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Rapid pulses of skull evolution coincide with changes to food acquisition strategies and diets, as well as the proliferation of bony skull ornaments. In contrast to the appendicular skeleton, which has been shown to evolve more rapidly in birds, avian cranial morphology is characterised by a striking deceleration in morphological evolution relative to non-avian dinosaurs. These results may be due to the reorganisation of skull structure in birds-including loss of a separate postorbital bone in adults and the emergence of new trade-offs with development and neurosensory demands. Taken together, the remarkable cranial shape diversity in birds was not a product of accelerated evolution from their non-avian relatives, despite their frequent portrayal as an icon of adaptive radiations.Epidermolysis Bullosa (EB), a genetic disorder of the skin that presents with eruptive lesions accompanied by blistering has multiple types. We present a case of dystrophic and epidermolysis bullosa (DEB), a rare variant of the disease with the underlying pathophysiology involving a mutation of type VII collagen that serves as an anchoring protein for basement membrane to the dermis. The patient presented with palmoplantar hyperkeratosis with blistering extending on multiple sites of the body, bilateral pleural effusion and an ejection fraction of 23% with moderate mitral regurgitation. The patient was treated symptomatically with diuretics and inotropic medication for the dilated heart, along with draining of pleural spaces. No case of DEB with pleural effusion has been reported prior to this one. We believe this is the first case that presented with both pleural effusion and dilated cardiomyopathy.Breast cancer is the most common etiology of leptomeningeal carcinomatosis (LC), with or without brain parenchymal involvement. However, only 5% of patients with breast cancer develop leptomeningeal metastasis even in late clinical course. It can rarely be detected on bone scintigraphy. MRI is the modality of choice.Management options for obstructive hydrocephalus in children with posterior fossa tumours have been debated upon throughout the course of neurosurgical practice. Permanent pre-operative CSF diversion via ventricular shunts or endoscopic third ventriculostomy have been employed to prevent the possible persistence of hydrocephalus after tumour removal, but is considered unnecessary and even dangerous amongst a large group of neurosurgeons. In this paper, we have reviewed the literature for the merits and demerits of pre-operative permanent CSF diversion in paediatric patients presenting with posterior fossa tumours.Happiness is an essential part of human health. The purpose of health care, including diabetes care, is to achieve happiness, or euthymia. Happiness, can also be viewed as a means to achieving good health, as well as a technique to overcome challenges, encourage team work and ensure better adherence to therapy. This opinion piece shares simple ways of achieving happiness in the diabetes care clinic. It lists best practices related to environment communication style, communication content, and inter-consultation contact. If integrated into daily practice, these will help create a happy health care ecosystem, which in turn will enhance patient satisfaction.Cardiovascular disease (CVD) is a major cause of morbidity and mortality across the globe. Prevention and management of the CVD pandemic calls for concerted action on part of all health care professionals, as well as other concerned stakeholders. We call for cardiovigilance in healthcare and define it as "the action or state of keeping careful watch, to prevent, screen, diagnose and manage cardiovascular disease (CVD) in a timely and appropriate manner". We expand upon the concept of cardiovigilance, describe its utility, and suggest various taxonomic rubrics to simplify its practice.This study aims to share the results of haemorrhoidal artery ligation under direct vision in the management of symptomatic haemorrhoids. We conducted a case series of 70 patients at Combined Military Hospital Rawalpindi & Quetta, from January 2015 to October 2017. All patients underwent Haemorrhoidal Artery Ligation (HAL) and Recto Anal Repair (RAR). Ligation of superior haemorrhoidal artery was done under direct vision following manual palpation. Patients were followed up postoperatively at 1, 3 and 6 months. At 1 month follow up, all 70 (100%) patients were pain free. Post operative bleeding was observed in 7 (10%) patients but did not require surgical intervention. Sixty two (89%) patients were able to return to their daily activities 1 week after surgery and 57 (81%) resumed military duties or joined their work place at 2 weeks. 70 (100%) patients were asymptomatic and 45 (64%) highly satisfied with their surgery at 3 months. This increased to 53 (75%) at 6 months. 48 (69%) said that they would recommend this procedure to someone else. Prolapse recurrence was observed in 1(1.42%) patient 6 months post operatively which was dealt by band ligation. All patients completed follow-up at 1, 3 and 6 months. HAL is a simple yet safe technique with few complications, acceptable patient satisfaction and early return to work.Right recurrent laryngeal nerve can take a "Non-Recurrent" course and can present as a Non Recurrent Laryngeal nerve which is a rare entity. Such anomalies can lead to difficulty in locating the laryngeal nerve during thyroid surgeries and there are higher chances of it being injured. Therefore, surgeons should be mindful of this entity. We report the case of a 53-year-old lady who underwent thyroid surgery and a right Non Recurrent Laryngeal Nerve was identified intra-operatively.We report peri- and post-operative management of haemostasis in a 11-year old girl with Glanzmann Thrombasthenia (GT) who had feminizing genitoplasty for genital ambiguity due to Congenital Adrenal Hyperplasia (CAH-21 Hydroxylase deficiency). A blend of Glanzmann Thrombasthenia (GT) and DSD 46XX due to CAH is not reported in literature. Surgery particularly genitourinary reconstruction in patients with GT is challenging due to risk of intra and post-operative bleeding. Haemostasis can successfully be achieved with platelet transfusions, antifibrinolytic (Tranexamic acid) and judicious use of recombinant factor VIIa (rFVIIa) even in a resource limited setting.Paediatric calcified tendinitis is a rare entity. Although trauma is a triggering factor, the aetiology is unknown. Conservative management is the treatment of choice with most patients experiencing symptom resolution within six weeks. We describe the case of a six-year-old male child with persistent wrist pain despite conservative treatment. Exploration revealed involvement of the extensor carpi radialis brevis, and complete recovery after surgical excision of the lesion identified on X-ray.We report a case of Eggerthella lenta bacteraemia. An elderly lady with metastasised endometrial adenocarcinoma presented with complaints of fever nausea vomiting and abdominal pain. CT scan of the abdomen showed enlarged liver with multiple metastatic lesions raising suspicion of small-bowel obstruction. Due to multiple comorbid conditions, surgery was contraindicated and she was treated empirically with meropenem and vancomycin. Blood culture received on admission grew Eggerthela lenta.The study is aimed to analyze female emergency physician domestic support, social activity, occupational satisfaction level, and subjective happiness scale results. An electronically designed questionnaire form was e-mailed to 380 female emergency physicians working in our country. Happiness level of the participants was rated using the Subjective Happiness Scale. Among 380 female emergency physicians working in Turkey, 100 completed questionnaire. We did not detect any significant differences between the happiness scale scores of the participants with respect to their age, duration of working as a physician, academic title, monthly income, institution, monthly number of night duties, and the daily number of patients visiting emergency department.Beta cell function Type-2 diabetes mellitus (T2DM) has always been considered a heterogeneous and broad-spectrum disease with many associated complications and variations. Worthwhile in this regard were the findings that different individuals with T2DM label had slightly different set of clinical features and end-organ damage. Evidence is also there that pharmacotherapy related response also varies between individuals for the same category "T2DM". This report uses the existing molecular evidence to provide a suggested sub-classification for T2DM by using newly available molecular evidences from literature. The study broadly categorizes these T2DM with patients having primarily beta cell dysfunction or insulin resistance. While common features exists between T2DM subjects like hyperglycaemia and various organ damages, still the literature search highlight the subtle difference between the aforementioned two categories. Patients with insulin resistance can be clustered into obese, lipid/liver type and lipodystrophy associated features. Similarly, beta cell function can be associated with raised pro-insulin levels or otherwise.Inferior vena caval (IVC) injuries are uncommon and challenging to treat. Less than 5% of patients with penetrating abdominal trauma and less than 0.5% of patients with blunt abdominal trauma have this injury. Patient can present with intraperitoneal haemorrhage or with a contained retroperitoneal haematoma. Mostly it is associated with other abdominal structures injuries. Most commonly injured segment is infrarenal IVC. Operative strategy is different for each segment of injured vein. Infrahepatic injuries are exposed by medial visceral rotation. Retrohepatic and suprahepatic injuries need infrequent exposures. Mortality remains high and range between 31-51% for the patient brought alive to the operative room. Glasgow coma scale, level of injury, haemodynamic status at presentation and free blood in the peritoneal cavity are some of the predictive factors for mortality in these patients.The literature review was planned to discuss the extent of opioid, alcohol and methamphetamine use disorder in Pakistan, the neurobiology of opioids, alcohol and methamphetamine, the importance of medication-assisted treatment and recommendations for Pakistan. selleck chemicals llc A PubMed literature search was conducted and newspaper articles were also reviewed. In per capita terms, Pakistan is reported to be the most heroin-addicted country in the world. Pakistan has a significant alcohol abuse issue as well. The newest epidemic is that of crystal methamphetamine or "ice" which is consuming the youth and urban elite. There are long-term structural and functional changes in the opioid-addicted brain and factors that influence the vulnerability to addiction. The genesis of Pakistan's opioid epidemic is critical to understand as the country became victim to the proximity to, and politics of, Iran and Afghanistan. There is poor resource allocation for the treatment of substance use disorder, especially in comparison to what is spent on counter-terrorism. Addiction has had a devastating effect on children and the youth of Pakistan. It is vital to recognise addiction as a chronic disease comparable to diabetes, hypertension and asthma; and not a personal weakness. Medication-assisted treatment includes using buprenorphine-naloxone and naltrexone for opioid use disorder, injectable naltrexone for alcohol use disorder, and mirtazapine and bupropion for amphetamine use disorder. Coordination between the healthcare system, the Anti-Narcotics Force, the pharmaceutical industry and parliament is important. A university-affiliated addiction centre should be developed so it can provide guidance with research and treatment. Buprenorphine-naloxone and injectable naltrexone are urgently needed at an institutional level for the treatment of opioid and alcohol use disorder.