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Background: Lung is the main organ at risk for radiation induced injury while treating breast cancers with Post Mastectomy Radiotherapy (PMRT). Restrictive lung changes are usually seen in spirometry which tends to normalize by 1 year. Central Lung Distance (CLD) is shown to correlate well with the percentage of ipsilateral lung volume irradiated. Aims and Objectives: Spirometric changes following Radiation Therapy (RT) to chest wall in breast cancer patients using conventional fractionation and its correlation with acute radiation pneumonitis. Materials and Methodology: Thirty Breast cancer patients who received RT to chest wall +/- supraclavicular fossa and axilla, following Modified Radical Mastectomy (MRM) and neoadjuvant or adjuvant chemotherapy using tangential beams with Co60 teletherapy to a dose of 50 Gray in conventional fractionation were included and followed up till 6 months post RT. Baseline chest X-ray and spirometry done pre-RT were compared with those taken at 1, 3 and 6 months after completion of RT. Patients were evaluated at each visit for signs and symptoms of radiation pneumonitis, when present were graded as per Radiation Therapy Oncology Group (RTOG) criteria. Results: There was a significant fall in Forced Vital Capacity (FVC) by the end of 3 months (p value

Background: The COVID-19 pandemic in Bangladesh is part of the worldwide pandemic of coronavirus disease 2019 which has crowded out services for both covid and non-covid patients, in a country where the health care system was already under huge stress even before the pandemic. Objectives: To postpone non-urgent surgeries along with active surveillance of thyroid cancer patients to make sure the hospitals are not unnecessarily occupied. Methods: Document based categorization of thyroid cancer patients, like- low risk, high risk and clinically extremely vulnerable groups who are at greatest risk of severe illness from coronavirus are to be done accordingly. Individuals with thyroid cancer are mostly not susceptible to COVID- 19. However, patients with thyroid cancer (papillary or medullary) having lung metastases or undergoing certain types of cancer treatment might be at increased risk of viral infection or complications. Risk benefit ratio is checked and explained to the patient and their attendants. Recommendations: As COVID-19 is spreading across the Bangladesh, hospitals are being forced to reallocate resources to the care of critically ill. So it is crucial to adhere to the advice from experts to reduce the risk of infection. All non-essential surgeries and hospital admissions can be postponed to make sure that hospitals are not unnecessarily occupied. Conclusion: In the face of the COVID-19 pandemic, cancer care has had to adapt rapidly given recommendations to postpone nonurgent surgeries with active surveillance of thyroid cancer patients except thyroid tumors requiring acute airway management. J Dhaka Medical College, Vol. 29, No.2, October, 2020, Page 178-181

Arthritis is one of the leading causes of disabilities and morbidity worldwide. Among various forms of arthritis, osteoporosis, osteoarthritis and rheumatoid arthritis have been considered the most common categories with significant pathophysiology. Although these types of arthritis torment many patients, the molecular level of pathogenesis has not been elucidated. In present study, we have identified the role of three circulating miRNAs targeting different molecular mechanisms in arthritis for identifying non-invasive diagnostic and therapeutic marker. A total of 42 arthritis patient's peripheral blood samples were collected and serum was separated. miRNA extraction was performed from serum samples and used for relative quantification of selected miRNAs (miRNA-33a, miRNA-146a and miRNA-203a) using SYBR Green-based Real-Time quantitative PCR. The results showed that all three miRNAs gets upregulated in arthritis patients however, miRNA-33a is the most significantly upregulated miRNA in total arthritis, osteoporosis, osteoarthritis and rheumatoid arthritis patient's samples as compared to other two miRNAs with respect to healthy controls. The correlation of relative fold change in expression levels of selected three miRNAs with disease categories showed the most significance in RA as compared to other groups. Among all three miRNAs, miRNA-33a as well as miRNA-146a showed significant upregulation in RA subjects as compared to OA and OP (***p

Background: A hydrocele is a fluid - filled sac surrounding a testis that results in the swelling of scrotum. They can develop due to inflammation or injury within the scrotum. Objective: This study aimed to evaluate the efficacy and adaptation of different surgical procedures in the repair of hydrocele. Study design: Comparative, Retrospective study .Place and duration of Study: The study was conducted at Fauji Foundation Hospital Karachi , Al-Tibri Medical College, Karachi and Civil Hospital Karachi from January, 2000 to December, 2013. Patients and methods: Patients with primary vaginal hydrocele registered during the period of thirteen years in the out patient department of surgery were selected. A total of 300 patients were assessed clinically, diagnostically and radiologically about the status of hydrocele before the surgical procedures and anesthetic opinion. The different surgical technique were carried out in different group of patients asJaboulay's technique in 70 patients, Lord's procedure in 70 patients, Aspiration and Sclerotherapy in 05 patients, Window operation technique in 05 patients and the Hydrocelectomyby supra pubic procedure were carried out in 150 patients out of total 300 registered patients. The data collected and analyzed statistically in SPSS version 19.00. Results: The different procedures have been adopted surgically in patients with primary vaginal hydrocele. The results showed that among the different operative techniques adopted, the best procedure regarding hydrocelectomy is the supra pubic approach line of treatment. It showed better result and recovery with very minimum complications and side effects as compared to other surgical procedure. Conclusions: The data thus concluded that hydrocelectomy done via supra pubic approach in number of patients proved to be the best procedure because of having very little complications.

Introduction: Stroke mimics constitute a good number of patients referred as acute strokes within the window period for acute therapies. Proper triaging can avoid unnecessary imaging and even thrombolytic therapies in these patients. This study looked at etiological spectrum of acute stroke mimics presenting within the 4.5 hours therapeutic window. We also evaluated the FAST (Face-Arm-Speech-Time), BEFAST (Balance -Eyes-Face-Arm-Speech-Time) and the ROSIER (Recognition of Stroke in the Emergency Room) tools in picking true strokes. Methods: A prospective observational cohort study over a 2- year period; A descriptive analysis of various etiologies presenting as acute stroke was done. The presenting symptoms, signs and the diagnostic value of the FAST, BEFAST, and the ROSIER Scores in both the stroke mimics and true strokes were noted and the sensitivity and specificity for picking up the stroke mimics were calculated. Student’s t test, univariate analysis and multivariate logistic regression analysis were done. Diagnosis of stroke was confirmed by MRI. Results: After initial screening by Neurologists, stroke mimics constituted 328/1635 (20%) of referrals for acute stroke. Focal and generalized seizures with transient weakness and peripheral vertigo were the most common acute stroke mimics; followed by metabolic causes and psychiatric disorders. Females were more in the stroke mimic group (p = 0.02). Ischemic heart disease and atherosclerotic risk factors (except diabetes mellitus) were significantly higher among true strokes. 4 (1.2%) of the stroke mimics were treated with IV thrombolysis. Diagnostic accuracy for different stroke differentiating tools were: FAST (Sensitivity 85,9% specificity 52.8% Odds 6.8), BEFAST (Sensitivity 97.0% specificity 31.4% Odds 14.9) And ROSIER Scale (Sensitivity 85.7% specificity 59.4% Odds 8.7%). In Conclusion, Stroke mimics can constitute up to 20% of cases evaluated as strokes. None of the triaging tools appear to have enough accuracy. A proper history and clinical examination should be given priority over fixed protocols whenever acute stroke mimic are suspected, especially before administering acute costly interventions. Auditing stroke mimics is important to improve acute stroke pathways.

Background: Inadequate Blood Transfusion is responsible for various problemsin children with Thalasseima. On the other hand, repeated transfusions are related with hazards.About 25-50% of the children with thalassemia major have impaired glucose tolerance (IGT)or diabetes. Objectives: To find out the frequency of IGT in children with blood transfusiondependent β thalassemia. Study Design: Descriptive analytical study. Setting: Department ofPediatrics, Shahida Islam Teaching Hospital, Lodhran. Period: 1st July 2017 to 31st December2017. Material and Methods: Known 120 cases of beta Thalassemia major children between3-17 years of age that were regularly transfused. Demographics, disease history and personalinformation regarding all the patients were collected. Glucose tolerance test was performedand Serum ferritin levels were measured. Results were analyzed by SPSS software version20.0. Results: There were 78 (65.0%) children between 3-10 years and 42 (35.0%) between11-17 years. There were 70(58.3) male and 50 (41.7%) female. Frequency of impaired glucosetolerance was noted in 15 (12.5%). Conclusion: Frequency of IGT is high amongst children withthalassemia major having regular blood transfusions.

Background: Dyslipidaemias is one of the major risk factor for Coronary artery diseases (CAD).There is an inverse correlation between high density lipoprotein cholesterol (HDL-C) and the risk of coronary artery disease. Understanding the angiographic characteristics of coronary artery diseases (CAD) in low and normal HDLC patients and its association with severity of CAD is very important for future intervention. Although highdensity lipoprotein cholesterol (HDL-C) is well established predictor of future cardiovascular event, little information is available regarding its correlation with the prevalence and severity of angiographically evaluated coronary artery diseases (CAD).Materials and Methods: This cross-sectional comparative study was conducted in the Department of Cardiology, Sylhet MAG Osmani Medical College Hospital, Sylhet during the period from January 2012 to December 2013. We included 100 patients with coronary artery diseases and divided into two groups. 50 patients with low HDL-C (40 mg/dl) were taken in control group (Group-B) according to inclusion and exclusion criteria. Coronary angiography was performed via the trans-femoral approach using standard techniques. Severity of CAD was determined by vessels score and Friesinger score.Results: The age [51.1 (SD 8.7) years vs 51.4 (SD 8.2) years; p>0.05] and sex [45 (90.0%) male and 5 (10.0%) female vs 41 (82.0%) male and 9 (18.0%) female; p=0.249] were similar in group-A and group-B. The conventional risk did not show any significant difference between low and normal HDL level group such as age, sex, smoking, diabetes mellitus, hypertension, BMI, hypercholesterolaemia, high serum LDL, hypertriglyceridaemia and family history of CAD (p>0.05 each). No significant vessel disease [3 (6.0%) vs 14 (28.0%); p=0.008] and single vessel disease [11 (22.0%) vs 25 (50.0%); p=0.020] were significantly fewer in group A than that of group-B; while double vessel disease [14 (28.0%) vs 5 (10.0%); p=0.039] and triple vessels disease [22 (44.0%) vs 6 (12.0%); p=0.002] were significantly higher in group-A than that of group-B. Friesinger score 0 [3 (6.0%) vs 11 (22.0%); p=0.033] and Friesinger score 1 to 4 [6 (12.0%) vs 24 (48.0%); p=0.01] were significantly fewer in group A than that of group-B; while Friesinger score 5 to 9 [20(40.0%) vs 9 (18.0%); p=0.041] and Friesinger score 10 to 15 [21 (42.0%) vs 6 (12.0%); p

Purpose To report 1-year treatment outcomes in the Primary Tube Versus Trabeculectomy (PTVT) Study. Design Multicenter, randomized clinical trial. Participants Two hundred forty-two eyes of 242 patients with medically uncontrolled glaucoma and no previous incisional ocular surgery, including 125 in the tube group and 117 in the trabeculectomy group. Methods Patients were enrolled at 16 clinical centers and assigned randomly to treatment with a tube shunt (350-mm 2 Baerveldt glaucoma implant) or trabeculectomy with mitomycin C (MMC; 0.4 mg/ml for 2 minutes). Main Outcome Measures Intraocular pressure (IOP), glaucoma medical therapy, visual acuity, visual fields, surgical complications, and failure (IOP of more than 21 mmHg or reduced by less than 20% from baseline, IOP of 5 mmHg or less, reoperation for glaucoma, or loss of light perception vision). Results The cumulative probability of failure during the first year of follow-up was 17.3% in the tube group and 7.9% in the trabeculectomy group ( P = 0.01; hazard ratio, 2.59; 95% confidence interval, 1.20–5.60). Mean ± standard deviation IOP was 13.8±4.1 mmHg in the tube group and 12.4±4.4 mmHg in the trabeculectomy group at 1 year ( P = 0.01), and the number of glaucoma medications was 2.1±1.4 in the tube group and 0.9±1.4 in the trabeculectomy group ( P P = 0.06). Serious complications requiring reoperation or producing a loss of 2 Snellen lines or more occurred in 1 patient (1%) in the tube group and 8 patients (7%) in the trabeculectomy group ( P = 0.03). Conclusions Trabeculectomy with MMC had a higher surgical success rate than tube shunt implantation after 1 year in the PTVT Study. Lower IOP with use of fewer glaucoma medications was achieved after trabeculectomy with MMC compared with tube shunt surgery during the first year of follow-up. The frequency of serious complications producing vision loss or requiring reoperation was lower after tube shunt surgery relative to trabeculectomy with MMC.

Central neurocytomas (CNs) occur typically in the lateral ventricle, adjacent to the septum pellucidum and foramen of Monro. The clinical presentation varies and many are incidentally detected. Incidence of spontaneous hemorrhage at presentation is rare. We hereby report a case of the intraventricular lesion with bleed which was operated on an emergency basis as it caused obstructive hydrocephalus and the patient was in altered sensorium. The exact cause of hemorrhage in CNs is not known, and the previously discussed explanations are discussed.

Background Coccinia grandis (L.) Voigt (Cucurbitaceae) is well known as ivy gourd/little gourd in English, found to be beneficial in the management of diabetes. Purpose This project was conducted to evaluate the beneficial effects of chemically characterized C. grandis ethanol extract in high fat (HF) diet fed rats. Methods Antidiabetic test was performed by oral glucose tolerance test, antioxidant evaluation was done by the assessment of the antioxidants, anti-oxidant enzyme activity as well as liver marker enzymes activities in the plasma and tissues collected from the rats. Cholesterol level was also quantified in rats used in different groups. To monitor the fibrosis in the liver and infiltration of inflammatory cells, histological staining was performed. Results C. grandis treatment significantly reduced cholesterol level, liver wet weight and peritoneal as well as epididymal fat accumulation in HF diet fed rats. Furthermore, C. grandis treatment significantly prevented the rise of liver enzymes and MPO activities in rats fed with HF diet. C. grandis treatment also successfully restored the activities of antioxidant enzymes in rats fed with HF diet. The outcomes for antioxidant potential specify that at both doses of C. grandis extracts (100 and 200 mg/kg) significantly prevented the oxidative stress parameters which are comparable to the standard metformin. Moreover, ethanolic extracts of C. grandis prevented inflammation or fibrosis in liver of HF diet fed rats. HPLC-DAD analysis of the extract identified and quantified significant number of phenolic compounds such as gallic acid, kaempferol and quercetin hydrate. Conclusion This study suggests that, ethanolic extract of C. grandis can prevent fat deposition, hyperlipidemia, glucose intolerance and oxidative stress in rats fed with HF diet.

Introduction: Distal sensory polyneuropathy (DSP) is one of the most common neurological disorders. Although several studies have studied the role of the neurological examination in DSP, there are only limited studies on the utility of timed vibration sense (VBS) and joint position sense (JPS) testing in the diagnosis of DSP. Objectives: The objective is to study the utility of timed VBS testing and JPS testing at the great toe in clinical detection of DSP. Methods: This study was prospectively conducted in the neurology department of a tertiary care hospital in India. Patients with DSP referred to the electrophysiology laboratory from August 2017 to December 2017 were screened. Patients with symptomatic DSP which was confirmed by electrophysiological studies were taken as cases and normal participants with no symptoms or electrophysiological findings suggestive of DSP served as controls. Results: We studied 127 patients and 194 controls. The mean age of the patients was 48.7 (14.5) years in the patient group and 39.7 (14.5) years in the control group. The male: female ratio was 77/50 in the patient group and 112/82 in the control group. Abnormal clinical examination was found in 95% of the patients with DSP. The most common abnormal examination components were impaired ankle reflexes (70%), vibration (85%), and JPS (39.6%) sensation. Using the receiver operating characteristic curve for the diagnosis of DSP, a vibratory response lasting 8 s at the great toe was a useful test to rule out DSP, and for JPS testing at the great toe, obtaining two or more incorrect responses was a useful test in ruling in the diagnosis of DSP.

Introduction The most obvious manifestation of arthritis involves inflammation and damage in synovial joints, whereas effect of lipid metabolism regulatory changes is barely understood. Clinical conditions of lipid abnormality in arthritis patients suggest role of altered lipid metabolism regulation in widespread inflammation-driven metabolic changes. Hence, the present study was undertaken to investigate the quantitative response of different lipid-binding transcriptional and post-transcriptional networks for understanding the effect of metabolic changes among three different forms of arthritis. Methods A total of 48 individuals (36 patients and 12 healthy controls) were included in this study. The 36 patient samples were distributed in three different categories of arthritis (osteoarthritis; n = 12, osteoporosis; n = 12 and rheumatoid arthritis; n = 12) based on their clinical parameters without overlapping inflammatory diseases. Peripheral blood samples were collected and used for gene transcripts (HFABP-4, HPSP and mTOR) and miRNAs (miRNA-124 and miRNA-497) expression analysis using quantitative polymerase chain reaction. Results Among three different gene transcripts, HFABP-4 was found to have significant increased levels in osteoporosis patients, while HPSP showed significantly increased levels in osteoarthritis and rheumatoid arthritis patients. No significant change was observed for mTOR in all three different forms of arthritis patients. Both the miRNAs (miRNA-124 and miRNA-497) had significant increased levels in osteoporosis and rheumatoid arthritis patients in circulation. Conclusion The present study has demonstrated that relative expression analysis of circulating lipid metabolism regulatory molecules plays significant role in molecular classification of osteoporosis, osteoarthritis and rheumatoid arthritis conditions.

Context: Trismus is one of the common late side effects of radiotherapy (RT) of head and neck cancers. It occurs in about 30% of patients treated by telecobalt. It, in turn, leads to significant morbidity, including malnutrition, difficulty in speaking, and compromised oral hygiene with severe psychosocial, and economic impacts. Aims: To determine the prevalence of trismus and its progression in patients who have received radical concurrent chemoradiation for head and neck cancer by telecobalt at our institution. To note the effect of early rehabilitative measures on the severity of trismus and to assess its impact on the quality of life (QOL). Subjects and Methods: A total of 47 evaluable patients of head and neck cancer patients treated by telecobalt with radical intent between January 2012 and December 2013 were analyzed and baseline maximal inter-incisal opening (MIO) and MIO at the completion of RT, after 3 months, 6 months, and 1 year, after completion of RT were noted. Grading of trismus was done using Modified Common Toxicity Criteria (CTCAE Version 3.0). QOL assessment was done using European Organization for Research and Treatment of Cancer QLQ-HN35. The time when the rehabilitative measures were started were also noted. Statistical Analysis Used: Chi-square test with Fisher exact probability test and Students t-test. Results: Radiation-induced trismus (RIT) was seen in 31.9%, 34.04%, and 38.39% of cases at 3, 6, and 12 months after completion of RT. Grade II and III trismus accounted for 17.02% and 6.38% at the end of 1 year. Patients who started regular rehabilitative exercises soon, after completion of RT had a better mean MIO as compared to those who were not compliant (32 mm vs. 24 mm at 1 year), and there was a trend toward delayed progression in them. Trismus was also seen to adversely affect QOL of the patients. Conclusions: RIT is a major cause for late morbidity in patients treated with conventional RT leading to poor QOL. Early rehabilitative measures are useful in preventing progression of trismus.

The aim of this study was to examine the effect of rosuvastatin in experimentally-induced hepatic inflammation and fibrosis in rats. Carbon tetra chloride (CCl4) was administered orally to induce liver damage in female Long Evans rats. Rats were treated with CCl4 alone twice a week over two weeks. Rosuvastatin (10 mg/kg) was also given daily to CCl4 treated rats concurrently by nasogastric gavage. After two weeks, various oxidative stress markers as well as liver markers enzymes were investigated in different animal groups tested in this study. Moreover, histological assessments were also done for inflammatory cell infiltration and fibrosis in the liver of all test groups. Plasma aspartate aminotransferase (AST), alanine aminotransferase (ALT) and alkaline phosphatase (ALP) activities were increased in the CCl4 group compared with the control group. Increased liver enzyme activities were significantly decreased by rosuvastatin treatment. Moreover, rosuvastatin treatment inhibited the formation of lipid peroxidation products in CCl4 administered rats. Rosuvastatin treatment also restored the decreased superoxide dismutase (SOD) activities as well as elevated the reduced glutathione concentration in CCl4 administered rats. Liver tissues from rats of control group also revealed no significant pathological changes, while CCl4 administered rats showed significant infiltration of inflammatory cells and liver fibrosis, which was further, normalized or significantly decreased by rosuvastatin treatment. This study revealed that, rosuvastatin treatment may ameliorate all necroinflammatory and fibrotic changes in liver tissues of CCl4 induced rats and could be used as an alternative therapy for chemical or drug-induced liver fibrosis. [ J Adv Biotechnol Exp Ther 2020; 3(1.000): 01-08]

Purpose The brainstem plays an important role in the control of micturition, and brainstem strokes are known to present with micturition dysfunction. Micturition dysfunction in cases of lateral medullary infarction (LMI) is uncommon, but often manifests as urinary retention. In this study, we investigated the neuro-anatomical correlates of urinary retention in patients with LMI. Methods This was a hospital-based retrospective study conducted in the neurology unit of a quaternary-level teaching hospital. Inpatient records from January 2008 to May 2018 were searched using a computerized database. Cases of isolated LMI were identified and those with micturition dysfunction were reviewed. MRI brain images of all patients were viewed, and individual lesions were mapped onto the Montreal Neurological Institute (MNI) space manually using MRIcron. Nonparametric mapping toolbox software was used for voxel-based lesion-symptom analysis. The Liebermeister test was used for statistical analysis, and the resultant statistical map was displayed on the MNI template using MRIcron. Results During the study period, 31 patients with isolated LMI were identified. Their mean age was 48 years and 28 (90%) were male. Six of these patients (19%) developed micturition dysfunction. All 6 patients had urinary retention and 1 patient each had urge incontinence and overflow incontinence. In patients with LMI, the lateral tegmentum of the medulla showed a significant association with urinary retention. Conclusion In patients with isolated LMI, we postulate that disruption of the descending pathway from the pontine micturition centre to the sacral spinal cord at the level of the lateral tegmentum results in urinary retention.

Molecular epidemiological studies have identified several risk factors linking to the genes and external factors in the pathogenesis of breast cancer. In this sense, genetic instability caused by DNA damage and DNA repair inefficiencies are important molecular events for the diagnosis and prognosis of therapies. Therefore, the objective of this study was to analyze correlation between sociocultural, occupational, and lifestyle risk factors with levels of genetic instability in non-neoplastic cells of breast cancer patients. Total 150 individuals were included in the study that included 50 breast cancer patients submitted to chemotherapy (QT), 50 breast cancer patients submitted to radiotherapy (RT), and 50 healthy women without any cancer. Cytogenetic biomarkers for apoptosis and DNA damage were evaluated in samples of buccal epithelial and peripheral blood cells through micronuclei and comet assay tests. Elder age patients (61-80 years) had higher levels of apoptosis (catriolysis by karyolysis) and DNA damage at the diagnosis (baseline damage) with increased cell damage during QT and especially during RT. We also reported the increased frequencies of cytogenetic biomarkers in patients who were exposed to ionizing radiation as well as for alcoholism and smoking. QT and RT induced high levels of fragmentation (karyorrhexis) and nuclear dissolution (karyolysis) and DNA damage. Correlations were observed between age and karyorrhexis at diagnosis; smoking and karyolysis during RT; and radiation and karyolysis during QT. These correlations indicate that risk factors may also influence the genetic instability in non-neoplastic cells caused to the patients during cancer therapies.

The population of the United States is aging. Currently people over the age of 65 years constitute 13% of the general population. By 2050 this number will rise to about 25% of the population. As the population ages, the number of older adults with mental illness will also rise. Available data indicates that there are inadequate numbers of trained geriatric psychiatrists in United States to care for older adults with mental illness. The additional burden for services in the future on an already strained healthcare system can lead to catastrophic failure of the system. International Medical Graduates (IMGs) constitute almost half of the work force of geriatric psychiatrists. The IMGs have had successful career as clinicians, educators, academics and researchers in geriatric psychiatry. In this symposium we will enumerate the unique challenges faced by the IMGs and strategies on enable them to integrate into the mainstream geriatric psychiatry workforce. We will review the roles of IMGs as private practitioners, educators, academicians and as researchers. We will also discuss how organizations like the AAGP can play a greater role in attracting larger number of IMGs to join the geriatric psychiatry workforce and also the AAGP. This will enable greater access to care for the older adults with mental illness and maintain the success of AAGP in being the national organization for geriatric psychiatry clinicians in the United States.

Clozapine is a second-generation antipsychotic typically reserved for refractory psychotic disorders due to its high-risk side effect profile to include agranulocytosis, with its attendant need for regular blood draws. While reports of extrapyramidal symptoms (EPS), including acute dystonic reactions, are exceedingly rare, we present the case of a 44-year-old male with a long-standing history of treatment-resistant schizoaffective disorder and no history of EPS who experienced an acute buccal dystonic reaction in the setting of clozapine initiation and discontinuation of depot and oral risperidone. This case report presents one of the few documented episodes of acute dystonic reactions occurring in the setting of clozapine administration. Based upon the patient’s history and the dosing time line of the medications, we propose that an interaction between the clozapine and residual risperidone was responsible for the development of the acute buccal dystonia.

Background: There are various drugs tried for relieving pain associated with radiation-induced mucositis. This paper aims to study role of honey in relieving pain due to radiation induced mucositis in head and neck cancer patients receiving concomitant chemoradiation. Materials and Methods: A randomized controlled trial on 78 subjects (40 in test group and 38 in control group) was undertaken to study the analgesic effect of honey, but the analysis of 69 patients was done as nine patients (four in test and five in control group) were lost to follow-up or left treatment in between the study. All patients were advised to do salt-soda and benzydamine mouth gargles, alternatively every 3 hours. Test group patients additionally received 20 ml honey three times a day during the entire course of radiation treatment and 3 months following radiation therapy (RT). Results: Honey significantly reduced the severity of mucositis associated pain and resulted in lesser treatment gaps and a decrease in overall radiotherapy treatment duration. None of the test group and majority of controls (51.5%) had severe pain score during the 7th week of RT. The same pattern was seen in the post-RT period. Mean pain score was significantly different in both groups during all weeks during and upto 6 weeks post-RT (mean score of 3.08 and 6.54 for test and control respectively at 7th week RT, P < 0.001). Conclusion: Honey being a cheap, palatable, and natural medicament can be used for decreasing pain associated with radiation-induced mucositis in cancer patients.

BACKGROUND: Concurrent chemo irradiation is the standard treatment for patients with head & neck cancer (HNC). Dysphagia is a common late toxicity of treatment. 7-21% of these patients have treatment induced stricture of the upper esophagus causing dysphagia, with a high incidence of the same in cases of carcinoma hypopharynx. The objective of the present study was to identify the incidence of treatment related stricture of the upper esophagus in patients with hypopharyngeal cancer in our institution. METHODS: A retrospective analysis on patients treated for carcinoma hypopharynx, in the department of Radiotherapy at our Institute, between 2008-12 was conducted. All patients who had received chemo irradiation were included Patients who had developed upper esophageal stricture post treatment diagnosed by upper GI endoscopy and required periodic dilatation were analyzed using Fisher's exact test. RESULTS: 377 patients of HN mean age 57yrs); out of which 10 patients developed treatment related stricture in the proximal esophagus (20%) (4 females, 6 males). Post cricoid primary had a higher incidence of stricture (7/10) (p=0.0012** two-tailed), followed by primary of the pyriform sinus (3/10). Posterior pharyngeal wall malignancies did not have treatment induced strictures. The mean interval between completion of treatment and endoscopic diagnosis of stricture was 4 months. 5 out of 10 patients underwent periodic dilatations up to an average of 13mm. CONCLUSIONS: Upper esophageal stricture is an important late effect of chemo irradiation in patients with carcinoma hypopharynx. Post cricoid cancers have a higher incidence of treatment induced strictures.

Fertility preservation is one of the major concerns of young patients diagnosed with gynecological cancer. With newer treatment regimens and better surgical techniques, survival rates after cancer treatment have improved, hence preservation of fertility has recently become an important issue in the treatment of gynecological cancers. Fertility sparing surgery may be an option for early-stage cervical cancer with the development of loop excision techniques and radical trachelectomy which allows a radical approach to cervix cancer at the same time preserving the uterus and thus fertility. Fertility preservation is possible in Stage 1 epithelial ovarian cancers, germ cell ovarian tumors, and borderline cancers. Hormonal therapy with progestin agents is effective in early endometrial cancer. In patients desiring future pregnancy, fertility sparing options must be explored before starting treatment for gynecologic cancers.

The aim of this study was to evaluate the morbidity and survival outcome following radical hysterectomy after chemoradiotherapy in the International Federation of Gynecology and Obstetrics (FIGO) stages IB-IIB cervical cancer patients in whom intracavitory brachytherapy was not feasible. We retrospectively reviewed the medical records of our patients who underwent adjuvant radical hysterectomy between January 2005 and December 2012. Post-operative complications were graded according to the grading system of Chassagne et al. (Radiother Oncol 26:195-202, 1993). Survival analysis was done using Kaplan-Meir method. Between January 2005 and December 2012, 43 patients underwent type 2 radical hysterectomy after external beam radiotherapy and concurrent chemotherapy. The median age of the study group was 44 years (range 28-63 years). There were no perioperative deaths. In the early post-operative period, there were 45 complications in 29 patients of which three were of grade 3 severity. The most common post operative complications were urinary tract infections and lymphoedema. The median follow-up time was 29 months (range 9-68 months). The 5-year overall survival was 85.5 % and disease-free survival 82.1 %. This study shows that radical hysterectomy is feasible with good survival outcome and acceptable morbidity after chemoradiotherapy in cervical cancer patients.

Scrub typhus is endemic in large parts of India and can cause multi-organ failure and death. Acute pancreatitis as a complication is very rare and is potentially fatal. This case series describes seven adult patients who presented with an acute febrile illness and were diagnosed to have scrub typhus with acute pancreatitis. The mean age of the seven patients with acute pancreatitis was 49.4 years, and mean duration of fever prior to presentation was 7.7 days. All seven patients had abdominal pain, and three had a pathognomonic eschar. The mean serum lipase level was 1,509 U/L (normal value

Objective To study the effect of thiamine administration on the resolution of pulmonary hypertension in exclusively breastfed infants. Design Prospective cohort study. Setting Hospital based study of a tertiary care hospital. Patients A total of 29 infants with 17 males (58.6%) and 12 females (41.4%) were included in the study. Intervention In addition to the management of shock, right heart failure and renal failure, patients received intravenous thiamine 100 mg/kg IV followed by 10 mg/day till introduction of supplementary feeds. Main outcomes measures Resolution of shock, metabolic complications and pulmonary hypertension. Results Mean age at presentation was 78.45 ± 30.7 days. All infants were exclusively breastfed. 86.2% of mothers were on customary dietary restrictions. Biventricular failure and tachycardia was commonly present. There were four deaths in our series. Acute metabolic acidosis was a universal feature with a mean pH of 7.21 ± 0.15. Pulmonary hypertension was present in all patients on admission. Intravenous thiamine 100 mg/kg IV stat was given immediately after documenting pulmonary hypertension. Repeat echocardiography showed complete resolution of pulmonary hypertension. Conclusion Many infants present to us with Shoshin beriberi with unusually high pulmonary pressures. These patients respond to thiamine challenge with prompt resolution of metabolic complications and reversal of pulmonary hypertension. We believe this is first of its kind from the region, which is reported.

A single-dose regimen of the current killed oral cholera vaccines that have been prequalified by the World Health Organization would make them more attractive for use against endemic and epidemic cholera. We conducted an efficacy trial of a single dose of the killed oral cholera vaccine Shanchol, which is currently given in a two-dose schedule, in an urban area in which cholera is highly endemic.Nonpregnant residents of Dhaka, Bangladesh, who were 1 year of age or older were randomly assigned to receive a single dose of oral cholera vaccine or oral placebo. The primary outcome was vaccine protective efficacy against culture-confirmed cholera occurring 7 to 180 days after dosing. Prespecified secondary outcomes included protective efficacy against severely dehydrating culture-confirmed cholera during the same interval, against cholera and severe cholera occurring 7 to 90 versus 91 to 180 days after dosing, and against cholera and severe cholera according to age at baseline.A total of 101 episodes of cholera, 37 associated with severe dehydration, were detected among the 204,700 persons who received one dose of vaccine or placebo. The vaccine protective efficacy was 40% (95% confidence interval [CI], 11 to 60%; 0.37 cases per 1000 vaccine recipients vs. 0.62 cases per 1000 placebo recipients) against all cholera episodes, 63% (95% CI, 24 to 82%; 0.10 vs. 0.26 cases per 1000 recipients) against severely dehydrating cholera episodes, and 63% (95% CI, -39 to 90%), 56% (95% CI, 16 to 77%), and 16% (95% CI, -49% to 53%) against all cholera episodes among persons vaccinated at the age of 5 to 14 years, 15 or more years, and 1 to 4 years, respectively, although the differences according to age were not significant (P=0.25). Adverse events occurred at similar frequencies in the two groups.A single dose of the oral cholera vaccine was efficacious in older children (≥5 years of age) and in adults in a setting with a high level of cholera endemicity. (Funded by the Bill and Melinda Gates Foundation and others; ClinicalTrials.gov number, NCT02027207.).

Kashmir has a population that largely consumes polished rice which is deficient in thiamine. Furthermore, lactating women in this region are prone to severe thiamine deficiency because of their traditional food avoidance practices. Infantile beriberi is common in exclusively breastfed infants of thiamine deficient mothers in Kashmir. This was a one year prospective hospital-based study. We included 50 exclusively breastfed infants in our study. All patients were evaluated as per unit protocol including complete septic workup and metabolic workup. Most of our patients belonged to low and middle income group families, and mothers were on customary dietary restriction. Demographic and anthropometric data were collected from all the study participants. In addition, data regarding the treatments received by the study population and overall mortality were collected. The mean age, male:female ratio, and mean weight of the study population were 3.15±0.97 months, 1.5:1, and 5.1±1.1 kg, respectively. Traditional food avoidance practices were followed by 80% of the mothers. Irritability was observed in 40 (80%) patients. Blepharoptosis was observed in 30 (60%). Septic workup including cerebro spinal fluid analysis was normal in all patients. Predominant magnetic resonance imaging finding was bilateral basal ganglia hyperintensity. Whole blood thiamine diphosphate levels showed a drastic decrease (10-49 nmol/L). Ten percent of the study infants died. In exclusively breastfed infants, we observed acute infantile encephalopathy with epidemiological, clinical, biochemical, and radiological features suggestive of infantile Wernicke’s encephalopathy and a favourable therapeutic response to thiamine supplementation during the acute stage.

Background: We investigated polymorphisms of immune related genes (CD14 and TLR4) and explore the associations of these variants and risk of CM. Method: We detected SNPs of CD14 (-159C>T) and TLR4 (299 A>G) using the polymerase chain reaction (PCR) with peripheral blood samples from 141 patients with CM and 198 healthy people, further analyzing their relations with the risk of CM. Result: The CT genotype of CD14 gene was found to be associated with CM and 1.84 folds increased risk to CM when compared to CC genotype (OR 1.84, 95% CI 1.18–2.88, P=0.0051). Heterozygotes (AG) of TLR4 gene were found to be predominant in the CM group when compared to controls (50.4%, 38.4% respectively, P=0.0081) with 1.79 folds increased risk for CM, which was statistically significant (OR 3.79, 95% CI 1.15–2.80, P=0.0081). Conclusion: Polymorphism in CD14 and TLR4 gene is associated with an increased risk of CM. The combined effects of polymorphisms within innate immune genes of CD14 and TLR14 may contribute to a high risk of CM.

OBJECTIVE To find out adhesive capsulitis patients in diabetes mellitus patients. STUDY DESIGN Cross-sectional study. STUDY SETTINGS & PARTICIPANTS Patients with diabetes mellitus from Ziauddin university hospital Clifton Karachi were included. 325 diabetic patients in which 81 patients were diagnosed with adhesive capsulitis. SAMPLE SIZE A Sample size of 325 patients was selected. SUBJECTS 170 men and 155 women aged between 40 to 79 years were selected. RESULT Frequency of shoulder adhesive capsulitis was 24.9% among diabetic subjects. CONCLUSION Adhesive capsulitis are under recognized in adult diabetic patients occurring in 18% of the cases. Physicians should consider examining the periarticular region of the joints in the hands and shoulders whenever a diabetic patient presents with musculoskeletal symptoms.

During magnetic resonance imaging (MRI), children are at risk for body temperature variations. The cold MRI environment that preserves the MRI magnet can cause serious hypothermia. On the other hand, hyperthermia may also develop because of radiofrequency-induced heating of the tissues, particularly in prolonged examinations. Because of a lack of MRI-compatible core temperature probes, temperature assessment is unreliable, and specific absorption rate-related patient heat gain must be calculated to determine the allowable scan duration. We compared an MRI-compatible temperature probe and a modification thereof to a standard esophageal core body temperature probe in children.Children undergoing general anesthesia were recruited, each patient serving as his/her own control. Core body temperature was measured using 3 different devices: (1) a fiberoptic MRI-compatible skin surface temperature probe (MRI-skin) located on the child's skin surface; (2) a fiberoptic MRI-compatible temperature probe modified with a single-use sleeve at the tip (MRI-core), located in the nasopharynx; and (3) a standard temperature monitor (STRD) located in the esophagus or nasopharynx. The Bland-Altman method was used for statistical analysis.We enrolled 60 children aged 7.8 ± 6 years (mean ± SD) weighing 32.4 (±26.4) kg. The estimated difference between the STRD and MRI-core measurements of core temperature was 0.06°C (confidence interval [CI]: -0.02, 0.15), and between the STRD and the MRI-skin 1.19°C (CI: 0.97, 1.41). According to the Bland-Altman analysis, the 95% limits of agreement ranged from -0.9 to 3.4 and from -1.3 to 1.2 between the STRD and the MRI-skin probe and the MRI-core probe, respectively.Our results show good agreement between standard esophageal measurements of core temperature and core temperature measured using a modified MRI-core probe during general anesthesia in a general surgical pediatric population. The ability to accurately assess core temperature in the MRI suite may safely allow longer scan times and therefore reduce repeat anesthetic exposure, improve patient safety, and enhance the quality of care in children.

Metastatic breast cancer presents with wide range of clinical presentation. Isolated endometrial metastasis from lobular carcinoma breast is a rare phenomenon. In a patient with postmenopausal bleeding while on tamoxifen, a detailed pathological analysis with immunohistochemistry is needed to diagnose metastatic carcinoma to endometrium. A 38-year-old lady with a histologically proven invasive lobular carcinoma breast on adjuvant hormonal treatment with tamoxifen presented with postmenopausal bleeding. She underwent endometrial biopsy which showed metastatic lobular carcinoma breast. This is a case of lobular carcinoma breast with isolated endometrial metastasis. We discuss the treatment options and review the literature on this rare presentation.

Background: Typhoid fever is widely recognized as a major public health problem in developing countries. A simple, reliable and rapid diagnostic test is needed for clinicians especially in areas where laboratory services are limited. Objective: To evaluate sensitivity and specificity of typhidot (IgM), a serological test to identify IgM antibodies against salmonella typhi. Study Design: This was a prospective study. Setting: Northern Institute of Medical Sciences (NIMS) and Ayub Teaching Hospital Abbottabad. Period: 1st November 2009 to 31st August 2010. Methods: A total of 100 patients with clinically suspected typhoid fever were studied and divided into three main groups as A, B and C, with definite typhoid fever, typhoid suspects plus non-typhoidal illnesses and healthy controls respectively. Blood culture and typhidot (IgM) tests were conducted for all subjects included in the study. The validity of typhidot (IgM) test has been evaluated by determining the sensitivity, specificity, positive and negative predictive values. Results: In our study, majority (75%) were males and (25%) females with M to F ratio of 3:1. The mean age of study group was 26.31±11.8 (SD) years. Among 100 clinically diagnosed typhoid fever patients, 19 had positive blood culture for S.typhi and 71 were typhidot (IgM) positive. Out of 19 culture positive patients, 18 (94.73%) were true typhidot (IgM) positive, which was also falsely positive in 05 (20.83%) among 24 non- typhoidal febrile controls. None of the healthy controls was positive for typhoid (IgM) test. The sensitivity, specificity, negative and positive predictive values of typhidot (IgM) test using blood culture as gold standard were 94.73%, 90%, 97.72% and 78.26% respectively for patients having typhoid fever. Conclusions: Typhidot (IgM) test is a simple, reliable, rapid and valid diagnostic tool for typhoid fever especially in areas where laboratory services are limited.

The population of the United States is aging. Currently people over the age of 65 years constitute 13% of the general population. By 2050 this number will rise to about 25% of the population. As the population ages, the number of older adults with mental illness will also rise. Available data indicates that there are inadequate numbers of trained geriatric psychiatrists in United States to care for older adults with mental illness. The additional burden for services in the future on an already strained healthcare system can lead to catastrophic failure of the system. International Medical Graduates (IMGs) constitute almost half of the work force of geriatric psychiatrists. The IMGs have had successful career as clinicians, educators, academics and researchers in geriatric psychiatry. In this symposium we will enumerate the unique challenges faced by the IMGs and strategies on enable them to integrate into the mainstream geriatric psychiatry workforce. We will review the roles of IMGs as private practitioners, educators, academicians and as researchers. We will also discuss how organizations like the AAGP can play a greater role in attracting larger number of IMGs to join the geriatric psychiatry workforce and also the AAGP. This will enable greater access to care for the older adults with mental illness and maintain the success of AAGP in being the national organization for geriatric psychiatry clinicians in the United States.

INTRODUCTION: The main aim of this study was to determine the frequency of Enterobius Vermicularis infections and other unique histopathological findings in patients diagnosed with acute appendicitis. MATERIALS: This retrospective study was conducted in a tertiary care hospital of Karachi, Pakistan over a time period of 9 years from 2005 to 2013. The recorded demographic and histopathological data for the 2956 appendectomies performed during this time frame were extracted using a structured template form. Negative and incidental appendectomies were excluded from the study. RESULTS: Out of the 2956 patients diagnosed with acute appendicitis, 84 (2.8%) patients had Enterobius Vermicularis infections. Malignancy (n=2, 0.1%) and infection with Ascaris (n=1, 0.1%) was found very rarely among the patients.Eggs in lumen (n=22, 0.7%), mucinous cystadenoma (n=28, 1.0%), mucocele (n=11, 0.4%), lymphoma (n=9, 0.3%), obstruction in lumen (n=17, 0.6%) and purulent exudate (n=37, 1.3%) were also seldom seen in the histopathological reports. CONCLUSION: Enterobius Vermicularis manifestation is a rare overall but a leading parasitic cause of appendicitis. Steps such as early diagnosis and regular de worming may help eradicate the need for surgeries.

Metastatic malignant melanoma is an aggressive rare skin cancer with fatal outcomes. Sole of the foot is often a lately identified site and misdiagnosed with other skin pathologies. We present a middle-aged male diagnosed with malignant melanoma of sole of the foot with extensive distant metastasis. He presented to the hospital with the complaints of enlarged inguinal lymph node. He was unaware of the lesion present on sole of the foot till it was diagnosed. Educational activities for health professionals and awareness programs for public are present day's need for identification of this disease in its early stage to enhance the possibilities of cure.

Summary Background: Pediatric sedation is of paramount importance but can be challenging. Fear and anticipatory anxiety before invasive procedures often lead to uncooperativeness. A novel device (PediSedate®) provides sedation through a combination of inhaled nitrous oxide and distraction (video game). We evaluated the acceptability and safety of the PediSedate® device in children. Methods: We enrolled children between 3 and 9 years old who were scheduled to undergo surgical procedures that required general inhalational anesthesia. After the device was applied, he/she played a video game while listening to the audio portion of the game through the earphones. Nitrous oxide in oxygen was administered via the nasal piece of the headset starting at 50% and increasing to 70%, in 10% increments every 8 min. Treatment failures, vital signs, arterial oxygen saturation, depth of sedation, airway patency, side effects, acceptance of the device and parental satisfaction were all evaluated. Results: Of 100 children included, treatment failure occurred in 18% mainly because of poor tolerance of the device. At least 96% of the children who completed the study exhibited an excellent degree of sedation, 22% had side effects, and none experienced serious airway obstruction. Nausea and vomiting were the most common side effects and no patients had hemodynamic instability. Conclusions: The PediSedate® device combines nonpharmacologic with pharmacologic methods of sedation. Most of the children we evaluated were able to tolerate the PediSedate® device and achieved an adequate degree of sedation.

Objective: To determine the use of information technology (IT) & electronic media for improving compliance rate to doctors’ advice in hypertensive patients in Karachi. Methods: Total 400 persons (200 males & 200 females) were randomly selected in six districts of Karachi. Data was collected through a pretested questionnaire. Following was sample criteria: age above 15 years, living in Karachi and ambulatory. Persons admitted in a hospital, individuals who were doing some physical activity during survey e.g. exercise, labor work etc., individual in stressed condition, non-cooperative individuals – not willing to get BP checked and fill questionnaire, and pregnant women were excluded. Those who did not sign the consent form were also excluded. SPSS was used for data analysis and descriptive statistics was employed for sensitivity analysis. Results: For healthcare awareness, people look for health programs on radio and TV channels. Short Message Service (SMS) and phone are highly appreciated by patients for reminders. To increase compliance to doctors’ advice, less educated people prefer phone calls over SMS whereas educated individuals favor SMS. Although price of medicine has not emerged as a major contributing factor for non-compliance, discount on medicinal products is highly appreciated by the patients. Conclusion: The study concludes that there is a widespread awareness of high blood pressure in the sample population of Karachi e.g. 72.5%. People consider reminder message system i.e. Calls and Short Messaging Service (SMS) would help them in improving compliance to doctors’ advice.

An 85-year-old woman, with a history of moderate dementia (with an MMSE of eighteen 6 months ago), hypertension, hyperlipidemia, coronary artery disease was admitted to the hospital because of altered mental status. History reveals worsening agitation after a fall about a week ago. Her current medications include oxybutynin for urinary incontinence, cimetidine for acid reflux, and citalopram 40 mg daily for depression, in addition to her antihypertensive and cardiovascular medications. Because she was agitated she had also been started on haloperidol (5 mg total daily) and 1 mg lorazepam every 6 h as needed a week ago with no improvement in behavior, but with further decrease in her eating and self-care. On physical exam she was noted to have cogwheeling, restlessness, and bruises on her arms and her left hip area. When palpating and performing range of motion of her left lower extremity, it was noted that she pulled back and got more agitated. Mini-Mental Status Exam was 12/30 with difficulties with orientation, spelling “WORLD” backwards, and recall. During the interview she stated that she wants to go home and dislikes medications. Staff reported that she has been refusing some of her medications. Labs were performed which indicated sodium 120, urinalysis positive for leukocyte esterase and nitrites, an EKG with QTc 490, and X-ray indicating ankle fracture. The patient was started on ciprofloxacin for urinary tract infection. A psychiatric consultation is requested for management of altered mental status and agitation, as well as for assessment of capacity to refuse treatment.

We report a 3-year-old girl who presented with Scimitar syndrome and underwent hypothermic circulatory arrest for correction of anomalous pulmonary veins and an atrial septal defect. In this case the Bispectral Index (BIS) correlated significantly with the gradual onset of hypothermia and circulatory arrest. However, BIS remained low during the rewarming phase of cardiopulmonary bypass, in spite of adequate pump flows and stable haemodynamics. We postulate that this significant lag in BIS during the rewarming phase of deep hypothermic circulatory arrest may represent neuronal bewilderment or perhaps stunning, and differs from previous studies that show significant increase in BIS during rewarming from mild hypothermia.

The authors analyzed data from 69 published case studies of Psychotic Disorder Due to Traumatic Brain Injury (PDTBI) in order to describe its common characteristics and assist in its diagnosis and differentiation from schizophrenia. The majority of these PDTBI patients were males with onset of symptoms occurring within the first 2 years after moderate to severe head injury. A majority showed abnormalities on MRI/CT and EEG with localization in the frontal and temporal areas. The general presentation included delusions and hallucinations without co-occurring negative symptoms. The findings demonstrate that patients with PDTBI have a profile that distinguishes itself from schizophrenia.

Gene delivery, with subsequent protein synthesis and secretion, in vivo has been proposed as an alternative way to deliver a therapeutic protein to the systemic circulation. Interferon-alpha (IFN) protein is effective in the treatment of viral and malignant diseases but has short serum half-life that requires frequent administration. An E1 region-deleted adenovirus vector encoding human IFN-alpha2b gene driven by the cytomegalovirus immediate early promoter (rAd-IFN) was generated to assess the serum concentration-time profiles of expressed IFN protein in animal models. Intravenous administration of rAd-IFN, normalized for body weight, resulted in dose-dependent serum IFN concentrations that persisted 8-40 days with similar concentration-time profiles in rats and rabbits. We sought to determine if serum concentration-time profiles in the rat and rabbit animal models would be predictive for a larger animal and would therefore be relevant models for potential dosing of human patients. Two chimpanzees (approximately 70 kg) dosed with rAd-IFN by intravenous administration normalized to body weight achieved serum IFN concentration-time profiles similar to those observed in rats and rabbits. The role of the immune response in limiting the persistence of transgene expression was highlighted by the persistence of serum IFN concentrations for over 200 days in beige/SCID immunodeficient mice. These studies suggest that serum concentration of secreted transgene products after gene delivery in small animal models may be highly predictive for larger species and will help define dosing strategies in human patients.

Background & Materials and Methods: In scrub typhus (ST) the correlation of disease severity to the presence or absence of eschar is not known. We describe the differences between patients with an eschar and those without. Results: In the 193 patients, 105 (56%) had an eschar. Patients with an eschar had a higher incidence of renal failure (18.1% vs. 5.7%; P = 0.01), respiratory system involvement (30.5% vs. 13.6%; P = 0.01) and cardiovascular system (CVS) involvement (21.9% vs. 10.2%; P = 0.03). Involvement of the central nervous system, hematological system and gastro-intestinal tract were not statistically significant between the two groups. ST patients with an eschar had significantly higher requirement for noninvasive ventilation (9.1% vs. 1.9%; P = 0.04). Requirement of invasive ventilation and inotropic supports were the same in both groups. Conclusion: The presence of an eschar in patients with ST is associated with a higher incidence of renal dysfunction, CVS and respiratory system involvement and a greater requirement of noninvasive ventilatory support.

The major aim of surgeons has always been a minimalist approach towards surgery, thereby reducing the complications associated with the surgery. The gold standard treatment for cholelithiasis with cholecystitis is currently the four port laparoscopic cholecystectomy (4 PLC). Recently, a newer technique has been introduced which uses a single port, rather than the four ports, for the removal of the gall bladder laparoscopically; it is known as Single Incision Laparoscopic Cholecystectomy (SILC). This is a comparatively minimal approach towards surgery. Therefore the purpose of this review is to compare the advantages and the disadvantages of SILC versus 4PLC, and hence, to give an idea of whether SILC is ready to replace the traditional approach as the new treatment of choice.

Dire shortages of psychiatrists with special expertise in geriatrics, substance abuse, forensics, and psychosomatics create barriers to care for populations with complex mental disorders and pose a significant public health concern. To address these disparities in access to care, we propose streamlining graduate medical education to increase efficiency and enhance cost-effectiveness while simultaneously increasing the number of psychiatric subspecialists in these key areas. We propose that trainees interested in subspecialties complete their general training in 3 years, while meeting ACGME required milestones, and then utilize their 4th year to complete subspecialty fellowship training. Eligible trainees would then qualify for psychiatry subspecialty certification and general psychiatry ABPN certification at the end of 4 years.