Challenges of conducting clinical trials in Asia

Unlike North America and European Union (EU), Asian continent appears to be an ideal destination for conducting cost-effective clinical trials utilizing the pool of treatment naïve subjects. With a population approaching 4.5 billion, recruitment of subjects can be done without a fear of limited patient pool across Asia. The burden of infectious and chronic diseases is also higher in Asian countries. The emerging clinical trial markets particularly China, South Korea, and Taiwan offers genetic diversity in population group, thus promoting the quality and generalizability of clinical trial’s data. Nonetheless, several challenges also exist for the Western sponsors in majority of the Asian countries; regulatory, operational and infrastructural challenges are atthe forefront. Challenges under the heads regulatory, operational, infrastructural, language and cultural, ethics, and future challenges have been discussed. SWOT analysis of Asian clinical trial’s market exhibits enormous opportunities for study sponsorswith manageable threats.

Clinical efficacy of unani herbal formulation garlina against primary hyperlipidemia

Primary hyperlipidemia and atherosclerosis are correlated to each other and these are major cibdutuuibs of coronary artery diseases. The objective of the study was to evaluate the efficacy of polyherbal Unani medicine [Garlina] a well-known herbal formulation to be used for Primary hyperlipidemia. This was an open, randomized, prospective, multicenter study on human subjects of 6 months duration. After the laboratory investigations for fasting plasma lipids of the suspected subjects, 25 subjects were identified, randomized and received the drug. The subjects were diagnosed and classified according to the international recommended levels of plasma lipids [PL] as total cholesterol levels were borderline high [200-239 mg/dL], triglycerides [TGs] were high [200-499 mg/dL], high density lipoprotein [HDL] were desirable but not optimal [41-59 mg/dL] while low density lipoproteins [LDL] were borderline high [130-159 mg/dL]. After 8 weeks administration of Garlina tablets 500 mg twice-a-day, the total cholesterol levels were reduced to 166.48+/- 35.59 mg/dL from 224.04+/-9.16 mg/dL, triglyceride levels were also reduced to 144.28+/- 37.11 mg/dL from 217.28+/-73.54 mg/dL at the base line, low density lipoprotein levels were reduced to S7.52+/-40.17 mg/dL from 133.96+/- 54.00 mg/dL while high density lipoprotein level was increased to 56.20±8.66 mg/dL from 48.28+/-10.57 mg/dL. The findings from this study demonstrated that there was significant difference [p<0.05] before and after treatment with Garlina [500 rqg] as mean lipid profiles of test group administered 1 tablet b.d. after meals. This is clearly evident that Garlina possesses a significant hypolipidemic therapeutic value for the treatment of primary hyperlipidemia

Comparison of large antecubital vein versus small vein on dorsum of hand for the prevention of propofol injection pain

Objective: To evaluate the effectiveness of using two different sizes of veins on upper limb for the prevention of propofol intravenous injection pain

Methodology: This prospective randomized clinical trial was conducted at Department of Anesthesia, King Saud University, Riyadh [KSA] from May 1, 2013 - May 31, 2014. A total of 160 patients, ages between 20-50 years, both male and female, American Society of Anesthesiologist [ASA] class I and II, posted for elective surgery under general anesthesia [GA] were included in the study and were divided into two groups. Patients with known history of allergy to lidocaine or propofol, obese patients, anticipated difficult intubation, already on any analgesics and pregnant patients were excluded from the study. Both groups received an admixture of propofol [1%] - lidocaine [2%] on induction of anesthesia through antecubital vein [Group-1] or through a vein on dorsum of hand [Group-2]. Pain was assessed as none, mild, moderate or severe

Results: Moderate to severe pain on intravenous injection of propofol-lidocaine admixture through antecubital vein and small vein on dorsum of hand was 20% vs 71%

Conclusion: There is marked reduction of pain when propofol - lidocaine admixture was injected through antecubital vein as compared to small vein on dorsum of hand

Non-islanded distally based sural artery flap: a reliable solution for an unreliable flap

Objective: to assess the reliability of non-islanded distally based sural artery flap, in terms of number of flap failure [partial and major flap necrosis], number of surgeries related to the problem for which flap surgery was performed, hospital stay and return to work, for coverage of soft tissue defects of the distal one-third of leg, ankle and heel

Study Design: cohort study

Place and Duration of Study: department of Plastic Surgery and Burn Unit, Mayo Hospital, KEMU, Lahore, Pakistan, from January 2003 to March 2014

Methodology: distally based sural artery flaps in 87 patients requiring coverage of distal lower lumb were studied, retrospectively. They were divided into two groups. G1 included 46 cases in which distally based sural artery flap was islanded. G2 included 41 cases in which flap was not islanded and pedicle was raised. The variables that were measured in two groups included age, gender, size and cause of defect, co-morbidities, number of surgeries, total hospital stay, return to work and flap related complications. Independent sample t-test and tests of proportions were used for comparison with significance at p < 0.05

Results: the mean age of patients was 38.4 +/- 16.2 years in G1 and 35.1 +/- 18.6 years in G2. In G1, 34 cases were traumatic, 5 caused by diabetic ulcers and another 7 cases were trophic ulcers in paraplegic patients caused by pressure sores. In G2, the cause was trauma in 32 cases, diabetic ulcers in 7 cases, trophic ulcers in 2 cases. The mean number of surgeries in G1 was 3 +/- 1 and 2 +/- 1 in G2 [p < 0.001]. The mean hospital stay in G1 was 43.1 +/- 3.6 days while 27.9 +/- 2.1days in G2 [p < 0.001]. There was epidermolysis in 21 out of 46 islanded distally based sural artery flaps [G1] and in 9 out of 41 non-islanded flaps [G2] [p=0.0203]. Partial necrosis occurred in 12 of flaps in G1 and in only 3 of G2 flaps [p=0.024]

Conclusion: distally based sural artery flap can be made more reliable and with lesser complications by raising the pedicle with skin rather than islanding the flap

Operating room [or] utilization and efficiency; a study to find out methods for improvement

Introduction: Operating room [OR] is a key department in any institution and it runs with heavy resources. Improper running carries not only loss of revenue but it also effects patient care. Delays in operating room are deleterious and methods to decrease these delays are important not only for patient care, but to maximize operating room resource utilization

Objective: To determine the causes effecting the OR utilization and efficiency and to find out ways to overcome it. Study Design: Observational Study. Period: 15-01-2011 to 08-06-2011. Setting: King Khalid Hospital, KSA

Patients and Methods: Operating room baseline data was collected for one month and it was compared with historical data of the last six month. Operating room utilization was found to be 41% overall and 34% for elective cases [benchmark 85%]. In patient pathway, on average 17 min were required from call to ward to enter in operating room. First incision time was 11%=8-8:30, 31% = 8:30-9 and 58%= 9+. Cancelation was 9%. Various improvement projects were started including surgical list management, OR rescheduling, start on time dashboard, pre-anesthesia clinic and reinforcement of day surgery program

Results: The results showed 47% improvement in elective OR utilization and OR utilization reaching 69%. There was 76% improvement in emergency case booking and 18% improvement in pre/ post-op process time. There was 64% improvement in 1[st] cases before 9 am

Conclusion: Integrated management working can improve the working and outcome of the operating room resulting in high efficiency and best patient satisfaction

Long term outcome of schizophrenia - a cross-sectional study

Objective: To assess the Positive and Negative Symptoms Scale pattern and World Health Organization Quality of Life-BREF scale scores of patients with schizophrenia after seven years of the initial diagnosis

Study Design: A cross sectional observational study

Place and Duration of Study: Department of Psychiatry, Military Hospital Rawalpindi from Jan 2007 to Dec 2008

Material and Methods: Thirty patients who were invalided out of military service with the diagnosis of schizophrenia in 2000 and 2001 were subjected to psychometric evaluation seven years after the initial diagnosis in 2007 and 2008. They were assessed for their current symptoms and Quality of life using Positive and Negative Symptoms Scale [PANSS] and World Health Organization Quality of Life [WHOQoL-BREF] scale respectively. Both are established psychometric tools to assess the entire spectrum of schizophrenia and quality of life

Result: All patients were males. Forty three percent of the subjects had Positive and Negative Symptoms Scale [PANSS] score i.e. below cut off value of 65. Mean PANSS score of the group was 72. A score of more than 12 on World Health Organization Quality of Life-BREF [WHOQoL-BREF] scale indicating better quality of life was seen in 43 % of the patients. Factors linked with PANSS score > 65 and poor Quality of life [Qol score 4-12] were being single, unemployed, living in cities, using psychoactive substances and in initial years of military service

Conclusion: More than half of the patients with diagnosis of schizophrenia continue to show high Positive and Negative Symptoms Scale [PANSS] score and poor quality of life after seven years of initial diagnosis of schizophrenia

Frequency of systemic risk factors in central serous chorioretinopathy

Objective: to determine the frequency of various systemic risk factors associated with acute central serous chorioretinopathy [CSCR] in our setup

Study Design: descriptive case series

Place and Duration of Study: armed Forces Institute of Ophthalmology [AFIO], Rawalpindi, from July 2011 to June 2014

Methodology: all consecutive patients with acute CSCR who presented in the outpatient department during the study period were recruited. Clinical findings were endorsed on a pre-devised proforma with special emphasis on inquiring about known systemic risk factors for CSCR in detail from each patient. Patients were managed conservatively with control of modifiable risk factors and topical 0.1% Nepafenac eye drops. Analysis of data was done using SPSS version 13.0

Results: forty-four eyes of 42 patients were eligible for final analysis. The mean age of study population was 37.38 +/-6.31 years with 38 [90.47%] male patients. Elevated serum cortisol and serum testosterone levels were found in 3 and 2 patients, respectively. Known systemic risk factors for CSCR were present in 36 [85.71%] patients with emotional stress/psychiatric disorder 15 [35.71%], Type A personality 11 [26.19%], smoking 10 [19.04%], hypertension 5 [11.90%], and acid peptic disease 4 [9.52%] were the most frequently found risk factors

Conclusion: emotional stress/psychiatric illness, hypertension, acid peptic disease and use of exogenous steroids and other medicines are the established risk factors for CSCR that can be modified / withdrawn to reduce the morbidity related to CSCR

Therapeutic implications of Nigella sativa against cancer metastasis

Nigella sativa [N. sativa], remedial usage against different diseases associated with skeleton, cardiovascular, digestive and urinary systems has a long-standing history. At present, efforts are underway to study its effects against various cancers at both the cellular and molecular levels. In this review, the role of active constituents like thymoquinone [TQ] on different types of cancer has been explored. TQ putative involvement in metastasis has been assessed by elucidating its effects on cell proliferation, adhesion, invasion and angiogenesis. Up regulation of caspase 3, Smac and down regulation of p-AKT, p65, XIAP, Bcl-2, COX-2 is also influenced by N. sativa. These findings prove a significant positive correlation between TQ concentrations and induction of apoptosis, decrease in motility and a reduction in invasion and angiogenesis in cancerous cells. However, there are still quite a few unaddressed domains, which need to be understood. One of these may include target specificity of N. sativa against cancerous tissues, mode of administration, dosage and downstream regulators in mediating these effects. In reference to earlier findings and low cost availability, N. sativa may, also, be suggested as either a suitable sole remedy for cancer or as a complementary to ongoing conventional therapy based extensive and rigorous in vivo optimization and validation

ESWL: a Safe modality for treatment of renal stones. a clinical study at kidney center, DHQ hospital, faisalabad

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

Significance of indwelling time for bacterial colonization of double J stents

Objectives: To determine the significance of indwelling time for bacterial colonization of DJ stents by measuring the frequency of bacterial colonization in such stents after endoscopic Urological surgery. Place And Duration: Study was done from September 2014 to November 2015 [15 months] in Department of Urology and Kidney Transplantation, Allied Hospital, Faisalabad

Methodology: 68 patient were included in the study who undergone Percutaneous nephrolithotomy [PCNL] and Ureterorenoscopy [URS] for renal and ureteric stones respectively with DJ stenting. Sterile nature of urine was assured in pre-operative circumstances and patients with active urinary tract infection were excluded from the study. Urinary cultures were performed at 2-4 weeks, 5[th] week and more than 6[th] week of indwelling time and lower end of DJ stent cultures were also performed after removal

Results: 68 patients were included in the study with mean age 48.5 years [20-77 years age limits]. Among 68, 38 were male patients and 30 were female. Percutaneous nephrolithotomy [n = 5] and ureterorenoscopy [n =63] were the procedures after which DJ stenting was performed. Out of 68, 36 patients undergone right sided stenting and 32 patients undergone left side ureteric stenting. Urine culture was positive in 1 [1.47%] case and DJ stent cultures were positive for bacterial colonization in 4 [5.8%] cases. We do not found any statistical association between stent culture analysis and variables like gender, age of patient, or laterality. However we find statistical significance between stent indwelling time and colonization as evident by the results that the rate of colonization was 2.7% when indwelling time was less than 4 weeks, 4% colonization when indwelling time was 5 weeks as compared to 28.5% colonization when indwelling time was more than 6 weeks

Conclusion: These results showed that colonization rates increases when indwelling time increases especially when indwelling time exceeds 6 weeks. This study also refers to the fact that DJ stents can be kept safely for maximum duration of 6 weeks and indwelling time greater than 6 weeks will be associated with complication of urinary tract infection. Moreover this study also showed that one may find an infected colonized stents even if urine culture is negative for any growth

Penile squamous cell carcinoma involving corpus cavernosum in a circumcised male - a case report

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

Analysis of physiological [PAO[2], pulse and blood pressure] changes during modified ECT under general anaesthesia

To study the changes in physiological parameters ie PAO[2], pulse and blood pressure changes during ECT under GA. Quasi-experimental study. Department of Psychiatry and Department of Anaesthesiology, Combined Military Hospital Abbottabad from Sep 2009 to Feb 2010. A total of 50 patients with depression were given four separate ECT sessions each. All patients were anaesthetized using propofol 180-200 mg I/V and suxamethonium 50 mg ie 0.75-1 mg per kg I/V without atropine. They were stratified according to physiological changes including PAO[2], pulse and blood pressure at 1, 2 and 5 min after ECT. Oxygen saturation was measured using a pulse oximeter, which measures saturations in the range of 65-100%. Age range was 19-65 years; mean 46 years [SD +/- 13]. Mean diastolic BP before ECT was 84.72 that decreased post ECT ie 78.02 and 77.46 and 74.44 at interval of 1, 2 and 5 minute respectively. Post-ECT pulse and PAO[2] behaved similarly. Post ECT systolic BP decreased at land 5 minutes. Pulse rate decreased after ECT. ECT under propofol is one of the most effective and safe modality of treatment for psychiatric patients under the supervision of qualified psychiatrists and anaesthesiologists and it gives more stable hemodynamic changes

Metabolic syndrome in patients with schizophrenia

OBJECTIVE: To determine frequency of metabolic syndrome in patients with Schizophrenia, in a tertiary care armed forces setup

STUDY DESIGN: Cross sectional study

PLACE AND DURATION: Department of Psychiatry, PNS SHIFA, Karachi from October 2009 to April 2010

MATERIALS AND METHODS: Fifty six patients with Schizophrenia reporting for management in PNS SHIFA were enrolled as subjects. Demographic variables and other confounding variables were recorded in a structured Performa, Blood Pressure [BP] and Waist Circumference [WC] were measured while Fasting Plasma Glucose [FPG], Triglycerides [TAG] and HDL-Cholesterol [HDL-C] levels were estimated by routine methods in laboratory with quality assurance

RESULTS: More than half i.e.30 [53.6%] of subjects had Metabolic Syndrome [MS] as per ATP IIIA criteria. Further 25% [n=14]of subjects were positive for two components of MS. Low HDL-C levels were most prevalent component followed by hyperglycaemia, hypertriglyceridemia and increased WC while hypertension was least common component

CONCLUSION: Metabolic Syndrome and its various components are frequently co morbidity in patients with Schizophrenia

Development of in-house standard reference material for estimation of metals in whole blood

To develop the standard in order to assure that a test run is valid and results are reliable and the shelf life of the reference material will be at least six months. Quantitative analysis of metals in clinical samples PCSIR Laboratories, Karachi during six months. For this purpose 500ml human blood sample, obtained from blood bank was used to make a reference solution. This solution was prepared by acid digestion. After diluting to an appropriate volume, working solutions were freshly made and calibrated for each metal using the method of standard addition after a certain interval of time. E. Merck stock standards of 1000mg/l, were used for each metal to make the standard addition solutions. Percentage recoveries of standard addition solutions were calculated using the standard formula. The analysis showed that the recoveries of most of the metals for both flame and graphite furnace were found to be within 4% of the actual values. The estimation of elements after an interval of about six weeks [four times] did not showed any difference from the intial concentration. This indicates the reproducibility of the results of metals was satisfactory. Similarly the internal spiking also showed the accuracy and comparability of the results. The prepared reference blood solution can be stored at ambient temperature and used as a reference standard at least for 6 months without change in the concentration of metals. It may be used as reference material if certified reference material is not available

Three years audit of maxillofacial trauma at Abbasi Shaheed hospital, Karachi

The purpose of this retrospective study was to analyze the maxillofacial fractures treated during three years period with special attention to the age, causes, fractures pattern, clinical management and treatment modalities. Retrospective study. This study was carried out Oral and Maxillofacial Surgery Department of Abbasi Shaheed Hospital during the period of January 2008 to December 2010 236 Patients data compiled. The data were reviewed and analyzed in terms of age, gender, aetiology, anatomical site and treatment methods. A total of 236 patients were included in this study presenting with maxillofacial trauma out of these 93.6% were males and 6.4% female .Overall male to female ratio was 15:1.The most common age involved was second decade. The most common cause was RTA [82%] followed by fall [7.2%] and then assault [5.5%]. The fracture of the mandible was the most common constituting about [72.5%] of the maxillofacial fractures followed by Zygomaticomaxillary complex [ZMC] fracture [14.4%] and then Maxilla [5.9%]. Regarding treatment more than 50% patients received ORIF [Open reduction Internal fixation] via bone plates while remaining received MMF [Maxillo-mandibular fixation].In ZMC Fracture, Gillies Temporal approach alone is the most common approach accounting 67% of cases while in Le-forte fracture ORIF constitute the most common treatment method. The causes and pattern of maxillofacial fractures reflect trauma patterns within the community and, as such, can provide a guide for the design of programs geared towards prevention and treatment

Flexor zone 5 cut injuries: emergency management and outcome

To determine the outcome and devise a protocol for emergency management of cut injuries in Flexor Zone 5 of hands. Descriptive study. Department of Plastic Surgery and Burn Unit, Mayo Hospital, KEMU, Lahore, Pakistan, from January 2009 to March 2013. All patients above 12 years of age with single sharp cut injuries in Flexor Zone 5, with no skeletal injuries, presenting within 12 hours in emergency were included with follow-up of 6 months, with active range of motion evaluated by Strickland's adjusted formula. Power of opponens pollicis and adductor muscles was evaluated from P0-4. Nerve repair results were evaluated serially by advancing Tinnel's sign, electrophysiological studies and sensory perception scored from S0-4 compared to the normal opposite upper limb. The study group comprised of 31 patients [M: F = 2.4: 1]. Average age was 27 years ranging from 17 - 53 years. In 25 [80%] cases, injury was accidental, in 3 [10%] homicidal and in 3 [10%] injury was suicidal. Four most commonly involved structures included Flexor carpi ulnaris, ulnar artery, ulnar nerve and Flexor digitorum superficialis. Median nerve and radial artery were involved in 10 cases each, while ulnar artery and ulnar nerve were involved in 14 cases each. Longtendons were involved in most cases with greater involvement of medial tendons. None of the patients required re-exploration for ischaemia of distal limb while doppler showed 22 out of 24 vascular anastomosis remained patent. Recovery of long-tendons was good and recovery after nerve repair was comparable in both median and ulnar nerves. Early and technically proper evaluation, exploration and repair of Zone 5 Flexor tendon injuries results in good functional and technical outcome

Comparison of nasal patency following submucosal diathermy of inferior turbinate versus inferior turbinectomy

To compare the nasal patency following sub mucosal diathermy [SMD] of inferior turbinate and inferior turbinectomy [IT]. Randomized controlled trial. Department of ENT Combined Military Hospital Rawalpindi. Study was completed in one year from 15[th] September 2009 to 15[th] September 2010. Total 160 patients with symptomatic inferior turbinate hypertrophy were included in the study. Patients were randomly divided into two groups of 80 each using random numbers table. Group A underwent submucosal diathermy [SMD] of inferior turbinate where as Group B underwent inferior turbinectomy [IT]. Post-operative nasal patency was judged after 03 weeks by visual analog scale [VAS]. Both the groups are comparable with respect to age and gender. Post-operative nasal patency is significantly better in group B as compared to group A. IT is a more effective method to improve nasal patency as compared to SMD in case of inferior turbinate hypertrophy

First cancer statistics report from Hazara division

'Cancer' is on rise globally. Cancer registry is vital for policy making, resource allocation, progress tracking and overall cancer control. In Pakistan, cancer prevention, screening and standardised clinical trials, as well as quality assurance through surveillance are badly hampered due to the lack of a National Cancer Registry. For Pakistan a well-integrated system of Cancer Registry is need of the day. This retrospective study was conducted on the hospital records at the Oncology Department of Ayub Teaching Hospital, Abbottabad from year 2007-12. Data were collected through a standard data capture form with a final figure of 555 patients. The malignancies were diagnosed clinically and histopathologically at different laboratories of Pakistan. Among these cases, 54.08% were male and 45.92% female. Incidence of cancer in patients below 14 years age was 8.47% and 91.53% above 14 years. Majority [31.95%] cases were from Mansehra followed by Abbottabad with 27.08% and Haripur 14.26% cases. Leukaemias were at top with 15.14% cases followed by breast carcinoma [13.69%], Lymphomas [12.07%], ovarian carcinomas [8.65%], and gastric carcinoma and skin cancers with 2.70% each. Among men, the highest incidence was of Hodgkin's lymphoma [14.9%] followed by lymphocytic leukaemia [14.3%]. Prostate cancer was seen in 8.3% male patients. Another 5.7% patients had lung cancer. In women, the highest incidence was carcinoma breast [19.7%] followed by ovarian carcinoma [13.4%], leukaemia [9.7%], and Hodgkin's lymphoma [4.3%]. A variety of cancers are prevalent in the indigent population. Record-keeping in wards is sub-optimal. Commonest cancers in the area have slight differences with rest of the country

Vitamin D supplement as an adjuvant in the management of chronic musculoskeletal pain

Vitamin D deficiency has been implicated in chronic musculoskeletal pain. This article reviews two cases of improvement/ resolution of chronic pain after vitamin D repletion in a pain practice setting in Lahore. Vitamin D insufficiency is common and its repletion may improve chronic musculoskeletal pain and improve quality of life. In some cases, it may result in complete resolution of symptoms. We observed 521 patients over a period of 1 year, of which 2 patients are described in detail. Written informed consent was taken from the patients to publish this report