Herpes Zoster During Immunosuppressive Therapy For Autoimmune Diseases.

BACKGROUND: Patients on immunosuppressive therapy are at a greater risk for herpes zoster reactivation and are more likely to have adverse outcomes. Propylactic antivrials and vaccinations may potentially prevent these complications. METHODS: Medical literature addressing the clinical course and therapy of herpes zoster in patients receiving immunosuppressive therapy for autoimmune disorders, and the roles of anti-viral prophylaxis and vaccination was reviewed. Research databases including PubMed, Ovid, Medline, Google Scholar and Cochrane were utilized. RESULTS: Acyclovir and its derivatives are most commonly used in this setting for treatment and reduction of post-zoster complications. Foscarnet may be used for acyclovir-resistant strains. At both conventional and ultralow doses, acyclovir has proven effective when used as prophylaxis, reducing the incidence of zoster and its complications in immunosuppressed patients. Additionally, ultra-low doses are associated with significantly reduced side effects. The zoster vaccine, Zostavax, a live-attenuated vaccine has shown promising results in several clinical trials. However, live-attenuated vaccines should be cautiously used in immunosuppressed patients. For patients who require immunosuppressive therapy, vaccination 2-3 months prior to therapy may be appropriate. CONCLUSIONS: Prophylactic antiviral therapy and vaccination help significantly reduce morbidity and mortality from zoster reactivation in patients receiving immunosuppressive therapy.

Effectiveness of behavioural management on migraine in adult patients visiting family practice clinics: a randomized controlled trial.

OBJECTIVES: To assess the effectiveness of behavioural management in the treatment of migraine among adult patients. METHODS: The randomised control trial was conducted from August 2011 to August 2012 at the Aga Khan University Hospital, Karachi, in which adult patients aged 18-65 years were recruited with diagnosis of migraine from five outpatient sites. The patients were randomised into 2 equal groups. The controls were given pharmacological treatment, while the cases were given a structured behavioural management and pharmacological treatment. Primary outcome was the change in frequency of migraine attacks. Secondary outcome included change in severity of migraine and effect on the quality of life. SPSS 19 was used for statistical analysis. RESULTS: Of the 90 subjects in the study, 72 (80%) were female. A significant reduction in the average frequency of migraine attacks was observed from baseline up to 4 weeks (p < 0.001) but no difference in the mean migraine attacks was observed in the two groups (p < 0.945). In the average score of severity of pain, significant reduction was observed for time (p < 0.001) as well as for the intervention status (p < 0.034). There was no significant difference (p < 0.450) between treatment type and duration of migraine, but a significantly better quality of life (p < 0.001) was observed in the trial group compared to the controls. CONCLUSION: There was significant decrease in frequency, severity and duration of migraine attacks in the trial group compared to the control group. The quality of life also showed improvement in the trial group.

Hepatocellular carcinoma in Native South Asian Pakistani population; trends, clinico-pathological characteristics & differences in viral marker negative & viral-hepatocellular carcinoma.

BACKGROUND: HCC is the fifth most common cancer globally. Our study was conducted to (1)investigate the trends and clinico-pathological characteristics of Hepatocellular carcinoma among native South Asian patients in Pakistan, (2)to estimate the prevalence as well as the trends of viral marker negative HCC and (3) to compare the clinico-pathological, radiological characteristics, applicability of treatment at diagnosis and prognostic factors among patients with both viral marker negative and viral marker positive-HCC being consulted at Aga Khan University Hospital(AKUH), Karachi, Pakistan. METHOD: Patients ≥18 years, already diagnosed to have HCC and visiting AKUH during 1999-2009 were identified using ICD code 1550. The diagnosis of HCC was made in the presence of characteristic features of HCC on triple-phasic CT scan/MRI or with histological findings on biopsy. RESULTS: 645 patients were enrolled. Of these 546(84.7%) were viral-HCC and 99(15.3%) were viral marker negative HCC. Among viral-HCC group underlying etiology of cirrhosis was HCV in 67.9%, HBV in 21.8% and concomitant HBV with HCV or HDV in 10.3% cases. Majority (62.8%) patients had advanced HCC. Larger tumor size (p < 0.001), shorter duration between diagnosis of cirrhosis and HCC (p 0.03), concomitant Diabetes Mellitus (p < 0.001) were found significant factors associated with viral marker negative HCC. CONCLUSION: The burden of hepatocellular carcinoma is rising among native South Asian Pakistani population and the viral marker negative HCC are not uncommon in our population. Viral marker negative HCC tend not to be under surveillance as compared to viral-HCC and are diagnosed mostly at advanced stage & when they became symptomatic.