Shalamar Hospital

Systemic disorder of unknown etiology, characterized by arthritis, fever, transient rash, and other systemic presentations. We report a case of AOSD with history of high-grade fever, joint pains and clinical examination, which revealed the characteristic Salmon-pink evanescent rash is seen in AOSD, which could have been easily missed as it disappears when fever subsides, and its diagnosis was supported by very high levels of serum ferritin, and we confirmed the diagnosis by fulfilling the Yamaguchi criteria after excluding the other possible diagnoses. She showed a partial response to prednisolone but later was advised to take methotrexate, which resulted in further alleviation of her residual symptoms. Conclusion: Every Fever doesn’t carry an infectious etiology; try to think outside of the box and careful history and examination and in turn, supported by the pertinent investigations, can lead to solve these sorts of enigmatic cases as was done in our case Keywords: Adult-onset still’s disease, AOSD, Arthritis, Evanescent rash, Prednisolone, Yamaguchi criteria

Chemotherapy-Induced Cardiotoxicity (CIC) has become a growing concern in modern oncology. While chemotherapy remains one of the most effective treatments against cancer, its potential to harm the heart often limits its use. The underlying mechanisms involve oxidative stress, mitochondrial dysfunction, and inflammation, all contributing to the gradual weakening of cardiac muscle. As cancer survival improves, the burden of cardiovascular complications is more visible than ever, emphasizing the need for early recognition, prevention, and long-term management. This review draws upon published literature, recent clinical trials, and translational research to explore current understanding and future directions in CIC. Studies on anthracyclines and HER2 inhibitors were reviewed in depth, along with new data on diagnostic biomarkers, imaging techniques, and evolving therapeutic strategies. Particular attention was given to the role of pharmacogenomics, preventive interventions, and emerging therapies aimed at protecting or restoring cardiac function in patients undergoing chemotherapy. CIC can present as heart failure, arrhythmia, hypertension, myocardial ischemia, or thromboembolism. Factors such as age, obesity, cumulative drug exposure, and genetic predisposition significantly raise the risk. Recent advances have improved early detection-troponins, natriuretic peptides, and echocardiography with Global Longitudinal Strain (GLS) allow for identification before overt symptoms appear. Preventive strategies, including dose adjustments, liposomal formulations, and the cardioprotective agent dexrazoxane, have shown measurable benefits. Established cardiotoxicity can be managed with conventional heart failure medications, antihypertensives, and anticoagulants. Experimental approaches-ranging from mitochondrial stabilizers and histone deacetylase inhibitors to mesenchymal stem cell therapy-show promise in reversing cardiac injury. CIC reflects a complex interaction between cancer biology, treatment intensity, and patientspecific vulnerability. A proactive, multidisciplinary approach involving both oncologists and cardiologists is key to balancing cancer control with heart health. Lifestyle measures such as regular exercise and dietary optimization can further strengthen cardiovascular resilience. Advances in genetic testing, molecular imaging, and regenerative therapy are gradually shifting the field toward more personalized cardio-oncology care. Chemotherapy-induced cardiotoxicity continues to challenge clinicians striving for a cure without compromise. The future of cancer care lies in integrating precision medicine with preventive cardiology to minimize cardiac injury while maintaining therapeutic efficacy. Continued research into molecular targets, biomarkers, and cell-based therapies offers genuine hope for improving both survival and quality of life in cancer patients.

To the Editor, Telesurgery, also known as robotic surgery conductor through high-speed telecommunication networks, is amongst the most evolving areas of modern surgical technology frontiers. Since the successful transcontinental telesurgery that led to the validation of the usability of telesurgery over thousands of miles, technology in robotic surgery has developed significantly with advancements in imaging capabilities, motion scaling, and Artificial Intelligence-based decision support[1]. Further development in telesurgery programs with standardized training courses in robotic surgery has also assisted in training experts across the globe in this technology[2,3]. Recent developments in 5G communication technology and fiber optic communication have decreased the time gap and made telesurgery ready to change the technological face of modern surgery in order to make specialty surgical facilities available to all, leaving no geographical hurdles in their way, especially in rural areas[4–6]. Nevertheless, despite these technological advancements, “latency measured as the time between a surgeon’s control command and the corresponding action performed by the robot remains the single most important technical issue that presently affects telesurgery safety and accuracy.” Latency was found to directly influence dexterity, synchronization, and mental task performance. Some important studies have established that there is a substantial loss of accuracy once a threshold of delay is crossed[7]. Later studies carried out on simulators have established specific delay levels above which a tolerance threshold is acceptable. Delays of sub-200 ms values protect task performance, but at a delay of about 300 ms, this is mostly feasible. However, above a delay of either 500 ms or 700 ms, there is a substantial drop-off in precision[8,9], and further studies using animal subjects continue to validate these ranges, which are also confirmed by successful task accomplishment within a delay range of about 220–320 ms, past which there is adverse effect on suturing and manipulation of tissues[10]. However, studies continue to corroborate that telesurgery could accomplish a task with an equal measure of precision as conventional surgery, despite varying amounts of delay[6]. In considering the confirmation of these assertions with the evidence that actually exists, the importance of the preconditions of scalability in the real world, infrastructure variety, and surgeon accommodation has been noted as an area still waiting for further investigation through systematic reviews[6]. Although contemporary robots are able to integrate the effects of small lag times with predictive motion analysis and adaptive control loops, these are still in the process of being developed and have had little opportunity for validation[5]. There is also great interest in the universal implementation of telesurgery that must be tempered with the realities of availability and the effects of variation on networks. Times under 200 ms are ideal for preserving the natural synchronization of the hands and the eyes, 200–320 times may be manageable with optimal implementations, but beyond that range, the clinical validity starts becoming important. Therefore, in light of the increasing focus on digital surgery reported recently in Annals of Medicine and Surgery, the discussion surrounding latency thresholds calls for a re-evaluation. It thus seems that although significant progress has been achieved with telesurgery technology, the proportionate interface between the claim and the evidence documented is imbalanced. We confirm that no AI tools were utilized in the conduct or writing of this manuscript, in accordance with the TITAN checklist[11].

Amyloidosis is increasingly recognized as a contributor to heart failure, particularly among older adults and patients with heart failure with preserved ejection fraction (HFpEF). Despite advances in diagnostic imaging and disease-modifying therapies, amyloidosis remains underdiagnosed in many settings, and population-level data examining its co-occurrence with cardiovascular disease on death certificates are limited. This study examined two decades of national mortality data to evaluate deaths co-coded with amyloidosis and cardiovascular disease (CVD) in the United States and to assess temporal trends and demographic disparities in age-adjusted mortality rates. A retrospective analysis was conducted using mortality data from the CDC WONDER database spanning 1999-2020. Age-adjusted mortality rates (AAMRs) per 1,000,000 persons were calculated, and trends were assessed using Average Annual Percentage Change (AAPC) and Annual Percent Change (APC) using Joinpoint 5.0.2. Between 1999 and 2020, 26,391 amyloidosis and CVD-related deaths occurred among adults aged 25 years and older in the United States. The overall AAMR for deaths co-coded with amyloidosis and CVD increased from 4.40 in 1999 to 9.31 in 2020, with an AAPC of 3.49 (p < 0.001). The most pronounced increase occurred between 2018 and 2020 (APC: 13.60). Rates were higher among men than women, with both sexes showing a marked increase in the last decade. African American or Black individuals had the highest rates (11.40), followed by White (5.11) and Hispanic (3.86) individuals. Rates were highest in the Northeast region (6.71). Metropolitan areas had higher rates than non-metropolitan areas (5.73 vs. 4.76), with a more pronounced increase in metropolitan regions. Age-adjusted mortality rates for deaths co-coded with amyloidosis and cardiovascular disease have increased over time, likely reflecting improved recognition and documentation. Higher rates of co-coded deaths were noted among men, African Americans, and individuals in the Northeast region, highlighting potential disparities in diagnostic access and recognition.

Glaucoma is the second leading cause of blindness worldwide. It is a neuropathic disease, mostly inherited in an autosomal recessive form. Primary congenital glaucoma (PGC) is characterized by increased intraocular pressure and optic nerve damage. It is a clinically and genetically heterogeneous eye disorder. To date, four genetic loci are reported to have been linked to PCG, including GLC3A, GLC3B, GLC3C, and GLC3D. The CYP1B1 gene resides in the GLC3A locus on chromosome 2. Mutations in the CYP1B1 gene are linked to PCG. It is most prevalent in countries like Pakistan, where consanguinity is common. Both familial and sporadic forms of PCG are common in Pakistan. This study was undertaken to analyze the mutations in the CYP1B1 gene in the cause of PCG in consanguineous Pakistani families. The CYP1B1 mutations linked to PCG in consanguineous Pakistani families were analyzed from a thorough analysis of the data available to date on Google Scholar, Medline, and PubMed, and were further demonstrated by a pie-chart diagram. The graphical representation of the percent prevalence of these mutations was accessed. A total of 98 missense, frameshift, and nonsense mutations were found. The missense mutation, p.Arg390His, was the most significant, particularly in Punjab, followed by the p.Glu229Lys mutation. In Pakistan, there is a higher prevalence of PCG in consanguineous families. Several mutations in the CYP1B1 gene cause PCG in the Pakistani population, with p.Arg390His being the dominant one. Knowledge of prevalent PCG-causing mutations in a population is useful in establishing prenatal and pre-symptomatic diagnoses for better glaucoma management.

Objective: To compare the effectiveness of combined surgery versus isolated prolapse surgery in alleviating urinary leakage symptoms. Study Design: Quasi-experimental study. Place and Duration of Study: Urogynecology unit of Shalamar Hospital, Lahore, Pakistan, from Sep 2024 to May 2025. Methodology: A total of 17 participants presenting with overt urinary leakage along with prolapse of pelvic viscera, scheduled for surgery, were included in the study. The primary outcome was the resolution of stress urinary incontinence (SUI). Negative cough stress test conducted at six months was considered an objective cure. Mean±SD was used for continuous variables, while categorical variables were presented as frequencies and percentages. Statistical significance was considered at a p-value of less than 0.05. Results: Out of the 17 patients, 9(52%) underwent exclusive prolapse repair, while 8(47%) received both prolapse repair and anti-incontinence surgery. At six months, women in the combined surgery group were more likely to report the absence of stress urinary incontinence (SUI) compared to those in the prolapse surgery-only group, with 75% versus 33%, respectively. Additionally, two women (25%) in the combined group required further treatment for SUI (all physiotherapy), compared to six women (66%) in the control group, who also received physiotherapy. Conclusions: Women are less prone to have incontinence after combined surgery compared with isolated POP surgery and are less likely to undergo additional treatment for SUI.

Thyroid peroxidase antibody (TPOAb) positivity is the most important risk factor for hypothyroidism and determines thyroid function follow-up during pregnancy. TPOAb positivity is usually defined by manufacturer cut-offs which typically derived from non-pregnant populations. However, as a state of immune tolerance, pregnancy can affect TPOAb concentrations. To improve the understanding of clinical relevance of TPOAb concentrations during pregnancy, we investigated the association of TPOAbs with maternal thyroid function. We performed an individual participant data meta-analysis embedded in the Consortium on Thyroid and Pregnancy. Participants with multiple gestations, pre-existing thyroid disease, thyroid (interfering) medication usage, or conception by in vitro fertilization were excluded. We used mixed effects regression models to assess the association of TPOAb percentiles calculated in each cohort with maternal thyroid function. The study population comprised 62,634 pregnant women from 24 cohorts. As compared to TPOAb percentiles ≤80, there were progressively higher mean thyroid stimulating hormone (TSH) concentrations across TPOAb percentiles ≥89, with corresponding mean differences ranging from +0.11 SD (95% confidence interval [CI] +0.04 SD, +0.19 SD) at the 89th percentile to +1.04 SD (95% CI+0.96 SD, 1.11 SD) at the 100th percentile. Higher TPOAb percentiles were associated with progressively lower mean free thyroxine (FT4) concentrations across TPOAb percentiles ≥91, with corresponding mean differences ranging from -0.08 SD (95% CI -0.16 SD, -0.01 SD) at the 91st percentile to -0.48 SD (95% CI -0.56 SD, -0.4 SD) at the 100th percentile. From the 89th TPOAb percentile upwards, there were progressively higher risks of TSH >4.0 mU/L, with absolute risks of 2.4%, 4.0%, and 28.1% in cases of ≤80th, 89th, and 100th TPOAb percentiles, respectively. Higher TPOAb percentiles were also associated with lower thyroidal response to human chorionic gonadotropin stimulation and higher risks of overt and subclinical hypothyroidism. In 19 of the included cohorts, there were 0.4-6.3% of pregnant women with TPOAb concentrations lower than the positivity cut-offs but larger than or equal to the 89th-percentile concentrations. The associations of TPOAbs with TSH and with FT4 were most apparent during early pregnancy (P for interaction <0.001 for both TSH and FT4). During pregnancy, TPOAbs were dose-dependently associated with TSH, FT4, and the risk of abnormal thyroid function. With concentrations below currently used positivity cut-offs, TPOAbs could be associated with lower maternal thyroid function, which indicates clinically relevant thyroid autoimmunity. These findings implicates that high normal TPOAb concentrations upon first assessment in pregnancy may warrant active follow-up.

Current ESC/EACTS guidelines recommend standard-duration dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI). However, the subsequent transition to either extended DAPT or single antiplatelet therapy (SAPT) remains debated due to limited comparative outcome data. This Bayesian meta-analysis and meta-regression evaluate the clinical safety of DAPT versus SAPT, and the impact of potential confounders on all-cause mortality. Following PRISMA guidelines, a systematic search of PubMed, Embase, Cochrane Library, ScienceDirect, and Scopus was conducted till April 2025 to identify randomized clinical trials (RCTs) and cohort studies. Primary outcomes were all-cause mortality and bleeding events. Bayesian random-effects meta-analysis was performed using the brms package in R with Markov Chain Monte Carlo sampling and weakly informative priors. Bayesian meta-regression of log-transformed odds ratios (OR) assessed associations with relevant covariates. Fourteen studies (9 RCTs and 5 cohort studies) comprising 56,572 patients were included. Compared with SAPT, DAPT was associated with increased all-cause mortality (OR 1.25; 95% credible interval [CrI], 1.04-1.51; posterior probability of harm, Pr[OR > 1] = 84%). DAPT also increased the risk of net adverse clinical events [NACE] (OR, 1.29; 95% CrI, 1.08-1.53), minor bleeding (OR, 1.60; 95% CrI, 1.10-2.33), major bleeding (OR, 1.70; 95% CrI, 1.30-2.23), and BARC 2-5 bleeding (OR, 1.78; 95% CrI, 1.40-2.26) with Pr [OR > 1] >90% for all outcomes. No significant differences were observed in cardiac death, cardiovascular mortality, major adverse cardiac and cerebrovascular events (MACCE), myocardial infarction (MI), stent thrombosis, or stroke. Meta-regression revealed that higher baseline odds of dyslipidemia (-0.89), hypertension (-1.19), prior MI (-0.94), and previous revascularization (-0.30) were associated with greater mortality benefit from DAPT. However, in the DAPT cohort, increased odds of adverse events, including cardiac death (0.41), MACCE (0.55), stroke (0.60), MI (0.29), and NACE (0.98), were significantly associated with higher all-cause mortality. Extended DAPT is associated with a higher all-cause mortality, bleeding events, and NACE. While DAPT may benefit high-risk populations, the increased odds of adverse events are significantly associated with mortality, warranting that it be carefully considered and monitored in post-PCI patients.

Abstract BACKGROUND : The presence of cardiovascular disease (CVD) in patients with leukemia leads to worse clinical outcomes, but the disparities in this issue are still not fully examined. This research investigates differences in the CVD burden related to leukemia deaths across various demographic and geographic contexts using CDC WONDER data from 1999 to 2020. METHODOLOGY : A disproportionality analysis was conducted to calculate reporting odds ratio (ROR) of CVD burden in leukemia patients compared to all-cause deaths across age groups 15–85 years. A ROR greater than 1 indicated a higher burden of CVD in cancer patients. Average Annual Percentage Changes (AAPCs) were calculated to evaluate trends, with p-values determining significance. RESULTS : The highest ROR was found in the 15–24 age cohort (2.565), decreasing with age but rising slightly in older adults (85+: 0.56). The 55–64 age group experienced the most significant annual increase (AAPC: 2.02). Males consistently showed higher RORs compared to females, however, the most notable rise was in middle-aged females (AAPC: 1.51). Among racial groups, young Hispanics had the highest ROR (2.637), whereas NH Whites (55–64 AG) experienced the largest AAPC (1.43). Midwest had the lowest ROR but also exhibited the steepest regional increase (45–54: 1.78). Urban regions reported higher RORs than rural areas, with medical facilities displaying the highest RORs. CONCLUSION : These results highlight the importance of developing focused cardiovascular care strategies, especially for high-risk groups such as younger individuals, males, Hispanics, and those residing in urban areas. Public health initiatives should target these disparities to enhance outcomes for patients with leukemia.

Abstract Background Cardiovascular disease (CVD) and cancer are the leading causes of mortality in the U.S., with significant overlap in risk factors and outcomes. This study examines the burden of CVD in cancer-related deaths using the Reporting Odds Ratio (ROR) to identify disparities by sex, race, region, and urbanization from 1999 to 2020. Methods A disproportionality analysis was conducted to calculate ROR of CVD burden in cancer patients compared to non-cancer population across age groups 15–85 years. A ROR greater than 1 indicated a higher burden of CVD in cancer patients. Average Annual Percentage Changes (AAPCs) were calculated to evaluate trends, with p-values determining significance. Results The highest ROR across age groups was in the 15–24 group at 1.83, declining to 0.34 in ages 55–64, and rising to 0.56 in ages 85+. The yearly trends showed ROR increased in all groups, with the highest increase in 55–64 group (AAPC: 1.69). Males exhibited higher RORs than females, with the steepest increase in middle-aged females (AAPC: 2.59). Young Hispanics had the highest ROR among racial groups (15–24: 2.558), while the Midwest showed the highest regional ROR (15–24: 2.311). Urban areas had higher RORs than rural areas, with medical facilities reporting the highest RORs. Conclusion This study highlights significant disparities in CVD burden among cancer patients, with younger individuals, males, Hispanics, and urban residents at higher risk. The trends underscore the need for targeted cardio-oncological interventions, to mitigate the increasing burden of CVD and cancer. Addressing systemic disparities in healthcare access and delivery is critical to improving outcomes.