An MRI study was carried out on a 1.5 Tesla scanner (Symphony, Siemens AG, Germany) using T2 weighted (half-Fourier acquisition single shot turbo spin echo [HASTE]; TR 4.3 ms, TE 2.15 ms) and TrueFISP (TR 1000 ms, TE 83 ms) sequences in sagittal, coronal, and axial planes which showed large markedly hyperintense lungs (as compared to foetal skeletal muscle) causing inversion of the diaphragms. The dilated trachea was exquisitely demonstrated as increased signal with a gap at the level of the larynx. The cardiac findings and ascites were also confirmed and no additional anomaly could be demonstrated (Figure 2). Based on ultrasound and MRI findings, diagnosis of CHAOS due to laryngeal atresia was made. The parents were counselled regarding the relatively poor prognosis and the pregnancy was terminated. DISCUSSION Congenital high airway obstruction syndrome is a constellation of findings which arise due to obstruction of the upper airway tract. The causes of obstruction include laryngeal atresia, stenosis or laryngeal cysts, and tracheal atresia or stenosis. 1-3 Cases of CHAOS are sporadic and the exact incidence is not known.

Background:Delayed anterior cruciate ligament (ACL) reconstruction may be associated with increased risk of subsequent knee joint damage and osteoarthritis (OA). The relationship between recurrent instability episodes and meniscal or cartilage damage after first-time ACL injury is unknown.Purpose:To assess the association between recurrent knee instability episodes and prevalence of meniscal lesions, cartilage damage, and OA after first-time ACL injury.Study Design:Systematic review; Level of evidence, 4.Methods:Six electronic databases were systematically searched using keywords and Medical Subject Heading terms. Studies selected were of English language, included original data, had a prospective design, and provided an outcome of recurrent instability and meniscal lesions, cartilage damage, or OA after first-time ACL injury. Adjusted odds ratios (ORs) were extracted or unadjusted ORs (95% CI) were calculated. PRISMA guidelines were followed, and 2 independent raters assessed study quality using Downs and Black criteria.Results:Of 905 potentially relevant studies, 7 were included. Sample sizes ranged from 43 to 541, and Downs and Black scores ranged from 2 to 12. Clinical and methodological heterogeneity precluded meta-analysis. Six studies reported a positive association between recurrent instability episodes and medial meniscal damage (OR range, 3.46 [95% CI, 1.24-9.99] to 11.56 [1.37-521.06]). The association between instability episodes and lateral meniscal or cartilage damage was inconsistent. No studies examined the association between instability episodes and OA.Conclusion:This systematic review provides preliminary evidence that recurrent instability episodes after first-time ACL injury may be associated with increased odds of medial meniscal damage. This highlights the importance of early diagnosis, education, and treatment for individuals with ACL injury, all of which must include a specific focus on the prevention and management of instability episodes. High-quality, prospective cohort studies are needed that assess the effects of diagnostic and treatment delay, recurrent instability episodes on secondary meniscal and cartilage damage, and OA after an initial ACL injury.

To find the perceptions and behaviours of the general public in response to the novel coronavirus pandemic in India.Design: An online survey was conducted during lockdown period of coronavirus pandemic.Participants: 304 respondents participated in the survey during the lockdown period of 21 days.Main Outcome Measures: Perceptions and behaviours of adult population to coronavirus infections and its prevention. Result:The mean age of the respondents was 38.38±12.34 years. Most of the respondents believed that coronavirus was a contagious infection could be transmitted via direct body contact and droplets and majority 285 (93.8%) of the respondents were aware that coronavirus is a contagious infection. Nonetheless, perceived chance of infection was found by 284 (93.4%) respondents due to public transport, mass gatherings or crowds and through contaminated food or takeaways in only 94 (30.9%). Perceived efficacy of preventive measures was social distancing (77.3%), hand washing (75.3%) and wearing a mask (48%). It is interesting to note that some people were taking multivitamin, Unani immune modulator, homoeopathic and Hydroxychloroquine medicines as prophylaxis. Conclusion:Coronavirus related perceptions and behaviours are crucial for designing preventive measures. Knowledge about the pandemic was high but misconceptions were also existed in the study group which need further improvement of appropriate IEC activities among Indian population.

Background:Treatment of patients with anterior cruciate ligament (ACL) injuries is often complicated by secondary damage to the meniscus and cartilage.Purpose:To assess the association between time from ACL tear to ACL reconstruction (ACLR) and the presence of intra-articular injuries at the time of ACLR, including meniscal tears, irreparable meniscal tears, chondral damage, and knee compartment degenerative changes.Study Design:Cross-sectional study; Level of evidence, 3.Methods:Consecutive patients undergoing primary ACLR performed by a single surgeon in a Canadian health system over a 5.5-year period were included. Age at ACLR, activity level prior to injury, time from injury to ACLR (TFI), presence and degree of radiographic osteoarthritic features (International Knee Documentation Committee [IKDC] score by tibiofemoral and/or patellofemoral compartment), and surgeon-recorded meniscal lesions (presence and treatment [repair or excision]) and chondral lesions (International Cartilage Repair Society [ICRS] scale grade >2) at time of ACLR were extracted from medical records. The association between TFI (in quartiles: first quartile [0-36 wk] through fourth quartile [110-1000 wk]) and each outcome was assessed with multivariable logistic regression adjusted for age at ACLR and activity level.Results:A total of 860 individual patient records were included. The median patient age was 27.0 years (range, 12-63 years), 47.5% were female (403/849), and 47.2% were classified as playing competitive or professional sports versus recreational sport (337/714). After adjustment for age and activity level, TFI was associated with presence of medial meniscal tear (odds ratio [OR] of fourth-quartile vs first-quartile patients, 3.86; 95% CI, 2.38-6.24; P < .001), medial meniscal tear requiring greater than two-thirds meniscectomy (OR, 5.64; 95% CI, 2.99-10.67; P < .001), medial femoral condyle chondral damage (OR, 3.42; 95% CI, 1.96-5.95; P < .001), and medial tibiofemoral radiographic osteoarthritic features (OR, 22.03; 95% CI, 5.17-93.86; P < .001). TFI was not associated with adverse outcomes in the lateral tibiofemoral or patellofemoral compartments.Conclusion:Increases in TFI are associated with medial meniscal tears, including irreparable medial meniscal tears, medial femoral condyle chondral damage, and early medial tibiofemoral compartment degenerative changes at time of ACLR. These findings highlight the importance of establishing a timely diagnosis and implementing an appropriate treatment plan for patients with ACL injuries. This approach may prevent further instability episodes that place patients at risk of sustaining additional intra-articular injuries in the affected knee. Further research is required to understand the implications of TFI and to determine whether decreasing the TFI alters the natural history after an ACL injury.

Supply chain agility (SCA) has become an important concept these days and gained a great deal of attention from the research fraternity. Researchers and scholars have mainly examined the dimensions of integration and flexibility as the antecedents of SCA from conceptual lenses in the past and suggested further explanations from empirical testing. Thus, this research aimed to investigate three key drivers of supply chain agility -i.e., strategic flexibility, employees' behavioral flexibility and relational (external) integration. The sample is comprised of 147 SMEs operating in Pakistan, collected via survey and then tested using moderated mediation structural equation modelling in MPlus software. As per the findings, customer integration, employees' behavioral flexibility and strategic flexibility have direct influence on supply chain agility (SCA). In addition to that, customer integration has indirect impact on SCA via strategic flexibility. Complexity, as a moderator, has conditional positive influence on the relationship between customer integration and SCA. This research advances supply chain literature by adding relationship-centric view in developing flexible and agile supply chains. Overall, the findings suggest Pakistani SME practitioners to allocate resources to activities that build flexible supply chains and invest in activities that create strong ties among downstream supply chain partners.

Objective: To determine the frequency of fatty liver (non-alcoholic) disease, Framingham 10-year cardiovascular risk score in rheumatoid arthritis patients. Methods: This study was conducted from September 1st to March 19, 2019, at Rheumatology OPD, Central Park Medical College Lahore. One hundred ninety two seropositive rheumatoid arthritis patients were recruited. Demographic details were noted, BP, BMI, smoking habits, and waist circumference were noted, then sent to radiology department for ultrasound scan of abdomen by an expert radiologist. On next day 10 ml blood was taken by phlebotomist for lipid profile and fasting blood sugar levels, after availability of results 10-years Framingham cardiovascular risk score was calculated. Results: Females were (81.3%) mean age of (45.4) years, fatty liver was present in n=39 (20.3%). In positive cases comorbid like metabolic syndrome was present (71.8%), diabetes mellitus (33.3%), hypertension (59%) FRS score (intermediate to high in (33.3%), history of hakeem/desi medication use (51.3%), while on regression analysis all study parameters except DMARD’s had significant association with fatty liver (p<0.05). Conclusion: Nonalcoholic fatty liver disease is very widely prevalent in rheumatoid arthritis patients. As in general population, it is multifactorial in origin and needs careful monitoring and treatment. doi: https://doi.org/10.12669/pjms.36.4.1984 How to cite this:Wagan AA, Bhutoo AQ, Khan D, Raheem A. Fatty liver in Pakistani cohort with rheumatoid arthritis. Pak J Med Sci. 2020;36(4):---------. doi: https://doi.org/10.12669/pjms.36.4.1984 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective: To fine out fatigue frequency and severity by FACIT-F scale in Pakistani cohort with rheumatoid arthritis. Methods: This study was conducted at department of Medicine division of rheumatology CPMC Lahore. After the approval of IRB, 192 patients of RA were recruited. Written, informed consent was taken, demographic details were noted, patients filled the URDU version of FACIT-F (fatigue severity scale). 5-ml of blood was taken for fasting blood sugar, viral markers and ESR by a trained phlebotomist. Each individual’s disease activity was assessed by DAS-28 and FACIT-F score was calculated. Results: The Mean age (39.9±10.5) years, (71.9%) were females. Fatigue frequency was 62% (n=126), age, education, hypertension, DAS-28, exercise levels and HCV gives significant association with fatigue score. Linear regression analysis, results showed one unit increase in DAS-28 will gives 2.71 unit increases in fatigue scores(P <0.05). Conclusions: We have very high frequency of fatigue in RA, increases with disease activity & associated conditions. doi: https://doi.org/10.12669/pjms.37.4.3602 How to cite this:Wagan AA, Raheem A, Bhatti A, Zafar T. Fatigue assessment by FACIT-F scale in Pakistani cohort with Rheumatoid Arthritis (FAF-RA) study. Pak J Med Sci. 2021;37(4):---------. doi: https://doi.org/10.12669/pjms.37.4.3602 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

A graph Γ (simple, finite, undirected) with an Ω-covering has an (α, δ)-Ω-antimagic labeling if the weights of all subgraphs Ω of graph Γ constitute an arithmetic progression with the common difference δ. Such a graph is called super (α, δ)-Ω-antimagic if ν(V(Γ)) = {1, 2, 3, . . . , |V(Γ)|}. In the present paper, the cycle coverings of subdivision of fan graphs has been considered and results are proved for several differences.