95% CI: 0.25–0.69; p<0.001). Day-5 serum creatinine was 0.78 versus 1.07 mg/dL (p<0.001). Mean urine output was 1.52 versus 1.33 mL/kg/hour (p<0.001). Theophylline was effective in 89.1% versus 65.5% of neonates. Transfer or death occurred in 5.5% versus 12.7% (p=0.185). Conclusion: Early prophylactic theophylline was associated with lower AKI risk and better short-term renal function after perinatal asphyxia.

Background: A balance between the benefits and risks of anticoagulation in patients with mechanical valve requires a holistic approach. Perspectives of the treating doctors will help in identifying areas for improvement. Objective: To explore the facilitators and barriers to anticoagulation in patients undergoing valve replacement surgery from the perspectives of treating doctors of a government institution. Methods: A qualitative phenomenological study was conducted among nine doctors of the cardiothoracic and vascular surgery department. Data were collected through in-depth semi-structured interviews. Interviews were audiorecorded, transcribed verbatim, and analysed using reflexive thematic analysis. These findings were subsequently interpreted using the Capability–Opportunity–Motivation–Behaviour (COM-B) framework. Results: Five interrelated themes emerged 1) Therapeutic balance and risk mitigation  2) Information and engagement 3) Monitoring and accessibility 4) health-system constraints 5) Integrated and Patient centered care. These themes aligned with the COM B model. Conclusion: Safe anticoagulant extends beyond prescribing. It requiresexpertise of the doctor, patient engagement, regular monitoring and supportive system. Appropriate anticoagulation is achieved through care continuity, adherence, and by ensuring patient safety.

BACKGROUND: Anemia in adults is clinically heterogeneous. Symptoms are often non-specific, while the underlying disorder may reflect nutritional deficiency, chronic inflammation, or vitamin deficiency. A combined clinical and laboratory profile can therefore guide more focused investigation and treatment. OBJECTIVE: To describe the clinical presentation, hematological pattern, severity, and etiological distribution of anemia in adults, and to examine differences in hematological and iron-profile parameters across morphological types. METHODS: A cross-sectional study included 200 adults with anemia. Clinical manifestations, complete blood count indices, serum ferritin, serum iron, total iron-binding capacity, transferrin saturation, morphological type, severity, and etiological category were analysed. Categorical variables were summarized as frequencies and percentages; continuous variables were expressed as mean ± standard deviation. The chi-square test and Kruskal-Wallis test were used where appropriate. RESULTS:

The mean age was 44.08 ± 13.22 years, and 115 (57.5%) participants were female. Pallor was the most frequent clinical finding (57.5%), followed by fatigue (39.5%) and weakness (30.0%). Normocytic normochromic anemia was the leading morphological pattern (43.0%), followed by microcytic hypochromic (30.5%) and macrocytic anemia (26.5%). Mild, moderate, and severe anemia accounted for 45.5%, 42.5%, and 12.0%, respectively. Anemia of chronic disease was the most frequent etiological category (43.0%), followed by iron deficiency (30.5%), vitamin B12 deficiency (13.5%), and folate deficiency (13.0%). Morphological type was strongly associated with severity (χ²=183.54, p<0.001), and all principal hematological and iron-profile measures differed across morphological groups (p<0.001). CONCLUSION: Adult anemia in this cohort was not dominated by a single mechanism. Normocytic anemia associated with chronic disease was most frequent, while iron deficiency and megaloblastic patterns together represented a substantial clinical burden. Morphology, automated red-cell indices, and iron studies were informative but not perfectly concordant, reinforcing the need for integrated interpretation and confirmatory evaluation when findings conflict.

Background: Selenium may improve glucose metabolism through antioxidant and insulin-sensitising effects. This study evaluated selenium supplementation as an adjunct to standard treatment for gestational diabetes mellitus (GDM). Methods: In this prospective comparative interventional study, 200 women with newly diagnosed GDM at 24–32 weeks’ gestation were assigned to standard treatment alone or standard treatment plus selenium-enriched yeast providing 200 µg elemental selenium daily for six weeks or until delivery. Primary outcomes were changes in fasting plasma glucose, postprandial plasma glucose and glycated haemoglobin (HbA1c). Results: Selenium supplementation produced greater reductions in fasting glucose, postprandial glucose and HbA1c than standard treatment alone. Baseline-adjusted mean differences were −4.4 mg/dL, −4.7 mg/dL and −0.09 percentage points, respectively (all p<0.001). Glycaemic targets were achieved more frequently with selenium (34.0% vs 14.0%), while insulin initiation was lower (23.9% vs 39.3%). Maternal and neonatal outcomes were comparable between groups. Adherence was high, and no selenium toxicity or serious adverse event occurred. Conclusion: Adjunctive selenium supplementation modestly improved glycaemic control and reduced insulin initiation in women with GDM without evident safety concerns. Larger randomized trials are required before routine use can be recommended.

Background: Cystic change in salivary gland lesions and cervical lymph nodes creates some of the most treacherous territory in head and neck cytology. Low-grade mucoepidermoid carcinoma may mimic a benign mucous cyst, cystic pleomorphic adenoma may be mistaken for a retention cyst, and cystic nodal metastasis of squamous cell carcinoma may resemble an infected keratinous or branchial cyst. Aims: To describe the cytomorphology of cystic salivary gland and lymph node lesions encountered in a prospective series of cystic head and neck masses and to analyse their diagnostic pitfalls. Materials and Methods: Among 90 palpable cystic head and neck lesions aspirated over two years (June 2018 to May 2020) at the Department of Pathology, J.J.M. Medical College, Davangere, 11 salivary gland cysts and three cystic lymph node lesions were identified. FNAC was performed with a 23-gauge needle; smears were stained with H&E, Papanicolaou and Giemsa stains. Salivary aspirates were categorised by the Milan System. Histopathological correlation was performed where specimens were available. Results: Salivary gland cysts formed 12.2% of all cystic lesions and comprised six benign lymphoepithelial cysts (Milan II), three pleomorphic adenomas with cystic change (Milan IV) and two low-grade mucoepidermoid carcinomas (Milan VI); cystic malignant change thus occurred in 18% of salivary lesions. All lymphoepithelial cysts occurred in males, without HIV association. The three cystic lymph node lesions comprised two metastatic squamous cell carcinomas, both in male chronic smokers, and one non-Hodgkin lymphoma in a 25-year-old man with mediastinal widening. Histopathological correlation, available in five cases, confirmed the cytological diagnosis in all.

Conclusion: FNAC distinguishes benign from malignant cystic lesions of the salivary glands and lymph nodes with high specificity, provided characteristic pitfalls are kept in mind: mucinous cystic salivary aspirates should raise low-grade mucoepidermoid carcinoma, atypia should be judged by nuclear rather than degenerative features, and unexplained cystic or necrotic lymph nodes should prompt exclusion of metastasis or lymphoma.

Background: Intra-articular hyaluronic acid (IA-HA) and platelet-rich plasma (IA-PRP) are established joint-preserving therapies for knee osteoarthritis (KOA), yet their comparative long-term effectiveness remains controversial.

Aim: To compare the clinical efficacy and safety of IA-HA and IA-PRP in patients with primary knee osteoarthritis. Methods: A ambispective (retrospective–prospective), parallel-group observational cohort study was conducted between November 2021 and May 2025. A total of 204 patients with Kellgren-Lawrence grade I–III knee osteoarthritis received either IA-HA (n=102) or leukocyte-poor IA-PRP (n=102). Clinical outcomes were assessed using WOMAC, Visual Analogue Scale (VAS), and IKDC scores over 12 months. Composite treatment failure and adverse events were also evaluated.

Results: Both groups demonstrated significant early improvement. From 3 months onward, IA-PRP produced significantly greater reductions in WOMAC and VAS scores and superior IKDC outcomes than IA-HA (p<0.001). At 12 months, composite treatment failure was significantly lower with IA-PRP (10.8%) than IA-HA (27.5%; p=0.002). Benefits were observed across all radiographic grades, particularly in Kellgren-Lawrence grades I–II. Both treatments were safe, with no serious adverse events.Conclusion: IA-PRP provided superior and more durable pain relief, functional improvement, and lower treatment failure than IA-HA while maintaining an excellent safety profile. These findings support leukocyte-poor PRP as the preferred biological injectable for patients with mild-to-moderate knee osteoarthritis and selected grade III disease.

Background: Arterial lactate is rapidly measurable in sepsis, but the prognostic value of serial concentrations relative to a single early measurement requires clarification. Objectives: To evaluate arterial lactate as a predictor of in-hospital mortality in patients with sepsis or septic shock presenting to the emergency department and to assess serial values and the recorded clearance index. Methods: This prospective observational study included 150 patients managed in a hospital over six months. Clinical variables, arterial lactate, total leukocyte count, and outcomes were recorded. Lactate was measured at baseline and at 24, 48, and 72 hours. Survivor and non-survivor values were compared, and receiver operating characteristic analysis assessed mortality discrimination. Results: Mean age was 46.60 ± 15.31 years, 65.3% were male, and in-hospital mortality was 40.0%. Mean lactate increased from 1.07 ± 0.32 mmol/L at baseline to 2.64 ± 1.91 mmol/L at 24 hours, declined to 2.39 ± 1.86 mmol/L at 48 hours, and reached 1.19 ± 0.67 mmol/L at 72 hours. Non-survivors had higher lactate than survivors at 24 hours (4.59 ± 1.20 versus 1.38 ± 1.00 mmol/L) and 48 hours (4.09 ± 1.63 versus 1.29 ± 0.95 mmol/L). The 24-hour area under the curve was 0.925; a 4.05 mmol/L cut-off provided 93.2% sensitivity and 95.6% specificity. The 48-hour area under the curve was 0.876. The signed clearance index showed poor discrimination. Conclusion: Arterial lactate at 24 and 48 hours identified mortality risk more accurately than baseline lactate or the recorded clearance index. Serial lactate assessment should complement haemodynamic and clinical reassessment in sepsis care.

Background: Age-related macular degeneration (AMD) is a leading cause of irreversible central vision loss in the elderly, primarily affecting the macula.

Objective: This review examines the pathophysiology of AMD, evaluates current treatment modalities, and highlights outcomes from ongoing management strategies.  Methods: Relevant clinical studies, epidemiological data, and randomized clinical trials were reviewed to assess disease mechanisms and the efficacy of available therapies.  Results: Oxidative stress, genetic susceptibility, and retinal pigment epithelium (RPE) dysfunction are central to AMD pathology. Anti-vascular endothelial growth factor (anti-VEGF) therapy significantly improves visual outcomes in neovascular (wet) AMD, whereas antioxidant supplementation offers limited benefit in dry AMD. Conclusion: AMD remains a significant public health concern. Anti-VEGF therapies have revolutionized the management of wet AMD, but preventive strategies and novel therapeutic approaches are essential to address the unmet needs in dry AMD.

Background: Type 2 diabetes mellitus (T2DM) is widely considered a lifelong, progressive condition. However, growing clinical evidence indicates that structured lifestyle interventions can restore normal blood sugar levels, reduce reliance on medications, and achieve true clinical remission. Objective: This study evaluates the clinical outcomes of an intensive, inpatient Low-Carbohydrate Healthy-Fat (LCHF) dietary intervention paired with supportive holistic therapies, based on the Disease Reversal Program (DIAREV) framework in Odisha. Methods: We examined a case series of 27 adult patients with T2DM who completed a supervised 5-day inpatient LCHF protocol. The program included comprehensive medical evaluations, personalized counselling, strict carbohydrate restriction (), supervised medication reduction, yoga, and breathwork, followed by structured post-discharge tracking. Statistical significance was determined using paired comparisons between baseline and post-intervention metrics. Results: Participants experienced profound metabolic improvements across all tracked markers. The average body weight dropped significantly by  (shifting from  to , ). Fasting blood sugar (FBS) levels fell by an average of  ( to , ), and postprandial blood sugar (PPBS) decreased by  ( to , ). Mean HbA1c levels fell by  ( down to , ). Overall, an  diabetes remission rate () was achieved, with  of the cohort reaching levels . Conclusion: A medically supervised LCHF inpatient protocol offers a safe, highly effective pathway for rapid glycemic recovery, safe medication de-escalation, and meaningful T2DM reversal.

Background: Chronic kidney disease (CKD) is a global burden and is now recognized as a major public health problem worldwide. Patients with CKD have alterations in thyroid hormone metabolism. This study aims to evaluate the status of thyroid hormone profile in different stages of CKD. Objectives of the study: To is to evaluate thyroid function abnormalities in patients with chronic kidney disease and correlate these changes  with the severity of renal impairment Materials and Methods : This was an observational case control study conducted in department of Medicine CMCRI , Chitradurga  for a duration of 12 months from June 2025 to June  2026. A total of 50 subjects were prospectively included in the study. Patients who fulfill the criteria for CRF and who were on conservative management were taken for the study. A thyroid profile was done in all patients who fulfill the criteria. Results : The mean T3 and T4 were decreased significantly with reduced creatinine clearance and later stages of CKD. Conclusion: The serum level of total T3 and free T4 is directly proportional to the creatinine clearance level. Total T3 and free T4 correlated with the severity of the renal failure. TSH values will be useful to differentiate hypothyroidism from non- thyroidal illness due to CKD.

Background: Varicocele is a major cause of infertility, affecting around 15% of males. Existing diagnostic tools are often insensitive to early parenchymal changes. Shear wave elastography (SWE) is a non-invasive method to measure tissue stiffness and evaluate testicular dysfunction.
Methods: We conducted a case-control study that included 50 patients with varicocele and 50 age-matched controls. Participants underwent scrotal ultrasound, SWE and semen analysis. Sarteschi classification was used to determine the varicocele grade. Testicular volume and stiffness were assessed and correlated with semen parameters and grade of varicocele.
Results: SWE was significantly stiffer in varicocele patients than in controls (left: 5.15 ± 0.67 vs. 3.06 ± 0.21 kPa/m/s; right: 3.67 ± 0.40 vs. 2.27 ± 0.20 kPa/m/s; p<0.001). Increased stiffness was associated with higher grades of varicocele (Grade II: 4.83 kPa/m/s; Grade IV: 6.4 kPa/m/s; p<0.001). An inverse correlation was found between left testicular stiffness and sperm concentration (r = -0.81; p<0.01), with 50% of cases showing oligospermia.
Conclusion: SWE shows a significant diagnostic potential in quantifying the increased testicular stiffness in patients with varicocele, which correlates strongly with higher grades and impaired semen quality.

Background: Intertrochanteric Fractures are one of the devastating injuries in elderly. These fractures are associated with complications like hypostatic pneumonia, catheter sepsis, deep vein thrombosis, cardio respiratory failure and decubitus ulcer. Urgent surgical treatment, early rehabilitation and mobilization of the patient is important for better prognosis of the patients. Proximal femoral nail (PFN) has the unique advantage of closed reduction, preservation of fracture hematoma, less tissue damage during surgery, early rehabilitation and early return to work. Method: Total number of 30 cases of intertrochanteric fractures were selected for this study at Department of Orthopaedics, R.K.Damani Medical College and Dr. Hedgewar Hospital, Chha.Sambhajinagar during the period of Jan. 2019 to Dec. 2021. Result: Total 30 patients were included in present study. Mean age of the patients was 70.30 ± 9.23 years. Female patients (57 %) were common than male patients (43 %).  History of fall (80 %) was most common mode of injury. According to Tranzo’s classification, Type 3 fractures (53 %) were most common, followed by type 2 fractures (33%). Assessment of hip function was done using modified Harris Hip scoring system. Good function was noted in 53% patients, excellent function in 27% followed by fair function in 13% patients and poor function in 7% patients respectively. One patient had implant related complication and one had limb shortening. There was no infection, mal-union, or non-union noted in our patients. Conclusion: It was found that PFN is stronger construct to withstand cyclical loading and unloading in trochanteric region. PFN was found to be better in high risk cases. PFN provides stable fixation, early mobilisation and good functional outcome.

Background: Type 2 diabetes mellitus (T2DM) is a multisystem disorder frequently associated with metabolic complications such as non-alcoholic fatty liver disease (NAFLD) and microalbuminuria. Both conditions are linked to insulin resistance and may reflect early hepatic and renal involvement. Objectives: To determine the prevalence of NAFLD in patients with T2DM and to assess its association with microalbuminuria. *A prospective observational study was conducted among 73 patients with T2DM at a tertiary care hospital from April 2024 to September 2025. NAFLD was diagnosed using ultrasonography, and microalbuminuria was assessed using the urine protein–creatinine ratio (UPCR). Biochemical parameters, including glycemic indices, lipid profile, and liver enzymes, were analyzed. Statistical significance was set at p < 0.05. Results: The prevalence of NAFLD was 67.12%, and microalbuminuria was present in 68.49% of participants. A statistically significant association was observed between NAFLD and microalbuminuria (p = 0.0173). NAFLD was more prevalent in patients with microalbuminuria (76.00%) than in those without (47.83%), corresponding to a 1.59-fold increased likelihood. Patients with NAFLD had significantly higher fasting and post-prandial blood glucose levels. Elevated SGPT levels suggested hepatocellular injury. LDL, triglycerides, and UPCR were higher in the NAFLD group, although absolute differences were modest. Coexistence of NAFLD and microalbuminuria was noted in 52.05% of participants, indicating a high-risk metabolic phenotype. Conclusion: NAFLD is highly prevalent among patients with T2DM and shows a significant association with microalbuminuria, suggesting early renal involvement. NAFLD should be regarded as a marker of systemic metabolic dysfunction. Early screening and integrated management targeting glycemic control, dyslipidemia, and renal parameters are essential to reduce disease progression and complications.

Background: Acute appendicitis is among the most frequent conditions causing acute abdominal pain that needs an immediate surgical intervention. Prompt and accurate diagnosis of the condition is very important for avoiding unneeded operations and complications of treatment delay. The Alvarado score is a very simple and popular clinical score system used to help diagnose acute appendicitis. At the same time, the accuracy of this score may vary in various population groups. The objective of the study was to assess the diagnostic accuracy of the Alvarado scoring system based on histological criteria. Methods A cross-sectional study design was used on 300 patients with a diagnosis of clinically suspected acute appendicitis by undergoing an appendectomy. Demographic data, clinical data, laboratory data, imaging data, intraoperative findings, and histopathologic diagnosis were obtained and analyzed through SPSS version 26 software. Comparison between continuous variables was done using independent samples t-test or Mann Whitney U-test while categorical variables were analyzed by Chi square test. Binary logistic regression was done for predictive ability of Alvarado score for histopathological diagnosis of acute appendicitis. Diagnostic accuracy was done by analyzing sensitivity, specificity, PPV, NPV, accuracy, and ROC curve analysis. Results: Of the total of 300 patients enrolled in this study, 191 patients (63.7%) had histopathologically proved acute appendicitis, while 109 patients (36.3%) were found to have no positive histopathological results. Migratory pain (P = 0.013), anorexia (P < 0.001), nausea and vomiting (P = 0.026), rebound tenderness (P < 0.001), and Alvarado risk category (P < 0.001) were significantly correlated with histopathologically proved acute appendicitis. However, there were no significant correlations for gender (P = 1.000), residence (P = 0.266), ultrasound results (P = 0.690), CT scan results (P = 0.648), type of surgery (P = 0.097), and intraoperative results (P = 0.751). Age was also not significantly different between histopathology positive and histopathology negative groups (independent-samples t-test: P = 0.967; Mann-Whitney U test: P = 0.944). The binary logistic regression revealed that the Alvarado score was significantly predicting histopathologically proved acute appendicitis (β = 1.585; OR = 4.88, 95% CI: 3.36-7.09; P < 0.001). With an Alvarado score cut-off value of ≥7, the score system attained a sensitivity of 83.77%, specificity of 100.0. Conclusion: Alvarado scoring was highly accurate in diagnosing acute appendicitis confirmed by histopathology. An Alvarado score of ≥7 was an excellent indicator of high specificity and positive predictive value in addition to sensitivity and accuracy. It was a good predictor of acute appendicitis independently and can be used in the evaluation of acute appendicitis.

Background: Acute appendicitis is among the most frequent conditions causing acute abdominal pain that needs an immediate surgical intervention. Prompt and accurate diagnosis of the condition is very important for avoiding unneeded operations and complications of treatment delay. The Alvarado score is a very simple and popular clinical score system used to help diagnose acute appendicitis. At the same time, the accuracy of this score may vary in various population groups. The objective of the study was to assess the diagnostic accuracy of the Alvarado scoring system based on histological criteria. Methods A cross-sectional study design was used on 300 patients with a diagnosis of clinically suspected acute appendicitis by undergoing an appendectomy. Demographic data, clinical data, laboratory data, imaging data, intraoperative findings, and histopathologic diagnosis were obtained and analyzed through SPSS version 26 software. Comparison between continuous variables was done using independent samples t-test or Mann Whitney U-test while categorical variables were analyzed by Chi square test. Binary logistic regression was done for predictive ability of Alvarado score for histopathological diagnosis of acute appendicitis. Diagnostic accuracy was done by analyzing sensitivity, specificity, PPV, NPV, accuracy, and ROC curve analysis. Results: Of the total of 300 patients enrolled in this study, 191 patients (63.7%) had histopathologically proved acute appendicitis, while 109 patients (36.3%) were found to have no positive histopathological results. Migratory pain (P = 0.013), anorexia (P < 0.001), nausea and vomiting (P = 0.026), rebound tenderness (P < 0.001), and Alvarado risk category (P < 0.001) were significantly correlated with histopathologically proved acute appendicitis. However, there were no significant correlations for gender (P = 1.000), residence (P = 0.266), ultrasound results (P = 0.690), CT scan results (P = 0.648), type of surgery (P = 0.097), and intraoperative results (P = 0.751). Age was also not significantly different between histopathology positive and histopathology negative groups (independent-samples t-test: P = 0.967; Mann-Whitney U test: P = 0.944). The binary logistic regression revealed that the Alvarado score was significantly predicting histopathologically proved acute appendicitis (β = 1.585; OR = 4.88, 95% CI: 3.36-7.09; P < 0.001). With an Alvarado score cut-off value of ≥7, the score system attained a sensitivity of 83.77%, specificity of 100.0. Conclusion: Alvarado scoring was highly accurate in diagnosing acute appendicitis confirmed by histopathology. An Alvarado score of ≥7 was an excellent indicator of high specificity and positive predictive value in addition to sensitivity and accuracy. It was a good predictor of acute appendicitis independently and can be used in the evaluation of acute appendicitis.

Introduction: Sleep disturbances and zinc deficiency are prevalent yet underrecognised clinical concerns in the geriatric population. Serum zinc, as an essential trace element involved in neurotransmission and neuroendocrine regulation, may have a significant role in sleep and mental health, though evidence specifically addressing older adults remains limited. Aim: To evaluate the associations between serum zinc levels, sleep quality, insomnia severity, and mental health outcomes in geriatric patients attending a tertiary care centre. Materials and Methods: This cross-sectional observational study was conducted at . Forty geriatric patients aged ≥60 years were enrolled. Serum zinc was measured by atomic absorption spectrophotometry and classified as low (<70 µg/dL), normal (70–120 µg/dL), or high (>120 µg/dL). Sleep quality, insomnia severity, depressive symptoms, and anxiety were assessed using the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Geriatric Depression Scale-15 (GDS-15), and Generalised Anxiety Disorder-7 (GAD-7). Statistical analyses were performed using SPSS version 28.0 (IBM Corp., Armonk, NY, USA). Pearson correlation and independent samples t-tests were applied; a p-value <0.05 was considered statistically significant. Results: The mean age was 72.3 ± 6.1 years; 55% were female. Low serum zinc was identified in 40% of participants. Poor sleep quality (PSQI >5) was present in 80%, moderate-to-severe insomnia (ISI ≥15) in 35%, and depressive symptoms (GDS-15 ≥5) in 45%. Serum zinc showed statistically significant negative correlations of moderate strength with PSQI (r = −0.45, p = 0.004) and ISI (r = −0.39, p = 0.010), and a weak but statistically significant negative correlation with GDS-15 (r = −0.31, p = 0.049). Participants with low serum zinc had significantly poorer sleep quality (PSQI: 11.2 ± 2.8 vs 9.0 ± 2.9, p = 0.010) and higher depressive scores (GDS-15: 6.2 ± 2.5 vs 4.6 ± 2.3, p = 0.020) compared to those with non-low zinc.

Conclusion: Zinc deficiency was prevalent in 40% of geriatric participants and was significantly associated with impaired sleep quality, greater insomnia severity, and higher depressive scores. Routine zinc assessment and targeted nutritional optimisation may represent a modifiable approach to improving sleep and mental health in older adults.

Introduction: Intrinsic capacity (IC), comprising cognition, psychological health, vitality, sensory function (vision, hearing), and locomotion, represents the functional reserve essential for healthy aging. Despite its relevance, limited data exist on IC among older adults with cancer. This study aimed to evaluate the proportion of impaired IC and its associated factors in geriatric oncology patients at a tertiary care center in eastern India. Methods: This hospital-based cross-sectional study was conducted from February 2024 to January 2025. A total of 231 cancer patients aged 60 years and above were selected. IC domains were assessed as follows: cognition (Mini-Mental State Examination score less than 24), psychological health (Geriatric Depression Scale-15 score of 5 or more), vitality (Mini Nutritional Assessment-Short Form), locomotion (Timed Up and Go test over 13 seconds), vision (screening question), and hearing (whisper test). Comorbidities were evaluated using the Charlson Comorbidity Index, and fall risk was assessed with the Morse Fall Risk Scale. Associations were analyzed using chi-square tests, t-tests, and Pearson correlation coefficients, with significance set at p < 0.05. Results: The mean age was 64 years, with 63.6% of participants being male. Impairment in at least one IC domain was present in 95.2% of patients. The most frequently affected domains were psychological health (78.8%), locomotion (51.1%), cognition (43.7%), and nutrition (83.1% were either malnourished or at risk). Multiple domain impairments were common, with 56.3% affected in three or more areas. Age, female sex, lower education, sleep disturbance, and certain comorbidities were significantly associated with IC deficits. Higher body mass index was linked to better cognition and lower depression scores. Conclusion: IC impairment is highly prevalent in older cancer patients, often involving multiple domains. Integrating IC assessment into routine geriatric oncology care can support targeted interventions that preserve functional capacity and improve quality of life.

Background: Vitamin D exerts effects on airway smooth muscle, innate antimicrobial defence and the glucocorticoid response, all of which are biologically plausible routes by which deficiency could worsen asthma. Objectives: To determine the prevalence of vitamin D deficiency among adults with physician-diagnosed asthma, and to examine its association with the level of asthma control, the frequency of exacerbations in the preceding twelve months, and spirometric function. Methods: A cross-sectional study was conducted in the Department of Biochemistry and Respiratory Medicine. One hundred and twenty adults aged 18–65 years with asthma diagnosed per Global Initiative for Asthma (GINA) criteria and on stable therapy for at least three months were enrolled. Serum 25(OH)D was measured by chemiluminescent immunoassay and classified as deficient (<20 ng/mL), insufficient (20–29 ng/mL) or sufficient (≥30 ng/mL). Asthma control was assessed by the Asthma Control Test (ACT), exacerbations in the previous year were ascertained from records and structured recall, and post-bronchodilator FEV₁ was recorded. Groups were compared by one-way ANOVA, Kruskal–Wallis and chi-square tests; associations were quantified by Pearson and Spearman correlation and by multiple linear regression adjusted for age, sex and body mass index. Results: Mean serum 25(OH)D was 20.08 ± 8.36 ng/mL. Sixty-four patients (53.3%) were deficient, 44 (36.7%) insufficient and only 12 (10.0%) sufficient. Serum 25(OH)D correlated positively with ACT score (r = 0.360, 95% CI 0.193–0.507; p < 0.001) and post-bronchodilator FEV₁ (r = 0.364; p < 0.001), and inversely with exacerbation count (r = −0.318, 95% CI −0.471 to −0.148; p < 0.001). Mean exacerbations fell across vitamin D strata from 1.92 ± 1.29 in deficient patients to 0.83 ± 1.03 in sufficient patients (Kruskal–Wallis H = 7.96; p = 0.019). In multivariable regression, each 1 ng/mL rise in 25(OH)D was associated with a 0.162-point increase in ACT score (95% CI 0.089–0.235; p < 0.001) independent of age, sex and BMI.  Conclusion: Vitamin D deficiency was highly prevalent in this asthma cohort, and serum 25(OH)D showed consistent, independent associations with asthma control, exacerbation frequency and lung function when analysed as a continuous variable. These associations attenuated when vitamin D status and outcomes were dichotomised, indicating that categorical cut-offs discard clinically meaningful information. The cross-sectional design precludes causal inference, and randomised supplementation data remain the appropriate basis for treatment decisions.

Introduction: Asthma and chronic obstructive pulmonary disease (COPD) are common conditions among general population. The prevalence of asthma is 1% to 18% whereas COPD affects 6% of adult population. pressurized Metered dose inhalers[PMDI] are the most commonly used routes of drug administration in these patients .The proper technique of using the PMDI is vital for treatment. Its observed from different studies thst most patients use the technique wrong at multiple steps This study is done to evaluate the wrong techniques in using Pmdi seen in patients and correct it. Methodology: patients were asked to show their technique of using PMDI. WHO checklist was used to assess the technique.Any error at each step was noted. The data was analysed to see the percentage of participants doing it wrong. Afterwards patients were notified their error and correct technique was demonstrated. Results: 93% patients in our study group did error while using PMDI. Maximum error was done on steps involving  holding the breathe after pressing the canister, inhaling while at same time  pressing canister and noting /adjusting dose (step-8 ,2,9). Conclusion: study shows that there is significant number of patients use the PMDI by erong technique.

Introduction: Aim: To study the pattern and frequency of dermatoses in patients aged 60 years and above, to describe the clinical pattern of various dermatological disorders in the elderly, and to determine the prevalence of skin diseases and their association with underlying systemic disorders. Methods: A hospital-based cross-sectional observational study was conducted among 300 consecutive patients aged ≥60 years attending the Dermatology Outpatient Department of a tertiary care teaching hospital. Detailed demographic data, clinical history, dermatological examination, physiological skin changes, and systemic comorbidities were recorded. Relevant laboratory investigations were performed whenever indicated. Data were analyzed using descriptive statistics and the Chi-square test, with p<0.05 considered statistically significant. Results: The majority of patients belonged to the 60–69 years age group (57.7%), with males constituting 60.7% of the study population. Itching was the most common presenting complaint (72.3%). Plaques (46.7%) were the predominant morphological lesion, while wrinkling (23.7%) and xerosis (20.7%) were the most frequent physiological skin changes. Fungal infections (22.7%) were the most common dermatological disorder, followed by eczematous disorders (12.7%), generalized pruritus (11.3%), and papulosquamous disorders (9.0%). Tinea cruris et corporis was the commonest fungal infection, asteatotic eczema was the predominant eczematous disorder, and herpes zoster was the most frequent viral infection. Hypertension (23.3%) and type 2 diabetes mellitus (21.7%) were the most prevalent systemic comorbidities. Generalized pruritus showed notable associations with diabetes mellitus and chronic kidney disease. No statistically significant association was observed between dermatological disorders and age group (p=0.553) or gender (p=0.516). Conclusion: Dermatological disorders are highly prevalent among the elderly, with fungal infections, eczematous disorders, and generalized pruritus being the most common conditions. Physiological skin changes and systemic comorbidities contribute substantially to disease burden. Comprehensive dermatological evaluation, regular screening for systemic illnesses, and integrated multidisciplinary management are essential for early diagnosis, appropriate treatment, and improved quality of life in the geriatric population.

Background: Acute pancreatitis (AP) in parts of India presents at a considerably younger age and with a far greater male preponderance than in Western series, a pattern attributed largely to alcohol-associated disease. Whether bedside clinical scoring tracks radiological severity in such demographically atypical cohorts has received little attention. Access to contrast-enhanced computed tomography (CECT) in district and rural hospitals is also limited, making the strength of the clinical–radiological relationship a question of practical consequence. Objectives: To describe the demographic and clinico-radiological profile of AP at a government tertiary centre in north Karnataka, and to quantify the relationship between the Bedside Index for Severity in Acute Pancreatitis (BISAP) and the modified CT severity index (mCTSI) as continuous and stratified measures. Methods: Fifty consecutive adults with AP admitted between June 2022 and December 2023 were enrolled prospectively. BISAP was calculated within 24 hours of admission and mCTSI from CECT of the abdomen and pelvis performed on days 3–7. Relationships were examined by Pearson and Spearman correlation, simple linear regression, and one-way analysis of variance of mCTSI across BISAP strata with test for linear trend. Results: Mean age was 33.82 ± 8.03 years (range 16–50) and 49 of 50 patients (98.0%) were male; no patient was above 60 years. Mean BISAP was 1.38 ± 0.97 and mean mCTSI 5.60 ± 1.85. Radiological severity was mild in 2 patients (4.0%), moderate in 39 (78.0%) and severe in 9 (18.0%). BISAP correlated significantly with mCTSI (Pearson r = 0.657, p < 0.001; Spearman ρ = 0.692, p < 0.001), explaining 43.1% of the variance. Regression yielded mCTSI = 3.86 + 1.26 × BISAP (95% CI for slope 0.84–1.68, p < 0.001). Mean mCTSI rose monotonically across BISAP strata from 3.60 ± 0.84 at BISAP 0 to 8.00 ± 1.41 at BISAP ≥ 3 (ANOVA F(3,46) = 11.95, p < 0.001; test for linear trend p < 0.001). Conclusions: In a young, overwhelmingly male AP cohort, BISAP showed a robust graded dose–response relationship with radiological severity, with each additional BISAP point corresponding to approximately 1.26 points of mCTSI. No patient met the age criterion of BISAP, compressing the usable score range and suggesting that locally recalibrated thresholds are needed. Bedside scoring offers a defensible interim severity estimate where CECT is delayed or unavailable.

Background: Thyroid cancer is most common endocrine malignancy and there is high incidence of thyroid nodule detection in ultrasonography in general population. Determination of the thyroid nodule as benign or malignant depends upon certain characteristic features like calcifications, vascularity, echogenicity of the nodule etc. Calcification within the thyroid gland occur in both benign and malignant thyroid disease. Calcification patterns within thyroid nodules, particularly microcalcifications, are considered important predictors of malignancy and are incorporated into various thyroid risk stratification systems. Objective: To evaluate the association of different ultrasonographic calcification patterns in thyroid nodules with thyroid malignancy. Materials and Methods: This Prospective observational study was conducted in the Department of Radiodiagnosis, Kidwai Memorial Institute of Oncology, Bengaluru, over the study period of 2 years (December 2020-December 2022). A total of 100 patients with thyroid nodules underwent ultrasonography followed by cytological or histopathological confirmation were included. Calcification patterns were classified as microcalcification, macrocalcification, peripheral rim calcification, and comet-tail artefacts. The sonographic findings were correlated with the final pathological diagnosis. Statistical analysis was performed to determine the association between calcification patterns and malignancy. Results: The study included 100 patients aged 12-75 years (mean age: 50.16 years). Of these, 79 were females and 21 were males. 53 nodules were benign and 47 were malignant. Microcalcifications were observed in 26 malignant nodules and only 6 benign nodules, demonstrating a significant association with malignancy. Macrocalcifications were identified in 7 nodules, including 4  benign and 3 malignant lesions. Peripheral rim calcification was observed in 2 malignant nodules, both of which also demonstrated microcalcifications. Comet-tail artefacts were predominantly associated with benign colloid nodules. Conclusion: Microcalcifications are a significant ultrasonographic predictor of thyroid malignancy, particularly papillary thyroid carcinoma. Accurate differentiation between microcalcifications, macrocalcifications, and comet-tail artefacts improves risk stratification and facilitates appropriate patient management.

Objective: To determine the correlation between body mass index and FSH and LH ratio in polycystic ovarian syndrome women. Study Design: Cross sectional study. Duration and Place of Study: Conducted from 15 November 2025 to 15 February 2026 at Department of Obstetrics and Gynaecology, PAF Hospital Sargodha. Methodology: A total of 80 women of age 18 to 40 years with polycystic ovarian syndrome were included. Body mass index was determined using the standard formula of body weight in kilograms divided by the square of height in meters. Venous blood specimens were collected to quantify serum follicle-stimulating hormone and luteinizing hormone concentrations after which the LH/FSH ratio was computed. Statistical evaluation of the collected data was performed using the SPSS version 26. Pearson correlation test was applied to assess association between body mass index and hormone ratio. Results: Mean age was 27.22 ± 5.75 years and mean body mass index was 27.30 ± 2.63 kg/m². Mean hormone ratio was 2.67 ± 0.28. Married women were 83.8%. A statistically significant positive association was observed between body mass index and the hormone ratio (r = 0.311, p = 0.005). Strongest correlation was seen in women with disease duration ≤ 24 months (r = 0.400, p = 0.005). Conclusion: Body mass index was positively associated with follicle stimulating hormone to luteinizing hormone ratio in polycystic ovarian syndrome women.

Background:  Hepatic encephalopathy (HE) marks a decisive turning point in the natural history of cirrhosis, converting compensated disease into a decompensated state with substantially reduced survival. Although the syndrome is in principle reversible once the precipitating event has been corrected, in-hospital mortality remains high. Whether outcome differs systematically according to which factor precipitated the episode, and how prognostic scores such as the Child–Pugh, MELD and MELD-Na indices perform in this setting, are questions of direct clinical relevance to triage and resource allocation in resource-limited hospitals. Objectives: To determine in-hospital mortality among cirrhotic patients admitted with hepatic encephalopathy stratified by precipitating factor, to describe the severity of underlying liver dysfunction using the Child–Pugh, MELD and MELD-Na scores, and to compare the mean duration of hospital stay associated with each major precipitant. Materials and Methods: A prospective, descriptive, hospital-based observational study was conducted in the Department of General Medicine, Ballari Medical College and Research Centre (formerly Vijayanagar Institute of Medical Sciences), Ballari, Karnataka. Eighty-five consecutive patients above 12 years of age with established cirrhosis presenting with hepatic encephalopathy of any grade were enrolled after Institutional Ethics Committee clearance and written informed consent. Patients with psychiatric illness, altered sensorium due to metabolic disease or head injury, acute alcohol intoxication or alcohol withdrawal were excluded. Sample size was estimated with nMaster v2.0. All patients underwent complete blood count, liver and renal function tests, serum electrolytes, coagulation profile, ascitic fluid analysis and abdominal ultrasonography. Child–Pugh, MELD and MELD-Na scores were computed for every patient, and in-hospital mortality and length of stay were recorded prospectively. Analysis was performed in IBM SPSS Statistics v23.0 using frequency and percentage analysis, with the chi-square or Fisher's exact test at a 5% significance level. Results: Overall in-hospital mortality was 29 of 85 (34.1%). Case fatality varied widely by precipitant: pneumonia 3 of 5 (60.0%), gastrointestinal bleeding 18 of 33 (54.5%), constipation 5 of 19 (26.3%), electrolyte imbalance 2 of 9 (22.2%) and spontaneous bacterial peritonitis 1 of 10 (10.0%); no deaths occurred among the 6 patients with iatrogenic or procedure-related precipitants. Gastrointestinal bleeding alone accounted for 18 of the 29 deaths (62.1%). Mean Child–Pugh score was 10.29, mean MELD score 24.06 and mean MELD-Na score 25.38, indicating advanced Child class C disease with high predicted short-term mortality. Mean length of stay was longest for constipation at 10.57 days, followed by infection (9.95), gastrointestinal bleeding (9.89) and electrolyte imbalance (9.71 days). Conclusion: One in three patients admitted with hepatic encephalopathy died in hospital. Gastrointestinal bleeding and pneumonia were the precipitants associated with the highest case fatality and together dominated mortality, whereas procedure-related and metabolic triggers were largely survivable. High mean Child–Pugh, MELD and MELD-Na scores confirm that these patients present with severely decompensated liver disease. Prompt endoscopic control of variceal haemorrhage and aggressive management of pneumonia offer the greatest scope for improving survival.