Prevalence of diabetic retinopathy in rural Pakistan: A population based cross-sectional study

Purpose: To estimate the prevalence of diabetic retinopathy (DR), an emerging cause of sight threat and blindness from a large rural population in Pakistan. Methods: This was a population?based cross?sectional study. We selected a rural district of Matiari Sindh Province in Pakistan, where we selected all the health facilities and their attached Lady Health Workers (LHWs)/Lady Health Supervisors (LHSs). These female health workers were trained to identify high?risk diabetic individuals in their catchment areas using pre?defined criteria and to refer them to the nearest health facilities for screening and testing random blood sugar (BSR). Adults of 18 years or above, male or female, were included in the study for DM and DR screening. Ophthalmic examination was conducted by the optometrists on those who had BSR level >180 mg/dl for the evidence of DR. Identified DR patients were referred to a linked tertiary?level ophthalmology institute for their free DR treatment. Results: Of the identified and referred 24,463 participants, 23,999 were tested for BSR and 2,331 (9.74%) were found to be high?risk patients (BSR >180 mg/dl) and had ophthalmic examination conducted. Of these, 563 had clinically established DR, a prevalence of 24.2% (95% CI, 22–26%). Significantly more DR patients (228, 40.5%) were found in the age group >60 years, with more among female (327, 58.1%) with DR. Conclusion: DR is highly prevalent in the Pakistani rural population. The establishment of an integrated approach within the health care system could decrease the burden of DR in Pakistan

A comparative study of RapidArc and intensity-modulated radiotherapy plan quality for cervical cancer treatment

Background: RapidArc therapy, a complex form of intensity-modulated radiotherapy (IMRT), is now widely used to treat cancer patients. Aims: This study aimed to investigate and compare the plan quality of IMRT and RapidArc techniques using various dosimetric indices to find the better treatment modality for treating patients with cervix cancer. Materials and Methods: Thirteen cervical cancer patients treated with IMRT were selected for analysis and original plans were subsequently re-optimized using the RapidArc technique. Plans were generated such that dose of 5000 cGy was delivered in 25 equal fractions. Inverse planning was done by Eclipse (Varian Medical Systems, Palo Alto, CA) treatment planning system for 15 MV photon beams from computed tomographic data. Double arcs were used for RapidArc plans. Quality of treatment plans was evaluated by calculating conformity index (CI), homogeneity index (HI), gradient index (GI), coverage, and unified dosimetry index (UDI) for each plan. Results and Conclusion: RapidArc resulted in better planning target volume (PTV) coverage as is evident from its superior conformation number, coverage, CI, HI, GI, and UDI. Regarding organs at risk (OARs), RapidArc plans exhibit superior organ sparing as is evident from integral dose comparison. Difference between both techniques was determined by statistical analysis. For all cases under study, modest differences between IMRT and RapidArc treatment were observed. RapidArc-based treatment planning is safer with similar planning goals compared to the standard fixed IMRT technique. This study clearly demonstrated that favorable dose distribution in PTV and OARs was achieved using RapidArc technique, and hence, the risk of damage to normal tissues is reduced.

Presentation and management of parathyroid tumors

Objective: To evaluate cases presenting with parathyroid tumors and the efficacy of treatments offered

Methods: Six cases presented with bony manifestations in mandible, femur, tibia and maxilla while one presented with an overt neck swelling. Renal calculi showed in one case. All cases were subjected to assessment of serum parathyroid hormone level and radionuleotide scan.Sonography was done in addition in two of the cases . In all cases parathyroid tumors were identified and subjected to exploratory parathyroid surgery, In addition bony pathologies were subjected to excisions of the lesions

Results: In all the cases serum parathyroid hormone levels were raised.MIBI scans picked parathyroid tumors in almost all the cases. Six of the excised tumors were parathyroid adenomas while one was adenocarcinoma. Additional surgeries done in these cases include excisions of mandibular growths, maxillectomy and osteotomies on tibia and femur. All were giant cell tumours.One case with adenocarcinoma expired. The other cases showed normalization of parathyroid hormone levels

Conclusion: Parathyroid adenoma is the common benign tumor of parathyroid gland usually presenting with exaggerated parathyroid hormone levels. Ultrasound scan screening with tc99 Sestamibi scanning are most helpful in establishing the diagnosis. Parathyroid surgery is safe in experienced hands and is the standard treatment modality to reverse the morbidity associated with pathologies. In all bony lesions with a doubtful clinical diagnosis screening for Parathyroid lesions is mandatory. Gross disfigurements, functional disabilities call for excision of bony lesions

Axial length variability in cataract surgery

To determine the mean axial length and biometric measures in patients undergoing cataract surgery and further compare the variability of axial length between the gender and with age. Cross-sectional observational study. Eye Unit I, Department of Ophthalmology, Liaquat University of Medical and Health Sciences, Hyderabad, Pakistan from January 2010 to December 2012. All patients referred for cataract surgery were assessed. The study included 886 eyes which were straightforward cataract cases with no other ocular problem. The data was collected for axial length, keratometric values and Intra-Ocular Lens [IOL] power prior to cataract surgery. The collected data was then analyzed using SPSS version 19 for windows software. Gender based comparison showed significant difference in age, axial length, keratometric values and IOL power between the two groups [p=0.000]. 86% of the eyes had an axial length between 21.00 mm and 23.99 mm. In univariate analysis there was significant [p=0.000] relation between overall age and axial length. The keratometric values ranged between 36.75 D and 52.50 D. Majority of the IOL powers ranged between 20.00 D and 23.00 D. The mean axial length of patients undergoing cataract surgery was 22.96 +/- 1.04 mm, was comparable to Indian and Chinese population but shorter than the Western population. Females had shorter axial lengths, similar to other studies. Axial length was positively associated with age among the females, the cause of which is yet to be determined

Congenital myasthenia gravis

Congenital myasthenia gravis is caused by genetic mutations affecting neuromuscular transmission, characterized by muscle weakness usually starting in childhood. A two and a half years old male child presented with bilateral ptosis and hoarseness of voice. The symptoms progressed giving the clinical impression of congenital myasthenia gravis. A series of tests were done including Ice Pack Test, acetylcholine receptor antibody test, trial of steroids and finally neostigmine test which confirmed the diagnosis. This case illustrates the challenges in diagnosing congenital myasthenia gravis and highlights the potential benefits of neostigmine test in its diagnosis

Study of tannery wastewater treatability by precipitation process

A study was conducted for the removal and recovery of chromium from tannery wastewater, using NaOH, MgO, Ca[OH[2]] and Al[2][SO[4]]. 18H[2]O as precipitating agents and comparing their effect on pH, total dissolved solids [TDS], total suspended solids [TSS], sludge volume and chromium removal. MgO and Ca[OH][2] produced least amount of sludge and dewatering of sludge was also easy as compared to Al[2] [SO[4]][3]. 18H[2]O and NaOH. The chromium removal of MgO and Ca[OH[2] was 95% and 96%, respectively

HBA1c status of diabetic control in urban Faisalabad

Type-2 DM is an epidemic globally and is the major heath problem. Public awareness has lead to increased screening and treatments. But unfortunately, control is very poor overall. People get treatment but do not check the advantages of treatment. To see the success and accuracy of treatment of DM, this study was conducted. Diabetic control was assessed by HBA1C level. Prospective study. Department of Medicine OPD of All major Hospitals Faisalabad. From 01-03-2009 to 14-05-2009. This multicentric was carried out in different hospitals of Faisalabad. Total of 67 patients of both sexes and different age groups with Type-2 DM were evaluated for primary goal of control of DM by measuring HBA1C with point of care [POC] technology. Various secondary features ware also noted. Total n = 67 males = 38 females = 29. Study revealed a poor control in all patients. Mean HBA1C in male was 85% and in female 87%. There were differences in HBA1C as regards to level of education, socio-economic status but there was no difference with regard to truncal obesity and type of transport used. DM control was very poor in all groups with respect to age, sex, and type of treatment. This is a matter of concern both to the patient and their attending physicians. Poor control has far reaching implications to the patients, society, and the family

Comparison of oral versus injectable vitamin-D for the treatment of nutritional vitamin-D deficiency rickets

To assess the safety and acceptability of a single dose of vitamin-D versus the efficacy of injectable Vitamin-D versus oral vitamin-D. Case control. It was carried out at the Department of Paediatrics, Kharadar General Hospital, Karachi, from August 2003 to April 2004. Children of the age of 6 months to 3 years with clinical, biochemical and radiological evidence of vitamin-D deficiency rickets were included. The history, clinical examination, complete blood picture, serum calcium. Phosphorus, alkaline phosphatase and X-ray of wrist joint were done. The children were divided into two groups A and B. Group A was given oral vitamin-D and group B was given intramuscular injection of vitamin-D on the first day and then they were followed for two more visits at 30 and 90 days with clinical, biochemical and radiological examinations to assess the outcome. There were 50 confirmed cases of rickets in each group. The mean age was 10.9 +/- 5.1 months and 14.7 +/- 8.1 months in group A and B respectively. In these children, clinical features were weakness, difficulty in walking, frontal bossing, ribcage deformity and widening of wrist were seen. After one dose of vitamin-D [cholecalciferol], there was appreciable gain of weight and height and raised levels of alkaline phosphatase became normal during follow-up. Radiological florid rickets and non-florid rickets in both groups healed clinically during follow-up period. Oral and injectable forms of vitamin-D [cholecalciferol] were effective but injectable form was shown to be statistically significant. There were no undesirable side effects and both forms of treatment were well-tolerated

Cotton bud for ears - friend or foe?

To study the causes and to evaluate the impact of using cotton bud in the ear in a cross section of population in Karachi. 100 consecutive cases who reported with complaints after using cotton buds for varying durations were selected at the keamari campus of Ziauddin Hospital over aperied of nine months. The ones with active suppurative disease were excluded. Queries were made about the mode and the motives for using cotton buds. Their complaints were registered in detail. They were all subjected to examination for ear with otoscope. A few were examined with microscope. Tuning fork test were done in all the cases. Observations were recorded on a proforma. Prospective observational. January 2007 to November 2007. Majority of cotton bud users belonged to the 11 to 30 years age group and reported usage for months. Among the reported complaints itching and pain dominated followed by feeling of fullness, discharge and hearing impairment. Tenderness of the pinna was observed, while oederna and erythema was the dominant finding [along the external meatus, followed by discharge and skin cracking. Otomycosis was definitely found in 13 cases while foreign bodies [pencil leads and rubber pieces] were detected in the under 10 years age group users. Wax was found in only 4 meati. 44 of the meati did not show any abnormal feature. Tympanic membrane showed perforations of various sizes in 4 of the cases. Hearing was impaired in 30 cases. Use of cotton bud is harmful and unsafe. Awareness about the causes of itching is vital and always necessitates an ear examination. Public knowledge about the possible hazards of using cotton buds should be dispersed on the media

In vitro microscopic analysis of apical 3mm obturation after GT, lightspeed, and profile root canal preparation

To compare the quality of continuous wave obturation technique following preparation of the apical third with three different NiTi rotary instrumentation systems. Mesiobuccal canals of 75 extracted human maxillary and mandibular molars were used in study. After instrumentation 25 canals each with GT ProFile .06 and Light Speed, canals were obturated with continuous wave technique 3-5 mm from the working length. Roots were sectioned at 1mm, 2 mm, and 3 mm from the apex and stained with methylene blue. Two operators evaluated pictures of each section [24X] for obturation quality. Grades of 1 - good adaptation, thin sealer film; 2- irregularities with thick film of sealer separating gutta-percha for up to 1/3 from the canal walls; 3- voids or thick film of sealer separating gutta-percha from the canal walls for more than 1/3 were assigned. The average obturation grade at 1mm was GT= 2.16, ProFile =1.96, LightSpeed =1.80; at 2 mm GT -1.84, ProFile =1.52, LightSpeed =1.52; at 3 mm GT =1.40, ProFile =1.40, LightSpeed =1.20. Overall LightSpeed showed better results but Kruskal-Wallis test showed no differences among groups at all three levels. Statistically significant improvements were revealed in the quality of filling as the distance from the apex increased. Under the conditions of this study, root canals shaped by GT, LightSpeed and ProFiles revealed similar quality of root canal obturation. The quality of root canal obturation improved in all groups as the distance from the apex increased

Giant cell tumours of the maxilla and tibia presenting concurrently as an initial manifestation of primary parathyroid adenoma

A 14 years female of Afghan origin reported with maxillofacial and tibia growths causing progressive deformities since nine months, both were giant cell tumours on histopathology. Serum calcium was normal, but the parathyroid hormone was exaggerated [678pg/ml]. Ultrasound indicated and Tc-99m Setamibi scan confirmed a left lower parathyroid lesion. A 4cm length mass was identified, removed and proved to be a parathyroid adenoma. Two weeks later a subtotal maxillectomy and six weeks later anterior wedge osteotomy of the tibia were carried out. Serum parathyroid hormone level normalized

Critical factors in determining mortality from penetrating abdominal vascular trauma: the Mayo Hospital experience

Mayo Hospital Lahore is a big and busy trauma center in Pakistan that receives a substantial number of patients with penetrating abdominal trauma. Vascular injuries in these patients are not uncommon. They are difficult to repair and are usually associated with a high mortality. The purpose of this study was to review treatment principles, complications and factors affecting the outcome variables in our setup in these cases, the main outcome variable being survival. Complete medical records of 411 patients with penetrating abdominal injuries, operated in our emergency over a four years period [January 1996 - December 1999], were reviewed. Amongst these 57[13.86%] had significant abdominal vascular injuries. The commonest afflicting agents were firearms [81%]. The overall mortality was 31.5%. The highest mortality was associated with retro-hepatic vena caval injuries [66.6%]. Very high mortality rates were seen in patients who were admitted with un-recordable blood pressure [72.2%] and in patients who had combined arterial and venous injuries i.e. more than one abdominal vascular injury [42.8%]. Mortality seems to be directly related to the site of the vascular injury [high for supra-renal / retro-hepatic vena caval injuries], the presence of shock on admission, free bleeding and the lack of retro-peritoneal tamponade at the time of surgery, and the presence of additional vascular injuries. The major cause of death in our patients was profound shock due to uncontrolled bleeding. Early diagnosis, prompt intervention and effective management could result in improved salvage rates

In vitro analysis of tau phosphorylation sites and its biological activity / 中国医学科学杂志(英文版)

<p><b>OBJECTIVE</b>To explore the association between the abnormal phosphorylation sites found in Alzheimer disease (AD) tau and the inhibition of its biological activity.</p><p><b>METHODS</b>Ultracentrifugation, chromatography, manual Edman degradation and autosequence techniques were used to prepare and phosphorylate human recombinant tau, isolate and purify 32P tau peptides and determine phosphorylation sites.</p><p><b>RESULTS</b>Phosphorylation of tau by casein kinase 1 (CK-1), cyclic AMP-dependent protein kinase (PKA) and glycogen synthetase kinase 3 (GSK-3) separately inhibited its biological activity and the inhibition of this activity by (CSK-3 was significantly increased if tau was prephosphorylated by CK-1 or PKA. The most potent inhibition was seen by a combined phosphorylation of tau with PKA and GSK-3. The treatment of tau by PKA and GSK-3 combination induced phosphorylation of tau at Ser-195, Ser-198, Ser-199, Ser-202, Thr-205, Thr-231, Ser-235, Ser-262, Ser-356, Ser-404, whereas Thr-181, Ser-184, Ser-262, Ser-356 and Ser-400 were phosphorylated by GSK-3 alone under the same condition.</p><p><b>CONCLUSION</b>Phosphorylation of tau by PKA plus GSK-3 at Thr-205 might play a key role in tau pathology in AD.</p>

Clinical versus intra-operative staging of T status in the laryngeal cancer: a comparative study

One hundred cases of proven squamous cell carcinoma of the larynx were analysed regarding their pre and post-surgical staging. Clinical underestimation was picked up in 9 cases of advanced lesions which staged as T3 but intra-operatively found to be T4. Clinical over estimation was not recorded in any of the case. In earlier lesions [T1 and T2] no clinical under or over estimation was recorded. Deep extension of the tumour with involvement of thyroid cartilage and extra-laryngeal structures are the commonest cause of clinical under estimation. We suggest that all T3 lesions must be treated by widefield total laryngectomy

Laryngeal involvement in pulmonary tuberculosis

Fifty-one patients with established pulmonary tuberculosis underwent clinical evaluation and endoscopic examination, of the larynx to determine the manifestations of laryngeal involvement. There were 46 males and 5 females [mean age 38 years]. Fever, cough and haemoptysis were the prime pulmonary complaints while hoarseness, weak voice and episodic dyspnoea were the main laryngeal symptoms. Sites of laryngeal lesions included true vocal cords, arytenoids and false vocal cords. Oedema, pallor, ulcers, vocal cord immobility and thickening were the main laryngeal lesions observed. Twenty-four [47%] cases showed morphological changes in the larynx. The presentation pattern was consistent with the classical description and predilection for laryngeal involvement was not demonstrated

Saw-blade: an unusual foreign body in the facial tissue

A 32 year old man was accidentally hit by a broken saw blade on the face. The blade caused a lacerated wound of entry on the cheek. Its impaction was not recognized initially when the wound was sutured. Subsequent cheek swelling and epistaxis prompted him for an ENT consultation. X-rays showed the saw blade lying in the soft tissue of the cheek. Under general anaesthesia, external manipulation showed the edge of the foreign body visible in the nasal cavity below the inferior turbinate. Intranasal removal was successful

Current options in the treatment of laryngeal carcinoma

The incidence rate of carcinoma of larynx varies globally. This malignancy is significant as it has a high rate of cure. Beside other factors topography and the clinical stage of the disease is important to decide the modality of treatment. Supraglottic carcinoma is amenable to treatment either by surgery, radiotherapy or by combining both. Radiotherapy is effective in supragloltic carcinoma in superficial growths only. T1 glottic carcinoma can be treated by radiotherapy, excision, laser evaporation with equivocal results. T2 lesions may be treated by either radiotherapy or hemilaryngectomy with similar outcome. T3 glottic lesion is treatable with radiotherapy and salvage surgery for recurrence. Conservation surgery is also possible for T3 lesions in the recent years. In selected cases partial laryngectomy and radiotherapy may permit preservation of laryngeal function. Total laryngectomy is the mainstay of treatment for T4 lesions along with resection of adnexal areas. Subglotlic cancers are only treatable by total laryngectomy. For transglottic growths partial laryngectomy is only feasible when cartilages are spared. Radiorecurrent growths are now considered amenable to conservation surgery. Induction chemotherapy is useful for tumour regression only in advanced cases. For the nodal disease prophylactic neck dissection has no value now in No status. Radical neck dissection is mandatary once the node figures out. For the relief of airway in advanced disease emergency laryngectomy should be avoided for the danger of stomal recurrence. Among the voice restoration procedures oesophageal speech is the most cost affective

Angiokeratoma tongue

A 4 year old girl from Swat presented with large protruding tongue which has gradually grown in 3 years. The exposed surface was swollen, congested and non tender. A punch biopsy was non diagnostic. Tracheostomy and partial glossectomy was done and revealed it to be a Angiokeratoma;a vascular lesion with hyperkeratosis. Angiokeratoma may be localised or generalised, and may presented in skin, cornea, gingiva and soft palate