Background and Aim: Epidemiology of liver cirrhosis suggests that although Hepatitis B and C are still common in developing countries, alcohol related cirrhosis is increasing in countries like India. Rising trends in alcohol consumption in North India, makes it essential to analyse the influence of these changes on the clinical profile of liver cirrhosis. Therefore, we aimed to study 50 patients of cirrhosis of liver in Dhauladhar region. Methods: In this descriptive hospital-based study, 50 patients with evidence of liver cirrhosis diagnosed on history, imaging and investigations were included for a period of 12 months. Results: In our study, 72% patients aged between 40-60 years with a mean age was 50.4±10.1 years. Around 58% patients had CTP Class C disease suggesting advanced disease in our study. In our study, 88% patients were anemic. 74% had thrombocytopenia. 40% patients also had kidney dysfunction. Conclusion: Cirrhosis is common in the most productive age and they also have co-morbidities like anemia, thrombocytopenia, and renal dysfunction.

Background and Aim: Liver diseases are associated with low testosterone. However, little is known about risk factors of changes in testosterone. This study determined skeletal mass index in liver cirrhosis and associated risk factors with the abnormal testosterone levels. Methods: In this descriptive hospital-based study, 50 patients with evidence of liver cirrhosis diagnosed on history, imaging and investigations were included for a period of 12 months. Sarcopenia was defined as value of ≤36.5 cm²/m² in males and ≤30.2 cm²/m² in females. Results: The mean age was 50.4±10.1 years. The most common symptom was abdominal distension (50%) followed by upper GI bleed (30%), altered sensorium (20%), and jaundice (10%). Majority of the patients (58%) in our study were in CTP class C, followed by 16 patients (32%) in CTP class B, and 5 patients (10%) in CTP class A. 66% of the patients had low skeletal mass index. SMI was not associated with CTP class (P=0.463). Conclusion: There is a significantly higher prevalence of loss of skeletal mass in liver cirrhotic patients in this region.

We read with interest the article by Taguchi et al. about a 70 years-old female who developed Guillain-Barre syndrome (GBS) two months after onset of a mild SARS-CoV-2 infection [1]. Her history was conspicuous for left carotid endarterectomy, infliximab-treated rheumatoid arthritis, thyroid carcinoma, and apixaban-treated atrial fibrillation [1]. After the second cycle of intravenous immunoglobulins (IVIGs) the patient’s mental status deteriorated and she developed unilateral facial palsy [1]. She partially recovered only after plasmapheresis therapy [1]. It was concluded that SARS-CoV-2 can trigger GBS even two months after onset of the viral infection [1]. The study is appealing but raises concerns that need to be discussed.

We disagree that there is a causal relationship between the COVID-19 infection and GBS. In a study of 220 patients with SARS-CoV-2 associated GBS the latency period between viral infection and the onset of GBS was <5 weeks in the vast majority of cases [2]. Furthermore, no increased cytokines (interleukin (IL)-6, IL-8, IL-1a, TNF-alpha) were detected in the cerebrospinal fluid (CSF), as previously shown in patients with SARS-CoV-2 associated GBS [3].

We do not agree that the patient had posterior reversible encephalopathy syndrome (PRES) [1]. PRES is usually associated with arterial hypertension and visual disturbances [4] and only rarely with GBS. However, the patient was not diagnosed with high blood pressure [1]. Another argument against PRES is the disappearance of the cerebral lesion with plasmaphereses. PRES usually resolves after blood pressure values have returned to normal. The beneficial effect of plasmapheresis suggests an immunological rather than a non-immunological cause of the lesions. Another argument against PRES is that the combination of PRES and GBS has rarely been reported. 

The patient received the last infliximab injection one month before the onset of her COVID-19 infection [1]. It should be discussed to what extent immunosuppression with infliximab favoured the development of the SARS-CoV-2 infection, since infliximab can attenuate the anti-SARS-CoV-2 antibody response [5]. 

The altered mental state of the patient is not adequately explained. The patient obviously had hypothyroidism [1]. It should be discussed whether the cerebral lesion is due to hypothyroid (Hashimoto) encephalopathy as previously reported. Since IVIGs do not usually cause encephalopathy, hypothyroidism should be considered as the cause of the psychological change. 

In order to diagnose AMSAN it is crucial to detect the axon loss not only in motor but also in sensory fibers. It should be reported in which sensory nerves the amplitude of the sensory nerve action potentials was reduced.

Since SARS-CoV-2 infections can be complicated by ischemic stroke, we should be informed about the presentation of the lesion on diffusion weighted imaging (DWI) and apparent diffusion coefficient (ADC) sequences in cerebral MRI. 

A sufficient explanation of the elevated creatine-kinase (CK) is lacking. CK elevation could also be due to muscle toxic drugs the patient was taking for COVID-19, such as chloroquine. To   that end, it is important to know what medication she was currently taking in order to be able to assess whether one of the medications she was taking regularly or used during her hospital stay was causative. CK elevation could also be due to rheumatoid arthritis if accompanied by polymyositis, rhabdomyolysis, or due to ischemic stroke.

Overall, the interesting study has limitations that call into question the results and their interpretation. The long latency between COVID-19 and GBS argues against a causal relationship. Alternative causes could be a delayed side effect of infliximab, another subclinical infection, or a vaccination.

We read with interest the review article by Taga and Lauria on the involvement of the peripheral nervous system (PNS) in SARS-CoV-2 infections [1]. In the period from January 1, 2020 to December 31, 2021 the authors identified 92 patients with Guillain-Barre syndrome (GBS), 37 patients with isolated cranial nerve neuropathies, and 18 patients with myositis [1]. Additionally, single patients with chronic inflammatory demyelinating polyneuropathy (CIDP), vasculitic neuropathy, neuralgic amyotrophy, critical care-related complications, and myasthenia gravis had been identified [1]. It was concluded that conclusions about a pathophysiological correlation between COVID-19 and PNS disorders remain premature and solely supported by their temporal association [1], that PNS complications after COVID-19 vaccines are limited to a possibly higher risk of facial nerve palsy and GBS, and that the widespread access to the ongoing vaccination campaign should not be discouraged [1]. The study is attractive but raises concerns that need to be discussed. 

We disagree with the finding that only 92 patients with SARS-CoV-2 associated GBS were reported between January 1, 2020 and December 31, 2021 [1]. At least 220 patients with SARS-CoV-2 associated GBS were already reported between January 1, 2020 and December 31, 2020 [2]. In the first half of 2021 another eighty patients with SARS-CoV-2 associated GBS were published [Finsterer, submitted]. Therefore, SARS-CoV-2 associated GBS is far more common than indicated in the review.

We disagree with the statement in the abstract that PNS complications secondary to COVID-19 vaccines mainly include cases of GBS, Bell's palsy, and cases of neuralgic amyotrophy [1]. In a recent review of the neurological side effects of SARS-CoV-2 vaccinations, >3000 patients with headache, 389 with GBS, 312 with venous sinus thrombosis (VST), 11 patients with transverse myelitis, and <5 patients each with facial nerve palsy, small fiber neuropathy, autoimmune encephalitis, reversible cerebral vasoconstriction syndrome (RCVS), multiple sclerosis, neuromyelitis optica spectrum disorder (NMO-SD), ischemic stroke, intracerebral bleeding, Tolosa-Hunt syndrome, hypophysitis, ventriculitis, hyperactive encephalopathy, and acute disseminated encephalomyelitis had been reported [3].

We disagree that PNS manifestations of neuro-COVID include only isolated cranial nerve palsies, GBS, autoimmune plexitis, vasculitic neuropathy, CIDP, myasthenia, myositis, and critical ill neuropathy. PNS lesions not included in the review include small fiber neuropathy, pressure palsies due to bedding on the intensive care unit (ICU), myasthenic syndrome, dermatomyositis, and trigeminal neuropathy [4].

The review did not discuss the PNS side effects of various drugs commonly given to patients with severe COVID-19, such as chloroquine, tocilizumab, remdesivir, ritonavir, lopinavir, steroids, and various antibiotics. Toxic neuropathy, rhabdomyolysis due to the neurotoxic or myotoxic effect of anti-SARS-CoV-2 drugs should be included in a review of the PNS complications of SARS-CoV-2 infections.

Overall, the interesting study has some limitations and inconsistencies that call the results and their interpretation into question. Discussing these limitations might enrich the conclusions and their practical implications. The spectrum of neuro-COVID of the PNS is broader than commonly assumed.

We eagerly read the article by Gogia et al. about a 58yo male with left peripheral facial nerve palsy and a left sensory trigeminal nerve lesion four days after onset of clinical COVID-19 [1]. Work-up included only the clinical exam, blood tests, and a cerebral MRI without contrast medium. Under valacyclovir only partial remission could be achieved but for suspected respiratory deterioration, the patient received steroids, and convalescent plasma. The study is appealing but raises concerns that require discussion. 

The main shortcoming of the study is that the patient did not undergo investigations of the cerebro-spinal fluid (CSF) [1]. Since the patient had developed nausea and vomiting, and a focal neurological deficit, it is crucial to exclude meningitis and encephalitis. Since the patient presented with polyneuritis cranialis it is also crucial to exclude any Guillain-Barre syndrome (GBS) subtype, including polyneuritis cranialis. Knowing the results of CSF investigations is essential for deciding which type of treatment should be applied. 

Another shortcoming is that no explanation was provided as why the patient presented with dysphagia. Since the clinical neurologic exam was not indicative of cranial nerve IX or X involvement, we should be told if there were any indications for a brainstem lesion or even a supra-tentorial lesion that could explain dysphagia. 

The conclusions are contradictory to what has been presented in the case description. In the conclusions the authors claim that patients with COVID-19 should be carefully investigated by serial neurological exams, neuroimaging, CSF investigations, neurophysiology, and eventually biopsy. However, in the case description neither the results of the CSF investigations nor those of nerve conduction studies (NCSs) have been provided. Those who claim adherence to standards should adhere first.

It is not comprehensible why the patient did not receive steroids or immunoglobulins. Assuming that polyneuritis cranialis in the index patient was related to the acute viral infection and the immune response against the virus, it is mandatory to investigate the patient for an abnormal immunological response by measuring immunological parameters, such as cytokines, chemokines, or glial markers in the CSF. They have been previously reported to be upregulated in patents with GBS or polyneuritis cranialis [2].

A further shortcoming is that the long-term outcome of the SARS-CoV-2 infection and the polyneuritis cranialis was not provided.

Missing is a discussion about the deterioration of the respiratory situation. We should know if this was due to affection of the respiratory muscles in GBS or only due to worsening pneumonia. This delineation is crucial as it may determine the treatment significantly. We should know if the patient profited from steroids and convalescent plasma also with regard to polyneuritis cranialis. 

Missing is the application of contrast medium, as it may help to document that cranial nerve lesions [3,4]. 

Overall, the interesting report has several limitations, which challenge the results, their interpretation, and the outcome of the index patient. These limitations should be addressed to improve the diagnostic and therapeutic management of future patient SARS-CoV-2 associated polyneuritis cranialis.              

We eagerly read the article by Kajita et al. about a 60yo female who developed dysgeusia and hyposmia 6 days after a positive PCR test for SARS-CoV-2 [1]. Ten days after the test she experienced coughing with sputum being treated with appropriate antibiotics [1]. By day 15 after the positive test, she additionally developed numbness of the upper limbs, lower limb weakness, and dyspnoea [1]. By day 24 after the test, she was no longer able to stand and additionally complained about dysphagia, and bifacial palsy [1]. Guillain-Barre syndrome (GBS) was diagnosed and the patient profited from intravenous immunoglobulins (IVIG) [1]. The study is appealing but raises the following comments and concerns.

There is a contradiction between the clinical presentation on admission describing bilateral peripheral facial palsy and the clinical neurologic exam on admission revealing “intact cranial nerves” [1]. It should be clarified if there was indeed bilateral facial palsy or not on admission.

The second discrepancy refers to dysphagia on admission but unaffected cranial nerves on clinical exam [1]. We should be told if dysphagia was explained by affection of cranial nerves IX and X or by involvement of the brainstem. Did the patient ever undergo central nervous system (CNS) imaging to assess if she had Bickerstaff encephalitis or a supra-tentorial lesion that could explain dysphagia?

Another discrepancy refers to the stocking-type sensory disturbances the patient was referred for. Surprisingly, nerve conduction studies (NCSs) of the sural nerves were normal regarding the sensory nerve action potential amplitude and the nerve conduction velocity. Again, it should be excluded that the sensory disturbances were due to a CNS lesion, either on the spinal level or the cerebral level. 

Results of NCSs were interpreted as demyelinating [1]. However, compound muscle action potential amplitude of the right median nerve, both tibial nerves, and the sensory nerve action potential amplitude of the right median nerve were reduced suggesting rather an axonal than a demyelinating lesion. We should know if GBS was classified as acute, demyelinating, inflammatory polyneuropathy (AIDP) or as acute, motor and sensory, axonal neuropathy (AMSAN).

We do not agree with the statement that the prevalence and incidence of patients with SARS-CoV-2 associated GBS is higher in Europe than anywhere else [1]. No systematic studies about the global prevalence and incidence of SARS-CoV-2 associated GBS (SC2aG) are available. The number of European patients with SC2aG reported in the literatures may be higher than those from other countries, presumably due to the high prevalence of COVID-19 in countries like the UK, Italy, and Spain during the first year of the pandemic [2,3]. This falsely gives the impression that the prevalence of SC2aG is higher than outside Europe. However, SC2aG has been reported from all over the world [4], suggesting that SC2aG occurs globally.      

It is not comprehensible why it took 24 days before the patient was seen by a neurologist. Was this prolonged delay between onset of neurological manifestations and the neurological work-up attributable to the patient’s own decision or did the neurological abnormalities remain unrecognised by the treating physicians during this period?

Overall, the interesting study has several limitations that should be addressed before drawing definite conclusions. All inconsistencies should be eliminated and all contradictions should be resolved. This will strengthen the results and conclusions and can contribute to the understanding of SC2aG.

The pseudo-aneurysm is defined as a blood mass formed following a vascular wound and retained by the tissues surrounding the affected vessel. Post-traumatic pseudo aneurysm of the hepatic artery remains a rare entity, found in nearly 1.2% of abdominal trauma with liver damage. The causes were once dominated by contusions and abdominal wounds of traumatic origin, cholepancreatic surgery, liver transplantation, laparoscopic surgery. More rarely, the pseudo aneurysm of the hepatic artery is of mycotic origin, congenital in the context of certain vasculitis. It is noted that this entity is asymptomatic in 90% of cases. The time elapsed between the trauma and the discovery of the aneurysm go from a few weeks to several months, making it difficult to establish the diagnosis. The worst complication remains aneurysmal rupture , with a pejorative prognosis and a high mortality rate despite the progress of medical and surgical procedures. The confirmation of the diagnosis goes through the realization of a paraclinical assessment. The therapeutic strategy is not codified. It varies on a case-by-case basis.

Background: Present study was done to evaluate the Postoperative Clinical and Radiological assessment among patients of proximal tibial fractures treated with open reduction internal fixation with locking compression plate. Material and Methods: The study was conducted during 1^st August 2019 to 31^st October 2020 in the Department of Orthopaedic Surgery, Indira Gandhi Medical College Shimla that included 21 prospective and 4 retrospective cases who fulfilled the inclusion criteria with closed tibial plateau fracture. Results: All the patients were above 18 years of age; 60% of patients were between 31 to 60 years with mean age of 42.5±14.4 years. There were 21 males and 4 females. The ratio between male to female patients was 5.3:1. Post-operatively eighty percent patients had no articular step and 20% had residual step less than 5 mm. Condylar width was normal in 84% patients while 16% patients had residual widening of less than 5mm. Osteoarthritis occurred or progressed by one or two grades in 16% patients. Eighty four percent of the patients had no or mild pain and 16% of the patients had moderate pain on activity involving the knee joint. Average knee flexion achieved at final follow up was 128.4⁰±9.2⁰ and average extension was 8.6⁰±1.2⁰ All patients exhibited excellent to good stability. Rasmussen’s criteria showed excellent functional result in 56% patient, good in 36% patient and 8% patient had fair result. Mean Rasmussen functional score was 27.32.Excellent radiological results were observed in 76% patients, 20% patients had good and 4% had fair results. Mean Rasmussen radiological score was 8.24. Conclusion: Post-operatively, there was decrease in articular depression, restoration of condylar widening to normal, osteoarthritis was not present or not progressed, restoration of full Range of motion both in flexion as well in extension and had excellent Clinical & Radiological results according to Rasmussen score in majority of treated patients.

Background: Present study was done to evaluate theFinal outcome and complications among patients of proximal tibial fractures treated with open reduction internal fixation with locking compression plate. Material and Methods: The study was conducted during 1^st August 2019 to 31^st October 2020 in the Department of Orthopaedic Surgery, Indira Gandhi Medical College Shimla that included 21 prospective and 4 retrospective cases who fulfilled the inclusion criteria with closed tibial plateau fracture. Final outcomes were obtained after combining functional and radiological outcomes. Results: All the patients were above 18 years of age; 60% of patients were between 31 to 60 years with mean age of 42.5±14.4 years. There were 21 males and 4 females. The ratio between male to female patients was 5.3:1. Fifty-six percent patients had excellent, 36% had good and 2% had fair functional outcome. Excellent radiological results were seen in 76%, good in 20% and fair in 4% patient. No patient had poor functional and radiological results. At the end of the study, we found that 92% of our patients had acceptable results which included excellent in 56% and good in 36%. While no patient had poor outcome, 8% patients reported a fair but non-acceptable final outcome. Final outcomes was dependent on age, activity level of the patients, type of fracture, associated injuries, other co-morbidities and compliance to physiotherapy presence or absence of complications, other co-morbidities and postoperative rehabilitation. Twenty percent patients had complications. Superficial infection (8%) and knee stiffness (8%) were the most common complications. Conclusion: Majority of patients of proximal tibial fractures treated with open reduction internal fixation with locking compression plate had excellent clinical and radiological results and had acceptable results. Superficial infection and knee stiffness were the most common complications.

Background: COVID 19 pandemic has caused additional challenges and insurmountable psychosocial impact for patients with opioid use disorders. The particularly challenging group include those seeking treatment with medication for OUD patients. This article discusses the bi-directional effects between opioid use disorder patients and covid 19. Method: PubMed and Google Scholar were searched with the following keywords- “COVID-19”, “opioid use disorder”, “pandemic”, “behavioural addiction”, “opioid”, “opioid agonist therapy”. Results: People with opioid use disorder are at a heightened risk of acquiring and increased severity of COVID 19 infections due to compromised immunity, homelessness or housing instability, lockdown and social distancing leading to failure of rehabilitation strategies, mucociliary dysfunction, cardiopulmonary morbidities, etc. Conclusion: covid 19 pandemic and opioid use disorder is on the verge of the collision so every effort must be taken by the government and health care sector to prevent a big wave of opioid overdose and relapse in our community.

Ever increasing use of technology in day to day life activities has made distance education evolved into online or E-learning, which has many benefits for teachers on one side and leaners on the other side. E-learning has now become a key application in many fields like education, business and commerce. In our study we tried to focus on various concepts of E-learning its evolution in India, technology used, various advantages and challenges involved in its adoption and implementation. The research shows that there is abundant availability of technology and E-learning tools which can be widely used in education systems and this is expected to grow hugely in the near future.

The relationship between a person's lifestyle and the degree of atherosclerosis is very important. Trying to find such a connection is the goal of many researchers. It is also the purpose of the author's work, a brief description of which is given in this review. Method: Study of information on the Internet, participation in medical conferences, participation (only for 2021) in 3 international webinars on atherosclerosis, publication of articles. Results: The importance of this issue for modern man is very great.

Dyes are referred to as stains which are used to add color to tissues and microbes to make them optical distinct. The dyes are both synthetic and natural, the synthetic ones may be harmful, hazardous to health and are costly to obtain. Natural dyes are eco-friendly, not costly and not hazardous to health as compared to synthetic dyes. In this study, various procedures such as H&E which serves as control as normal routine staining in histopathology laboratory was used to compare Beetroot and Eosin (B&E), Haematoxylin and Turmeric (H&T). Beetroot and Turmeric (B&T) Beetroot and Eosin stains collagen fibre almost similar to H&E, that shows beetroot can be used as alternative for Haematoxylin in H&E staining technique. Haematoxylin and Turmeric stained the tissue almost similar to H&E which shows that Turmeric can replace Eosin. However, B&T poorly stained collagen fibre when compared with H &E. The conclusion came out that, Beetroot containing Betanin which gives it a red color has the same ability of staining Nuclei Bluish because of its basic content and may require a mordant (Vineger) as attain enhancer for most of the tissues. Turmeric exhibits the basophilic-like effect on collage fibre, it stains the cytoplasm fairly yellowish, because of its curcumin that makes it yellow Beetroot and Turmeric as a direct replacement of H&E staining technique in Histopathology laboratory should further be studied with adequate concentration and mordant as the features is suggestive that B&T can replace H&E.

Background: Now a day, type-2 diabetes mellitus and hypertension are considered to be the first and second leading causes of all deaths and morbidities respectively. Increasing age, trend of obesity and worsening renal function increasing the prevalence of hypertension in people with type-2 diabetes mellitus. We have very few research-based information regarding these issues. Aim of the study: The aim of this study was to assess the prevalence of hypertension in patients with type-2 diabetes mellitus. Methods: This was a cross-sectional study which was conducted in the Department of Medicine and Endocrinology of Bangabandhu Sheikh Mujib Medical University, Dhaka Bangladesh. In total 142 patients with type-2 diabetes mellitus attended to the mentioned hospital with proper documents were finalized as the study people. Besides data regarding type 2 diabetes mellitus, data of blood pressure and macro-vascular as well as micro-vascular complications were collected. A predesigned questioner was applied to collect patient data. All data were processed, analyzed and disseminated by MS Office and SPSS version 20. Results: In this study, among total participants in analyzing the prevalence of hypertension we observed out of 142 patients with T2DM only 45 were with hypertension which was 32%. In analyzing the stages of hypertension among total participants we found, 23.39% were with normal and 35.92% pre-hypertension (In total 68.31%). On the other hand, among 32% hypertensive participants, 19.72% (n = 28) were with stage I HTN whereas 11.97% (n = 17) were with stage II HTN. Conclusion: In this study, the prevalence of hypertension among type 2 diabetes patients was found some higher than that in normal. But if we consider the number of pre-hypertensive patients as a potential concern, then it is alarming. The findings of this study may be helpful in the treatment arena of diabetes and in similar further studies. 

Type 2 Diabetes mellitus (T2DM) is characterized by high blood sugar caused by a lack of insulin, insulin resistance, or both. It's linked to the onset of secondary problems, which can lead to a variety of co-morbidities. Recent research has found that diabetics are more likely to acquire cognitive impairment or dementia. Diabetes is linked to a number of neurological illnesses, including Alzheimer's disease (AD). Evidence of a relationship between diabetes and AD is growing. Insulin signalling disruption in the brain has been discovered, resulting in increased tau protein phosphorylation (hyperphosphorylation), a hallmark and diagnostic of AD pathology, and the buildup of neurofibrillary tangles (NFT). Insulin malfunction in the brain has been shown to modify glycogen synthase kinase-3β (GSK-3β) activity, resulting in increased β amyloid and tau phosphorylation in diabetics. GSK-3β signalling has been implicated in the physiological and pathological processes of diabetes and AD, respectively. This could explain why diabetic individuals have a higher chance of developing AD as their diabetes progresses and they get older. Interestingly, several in vivo investigations with oral antidiabetic medications and insulin treatment in diabetic patients showed improved cognitive function and lower tau hyperphosphorylation. The relationship between T2DM and AD as it relates to amyloid and tau pathology will be discussed in this article. A better knowledge of the relationship between T2DM and AD could transform how researchers and doctors handle both diseases in the future, potentially leading to new therapies and prevention techniques.

Aims and Objectives: To study the role of ESS in diagnosis of OSA. Material and Methods: Sample size: 50. patients visiting Pulmonary Medicine OPD. Inclusion Criteria: Patients age 20 years and above. Patients with BMI more than 25. Patients consenting for study. Patients on regular follow-up in OPD. Exclusive Criteria: Patients not consenting for study. Patients with active tuberculosis. Patients on anti-psychotic medications. Patients with GCS less than 12.

Aims and Objectives: To determine the impact of pulmonary rehabilitation program in patients with COPD regarding. Clinical symptoms. Status of exercise tolerance. Status of physical and social performance. Quality of life. Method: 50 patients with stable COPD, who were willing to participate, were included in study. All patients were taught chest physiotherapy, bronchial hygiene, education about disease and its management and proper nutrition. All patients were assessed regarding any psychological problems. Daily 30-35 minute sessions were conducted at institute for initial 4 weeks and then home care was taught. Patient was assessed periodically for symptoms, quality of life and spirometric findings. All variables were recorded at baseline and after completion. Statistical analysis were performed using student’s‘t’ test and p values observed. Result: Dyspnea scale measured by Modified Medical Research Council (MMRC) (3.0 ± 0.66) improved after program (1.89 ± 0.83, p value <0.0001) which is statistically very significant. Health related quality of life measured by using St. George’s Respiratory Questionnaire 49.74 ± 5.17 improved significantly 40.92 ± 4.87 after program (p value <0.0001). 6-minute walk distance (280.9 ± 18.04) improved significantly after program (303 ± 17.34) (‘p’ value <0.0001). Spirometric parameters like FVC (p value 0.02), FEV₁ (p value 0.17) and FEV₁ / FVC ratio (p value 0.76) do not show any statistically significant changes after program.

Corona virus pandemic started in the December 2019 in Wuhan state of China. From this city the virus spreads throughout the world within very short duration. Experts predicted that like other pandemics, world has encountered in past, this corona pandemic should be followed by second and third wave. The corona virus second wave, like first wave also affects every aspects of life. Huge amount of death results in developing countries due to inadequate oxygen supply and lack of proper treatment. Some areas of the world where number of coronavirus infections were huge during the first wave, cases of corona infection reduce but again increased cases were reported during “second wave”. In this article, we have focussed on the effect of second wave of Covid-19 pandemic on environment, industries and economy. 

This paper aims to assess the prevalence of primary infertility among women of reproductive age, where the study was conducted in Al-Dholuiya General Hospital, Al-Shiqat General Hospital, Salah Al-Din, Iraq. Where 100 women patients (infertility) and 100 women were collected as a control group. The analysis of data and demographic information for patients and the control group was based on the statistical analysis program SPSS soft 22, mean value and SD to the ages of the patients were identified, and study design based on questionnaire questions and private interviews in order to find more information and data about patients and statistical differences were found between the two groups of patients and the control group, at ≤0.05

Background: Spain is one of the main countries in the world in international adoption, and Nepali children account for 0.8% of all adoptees. According to United Nations, Nepal is a poorly developed country. Due to the quality of medical care that Nepali children receive in orphanages, it has been reported that the diagnoses described in the pre-adoptive medical reports do not offer an absolute guarantee of accuracy, and sometimes these reports are not provided to adoptive families. The objective of this study was to describe epidemiological characteristics, pre-adoptive history, and medical problems observed in the post-adoption evaluation in a cohort of children adopted from Nepal. Material and Methods: Retrospective descriptive study on 11 Nepali adopted children from 2005 to 2011, examined according to a standardized protocol. Variables were collected from pre-adoption medical reports, interviews with the family, and post-adoption evaluation records. Results: Epidemiological characteristics and pre-adoptive history: females, 63.6%; all were abandoned and adopted from orphanages; mean age at institutionalization was 32 months, and at adoption was 55 months. 72.7% had a pre-adoptive medical report, and all were diagnosed as "healthy". 54.5% had a vaccination certificate. Medical problems most frequent diagnosed in post-adoption evaluation were iron deficiency anemia (72.7%), xerosis cutis (54.4%), neurodevelopmental delay (45.5%), underweight and stunting (36.4%), and acute bronchitis (36.4%). Only one child had a serious problem (cerebral palsy). The BCG vaccination scar was present in 81.8%. 72.7% showed vaccination immunity against hepatitis B virus. Conclusion:The pre-adoption medical information for the Nepali children was unreliable, and all showed more than one medical problem in the post-adoption evaluation. Adoptive families should seek pre-travel specialized medical advice regarding the medical reports and health of the child to be adopted, the updating of routine immunizations, and the destination-specific health problems.

With interest we read the article by Krueger et al. about four pediatric patients with symptomatic COVID-19 who experienced severe neurological complications from the viral infection [1]. A 16 years old female experienced polyradiculitis (patient-1), a 15 years old male developed Guillain-Barre syndrome (GBS) subtype acute, inflammatory, demyelinating neuropathy (AIDP) (patient-2), a 5 years old female developed acute intracranial hypertension (patient-3), and a 2 years old male experienced focal seizures during the infection (patient-4) [1]. The study is appealing but raises some concerns and comments.

We do not agree with the notion that COVID-19 in pediatric patients usually takes a mild course [1]. There are several reports about paediatric patients with severe COVID-19 or its complications [2,3].

Cranial MRI of patient-1 showed contrast enhancement of cranial nerves VII and VIII bilaterally but clinical neurological exam did not detected any abnormalities of these nerves [1]. How do the authors explain this discrepancy? We should be told if there was hearing impairment, vertigo, or facial palsy bilaterally. 

A limitation is that table 1 does contain reference limits [1]. Applying our own reference limits, patient-1 had only mild pleocytosis, which does not exclude GBS, particularly in the light that patient-1 also had Dengue. Thus, it is conceivable that the patient had GBS triggered by Dengue and not by SARS-CoV-2.

Concerning patient-3, it is not certain that SARS-CoV-2 was responsible for intracranial hypertension. The patient had a history of a hypertensive arachnoid cyst requiring cerebro-spinal fluid (CSF) derivation via a ventriculo-peritoneal shunt [1]. It is conceivable that the shunt function was impaired due to an altered composition of the CSF resulting in increased intracranial pressure. It is also conceivable that the patient had experienced venous sinus thrombosis (VST), a frequent complication of SARS-CoV-2 infections [4]. We should be informed about the results of magnetic resonance venography (MRV) and the D-dimer. 

Concerning patient-4 we should be told if “cerebral MRI” also included MRV and if the D-dimer was elevated. VST is frequently complicated by seizures [5]. We should also know if the family history was positive for epilepsy and if patient-4 had seizures already prior to the SARS-CoV-2 infection. A causal relation between COVID-19 and epilepsy in this patient remains unproven.

It should be emphasised that SARS-CoV-2 RNA was found in the CSF of patient-1 [1]. This finding is remarkable as only in two other patients (one adult, one pediatric patient) SARS-CoV-2 was detected in the CSF so far [6,7]. Virus RNA is usually absent in the CSF of patients with SARS-CoV-2 associated GBS [8] but in infectious polyradiculitis presence of SARS-CoV-2 in the CSF may support the speculation that an intrathecal virus infection was truly responsible for the clinical presentation.

Overall, the elegant study has several limitations which challenge the results and their interpretation. SARS-CoV-2 infected patients with severe neurological complications need to be thoroughly investigated to explain the clinical presentation and to apply appropriate treatment. Before establishing a causal relation  between

COVID-19 and neurological compromise, thorough work-up and exclusion of differentials is compulsory.

With interest we read the article by Correa et al. about cranial nerve imaging findings in six patients infected with SARS-CoV-2 who developed concomitant facial nerve palsy (n=4), optic nerve involvement (n=1), abducens palsy (n=1), and an olfactory nerve lesion (n=1) [1]. It was concluded that the full neurological features of COVID-19 remain to be characterized, that cranial nerve lesions are part of COVID-19, and that MRI can help detecting these abnormalities [1]. We have the following comments and concerns.

An infection with SARS-CoV-2 may not only be associated with a lesion of cranial nerves I, II, VI, or VII but has been reported also for cranial nerves III [2], IX and X [3].

In the method section it is stated that all patients presented with pulmonary symptoms [1]. However, patient-4 had only mild fever and a sore throat, patient-5 had only fever and myalgia, and patient-6 had only fever [1]. This discrepancy should be clarified. 

Affection of cranial nerves may occur in the context of Guillain-Barre syndrome (GBS) [4]. Thus, it is crucial that GBS is excluded in all patients in whom a clear etiological determination is not possible, such as patient-4, patient-5, and patient-6. Cranial nerve lesions may also occur together with Bickerstaff encephalitis, a subtype of GBS. We should know if Bickerstaff encephalitis was appropriately excluded in each patient. 

SARS-CoV-2 as the cause of bilateral, peripheral facial palsy in patient-6 was not substantiated. The patient was only mildly symptomatic (fever) and facial palsy developed two weeks after having been tested positive for SARS-CoV-2. Furthermore, enhancement of the nerve was found in the canalicular and labyrinthine portions, a location which is frequently affected in Bell’s palsy [5]. Thus, it is conceivable that facial palsy was in fact Bell’s palsy and independent of the previous SARS-CoV-2 infection. A further argument for Bell’s palsy is the beneficial effect of steroids.

There is also no convincing findings arguing in favour of a causal relation between SARS-CoV-2 and right unilateral, peripheral facial palsy in patient-4 [1]. The patient only presented with mild fever and sore throat. Facial palsy developed 10 days after the initial symptoms. Thus, it is conceivable that also patient-4 had Bell’s palsy without a causal relation to SARS-CoV-2. A further argument against the SARS-CoV-2 etiology is that the frequency of peripheral facial palsies did not increase since the outbreak of the pandemic. 

We also should know how a subacute, lacunar ischemic stroke in the pons of patient-3 was excluded. The MRI findings regarding the right facial nerve are not convincing. It is more likely that the right facial nerve was affected by the abducens nucleus lesion since the facial nerve surrounds the abducens nucleus in this location.

The authors argue that SARS-CoV-2 does not occur in the CSF but only patient-5 underwent CSF investigations. 

In patient-2. optic neuritis was diagnosed. How was acute, ischemic optic neuropathy (AION) or posterior, ischemic optic neuropathy (PION) excluded? Even if aquaporin antibodies are negative, neuromyelitis optica (NMO) can be present. Were MOG-antibodies positive? We should know the results of CSF investigations, if intrathecal   IgG   were  elevated   and if oligoclonal bands(OCB) were positive. It is also conceivable that that patient had a retro-bulbar neuritis (RBN) and has to be diagnosed with cerebral isolated syndrome (CIS).

A further shortcoming of the study is that no delineation between central and peripheral facial palsy was carried out. The distinction is crucial for diagnostic and therapeutic purposes. 

Overall, the interesting study has several shortcomings, which should be addressed before drawing conclusions as those presented. Particularly, a causal relation between SARS-CoV-2 should be established in patient-4, patient-5, and patient-6, peripheral and central facial nerve lesion should be delineated, nerve conduction studies should be carried out to confirm the peripheral nature of the lesion, and in all patients GBS should be excluded.

Kawasaki disease (KD), also known as Kawasaki syndrome, is an acute febrile illness of unknown cause that primarily affects children younger than 5 years of age. The present study was conducted to study the clinical profile and outcome and risk factors of Kawasaki disease in children. This observational prospective study was conducted in cardiology ward with a diagnosis of Kawasaki disease from 1^st June 2020 to 31 July 2021 in Bangabandhu Sheikh Mujib Medical University Hospital Dhaka, Bangladesh. Forty-five (45) children aged between 3 months to 10 years were studied. Kawasaki disease is more prevalent among male child (73.33%). Most commonly encountered risk factor for cardiovascular involvement especially coronary dilatation or aneurysmal change is more observed in younger age of presentation. Fever, rash, conjunctivitis, erythema and edema of limbs, periungual skin desquamations are the presenting features. Cardiovascular involvement of left main coronary artery dilation is the most frequently observed aneurismal change observed among study population which was evident in 68% of the children having coronary involvement. All the study patient received high dose aspirin (100%) and 93% received IVIG of whom 6.66% had IVIG- resistant Kawasaki disease. Commonly occurring complication is uveitis (17.77%). Among the total 45 study population 1 patient expired (2.22%). Clinicians should have a high index of suspicion of Kawasaki disease in persistently febrile patients and once clinically diagnosed, echocardiography should be done and IVIG therapy along with aspirin should be started, specially in infants (<6 months) as they have the higher tendency to develop coronary aneurysm.

Background: Confusion about elements of a research paper is common among students. The key to writing a good research paper is to know these common elements and their definitions. Maybe find that writing a research paper is not as easy as it seems. There are many parts and steps to the process, and it can be hard to figure out what needs to do and when. Objective: This article aims to teach these common aspects of a research paper to avoid common mistakes while drafting own. Conclusion: Each section of the research paper serves a distinct purpose and highlights a different aspect of the research. However, before starting drafting the manuscript, having a clear understanding of each section's purposes will help avoid mistakes.

The research aims to determine the frequent causes of infertility in infertile couples Where 500 patients were collected from Alhusaina Hospital, Karbala, Iraq. and all causes leading to infertility were studied, and by relying on statistical analysis to analyze data and demographic information on patients, it was found that the most common causes leading to infertility in women were menstrual problems and ovarian cysts, a condition that leads to infertility in women as for men, it is the presence of disorders in the semen.