Assessment of the risk posed to Singapore by the emergence of artemisinin-resistant malaria in the Greater Mekong Subregion

Objective@#To assess the public health risk to Singapore posed by the emergence of artemisinin-resistant (ART-R) malaria in the Greater Mekong Subregion (GMS).@*Methods@#We assessed the likelihood of importation of drug-resistant malaria into Singapore and the impact on public health of its subsequent secondary spread in Singapore. Literature on the epidemiology and contextual factors associated with ART-R malaria was reviewed. The epidemiology of malaria cases in Singapore was analysed. The vulnerability and receptivity of Singapore were examined, including the connectivity with countries reporting ART-R malaria, as well as the preparedness of Singaporean health authorities. Sources of information include international journals, World Health Organization guidelines, data from the Singapore Ministry of Health and National Public Health Laboratory of the National Centre for Infectious Diseases, and the International Air Transport Association.@*Results@#The importation of ART-R malaria into Singapore is possible given the close proximity and significant travel volume between Singapore and the GMS countries reporting artemisinin resistance. Singapore’s vulnerability is further enhanced by the presence of foreign workers from neighbouring endemic countries. Nonetheless, the overall likelihood of such an event is low based on the rarity and decreasing trend of imported malaria incidence. With the presence of Anopheles vectors in Singapore, imported cases of drug-resistant malaria could cause secondary transmission. Nevertheless, the risk of sustained spread is likely to be mitigated by the comprehensive surveillance and control system in place for both infected vectors and human cases.@*Discussion@#This risk assessment highlights the need for a continued high degree of vigilance of ART-R malaria locally and globally to minimize the risk and public health impact of drug-resistant malaria in Singapore.

Evaluation of blood glucose concentration in patients with diabetes undergoing tooth extraction after administration of local anesthesia with or without adrenaline

The aim of this study was to determine the mean blood glucose concentration in patients with dia-betes undergoing tooth extraction after administration of local anesthesia with or without adrenaline. A Randomized control trial [RCT] study was carried out from October 2015 to June 2016 in the De-partment of Oral and Maxillofacial Surgery of Islamic International Dental Hospital [IIDH] Islamabad on 60 diabetic patients undergoing tooth extraction requiring administration of local anesthesia. All patients were randomly divided into two equal groups that is group A [lignocaine without adrenaline] and group B [lignocaine with adrenaline]. Blood glucose concentration measurements were taken 10 minutes before, 10 minutes and 20 minutes after administration of local anesthesia. Data were analyzed through SPSS version 17.Patient's age ranged from 25-75 years. Average age of patient was 64.5+/-9.86. There were 37% males and 23% females in both groups. The mean blood glucose concentration was increased in group B when compared to group A from 154 to 163.2mg/dl at 10 minutes. This increase in blood glucose concentration was statistically not significant [P ? 0.05]. There was statistically significant [P<0.05] increase in blood glucose concentration in group B when compared to group A from 155.0 to 176.16 mg/dl at 20 minutes.It was concluded that though 2% lignocaine with adrenaline is widely used local anesthetic, it should be cautiously used in type 2 diabetics

Formulation and in vitro evaluation of directly compressed controlled release tablets designed from the Co-precipitates

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

Successful use of deltopectoral flap in reconstruction of defect caused by squamous cell carcinoma

Deltopectoral flap is a widely used flap in reconstruction surgery. A patient presented with extra-oral solitary swelling on the right lower jaw and an intra-oral exophytic growth located along the lower border of right mandibular jaw. Incisional biopsy was done which revealed moderately-differentiated squamous cell carcinoma. Clinical staging was T4N1M0. Treatment plan devised was segmental mandibulectomy along with excision of involved skin, supraomohyoid neck dissection followed by reconstruction. Apron incision with lip split was used. The defect caused by the resection was closed using deltopectoral flap. Deltopectoral flap was preferred for reconstruction as it is convenient for patients with low socioeconomic status and for hospitals with less technical facilities. It can easily be raised from anterior chest area because of its pliability. This case report highlights the role of deltopectoral flap as an alternate to free flap for reconstruction

Assessment of the risk posed to Singapore by the 2015 Middle East respiratory syndrome outbreak in the Republic of Korea

OBJECTIVE: To assess the public health risk to Singapore posed by the Middle East respiratory syndrome (MERS) outbreak in the Republic of Korea in 2015. METHODS: The likelihood of importation of MERS cases and the magnitude of the public health impact in Singapore were assessed to determine overall risk. Literature on the epidemiology and contextual factors associated with MERS coronavirus infection was collected and reviewed. Connectivity between the Republic of Korea and Singapore was analysed. Public health measures implemented by the two countries were reviewed. RESULTS: The epidemiology of the 2015 MERS outbreak in the Republic of Korea remained similar to the MERS outbreaks in Saudi Arabia. In addition, strong infection control and response measures were effective in controlling the outbreak. In view of the air traffic between Singapore and MERS-affected areas, importation of MERS cases into Singapore is possible. Nonetheless, the risk of a serious public health impact to Singapore in the event of an imported case of MERS would be mitigated by its strong health-care system and established infection control practices. DISCUSSION: The MERS outbreak was sparked by an exported case from the Middle East, which remains a concern as the reservoir of infection (thought to be camels) continues to exist in the Middle East, and sporadic cases in the community and outbreaks in health-care settings continue to occur there. This risk assessment highlights the need for Singapore to stay vigilant and to continue enhancing core public health capacities to detect and respond to MERS coronavirus.

Controlled release matrix tablets of glipizide: influence of different grades of ethocel and Co-excipient on drug release

The aim of the current study was to formulate and evaluate glipizide controlled release matrix tablets by means of different grades of polymer Ethoceland different co-excipients in order to evaluate their effect on drug release profiles during in vitro dissolution studies. Type II diabetes mellitus is usually treated with Glipizide. Glipizide belongs to sulfonylurea group. Gastric disturbance and severe hypoglycemia has been observed after taking glipizide orally. To overcome these problems, controlled release matrices were developed using different grades of ethyl cellulose polymer with a drug-polymer ratio of 1: 3by the direct compression method. The effect on drug release of partial replacement of lactose by different co-excipients, HPMC K100M, starch and CMC, were also studied. Diameter, thickness, hardness, friability, weight variations, drug contents of formulations were tested, these properties were within prescribed limits. Co-excipients and polymer containing formulations were compared to the without co-excipients and polymer containing formulations with respect to their release profile. After a 24-hour release study, ethyl cellulose polymer containing formulation exhibited prolonged release for 5-16 hours; however the polymer Ethocel standard FP 7 Premium without co-excipient containing formulation exhibited controlled release for 24 hours. Incompatibility was investigated between drugs, co-excipient DSC and polymer study was performed and any type of interaction was not found. Different kinetic models were used to study the release mechanism. An enhanced release rate was observed in case of excipients containing formulations

assessment of dentists' knowledge about medical emergencies

Medical emergency when occurs in a dental environment should be handled efficiently and effectively in order to sustain life until medical help arrives. This study aimed to enhance knowledge amongst dental practitioners about the possible risks of a medical emergency to improve patient care. A questionnaire based study was conducted in the dental teaching hospitals of the twin cities, Rawalpindi and Islamabad in 2015. The questionnaire comprised of three sections to assess dentists' perception and dentists' knowledge on the commonly faced medical emergencies along with dentists' confidence in performing Basic Life Support [BLS]. 215 questionnaires were distributed out of which 192 were returned. The study sample included 122 female and 70 male dentists with a minimum clinical experience of one year. The results showed 71.4% received a formal BLS training while 84.4% wanted to receive thetraining. Moreover, the mean medical emergency score obtained was 5.28 out of a maximum of 10. 55.2% of the dental practitioners felt confident in performing Cardio Pulmonary Resuscitation [CPR], out of which, 80.5% had the correct knowledge of performing a CPR according to this study. The most significant finding was almost half of the dentists lack the knowledge and necessary training. Hence, in order to improve quality of patient care annual BLS courses should be made mandatory

Extrathyroidal uptake from thyroid carcinoma on [99m]Tc-pertechnetate scintigraphy

Three cases of imaging with 99mTc-pertechnetate [[99m]TcO[4]] and unusual positive lymph node uptake in the neck are reported hereby. Two cases were later diagnosed to be well-differentiated thyroid carcinoma, [DTC] with nodal metastasis. The third was a confirmed case of carcinoma thyroid that had presented with mass in the neck soon after surgery, being prepared for ablative dose of radioactive iodine [131]I. All three were young females under 40 years of age. These 3 cases signify that extra thyroidal areas of uptake on a routine thyroid scan with [99m]TcO[4] can some time be due to thyroid carcinoma with regional metastases. Foci of metastasis in patients with DTC may be incidentlly detected with [99m]TcO[4] scan. Multinodular goiter with palpable lymph node should always be investigated for exclusion of malignancy. The patients underwent near total thyroidectomy and radical neck dissection; histopathology confirmed the scan findings

Percutaneous nephrolithotomy for the treatment of renal stones larger than 2.5 CM

To share our experience regarding the safety and efficacy of Percutaneous Nephrolithotomy for the treatment of renal stones of larger than 2.5 cm and to study the frequency of any postoperative complications associated with this procedure. This is a descriptive study conducted during the period from June 2007 to December 2009. Using non-probability convenient sampling, total 88 patients with renal stones of more than 2.5 cm were selected for PCNL. Data was analyzed on SPSS version 10 for windows XP. In a cohort of 88 patients [57 male and, 31 female] PCNL was performed for renal stone treatment. The mean age was 33.5 [9 - 65] years. The mean operative time was 85 [60 - 180] minutes and the mean stone size was 3.2 cm range [2.5-4.8] cm. There were 37 staghorn and 51 non staghorn stone. PCNL via a single access tract was accomplished in 86% [76/88] of procedures, with upper pole calyx in 30, middle calyx in 27 and lower pole calyx in 19 procedures, while multiple tracts were used in 14% of procedures [12/88] with 09 procedures using the upper and middle calyxes and 05 procedures using lower and middle calyxes. The stone-free rates for staghorn stone at discharge and at 3 months were 83.7% and 90.8% respectively, while for non staghorn stone the figures were 85.8% and 92.5% respectively. Postoperative complications were observed in 9% of the procedures [8/88], the commonest of which was bleeding necessitating blood transfusion in 4 patients. PCNL is safe and Effective treatment for renal calculi associated with less morbidity, shorter hospital stay and is cost effective

Gated MIBI myocardial spect showing balanced ischemia and global hypokinesia in patient having thrombus in basal segment of dominant circumflex system blocking both left anterior descending and circumflex artery

Myocardial perfusion imaging [MPI] is a powerful diagnostic and prognostic tool for evaluating coronary artery disease [CAD]. Gating myocardial perfusion gives important diagnostic and prognostic information. This 43 years old patient was referred for cardiac scan. Exercise stress test showed > 2mm horizontal ST segment depression. Cardiac scan was normal except for left ventricular cavity dilatation on stress images. Gated images showed global hypokinesia and increased end-diastolic volume. Patient was suspected to have balanced ischemia and was referred for Angiography. Angiography showed total occlusion with no flow in proximal Left Anterior Descending Artery and distal circumflex artery. It is very important to evaluate symptomatic patients and patients with risk factors carefully with normal myocardial perfusion scan

Clinical presetations and complications associated with tubal rupture in patients with tubal ectopic pregnancy

The objectives of study was to describe the clinical presentation, frequency of tubal ruptur and short term maternal morbidity and mortality in cases of tubal ectopic pregnancy presenting to a tertiary care teaching hospital. This was a descriptive study of 50 cases of tubal ectopic pregnancy; both ruptured and unruptured, presented at Khyber Teaching Hospital Peshawar from September 2002 to December 2003. Detailed history regarding age, parity, presenting features, past medical and surgical history and history regarding risk factors was taken. Operative findings regarding surgical procedures were noted. Data collected was analysed on SPSSv.10 and chi square test was used as a test of significance. The mean age of the sample was 29.50+10.50. Among the etiologic factors, PID was [14%], previous ectopic [4%], ovulation induction [4%] and IUCD insertion [2%]. Common clinical features were abdominal pain [90%], amenorrhea [84%], vaginal bleeding [70%], shock [32%]. Clinical signs raising suspicion of tubal rupture were shock [36.3%], anemia [86.3%] and irregular mass in pouch of douglas [88.6%]. Diagnosis was made clinically [92% cases] and abdominal USG with positive findings [92.5°/ cases]. Laparotomy showed ruptured tube in 88% cases, of which 88% had rupture of ampullary region. Surgical procedures done were salpingectomy for 97% and salpingoophrectomy for 7% of ruptured tubal ectopics. Short term morbidities were shock [32%], peritonitis [32%] and severe anemia [10%]. No maternal mortality was recorded. The most common risk factor was PID and the most common presenting complaint was abdominal pain and amenorrhea

Dual phase MIBI scintigraphy in diagnosis of parathyroid adenoma followed by ultrasound guided percutaneous alcoholic ablation

Primary Hyperparathyroidism [HPT] is an inappropriate hyper secretion of parathyroid hormone [PTH]. Primary HPT is caused by parathyroid adenoma in 80-85% of patients. Clinical manifestations are kidney stones, abdominal groans, painful bones, psychic moans, and fatigue overtones. Ultrasonography is widely used in suspected cases for localization of parathyroid adenoma. There is considerable intra-observer variation and it is difficult for ultrasound alone to differentiate parathyroid lesion form that of thyroid. Dual phase Tc-99m MIBI scinitigraphy for detection of parathyroid adenomas has sensitivity and specificity values ranging from 82% to 100% and from 89% to 100%, respectively. Percutaneous ethanol injection for parathyroid glands can be applied effectively in selected cases when surgery is unadvisable either for technical reasons e.g., recurrence of hyperplastic glands in the neck after subtotal surgery or intrathyroideal parathyroid tumors or the poor clinical state of the patient

Pattern of change in the frequency of Helicobacter pylori with perforated duodenal ulcer

Peptic ulcers were believed to be caused by stress, dietary factors, and gastric acid, but the link between H. pylori and peptic ulcers was identified in 1983. To see the frequency of Helicobacter pylori infection in patients with perforated duodenal ulcer and advise eradication therapy in these patients. This cross sectional study was conducted in Surgical Unit Hayatabad Medical Complex, Peshawar, during January 2007-June 2008. A total of 50 cases were included in the study. All cases presenting to our unit with acute perforated duodenal ulcer were recruited. After resuscitation and baseline investigations, all underwent emergency laparotomy via upper midline incision, after thorough peritoneal lavage, the perforation margins were freshened and closed over an omental patch. Serum from every patient was tested for H. pylori and accordingly managed. Out of the 50 cases, 45 were males, and 5 were females. Age ranged from 20- 80 years old. All patients underwent emergency laparotomy. Postoperatively, all were started on PPI treatment and serum testing for H. pylori was done. Thirty-four [68%] turned out positive and 16 [32%] were found to be negative for H. pylori. There is still a high frequency of H. pylori infection in patients with perforated duodenal ulcer. But comparing these results with the various data available, there is a significant decline in H pylori positive perforated duodenal ulcer patients

Bone stress injuries in the army cadets of Pakistan Military Academy

Bone stress injuries are common among army cadets during training period and these injuries give rise to morbidity and loss of training hours. Some cadets with stress fractures re-join their duties while some are kept out of services resulting in attrition and economic loss. A retrospective analysis of bone stress injuries of one hundred and twenty cadets between June 2006 and Dec 2007 was conducted from the case documents available at Institute of Nuclear Medicine, Oncology and Radiotherapy [INOR] Abbottabad. The occurrence of stress fractures among cadets at Pakistan Military Academy, presenting with exercise induced pain was 68.3% amongst these cadets. Seventy fours percent f the fractures were labelled grade-I. High grade fractures were confined to tibia. Tibia was the commonest site of stress fractures in both sexes, accounting for about 73% of all stress fractures. Fifty percent of these patients were labelled as having shin splints and 3% as thigh splints. Most of the stress injuries were confined to the tibia. The referral was considered early as most of the stress injuries were of low grade