A Network Meta-Analysis Comparing Osteoporotic Fracture among Different Direct Oral Anticoagulants and Vitamin K Antagonists in Patients with Atrial Fibrillation

Background@#There are limited studies comparing the risk of osteoporosis and fractures between different direct oral anticoagulants (DOACs) and vitamin K antagonists (VKA) in non-valvular atrial fibrillation (AF). Using a network meta-analysis (NMA), we compared osteoporotic fractures among 5 different treatment arms, viz. dabigatran, rivaroxaban, apixaban, edoxaban, and VKA. @*Methods@#Ten studies, including 5 randomized control trials and 5 population-based studies, with a total of 321,844 patients (148,751 and 173,093 in the VKA and DOAC group, respectively) with a median follow-up of 2 years, were included. A Bayesian random-effects NMA model comparing fractures among the treatment arms was performed using MetInsight V3. Sensitivity analysis excluded studies with the highest residual deviances from the NMA model. @*Results@#The mean age of the patients was 70 years. The meta-analysis favored DOACs over VKA with significantly lower osteoporotic fracture (odds ratio [OR], 0.77; 95% credible interval [CrI], 0.70-0.86). The NMA demonstrated that fractures were significantly lower with apixaban compared with dabigatran (OR, 0.64; 95% CrI, 0.44-0.95); however, fractures were statistically similar between apixaban and rivaroxaban (OR, 0.84; 95% CrI, 0.58-1.24) and dabigatran and rivaroxaban (OR, 1.32; 95% CrI, 0.90-1.87). Based on the Bayesian model of NMA, the probability of osteoporotic fracture was highest with VKA and lowest with apixaban, followed by rivaroxaban, edoxaban, and dabigatran. @*Conclusions@#The decision to prescribe anticoagulants in elderly patients with AF should be made not only based on thrombotic and bleeding risks but also on the risk of osteoporotic fracture; these factors should be considered and incorporated in contemporary cardiology practice.

A Network Meta-Analysis Comparing Osteoporotic Fracture among Different Direct Oral Anticoagulants and Vitamin K Antagonists in Patients with Atrial Fibrillation

Background@#There are limited studies comparing the risk of osteoporosis and fractures between different direct oral anticoagulants (DOACs) and vitamin K antagonists (VKA) in non-valvular atrial fibrillation (AF). Using a network meta-analysis (NMA), we compared osteoporotic fractures among 5 different treatment arms, viz. dabigatran, rivaroxaban, apixaban, edoxaban, and VKA. @*Methods@#Ten studies, including 5 randomized control trials and 5 population-based studies, with a total of 321,844 patients (148,751 and 173,093 in the VKA and DOAC group, respectively) with a median follow-up of 2 years, were included. A Bayesian random-effects NMA model comparing fractures among the treatment arms was performed using MetInsight V3. Sensitivity analysis excluded studies with the highest residual deviances from the NMA model. @*Results@#The mean age of the patients was 70 years. The meta-analysis favored DOACs over VKA with significantly lower osteoporotic fracture (odds ratio [OR], 0.77; 95% credible interval [CrI], 0.70-0.86). The NMA demonstrated that fractures were significantly lower with apixaban compared with dabigatran (OR, 0.64; 95% CrI, 0.44-0.95); however, fractures were statistically similar between apixaban and rivaroxaban (OR, 0.84; 95% CrI, 0.58-1.24) and dabigatran and rivaroxaban (OR, 1.32; 95% CrI, 0.90-1.87). Based on the Bayesian model of NMA, the probability of osteoporotic fracture was highest with VKA and lowest with apixaban, followed by rivaroxaban, edoxaban, and dabigatran. @*Conclusions@#The decision to prescribe anticoagulants in elderly patients with AF should be made not only based on thrombotic and bleeding risks but also on the risk of osteoporotic fracture; these factors should be considered and incorporated in contemporary cardiology practice.

Knowledge and attitude of house officers regarding rubber dam use

Rubber dam is considered as a standard of care for tooth isolation during dental procedures since long. Rubber dam offers utmost protection to both, the dentist and the patient. The aim of the study was to determine the knowledge and attitude of house officers in regard to placement and usage of rubber dam, identifying the problems encountered in its use. A descriptive cross sectional study was conducted from August to September 2017 in seven dental hospitals in Rawalpindi/Islamabad. Using the convenience sampling technique the questionnaire was distributed among the house officers of all the hospitals. Data was entered and analyzed using SPSS version 22.0.The overall response rate from all the seven hospitals was 71%. A total of 220 house officers participated in the study.90% of house officers believed that rubber dam improves vision during restorative or endodontic procedure, 83.2% thought that it improves access to the tooth, 96.8% knew that it improves isolation and 86.4% believed that the procedures performed under rubber dam are more successful in terms of their longevity and clinical standards.51.4% of the house officers used rubber dam in restorative and endodontic procedures sometimes while 45% did not use rubber dam and only 3.6% always used rubber dam in the endodontic and restorative procedures. The major causes of not using rubber dam in clinical practice by the house officers were extra time required for the rubber dam placement, difficult placement procedure and lack of adequate training. This study shows that greater emphasis should be placed on advantages of using rubber dam in clinical dentistry and continuing education for updating knowledge about rubber dam is required

Wolbachia pipientis: A potential candidate for combating and eradicating dengue epidemics in Pakistan

Dengue virus syndrome is an emerging global health challenge which is endemic in tropical countries like Pakistan. In recent years dengue incidences have increased considerably in different areas of Pakistan with more sever impacts on urban and peri-urban populations. This review is an effort to highlight the changing epidemiology of dengue fever, role of Government of Pakistan in disease management and control using preventive and community based approaches in the region. Moreover, there is an emphasis on application of Wolbachia as novel, inexpensive and environmentally benign candidate for control and eradication of dengue transmitting vectors.

Dental phobia among orthodontic patients

A Phobia is an intense, unpleasant feeling which may prohibit patients from orthodontic treatment. To evaluate different types of dental phobia in patients undergoing orthodontic treatment. Descriptive cross- sectional study. Peshawar Dental College Hospital, Peshawar. Duration of study was from August, 2014 to February, 2015. Both males and females reporting for orthodontic treatment that consented to participate in the study were included. All patients were interviewed regarding their fears about the said treatment using structured questionnaire. The information was classified into 3 groups as strongly phobic, moderate phobic and not phobic. A total of 110 patients were selected for the study. Strong phobia was observed in 56%, moderate in 18% whereas 26% were not having phobia. Besides, dental phobia was same at different stages of treatment, higher in the adolescent age and more in females as compared to males. Confidence to ask questions from the dentists was observed in 20% patients. Eighty percent patients were satisfied from the attitude and way of treatment of the orthodontists. Orthodontists should recognize the existence of dental phobia in patients coming for treatment. To reduce phobia, they need to develop skill to communicate effectively with the patients before undertaking any treatment

Pattern of cigarette smoking among college students of Mardan

Cigarette smoking habit is mostly acquired during college and later it becomes an addiction leading to high morbidity and premature death. To determine the pattern of cigarette smoking among college students of Mardan and factors that encourages its use. Cross-sectional study, done in 2014 in seven colleges of Mardan over 3 months period. All students were encouraged to participate and fill the questionnaire. The data on smoking pattern, contributing factors to the habit, peak time/ places of smoking, sources of hazards awareness, and number of cigarettes smoked per day, reasons for smoking, not smoking and quitting were collected through a pre-tested questionnaire. The data were entered in the computer and analyzed using means and percentages. A total of 954 students returned the filled questionnaire. Their ages ranged between 17 and 24 years with male to female ratio of 5:1. Out of the total, 31.2% were smokers, 2.2% ex-smokers and 66.6% non-smokers. The habit was found more common in students whose fathers or brothers were smokers and many students acquired this habit for charm and relaxation. Most smokers consumed less than 10 cigarettes per day. No female student was a smoker or ex- smoker. Significantly less smoking [p < 0.05] was observed in one institute as compared to other six institutes because of strict discipline. Most of the smokers started smoking after entry in the college life. Smoking was more in boarding students, those whose mothers were working and those living in the urban areas. Non-smokers and ex-smokers avoided cigarettes either due to family pressure, religion or its adverse effects on health. Females had significantly [p < 0.05] more knowledge about tobacco hazards as compared to males and most students mentioned that doctors were their main source of awareness. Ahnost 31.2% students in various colleges of Mardan were smokers. Smoking was not seen in female students. Most boys [68%] started smoking when they entered the college [first year]. Health awareness, family support, religious knowledge and strict discipline in the colleges were the main reasons to not to smoke or quit smoking

Wolbachia pipientis: A potential candidate for combating and eradicating dengue epidemics in Pakistan

Dengue virus syndrome is an emerging global health challenge which is endemic in tropical countries like Pakistan. In recent years dengue incidences have increased considerably in different areas of Pakistan with more sever impacts on urban and peri-urban populations. This review is an effort to highlight the changing epidemiology of dengue fever, role of Government of Pakistan in disease management and control using preventive and community based approaches in the region. Moreover, there is an emphasis on application of Wolbachia as novel, inexpensive and environmentally benign candidate for control and eradication of dengue transmitting vectors.

Immunological study of type 2 diabetic patients with periodontal disease

To evaluate the IgA, IgG and IgM levels in the serum samples of type 2 diabetic and Periodontal patients of the Peshawar area having different life style set up. Case control study. This study was carried out on subjects who fulfilled our criteria and agreed to participate in the study were included. They were residents of Peshawar area and visited OPDs of Khyber College of dentistry, Peshawar during July, 2012 to June, 2013. Among 120 participants, 30 were healthy, 30 were with periodontitis, 30 had diabetes and the remaining 30 had both diabetes and periodontitis. All of them had at least 20 natural teeth. Diabetic patients had the disease history minimum of five years while the periodontal patients had clinically confirmed the disease. Blood samples were collected from each of the participant and immunoglobulins A, G and M were measured. The observed data were analyzed accordingly through standard statistical methods. Male patients were found more as compared to females [ratio 1: 0.87] in the two diseases. The age range was 35 to 54 years with the mean 44 +/- 5. As per HBA1C results; 40% had good control of diabetes, 26% moderate while in 34% control was poor. Immunoglobulin A and G levels were found significantly higher [p < 0.05] in the three disease groups as compared to control group. Whereas the concentration of IgM was not changed by the said diseases. Besides, the gender has no influence on the levels of the three immunoglobulins. The IgG levels increased with the increase in severity of the Periodontitis disease. While IgA showed slight decrease with the increase in clinical grades of the Diabetes disease. The result of the current study indicates the role of humoral immune response in the two mentioned diseases. The higher levels of immunoglobins particularly IgA and IgG might be due to protective mechanism against the weak immune response and the increased bacterial challenge in diabetes and periodontitis

Prevalence of zinc deficiency among rural women during childbearing age in Peshawar, Pakistan

Zinc deficiency is a commonly reported health problem throughout the world. This cross sectional survey was conducted in rural Peshawar with an aim to estimate the prevalence of zinc deficiency in women of child bearing age and find its association with age, marital, pregnancy status and parity. Data was collected from 353 women age 15-45 years. EPI INFO version 6.04 was used for data analysis. Overall 98 [27.8%] women were zinc deficient [

Pattern of early loss of deciduous molars and a cross sectional study

A cross-sectional study was conducted at the Department of Oral and Maxillofacial Surgery of Fatima Jinnah Dental College, Karachi to find out the factors responsible for premature loss of deciduous molars in children aged three to nine years. All children aged 3 - 9 years visiting the Dental OPD of Fatima Jinnah Dental College Karachi for extraction of deciduous molars from Feb 2011 to Feb 2012 were included in the study. 256 children format the study group. The data were collected on a predesigned Proforma filled by a single operator. Parameters taken into consideration were age, sex, tooth brushing and reasons for extraction. In this study 176 were male and 80 female. Overall 368 deciduous molars were extracted, 237 deciduous molars were extracted in males and 131 in females. Among the investigated subjects, 17% of children reported no tooth-brushing. Caries was the commonest cause of premature loss of deciduous molars accounted for 96.1% followed by tooth fracture 2.3% and malocclusion 1.6%. The frequency of only one deciduous molar loss was 67.2%. Maximum deciduous molar loss 50.7% was observed in children aged 8 years. Most commonly extracted tooth was mandibular left first deciduous molar [37.7%]. Results of this study suggested that improper tooth-brushing dental caries and no-treatment of carious deciduous molars were major risk factors in its early loss

Miscellaneous liver diseases in infancy and childhood in several hospitals

Most of the liver diseases are different in pediatric age group, as compared to those in adult in many respects. Beside inflammatory, neoplastic and metabolic liver diseases; pediatric liver diseases also exhibit specific features of genetic predisposition, as well as environmental or other acquired diseases. In congenital diseases choledochal cyst, biliary atresia and cholestasis are included. While in environmental or acquired/nutritional diseases, fatty change liver and Kawashiorkor are found. A study is done to overview the miscellaneous congenital and acquired liver diseases in infancy and childhood which are important but less common as compare to inflammatory, metabolic and other liver diseases. Retrospective Study. This study was conducted at Department of Pathology, Basic Medical Science Institute [BMSI], Jinnah Postgraduate Medical Center, Karachi from 1995 to 2004. Slides / paraffin blocks of liver biopsies were taken from patients under 15 years of age. The cases were retrospective. The distribution of 100 cases of miscellaneous liver diseases in infancy and childhood were according to age and sex. Total 48 [48%] cases were encountered in the youngest of 0-5 year's age group, 36 [36%] cases in 6-10 years and only 16 [16%] cases in 11-15 years age group. It is observed that the tendency of miscellaneous liver diseases are higher up till 5 years of age and sexual differentiation showing male predominance with male to female ratio of 3:2. The miscellaneous liver diseases in younger children, may be congenital like biliary atresia, intra hepatic biliary hypoplasia and cholestasis or acquired; like tuberculosis and the Kawashiorkor [malnutrition].These are well known in third world countries and in Pakistan

Pattern of cigarette smoking among college students of Quetta

Cigarette smoking habit is developed more at the young age, hazardous to health and causes premature mortality. To determine the pattern of cigarette smoking and factors contributing to the said habit among college students of Quetta. Randomized study. This study was conducted at the Bolan Medical College, Quetta during the academic year 2010-2011. a total of 850 students from different colleges of Quetta were randomly selected during the academic year 2010-2011. Prevalence and influence of factors associated with the cigarette smoking were recorded on a predesigned questionnaire. The collected data was analyzed with the help of statistical procedures. Out of the total, 122 students were smokers, 23 ex-smokers and 705 non-smokers. Smokers had the habit for charm and relaxation. While non-smokers and ex-smokers avoided cigarettes use due to family blame, religion and its adverse effect on health. Besides, the habit was found more common among students whose fathers and brothers were smokers. Majority of them knew the hazards and very little number was smoking in the public places. Young age and transition period from school to college is a critical time to adopt the habit of cigarette smoking, hence needs an immense attention of the authority designing tobacco control policies. Healthy recreational activities, awareness programs related to its hazards, non-smoking home environment, increased tax and ban on its advertisements are the essential measures, which can minimize the habit. In addition, the present basic work would serve as a template to conduct further advanced studies on this line

Gallbladder carcinoma; frequency in patients under going cholecystectomy for chronic cholecystitis

Chronic Cholecystitis is one of the commonest diseases presenting in surgical department and is subjected to cholecystectomy each time. Asuspicious gall bladder on ultrasound initiates further investigations to rule out carcinoma of gall bladder yet some times a benign looking gall bladder on ultrasound turns out to be carcinoma of gall bladder on histopathology. Descriptive study. District Head Quarters Hospital, Sargodha, from September 2007 to March 2009. 200 patients who underwent both open and Laparoscopic cholecystectomy for cholelithiasis were subjected to this study. All relevant data was documented on a standardized data form. Patients were between the ages of 28-74. Patients already diagnosed as Gallbladder Carcinoma, empyema gall bladder, mucocele and gall bladder polyp were excluded from the study. Gall bladders removed after each surgery ware sent to laboratory for histopathological evaluation. A total of 200 cases were studied [161 females, 39 males; M: F ratio 1:4]. The mean age was 45 years [range 28-74 years]. The most common presenting complaint was pain right hypochondrium with nausea and vomiting [85%].The average operating time was 50 minutes in case of open cholecystectomy and 1 hour in laparoscopic cholecystectomy. Complications included biliary leak in 2 patients [1%], Wound Infection in 3 patients [1.5%] and death in one case [0.5%]. The overall rate of complications was 3%. There were a total of 5 patients of laparoscopic cholecystectomy who required extension of the incision, for Carcinoma Gallbladder. Carcinoma of gall bladder is a very aggressive malignancy and usually presents at a very advance stage as its symptoms mostly are marked by symptoms of cholecystitis. Detection of gall bladder carcinoma is very difficult in early stages on ultrasound. Any findings in ultrasound suggesting malignancy should be confirmed on further investigations like CT scan .Carcinoma of Gall bladder is not very common in cases of cholecystectomy for chronic Cholecystitis but once found should be dealt with extreme precision following established operating protocols

Diurnal variations in the levels of progesterone during late pregnancy

Progesterone is a C-21 steroid hormone, plays a major role in the occurrence, maintenance and termination of pregnancy. To study the diurnal variations in the levels of progesterone at the start and end of the day during late pregnancy in women having different life set ups. Experimental and Observational Study. This study was conducted at the Department of Gynae and Obs., Khyber Medical College, Peshawar. Blood samples of 50 women between 26-40 weeks of gestation were collected at two different intervals with a gap of 12 hours. Progesterone level was estimated by Serozyme EIA method. The concentration of progesterone was found low in the early morning and high in the late evening in our population. Besides, the magnitude of fluctuations in the samples of two different intervals declined with progress of age and weeks of gestation. Our findings support the recommendation of restricting progesterone measurements to morning hours at all ages particularly during late pregnancy which is important information for clinicians at the time of interpretation of results

Cardiac surgery in octogenarians

In Europe and North America, cardiac surgery can be done successfully on octogenarians, but differences in patient selection, surgical and bypass techniques prevent us from concluding similarly in Pakistan. This study investigated the short and long-term outcomes of cardiac surgery in octogenarians operated over a 5 years period at The Aga Khan University Hospital, from January 2001 to December 2006. Seventeen octogenarians, [mean age 81.7 +/- 2.3] underwent coronary artery bypass graft [CABG]. Thirty-days hospital mortality was reported in only 1 patient. Surgical complication of any kind was reported in 13 [76.5%] patients with pleural effusion being the commonest in hospital complication seen in 11 [64.7%] patients. About 13 [92.9%] patients were satisfied with the results of the surgery and reported post-surgery improvement in quality of their life. Cardiac surgery has an important role in the management of elderly patients with medically refractory cardiac symptoms, but the implications of widespread cardiac surgery in the elderly need to be addressed

Wound infection; frequency in clean surgical operations

The aim of the study was to evaluate the frequency of infection in clean surgical cases [General and Orthopaedic]. A descriptive study. This descriptive study was conducted at department of surgery and orthopaedic DHQ Teaching Hospital Sargodha from July 2007 to Dec, 2008. In this study 1500 clean surgical cases were included. Wounds were examined on third post operative day and then regularly after removal of stitches. Surgical wounds were examined finally on fifteenth post operative days. Description of wound condition and detailed data of patients were collected on preformed performas. Patients with wound infection developed pain at operation site and fever on third post operative day. Wounds were examined for swelling, redness, discharge; stitch abscess. Routine investigations were done as per protocol ie complete blood examination, complete urine examination, blood sugar, C-reactive proteins etc. Wounds swab was taken for microscopy and culture sensitivity. This study was carried out on fifteen hundred clean surgical cases [General and Orthopaedic]. There were 1064 males and 436 females. Male to Female ratio was 2.4:1. Infection was detected in 110 patients [7.3%] while no infection was found in 1390. Infection was maximum in patients more than 60 yrs of age [10.9%]. Wound infection was minimum in young patients [3.5%].commonest micro organism isolated from the infected wound was staphylococcus areus. Other organism isolated was streptococcus pyogenes, proteus and pseudomonas. No MRSA was detected. In our case study clean cases were found generally free of infection especially young patients. Whereas increased incidence of infection was noted in old patients. Wound infection is associated with significant morbidity in the form of delayed wound heeling, prolonged hospital stay and increased economical pressure on the patient

Giant multiple intra-abdominal hydatid cysts

Hydatid disease is endemic in the cattle grazing areas. It is a parasitic infection caused by the Echinoccocus Granulosus. Dogs are the definitive host and humans get infected either by contact with the definitive host or by consuming hydatid ova contaminated vegetables. A 42 yr old lady presented with shortness of breath on exertion, orthopnea and progressively increasing abdominal distention. She had past history of hydatid disease and had progressively increasing abdominal distention three laparatomies and a right thoracotomy, in the past five years. On physical examination, she had a distended, non-tender abdomen. Her routine laboratory investigations were normal. Echinococcus antibody titres were 1:64 [Normal 1:32]. Computed Tomography [CT] scan revealed multiple, well defined cysts throughout the abdomen. Laparotmy and right thoracotomy was planned. Patient refused to undergo any further surgical procedure. She was discharged from the clinic with a prescription of Albendazole 400 mg twice a day for an indefinite period. Symptomatic or large cysts should be surgically treated. In cases suspected of having peritoneal spillage, antihelminthic drugs should be administered. In addition, small asymptomatic cysts, some daughter cysts, and peritoneal secondary cysts and splenic cysts may also be effectively treated with Albendazole

Coexistence of caseating granulomas with hodgkin's lymphoma: a diagnostic and clinical dilemma

Hodgkin's lymphoma [HL] is a neoplasm of the B lymphocytes. The histological picture may resemble granulomatous lesions similar to those seen in tuberculosis as collections of epitheloid cells are not uncommonly seen in HL. In areas which are endemic to tuberculosis, the close association and the coexistence of the two must be recognized for the proper diagnosis and treatment of the illness. A series of cases of Hodgkin's lymphoma is reported in which the biopsy specimens from different parts of the body portrayed caseating granulomatous lesions