Opalski syndrome, a rare variant of wallenberg syndrome, the first case reported from Pakistan: A case report.

Background: Wallenberg syndrome, also known as a lateral medullary syndrome, is a rare neurological condition caused by an infarction in the brainstem's lateral medulla. There are subtypes of Wallenberg syndrome with distinctive and atypical symptoms, such as Opalski syndrome. Case presentation: A 41-year-old hypertensive male arrived at the emergency department with abrupt onset of right-sided bodily weakness, vertigo, facial numbness, dysphagia, hoarseness of voice, and double vision. The neurological examination indicated right hemiparesis, right facial numbness, crossed sensory deficit, right limb ataxia, right uvulopalatal deviation, and vertical double vision. An MRI showed a lateral medullary infarct leading to the suspicion of the atypical lateral medullary syndrome. The patient was treated with physiotherapy and daily oral medications including aspirin, clopidogrel, atorvastatin, and Cap Risek. On follow-up 14 days later, the patient's condition had significantly improved. Conclusion: This case study demonstrates the significance of recognizing atypical variants of Wallenberg syndrome, such as Opalski syndrome, in order to provide a correct diagnosis and the most effective treatment. Our patient's condition improved as a result of the therapy measures used, however, people with Opalski syndrome may have a poor prognosis and require continuous monitoring.

Brait-Fahn-Schwartz Disease: A Unique Co-Occurrence of Parkinson's Disease and Amyotrophic Lateral Sclerosis.

The Parkinson's disease-amyotrophic lateral sclerosis (ALS) complex typically manifests as levodopa-responsive parkinsonism, followed by ALS. It is extremely rare for Parkinson's disease and ALS to coexist without other neurological disorders. Named after the scientists who first described this overlap of two neurodegenerative conditions, it is referred to as Brait-Fahn-Schwartz disease. Given its variable presentation, increasing rarity, and lack of any diagnostic test, it poses a diagnostic challenge for physicians. We present a case of a 55-year-old Pakistani male experiencing progressive quadriparesis with spastic lower limbs and flaccid upper limbs, in addition to the cardinal features of idiopathic Parkinson's disease. Since there is currently no cure available for either Parkinson's disease or ALS, all available treatment focuses on improving quality of life, which we achieved in our patient. This case is unique in being the first incidence of Parkinson's disease-ALS complex in a novel geographic region such as Pakistan, where genetic testing and cost constraints limit the diagnosis of rare disorders. The coexistence of extrapyramidal symptoms and pyramidal symptoms is uncommon. In such situations, physicians may overlook one group of symptoms, potentially leading to a misdiagnosis. This case highlights the value of a thorough physical examination and electrodiagnostic studies and suggests the association between Parkinson's disease and ALS. This case demonstrates the significance of understanding when Parkinson's disease symptoms start to appear in patients with ALS and the need to start dopaminergic therapy in those who had Parkinson's disease features before ALS to alleviate the suffering of an individual and enhance quality of life.

Assessment of health-related quality of life among patients with obesity, hypertension and type 2 diabetes mellitus and its relationship with multimorbidity.

Obesity, hypertension (HTN) and type 2 diabetes (T2D) are among the multifactorial disorders that occur at higher prevalence in a population. This study aims to assess the health-related quality of life (HRQoL) of patients with obesity, HTN and T2D individually and in the form of multimorbidity. A questionnaire-based cross-sectional study was conducted among the patients in 15 private clinics of Punjab, Pakistan. A stratified random sampling technique was used to collect the data from patients with obesity, HTN and T2D or their comorbidity. A total of 1350 patients responded by completing the questionnaire. The HRQoL of these patients was assessed using the EQ-5D-5L questionnaire (a standardized instrument for measuring generic health status). Statistical analysis was performed using chi-square test, Mann-Whitney U test, and Kruskal-Wallis test. Multivariate linear regression model was used to model the visual analogue scale (VAS) score. In total, 15% of patients had combined obesity, HTN and T2D; 16.5% had HTN and T2D; 13.5% had obesity and HTN and 12.8% had obesity and T2D. Only 15.8% of patients had obesity, 14.3% had HTN, and 12% had T2D. Mann Whitney-U test gave the statistically significant (p = <0.001) HRQoL VAS score55.1 (±23.2) of patients with the obesity. HRQoL VAS scores of patients with obesity were found to be higher when compared to patients with both T2D 49.8 (±15.4) and HTN 48.2 (±21). Diagnosis of one, two and three diseases showed significant results in VAS with all variables including gender (p = 0.004), educational level (p = <0.001), marital status (p<0.001), residence (p = <0.001), financial situation (p = <0.001) and monthly income (p = <0.001). The most frequently observed extremely problematic dimension was anxiety/ depression (47%) and the self-care (10%) was the least affected. Patient HRQoL is decreased by T2D, HTN, and obesity. The impact of these diseases coexisting is more detrimental to HRQoL.

Neuropathy following intramuscular injections: a clinical and neurophysiological study from a tertiary care centre in Pakistan.

OBJECTIVE: To assess the clinical and neurophysiological profile of peripheral nerve injuries in patients following intramuscular injections. METHODS: The descriptive, cross-sectional study was conducted at the Department of Neurology, Mayo Hospital, Lahore, Pakistan, from July 2019 to January 2021, and comprised adult patients of either gender with isolated peripheral nerve injuries following intramuscular injections. Nerve conduction studies were performed for each patient. Data was analysed using SPSS 26. RESULTS: Of the 99 patients, 59(59.6%) were males and 40(40.4%) were females. The mean age was 26.7+/-18.1 years, 34(34.3%) patients were under weight and 78(78.8%) were either illiterate or had low literacy level. Radial nerve was involved in 56(56.6%) cases, followed by sciatic in 39(39.4%) and axillary nerve 4(4.04%). Overall, 14(14.14%) injection had been administered by doctors, while the other 85(85.85%) were given by paramadics. Marked reduction in compound muscle action potential 72(72.7%) and sensory nerve action potential 82(82.8%) was noted, while re-innervation was seen in 78(78.7%). CONCLUSIONS: Intramuscular nerve injuries can be greatly minimised by spreading awareness regarding safe injection techniques and strict implementation of standard operating procedures in hospitals and clinics.

Inbreeding-Driven Innate Behavioral Changes in Drosophila melanogaster.

Drosophila melanogaster has long been used to demonstrate the effect of inbreeding, particularly in relation to reproductive fitness and stress tolerance. In comparison, less attention has been given to exploring the influence of inbreeding on the innate behavior of D. melanogaster. In this study, multiple replicates of six different types of crosses were set in pair conformation of the laboratory-maintained wild-type D. melanogaster. This resulted in progeny with six different levels of inbreeding coefficients. Larvae and adult flies of varied inbreeding coefficients were subjected to different behavioral assays. In addition to the expected inbreeding depression in the-egg to-adult viability, noticeable aberrations were observed in the crawling and phototaxis behaviors of larvae. Negative geotactic behavior as well as positive phototactic behavior of the flies were also found to be adversely affected with increasing levels of inbreeding. Interestingly, positively phototactic inbred flies demonstrated improved learning compared to outbred flies, potentially the consequence of purging. Flies with higher levels of inbreeding exhibited a delay in the manifestation of aggression and courtship. In summary, our findings demonstrate that inbreeding influences the innate behaviors in D. melanogaster, which in turn may affect the overall biological fitness of the flies.

Fahr's syndrome as a manifestation of autoimmune polyendocrine syndrome-1 and its unusual association with neuromyelitis optica spectrum disorder.

Fahr's syndrome, also known as bilateral striopallidodendate calcinosis, is a rare inherited neurodegenerative illness characterized by abnormal calcium deposition in several areas of the brain, resulting in a wide range of neuropsychological symptoms. Fahr's syndrome, secondary to autoimmune polyendocrine syndrome type 1, which includes adrenal insufficiency and mucocutaneous candidiasis in addition to hypoparathyroidism, is exceedingly rare. No case report has been documented to date to show the co-occurrence of Fahr's syndrome and neuromyelitis optica spectrum disorder. Here, we discuss the case of a 30-year-old man with a previous history of seizures and symptoms of ectodermal dystrophy presented with seizures, left-sided hemiparesis, dysarthria, and other characteristics indicative of severe hypocalcemia. The neuroimaging findings strongly suggested Fahr's syndrome, with radiographic evidence of Neuromyelitis optica spectrum disorder as longitudinal extensive transverse myelitis in the cervical spinal cord, high titers of serum aquaporin-4 antibodies, and demyelinating neuropathy on nerve conduction studies. This distinct neuropsychological presentation and neuroimaging findings led to the diagnosis of Fahr's syndrome as a result of hypoparathyroidism caused by autoimmune polyendocrine syndrome type 1 with cooccurrence of neuromyelitis optica spectrum disorder. The patient's clinical symptoms improved considerably after he was treated based on a provisional diagnosis. The clinical importance of our case is significant for both neuropsychiatrists and endocrinologists, as autoimmune polyendocrine syndrome should be considered as the etiology of Fahr's syndrome. This case report also aims to report this unusual association of Neuromyelitis optica spectrum disorder with Fahr's syndrome to give the future prospective to know whether this association is incidental or there is a missing link between these two different disorders.

The Analysis of Facio-Dental Proportions to Determine the Width of Maxillary Anterior Teeth: A Clinical Study.

The present study aimed to analyze mid horizontal facial third proportions, those being the interpupillary, inner intercanthal, and bizygomatic distance modified with golden proportion, The Preston proportion, golden percentage and 70% recurring esthetic dental proportion were used for determining maxillary anterior teeth width. A total of 230 participants took part in this study. The front dental and facial photographs along dental stone cast which were converted to three-dimensional (3D) models were used for evaluation. The mid horizontal facial third proportions showed no significant relationship with maxillary anterior teeth width without modification with dental proportions. Whereas, with modification, no statistically significant difference was found between inner-intercanthal distance by golden percentage and width of central incisors. The bizygomatic distance was greater than intercanine distance. While the interpupillary distance by golden proportion was found to be consistent with intercanine distance in female participants. The modified anterior teeth width was significantly different from measured values, when determined by using the three mid facial proportions with Preston and 70% recurring esthetic dental (RED) proportion. Furthermore, the measured width of maxillary anterior teeth showed no difference when plaster dental casts widths were compared with 3D models. The interpupillary, inner-intercanthal, and bizygomatic distance should not be directly used to determine maxillary anterior teeth width. While maxillary anterior teeth width can be determined by modifying the inner inter-canthal distance with golden percentage and interpupillary distance with golden proportion. Moreover, the midfacial third proportions modified with Preston and 70% recurrent esthetic dental proportion were found to be unreliable for the determination of maxillary anterior teeth widths.

Etiology and risk factors of stroke in young adults: A multicentric study.

Objective: The main objective of this research was to assess the risk factors and causes of ischemic stroke in the young population (age less than 50 years). Methods: This was a prospective multicenter study conducted at Pakistan Atomic Energy Commission General Hospital, Islamabad, and Mayo hospital Lahore from June 2019 to June 2020. In this research, patients with ischemic stroke, aged 15-50 years were included. Prior to noting demographics, each patient gave ethical approval via filling out consent forms. After that, all demographical details including residence, education, gender and age, and socioeconomic status were noted. Risk factors were evaluated on the questionnaire proforma. Outcomes were measured using the modified Rankin scale (MRS) score. Additionally, data were analyzed by using SPSS V26. A P-value of <0.05 was set as statistically significant. Results: Out of 80 patients, 53 (66.25%) were male, while 27 (33.75%) were female. Six (7.5%) patients were between the ages of 15 and 25 years, 18 (22.5%) patients were between 26 and 35 years, 48 (60%) patients were between the ages of 36 and 45, and eight (10%) patients were between the ages of 46 and 50. According to this research, hypertension was found to be the most frequently occurring risk factor in 28 participants (35%), Diabetes mellitus in 23 patients (28.75%), dyslipidemia in 20 patients (22.5%), and smoking in 18 patients (22.5%). The etiology remained undetermined in 30 patients (37.5%). Most of the patients (87.5%) reported positive functional outcomes (MRS score 0-2). However, 3 (3.75%) patients died during the study period. Conclusion: This research showed that common risk factors of ischemic stroke in the local young population included hypertension, diabetes mellitus, and smoking, whereas the etiology of stroke remained unidentified in the majority of patients.

Relationship between muscular impairment and psychological health with lower extremity functions in patients with transtibial amputation.

OBJECTIVE: To determine the relationship of muscular impairment and psychological health with lower extremity functions in patients with transtibial amputation. METHODS: The correlational study was conducted from March to September 2021 at the Fauji Foundation Hospital, Rawalpindi, Pakistan, and comprised male patients with transtibial amputation. Data was collected using the depression anxiety stress scale and the lower extremity functional scale. The correlation of muscular impairment and psychological health with lower extremity functions was determined. Data was analysed using SPSS 21. RESULTS: There were 85 male patients with a mean age of 53.74±11.30 years. There was weak iliopsoas muscle strength 4.64±0.50 and reduced muscle length of hamstrings 67.00±6.41 on the affected side. There was non-significant correlation in muscle atrophy of both amputated limb (p=0.82) and non-amputated limb (p=0.58) with lower extremity function. Significant inverse correlation was present between depression, anxiety and stress (p=0.001) with lower extremity function. CONCLUSIONS: Weak iliopsoas muscle strength and tight hamstrings were observed on the amputated side. Muscle atrophy was more in non-amputated limb than amputated limb. There was significant inverse correlation of depression, anxiety and stress with lower extremity function.

Design and Immunoinformatic Assessment of Candidate Multivariant mRNA Vaccine Construct against Immune Escape Variants of SARS-CoV-2.

To effectively counter the evolving threat of SARS-CoV-2 variants, modifications and/or redesigning of mRNA vaccine construct are essentially required. Herein, the design and immunoinformatic assessment of a candidate novel mRNA vaccine construct, DOW-21, are discussed. Briefly, immunologically important domains, N-terminal domain (NTD) and receptor binding domain (RBD), of the spike protein of SARS-CoV-2 variants of concern (VOCs) and variants of interest (VOIs) were assessed for sequence, structure, and epitope variations. Based on the assessment, a novel hypothetical NTD (h-NTD) and RBD (h-RBD) were designed to hold all overlapping immune escape variations. The construct sequence was then developed, where h-NTD and h-RBD were intervened by 10-mer gly-ala repeat and the terminals were flanked by regulatory sequences for better intracellular transportation and expression of the coding regions. The protein encoded by the construct holds structural attributes (RMSD NTD: 0.42 Å; RMSD RBD: 0.15 Å) found in the respective domains of SARS-CoV-2 immune escape variants. In addition, it provides coverage to the immunogenic sites of the respective domains found in SARS-CoV-2 variants. Later, the nucleotide sequence of the construct was optimized for GC ratio (56%) and microRNA binding sites to ensure smooth translation. Post-injection antibody titer was also predicted (~12000 AU) to be robust. In summary, the construct proposed in this study could potentially provide broad spectrum coverage in relation to SARS-CoV-2 immune escape variants.

Rarest of the rare: a case of pharyngeal-cervical-brachial variant of Guillain-Barré syndrome presenting with a demyelinating neuropathy.

BACKGROUND: Guillain-Barré syndrome (GBS) is a heterogeneous disease characterized by rapidly progressive, symmetrical limb weakness with hyporeflexia or areflexia. The rare pharyngeal-cervical-brachial (PCB) variant of GBS occurs in 3% of patients, presenting as rapidly progressive oropharyngeal and cervicobrachial weakness characterised by axonal, rather than a demyelinating neuropathy on nerve conduction studies. CASE DESCRIPTION: A 35 year old male presented with a 5-day history of dysphagia, dysarthria, slurred speech and upper limb weakness. Physical examination showed bilateral facial nerve weakness and an impaired gag reflex. Nerve conduction study was suggestive of sensory and motor polyneuropathy of predominantly demyelinating variety. As the condition of the patient worsened, respiratory support was required and plasmapharesis was started. There was significant improvement in his condition after completion of 5 sessions of plasmapharesis. CONCLUSION: The rare PCB variant may present with a predominantly demyelinating neuropathy. Early clinical recognition of this variant and prompt treatment with plasmapharesis is essential for preventing respiratory complications.

Pleomorphic Adenoma of Minor Salivary Gland.

Pleomorphic adenoma is a benign tumor of salivary glands, arising from minor salivary glands, is very rare and presents with a minor female predilection; and the highest occurrence is between the fourth and sixth decades of life. It is of glandular origin, usually presenting as a slowly growing, painless, firm swelling that does not cause ulceration of the overlying mucosa. In this case, a 27-year male presented with swelling on buccal mucosa for three years. The swelling was firm and well circumscribed. Excisional biopsy was done under general anesthesia and the mass was excised. The histopathological evaluation revealed pleomorphic adenoma. This case highlights the need to keep this entity in the differential diagnosis of intra-oral indolent swellings of some duration. Key Words: Pleomorphic adenoma, Buccal mucosa, Minor salivary glands.

Postpartum superior sagittal, left transverse sinus and right internal jugular vein thrombosis with left parietal infarct: A case report.

Cerebral venous sinus thrombosis is a rarely occurring condition. Pregnancy and postpartum are both known risk factors for cerebral venous sinus thrombosis. Early detection and treatment are critical, as CVST can be potentially life-threatening. Here, we present a case of a patient who developed left transverse and superior sagittal sinus thrombosis 15 days after normal vaginal delivery. The patient presented to the emergency department with complaints of irritability and an altered state of consciousness for two days. The patient also developed seizures extending from the lower limb to the upper body. Laboratory investigations revealed abnormalities in the complete blood count report and urine complete examination. The patient's coagulation profile was totally abnormal, indicating a presence of a thrombus. All the other diagnostic techniques, including Electrocardiogram, Carotid Doppler Scan, and Ultrasound abdomen, revealed no findings. However, Magnetic resonance venography + Magnetic resonance imaging showed partial superior sagittal sinus thrombosis in the anterior and upper parietal regions, right internal jugular vein thrombosis, and left transverse thrombosis with associated left parietal infarcts. The presence of thrombosis in sinuses and jugular vein resulted in seizures, altered state of consciousness, and other associated symptoms. The patient was treated with sodium valproate, heparin, and other medications accordingly. The above-mentioned case was unique due to the involvement of unusual sinuses (transverse sinus) as previous studies have only reported cases of thrombus presence in the superior sagittal sinus. This case study will discuss patient diagnosis and management with Heparin and Diazepam to stop altered state of consciousness and seizures in females.

An Analysis of Maxillary Anterior Teeth Crown Width-Height Ratios: A Photographic, Three-Dimensional, and Standardized Plaster Model's Study.

OBJECTIVE: To analyze the width and height ratios of maxillary anterior teeth at different crown levels through photographs, 3D, and plaster dental model techniques in a subset of the Pakistani population. Material and Methods. This clinical study consisted of 230 participants. The maxillary impression, standardized photographs, and models were constructed for crown width and height analysis. The SPSS version 25 was used for statistical analysis. Descriptive statistics were carried out for mean, standard deviation, and percentage calculation of teeth width and height, gender, and age of participants. Paired t-test analysis was carried out to compare the dependent variables (teeth size, width, and height ratios) with independent variables (techniques applied, side disparity). A p value of ≤ 0.05 was considered statistically significant. RESULTS: The mean width and height of maxillary anterior teeth obtained through photographs, 3D, and plater models were statistically different. The 3D dental model analysis showed reliable and accurate results. The mean width and height ratio of teeth were different on both sides of the arch. There was a significant difference (p = 0.001) in crown width-height ratios at different crown levels. CONCLUSION: The width and height ratios in the studied population were different at various crown levels. The dimensions of teeth varied from the incisal to the cervical part of the crown. Hence, rather than relying on a single, fixed ratio of 78% to 80% suggested by researchers for anterior teeth, the clinician should adopt different crown width-height ratios to restore teeth with the optimum esthetic outcome.

Whole genome sequence analysis showing unique SARS-CoV-2 lineages of B.1.524 and AU.2 in Malaysia.

SARS-CoV-2 has spread throughout the world since its discovery in China, and Malaysia is no exception. WGS has been a crucial approach in studying the evolution and genetic diversity of SARS-CoV-2 in the ongoing pandemic. Despite considerable number of SARS-CoV-2 genome sequences have been submitted to GISAID and NCBI databases, there is still scarcity of data from Malaysia. This study aims to report new Malaysian lineages of the virus, responsible for the sustained spikes in COVID-19 cases during the third wave of the pandemic. Patients with nasopharyngeal and/or oropharyngeal swabs confirmed COVID-19 positive by real-time RT-PCR with CT value < 25 were chosen for WGS. The selected SARS-CoV-2 isolates were then sequenced, characterized and analyzed along with 986 sequences of the dominant lineages of D614G variants currently circulating throughout Malaysia. The prevalence of clade GH and G formed strong ground for the presence of two Malaysian lineages of AU.2 and B.1.524 that has caused sustained spikes of cases in the country. Statistical analysis on the association of gender and age group with Malaysian lineages revealed a significant association (p <0.05). Phylogenetic analysis revealed dispersion of 41 lineages, of these, 22 lineages are still active. Mutational analysis showed presence of unique G1223C missense mutation in transmembrane domain of the spike protein. For better understanding of the SARS-CoV-2 evolution in Malaysia especially with reference to the reported lineages, large scale studies based on WGS are warranted.

An infant with omenn syndrome: A case report.

BACKGROUND: Omenn syndrome is a rare, autosomal recessive disorder. It is a disorder that stems from severe combined immunodeficiency in an affected individual. The disease is also of rare occurrence in children in Pakistan because this is the age where this disease usually presents, after having developed in the child. This case report will explore all the reasons that lead to the occurrence of this syndrome while also reflecting on the management profile of the child. CASE PRESENTATION: This case report deals with the discussion of one such child who was diagnosed with Omenn Syndrome after being diagnosed with several other diseases, which were being mistaken for being the actual problem and disease, but the reality was that the child was suffering from Omenn syndrome. DISCUSSION: The child is only 3 months old and his symptoms pose a great risk to his overall health status while also making him predisposed to develop several complications and nutritional deficiencies as a result, all of which keep on adding to the burden of diseases that the child faced. In Omenn syndrome, there is an increased susceptibility to develop infections of the skin, lungs, joints, as well as sepsis. Usually, the death of the patient ensues due to pneumonia and septicemia or septic shock. CONCLUSION: Omenn syndrome is a rare disease caused by missense mutations in the recombinase activating genes. It can be treated by bone marrow transplantation or lymphocytic stimulation depending on the severity of the presenting underlying immunodeficiency.

Assessment of health-related quality of life in hypertensive hemodialysis patients.

BACKGROUND AND OBJECTIVES: Globally, the prevalence of hypertension (HTN) with the coexistence of chronic kidney disease (CKD) is increasing, resulting in poor quality of life. The main objective of the study was to measure the health-related quality of life (HRQoL) of hypertensive hemodialysis patients. METHODS: A multicenter follow-up study was carried out in six public and two private dialysis centers in Pakistan. A total of 517 hypertensive hemodialysis patients responded by completing the questionnaire at baseline and two subsequent phases. The quality of life of these patients was assessed using the EQ-5D-5L questionnaire (a standardized instrument for measuring generic health status). Statistical analysis was done using a multivariate linear regression model, Friedman test and Kruskal Wallis test. RESULTS: The majority of patients (58.2%) had normal body mass index and about 60.5% of the patients were taking less salt due to HTN. Friedman test gave the statistically significant results (p ≤ 0.001) in systolic blood pressure (BP), diastolic BP and EQ-5D visual analogue scale (VAS) score between three phases (initial visit, first follow-up and second follow-up). A significant improvement was observed in self-care and usual activities from initial visit to first follow-up (p < 0.05). The most problematic dimension among the hypertensive patients with CKD was pain/discomfort (86.5%). CONCLUSIONS: HTN with coexisting CKD in hemodialysis patients severely affected HRQoL. Pain/discomfort was the most problematic dimension among the participants.

Functional Compatibility of Local Flaps for Coverage of Digital Skin Defects.

OBJECTIVE: To determine if local flap coverage is functionally compatible of digital defects. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Department of Plastic and Reconstructive Surgery, Fauji Foundation Hospital, Rawalpindi, from January 2017 to June 2019. METHODOLOGY: Patients with small and medium skin defects on digits were included. Data was collected for both independent and dependent variables, emphasising on functional outcome based on five parameters (adequate coverage of the defect, functional length of the digit, painless scar, finger-tip sensation, and inter-phalangeal joint motion). Follow-up was done for six months. RESULTS: Total number of patients included in the study was 96, with 45 male and 51 female patients. Mean age of study participants was 26.6 ± 16.9 years. Small to medium size defects were included in the study for coverage by local flaps like cross figure, lateral proximal phalanx, flag, thenar, homo-digital flaps etc. Results were studied in terms of functional outcomes. All the five parameters were achieved in 84 (87.5%) patients. Complications were observed in 10 (10.4%) patients. The most frequent complication was wound infection, which was observed in 2 (2.1%) patients. CONCLUSION: Local flaps for finger defects are a very effective way of providing durable soft tissue coverage. Key Words: Digital defects, Digital reconstruction, Local flaps for digits, Hand injuries.

Antibiotic use: A cross-sectional survey assessing the knowledge, attitudes, and practices amongst students of Punjab, Pakistan.

Objective: The aim of the study was to assess the knowledge, attitudes and practices of students regarding the use of antibiotics in Punjab, Pakistan. Participants: 525 medical and non-medical students from Punjab in Pakistan. Methods: The t-test and ANOVA were used to compare the average response of respondents. Chi-square test was used to measure the association of different elements. Results: The mean age was 20.78 ± 2.10%. About 14% of the students agreed about the appropriateness of antibiotics for viral infections, and 15% of students said they stopped taking the drugs when symptoms subsided. 65.7% of students took antibiotics only when prescribed by a doctor and 54% bought antibiotics without prescription. Statistically significant results were found among the students who had heard about the antibiotic resistance (p < 0.05). Conclusion: This study will help assess the adequacy of current educational campaigns, maximize rationalization of antibiotic use, and minimize gaps in knowledge and attitudes.

Structural Imaging Characteristic, Clinical Features and Risk Factors of Cerebral Venous Sinus Thrombosis: A Prospective Cross-Sectional Analysis from a Tertiary Care Hospital in Pakistan.

Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke that accounts for 0.5-1.0% of all strokes. Clinical presentation, predisposing factors, neuroimaging findings, and outcomes of CVST are extremely diverse, which causes a high index of suspicion in diagnosis. Therefore, early diagnosis of CVST is crucial for prompt treatment to prevent morbidity and mortality. OBJECTIVE: The purpose of this prospective study is aimed at assessing the clinical characteristics, potential risk factors, and neuro-radiological features along with the topography of venous sinus involved in CVST patients in a tertiary care hospital, Lahore, Pakistan. MATERIAL AND METHODS: Consecutive patients enrolled in this study had a computed tomography (CT) scan, magnetic resonance imaging (MRI), and magnetic resonance venography (MRV) along with a clinical presentation to confirm the diagnosis of CVST. Categorical data were presented as percentages. Continuous variable and categorical data were compared (parenchymal lesions vs. non-parenchymal lesions) using the Student's t-test and Chi-square test, respectively. RESULTS: A total of 3261 patients with stroke were presented during the study period. Out of all patients, 53 confirmed patients with CVST (1.6%) were recruited; the predominant population was female (84.91%), having a male to female ratio of 1:4. Mean age of the cohort was 28.39 ± 7.19 years. Most frequent symptoms observed were headache (92.45%) followed by vomiting (75.47%), seizures (62.26%), papilledema (54.72%), visual impairment (41.51%), and altered consciousness disturbance (52.83%). The presumed risk factors associated with CVST were puerperium (52.83%), use of oral contraceptives (13.21%), antiphospholipid syndrome (7.55%), elevated serum levels of protein C and S (5.66%), and CNS infection (3.77%). On cranial CT scans, 50 patients (94.33%) showed abnormalities while 32 patients exhibited various parenchymal lesions. Seizures were more frequent in CVST patients with parenchymal lesions compared with subjects lacking parenchymal lesions. Seventy-two sinuses, either single or in combination, were involved in CVST patients, being more common in patients with parenchymal lesions than those without parenchymal lesions. The most frequent locations of CVST were the superior sagittal and transverse sinus. CONCLUSION: In short, non-contrast CT brain may be used as a first line investigation in suspected cases of CVST. Our study also demonstrates some regional differences in the clinical features, risk factors, and neuroimaging details of CVST as described by some other studies. Therefore, care must be taken while diagnosing and predicting the outcome of the CVST.