The comparison of dexmedetomidine, esmolol, and combination of dexmedetomidine with esmolol for attenuation of sympathomimetic response to laryngoscopy and intubation in patients undergoing coronary artery bypass grafting

Background: The aim of this study was to compare the effects of dexmedetomidine, esmolol, and combination of both on control of sympathetic response to laryngoscopy and tracheal intubation in coronary artery disease patients. Material and Methods: A prospective, randomized, double-blinded clinical study included 90 patients scheduled for elective coronary artery bypass surgery. Patients were randomly allocated into three groups of 30 each: dexmedetomidine group (Group D) 1 μg/kg, esmolol group (Group E) 2 mg/kg, and group dexmedetomidine with esmolol (Group DE) 0.5 μg/kg of dexmedetomidine with 1 mg/kg of esmolol. Each drug was diluted with 0.9% normal saline to 20 ml volume and infused in 10 min before induction of anesthesia. Hemodynamic changes (heart rate [HR], arterial blood pressure, and pulmonary artery pressure) were compared at various time intervals as follows-baseline, after study drug, after induction, and 1, 3, and 5 min after intubation. Statistical analysis included analysis of variance, Chi-square, and Fisher's exact test. Results: In Group DE, there was no significant increase in HR at all-time intervals, and the HR was stable compared to Group D and Group E. Blood pressure values were comparable in all groups except in Group E at 5 min. The pulmonary arterial pressures were statistically less in DE group except at 3 and 5 min. Conclusions: The combination of dexmedetomidine and esmolol group has beneficial effect on HR and pulmonary arterial pressures but has no additional advantage with respect to arterial blood pressure when compared with dexmedetomidine and esmolol groups in patients undergoing elective coronary artery bypass grafting.

Breast cancer screening programme: experience from Eastern province, Saudi Arabia

Programmes for early diagnosis of breast cancer are lacking in most countries in the Eastern Mediterranean Region. This paper reviews a nongovernmental screening programme launched in October 2009 in the Eastern Province of Saudi Arabia, in which 14 health centres were covered by 2 mobile mammography machines. Annual screening was offered to all women aged 40 years and above. Up to February 2014 a total of 8061 women were screened, an uptake rate of 15.0%. The recall rate was 7.9%. The number of cancers detected was 47, a cancer detection rate of 5.83 per 1000 women screened; 70.2% of the cancers detected had either no mass or the lesions were smaller than 2 cm. The mean age of women with cancer was 50.4 [SD 7.6] years. The screening parameters of our study correlated well with international standards. Despite the controversies regarding universal breast cancer screening, a national breast cancer screening programme for Saudi Arabia is needed

Pertussis. A reemerging and an underreported infectious disease

Pertussis or whooping cough is a highly infectious, vaccine preventable disease. The incidence of the disease has greatly been reduced since the introduction of the diphtheria, tetanus, pertussis vaccine. Pertussis resurgence has been observed in highly vaccinated populations of Western countries since 1990s. Poor vaccine quality, waning vaccine induced immunity, pathogen adaptation, and enhanced surveillance as well as advancements in diagnostic facilities are some of the reasons considered responsible for the increased reporting of pertussis cases. Pertussis may have been ignored and unnoticed due to its atypical manifestations in partially immunized population or people with waning immunity. We review the reports of pertussis resurgence from different countries and attempt to investigate reasons behind the reappearance of the disease. Pertussis is still an under reported disease and the available data from the developing countries is not a true picture of the story. Therefore, developing countries need to improve their surveillance systems

Metabolic outcomes 1 year after gastric bypass surgery in obese people with type 2 diabetes

To assess metabolic outcomes in obese people with type 2 diabetes [T2D] in the first year following gastric bypass surgery. Forty-nine obese patients with T2D who had undergone gastric bypass surgery 12 or more months previously were identified. Body weight and glycosylated haemoglobin [HbA[1c]] pre-operatively and 3, 6 and 12 months postoperatively, changes to glucose-lowering therapies, and blood pressure [BP] and total and high-density lipoprotein [HDL] cholesterol pre-operatively and 12 months postoperatively were recorded. The primary outcome measure was change in HbA[1c]; secondary outcomes included changes in BP and lipid profile. The mean pre-operative body weight was 141.4 kg, the body mass index 49.4 and HbA[1c] 8.1%. The mean postoperative percentage of excess body weight loss at 3, 6 and 12 months was 39.0, 53.9 and 71.1 with reduction in HbA[1c] to 6.6, 6.2 and 5.8%, respectively [p < 0.0001]. Remission of diabetes [HbA[1c] <6.5%] occurred in 12 of 18 patients [67%] at 3 months, 20 of 27 [74%] at 6 months and 21 of 25 [84%] at 12 months; of 41 patients under glucose-lowering treatment, 26 [63%] achieved complete withdrawal of treatment and 7 [17%] had their doses reduced. The mean of differences between baseline and 12-month measurements of systolic BP was 10.5 mm Hg [p = 0.021] and the total-to-HDL cholesterol ratio 0.9 [p < 0.002]. Our study confirmed the finding of previous studies that gastric bypass surgery in obese people with T2D results in significant weight loss, and improved glycaemic, BP and lipid profiles. Bariatric surgery should be regarded as an effective therapeutic intervention in this patient population

Overseas Pakistanis seeking medical education in Pakistan

Background: Pakistanis migrated to western countries face difficulty in letting their children get higher education from abroad. It has been observed that many overseas Pakistanis feel secured to send their children to Pakistan to acquire higher education. The purpose of this study was to evaluate the reasons for overseas Pakistani students seeking medical education in Pakistan. Methods: A cross-sectional survey was conducted from October 2010 to May 2011 recruiting overseas Pakistani students studying in different medical colleges of Sindh, Pakistan. Cluster of 8 medical colleges were selected and a convenient sample [n=700] was recruited. Of the 700 administered questionnaires, 530 [76%] were returned and 25 were incomplete and therefore, rejected. A total of 505 [72%] were included in the analysis. Results: A statistical significance was found when origin of students was compared with the economic aspect of medical education in Pakistan [p=0.01]. Overall 71% students agreed that the cost of medical education in Pakistan is much less then their respective countries of origin. Another highly significant difference was observed [p<0.001] between student's origin and their reasons behind taking medicine as a career. Conclusion: The study establishes that Pakistan as a country offers quality medical education in minimum possible costs and more foreign students can pursue medical education in Pakistan

Polymorphic analysis of MHClinked Heat Shock Protein 70 genes: Their susceptibility and prognostic implication in Kangri cancer cases of Kashmiri population.

Kangri cancer is a unique thermally-induced squamous cell carcinoma (SCC) of skin that develops due to persistent use of Kangri (a brazier), used by Kashmiri people, to combat the chilling cold during winter months. We designed a large scale case-control study to characterize the frequency of two polymorphisms within the MHC class III-linked HSP70genes, Hsp70-2 and Hsp70-hom, in order to find any association of these genotypic variants for predisposition to and clinical outcome of Kangri cancer patients from Kashmir valley in North India. Polymerase Chain Reaction and restriction enzymes were utilized to characterize the frequency of two polymorphisms with in Hsp70-2 and Hsp70-hom genes in 118 Kangri carcinoma cases and 95 healthy controls from the same population of Kashmir. Association of high frequency allelic variants of Hsp70genes with various clinicopathological features of prognostic significance was assessed by Chi-square test using SPSS software. In this study, allelic frequency of Hsp70-2 A/G heterozygote (0.87) (P = 0.012) was found to be significantly high in Kangri cancer cases compared to control (0.736) with a Relative Risk of 2.45 fold. Conversely, the allelic frequency of Hsp70-2 A/A allele in homozygous condition was significantly low in Kangri cancer cases and worked out to be 0.084 (Vs 0.252 in control) with P is equal to 0.001, implicating it as a protective allele against Kangri cancer in subjects with this genotype. Similarly, significantly high frequency of 0.50 (Vs 0.29 in control) of Hsp70-homC/C allele was found in homozygous condition in Kangri cancer cases suggestive of a positive relative risk associated with this genotype (RR is equal to 2.47) (P is equal to 0.002). The overall allele frequency data analysis of Hsp70-2 and Hsp70-hom genes was significant (χ2 is equal to 12.38, P is equal to 0.002; and χ2 is equal to 12.21, P is equal to 0.002). The study also reveals considerable association of high frequency alleles of HSP70 genes, especially of Hsp70-2 A/G or G/G in Kangri tumors with clinico-pathological features of poor prognosis. These results indicate that the relative risk of Kangri cancer associated with Hsp70-2 and Hsp70- hom gene polymorphisms is confined to Hsp70-2 A/G or G/G and Hsp70homC/C haplotype in our population. The study, therefore, suggests Hsp70-2 A/G or G/G and Hsp70homC/C genotypes as potential susceptibility markers and independent prognostic indicators in Kangri carcinoma patients in Kashmiri population.

Molecular gate keepers succumb to gene aberrations in colorectal cancer in Kashmiri population, revealing a high incidence area

Colorectal cancer [CRC] is one of the leading malignancies worldwide and has been reported to show geographical variation in its incidence, even within areas of ethnic homogeneity. The aim of this study was to identify p53 and K-ras gene mutations in CRC patients in a Kashmiri population, and to assess whether these mutations are linked with clinicopathological parameters. Paired tumor and normal tissue samples from a consecutive series of 53 patients undergoing resective surgery for CRC were prospectively studied for p53 and K-ras gene mutations by PCR/single strand conformation polymorphism [SSCP]. Less than half [45%, 19/42] of the patients presented mutations in the p53 gene. Twenty eight mutations were found in the p53 gene, which comprised of 23 substitutions [17 transitions + 6 transversions], and five insertions. The 23 substitutions constituted 18 missense mutations, two nonsense mutations, and three silent mutations. Of the 28 mutations [7.14%] observed in this study, 2 were not previously reported for CRC samples and were identified as novel p53 mutations. A few patients [22.64%, 12/53] presented with mutations in K-ras, constituting 13 missense mutations, out of which 11 were G-A transitions, one was a G-C transversion, and one a G-T transversion. More than half [61.5%] of the mutations occurred in codon 12 whereas a few [38.5%] occurred in codon 13. One tumor contained missense mutations in both codons. Comparison of the mutation profiles of our patients with those of other ethnic populations and regions reflected both differences and similarities, indicating co-exposure to a unique set of risk factors. Mutations of the p53 and K-ras genes are some of the most common genetic changes in the development of human CRC. The high frequency of p53 gene mutations implicates p53 as a predominant factor for CRC in the high-risk ethnic Kashmiri population

Experience with oral mexiletine in primary erythromelalgia in children

Primary erythromelalgia is characterized by burning pain, redness, and warmth in the extremities. We present two cases of primary erythromelalgia both of whom presented with a history of several months of severe burning pain in both hands and feet. Both patients had received multiple pain medications with no improvement in symptoms. Pain was relieved by putting affected parts in ice cold water, which resulted in immersion injury of the affected parts. Both patients stopped taking part in school and social activities. We tried oral mexiletine, a class Ib antiarrythmic agent, in view of its reported role in various chronic painful conditions. Dramatic improvement was observed with its use. Both patients improved after several weeks of use, and there were fewer soaking episodes. We observed no adverse effects with mexilitine therapy

Neuroleptic malignant syndrome: need for early diagnosis and therapy

Neuroleptic Malignant Syndrome [NMS] is a medical entity that has received little attention in the clinical settings in Pakistan. The aim of our study was to review the predisposing factors, outcomes and characteristics of in-patients diagnosed with NMS. We performed a retrospective chart review of all cases [age > 15 years] at a tertiary care center in Karachi between January 01, 1990 and November 30, 2001, diagnosed using ICD 10 coding. Data was collected using a standardized data entry form and statistical analysis was performed using Epi Info 6, Version 6.02. There were a total of 20 patients diagnosed with NMS [11 male and 9 female] in our study with a mean age of 46.6 +/- 15.9 years. Haloperidol was the most frequently responsible neuroleptic. Of the 18 patients on a neuroleptic, most developed NMS after 8 weeks of therapy. There were 5 mortalities all of which were associated with septic shock. Fourteen patients recovered completely from the episode and did not have any neurologic sequelae. NMS is an important preventable clinical entity. Early diagnosis and judicious use of antipsychotics is warranted to prevent mortality and heightened morbidity

Comparison of complications between mayo's repair and mesh repair [pre-peritoneal approach] for para-umbilical hernia

To compare the complications of Mayo's technique of repair of para umbilical hernia with mesh repair.This study was conducted in the Department of Surgery at Nishtar Hospital, Multan. Fifty patients were recruited into study randomly. Two groups of 25 each, were made. Routine investigations were performed. All patients underwent surgery under general anaesthesia. Standard technique of repair was used in either groups. Complications were noted on a proforma designed for that purpose. Spearman's rank correlation coefficient test. A 'p' value of<0.05 was considered significant. Ten [20%] complications were observed. The main complications were wound haematoma in four patients [8.0%], wound infection in two patients [4%], seroma formation in two patients [4%], sinus formation in one patient [2.0%], mesh infection in one patients [2.0%] and no recurrence in any patients. Out of these 10 patients who developed complications, eight [16.0%] were in group-I [Mayo's technique] and two [4.0%] were in group-II [Mesh repair]. All were managed conservatively. Mesh repair found to be superior to the Mayo's technique in terms of complications

Predictors pf ischemic versus hemorrhagic strokes in hypertensive patients

To identify the factors that predispose to ischemic versus hemorrhagic stroke in hypertensive patients. Cohort study. The study was conducted at the Aga Khan University Hospital [AKUH], Karachi, from August 1999 to May 2001. All the hypertensive patients, who were registered in AKUH acute stroke outcome data base, over a period of 22 months, were identified and from this cohort the patients with first ever stroke were selected. The data regarding demographics, stroke type [ischemic vs. hemorrhagic], pre-existing medical problems, laboratory and radiological investigations was recorded and analyzed. Five hundred and nineteen patients with either ischemic stroke or parenchymal hemorrhage were registered over a period of 22 months. Three hundred and forty-eight patients [67%] had hypertension and of these, 250 had first ever stroke at the time of admission. Presence of diabetes mellitus [OR: 3.76; CI: 1.67-8.46] and ischemic heart disease [OR: 6.97; CI: 1.57-30.98] were found to be independent predictors of ischemic strokes. Presence of diabetes mellitus and ischemic heart disease predict ischemic stroke in a patient with hypertension

Kleine Levin syndrome

Kleine-Levin Syndrome [KLS] is a rare disorder of uncertain etiology, characterized by recurring episodes of undue sleepiness lasting for days. We report a case of young female presenting with episodes of undue sleep along with hypersexuality and excessive food intake, who improved significantly on lithium and valproate. KLS should be considered in young patients, who present with episodes of undue somnolence

Autonomic dysfunction in extra-hepatic portal vein obstruction: correlation with cardiovascular haemodynamics.

Various autonomic dysfunctions (AD) are known to occur in cirrhosis of the liver. The haemodynamic abnormalities of cirrhosis have been correlated with AD and have prognostic implications. The relevance of AD in extrahepatic portal vein obstruction (EHPVO) is not well established. We evaluated AD and cardiac indices in 30 patients, 19 male and 11 female and compared the results with those of 10 controls. The mean age of the patients and controls was 23.77 +/- 1.33 and 20.5 +/- 2.51 years, respectively. Five standard autonomic function tests were done in all the patients. Cardiac output (CO) was measured by echocardiography. Anthropometric measurements were done to determine the cardiac index (CI = Cardiac output/Body surface area) and indicized peripheral vascular resistance (iPVR) was calculated using the formula: mean arterial pressure (MAP) x 80/CI. Each autonomic function test was given a score and the results were interpreted as normal, early or definite, according to the score. AD was recorded as normal in 5, early in 11 and definite in 14 patients. None of the controls had any abnormality in autonomic function. There was a significant difference in the baseline heart rate of controls and patients (76 +/- 2.55 v. 98.9 +/- 2.96 beats/min). There was no difference in the MAP (92.65 +/- 1.71 v. 81.7 +/- 1.99 mmHg), CI (2.99 +/- 0.15 v. 3.23 +/- 0.08), iPVR (2533.59 +/- 124 v. 2176 + 104). CI, iPVR and MAP were also calculated separately in patients in the normal (N), early (E) and definite (D) AD groups. Their respective values were as follows CI: N 3.44 +/- 0.19, E 3.44 +/- 0.19, D 3.23 +/- 0.6; iPVR: N 2150 +/- 75.4, E 2140 +/- 180, D 2372 +/- 142; MAP: N 86 +/- 3.01, E 85.8 +/- 3.59, D 90.79 +/- 3.09. Results are expressed as mean +/- SE. Unlike in cirrhotics, cardiovascular haemodynamics are not altered in patients with EHPVO, even in the presence of AD.

Cost of acute stroke care at a tertiary care hospital in Karachi, Pakistan

To evaluate cost of acute stroke care and its determinants at a tertiary care hospital in Karachi and to find out predictors of high cost care. Acute stroke is a leading cause of morbidity and mortality. Cost of care is the single most important determinant in availability of acute stroke care at a tertiary care hospital in Pakistan. It is also an important factor in development of public health policies and medical insurance plans. Average annual income in Pakistan is 4881 rupees [U$ 85]. Medical and billing records of 443 patients with acute stroke were retrospectively reviewed from 1998-2001 at The Aga Khan University Hospital [AKUH], Karachi. Acute stroke care at AKUH usually includes routine laboratory investigation including Lipid profile, Magnetic resonance imaging/angiography [MRI/MRA], Echocardiogram, Carotid Doppler's ultrasound and medical management in the Stroke care unit. 443 patients were included in study. Age range was 25-98 years [Mean 58 years]. 269 [61%] were male. Length of hospital stay was 1 day; 67 patients, 2 days; 83 patients, 3 days; 70 patients, 4-5 days; 87 patients, 6-10 days; 75 patients, 11-30 days; 49 patients and more than 30 days; 12 patients. Average length of stay was five days and median length was three days. Average total cost was 70,714 rupees [U$1179] which included average radiology cost; 12,507 rupees [U$ 208], average laboratory cost; 8365 rupees [U$139], average pharmacy cost; 13,320 rupees [U$222] and average bed/room charges; 27, 552 rupees [U$459]. Length of hospital stay is the most important determinant of cost. Average total cost for patients who stayed for 1 day was 19,597 rupees [U$ 326], 2-3 days; 25,568 rupees [U$426], 4-7 days; 49,705 rupees [U$828], 8-30 days; 153,586 rupees [U$2559], more than 30 days; 588,239 rupees [U$9804]. Average cost for general ward was 60,574 rupees [U$1010], private ward was 74,880 rupees [U$1248] and intensive care unit was 155,010 rupees [U$2583]. Cost of acute stroke care is extremely high as compared to average national income at our hospital. Most important determinant of cost is length of hospital stay. Cost cutting measures and increased funding from state are necessary to increase the availability of acute stroke care

Should carotid endarterectomy be performed for symptomatic carotid stenosis in Pakistan?

The risk of stroke and death associated with carotid endarterctomy is operator dependant. Data regarding risks of this procedure are not available in Pakistan and therefore it is difficult to make accurate risk benefit analysis for individual patients. Our objective was to determine safety of carotid endarterectomy at an academic tertiary care center in Pakistan. Patients who underwent carotid endarterectomy [CEA] at our hospital during a ten-year period were identified through ICD-9 coding system of the hospital medical records. Demographic features, associated medical problems and immediate postoperative complications were recorded and analyzed. Sixty-three carotid endarterectomies were performed on 59 patients. Ages range from 43 to 80 [mean 61 +/- 8] years; 53 were male and 10 were female. Common associated diseases among these patients were hypertension; 38 [64.4%], ischemic heart disease; 26 [44%], diabetes mellitus; 24 [40.7%], dyslipidemia; 19 [32.2%] and renal insufficiency; 13 [22%]. Most common complication was neuropraxia [transient neuropathy]; 5 [7.9%], followed by pneumonia and stroke; each in 3 [4.8%] patients. None of the strokes related to the surgical procedure were disabling. Two of the patients who had stroke, recovered fully within 17 weeks and one recovered partly but was independent in all daily activities of living [ADLs]. One patient died following simultaneous coronary artery bypass graft [CABG] and CEA. The risk of stroke or death for patients undergoing CEA was high with simultaneous CABG [3/11, 27%] and low for patients undergoing CEA alone [1/52, 2%]. Carotid endarterectomy is a safe procedure in patients with symptomatic carotid stenosis at our hospital and should be performed, when indicated

Early changes in thyroid-stimulating antibody activity following radio iodine therapy

The aim of this study was to determine whether or not the titre of thyroid-stimulating hormone receptor antibody with stimulating [TRAb-S] activity changes in patients with Graves' disease [GD] or toxic multinodular goitres [TMNG] 3 months after treatment with sodium iodide [131I]. Subjects and Serum specimens were obtained from 21 hyperthyroid patients [15 with GD and 6 with TMNG] at a median 0.5 months before and 3 months after 131I treatment using a standard ablative dose of 555 MBq. TRAb-S activity was measured in a sensitive and specific luminescent bioassay employing the lulu cell line and expressed as a stimulation index [SI; normal 1.5]. The mean TRAb-S in the GD patients was 2.72 SI [95% CI: 1.51-4.03] 0.5 months before administration of 131I and 3.98 SI [95% CI: 1.20-6.76] 3 months after administration of 131I. The difference was not statistically significant at p < 0.8. It was not elevated in the TMNG patients before [0.57 SI; 95% CI: 0.41- 0.73] and after [1.00 SI; 95% CI: 0.74-1.26] treatment either. Conclusions: Radioiodine therapy for GD or TMNG did not induce a significant change in TRAb-S activity at 3 months after treatment with 131I, probably due to effective antithyroid therapy or the timing of samples

effect of benzo [A] pyrene on glutathione s-transferase glutathione peroxidase the liver and kidney mouse mus musculus

The effect of benzo[a]pyrene [BaP] on the activities of glutathione S-transferase [GST] and glutathione peroxidase [GPx] and histology in the liver and kidney of the mouse, Mus musculus were investigated. Three treatment groups of mice [6 in each group] were injected with 200mg/kg BaP once a week. Groups 1,2 and 3 were sacrificed after two, four and eight weeks, respectively by cervical dislocation. Similarly three control groups of mice injected with corn-oil were sacrificed at week 2, week 4 and week 8. Sections of the liver and kidney of mice were stained with hematoxylin and eosin. The GST activity in the liver and kidney was significantly increased after two weeks compared to the control group [P<0.05]. The GPx activity in the liver significantly increased to a maximum at four weeks. After eight weeks, GST and GPx activities decreased in the treated mice liver compared to the control group. Grey-white hyperplastic nodules were visible in the liver after four weeks of treatment. The slides prepared from these tissues showed marked morphological changes where the hepatocytes were paler, more vacuolated and had lost their normal shape and arrangement. The kidney cells showed mild inflammation within the medulla and glomeruli after four weeks. After eight weeks severe inflammation was observed in medulla but there was no change in the other parts. In this study, it was found that differences in morphology and cellular changes in liver and kidney were time dependent. It is concluded that assay of GST activity provides a method to monitor antioxidant changes in mice liver and kidney after exposure to BaP. The result indicated that liver was main target for chemically induced toxicity