Background: Access to advanced histomolecular diagnostic testing for central nervous system(CNS) tumors is limited in low and middle-income countries (LMICs), hindering adequate characterization and failure to reach a WHO CNS 2021 diagnosis. LMICs also lack access to targeted therapies, and even conventional chemotherapy and radiation therapies vary between LMICs and high-income countries. Consequently, whether histomolecular subclassification is clinically beneficial and if it provides prognostic information in an LMIC setting is not clear. Here, we address this question by presenting the first systematic prospective study of CNS glioma patients from Pakistan, examining differences in overall survival (OS) by histomolecular subtype. Methods: A total of 194 patients with CNS tumors were enrolled at a single tertiary-care centerin Karachi, Pakistan. Routine histochemical processing, immunohistochemistry, and molecular testing using fluorescence in situ hybridization analysis, limited targeted-panel next-generation sequencing, and polymerase chain reaction were performed to test for isocitrate dehydrogenase (IDH) 1 and 2, P53, ATRX, Ki-67, 1p/19q co-deletion, and MGMT promoter methylation. Results: The results revealed that IDH status was a significant independent prognostic factor,regardless of age (p=0.016), with a 1-year survival rate of 76% and median OS of 16.15 months in IDH-wildtype high-grade gliomas. Conversely, the 1-year survival rate was 95% for IDH-mutant gliomas. Significant survival differences were observed for ATRX status (retained vs. loss) in IDH-mutant gliomas (p=0.046), P53 mutations in IDH-wildtype high-grade gliomas (p=0.05), and 1p/19q co-deletion in grade 3 gliomas (log-rank p=0.023). Conclusion We provide empirical evidence supporting a role for histo-morphological and limitedmolecular testing in neuro-oncology practice in LMICs.

Background: Cerebellopontine angle (CPA) tumors present surgical challenges due to their proxim-ity to the facial nerve. Despite preservation efforts, facial nerve paresis is a major issue. This study aims to identify key factors affecting facial nerve preservation during microsurgical resection of large CPA tumors in a low- and middle-income countries (LMIC) setting. Methods: This retrospective cross-sectional study, conducted at Aga Khan University, includedpatients who underwent microsurgical resection of large (>3 cm) CPA tumors with House-Brackmann (HB) grades 1–4. Postoperative facial nerve function was assessed using the HB grading system. Data was extracted from medical records and analyzed using SPSS 22. Results: This study analyzed 95 patients (M:F=1:1.16, mean age 44.24±13.71 years) withCPA tumors who underwent microsurgical resection. Common presenting complaints included a complete hearing loss (57.9%), headache (52.6%), and abnormal gait (40%). Preoperative facial nerve function was normal (HB grade I) in 75%, with 19%, 7%, and 2% having HB grades II, III, and IV, respectively. Schwannoma (69.5%), meningioma (16.8%), and epidermoid cyst (10.5%) were the most common diagnoses. Postoperative preservation of facial nerve function was achieved in 73.7% of patients. At six months, HB grades I and II were observed in 64% and 11.5%, respectively, while none had complete facial nerve palsy. On univariate analysis, larger tumor size and higher HB grade correlated with worse facial nerve outcomes (p=0.02). Complications were more frequent in patients with worsened outcomes (72% vs. 38.6%, p=0.004). However, in multivariate analysis, only preoperative HB grade was identified as a predictor. Conclusion Facial nerve preservation during CPA tumor resection is influenced by intrinsic tumorcharacteristics, surgical complexity, and patient-specific factors. Detailed preoperative counseling is crucial to set realistic expectations.

Introduction: Obstructive sleep apnoea (OSA) is characterised by recurrent pharyngeal collapses that occur five or more times per hour of sleep or more and reduce or completely block airflow for at least 10 seconds. Obesity predis-poses individuals to and potentiates OSA. Materials and methods: As a pre- and post-training activity measure, 30 obese people between the ages of 25 and 45 were asked to complete the STOP-BANG questionnaire and a 6-minute walk test. After that, they engaged in aerobic activity. Results: The scores for the six-minute walk test and the stop-bang questionnaire were 0.0005 and 0.0003, respectively with a “p” value- ≤0.001 (significant). In our investigation, the effects of aerobic exercise on exercise tolerance and obstructive sleep apnoea were significantly different. Con-clusion: Aerobic exercise is a better intervention for increasing exercise tolerance and obstructive sleep apnoea in obese patients. This intervention may be a significant contributor to cardiorespiratory fitness and can be considered a useful tool for enhancing quality of life.

Abstract Hyperkalemia (serum potassium >5.0 mEq/l) is a significant complication in patients with heart failure, chronic kidney disease, and diabetes mellitus, particularly when treated with renin-angiotensin-aldosterone system inhibitors (RAASi). Both hyperkalemia and RAASi interruption are associated with increased cardiovascular events, hospitalizations, and mortality. This expert opinion document, developed between January and December 2024 through a systematic process, aims to establish guidance for hyperkalemia treatment in Indonesian patients with cardiorenal diseases receiving RAASi therapy, addressing the unique challenges within the Indonesian healthcare context. A comprehensive literature review of international guidelines and regional studies was conducted by a panel of 11 expert specialists (3 cardiologists, 6 internist-nephrologists, and 2 internist-cardiologists), who evaluated 29 statements covering diagnosis, monitoring, prevention, and treatment of hyperkalemia. Of the 29 statements, 26 reached consensus: 17 statements achieved very high agreement (≥90%) and 9 attained high agreement (≥67% – <90%). The agreed statements covered key areas, including potassium monitoring frequency, RAASi dose optimization strategies, dietary modifications, and treatment thresholds. Three statements regarding alternative therapeutic approaches did not receive agreement (<67%) due to limited local availability and cost considerations. Key recommendations include structured monitoring protocols for high-risk patients, strategies for RAASi dose optimization while managing hyperkalemia risk, and specific interventions adapted to local resources. This document provides a practical approach for managing hyperkalemia in Indonesian patients with cardiorenal diseases while maintaining optimal RAASi therapy, considering local Indonesian healthcare resources and constraints.
Hyperkalemia ; Cardio-Renal Syndrome ; Renin-Angiotensin System ; Indonesia

We report a case of a previously healthy 9-year-old boy who presented to the emergency department following accidental ingestion of 35% hydrogen peroxide. He developed emesis and mild abdominal pain and was found to have extensive portal venous gas, severe gastric pneumatosis, and free intraperitoneal air on a computed tomography scan. He was transferred to an outside hospital for hyperbaric oxygen therapy, with no emergency surgical intervention indicated. This case highlights the dangers of ingesting even a small amount of concentrated hydrogen peroxide in children and underscores the safe storage practices at home.

Thioacetamide (TAA)-induced liver fibrosis, triggered by inflammation and oxidative stress, is prompted by hepatic stellate cells (HSCs) activation via several pathways. This study explores the hepatoprotective effect of aloe vera gel (AVG) extract and bone marrow mesenchymal stem cells (BM-MSCs) transplantation on regulating long intergenic noncoding RNA (lincRNA-p21) and microRNA (miR-17-5p) expressions and their impact on TGF-β1/Smad-3 and Wnt-10a/ β-Catenin cascades in TAA-induced liver damage. The study involved 48 adult male albino rats divided into four groups:control, TAA, TAA treated with BM-MSCs, and TAA treated with BM-MSCs+AVG extract. After 8 weeks, liver enzymes and hepatic oxidative parameters were evaluated alongside lincRNA-p21, miR-17-5p, TGF-β1, Smad-3, Wnt-10a, and β-Catenin expressions. Liver tissue sections were examined by light and electron microscopes and analyzed morphometrically. Group II showed increased aspartate aminotransferase, alanine aminotransferase, malondialdehyde, reduced glutathione levels, and deteriorated hepatocytes with distorted mitochondria and dilated rough endoplasmic reticulum. Group IV restored lincRNA-p21 expression, which downregulated miR-17-5p and suppressed activated HSCs by inhibiting TGF-β1/Smad-3 and Wnt-10a/β-Catenin pathways, and improved hepatic tissue architecture. Additionally, immunohistochemically, alpha-smooth muscle actin and cyclin D1 expressions were markedly decreased in group IV compared to group II. We concluded that AVG suppresses fibrotic pathways, boosts BM-MSCs differentiation, and reduces HSCs activation in liver fibrosis caused by TAA.

Background: The Ascertain Dementia 8-item Questionnaire (AD8) is a validated informant-based interview for early dementia detection. Research suggests the utility of self-rated AD8 to identify milder dementia forms in research settings. This study compares the factor structure, reliability, and diagnostic performance between AD8-Self and AD8-Informant for early cognitive impairment (ECI) in a clinical setting. Methods: Five hundreds fifteen patient-informant dyads (43 cognitively intact and 472 ECI) from a tertiary memory clinic completed both self-reported and informant AD8. We conducted exploratory factor analysis to determine the factor structure, Cronbach’s alpha for internal consistency, and receiver operating characteristic (ROC) curve analysis for ECI, including a subgroup analysis for mild cognitive impairment (MCI). Results: The mean age and education of ECI participants were 75.61 years (range, 51–95) and 5.6 years (range, 0–20), respectively, and 72.6 years (range, 51–89) and 6.8 years (range, 0–16) in the MCI subgroup. Unlike AD8-Informant’s one-factor structure, AD8-Self had a two-factor structure corresponding to memory and non-memory domains. AD8-Self demonstrated lower reliability (Cronbach’s alpha: ECI 0.666 vs. 0.764; MCI 0.663 vs. 0.709). In ECI, AD8-Informant (cutoff score ≥3) showed better diagnostic performance (sensitivity 89%, specificity 79%) than AD8-Self (cutoff score ≥4; sensitivity 27.1%, specificity 95.3%) (AUC 0.915 vs. 0.593; p<0.001). Similar results were found in MCI (sensitivity 64.7% vs. 26.5%; specificity 79.1% vs. 95.3%; AUC 0.745 vs. 0.600; p=0.002). Conclusion AD8-Self has a distinct factor structure, lower reliability, and inferior diagnostic performance compared to AD8-Informant for ECI/MCI detection. Our result do not support AD8-Self as a standalone tool for detecting ECI or MCI.

Background: s/Aims: Portal vein embolization (PVE) and Yttrium-90 (Y-90) radioembolization are used to induce liver hypertrophy, increasing future liver remnant volume and reducing the risk of post-resection liver failure. This systematic review compares the effectiveness of PVE and Y-90 radioembolization in promoting liver hypertrophy in patients undergoing liver resection. Methods: A systematic review was conducted in accordance with PRISMA guidelines. PubMed, Embase, Cochrane, and Web of Science were searched for studies published between January 2000 and August 2023. Studies comparing PVE and Y-90 radioembolization with respect to liver hypertrophy were included. Risk of bias was assessed using the Newcastle–Ottawa Scale. Pooled mean differences were calculated using an inverse-variance random-effects model. Results: Of 1,965 studies identified, three retrospective cohort studies met inclusion criteria, comprising 125 patients. Among these, 67.3% underwent PVE and 32.7% received Y-90 radioembolization. Hepatocellular carcinoma was the most common diagnosis (55.9%), followed by metastatic disease (32.3%) and cholangiocarcinoma (11.8%). PVE was more commonly used as a preoperative strategy for liver resection, while Y-90 radioembolization was primarily employed for palliative intent. One study reported greater hypertrophy with Y-90 compared to PVE (63% vs. 36%); however, hypertrophy was assessed over a longer interval (150 vs. 30 days). In pooled analysis, PVE was associated with significantly greater hypertrophy (mean difference 23.75%; 95% CI 12.02–35.48; p < 0.0001; I 2 = 48%). Conclusions Evidence directly comparing PVE and Y-90 radioembolization for liver hypertrophy remains limited. While pooled results favor PVE, procedure selection should be individualized based on clinical context.

Background: s/Aims: Left lateral sectionectomy (LLS) is a commonly performed liver resection. The Rex-recess technique, an extrahepatic Glissonian approach through the umbilical fissure, provides earlier extrahepatic vascular control, potentially resulting in safer and faster resections. However, comparative data between these approaches is limited. This study aims to compare the Rex-recess technique with the standard technique for LLS regarding operative parameters, intraoperative blood loss, and postoperative outcomes. Methods: This retrospective cohort study included 48 consecutive adult patients who underwent open LLS at a tertiary hepatobiliary centre between January 2021 and November 2025. Patients were categorized based on the surgical technique used: standard technique (n = 25) and Rex-recess technique (n = 23). Primary outcomes assessed included operative time, blood loss, transfusion requirements, and postoperative complications. Secondary outcomes focused on selected early postoperative recovery parameters. Results: Baseline demographics were comparable between groups. The Rex-recess technique significantly reduced operative time (90 ± 17.1 minutes vs. 162 ± 27.2 minutes; p < 0.0001) and intraoperative blood loss (80 ± 42.3 mL vs. 250 ± 67.2 mL; p < 0.0001).Other postoperative outcomes, including complication rates and length of hospital stay, were comparable between the two groups. Conclusions The Rex-recess approach appears to be a feasible and anatomically sound technique for LLS, offering advantages in operative efficiency, such as reduced operative time and blood loss. However, due to the retrospective design and non-randomized allocation, these findings should be interpreted with caution. Further prospective studies are needed to validate these results.