Aim: The aim of the study was to compare the efficacy of intravitreal Diclofenac (IV-D) with bevacizumab (IV-B) in improving pathophysiology of diabetic macular edema (DME).

Material and Methods: In this comparative case series interventional study, 50 eyes from 25 patients with bilateral diabetic macular edema were selected and randomly allocated to either intravitreal diclofenac or bevacizumab with exclusion and inclusion criteria devised for the study participants. The participants were observed for 24 weeks (6 months) for any improvement in best corrected visual acuity (BCVA) and central macular thickness by spectral domain OCT, the patients were also evaluated for intraocular pressure (IOP).

Results: Fifty eyes of 25 patients were analyzed. 25 eyes were given intravitreal diclofenac 500µg/0.1ml, while 25 eyes received 1.25mg/0.05ml bevacizumab. After 6 months of follow up, there was improvement in the visual acuity from 0.54 ± 0.11 in IV-B and 0.56 ± 0.13 LogMAR in IV-D before injections to 0.24 ± 0.13 and 0.28 ± 0.10 respectively. In both groups marked reduction in CMT from baseline was observed but there was no statistically significant difference noted between the groups. Interestingly in IV-D, but not IV-B, decreased intraocular pressure (IOP) was noted, achieving statistically significant level. No adverse injections related side effects were observed. (Endophthalmitis, intra-ocular inflammation and cataract).

Conclusion: This study showed that intravitreal diclofenac (IV-D) by virtue of its anti-inflammatory properties showed improvement both in terms of visual acuity as well as reduction of the central macular thickness almost similar to bevacizumab but without any side effects of steroids.

Background: Cataract is one of the commonest causes of avoidable blindness in Pakistan. So Barriers that delay the surgical uptake in cataract patients become important investigation. Objective: To evaluate the barriers towards cataract surgery among patients visiting the Out Patient Department of Ayub Teaching Hospital, Abbottabad. Materials and methods: It was a cross sectional study which was carried out at general OPDs (both paid and non-paid categories) of Ayub Teaching Hospital, Abbottabad. Three hundred and forty patients were interviewed by consecutive non-random sampling technique. Structured questionnaire was used with informed consent to collect the data. Results: Major barriers reported in the study were non-availability of eye hospital near home 69.7% (237), unawareness of cost effective treatment of cataract 67.1% (228), fear of surgery 58.2% (198), lack of knowledge about eye hospital in public/private sector 56.2 (191), difficulty to visit an eye hospital 54.7% (186) and non-affordability of free surgery locally as 51.8% (176) pay more than thousand rupees fare for one turn to go an eye hospital. Conclusions: Non- availability, lack of awareness, non-affordability, transport and fear of surgery were the major factors delaying cataract surgery.

Background: Distal tibial fractures remain a challenging injury to manage because of limited soft-tissue coverage, compromised vascularity, and the need to balance mechanical stability with biological preservation. Minimally Invasive Plate Osteosynthesis (MIPO) has gained popularity as an alternative to conventional Open Reduction and Internal Fixation (ORIF) by minimizing periosteal disruption and preserving fracture biology. The present study compared functional, radiological, and complication outcomes between MIPO and ORIF in patients with distal tibial fractures. Methods: A comparative cohort study was performed involving 45 patients who underwent operative fixation for distal tibial fractures. Twenty-nine patients were treated using MIPO and 16 underwent ORIF. Primary outcomes included time to radiological union and functional outcome assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) score. Secondary outcomes included delayed union and surgical site infection. Statistical analyses included independent sample t-tests, Mann–Whitney U tests, and multivariable logistic regression.  Results: The mean age of the study population was 67.73 ± 5.09 years, and 62.2% were male. Median time to union was significantly shorter in the MIPO group than in the ORIF group (17.0 versus 24.0 weeks, p<0.001). Patients treated with MIPO demonstrated significantly superior functional outcomes with a mean AOFAS score of 87.31 compared with 73.69 in the ORIF group (p<0.001). Delayed union occurred more in the ORIF group (62.5% vs. 27.6%, p<0.001). Surgical site infection was observed in 31.3% of patients treated with ORIF compared with 3.4% following MIPO (p=0.016). Logistic regression identified ORIF as an independent predictor of postoperative infection (OR 14.12, 95% CI 1.34–149.09, p=0.028). Conclusion: MIPO was associated with faster fracture healing, improved functional outcomes, and lower complication rates compared with ORIF. These findings support the use of biological fixation techniques in the management of distal tibial fractures, particularly in older patients with compromised soft-tissue conditions.

Background: Antimicrobial resistance (AMR) is a growing global health threat that compromises the effectiveness of antimicrobial therapy and contributes to increased morbidity, mortality, and healthcare costs. Healthcare-associated wastewater serves as an important environmental reservoir of antimicrobial resistance genes (ARGs), facilitating their dissemination into surrounding ecosystems. This study aimed to investigate the prevalence, abundance, and distribution of ARGs in wastewater collected from urban healthcare settings. Methods: A cross-sectional observational study was conducted at Telangana Territory Centre and College, Telangana, India. A total of 160 wastewater samples were collected from hospital effluent outlets, sewage collection chambers, wastewater conveyance systems, and wastewater treatment plant inlets. Results: ARGs were detected in 147 (91.9%) samples. The most prevalent genes were sul1 (70.0%), blaTEM (65.0%), and tetA (60.0%). Carbapenem resistance genes blaNDM and blaOXA-48 were identified in 31.3% and 25.0% of samples, respectively, while mcr-1 was detected in 15.0% of samples. Conclusion: Healthcare-associated wastewater harbored a substantial burden of antimicrobial resistance genes, including clinically important carbapenem and colistin resistance determinants. Wastewater surveillance offers a valuable One Health approach for monitoring AMR dissemination and supporting public health interventions aimed at reducing environmental transmission of resistance.

BACKGROUND: Major abdominal surgeries are associated with an increased risk of perioperative blood transfusion, which in turn increases healthcare expenses, length of hospital stay, and morbidity due to preoperative anemia. Potentially better patient outcomes and less need for intraoperative transfusions could result from optimizing hemoglobin (Hb) levels before surgery via a coordinated hospital-wide strategy. Patients undergoing major abdominal surgeries were the target of this study, which sought to assess the efficacy of a preoperative hemoglobin optimization strategy in minimizing transfusion needs. Methods: An interventional investigation was undertaken on 40 patients slated for elective major abdominal surgery. Patients with preoperative hemoglobin levels below 12 g/dL (females) and below 13 g/dL (males) were incorporated into the optimization process. Interventions comprised oral or intravenous iron therapy, vitamin B12, folic acid supplementation, and erythropoietin when warranted. Hemoglobin levels were evaluated at baseline and immediately before operation. Intraoperative hemorrhage and transfusion needs were documented. Results were evaluated against conventional transfusion thresholds. Results: Preoperative anemia was found in 26 out of 40 patients, or 65%. The mean hemoglobin level greatly rose from 9.8 ± 1.2 g/dL to 11.6 ± 1.1 g/dL after optimization (p < 0.001). While previous research suggested a risk of about 40%, 8 patients (20%) actually needed intraoperative transfusions. From 1.8 ± 0.6 units to 0.7 ± 0.4 units, the average unit number of packed red blood cell transfusions per patient fell. In comparison to patients with hemoglobin levels below 11 g/dL (35% of the time), patients with hemoglobin levels equal to or more than 11 g/dL before surgery had a substantially lower transfusion rate (10%). We did not observe any side events associated with optimization therapy. Conclusion: Hemoglobin levels and the need for intraoperative transfusions were both greatly improved after a hospital-wide preoperative hemoglobin optimization strategy was implemented for large abdominal procedures. Improved surgical results and less need for blood transfusions can result from early detection and treatment of anemia. This method lends credence to the idea that standard surgical care should incorporate patient blood control measures.

Background: Staphylococcus aureus remains a leading cause of hospital-acquired infections worldwide. The emergence of methicillin-resistant S. aureus (MRSA) and multidrug-resistant strains has severely limited therapeutic options. Understanding local resistance patterns is essential for guiding empiric treatment and infection control policies. Methods: A cross-sectional study was conducted at a 600-bed tertiary care hospital over 24 months. Clinical S. aureus isolates were collected from hospitalized patients. Species identification was performed using MALDI-TOF mass spectrometry, and antimicrobial susceptibility testing was conducted using the Kirby-Bauer disk diffusion method and broth microdilution, interpreted per CLSI 2020 guidelines. Results: A total of 200 non-duplicate S. aureus isolates were included. MRSA accounted for 43.5% (n=87). High resistance rates were observed for ciprofloxacin (78.2% in MRSA, 18.6% in MSSA), erythromycin (74.7% vs. 32.7%), and tetracycline (51.7% vs. 26.5%). Multidrug resistance (MDR) was detected in 67.5% of all isolates. All isolates remained susceptible to vancomycin and daptomycin. XDR phenotypes were significantly more common in MRSA (39.1% vs. 15.0%, p<0.001). Conclusions: The high prevalence of MRSA and MDR isolates in this institution underscores the urgent need for antimicrobial stewardship programs, rigorous infection control measures, and routine surveillance. Vancomycin and daptomycin remain reliable for MRSA treatment, but the rising prevalence of XDR strains demands continuous monitoring.

Introduction Osteoporosis is a common, but often underdiagnosed, condition in elderly males, characterized by decreased bone mineral density (BMD), which leads to an increased risk of fractures. This study aims to assess the prevalence of osteoporosis and osteopenia in elderly men and investigate the association between osteoporosis, serum testosterone, and vitamin D levels. Methodology This cross-sectional study was carried out in a tertiary care centre during a period of two years (2019-2020). The study recruited 370 elderly male patients who were aged 60 years old or older. Patients had clinical examination with detailed medical history, physical examination, and laboratory investigations for measurement of serum total testosterone and vitamin D. Bone mineral density (BMD) was measured using DEXA scans, and subjects were classified according to their T-scores as having osteoporosis, osteopenia, and normal BMD. The relationship of T with VitD deficiency and osteoporosis was considered. Results The prevalence of osteoporosis, osteopenia, and normal BMD was 39.5%, 48.3%, and 12.2%, respectively. Low testosterone level was significantly associated with osteoporosis, and 47.5% of patients with low testosterone (<3 ng/ml) were osteoporotic (P = 0.001). Vitamin D deficiency was high and 50.6% of participants were having D level less than 20 ng/ml. Prevalence of osteoporosis was significantly higher in participants with vitamin D deficiency in comparison to those without (p-value = 0.03). The findings suggest that having the right amounts of testosterone and vitamin D are important for maximum bone health. Conclusion Osteoporosis and osteopenia are prevalent in a high proportion of elderly males, and deficiency in serum testosterone and vitamin D are significant risk factors. The early detection of those deficiencies and further management, replacement therapy of testosterone, and supplementation of vitamin D, could be used to prevent the oncoming of osteoporosis and related fractures. The results of this study underscore the importance of implementing standing programs and assessments designed to maintain bone health and thus also reduce the burden fracture-related osteoporosis has on elderly males by enhancing their quality of life.

Introduction: Obstructive sleep apnea (OSA) is a prevalent sleep disorder characterized by recurrent episodes of partial or complete upper airway obstruction during sleep. OSA is associated with significant morbidity, including cardiovascular diseases, metabolic syndrome, and impaired quality of life. Understanding the predisposing factors for OSA is crucial for early diagnosis and effective management. This study aims to identify the key factors predisposing adults to OSA, including obesity, anatomical abnormalities, lifestyle factors, and comorbidities. Materials and Methods: A cross-sectional study was conducted on 70 adults aged 18–65 years. Participants underwent polysomnography and completed questionnaires assessing lifestyle, medical history, and symptoms of OSA. Inclusion criteria included adults with suspected sleep-disordered breathing, while exclusion criteria included individuals with central sleep apnea or severe psychiatric disorders. Participants underwent overnight polysomnography to assess the apnea-hypopnea index (AHI), oxygen desaturation index (ODI), and other sleep parameters.  Results: The study identified obesity (BMI ≥30), male gender, age >40 years, and smoking as significant predisposing factors. An AHI ≥5 is diagnostic for OSA, and the mean AHI of 18.5 in the OSA group indicates moderate OSA. The extremely low AHI in the non-OSA group (2.1) confirms the absence of significant sleep-disordered breathing. The ODI measures the number of times per hour that blood oxygen levels drop by ≥3% from baseline. The OSA group had a significantly higher ODI (15.2 events/hour) compared to the non-OSA group (1.8 events/hour), indicating frequent oxygen desaturations in OSA patients. The OSA group had a lower mean SpO₂ (91.3%) compared to the non-OSA group (95.6%), indicating poorer oxygenation in OSA patients.  Conclusion: Obesity, anatomical abnormalities, and lifestyle factors are major contributors to OSA. Early identification and intervention can reduce the burden of OSA-related complications.

Background: Pulpotomy is a conservative treatment modality that aims to preserve radicular pulp vitality in cases of reversible pulpitis or traumatic pulp exposure in permanent teeth. Mineral Trioxide Aggregate (MTA) has been widely used due to its biocompatibility and sealing ability, but it has certain limitations such as prolonged setting time and discoloration. Bio dentine, a calcium silicate-based material, has been introduced as a promising alternative with improved physical properties. Objective: This systematic review aimed to evaluate and compare the clinical and radiographic success of Bio dentine and MTA in pulpotomy of permanent teeth. Methods: A comprehensive literature search was conducted in PubMed, Scopus, Cochrane, and Google Scholar databases. Ten eligible studies, including randomized controlled trials and clinical evaluations, were selected according to PRISMA 2020 guidelines. Data regarding clinical outcomes, radiographic healing, postoperative symptoms, and handling characteristics were extracted and synthesized. Results: Both Biodentine and MTA showed comparable success rates, ranging from 90–97%, with no statistically significant differences. Biodentine exhibited superior handling and faster setting time. Conclusion: Biodentine is a clinically effective and practical alternative to MTA for pulpotomy in permanent teeth, offering similar success rates with added advantages in manipulation and setting characteristics.

In 2001 the annual estimated cost of dealing with bladder problems was £353.6 million.9 This included expenditure on pads. It is expected to be much higher now. Only a small proportion of the above amount was spent on drugs,10 the remainder being spent on secondary care and surgical treatment.

Bearing this in mind, it makes sense that the general practitioner (GP) is ideally placed to screen and manage these patients in primary care. It is not necessary to refer all patients to secondary care. With the ever-increasing pressure on GPs to reduce unnecessary referrals, there is now a scope for commissioning this service. However, management of an overactive bladder is not part of the Quality and Outcome Framework - could be one reason why GPs are not keen or enthusiastic

Introduction: The nationwide implementation of ‘run-through’ training in 2007, based upon the new system of postgraduate medical training known as Modernizing Medical Careers (MMC), was the subject of much debate as to the suitability of the selection process, and the feasibility of the new system itself. One year after the start of the new Speciality Training (ST) grade this study obtains the views of core surgical trainees in the Oxford Deanery. Methods: Forty-six trainees in ST1, ST2, Fixed Term Specialty Training Appointment (FTSTA) 1 and FTSTA2 posts completed questionnaires at three and nine months from appointments in August 2007. Results: Fifty two percent (n=24) of respondents were appointed to their training posts from Round 1a, with 67% (n=16) to ST1 or ST2 level. Despite 61% (n=28) having initially selected Oxford as their first-choice deanery, 93% (n=43) now wished to remain in the region for further training, with 57% (n=27) of all trainees satisfied with their current position. At three months, only 9% (n=4) felt well informed regarding their surgical training, and 28% (n=13) well supported by their seniors; however, six months later these figures had risen to 64% (n=29) and 60% (n=24) respectively. Nearly half (43%, n=20) of surgical trainees had looked into moving abroad to train, and two thirds had considered leaving surgery all together. From August 2008, 70% (n=9) of ST2 trainees and 57% (n=4) of FTSTA2 trainees had obtained ST3 positions, with all but one in their desired surgical specialty. Conclusion: Despite MMC’s difficult introduction into higher specialist training, the majority of trainees surveyed expressed encouraging levels of job satisfaction, felt increasingly well informed and well supported, and had successfully negotiated the initial stages of the ‘run-through’ track. With continuing debate surrounding how MMC-based surgical training will work within the confines of National Health Service (NHS) provision and the European Working Time Directive, we present the opinions and outcomes of the first cohort of ‘run-through’ surgical trainees.

Cystic hydatidosis is a rare disease which mainly involves the liver and lungs, and rarely the brain. Cysts may be single or multiple. A 6-year-old boy presented with the chief complaint of ataxia. Brain imaging revealed a huge cystic structure involving the right side of the brain. A diagnosis of brain hydatid cyst was made and the patient was operated on. A large cyst was successfully delivered without rupture. Antihelminthic medication was started and the patient was discharged with full recovery of neurological function. Hydatid cysts must be considered as a differential diagnosis in patients with cystic lesions of the brain, especially in children. Surgery remains the standard method of treatment, and care must be taken in order to recover the cyst without rupture to avoid severe complications and recurrence.

A 36-year-old African American male with a history of chronic pancreatitis presented to the emergency department for abdominal pain in the epigastric area along with nausea, vomiting, diarrhoea, fever. His symptoms began 3-4 days before presentation. The abdominal pain was dull in nature and 6/10 in intensity, non-radiating. His past medical history was significant for HTN, diabetes mellitus and chronic diarrhoea secondary to chronic pancreatitis.

On admission the patient was alert and oriented, blood pressure was 97/44 mm Hg, heart rate 16 beats per minute, respiration 16 per minute, oxygen saturation 94% on room air and temperature 102*F. Abdominal examination revealed hyperactive bowel sounds and tenderness in the epigastrium & RUQ. Liver span was 14 cm. The rest of the examination was unremarkable.

Coronary vasospasm is an episodic, augmented, contractile response of coronary smooth muscles to variety of stimuli in the setting of established endothelial dysfunction. Various physiological including cold, stress and pathological factors like smoking, and ethanol have been well known to precipitate vasospasm. Despite these omnipresent factors, coronary vasospasm has become infrequent, in particular due to judicious use of medication including calcium channel blockers, statins and aspirin. We present a case of severe coronary vasospasm resulting in haemodynamic instability, in a patient with hypoxic respiratory failure. Recurrent symptomatic episodes required coronary angiography for the diagnosis and patient was successfully treated with calcium channel blockers.