Background: Sick sinus syndrome (SSS), also known as sinus node dysfunction (SND), is a disorder of the sinoatrial (SA) node caused by impaired pacemaker function and impulse transmission producing a constellation of abnormal rhythms. Sick Sinus Syndrome is a highly relevant clinical entity, being responsible for the implantation of the majority of electronic pacemakers worldwide. Case Summary: An 80-year-old patient with a recent diagnosis of atrial fibrillation after a syncopal attack, presented to our clinic complaining of new onset lightheadedness. Following a pre-syncopal attack in our clinic, extensive analysis was performed and showed no underlying causes for the light headedness. A 24-hour Holter monitoring was performed and demonstrated signs of sick sinus syndrome with unusually prolonged sinus pauses without an escape rhythm. Urgent correction with permanent dual chamber pacemaker was performed with an uneventful postoperative recovery. Discussion: In sick sinus syndrome, cessation of sinus rhythm (sinus arrest) for short intervals without an escape rhythm, or longer periods of pause with replacement of sinus rhythm by an atrial or junctional rhythm are commonly seen. However, recurrent prolonged ventricular asystolic episodes are infrequently encountered and an extremely rare cause of syncope. It is known that triggers like anaesthesia, certain drugs or epilepsy can unmask sinus node dysfunction, which then manifests as significant atrial dysrhythmias and “rarely” asystole but long asystolic episodes of such duration were never reported in the absence of any trigger in patients with sick sinus syndrome. Permanent pacemaker placement is the recommended treatment for sick sinus syndrome.

Background: The Education system has taken a 180-degree paradigm shift since Covid-19 wrapped up the prevailing global system. Now educational system used made electronic communication devices the prerequisite. Not only were the students, parents, and teachers dragged out of their comfort zone to learn and stretch their expertise in the digitalization of education and work. The endeavor has brought us to set standards and meet the needs of new standers. This study aimed to discover the suggestions of students and faculty to deal with the resentment that is being experienced with this online facade. Methodology: Cross-sectional study from March to May 2020, total participants was 523 including male and female medical students and faculty. Ethical approval was obtained from Ethical committee CMH Lahore Medical College and Institute of Dentistry (CMH LMC & IOD). Verbal informed consent was obtained. Self-administered questionnaires were given to the participants. Results: E-Learning opportunities need to be taught explicitly. Modern tools are the need of time. The faculty needs to understand student psychology as well as the application of modern tools and gadgets. Conclusions: E-learning posed a technological divide among the faculty members and students. The pandemic allowed us an opportunity to explore the realms of the digital world and expand our horizons to challenge the already existing medical education system, curriculum, and mode of its execution.

Background: Parents do experience stress from their family structure and occupation, and these stress can be transferred to their children. Since the stress imposed by the different occupations and the different family structures are different, the stress transferred to the children will depend on the occupation and family structure of their parents. Objective: This study was therefore designed to understand the influence of the stress incurred by parents from their family structure and occupation on the academic/examination stress of their children in Oroke High School Akungba -Akoko, Ondo State, SW Nigeria. Method: The population of the study comprises all the students of Oroke High School, Akungba Akoko (650) out of which a sample of 313 that satisfied our criteria was selected, using purposive sampling technique. Digital sphygmomanometer was used to measure the actual blood pressure readings of the respondents twice, with at least thirty minutes interval in sitting positions. The mean reading was used. The measurements were carried out three times during the study: two weeks after resumption for the second term of the 2017/2018 academic year, two weeks before the second term examination and four weeks after exam. Results: Students were grouped according to their family structure and also according to the occupation of their fathers or their mothers. The study finds that the systolic blood pressure generally increases as students go from the beginning of the term to two weeks before the terminal examination and decreases after the exam for the different types of family structure and occupation of their fathers or their mothers when the academic stress is removed. Conclusion and recommendation: Under whatever stress that parents may be, it is recommended that they should make the home environment congenial and stress less for study so that the children can go to school the next day with little or no transferred stress.

Background: Immunization remains one of the paramount public health interventions and a cost effective method to reduce both the ailment and death associated with infectious diseases. Uptake of vaccination is dependent not only on providing of the vaccination services but also on other influences including awareness and practice of women. Objectives: To assess tetanus toxoid immunization status of mother’s. In addition, to address the factors influencing their immunization status. Method: Cross sectional study conducted in ten primary health care centers in Baghdad for the period from February until the end of October 2020. Convenient sample of mothers, who had delivered a live baby within the previous 12 months from the study and attended the selected primary health care centers in Baghdad were recruited. An interview questionnaire used to collect data regarding history of tetanus toxoid vaccine up take of the mothers during their last pregnancy. Results: The total number of mothers enrolled in the study was 400, 214(53.5%) of them were received tetanus toxoid vaccine (TTV) during their last pregnancy. 127(59.3%) of the mothers were uptake two doses of TTV. Among the study group, 31.75% of mothers were considered as immunized according to WHO classification. Age of mother, education, and respondents’ working status; alongside with antenatal care attendance and place of delivery all had insignificant impact on the immunization status. Lack of time was the main reason for not vaccination (22.6%). Conclusion: Tetanus toxoid immunization coverage was inadequate. For that reason, immunization campaigns targeting enhanced utilization of immunization services by mothers and women of childbearing age are highly recommended.

Biliary lithiasis is a very frequent and benign pathology but can be the cause of rich and varied symptomatology as well as serious complications. Our study aims to estimate the prevalence and some risk factors of biliary lithiasis and especially to look for the correlation between this pathology and anthropometric measurements. Therefore, we conducted a campaign that included 1358 citizens to perform ultrasound screening for biliary lithiasis, hepatic steatosis, and hydatid cyst. In our study, the prevalence of biliary lithiasis was 19.2%. The average age was 47.7 years with a predominance of women, i.e. a percentage of 76.6%. The risk factors significantly associated with gallstones were abdominal obesity, male sex, and age below 40 years were protective factors, however, neither diabetes nor a history of hypercholesterolemia was associated with the risk of gallstones.

anticoagulation therapy would be the removal of this arrhythmia and any future recurrence, a goal often difficult to achieve.The aim of this work is to evaluate the efficacy of atrial fibrillation cardioversion as well as the success predictive factors of sinus rhythm maintenance at one year following a successful cardioversion. Materials and methods: 50 patients with non-valvular atrial fibrillation underwent cardioversion: 70% by electrical shock and 30% by pharmacological means, the clinical characteristics of the patients the results of cardioversion and follow-up were collected and analyzed. Results: The average age of our patients was 53 years with a sex ratio of 2. 30% of patients had hypertensive heart disease, 8% ischemic heart disease, 8% dilated cardiomyopathy and the rest had no underlying heart disease. The average diameter of the left atrium was 41 mm and the average surface area was 20 cm². Primary success rate of cardioversion was 82% with better efficacy of electric shock compared to pharmacological cardioversion. The maintenance rate of sinus rhythm at 1 year was 70%. Predictive factors of failure and / or recurrence at 1 year were old atrial fibrillation and significant dilation of the left atrium. Conclusion: This study confirms the interest of atrial fibrillation cardioversion and underlines the importance of preliminary selection of the patients, such a selection must be made on the basis of the predictive factors of success usually recognized in the literature.

Wolff-Parkinson-White (WPW) syndrome is a relatively rare cardiac rhythm disorder entity encountered during pregnancy. However, its exacerbation under this physiological condition could be responsible, in certain cases, for life-threatening arrhythmias compromising both maternal and foetal prognosis. We report the observations of 03 pregnant women, without past medical history, presenting to the emergency room for palpitations related to a Wolff-Parkinson-White syndrome, complicated in one case with foetal death. The substantial severity of the WPW syndrome during pregnancy requires a prompt and adequate management strategy, based on a multidisciplinary cooperation between obstetricians, cardiologists and neonatologists.

Introduction: Wellens syndrome or anterior interventricular artery (AIV) disease is an electrocardiographic abnormality defined by the presence, apart from painful episodes, of biphasic T waves in the anterior leads (type 1), or deeply inverted T waves (type 2) in association with critical stenosis of the proximal AIV. It warrants aggressive management given the rather high incidence of death and re-infarction. Objectif: To report an atypical form of this syndrome through this observation and to provide an update on this rare entity through a literature review. Case report: A 48-year-old patient, chronic smoker with 40 BPs still active, admitted following an episode of infarct chest pain. At admission, the patient was asymptomatic. The clinical examination was unremarkable. The ECG showed biphasic T waves, negative in its terminal part in V2-V3-V4, without planed R waves, nor Q waves of necrosis or significant ST abnormality evoking a WELLENS type 1 syndrome. Ultrasensitive troponin was measured at 260 ng/L. The evolution was marked by the appearance of a fleeting negativation of T waves, without chest pain. Chest echocardiography showed a non-dilated left ventricle with preserved systolic function and no detectable segmental or global kinetic disorders, associated with concentric left ventricular hypertrophy. The coronary angiography performed in emergency shows tritroncular lesions, a very tight stenosis of the middle interventricular and the first diagonal, a tight stenosis of the middle circumflex and the middle right coronary, revealing a coronary artery bypass graft. Discussion and conclusion: Wellens syndrome is characterized by T-wave abnormalities that often fluctuate (from type 1 to type 2 or vice versa) during pain-free intervals, reflecting spontaneous reperfusion and the unstable nature of the coronary lesion found, which is represented mainly by involvement of the proximal AVI. Involvement of the middle IVA associated with other lesions is rarely observed. It is associated with a greater risk of anterior infarction or sudden death if not recognized and treated rapidly, so it seems essential to recognize the electrocardiographic criteria of this syndrome in order to propose coronary angiography for early revascularization.

Dengue fever is public health concerns in Bangladesh, where it occurs in epidemics and has a high mortality in the advanced stages. Clinical features are nonspecific and diagnosis is supported by lab features. Common lab tests include Platelet count, leucocyte count and platelet indices are useful in small rural set ups for early diagnosis and prognosis of dengue. The aim of this study is to evaluate relationship between platelet count, leukocytes and platelet indices. This retrospective cross-sectional study was conducted at Department of Laboratory Medicine in collaboration with Department of Internal Medicine, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from July 2019 to September 2019. Clinical records of 260 cases were preserved in a structured Clinical Record Form (CRF). Only those, with antigen/antibody supported cases was enrolled in the study. Mean neutrophil (%), mean lymphocyte (%) and mean eosinophil (%) count were statistically significant difference among different platelet count groups (p<0.05). There was significant negative correlation between PDW and platelet count (r= -0.228, p<0.001). MPV was also negatively correlated with platelet count but not significant (r= -0.106, p= 0.088). Beside Platelet count and leukocyte count, Platelet indices such as PDW and MPV are also useful to monitor dengue fever.

This semi-systematic review aimed to quantitatively map and identify data gaps in the patient journey touchpoints for depression in Kingdom of Saudi Arabia namely disease prevalence, awareness, screening, diagnosis, treatment, adherence and management. A structured search was conducted using the predefined inclusion criteria to identify relevant studies from Jan 2010–Dec 2019. To address the data gaps, an unstructured literature search and anecdotal data were also included. Data obtained were synthesized and simple or weighted mean was calculated. Of the 2,025 articles retrieved from structured and unstructured search, eight were included for final analyses. Two anecdotal data sources recommended by the local experts were also included. Most of the articles included were cross-sectional in design. The overall prevalence of depression was estimated at 18.2%. Synthesized evidence indicated that 41.8% of the patients had awareness, 44.9% received treatment and 40.7% adhered to treatment. According to anecdotal evidence, the rate of screening and diagnosis of depression was 35.0% and 55.0%, respectively, of which 60.0% of the patients achieved symptom remission. Lack of data in patient journey touchpoints for depression in Saudi Arabia highlight the need for more evidence based studies. This might improve patient care and support national level decision-making.

Severe cholangitis is an urgent indication for endoscopic treatment, represented by endoscopic retrograde pancreatography (ERCP) and endoscopic sphincterotomy. It ensures good bile drainage, and improves patient morbidity and mortality. Materials and methods: This is a retrospective study carried out within our department between January 2010 and April 2018. All patients with severe cholangitis who benefited from therapeutic ERCP were enrolled. We analyzed the epidemiological data of the patients, the results of the ERCP, as well as the post-sphincterotomy mortality. We also performed multivariate analysis for predictive factors for mortality. Results: 88 patients were enrolled. The average age of the patients was 60.14 years [17-102 years], with a female predominance (n = 45, 51.1%). Twelve patients (13.6%) underwent a cholecystectomy. Almost 68, 18% patients (n = 60) had obstructive choledocholithiasis, fifteen patients (17,04%) had o cyst hydatic and 13 patients (14,77%) had tumor obstruction. Successful catheterization of the main bile duct was reported in 60 patients (68.18%), and failure in 28 cases (31.81%). The use of precut was performed in 28 cases (31.81%), which enabled successful access to main bile duct in 24 patients (85.71%). Failure of catheterization after a precut concerned 4 patients (14.28%): 3 patients (75%) benefited from a resumption of ERCP with success, and only one patient (25%) was proposed for surgery. fifty-five patients (91,66%) underwent stone evacuation (Figure 1). For 5 patients (8, 33%), failure of stone extraction was followed by successful surgery. Twenty-one patients benefited from successful implementation of a biliary prosthesis were objectified in 21 patients (25%). 5 patients (23.80%) failed. Among them, percutaneous drainage was done 4 patients (80%) and 1 patient (20%) was operated. The main post-ERCP complications were represented by: 5 cases (5.7%) of papillary bleeding, and 1 case of acute pancreatitis. The overall death rate was 11,36% (n=10). The course was marked by clinical and biological remission in the other patients with successful endoscopic drainage. The main predictors of mortality in multivariate analysis were impaired of consciousness upon admission (p = 0.023, OR=4, 5678 [2,678‑10, 7890]), and the presence of renal failure (p = 0.001, OR=6, 4809 [2,089‑15,781]). Conclusion: Endoscopic treatment is the gold standard for the treatment of severe cholangitis. Its results are satisfactory, with a lower mortality compared to surgical treatment with fewer hospitalizations.

Introduction: Left vocal cord palsy by Compression of the left recurrent nerve by the left atrium in tight mitral stenosis defines Ortner's cardio-vocal syndrome. The vascular etiology of compression thoracic aortic aneurysm is well described in the literature. Left vocal cord palsy by Compression of the left recurrent nerve by the left atrium in tight mitral stenosis defines Ortner's cardio-vocal syndrome. The vascular etiology of compression thoracic aortic aneurysm is well described in the literature. Case Record: We present the case of an 80-year-old man with a history of thoracic trauma and recent onset dysphonia and simultaneous discovery of an aortic isthmus pseudoaneurysm and left vocal cord paralysis. Discussion: The place of dysphonia during post traumatic false aneurysm of the aortic isthmus is commented. This observation documents the mechanism of compression of the recurrent left nerve by a post-traumatic false aneurysm of the thoracic aorta. Adequate management can improve the patient's prognosis and quality of life.

Introduction: Paraganglioma or chemodectoma of the carotid corpuscle or carotid glomus is a relatively rare neoplasm of slow progression, late diagnosis and uncertain prognosis. This tumor originates from the chemoreceptors of the carotid bifurcation and clinically presents as a laterocervical mass. It represents the majority of paragangliomas of the head and neck (60-70%). Observation: We report the observation of a 56-year-old female patient who consulted for a right laterocervical swelling without any other associated clinical signs. A complete radiological workup (Angioscanner/Angiography) will confirm the vascular nature of the lesion, characterize the size of the mass, its nature, its mapping, and its relationship to adjacent organs. Surgical excision had confirmed the diagnosis on histopathological examination. From this observation, we review the clinical, radiological and histopathological features of this tumor, as well as its uncertain evolutionary mode and the therapeutic modalities. Conclusion: Lateral cervical paragangliomas remain rare and poorly known affections which require an early diagnosis and a multidisciplinary management: ENT surgeon, vascular surgeon, oncologist and radiotherapist according to the evolutive forms.

Background and objective: we conducted this study to find out the important relationship between time-management skills and physician career satisfaction and explore the importance of utilizing strategies that promote efficient time management. Methods: In this cross-section study, used a self-designed and validated questionnaire. The current study was conducted during a series of workshops, in CMH Lahore Medical College & IOD from August-October 2021. Participants were, no prerequisite knowledge, skills, or resources were required for the workshop. Results: A total of 157 participants were enrolled for a workshop and 155 participants fill the questionnaire completely so the response rate was 98.72%. Questionnaire, Cronbach’s Alpha value was 0.78 male participants were 60 (38%) and females 96 (61.4%). The age average was 25-39 years. Most participants are demonstrators/lecturers/registrars. About 77 (49%) of the physician’s sleep duration was normal hours and 78 (51%) complain to insomnia. Only 67 (43.9%) physicians give family time properly but 88 (56.4%) spend less than 4 hours with their families. Doctors spend less time on their smart devices 16 (10.3%) spend more than 2 hours/day. Very few physicians do their favorite hobby or any physical activity daily. Conclusion: Physicians are not good time managers, its means their patients are kept waiting, they get stressed, their work becomes less enjoyable, stress can build, they lose their sense of humor and they lose valuable time for family, exercise, and sleep, insignificantly different across gender, age, experience and entering qualification.

Phenibut is an anxiolytic and nootropic drug, discovered in the Soviet Union used to treat several psychiatric disorders. Currently it is available online as supplement. The case report highlights the abuse potential of phenibut, with the associated clinical presentation of intoxication, withdrawal, and relapse, as well as the use of baclofen as a potential treatment of phenibut withdrawal.

Case summary: A 19-year-old Saudi male morbidly obese patient (BMI 48 kg/m2). The patients underwent sleeve gastrectomy 5 months ago and cholecystitis 1 month ago. The patient presented to our emergency department (ER) with all limb numbness in the last 3 weeks, difficulty walking, blurred vision, headache, and nausea for the last week. The patient was diagnosed with Wernicke encephalopathy based on his symptoms, physical signs, and classical MRI brain findings. Conclusion: Bariatric surgery can complicate Wernicke encephalopathy, associated with thiamine deficiency. Prophylactic thiamine supplements can prevent the subsequent bariatric WE condition.

The purpose of this study is to assess the effect of ethanolic stem bark extract of Persea americana on lipid profile and oxidative stress markers of male Wistar rats. The rats were randomly divided into three groups of five rats each. They were treated with ethanolic extract of Persea americana (except the control group) for a period of 21days. Group1 received distilled water. Group2 received 200mg/kg of the extract and Group3 received 400mg/kg of the extract. The administration was done for 21days. At the end, the rats were sacrificed and blood sample was collected and sent to the laboratory for analysis. The data obtained was statistically analysed using SPSS software version 21. The result showed that, there was no significant difference in serum total cholesterol, triglyceride, high density lipoprotein and low density lipoprotein when test groups were compared to control. There was a significant decrease in serum very low density lipoprotein level in Group3 (400mg/kg) when compared to Group1 (Control). There was no significant alteration in glutathione reductase, catalase and superoxide dismutase enzyme activities. There was a significant difference in malondialdehyde level (a decrease). In conclusion, the ethanolic extract of Persea americana stem bark exhibited slight hypolipidemic effect because of the significant reduction in Very Low Density Lipoprotein. Also, the extract showed a significant decrease in Malondialdehyde at low dose, which shows that Persea americana may have an anti-oxidative property.