Role of Simulated Training for Carotid Endarterectomy: A Systematic Review

Vascular surgery trainees often do not get to perform carotid endarterectomy (CEA) directly on the patients as it requires meticulous surgical technique and has a high risk of procedure-related complications. Hence, the role of simulation in training future vascular surgeons becomes essential. This review aims to assess the types and utility of simulators available for CEA. In this systematic review, all the studies performed on CEA simulation were included. The purpose of this review was to assess different types of simulators and their usefulness for CEA. We identified 122 articles, of which 10 were eligible for review. A variety of simulators, ranging from animal models, virtual reality simulators and commercially designed models with high fidelity options were used. Technical competence was the major domain assessed in the majority of the studies (n=8), whereas four studies evaluated anatomical and procedural knowledge. Blinding was done in five studies for assessment purposes. The majority of studies (n=9) found the simulation to be an effective tool for achieving technical competence. This review shows the potential usefulness of simulation in acquiring technical skills and procedural acumen for CEA. The available literature is unfortunately too diverse to have a common recommendation.

Evaluation of Early Renal Involvement in Essential Hypertension by Measuring Urinary Biomarkers

Hypertensive kidney damage results in glomerular as well as tubular dysfunction. Albuminuria is a well-known marker of glomerular damage. On the other hand, urinary uromodulin is increasingly considered as a potential biomarker of early tubular dysfunction. The aim of the study was to assess glomerular and tubular function of the kidney by measuring urinary albumin and uromodulin excretion in hypertensive subjects. This cross-sectional study was conducted from July 2018 to June 2019 in Hypertension Clinic of Dhaka Medical College Hospital, Dhaka and Kidney Care and Research Centre, Sonargaon, Narayanganj, Bangladesh. In this study 122 hypertensive subjects with age >30 years, duration of hypertension <5 years, without accelerated or malignant BP, absence of dipstick proteinuria and eGFR >60ml/min were included. There were also 33 normotensive individuals included as healthy controls. Albumin-creatinine ratio (uACR mg/g), urine uromodulin-creatinine ratio (uUMODμg/g), urinary sodium-creatinine ratio (mEq/g) and potassium-creatinine ratio (mEq/g) were measured from single morning spot urine sample. Urinary uromodulin levels were measured by ELISA method. The hypertensive and normotensive subjects were age matched 49.0±12.0 vs. 48.0±11.0, years (p=NS). The mean uACR was 29.0±65.0 versus 5.6±2.7mg/g, (p<0.001) respectively. The median uUMOD in hypertensive subjects was 3.38 (1.73-9.06) and in normotensives 3.85(2.28-5.69) μg/g (p=non significant). Multivariate analysis showed significant inverse association between diastolic blood pressure and urinary uromodulin excretion. A uUMOD cut-off of 2.9 (25th percentile) showed eGFR, urinary sodium and potassium excretions were significantly lower at low uromodulin group. The glomerular involvement was found in 21.0% of hypertensive subjects as evidenced by albuminuria. No difference was observed in urinary uromodulin level between hypertensive and normotensive subjects. Low urinary uromodulin level was associated with lower eGFR, Na+ and K+ excretion which indicate simultaneous tubular and glomerular involvement.

The Use of Formative Assessment in Postgraduate Urology Training: A Systematic Review

Formative assessment is an essential component of surgical training. However, it is not usually a mandatory component in postgraduate curricula. The purpose of this study is to identify and evaluate how formative assessments are integrated into postgraduate urology training in programs across the globe. This study consisted of a systemic review to see how formative assessments are being implemented in various urology programs globally. A total of 427 articles were identified for the literature review. Of these, only 10 were included and critically appraised. These studies explored various techniques for exploration of formative assessments in urology training programs, which included established tools, such as portfolio reviews, and direct observations of procedure skills (DOPS); novel tools, including the Dutch urology practical skills (D-UPS) program and Ottawa surgical competency operating room evaluation (O-SCORE); and curricular models. Nine of the 10 articles favored their potential utility in formative assessments. Current literature involving formative assessments in postgraduate urology programs is scarce, and available resources have a high heterogeneity between them. More structured formative assessments need to be incorporated into surgical training programs, and affiliated training institutions should be encouraged to integrate them into their curricula.

COVID-19 pandemic in Uttarakhand, India: Environmental recovery or degradation?

The human coronavirus disease-2019 (COVID-19) caused by SARS-CoV-2 is now a global pandemic. Personal hygiene such as hand-washing, the use of personal protective equipment, and social distancing via local and national lockdowns are used to reduce the risk of transmission of SARS-CoV-2. COVID-19 and the associated lockdowns may have significant impacts on environmental quality and ergonomics. However, limited studies exists on the impacts of COVID-19 and the associated lockdowns on environmental quality and ergonomics in low-income settings. Therefore, the present study investigated the impacts of the COVID-19 outbreak on socioeconomics, ergonomics and environment (water quality, air quality and noise) in Uttarakhand, India. Approximately 55% of respondents experienced headaches, and the other common health-related issue was back pain, with 45% of respondents having problems with their backs. Water and air quality significantly improved during the lockdown relative to the pre-lockdown period, but was observed to return to their previous characteristics afterwards. Lockdowns significant increased the concentration of indoor air pollutants while noise pollution levels significantly declined. In summary, lockdowns have adverse impacts on ergonomics, resulting in work-related human health risks. The impacts of lockdowns on environmental quality are mixed: temporary improvements on water and air quality, and noise reduction were observed, but indoor air quality deteriorated. Therefore, during lockdowns there is a need to minimize the adverse environmental and ergonomic impacts of lockdowns while simultaneously enhancing the beneficial impacts.

Magnitude of unreported kala-azar cases in a highly endemic district of Bihar, India: A positive impact of Indian elimination programme

BACKGROUND & OBJECTIVES

In India, kala-azar surveillance is weak and no public-private partnership exists for disease containment. Estimate of disease burden is not reliably available and still cases are going to private providers for the treatment. The present study aimed to assess the magnitude of kala-azar cases actually detected and managed at private set-up and unreported to existing health management information system.

METHODS

Institution based cross-sectional prospective pilot study was conducted. List of facilities was created with the help of key informants. The information about incidence of kala-azar cases were captured on monthly basis from July 2010 to June 2011. Rapid diagnostic strip test (rk-39) or bone marrow/splenic puncture were applied as laboratory methods for the diagnosis of kala-azar. Descriptive statistics as well as chi-square test for comparison between proportions was conducted.

RESULTS

Overall availability of private practitioners (PPs) was 4.59/1,00,000 population and maximum PPs (46; 93.9%) were from qualified category. The median years of medical practice was 25 yr (inter quartile-range [18, 28]). Interestingly, only a small proportion (240; 19%) of cases was managed by PPs. Amongst the PPs, only low proportion (32; 18.2%) managed >2 cases per month. The mean number of kala-azar suspects and cases identified varied significantly between different PPs' professions with p <0.048 and p <0.032, respectively. A highly significant difference (p <0.0001) was observed for kala-azar case load between qualified and unqualified practitioners. A small proportion (38; 15.8%) of kala-azar cases was not present in the public health system record.

INTERPRETATION & CONCLUSION

Still sizeable proportions of cases are going to PPs and unrecorded into government surveillance system. A mechanism need to be devised to involve at least qualified PPs in order to reduce treatment delay and increase case detection in the region.

Assessment of environmental and ergonomic hazard associated to printing and photocopying: a review

"Knowledge is power" and distribution of knowledge is fueled by printing and photocopying industry. Even as printing and photocopying industry have revolutionized the availability of documents and perceptible image quickly at extremely inexpensive and affordable cost, the boon of its revolution has turned into a bane by irresponsible, uncontrolled and extensive use, causing irreversible degradation to not only ecosystem by continuous release of ozone and other volatile organic compounds (VOCs) but also the health of workers occupationally exposed to it. Indoor ozone level due to emission from different photocopying equipment's increases drastically and the condition of other air quality parameters are not different. This situation is particularly sedate in extremely sensitive educational and research industry where sharing of knowledge is extremely important to meet the demands. This work is an attempt to catalogue all the environmental as well as health impacts of printing or photocopying. It has been observed that printing/photocopying operation is a significant factor contributing to indoor air quality degradation, which includes increase in concentration of ozone, VOCs, semi-volatile organic compounds (SVOCs) and heavy metals such as cadmium, selenium, arsenic, zinc, nickel, and other pollutants from photocopy machines. The outcome of this study will empower the manufactures with information regarding ozone and other significant emission, so that their impact can be reduced.

Multiple Skip Incisions Versus Single Long Incision for Single-stage Basilic Transposition Arteriovenous Fistula: A Cohort Study

BACKGROUND

Basilic vein transposition via single long incision is a renowned technique despite its known wound-related complications. Contrary to that, multiple skip incisions technique is thought to have relatively lower wound-related complications. But to the best of our knowledge, these 2 techniques have never been formally compared. Therefore, we conducted this study to compare both.

MATERIAL AND METHODS

This was a retrospective cohort study. Patients who underwent basilic vein transposition arteriovenous fistula (AVF) from January 2011 till May 2016 at Aga Khan University Hospital, Pakistan were eligible for inclusion in the study. Study population was divided into 2 groups; one group comprising of patients who underwent fistula formation through single long incision and the other group had the procedure carried out via multiple skip incisions. Wound-related complications including wound infection and dehiscence, fistula maturation time, duration of surgery, and primary patency at a follow-up of 12 months were recorded.

RESULTS

Both the groups were comparable regarding baseline variables. Incidence proportion of wound infection, hematoma, and dehiscence was higher in long incision group; however, it was statistically insignificant. Primary patency at 12 months in skip versus long incision group was 73.0% vs. 69.7% (P-value: 0.62). The mean maturation time for fistula was 42.8 ± 9.5 days and 44.3 ± 10.4 days in skip and long incision group, respectively (P-value:0.31). Duration of surgery was comparable in both.

CONCLUSIONS

Although skip technique does not have significant benefit over long incision technique based on these results, but it is a valid alternative. Randomized control trial is required to better differentiate between these two.

Predictors for the development of post-thrombotic syndrome in patients with primary lower limb deep venous thrombosis: A case-control study

Introduction Post-thrombotic syndrome is a common and debilitating sequelae of lower limb deep venous thrombosis. Very little awareness is present about the risk factors and about the diagnosis, prevention, and treatment of this condition. Objective The objective of this study is to identify the predictors of post-thrombotic syndrome after lower limb deep venous thrombosis. Materials and methods A case-control study was conducted on all adult patients who were admitted with lower limb deep venous thrombosis at our institution from January 2005 to June 2012. These patients were scheduled for a research clinic visit, which included informed consent, data collection, and physical examination. Patients found to have post-thrombotic syndrome served as cases and those without post-thrombotic syndrome served as controls. Villalta scoring system was used to diagnose the post-thrombotic syndrome and then to assess the severity of the condition in both the groups. Cox regression risk factor analysis was performed to identify the predictors of post-thrombotic syndrome. Results Out of the 125 patients examined, 49 were found to have post-thrombotic syndrome. Risk factors found to be significant were body mass index of more than 35 kg/m² ( n = 13, p = 0.003), history of immobilization ( n = 19, p = 0.003), one or more hypercoagable disorders ( n = 32, p = 0.02), iliofemoral deep venous thrombosis ( n = 18, p = 0.001), complete obstruction on ultrasound ( n = 26, p = 0.016), unstable range of international normalized ratio ( n = 23, p = 0.041) and non-compliance for the use of compressions stockings ( n = 14, p = 0.001). On multivariate analysis, one or more hypercoagable disorder, iliofemoral deep venous thrombosis, and non-compliance to the use of compression stockings were found to be independent risk factors for the development of post-thrombotic syndrome. Conclusion One or more hypercoagable disorders, iliofemoral deep venous thrombosis and non-compliance to the use of compression stockings were independent predictors of post-thrombotic syndrome after deep venous thrombosis. These findings will help prognosticate and prevent development of PTS in similar patient populations.

Pacemaker placement and shoulder surgery: is there a risk?

INTRODUCTION

Surgery to the anterior aspect of the shoulder is performed by many surgical specialties but the techniques used by our cardiology colleagues for insertion of cardiac pacemaker wires are often not appreciated by the surgical community. The deltopectoral approach has been used for open pacemaker wire insertion for many years by cardiologists.

METHODS

We surveyed a group of subspecialty shoulder surgeons as well as orthopaedic trainees to see if this approach for pacemakers is well recognised. We tried to assess what level of knowledge exists regarding pacemaker placement in general as well as specific risks.

RESULTS

There appears to be a paucity of knowledge regarding pacemaker placement and related patient safety issues in both surveyed groups. There was no difference between the two groups, suggesting that the level of knowledge does not increase with experience and specialisation.

CONCLUSIONS

There is the potential to cause harm to patients if the insertion site and type of device is not identified before commencing surgery in this region and steps must be taken to minimise any intra-operative risk. There is a risk from direct injury to the pacemaker and/or leads as well as the hazards of using diathermy in close proximity to a pacemaker. There must be more widespread dissemination of this information in order to minimise risks to patients with pacemakers in situ.

Asymptomatic infection of visceral leishmaniasis in hyperendemic areas of Vaishali district, Bihar, India: a challenge to kala-azar elimination programmes

A cohort of 91 asymptomatic individuals with visceral leishmaniasis (VL) were identified during base line screening using recombinant 39-aminoacid antigen (rk-39) and polymerase chain reaction (PCR) conducted from December 2005 to June 2006 involving 997 individuals of two highly endemic villages of Vaishali district, Bihar. The point prevalence of asymptomatic infection was 98 per 1000 persons at baseline. There was no statistically significant difference between rk-39 and PCR positivity rate (P>0.05), even though PCR positivity alone was found significantly higher (4.2%) than rk-39 positivity alone (2.6%). The monthly follow-up of the asymptomatic cohort revealed a disease conversion rate of 23.1 per 100 persons within a year. There was a statistically significant difference in conversion of disease when individuals were positive by both tests as compared to single tests by rk-39 and PCR (P<0.01). Disease conversion rate in the subjects residing in households with a history of VL (62%, 13/21) was higher than those residing in the households without a history of VL (38%, 8/21). Most of the identified asymptomatic individuals were from low socio-economic strata similar to that of VL cases in general. Apart from rk-39, PCR may be considered for screening of asymptomatic Leishmania donovani infection in large-scale epidemiological studies. Screening of asymptomatic cases and their close follow-up to ascertain early detection and treatment of VL may be considered in addition to the existing VL control strategies.

Imaging characteristics of primary laryngeal lymphoma

BACKGROUND AND PURPOSE

The larynx is a rare site for primary NHL. Fewer than 100 cases have been reported in the literature, with the largest imaging review involving only 4 patients. We describe the findings of laryngeal lymphoma on CT, PET, and MR imaging and identify features that may distinguish laryngeal lymphoma from the far more common laryngeal squamous cell carcinoma.

MATERIALS AND METHODS

Multi-institutional retrospective chart review revealed 20 patients with histopathologically proved laryngeal lymphoma. Pretreatment CT, PET, and MR images were reviewed by a head and neck radiologist, focusing on extent of tumor, cervical lymph node involvement, and enhancement patterns.

RESULTS

Patients ranged from 30 to 90 years of age with a mean of 63 years at the time of initial diagnosis and a 2:1 female predominance. The average tumor size was 37 +/- 19 mm. In all patients, laryngeal lymphoma involved the supraglottis but also extended into the glottis (65%) and hypopharynx (60%). The subglottis was less frequently involved (35%). Laryngeal cartilage invasion and cervical lymphadenopathy were each seen in 20% of patients. Lymphoma was consistently FDG-avid (100%) and usually enhanced uniformly with iodinated contrast (73%). Necrosis and calcification were not seen in any cases.

CONCLUSIONS

Although laryngeal lymphoma is rare, particular imaging features suggest this diagnosis. A large uniformly enhancing supraglottic tumor without central necrosis and without cervical lymphadenopathy is a characteristic finding of lymphoma. Similar to squamous cell carcinoma, lymphoma may extend into the subglottis, pharynx, and laryngeal cartilages.

Awareness about kala-azar disease and related preventive attitudes and practices in a highly endemic rural area of India

This study was undertaken to assess the extent of community awareness and related practices about kala-azar undertaken by them to control the disease, in an highly endemic focus of Bihar, India. A household-based cross-sectional knowledge, attitude, and practices (KAP) survey consisting of quantitative components on knowledge, attitude, and practices concerning kala-azar was administered to heads-of-household through a semi-structured questionnaire. Data indicated that 61% respondents were illiterate, 4% had correct knowledge that sandfly bites caused kala-azar, 26% do not know any specific transmission agents for kala-azar. A majority (72%) of respondents were not able to recognize sandfly, 33% had no specific knowledge about the symptoms. All of them (100%) believed that this disease could affect his or her family income. Nearly all (95%) were positive that the kala-azar cases could be reduced with implementation of proper health measures. A few (11%) suggested isolation of patients to avoid contacting kala-azar while a high proportion (93%) of respondents favored specific allopathic medicine, and a majority (72%) favored the utilization of the services offered by primary health centers or government hospitals. Just over half (66%) of the respondents were not using any prevention measures to avoid contacting disease. These results could prove to be useful for health planners in developing suitable control strategies.

Stem cells for tendon and ligament tissue engineering and regeneration

Tendons and ligaments are frequently injured. Due to their relatively avascular nature, repair is slow and often incomplete. Stem cells offer a new approach to augment healing of native tissues, as well as providing materials to surgically replace injured structures that are beyond repair. Here we discuss the various roles of stem cells in natural repair processes compared to engineered tissues to assist healing or replace tissues.

Knowledge about sandflies in relation to public and domestic control activities of kala-azar in rural endemic areas of Bihar

Visceral Leishmaniasis (VL) control is a global cause of concern. To identify the gaps in People's knowledge/awareness about sand flies and control activities of kala-azar in rural endemic areas of Bihar, this study consisting of 450 respondents with 288 male and 162 female was carried out. The result showed that 95% respondents had heard about the disease up to some extent, but majority respondents were neither aware about the vector of kala-azar, nor they had any idea about transmission of the disease. About 61% had wrong impression that mosquitoes were causing kala-azar. Regarding knowledge about breeding and resting sites of vectors, 20% reported cattle shed, 16% crevices in the household followed by 15% damp dark places. The attitude of respondents towards vector control programme was poor, as 99% lost faith in the DDT spraying because of ineffectiveness, like no reduction in mosquito nuisance. Bed net was considered the best protection method against sand fly or mosquito nuisance but the cost was considered the major constraint in its use. Proper health education programme in Simple and local language along with visual demonstration should be promoted to enhance the awareness and co-operation at community level.

Erythrocyte sedimentation rate in healthy first year medical students

OBJECTIVE

To determine the reference value of erythrocyte sedimentation rate (ESR) in young healthy individuals following the standardized criteria of the International Committee for Standardization in Hematology.

METHODS

The ESR was determined in a sample of 422 medical students of Karachi, Pakistan from the year 1998 to 2004. After considering exclusion criteria, the data of 311 students (132 males and 179 females) were analyzed.

RESULTS

The reference values found in this study are 0-13 in the 1st hour for healthy young males and 0-40 mm in the 1st hour for healthy young female students.

CONCLUSION

We suggest that the reference values for ESR should be determined for various segments of the local population.

A pilot study on the status of lymphatic filariasis in a rural community of Bihar

A pilot study of lymphatic filariasis was conducted in two contiguous villages of Patna district in Bihar situated at the side of the river Ganges, known to be endemic for lymphatic filariasis, to study present status of transmission parameters of filariasis. Of the 1872 persons examined, 8.4% were found asymptomatic but microfilaraemic. Morbidity pattern due to filarial infection showed an increase with advancement of age and significantly high in males as compared to female (p < 0.001). Acute and chronic filarial disease was observed as 0.5% and 9% respectively. Microfilaria was found in 10% of acute and 11.2% of chronic filarial cases. The Mf rate was found to be 9.9% in males and 9.0% in females respectively. The parasite species was identified as W. bancrofti. The vector fauna surveyed show highest prevalence of vector species of Cx. quinquefasciatus (43%) in both domestic as well as predomestic area in the community. Other species like Cx. vishnui and Ma. uniformis were also seen. Each household and predomestic area was searched for mosquito fauna at night. The infection rate in vectors was found to be 14% and infectivity rate (L3) was 8%. The filariasis cases detected in the study were treated with 12 days course of DEC 6 mg/kg body weight.

Visceral leishmaniasis and tuberculosis in patients with HIV co-infection

We describe here two cases, one male and one female, both age 40 years, with visceral leishmaniasis and HIV-1 co-infection. The female patient had features of Koch's abdomen. The male patient had features of tuberculous lymphadenitis and bilateral pleural effusion more marked on the right side. Both were treated with highly active antiretroviral therapy, antituberculous drugs, antibiotics, antifungal medicine (fluconazole) and miltefosine. Both patients showed marked improvement with therapy.

Prevalence of exercise-induced bronchospasm in national hockey players of Pakistan

OBJECTIVE

To determine prevalence of Exercise-induced Bronchospasm (EIB) in hockey players, who had represented or were aspiring to represent Pakistan at international level.

METHOD

An observational, cross-sectional study was done on the prevalence of EIB in national hockey players of Pakistan. All participants of the training camp (n = 27) players were included in this study, after obtaining permission from the Pakistan Hockey Federation. An acquaintance session was conducted to introduce the study, and for the correct recording of Peak Expiratory Flow (PEF) rate. On field-testing day, pulse and PEF rates were measured first without any exercise and warm up (pre-exercise PEF rate). After competitive 6 minute (6-min) field free running, pulse rate was measured to ensure that players heart rate has reached 70% of the predicted maximum heart rate. PEF and pulse rates were measured at 5-min, 15-min and 30-min post exercise. A player was considered EIB positive based on a post exercise decrement in PEF rate > or = 15% at any defined point of time.

RESULTS

Twenty-seven players participated in our study out of which 5 players (19%) had EIB.

CONCLUSION

Our findings indicate that a significant number of cases of EIB exist among national field hockey players. We suggest that active screening for EIB should be made part of training sessions, so that performance of players could be enhanced. Diagnosed cases should be treated as per the guidelines laid down by International Olympic Committee Medical Commission.

Relation of body mass index with lipid profile and blood pressure in young healthy students at Ziauddin Medical University

BACKGROUND

This study was conducted to assess serum lipids in healthy young subjects in relation with their BMI.

METHODS

Students of Ziauddin Medical University were assessed for anthropometric measures, blood pressure and lipid profile at the time of their admission for MBBS program.

RESULTS

Out of 426 students all parameters were available for 301 students and they were selected for analysis in this study. Mean serum cholesterol in 301 students was 149.3 +/- 31.3 mg/dl, mean LDL-C was 91.3 mg/dl +/- 27.7, mean HDL-C was 40.0 mg/dl +/- 42.2. mean triglycerides were 89.9 mg/dl +/- 42.2. mean systolic blood pressure was 113.1 mmHg +/- 13.5 and mean diastolic blood pressure was 74.0 mmHg +/- 8.1. The mean BMI of students was 21.6 Kg/m2 +/- 4.2. Among 301 students, 88 were underweight, 175 were normal and 38 were overweight according to their BMI. We found no significant difference in mean serum cholesterol and LDL-C while there were significant difference in mean serum HDL-C, triglycerides, systolic and diastolic blood pressure among the three BMI groups.

CONCLUSION

In our study, there are high numbers of at-risk individuals. Therefore, strategies should be designed for weight reduction in children and adults to prevent cardiovascular disease.

Staging quality is related to the survival of women with endometrial cancer: a Scottish population based study. Deficient surgical staging and omission of adjuvant radiotherapy is associated with poorer survival of women diagnosed with endometrial cancer in Scotland during 1996 and 1997

The association between treatment variation and survival of women with endometrial cancer was investigated. A retrospective cohort based upon the complete Scottish population registered on in-patient and day-case hospital discharge data (Scottish Morbidity Record-1) and cancer registration (Scottish Morbidity Record-6) coded C54 and C55 in ICD10, between 1st January 1996 to 31st December 1997 were analysed. Seven hundred and three patients who underwent surgical treatment out of 781 patients that were diagnosed with endometrial cancer in Scotland during 1996 and 1997. The overall quality of surgical staging was poor. The quality of staging was related to both the year that the surgeon passed the Member of the Royal College of Obstetricians and Gynaecologists examination and also to 'specialist' status but was not related to surgeon caseload. Two clinically important prognostic factors were found to be associated with survival; whether the International Federation of Obstetrics and Gynaecology stage was documented, RHR=2.0 (95% CI=1.3 to 3.1) and also to the use of adjuvant radiotherapy, RHR=2.2 (95% CI=1.5 to 3.5). The associations with survival were strongest in patients with advanced disease, International Federation of Obstetrics and Gynaecology stages 1C through to stage 3. Deficiencies in staging and variations in the use of adjuvant radiotherapy represent a possible source of avoidable mortality in patients with endometrial cancer. Consequently, there should be a greater emphasis on improving the overall quality of surgical staging in endometrial cancer.

A randomized clinical trial of low dosage combination of pentamidine and allopurinol in the treatment of antimony unresponsive cases of visceral leishmaniasis

OBJECTIVES

A randomized clinical trial of low dosage combination of pentamidine and allopurinol was carried out with objectives to assess the efficacy and toxicity as compared to full dosage of pentamidine in antimony unresponsive visceral leishmaniasis (VL) patients.

METHODS

Using a randomized control clinical trial, a total of 158 antimony unresponsive patients of VL were randomly allocated into two treatment groups. Patients in one group (n=80) received half the dosage of pentamidine i.e. 2 mg/kg body weight by IM route on alternate day and allopurinol in dose of 15 mg/kg body weight in three divided dosages for 30 days; patients in the second group (n=78) received pentamidine in dose of 4 mg/kg body weight by IM route on alternate day for 15 injections in 30 days. The efficacy and safety of the two regimens were compared.

RESULTS

Apparent cure i.e. clinical and pathological cure at the end of therapy, in 78 (97.5%) and 67 (86%), and ultimate cure i.e. clinical and parasitological cure at the end of follow-up of six months, in 73 (91.25%) and 58 (74.35%) patients was observed in the combination regimen and single regimen group respectively. The difference of the ultimate cure between two groups of the patients was statistically significant (p < 0.01). In single regimen group, 11 (14%) patients showed primary unresponsiveness (with no response during treatment) and nine (13%) relapse (after six months of follow-up) respectively, where as in combination regimen group, two (2.5%) patients showed primary unresponsiveness and five (6.4%) relapse respectively. By the end of the treatment, the incidence of injection-related toxicity, such as rigor and fever, was same in both groups. No hyperglycemia was observed in combination therapy probably due to reduced dose of pentamidine and three patients in single regimen developed hyperglycemia and one of them developed irreversible hyperglycemia.

CONCLUSIONS

The study showed that the combination of pentamidine (half dose) and allopurinol is more effective in achieving ultimate cure with an added advantage of reduced toxicity in unresponsive cases as compared to full pentamidine dose.

An integrated curriculum for MBBS

OBJECTIVE

To report the formulation and implementation of an organ system based integrated curriculum for MBBS students at Ziauddin Medical University (ZMU) Karachi.

STEPS OF INTEGRATION

The Basic Medical Science Faculty (Anatomy, Physiology and Biochemistry) along with representatives from Medicine, Surgery and Community Health Sciences held joint meetings spread over weeks to design a system based integrated curriculum for the first two years of the MBBS class. Objectives of an integrated course were devised and the duties of term coordinator determined.

CONCLUSION

Horizontal integration of Basic Science subjects can be achieved, with the subject specialists coordinating the teaching of a system based as opposed to subject based curriculum. The basic sciences can also be integrated with Community Health Sciences to achieve partial vertical integration.

Osteoporosis in older men: discovering when and how to treat it

Nearly 1.5 million American men age 65 and older have osteoporosis, and another 3.5 million are at risk. Hip fractures in older men have a higher mortality than in women and represent a growing medical problem. Glucocorticoid treatment, hypogonadism, and excessive alcohol consumption are important secondary etiologies for loss of bone mass in men. Detection of hypogonadism may be difficult, and testosterone replacement is indicated for only a well-defined subset of patients. Because of a lack of data on pathogenesis, risk factors, and therapeutic interventions in men, treatment decisions are usually based on extrapolation from studies in women. None of the medications approved by the FDA for the treatment of osteoporosis in postmenopausal women has been approved for use in older men, but physicians are prescribing bisphosphonates and calcitonin.

Retinoic acid receptors and retinoid binding proteins in endometrial adenocarcinoma: differential expression of cellular retinoid binding proteins in endometrioid tumours

Retinoic acid is apparently required for the normal differentiation of reproductive epithelium. Cellular abnormalities in retinoid homeostasis could be a factor in the development of endometrial malignancy. We have thus investigated the expression of nuclear retinoic acid receptors (RARs and RXRs) and cellular binding proteins for retinol (CRBP) and retinoic acid (CRABP) in endometrial adenocarcinoma of the endometrioid histological subtype. Ten grade I, II grade 2 and 10 grade 3 tumour samples, as well as 4 samples of severe atypical precancerous endometrial hyperplasia, were studied. No significant difference in expression of RAR-beta was detected in tumour samples compared with normal epithelial cells. RAR-gamma was significantly elevated in grade 1 and 2 carcinomas, but this may be due to greater stromal cell involvement in these lower grade tumours. There was significant elevation of CRBP I mRNA in tumour samples. Furthermore, although undetectable in normal endometrial epithelium, CRABP I was expressed in 3/II grade 2 and 9/10 grade 3 carcinomas, with expression being significantly higher where the primary tumour had invaded more than 50% of the total myometrial thickness. Analysis of 2 epithelial-like endometrial adenocarcinoma cell lines supported the idea that CRABP I expression is characteristic of poorly differentiated endometrial adenocarcinoma. Our data suggest that alterations in mechanisms of retinoid homeostasis are a feature of endometrial adenocarcinoma and may contribute to the severity of disease.

Cellular retinoid binding proteins and nuclear retinoic acid receptors in endometrial epithelial cells

Retinoic acid, one of the most potent of the naturally occurring retinoids (retinol and derivatives), is required in vivo for the maintenance of epithelial cell growth. This study describes the pattern of expression of nuclear retinoic acid receptors (RARs and RXRs), and cellular binding proteins for retinol and retinoic acid (CRBP I, CRABP I and II), in endometrial epithelial cells. The effects of retinoic acid on the expression of these receptors in endometrial epithelial cells have also been studied and compared with its effects in endometrial stromal cells. Messenger RNA for RAR-alpha, RAR-beta, RAR-gamma, RXR-alpha, CRBP I and CRABP II was detected by Northern blotting of total RNA extracted from cultured epithelial cells. In comparison with stromal cell RNA that was used as an internal standard, CRBP I appeared to be more abundant in epithelial cells, whereas CRABP II appeared to be more abundant in the stromal cells. This implies that the intracellular concentration of retinoic acid may be maintained at higher levels in epithelial cells compared to stromal cells. In addition, the response of the two cell types to retinoic acid differs: RAR-beta is induced in stromal cells treated with all-trans retinoic acid but not in epithelial cells. From these data we suggest that retinoid physiology differs between endometrial epithelial and stromal cells. Furthermore, by analogy with other studies, we propose that retinoic acid may be maintained at a higher intracellular concentration in endometrial epithelial cells to facilitate differentiation to a glandular phenotype.(ABSTRACT TRUNCATED AT 250 WORDS)

Estimation of nor-adrenaline content of human penile tissue in diabeticmen with/without neuropathy

Penile tissue consisting of corps cavernosum (cc) and tunica albuginea (TA) was obtained from 35 impotent patients undergoing surgery for implantation of penile prostheses and was examined for nor adrenaline content. 10 patients were classified as a non diabetic non neuropathic group, on the basis of their clinical history and differential diagnostic symptoms which included Peyronie's disease, vascular disease, hypertension and psychogenic impotence. The nor adrenaline content was found to be significantly lower in tunica albuginea than the corpus cavernosum (P<0.02) in this group. The nor adrenaline content of corpus cavernosum from insulin dependent (IDDM) and non insulin dependent (NIDDM) diabetic neuropathic patients was also found to be significantly lower (P <0.02) than that of non diabetic non neuropathic patients. The nor adrenaline content of tunica albuginea however, was similar in both groups. A non significant association in the content of nor adrenaline in corpus cavernosum and tunica albuginea among IDDM and NIDDM diabetic neuropathics was also observed. These results provide evidence that an underlying neuropathic factor itself causes vascular as well as metabolic changes in the adrenergic nerves of the penis in diabetics due to neuropathy in addition to the effect of the disease and thus may contribute to the development of impotence in these patients irrespective of their type of diabetes.

Anaemia in pregnancy--a report of two trials

In two separate trials, 140 cases of Pregnancy Anaemia were investigated in the University Teaching Hospital, Lusaka. The distribution of anaemia was as follows: Iron deficiency 118 (84.2%); dual deficiency 15 (19.7%); haemolytic five (35%); and megaloblastic 2 (1.4%). Anaemia with megaloblastic change was more common in the second study.