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Purpose: To describe the long?term outcomes of transcutaneous retrobulbar amphotericin B (TRAMB) in COVID?19?associated mucormycosis. Methods: In total, 18 cases of COVID?19?associated mucormycosis were reviewed. In addition to the recommended treatment protocol, all patients were to be given 3.5 mg/ml/day of TRAMB for five days. Results: Of the 18 patients, 2 presented with stage 3a disease, 13 had stage 3c disease, and 3 patients had central nervous system (CNS) involvement (stage 4a and 4c). In addition to planned retrobulbar doses, five patients were given more while two patients received fewer injections (i.e., <5). At the last mean follow?up of 34.67 (±8.88) weeks, 11 patients were in radiological regression and 4 had stable disease while 2 patients had to undergo exenteration; one mortality was observed because of disease progression. Clinical regression in terms of visual and ptosis improvement was seen in seven and nine patients, respectively. Conclusion: Rhino?orbito?cerebral mucormycosis is a serious condition which warrants an aggressive treatment strategy. In unprecedented situations witnessed recently, TRAMB turned out to be an effective and economical alternative. Though large randomized studies are needed to establish its efficacy, TRAMB still manages to halt progression and salvage the globe in significant number of patients, and hence its use should be encouraged on a case?to?case basis especially in developing countries with limited resources
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Background: The relation between the extent and progression of baldness and coronary heart disease is not totally clarified yet. Some study reveals that male patients with male pattern baldness are at higher risk of CVD than those without male pattern baldness.The aim of this study was to find the prevalence of Acute Coronary Syndrome in male patients with or without vertex baldness.Material & Methods:This cross-sectional observational study was conducted in the Department of cardiology, Mymensingh Medical College Hospital, Mymensingh from October 2014 to September 2015. A total 100 male patients with or without vertex baldness were included in this study from male patients with a first lack of acute coronary syndrome admitted in the coronary care unit (CCL) of MMCH within 24 hours of onset of symptoms.Results:Mean age was found 45.3±7.2 years in group A and 44.5±6.7 years in group B. The mean age difference was not significant (>0.05). STEMI and NSTEMI were higher in group A than group B on contrast UA was higher in group B than group A. The total mean BMI was observed 22.8±3.0 kg/m2. The mean difference was statistically insignificant in both groups (p=0.31). The mean waist circumference was observed 89.4±8.7 vas 84.5±8.4 cm in group A and group B respectively. The mean was higher in group A than group B with statistically significantly difference (p=0.005). Biochemical status of the study that the mean FBS, total cholesterol, triglyceride and HDL cholesterol level were statistically significant between two groups (p=0.01), but the mean difference of LDL cholesterol was not statistically significant between the two groups (p=0.20).Conclusion:The patients with vertex baldness or male pattern baldness are associated with more risk of CVD than without vertex baldness. Vertex baldness may be a marker for Acute Coronary Syndrome.
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Background: Selenium has been reported to be insulinomimetic and to reduce blood glucose level in type 2 diabetes.Material & Methods:This study describes an inverse correlation of serum selenium with blood glucose level. This is a case control study conducted among 30 low BMI and 70 normal BMI diabetes and 50 low BMI non-diabetic controls. Serum selenium concentration was determined by atomic absorption graphite spectrophotometry.Results:Serum selenium concentration was estimated to be 44�礸/L, 48�礸/L and 59�礸/L respectively in low BMI (<18.5) and normal BMI (18.5-24.9) diabetics and low BMI non-diabetics controls. A trend of inverse correlation was found between serum selenium and blood glucose levels. Serum selenium level at > 40 (41-60) 礸/L was found to be inversely correlated (p<0.05) with blood glucose level.Conclusions:Lower serum selenium was observed in the diabetic patients and it was inversely correlated with blood glucose level
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@#Introduction: Antibacterial products contain active ingredients that are used to prevent bacterial growth and contamination. Previous studies suggest that antibacterial products are no more effective at removing s kin pathogen compared to plain soap. It is essential to collect the data regarding the effectiveness of antibacterial products with the purpose of continuous surveillance in the detection of emerging resistance pattern. Method: In vitro antimicrobial activity of six products were established on four species of bacteria namely Staphylococcus aureus, Streptococcus pyogenes, Escherichia coli, and Pseudomonas aeruginosa that represent the bacterial pathogen commonly found on human skin and the surrounding environment. These pathogens are also implicated as the causative organisms for skin infections. Results: Product that contains triclosan has the highest bactericidal effect as it is effective against a broad spectrum of bacteria. Body washes without any antibacterial agent also exhibit bactericidal activity but at higher concentrations. Gram-positive bacteria showed more sensitivity compared to gram-negative bacteria. Conclusion: Antibacterial and non-antibacterial products have bactericidal effects at different concentration. Different active ingredients showed different antibacterial effects on tested bacteria. Extend usage of antibacterial products pose adverse effects on skin normal flora and can lead to antimicrobial resistance.
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A novel of polymer combination promotes an increase of the ability for controlling the drug release. The objectiveof this research was to characterize the inter-polymer complexes (IPCs) of Eudragit (Eud) types (Eud RS, Eud L, orEud E) and Kollidon SR (KSR), and elucidate their effects on the drug release kinetics and mechanism. Differentpreparation techniques were proposed using spray drying and ultrasonic-assisted anti-solvent techniques. The thermalactivity, e.g., glass transition temperature (Tg) and Fourier transform infrared spectroscopy were used to characterizethe molecular interaction of these IPCs. Theophylline (THP) was selected as a drug model. The effect on the drugrelease kinetics and mechanism was the main concern of this study. Depending on the results, the hydrogen bondingformation between polymers was observed by a shifting of OH and carbonyl group vibrations. In addition, the van derWaals interaction was identified by an alteration in the vibrational band around the 1,000–1,500 cm−1. Meanwhile, thechange of physicochemical characteristic was identified by the Tg of IPCs. Eud E-KSR and Eud E-Eud L IPC wereunable to control the THP release. Meanwhile, Eud L-KSR IPC and Eud RS-KSR IPC were success to control theTHP release, but it was pH dependent and independent, respectively. This study concluded that the IPCs allowed theTHP release in a controlled manner based on the IPC characteristics and their interactions. Either positive or negativeinteractions on the drug release were observed due to native characteristics of polymers.
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BACKGROUND: Increasing workplace health-care perception has become a major issue in the world. Most of the health-related problems are faced because of the lack of health management instruments. The level of health care can be improved through workplace health well-being regulations. The aim of the present study is to formulate a conceptual model of physical checkup. METHODS: This study applied conceptual theories and figures and used secondary data from articles and relevant websites for evaluating the validity of the study. RESULTS: Annual health checkup increases health-care awareness perception of states, organizations, employees, and their families and manages the annual health record of employees, organizations, and states. CONCLUSIONS: Health care and awareness perception of states, organizations, employees, and families improves with annual health checkup, and annual health checkup also prevents unhealthy acts.
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Humans , Delivery of Health Care , Health Status , Social Control, FormalABSTRACT
Objective: The objective of the study was to identify "implications" of guidelines provided to participants at the end of a survey for improvement in stethoscope hygiene
Methodology: A cross sectional survey was conducted from January to March 2016 in which a questionnaire was designed to know the awareness of stethoscope hygiene among health care practitioners. The questionnaire was distributed to 150 consented participants, out of which 138 complete [92%] responses [49, [32%] attending physicians, 50[33%] residents and 39[26%] medical students]; comprising of 84 [61%] females and 54 [39%] males was acquired. The responses included following consulting clinics [n=30, 22%], wards [n=41, 30%], intensive care units [n=41, 30%] and acute care units [n=26, 18%]. At the end of the survey practicing guidelines were discussed and hard copy given to respondents. They were then asked to tell about to the impact of these guide lines on their measures to maintain stethoscope hygiene
Results: It was observed that health care practioners consented to start stethoscope cleaning at the start of every clinic, 33.3% showed their intentions for educating others by verbal instructions, and 66.7% were said they will recommend alcohol swab for cleaning of stethoscope
Conclusion: The survey on stethoscope hygiene with practicing guidelines reflects the awareness generated in the respondents. It is further expected that they will disseminate the information and educate others to consider importance of stethoscope sanitation and practice its hygiene
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Objective: To analyse the clinicopathological spectrum of synovial sarcoma cases presenting in our institution. Study Design: Descriptive case series. Place and Duration of study: Armed Forces Institute of Pathology [AFIP] Rawalpindi, from Jan 2010 to Jan 2015
Material and Methods: All cases of synovial sarcoma diagnosed on histopathological examination were recovered from the Armed Forces Institute of Pathology [AFIP] laboratory information management system. The inclusion criteria consisted of optimally processed Haematoxylin and Eosin stained slides. Positive immunohistochemistry for epithelial membrane antigen/cytokeratin and CD99. Both genders were included. Patients' gender, age, tumour size, site, histological subtype, grade, microscopic margin status, depth and stage were noted. The data were analysed using SPSS Version 21. Frequencies and percentages were calculated for qualitative data and the standard deviation and mean for quantitative data
Results: Sixty-seven cases of synovial sarcoma [SS] were included in this study. The mean age of the patients was 35.1 years, with males at 55.2%. The most common site was the lower extremity 41.8%. The average size was 8.5 cm. The most common stage was pT2b [64.2%]. Monophasic histological subtype was more common at 58.2%. Grade 2 tumours were 77.6%. Microscopic positive margins were 30.0%. Specimens that were fragmented or not oriented properly were 33.3%
Conclusion: The clinicopathological spectrum of synovial sarcoma in our institution is similar to that of other parts of the world. This study has highlighted that a significant proportion [33.3%] of resection specimens were fragmented or unmarked; therefore surgical margins could not be evaluated in these cases, increasing the chances of inadequate surgeries
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This study was conducted to determine postoperative donor site complications after bone harvesting from iliac crest for maxillofacial reconstruction in patients presented at Pakistan Institute of Medical Sciences [PIMS Hospital Islamabad]. One hundred and ten patients having bony defects in maxillofacial region had undergone iliac crest grafting over a period of one year. The data were recorded on a strurctured proformas and were entered in SPSS version 17.0 [SPSS, Inc, Chicago, IL, USA]. Analysis was done to determine the frequency and percentages for all variables. Morbidity to donar site [Illiac crest] was evaluated postoperatively at 3[rd] month. Among 110 patients, male to female ratio was 1:1.2. Out of total 16.4% had mild pain, 0.9% had gait disturbances with walking aid needed. It was concluded that complications after iliac crest harvesting was found to be moderate to low, but the procedure was still necessary and frequently used with predictable results in terms of pain and gait disturbance at donor site
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Introduction: Tuberculosis has remained and is one of the major issues of the under developed world including Pakistan. About 10-11 percent cases of tuberculosis are from pediatric population. Isoniazid, rifampicin and pyrazinamide constitutes generally used therapeutic regime. Directly observed treatment short course [DOTS] is now much popular strategy. Ant tuberculosis drug-induced liver injury creates obstacles in treatment and also exerts socioeconomic strain on resources
Objective: To determine the frequency, severity and pattern of the Anti-tuberculosis Drug-Induced Liver Injury in children under 14 years of age
Study Design: Case series study
Duration of Study: 02-10-2015 to 03-10-2016
Setting: Department of Pediatric Medicine Unit-1, Allied Hospital, Faisalabad. Sample size: The total sample size is 100 cases. Sampling Technique: Non-probability purposive sampling. Methodology: Total of 100 patients with either sex from 1 to 15 years of age, on anti-tuberculosis therapy due to any variety of tuberculosis having normal liver anatomy and function initially were studied. Patients already having hepatobiliary disease regardless of etiology were not enrolled in study. Initial diagnosis was confirmed using set criteria. All patients underwent detailed medical history and physical examination followed by investigations. Data comprising age, sex, type of tuberculosis, treatment interval, and hepatotoxicity etc. was collected using designed Performa by the researcher. The data was analyzed through SPSS-20 by means of descriptive statistic
Results: In our study, out of 100 children, minimum age was 6 months and maximum age was 156 months and Mean + SD was calculated as 38.07+/-37.368 months, 51 [53.1 percent] were male and 45 [46.9 percent] were females, ventilator associated pneumonia was recorded in 19 [19.8 percent] while 77[80.2 percent] had no findings of the ventilator associated pneumonia
Conclusion: The frequency of TB DILI was 14.0 percent in this study, indicating the importance of keeping index of suspicion high for the development of hepatotoxicity with anti-tuberculosis therapy in children being treated for any variety of tuberculosis
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Controlled release dosage forms provide sustained therapeutics effects for prolonged period of time and improve patient compliance. In present study, controlled release co-precipitates of Metoprolol Tartrate and Losartan Potassium were prepared by solvent evaporation method using polymers such as Eudragit RL 100 and Carbopol 974PNF and controlled release tablets were directly compressed into tablets. In-vitro dissolution of controlled release coprecipitates were performed by USP Method-II [paddle method] and tablets were evaluated by USP Method-I [rotating basket method] in phosphate buffer [PH 6.8] using pharma test dissolution apparatus. The temperature was maintained constant at 37 +/- 1.0 0 C and the rotation speed of paddle and basket was kept constant at 100rpm. Drug release mechanisms were determined by applying Power Law kinetic model. The difference and similarity of dissolution profiles test formulations with reference standards were also determined by applying difference factor [f1] and similarity factor [f2]. The results showed that the controlled release co-precipitates with polymer Eudragit RL 100 of both the drug extended the drug release rates for 10 hours and those having polymer Carbopol 974P NF extended the drug release rates for 12 hours. The controlled release tablets prepared from controlled release co-precipitates extended the drugs release up to 24 hours with both the polymers. The drug was released by all tests anomalous non fickian mechanism except F1 and F5 do not follow Power Law. The f1 and f2 values obtained were not in acceptable limits except F15 whose values were in acceptable limits. It is concluded from the present study that polymers [Eudragit RL 100 and Carbopol 974P NF] can be efficiently used in development of controlled release dosage forms having predictable kinetics
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Objective: To evaluate integrated learning program of neurosciences for continuation of integrated learning in the forthcoming teaching and learning modules of undergraduate medical curriculum at Bahria University Medical a Dental College [BUMDC]
Methods: A mixed method design was conducted from August 2016 to February 2017 after ethical approval from BUMDC. The quantitative aspect was evaluated retrospectively by desk records of marks obtained in integrated module and nonintegrated module. Focused group discussion were conducted with primary intended users [chair of integration committee, faculty and students of first and second year MBBS] to share their expectations and concerns and get responses on key evaluation questions for implementation and outcome evaluation of integrated learning program
Results: The desk record revealed a positive perception of students and faculty at the time of implementation with improvement in results after integration in subjects of basic sciences. The discussions highlighted reasons which resulted in failure of its continuation and affirmed readiness for re-induction and continuation of integration with clinical sciences
Conclusion: Evaluators considered approval and re-application of integrated curriculum at BUMDC after utilization focused evaluation
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Humans , Utilization Review , Teaching , Students, Medical , NeurosciencesABSTRACT
Objective: To investigate the outcome of rhegmatogenous retinal detachment repair at Vitreoretinal unit of Jinnah Post Graduate Medical Centre Karachi in year 2014
Methods: One hundred and three eyes of one hundred and three patients, who underwent three ports parsplana vitrectomy + band + silicone oil, three ports pars plana vitrectomy + silicone oil, three ports pars plana vitrectomy + C3F8 for rhegmatogenous retinal detachment [RRD] repair, at Jinnah Post Graduate Medical Centre, were included in this observational prospective study. Parsplana vitrectomy was done using 23G vitrectomy system. Duration of study was one year. Removal of silicone oil [ROSO] was done on the basis of completely flat retina at least for eight weeks or because of complications due to silicone oil. Patients were followed up post operatively on day one and after one week and then at four weekly interval till the end of the study
Results: Anatomical success was achieved in 91 eyes [88.3%]. However in 12 eyes [11.7%] retina redetached after removal of silicone oil. Functional success achievement of visual acuity of 3/60 or better was achieved in 85 [82.5%] of eyes post operatively after removal of silicone oil or absorption of gas C3F8 as the case may be
Conclusion: Re-detachment is common after removal of silicone oil and incidence of re-detachment is related to the degree of preoperative PVR and location of breaks. Re-detachment occurs more commonly if the breaks are inferiorly located as compared to the superior ones
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Objective: To determine seroprevalence of transfusion transmissible infections [TTIs] in blood donors and to compare the present results with the data from studies conducted in past
Study Design: Descriptive study
Place and Duration of Study: Armed Forces Institute of Transfusion [AFIT], Rawalpindi from January 2010 to December 2012
Material and Methods: All the blood donors who had donated blood at AFIT during the three year study period were included. Prior to blood donation at the institute, all the donors were subjected to a preset, structured questionnaire to determine their eligibility for donation as per the criteria set by the institute. Donors7 serum samples were screened for hepatitis B virus [HBV], hepatitis C virus [HCV], human immunodeficiency virus [HIV] and syphilis by using HBsAg, anti-HCV, HIV antigen-antibody combination assay and syphilis antibody test, respectively. The repeatedly reactive samples were considered as true reactive
Results: A total 160552 blood donors were screened during the study period. The mean age of the donors was 29 ++/- 10.2 years [Range: 18 - 60 years]. Out of these, 158144 [98.5%] were male donors and 2408 [1.5%] were female donors. 7385 [4.6%] donors were volunteer and 153167 [95.4%] donors the replacement donors. The seroprevalence of TTIs in the donors for HBV, HCV, HIV and syphilis was 2385 [1.48%], 4194 [2.61%] 26 [0.02%] and 1520 [0.95%], respectively. The seroprevalence of HBV was higher and statistically significant [p value<0.05] in Gp-II [31-45 years] and the seroprevalence of both HCV and Syphilis was higher and statistically significant [p value <0.05] in both GP-II [31-45 years] and GP-III [46 years and above] when compared with overall seroprevalence of the respective infections in all age groups
Conclusion: This study highlights that the seroprevalence of HBV and HCV is decreasing in our blood donors, but still it is an important risk factor for spread of these infections. The seroprevalence of HIV is rising gradually in the blood donors
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Humans , Male , Female , Adult , Middle Aged , Seroepidemiologic Studies , Blood Transfusion , InfectionsABSTRACT
Objective: To evaluate the role of CT scan of nasal cavity and paranasal sinuses in preoperative assessment of anatomical variants and in determining their frequencies
Materials and Methods: This descriptive study was done as a part of residency training for FCPS in the subject of Radiology on 132 patients who visited the hospital, Sindh Institute of Urology and Transplantation [SIUT] from March 2012 to April 2013. All CT scans were reviewed for presence of concha bullosa, variations of uncinate process, haller cell, onodi cells, aggernasi cells, ethmoid bulla, paradoxical middle turbinate, deviated nasal septum [DNS], pneumatization in the nasal septum, superior and middle turbinate, and uncinate process. Frequencies of all anatomical variants were calculated using SPSS version 16
Results: Deviated nasal septum was found to be the most frequent variant 31% followed by Concha bullosa 18.9% and variations in uncinate process 12%. Rhino sinusitis was found in all cases with paradoxical medial turbinate and patients with variation in uncinate process
Conclusion: CT scan can play an important role in preoperative assessment of variants and in determining their frequencies in nasal cavity and paranasal sinuses. It could be of great help for surgical planning and minimizing the surgical complications in patients
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Introduction: The demand of long term central venous access devices has risen over the last few decades. These devices are increasingly being used for administration of antibiotics and chemotherapeutic drugs, for total parentral nutrition and providing high flow access for hemodialysis and plasmapherisis. Inadvertent arterial puncture, ateriovenous fistula, thoracic duct injury, brachial plexus injury, laceration of the subclavian vein, and air embolism are the well described complications of the central line insertion
Objective: This study was designed to find out the frequency of complications during Central venous line insertion via sub clavian route
Methodology: This cross-sectional descriptive study was conducted at DHQ Hospital Sargodha from April 2014 to April 2015. Two hundred patients both male and female requiring hemodialysis were included in the study. All patient underwent double lumen catheterization of subclavian vein after informed consent
Results: Mean Age of the patients was 54.55 +/- 10.45. 71% of the patients were female and 29% of the patients were male. Out of 200 patients subjected to double lumen catheterizations; 28 [14.0%] developed various complications related to insertion. Out of 28 patients who developed complications, in 08 [28.57%] cases complication was failure to cannulate, in 08 [28.57%] cases there was arterial puncture, in 04 [14.28%] cases catheters were mal-positioned/kincking. Hemothorax and subclavian arterio-venous fistula developed in 02 [7.14%] each. 02 [7.14%] cases had arrhythmias and death occurred in 02 [7.14%] cases
Conclusions and Recommendations: Subclavian double lumen catheters proved to be reasonably safe, easy and a reliable way of obtaining vascular access for hemodialysis. The procedure is a short term alternative to AV fistula formation for patients requiring long term hemodialysis. It is recommended that double lumen subclavian vein catheterization should be part of post graduate training in large units where hemodialysis is available
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Introduction: Renal stones have been one of the most commonly encountered diagnosis in patients visiting Urology clinics and Extra-Corporeal Shock Wave Lithotripsy [ESWL] has been an effective method for management of renal stones of certain size [Up to 2.5 cm]
Objective: To determine the complication rates in patients undergoing ESWL to look for safety level of the procedure. Duration And Setting: Study was conducted From December 2015-March 2016 in Kidney Center, DHQ Hospital, Faisalabad
Methodology: First 225 patients undergoing ESWL at Kidney Center, DHQ Hospital, Faisalabad were included in the study and they were observed for short term complications as post procedure pain, hematuria, fever and ureteric obstruction
Results: 225 patients included in the study. Among them 132 [58.7%] were male, 93 [41.3%] were female. Average age of patient was 38.2 years with minimum range as 5 years and maximum as 75 years. Stone size ranged from 7mm to 2.5cm with average size as 1.541cm. Fragmentation was observed in 218 [96.9 %] patients in first two sessions while no fragmentation was observed in 7 [3.1%] patients after two sessions. Out of 225, 37[16.4%] patients developed pain, 19 [8.4%] observed hematuria, 7 [3.11%] have fever and 6 [2.66%] developed ureteric obstruction. Only 3 patients developed two complications simultaneously. No statistical association was found for development of complication after ESWL in our study
Conclusion: Inference drawn from the statistics clearly showed that ESWL is still a very safe and effective modality for renal stone management
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Objectives: To compare the efficacy of combination of lactobacillus acidophilus DDS-1, lactobacillus bulgaricus, bifidobacterium infantis in the prevention of necrotizing enterocolitis in preterm neonates with placebo. Study Design: Randomized controlled trial. Duration of Study: May 2012 to October 2012. Setting: Department of Pediatric Medicine, Allied Hospital, Faisalabad
Methodology: Over 6 months, 220 preterm neonates meeting the inclusion criteria were selected and were assigned randomly to two groups after parental informed consent was obtained. The neonates in study group received probiotic with breast milk or preterm formula milk and neonates in control group received breast milk or preterm formula milk. Both groups were observed for the development of clinical evidence of NEC. The Data was statistically analyzed; Chi square test and Fischer's exact test was applied to compare both groups for presence of NEC
Results: The number of days required to reach full enteral feeding [study group 8.73 +/- 3.87 days vs control group 10.72 +/- 5.43 days; p-value 0.002] and duration of hospital stay was [study group 11.35 +/- 6.74 vs control group 15.35 +/- 10.29; p-value 0.001] significantly low in the probiotic-exposed group compared with the control. The incidence of NEC [study group 10.0% vs control group 22.72%; p-value 0.011] was significantly low in the probiotic-exposed group when compared with non-exposed group
Conclusion: Alteration of microbial florae following oral supplementation of probiotics along with human milk have beneficial effects in reducing the incidence of NEC especially in pre-term neonates
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Background: Penile carcinoma is an uncommon condition, accounting for less than 1% of all male cancers. It typically presents as a superficial lesion involving the Glans and Penile Shaft. Risk factors for penile carcinoma include phimosis, human papilloma virus infection and tobacco smoking. The spread of the tumor to the loco-regional lymph nodes is the most relevant prognostic factor
Case Presentation: The current case report is about a 65 years old male who presented with non-healing ulcer involving glans and shaft of penis for two months. Examination of Perineum revealed an ulcer of size about 3 cm in length involving glans and distal penile shaft, with eaten up most of glans surface. Wedge biopsy histopathology report showed moderately differentiated Squamous cell carcinoma of the penis involving sub-epithelial tissue with lympho-vascular invasion and involvement of corpora cavernosa. CT-Scan abdomen with IV contrast showed no evidence of metastasis or lymphadenopathy. So partial penectomy was planned and carried out subsequently
Conclusion: Although squamous cell carcinoma of the penis a rare disease, mainly affecting the elderly population but all the penile ulcers not responding to medial therapy must be evaluated for malignancy. Most of these cases remain neglected because of inadequate evaluation and investigation by the local doctors which leads to late presentation. Due to these circumstances the patients have already metastatic disease at presentation. So, it is required to educate local doctors as well as general population to create proper awareness of this disease