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We describe 4 cases of eyes initially treated with phacoemulsification and iStent trabecular microbypass (Glaukos Corporation). These patients subsequently required further surgery and were successfully treated with the removal of the iStent device followed by gonioscopy-assisted transluminal trabeculotomy (GATT), using the iTrack catheter (Ellex Medical Lasers Ltd). Three of the cases had prior first-generation iStent (G1), and 1 had prior second-generation iStent (G2). This case series demonstrates that in selected cases, a further angle procedure in the form of a GATT can show efficacy and durability in the medium term. Our patients had controlled intraocular pressures (IOPs) at 1-year post-GATT: 2 on IOP-lowering therapy and 2 without any IOP-lowering medications. Three patients had transient hyphema and 2 with high IOP in the immediate postoperative period. No patients experienced a decrease in best-corrected visual acuity postoperatively. To the best of our knowledge, there is no prior literature describing this surgical strategy. This series demonstrates that GATT could potentially be an effective procedure in the case of a failed initial iStent microtrabecular bypass.

The incidence of breast cancer is increasing in Pakistan as well as globally. Awareness of women about breast cancer plays a cornerstone role in its early detection, better management, and prevention. Keeping this in mind, a cross-sectional study was carried out to assess the awareness of female university students about breast cancer’s risk factors, signs and symptoms, and breast cancer examination. The data was collected from female university students studying in Pakistan. A total of 774 participants completed the survey and recorded their responses on an online pre-tested self-administered questionnaire. Only 29.8% of the participants have identified breast cancer history in their first-degree relatives as a risk factor. Moreover, 14.1% of the participant considered that the use of oral contraceptives for more than 5 years can increase the risk of developing breast cancer. In addition, inward pulled nipple, wounds around the nipple, and abrupt changes in the breast size were considered as the sign and symptoms of breast cancer by 25.2%, 25.7%, and 31.7% of the participants, respectively. Moreover, only 20.9% of the participants identified the correct year for starting breast cancer examination and 44.4% of the respondents marked that mammography should be initiated after 40 years. Overall, the university female students of Pakistan were poorly aware of breast cancer’s risk factors, signs and symptoms, and breast examination. This study has highlighted the need for initiation of aggressive strategies regarding breast cancer awareness in both the literate and illiterate female population of Pakistan.

To evaluate 5-year safety and efficacy of 2 trabecular micro-bypass stents versus prostaglandin as initial stand-alone treatment for newly diagnosed, treatment-naive primary open-angle glaucoma (POAG).Prospective, randomized, controlled, multi-surgeon clinical trial.Enrolled eyes (n = 101) were phakic and had a confirmed POAG diagnosis, normal angle anatomy, mean diurnal intraocular pressure (IOP) 21 to 40 mmHg, and vertical cup-to-disc (C:D) ratio ≤0.9.Eyes were randomized (1:1) to receive either 2 stents (iStent trabecular micro-bypass; Glaukos Corporation, San Clemente, CA) or once-daily topical travoprost.The primary and secondary efficacy end points were the change from screening in mean diurnal IOP at months 12 and 24, respectively, without glaucoma surgery or add-on medication (any medication in stent eyes or a second medication in travoprost eyes). Two additional secondary end points were the proportion of eyes achieving treatment success at months 12 and 24, defined as IOP 6 to 18 mmHg without additional medication or glaucoma surgery. This report shows these efficacy measures through 60 months. Safety measures included best-corrected visual acuity, C:D ratio, visual field, pachymetry, complications, and adverse events.Of 101 enrolled eyes (54 stent eyes, 47 travoprost eyes), 90 eyes (49 stent eyes, 41 travoprost eyes) completed 5-year follow-up. Five-year mean diurnal IOP was 16.5±1.2 mmHg in stent eyes (35.3% reduced vs. 25.5±2.5 mmHg preoperatively; P0.0001) and 16.3±1.9 mmHg in travoprost eyes (35.1% reduced vs. 25.1±4.6 mmHg preoperatively; P0.0001). During follow-up, add-on medication was initiated in 12 stent eyes (22.2% of the initial 54-eyes) and 18 travoprost eyes (38.3% of the initial 47-eyes). By 5 years, 17% (6/35) of stent eyes and 44% (14/32) of travoprost eyes needed add-on medication to control IOP (P = 0.017). Treatment success was achieved in 77% (27/35) of stent eyes and 53% (17/32) of travoprost eyes (P = 0.04). Both groups exhibited excellent safety.This prospective randomized trial demonstrates 5-year effectiveness and safety of 2 trabecular bypass stents in patients with newly diagnosed, treatment-naive POAG, with comparably favorable outcomes as topical prostaglandin.

Background The model of community pharmacy practice is changing remarkably not only in the West but also in developing countries, which has led retail pharmacies to transform into chain community pharmacies. However, very little is known about consumers’ expectations and experiences with chain community pharmacies in developing countries. Objective This study aims to assess the expectations and experiences of consumers with services provided by chain community pharmacies in Lahore, Pakistan. Setting Four random chain community pharmacies. Methods A qualitative study design was employed and face-to-face, audio-recorded, interviews were conducted with 12 consumers attending 4 randomly selected chain community pharmacies. All interviews were transcribed verbatim and the interview data were analysed thematically using NVivo® software. Main outcome measure Consumers’ expectations and experiences with chain community pharmacies. Results The results contributed to a deeper understanding of the consumers’ expectations and experiences with the services provided by chain community pharmacies. Six themes emerged from interview data including; access to pharmacists, quality use of medicines, range of distinct services, staff’s behaviour, inventory management, and scope of services. The consumers reported that pharmacists working in chain community pharmacies were building trusting relationships and encouraging them to take an active role in healthcare. Pharmacists working there were providing them medication information and counselling services, which they normally do not expect from traditional pharmacies. Consumers mentioned that they had access to pharmacists and quality services, but the inventory of pharmacies was limited. Conclusions This exploratory study provides preliminary evidence that some of the consumers’ expectations and experiences were aligned. However, some deficiencies were highlighted by the consumers that need to be addressed by relevant stakeholders. Further research is needed to assess the expectations and experiences of pharmacists working in the chain community pharmacy sector.

This study was conducted to assess quality of counseling provided to type 2 diabetic patients. For this cross-sectional study, a simulated patient method was applied in 562 selected community pharmacies of Punjab, Pakistan. A scenario for the metformin oral therapy was developed that illustrates direct counseling for adult diabetic patients. Counseling and communication skills were also assessed. Descriptive statistics and chi-square tests were used for analysis. Only 29.4% of simulated patients received medication counseling directly; 47.6% received it on request. About 32.8% of clients were referred to a physician without counseling. The most frequently provided information was dietary instruction (94.8%) and dose of therapy (84.5%). Only one quarter (25.3%) of simulated patients were asked about disease duration and similar rate (25.0%) was found for discussions of special warnings. The side effects, drug storage, drug-drug interactions and duration of therapy were ignored. Minimal information was provided about other medication during therapy (0.2%) and effect of medicine withdrawal (2.7%). About 59.5% simulated patients were instructed for compliance to medication. Counseling to type 2 diabetic patients in Pakistani community pharmacies is not very satisfactory. Pharmacies' staff have little focus on counseling. Professional training of staff could improve counseling and communication skills.

Evaluate the efficacy, safety, and complication rates of phacoemulsification cataract surgery when combined with either gonioscopy-assisted transluminal trabeculotomy (GATT) or iStent Inject. This is a retrospective case-control study to compare the surgical outcomes of combined phacoemulsification cataract surgery with either GATT (phaco-GATT) or iStent Inject (phaco-iStent). Both groups had at least 1-year follow-up. The primary outcome measures were IOP and number of glaucoma medications (NGMs) at 1 year. Secondary outcomes measures were best corrected visual acuity (BCVA) and intra- or postoperative complications within the first year of follow-up. Success was defined as intraocular pressure (IOP) < 21 mmHg and ≥ 20% reduction in IOP at 1 year regardless of the NGM. Each group included 37 patients. The median baseline IOP (24 vs 17) and NGM (3 vs 2) were higher in the phaco-GATT group (p < 0.001). Phaco-GATT achieved a 38% (p < 0.0001) reduction in IOP compared to 13.2% (p < 0.001) in the phaco-iStent group at 1-year follow-up. The reduction in IOP and NGM was significantly higher in the phaco-GATT group (p < 0.01). After adjusting for baseline IOP, the reduction in IOP at 12 months was still significantly higher in the phaco-GATT group (p = 0.042). At 1 year, 86.4% of patients in the phaco-GATT group met the success criteria compared to 35.1% in the phaco-iStent group. Safety outcomes were slightly favourable in the phaco-iStent group. Phaco-GATT and phaco-iStent showed a significant reduction in IOP and NGM, with phaco-GATT having a significantly higher reduction. Phaco-iStent appears to have a higher safety profile and is probably preferable in monocular patients and those with a high risk of bleeding.

High prevalence of blindness coupled with low public awareness of eye diseases is a severe problem in Pakistan. The objective of this study was to evaluate the awareness, attitude and practices related to common ocular problems and eye care use among general population of Punjab, Pakistan. Data were collected cross-sectionally, using random selection of participants from five districts of Punjab, Pakistan. A pre-tested questionnaire was used to collect the data from January to March 2017. The ordinal data were converted to interval--based data by Rasch analysis, which is termed as &ldquo, knowledge score&rdquo, and ranges from &minus, 3 to +3. Descriptive statistics, linear regression, binary logistic regression and chi square analysis were performed to evaluate the data. Of the 2073 people contacted, 96.4% (2019) responded the interviewer. The mean (SD) age was 39.9 (11.4) years, majority were males (64.8%) and only 3.1% were illiterate. The majority (68.1%) of respondents were aware that blindness can be prevented and are least aware of age-related macular degradation (31.4%). Multivariate analysis to knowledge scores demonstrated that male gender (&beta, = 0.53 95%CI = 0.39, 0.66, p &lt, 0.001), higher education (&beta, = 0.31 95%CI = 0.25, 0.37, p &lt, 0.001) were significantly associated with knowledge score. Eighty-two percent of our respondents had a positive attitude towards health-seeking behavior and those who had adequate income on most of occasions were 1.82 (AOR = 1.82 95%CI = 1.26, 2.62 p = 0.001) times more prone towards health-seeking behavior than those who had insufficient income. Out of all respondents, 21.5% had an eye examination at least once a year and this frequency was significantly higher in lower age, females, high education and high Socio Economic Status level (p &lt, 0.05). Among the general population of Pakistan, awareness about prevention of blindness and refractive error was optimum, while awareness of blindness causing eye conditions, like age-related macular degradation was low. Intensive improvements in the health literacy and public interventions&mdash, specifically in old age people, males and respondents with lower education&mdash, are urgently needed.

Background: Community pharmacies are an integrated part of healthcare systems worldwide. In low and middle income countries like Pakistan, the paradigm of pharmacy practice is shifting from dispensing medicines to clinical activities. There are disparities in these practices according to location. Pharmacies in urban localities are better than those in rural areas. This qualitative study was conducted to explore patients&rsquo, expectations and current practices in rural pharmacies. Methods: A cohort of adult pharmacy visitors (aged &gt, 18 years) that reside in rural community was selected. Consenting participants were recruited by purposive sampling technique until thematic saturation level was achieved. A total of 34 patients were interviewed. Face-to-face interviews were conducted using a semi structured interview guide. All the data were transcribed and used to originate the themes. Results: On analysis, a total of 20 themes were obtained. Sixteen themes pronounced the current provided services. Four themes provided some suggestions for the development of better pharmacies. On call services to provide medicines, limited free extended pharmacy services, interest in patients&rsquo, wellbeing, appropriate referral, vaccination, free medical camp, medical services at home, first aid, and counseling were appreciated by patients. Patients stated that medicines are inappropriately stored in unhygienic conditions, prices of medicines are comparatively high, and medicines are substandard. Unavailability of medicines, inept dispensing, limited staffing with poor knowledge, limited working hours, and quackery promotion are challenges in rural pharmacy practice. Patients say that non marginal pricing, informative services, new legislation, and proper vigilance by officials can improve the pharmacy services in rural communities. Conclusions: Patients alleged that rural pharmacies perform deprived practices. To improve service, new legislation and the proper implementation of existing law is needed.

Purpose: Patient satisfaction can identify specific areas of improvement in community pharmacy services. Currently in Pakistan, no evidence exists in this regard. This study was conducted to determine the needs of patients and the current standards of pharmacies. Methods: A cross-sectional study was conducted between October 2016 and June 2017. A pilot tested questionnaire was used to collected the data from 1088 patients of 544 community pharmacies. Likert scale and one way ANOVA was used to analyze the data. Results: The response rate of community pharmacies was 80% and that of purchasers was 68.1%. The mean age of participants was 35.2 years. The mean overall satisfaction score of participants was 2.78/5.00. Many patients were dissatisfied (1.65/5.00) with parking facilities provided by pharmacies. Pharmacy service time fulfilled the requirements of most patients (4.16/5.00). The counseling person’s good attitude (3.99/5.00) was credited by purchasers. Level of patient satisfaction with the availability of medicines (3.19/5.00), safe storage of medicines in pharmacy stores (3.66/5.00), and quality of medicines (3.41/5.00) were almost moderate. Many patients were very satisfied (4.35/5.00) with readable instructions for their medications. Approximately half of the patients were dissatisfied with the waiting time. Many patients were also dissatisfied (2.28/5.00) with the knowledge of the counseling person. Patients perceived that staff interest in patient recovery (2.24/5.00) was low. No significant difference in level of satisfaction with regard to participant’s characteristics was found. Conclusions: The current study demonstrated a low level of patient satisfaction with regard to community pharmacy services in Pakistan. These services need improvement.

ObjectivePerforming surgery on patients with only one seeing-eye, where complications may result in catastrophic vision loss, presents unique challenges for the ophthalmic care team. There is currently no evidence regarding how surgeons augment their care when treating only eye patients and no guidelines for how these patients should be managed in hospital eye services. This study aimed to explore ophthalmic surgeons’ experiences of only eye surgery and perceptions of current practice.Design and participantsTen ophthalmic surgeons were asked to relate their experiences and views on performing only eye surgery in indepth, semistructured interviews. Interviews were audio-recorded and transcribed. Qualitative data were subjected to thematic analysis to identify key themes.SettingHospital eye service.ResultsFive key themes emerged relating to surgeons’ experiences and perceptions of only eye surgery: (1) differences in approach to consent, (2) strategies for risk reduction, (3) unmet training needs, (4) value of surgical mentor and (5) emotional impact of unsuccessful outcomes. Recommendations for improving the surgical journey for both the patient and the surgeon related primarily to better recognition and understanding of the complexities inherent with only eye surgery.ConclusionsOutcomes of only eye surgery may be improved through a number of methods, including development of purpose-designed training fellowships, adoption of stress-reducing strategies and enhancement of available support services. The findings identify emerging themes unique to only eye surgery and the need for guidelines on the provision of care for these high-stakes surgical patients.

Background: Diabetes mellitus (DM) has a very high prevalence and poses a huge financial encumbrance on patients. This study aimed to evaluate the cost of diabetes care among patients with type 2 diabetes in private clinics of southern Punjab, Pakistan. Research design and methods: This was a descriptive, cross-sectional, prevalence-based, cost-of-illness (COI) study conducted in six private clinics of southern Punjab from July to September 2016, using a pretested questionnaire. Study participants were recruited using a random selection method. Continuous variables, including direct and indirect costs, were summarized using descriptive statistics. Inferential statistics were also used to analyze the correlation between the variables and cost. Results: The mean annual direct cost per patient with diabetes was estimated to be 332 USD. Medications accounted for the largest share (60.4%) of this cost. Age, locality, high socioeconomic status, and prolonged disease duration were significantly associated with the direct costs of illness (p?0.05). Moreover, 19% of total earnings among very low-income patients were spent on diabetes care. Conclusions: A substantial proportion of patients? income is spent on diabetes care in Punjab. Our findings support the substantial individual and societal burden caused by diabetes. This study was approved by the Ethics Committee for Medical Research of Xi?an Jiaotong University in Shaanxi, China. Permission was obtained from all practitioners in private clinics. Literate patients were asked to sign the consent form approved by the ethics committee. Illiterate patients received clarification about the contents of the written consent form, and a data collector received the patient?s permission to sign the consent form on their behalf. Scopus

Purpose The purpose of this article was to describe (i) a novel case of severe intraocular pressure (IOP) elevation due to intracameral Healon 5 for management of early postoperative (post-op) hypotony following XEN Gel Stent insertion and (ii) the management of this complication. Materials and methods A case report. Results A 52-year-old man, with primary open-angle glaucoma and suboptimal left IOP control on maximally tolerated medical therapy, was managed with XEN Gel Stent insertion at another tertiary eye unit. Post-op, the IOP was 2 mm Hg with a shallow anterior chamber (AC) and choroidal effusions. Intracameral injections of Provisc on post-op days 1 and 3 failed to reverse hypotony. At 1 week post-op, persistent clinically significant hypotony was managed with Healon 5 injection into the AC. Twelve hours later, the patient experienced significant pain and reduced vision and presented to a different tertiary eye unit, where left visual acuity was hand movements, IOP was 70 mm Hg with a deep AC (complete ophthalmic viscosurgical device fill with Healon 5) and a flat drainage bleb with no external drainage. Emergency AC washout of the Healon 5 was performed with resolution of symptoms, visual acuity, and IOP control. Conclusions We caution against the use of intracameral Healon 5 in the management of post-op hypotony following XEN Gel Stent insertion, given the potential risk for extreme IOP elevation and sight loss.

Introduction This study evaluates long-term outcomes of two trabecular micro-bypass stents, one suprachoroidal stent, and postoperative prostaglandin in eyes with refractory open angle glaucoma (OAG). Methods Prospective ongoing 5-year study of 80 eligible subjects (70 with 4-year follow-up) with OAG and IOP ≥ 18 mmHg after prior trabeculectomy and while taking 1–3 glaucoma medications. Subjects received two iStent® trabecular micro-bypass stents, one iStent Supra® suprachoroidal stent, and postoperative travoprost. Postoperative IOP was measured with medication and annually following medication washouts. Performance was measured by the proportion of eyes with ≥ 20% IOP reduction on one medication (the protocol-specified prostaglandin) versus preoperative medicated IOP (primary outcome); and the proportion of eyes with postoperative IOP ≤ 15 and ≤ 18 mmHg on one medication (secondary outcome). Additional clinical and safety data included medications, visual field, pachymetry, gonioscopy, adverse events, visual acuity, and slit-lamp and fundus examinations. Results Preoperatively, mean medicated IOP was 22.0 ± 3.1 mmHg on 1.2 ± 0.4 medications, and mean unmedicated IOP was 26.4 ± 2.4 mmHg. Postoperatively, among eyes without later cataract surgery, mean medicated IOP at all visits through 48 months was ≤ 13.7 mmHg (≥ 37% reduction), and annual unmedicated IOP was ≤ 18.4 mmHg (reductions of ≥ 30% vs. preoperative unmedicated IOP and ≥ 16% vs. preoperative medicated IOP). At all postoperative visits among eyes without additional surgery or medication, ≥ 91% of eyes had ≥ 20% IOP reduction on one medication versus preoperative medicated IOP. At month 48, 97 and 98% of eyes achieved IOP ≤ 15 and ≤ 18 mmHg, respectively, on one medication. Six eyes required additional medication, no eyes required additional glaucoma surgery, and safety measurements were favorable throughout follow-up. Conclusion IOP control was achieved safely with two trabecular micro-bypass stents, one suprachoroidal stent, and postoperative prostaglandin. This microinvasive, ab interno approach introduces a possible new treatment option for refractory disease. Trial Registration NCT01456390. Funding Glaukos Corporation. Electronic supplementary material The online version of this article (10.1007/s12325-018-0666-4) contains supplementary material, which is available to authorized users.

The history of cancer chemotherapy is as old as cancer itself. With the increase in the complexities of cancer and the development of resistance towards existing anticancer agents, increased attention is now being paid to the advancement of chemotherapy. Some chemotherapeutic agents were discovered by accident or trial-and-error methods while others were found to be useful for neoplasia when they were being evaluated for some other purpose. Broadly, these agents have been classified as alkylating agents, antimetabolites, platinum compounds, antitumor antibiotics and natural products. Hormones and compounds interfering with hormone metabolism are widely used in cancer treatment, besides monoclonal antibodies and small molecules targeting angiogenesis. In this review an attempt is made to discuss the major breakthroughs that have shaped the course of cancer chemotherapy, helping to decrease the mortality as well as lessen the suffering of patients.

Background Chronic kidney disease (CKD) alters the pharmacokinetic and pharmacodynamic response of various drugs and increases the risk of toxicity. The data regarding the pattern and predictors of medication dosing errors is scare from the developing countries. Therefore, the present study was conducted to assess the pattern and predictors of medication dosing errors in CKD patients in a tertiary care setting in Pakistan. Methods A retrospective study design was employed and medical charts of all those CKD patients who had an eGFR ≤60ml/min/1.73m2, hospitalization ≥24 hours, and admitted in the nephrology unit during January 2013 to December 2014 were assessed. Descriptive statistics and the logistic regression analysis were done using IBM SPSS version 20. Results In total, 205 medical charts were assessed. The mean age of patients was 38.64 (±16.82) years. Overall, 1534 drugs were prescribed to CKD patients, of which, nearly 34.0% drugs required dose adjustment. Among those drugs, only 41.8% were properly adjusted, and the remaining 58.2% were unadjusted. The logistic regression analysis revealed that the medication dosing errors were significantly associated with the CKD stages, i.e. stage 4 (OR 0.054; 95% CI [0.017–0.177]; p

Background Access to medicines without prescription is a major contributing factor for self-medication practices. This study was designed to examine the ratio of non-prescribed medicines sales and self-medication practices in Punjab, Pakistan. This study also evaluates the reasons for self-medication within its communities. Methods An observational study was conducted in 272 systemically selected pharmacies to analyze medicines-related sales, with or without prescription. A cross-sectional survey was performed between June 2015 and November 2016. Consumers were interviewed about their self-medication practices. Results Of the pharmacies surveyed, 65.3% participated in the study. A total of 4348 medicines were purchased for self-medication by 3037 consumers (15.2% of all study participants), of which 873 (28.7%) participated in an interview. Majority (81.2%) medicine purchaser, (90.9%) interview participants, and (59.4%) drug users were male. On average, each community pharmacy sold 7.9 medicines without prescription each day, to an average of 5.5 customers. Many participants (28.9%) had matriculation in their formal education. The medicines most often sold for self-medication were analgesics and antipyretics(39.4%). More than 25% of participants reported fever symptoms and 47.8% assumed their illness was too trivial to consult a doctor. Media advertisements were the most common source of information for participants (46.7%). Conclusion Many types of medicines were often sold without prescription from community pharmacies. Self-medication was common practice for a wide range of illnesses. Pakistan also needs effective implementation of policies to monitor medication sales. Public education about rational medication and limits to advertising medicine are very necessary.

To evaluate diabetes awareness among general population of Bahawalpur, Pakistan.A questionnaire based descriptive cross sectional study was performed during 2014. Descriptive and inferential statistics were applied using the IBM Statistical Package for Social Sciences version 20.Total 383 respondents participated in this study giving a response rate of about 88%. Mean age of the participants was 33±13.3 years and the majority of the participants were females (50.4%). Mean scores of the participants were 20.77±6.65 out of 34 and only one participant scored 34/34 marks. Kruskal-Wallis and Mann-Whitney U test revealed that females scored significantly higher diabetes awareness score than males (p0.05). Moreover, urban residential status, better education and higher socioeconomic status were significantly associated with higher diabetes awareness.Majority of our study population had adequate awareness regarding diabetes. However, lack of awareness was observed among illiterate, poor and rural participants that indicated the immediate need of diabetes awareness programs for these participants.

Diabetes mellitus (DM) is a common disease in which excessive levels of blood glucose (sugar) occur. In simple terms, diabetes is generally due to failure in the effective functioning of insulin. Common types of diabetes include type 1 and type 2, which have different treatment options. In the general population, type 2 diabetes is more prevalent than type 1, and type 2 accounts for more than 90% of all known cases of diabetes. The current review examines the contributions of pharmacists to the more positive, long-term prognosis of patients with DM through improvements in its control and management. The authors conducted a systematic literature search. Twenty-seven studies were identified that demonstrated the effects of a pharmacist's intervention on glycated hemoglobin (HbA1c). In all cases, it was reported that the intervention was successful in reducing HbA1c in patients with DM. Pharmacist interventions have also proven successful in improving patient lipid profiles, cardiovascular outcomes, and body mass indexes (BMIs), and in reducing other complications associated with the disease. It was also reported that economic advantages were associated with a pharmacist's management of DM.

Objective Although the beneficial effect of aspirin prescription after coronary surgery has been established, the efficacy of clopidogrel has never been compared with that of aspirin in the critical early postoperative period. We therefore conducted a prospective, double-blind, randomized controlled trial to compare the efficacies of these antiplatelet regimens. Methods Patients undergoing elective primary coronary artery bypass surgery were invited to participate. After the operation, patients were randomized to receive 100 mg aspirin, 325 mg aspirin, or 75 mg clopidogrel tablets daily for 5 days. Our primary outcome measure was platelet aggregation on day 5, expressed as percentage of baseline. Assessment of platelet aggregation was undertaken with the technique of Born. Results From September 2002 to July 2003, a total of 54 patients were randomized into the study. There were 2 self-withdrawals and 2 protocol violations, leaving 50 patients for analysis, 34 in the aspirin group and 16 in the clopidogrel arm. Compared with baseline, the mean percentage aggregations with collagen on day 5 were 56% for aspirin and 99% for clopidogrel. The mean difference between the two arms was 42% (95% confidence interval 27%-56%) in favor of aspirin. At the same time point, the effective concentration to inhibit 50% aggregation in the samples from patients randomly assigned to receive clopidogrel were not raised for our entire panel of agonists (changes of −0.04 μg/L for collagen, −0.01 μmol/L for epinephrine, and −0.02 μmol/L for adenosine diphosphate). Conclusion Clopidogrel, unlike aspirin, did not inhibit platelet aggregation in the first 5 postoperative days and therefore should not be used as a sole antiplatelet agent early after coronary surgery.

A female aged 9 years with a recent episode of acute otitis media (AOM) presented to her primary care physician with complaints of severe abdominal pain with right lower quadrant rebound tenderness, suggestive of an acute surgical abdomen. Neurological examination was normal on presentation. She was transferred to the local children's hospital for workup of appendicitis, during which she began exhibiting ataxia and slurred speech. Further evaluation revealed mastoiditis, venous sinus thrombosis and subdural empyema. Appendicitis was ruled out. We describe the first documented case of neurological complications of AOM presenting as an acute surgical abdomen without initial neurological findings.

Objective: Although a number of pharmacologic agents have been shown to reduce intimal hyperplasia in animal models of restenosis, to date no systemic agent has conclusively been shown to be effective in humans. Recently, considerable attention has been directed towards endothelin (ET), a potent vasoconstrictor and a powerful mitogen for vascular smooth muscle cells, as a mediator of intimal hyperplasia. Endothelin-1 has been shown to be mitogenic for human saphenous vein smooth muscle cells, and expression also is elevated in human vein graft stenosis. The aim of this study was the investigation of whether ET receptor antagonists can attenuate neointima formation in a laboratory model of vein graft intimal hyperplasia and the determination of whether the effects are mediated by a specific ET receptor subtype. Methods: We used an organ culture of human saphenous vein, a well-validated model of vein graft intimal hyperplasia. Paired segments of human long saphenous vein were cultured with and without the following antagonists: bosentan, a nonselective ET receptor antagonist; BQ 123, a specific endothelin-A antagonist; or BQ 788, a specific endothelin-B (ET B ) antagonist. After 14 days in the culture, the segments were fixed and processed and the sections were immunostained to facilitate the measurements of neointimal thickness with a computerized image analysis system. Results: The nonselective antagonist bosentan and the ET B selective antagonist BQ 788 significantly reduced neointima formation by 70% ( P = .001) and 50% ( P = .03), respectively, but the ET A antagonist BQ 123 had no significant effect on the reduction of neointima formation ( P = 1.0). Conclusion: The results of this study imply an important role for ET as a mediator of human vein graft intimal hyperplasia and imply further that a specific ET B antagonist may have a therapeutic potential for the prevention of vein graft stenosis. (J Vasc Surg 1998;28:695-701.)

Finger clubbing has many well known causes. We present a rare association of finger clubbing in patient with myelofibrosis and non metastatic renal cell carcinoma, with no evidence of these well known.

The study aims to evaluate general public perceptions regarding the use of Traditional and Complementary Medicines (TCM) for aphrodisiac purposes. A questionnaire based, cross-sectional study was undertaken. Respondents were selected in the state of Penang, Malaysia. A total of 392 respondents were included in the study. Descriptive statistics were used for data analysis. Chi Square/Fischer Exact tests were used where appropriate. Out of 392 respondents, 150 (38.26%) reported using specific Traditional medicines for aphrodisiac purposes. Most respondents (46.94%) agreed that aphrodisiac medicines were easily available t. Moreover, 40.31% of the respondents reported that traditional aphrodisiac medicines were cheaper than modern (prescription) medicines. This study highlights limited public knowledge regarding the use of traditional aphrodisiac medicine. Healthcare professionals should be aware of informal TCM usage when prescribing allopathic medicines.

Fahr's syndrome is a rare idiopathic neurodegenerative disorder which can present with wide spectrum of symptoms. It is characterized by bilateral symmetrical dystrophic intracranial calcification. It most commonly involves basal ganglia. A 30 years old male patient presented with progressive speech slurring and tremors of the right upper limb for last five years. His brain imaging studies revealed findings of extensive dystrophic calcification. He had an elder sister who had progressive limb weakness, tremors and speech slurring. Her brain imaging studies also showed same findings. On the basis of family history, neuroimaging findings and laboratory investigations, patient was diagnosed with the case of familial Fahr's disease. Fahr's disease should be considered as an important differential diagnosis in cases of Parkinsonism refractory to the treatment.

Warburg Micro syndrome and Martsolf syndrome are heterogenous autosomal-recessive developmental disorders characterized by brain, eye, and endocrine abnormalities. Previously, identification of mutations in RAB3GAP1 and RAB3GAP2 in both these syndromes implicated dysregulation of the RAB3 cycle (which controls calcium-mediated exocytosis of neurotransmitters and hormones) in disease pathogenesis. RAB3GAP1 and RAB3GAP2 encode the catalytic and noncatalytic subunits of the hetrodimeric enzyme RAB3GAP (RAB3GTPase-activating protein), a key regulator of the RAB3 cycle. We performed autozygosity mapping in five consanguineous families without RAB3GAP1/2 mutations and identified loss-of-function mutations in RAB18. A c.71T > A (p.Leu24Gln) founder mutation was identified in four Pakistani families, and a homozygous exon 2 deletion (predicted to result in a frameshift) was found in the fifth family. A single family whose members were compound heterozygotes for an anti-termination mutation of the stop codon c.619T > C (p.X207QextX20) and an inframe arginine deletion c.277_279 del (p.Arg93 del) were identified after direct gene sequencing and multiplex ligation-dependent probe amplification (MLPA) of a further 58 families. Nucleotide binding assays for RAB18(Leu24Gln) and RAB18(Arg93del) showed that these mutant proteins were functionally null in that they were unable to bind guanine. The clinical features of Warburg Micro syndrome patients with RAB3GAP1 or RAB3GAP2 mutations and RAB18 mutations are indistinguishable, although the role of RAB18 in trafficking is still emerging, and it has not been linked previously to the RAB3 pathway. Knockdown of rab18 in zebrafish suggests that it might have a conserved developmental role. Our findings imply that RAB18 has a critical role in human brain and eye development and neurodegeneration.

Insufflation of carbon dioxide during laparoscopic cholecystectomy leads to postoperative shoulder tip pain. The origin of shoulder pain is commonly assumed to be due to overstretching of the diaphragmatic muscle fibres owing to a high carbon dioxide pressure.To study the frequency and intensity of post operative shoulder tip pain in laparoscopic cholecystectomy and compare low and standard pressure pneumoperitoneum during laparoscopic cholecystectomy with respect to post operative shoulder tip pain.Patients admitted in the department of surgery for elective cholecystectomy were enrolled in the study. The patients were randomly allocated to two groups (group A and group B). In group A (n = 50), low pressure pneumoperitoneum (8 mm Hg) and in group B (n = 50), standard pressure pneumoperitoneum (14 mm Hg) was generated during laparoscopic cholecystectomy. Postoperative shoulder tip pain was assessed at 4, 8 and 24 h after operation by the Visual Analogue Scale of Pain.14 patients (28%) in group B complained of post operative shoulder tip pain as compared to only 5 patients (10%) in group A. The mean intensity of post operative shoulder tip pain assessed by visual analogue scoring scale at 4, 8 and 24 h was less in group A as compared to group B, although statistical significance was seen only at 4 h. Analgesic requirements and the mean length of post operative stay in the hospital were also less in group A as compared to group B.Low pressure laparoscopic cholecystectomy (LPLC) significantly decreases the frequency and intensity of postoperative shoulder tip pain. LPLC decreases the demand for postoperative analgesics, decreases postoperative hospital stay and hence improves the quality of life in the early stage of postoperative rehabilitation.

Introduction Temporal artery biopsy is a widely performed procedure for clinically suspected temporal arteritis. We the report the case of a 79-year-old male with mantle cell non-Hodgkin's lymphoma previously treated with chemotherapy under follow-up with right-sided orbital recurrence, who developed right temporal headache, tenderness, and visual symptoms in the right eye. His symptoms were unresponsive to steroid treatment and he underwent a temporal artery biopsy. Methods The temporal artery was fixed in standard 10% buffered formalin, processed to paraffin wax, 4 micron sections cut through the entire artery and stained with standard haematoxylin and eosin. Some sections were exposed to CD20, CD5, and cyclin D1 immunohistochemistry. Results Histology showed a perivascular, nodular lymphoid infiltrate composed of small centrocyte-type lymphocytes around the main artery and identical lymphocytes within the wall of a main artery branch. Additionally, the lymphocytes were located around a peripheral nerve in the peri-artery connective soft tissues. These lymphocytes were positive for CD5, CD20, and cyclin D1 indicating a diagnosis of peri-neural, peri-vascular mantle cell non-Hodgkin's lymphoma of identical appearance to that in the index biopsy. Conclusions This report describes a highly unusual histological and clinical scenario of peri-temporal artery Mantle cell lymphoma causing temporal headache from peripheral nerve and artery side branch involvement by the lymphoma immediately adjacent to the temporal artery. We propose that involvement of a temporal artery by lymphoma be considered in the differential diagnosis, in patients with an established diagnosis of lymphoma, if presenting with “temporal arteritis” type headache symptoms.

Maternal mortality ratio is an indicator to measure the summary of information about mother and child health. It is estimated that about 500 maternal deaths occur per 100,000 live births each year in Pakistan. It is a well known fact that all health statistics coming out of the developing countries are calculated "guesstimates" some are perhaps more close to the real figures than the others. There is a dire need to help generate information that can be used by health professionals, health care planners and managers to save women's lives by improving the quality of care provided to turn away maternal mortality. The maternal mortality ratio for Pakistan as well as for NWFP is projected as 533/100,000 live births for the year 1990-91 produced by National Institute of Population Studies, Pakistan.This was a retrospective cross-sectional quantitative study for the period (2001-2002) conducted in five districts of (NWFP) North Western Frontier Province, Pakistan.National HMIS data opened the maternal mortality ratio for; Haripur as 0.168 and 0.173, Mansehra 00 and 00, Battagram 00 and 00, Swat 0.051. and 0.524 and Swabi 00 and 0.968 per/1000 live births, respectively. The small part exercise outcome (the study) endorsed more shadowy side of the actual maternal mortality ratio for the same period in the same districts.In our country there is a urgent need to institute an efficient mode of operation to get accurate maternal mortality database. Verbal Autopsy method is cost effective and feasible approach for implementation in a country like Pakistan.

Cystoid macular edema (CME) is an important cause of visual impairment following phacoemulsification surgery. Imatinib is a new drug that is being used as adjunctive therapy in the management of various malignancies. A reported ocular side effect of this drug is spontaneous retinal edema. We report the case of a patient on imatinib who developed significant premature CME following uneventful phacoemulsification surgery. This resolved soon after cessation of imatinib therapy, and there was an improvement in visual acuity.