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The fourth part of the interview focuses on emotional status including religious and cultural beliefs about diabetes management and presence of diabetes related distress. Special attention should be paid to the financial status of patients who are paying for their treatment out of pocket. The interview should conclude with summarization of current issues with regards to diabetes management and a therapeutic plan individualized for the patient.Thyroid disorders can be difficult to manage, especially in childhood and adolescence. Sudden fluctuations may occur in thyroid function, due to a variety of physiological, pathological, pharmacological and psychosocial reasons. This communication describes the etiology and management of such conditions. We term these fluctuations as thyroid tantrums, and define them as sudden disruptions in thyroid function, in persons on treatment for hypothyroidism. Thyroid tantrums may be recognized clinically or on the basis of laboratory findings. A pragmatic approach to management, focusing on therapy assessment, testing technique, targeting biomedical illness and training, is suggested in this article.Amongst the benign cardiac tumours, atrial myxomas are the commonest. Tricuspid valve attachment is an uncommon site for cardiac myxoma. Here we present the case of an 18-year-old girl who presented with a history of shortness of breath, abdominal distension, leg swelling, palpitations and dizziness for the past two months. On echocardiography, there was a large pedunculated mass attached to the tricuspid valve. She underwent surgical excision of the mass and biopsy confirmed the diagnosis of myxoma. In conclusion, myxoma originating from tricuspid valve is a rare tumour, which can cause tricuspid valve obstruction and right heart failure symptoms due to their location. In these cases, shortness of breath, embolisation and symptoms of venous congestion are commonly observed.Carbuncle is a painful subcutaneous mass of interconnected infected hair follicles with multiple discharging sinuses. It has predisposition in conditions like diabetes, immune-compromised states, chronic skin diseases etc. The authors present a case of a 67 year old diabetic male admitted in July 2020 at Akbar Niazi Teaching Hospital (ANTH) Islamabad, with a giant carbuncle on his back. Due to its large size, systemic co-morbidity, and increased risk of complications in surgical treatment, a multi-disciplinary team approach was employed. Both general and plastic surgeons were involved, who performed excision and soft tissue coverage respectively. The aim of the surgical intervention methods, like wide excision and debridement, application of vacuum assisted wound closure (VAC), and skin grafting was to minimise the healing time and risk of development of post-operative infection. The patient was surgically managed and sent home in a good condition.Uterovaginal prolapse is the downward descent of the pelvic organs, resulting in protrusion of the vagina, uterus, bladder or rectum. The association between POP and hydronephrosis has been shown by various studies, but severe hydronephrosis that leads to renal dysfunction is rarely seen. We report the case of a 70 year old female with massive vaginal prolapse and chronic renal impairment. She presented with urinary tract infection (UTI) and raised creatinine levels of 4.5mg/dl. After the treatment of UTI, we surgically managed to treat her obstructive symptoms. After surgery her creatinine levels dropped to 2.0mg/dl but chronic renal failure persisted. Advanced stage prolapsed may damage renal function if left untreated. Timely diagnosis and management may help to prevent irreversible damage to kidneys.Multiple Myeloma is a clonal proliferation of plasma cells with bone marrow as the primary site of occurrence. Extramedullary multiple myeloma is uncommonly seen either at presentation or later during the course of the disease. Central nervous system involvement by multiple myeloma is an extremely rare entity with a dismal outcome. This case report focuses on a 45-year-old male who presented with bone aches. Investigation findings leading to the diagnosis included elevated calcium levels, lytic lesions on radiological examination and clonal plasma cells in bone marrow biopsy. During his treatment, the patient was given chemotherapy regimens containing Lenalidomide, Bortezomib, Cyclophosamide, and Prednisolone. Thereafter, he developed neurological complications (CNS myelomatosis), which resulted in his demise. The clinical presentation, diagnosis, treatment and outcome of this rare condition is detailed below.Ataxia telangiectasia is a rare autosomal recessive condition which develops due to a mutation in the ataxia telangiectasia mutated gene (ATM gene). As a result of this mutation, the ability of the DNA to undergo repair is undermined. The resulting cellular demise is responsible for the diverse presentation of the clinical condition. Neurological symptoms such as cerebellar ataxia, abnormal eye movements and malignancies occur commonly, while immunodeficiency predisposes these patients to recurrent infections. Perioperative management of patients with this rare condition can be associated with increased morbidity. Therefore, it is recommended that patients with ataxia telangiectasia should be managed in a multidisciplinary centre, under the supervision of senior clinicians who have the insight into the clinical needs of such patients. We report herein, the perioperative management of a patient with ataxia telangiectasia undergoing laparoscopic procedure. This case report will allow the readers to increase their knowledge and understanding when it comes to the management of these patients.Constrictive pericarditis is a rare disease with a difficult diagnosis. Cardiac magnetic resonance (CMR) imaging data of Aga Khan University Hospital from January 2011 to March 2020 was retrospectively reviewed and patients with the diagnosis of constrictive pericarditis were included. check details A total of 22 patients were included with the mean age of 46±16 years and majority 17(77%) were male. The most common findings on transthoracic echo were significant respiratory variation in mitral and tricuspid inflow velocities in 20(91%), and septal annular e’>9 in 10 (86%). The most common finding on CMR was respiratory septal shift in 22(100%), followed by septal bounce in 21(95%) and thickened pericardium in 18(82%). Nearly two-third of the patients, 15(70%) were considered for pericardiectomy but it was deferred in 5 patients due to high surgical risk. Ten patients underwent pericardiectomy, with no mortality on a mean follow up of 4±2 years.A functional referral system for addressing health emergencies requires coordinated efforts by health system’s stakeholders and the community. Using the Rural Health Programme (RHP) Thatta as a platform provided by an academic institution, district health system stakeholders and the community of Mirpur Sakro, taluka of Thatta, were engaged to strengthen the referral system for health emergencies through active community engagement. Through consultations with stakeholders, a referral system plan was developed with community volunteers from each village as focal persons for transportation, referring patients to health facilities and maintaining referral documentation. The stakeholders’ experience and perceptions about the referral system were assessed through qualitative in-depth interviews. Patients’ experiences of referral system improved with enhanced transport availability, but they faced structural challenges, including out of pocket transport expenses, weak back-referral links, lack of trust between the community and healthcare providers and poor availability of medicines.To assess the knowledge, behaviours and attitudes towards Patient Safety (PS) among interns of a tertiary care hospital, a cross sectional survey was conducted among 126 interns of Combined Military Hospital, Lahore (CMH Lhr), using Questionnaire (APSQ -4) in December 2019. Statistical analysis was done on SPSS 23. The interns exhibited good PS knowledge. The highest response was evident for “Attitude to Medical Error Reporting” domain (53.34±7.62) followed by “PS Knowledge” (50.88±6.85) with lowest response for “Attitude to PS Skills” domain (Mean = 16.34 ± 3.46). Independent Sample T Tests for comparison of mean responses of civilian and military interns revealed significant difference for PS Attitude to PS Training only, T Test (df)1.940 (124) p-value = 0.055. PS knowledge exists among the interns with limited training and practices. Medical educationists and supervisors should incorporate PS culture in junior doctors through rigorous training.A cross-sectional observational study was performed at the Poonch Medical College, Azad Kashmir, Pakistan, from June 2018 to June 2019 to assess the relationship between self-esteem and the academic score of undergraduate medical students. Rosenberg Self-Esteem (RSE) scale was used as data collection tool. The study questionnaire was electronically distributed to all 500 students enrolled in the Bachelor of Medicine and Surgery (M.B.B.S) programme out of which 253 submitted the questionnaire (response rate 50.6%). The mean academic score of all students was 66.61± 5.42 and the mean RSE score was 28.66± 3.98). A statistically significant correlation was not found between age, academic score, and RSE score. Female students had slightly higher academic performance scores and RSE scores compared to the male students, but this difference was not statistically significant. Future studies are required to assess the contributing factors responsible for better academic performance.Patients with type 2 diabetes (T2D) are at high risk of cardiovascular complications. Novel anti-diabetic medications such as sodium-glucose cotransporter-2 inhibitors (SGLT-2i) and Glucagon-like peptide-1 receptor agonists (GLP-1RA) have been shown to possess cardiac and renal protective effects beyond their ability to lower plasma glucose. Use of SGLT-2i and GLP-1RA in patients with T2D and heart failure reduce cardiovascular risk and heart failure-related hospitalisations. SGLT-2i treatment has been shown to improve the long-term prognosis of patients with heart failure. Both drugs also have the potential to normalise ventricular-arterial coupling (VAC). VAC is the crosstalk between the left ventricular function and arterial system, and is an indicator of the global cardiovascular performance. In this overview, we will describe the concept of VAC and the features of diabetic cardiomyopathy, as well as VAC as a potential therapeutic target in diabetes by the use of novel anti-diabetic drugs, primarily SGLT-2i and GLP-1RA.The descriptive cross-sectional study was planned to evaluate drug-related problems, including drug-drug interactions, dose error, use of nephrotoxic drugs and polypharmacy, with special emphasis on kidney disease patients. The study was conducted from January to June 2019 in the Nephrology Ward of Ayub Teaching Hospital, Abbottabad, Pakistan. Doses of medicine and drug-drug interactions were evaluated by comparing it with standard protocols in British National Formulary and Lexicomp. Prescriptions were also evaluated for polypharmacy and use of nephrotoxic drugs. Out of 131 patients, 72 (55%) were males. Drug-drug interactions were found in 69 (52.7%) patients among whom the highest percentage was of moderate drug-drug interaction 63 (48.1%), followed by major 39 (29.8%) and minor 29 (22%) drug-drug interactions. Incidence of polypharmacy 68 (51.9%) and use of nephrotoxic drug 101 (77%) was high, while dose error was low 14 (10.7%). All drug-related problems were present with a high percentage in patients with chronic kidney diseases 29 (78.