Mucosal transcriptomics highlight lncRNAs implicated in ulcerative colitis, Crohn's disease, and celiac disease.

Ulcerative colitis (UC), Crohn's disease (CD), and celiac disease are prevalent intestinal inflammatory disorders with nonsatisfactory therapeutic interventions. Analyzing patient data-driven cohorts can highlight disease pathways and new targets for interventions. Long noncoding RNAs (lncRNAs) are attractive candidates, since they are readily targetable by RNA therapeutics, show relative cell-specific expression, and play key cellular functions. Uniformly analyzing gut mucosal transcriptomics from 696 subjects, we have highlighted lncRNA expression along the gastrointestinal (GI) tract, demonstrating that, in control samples, lncRNAs have a more location-specific expression in comparison with protein-coding genes. We defined dysregulation of lncRNAs in treatment-naive UC, CD, and celiac diseases using independent test and validation cohorts. Using the Predicting Response to Standardized Pediatric Colitis Therapy (PROTECT) inception UC cohort, we defined and prioritized lncRNA linked with UC severity and prospective outcomes, and we highlighted lncRNAs linked with gut microbes previously implicated in mucosal homeostasis. HNF1A-AS1 lncRNA was reduced in all 3 conditions and was further reduced in more severe UC form. Similarly, the reduction of HNF1A-AS1 ortholog in mice gut epithelia showed higher sensitivity to dextran sodium sulfate-induced colitis, which was coupled with alteration in the gut microbial community. These analyses highlight prioritized dysregulated lncRNAs that can guide future preclinical studies for testing them as potential targets.

Associations Between Eight Earth Observation-Derived Climate Variables and Enteropathogen Infection: An Independent Participant Data Meta-Analysis of Surveillance Studies With Broad Spectrum Nucleic Acid Diagnostics.

Diarrheal disease, still a major cause of childhood illness, is caused by numerous, diverse infectious microorganisms, which are differentially sensitive to environmental conditions. Enteropathogen-specific impacts of climate remain underexplored. Results from 15 studies that diagnosed enteropathogens in 64,788 stool samples from 20,760 children in 19 countries were combined. Infection status for 10 common enteropathogens-adenovirus, astrovirus, norovirus, rotavirus, sapovirus, Campylobacter, ETEC, Shigella, Cryptosporidium and Giardia-was matched by date with hydrometeorological variables from a global Earth observation dataset-precipitation and runoff volume, humidity, soil moisture, solar radiation, air pressure, temperature, and wind speed. Models were fitted for each pathogen, accounting for lags, nonlinearity, confounders, and threshold effects. Different variables showed complex, non-linear associations with infection risk varying in magnitude and direction depending on pathogen species. Rotavirus infection decreased markedly following increasing 7-day average temperatures-a relative risk of 0.76 (95% confidence interval: 0.69-0.85) above 28°C-while ETEC risk increased by almost half, 1.43 (1.36-1.50), in the 20-35°C range. Risk for all pathogens was highest following soil moistures in the upper range. Humidity was associated with increases in bacterial infections and decreases in most viral infections. Several virus species' risk increased following lower-than-average rainfall, while rotavirus and ETEC increased with heavier runoff. Temperature, soil moisture, and humidity are particularly influential parameters across all enteropathogens, likely impacting pathogen survival outside the host. Precipitation and runoff have divergent associations with different enteric viruses. These effects may engender shifts in the relative burden of diarrhea-causing agents as the global climate changes.

Atypical Noninfectious Surgically Induced Necrotizing Scleritis in a Child.

Surgically induced necrotizing scleritis (SINS) is recognized as a rare and vision-threatening complication of ocular surgery. In adults, it has been mostly described after multiple ocular surgical procedures such as pterygium excision, glaucoma, and retinal detachment in the same eye. SINS is relatively less likely with single ocular surgery. It has been postulated that multiple surgeries may result in exposure of an antigen that leads to hypersensitivity reaction. Interestingly, it has also been reported after single strabismus surgery in adults. We present a case of unilateral surgically induced scleral necrosis resulting in complete loss of left inferior rectus muscle and muscle sheath in a child 2 weeks after uneventful bilateral strabismus surgery for hypertropia.

A Case Report of Probable Creutzfeldt-Jakob Disease Based on Positive MRI Findings and the World Health Organization Criteria.

Creutzfeldt-Jakob disease (CJD) is the most common prion disease. It is characterized by neuronal loss, glial cell proliferation, and inflammatory reaction absence. It typically involves deep grey structures, including the caudate nucleus, putamen, and thalamus, with sparing of the hippocampus. Death usually occurs within one year of the onset of symptoms. A 59-year-old male presented to the outpatient department (OPD) with involuntary jerky movements of his right arm, progressive stiffness of the right half of his body, and slurring of speech for two months. His stiffness had led him to be completely bed-bound. He was admitted and during the hospital stay, he started showing cognitive decline. His MRI brain revealed a bright FLAIR signal in the left basal ganglia, claustrum, sub-, and peri-insular cortex extending into the left parietal parasagittal cortex. He was discharged with a probable diagnosis of CJD with advice to undergo a follow-up MRI brain after one month. He presented again to the hospital after four months with sepsis secondary to urinary tract infection, bedsores, and infected percutaneous endoscopic gastrostomy (PEG) site. His Glasgow Coma Scale (GCS) score on presentation was 8/15, with a fixed gaze and tonic posturing of upper and lower limbs. A follow-up MRI brain showed rapidly progressive cortical atrophy and communicating hydrocephalus consistent with CJD. The diagnosis of CJD requires the presence of clinical findings with a positive electroencephalogram (EEG), cerebrospinal fluid (CSF) findings, and neuroimaging, or pathological findings. In our patient, a diagnosis of probable CJD was made based on clinical symptoms and positive cortical ribboning on the MRI brain using the World Health Organization (WHO) criteria. EEG was nonspecific, and CSF tau proteins and brain biopsy could not be done.

Infectious Etiologies of Intussusception Among Children <2 Years Old in 4 Asian Countries.

BACKGROUND: The etiology of intussusception, the leading cause of bowel obstruction in infants, is unknown in most cases. Adenovirus has been associated with intussusception and slightly increased risk of intussusception with rotavirus vaccination has been found. We conducted a case-control study among children <2 years old in Bangladesh, Nepal, Pakistan, and Vietnam to evaluate infectious etiologies of intussusception before rotavirus vaccine introduction. METHODS: From 2015 to 2017, we enrolled 1-to-1 matched intussusception cases and hospital controls; 249 pairs were included. Stool specimens were tested for 37 infectious agents using TaqMan Array technology. We used conditional logistic regression to estimate odds ratio (OR) and 95% confidence interval (CI) of each pathogen associated with intussusception in a pooled analysis and quantitative subanalyses. RESULTS: Adenovirus (OR, 2.67; 95% CI, 1.75-4.36) and human herpes virus 6 (OR, 3.50; 95% CI, 1.15-10.63) were detected more frequently in cases than controls. Adenovirus C detection <20 quantification cycles was associated with intussusception (OR, 18.59; 95% CI, 2.45-140.89). Wild-type rotavirus was not associated with intussusception (OR, 1.07; 95% CI, 0.52-2.22). CONCLUSIONS: In this comprehensive evaluation, adenovirus and HHV-6 were associated with intussusception. Future research is needed to better understand mechanisms leading to intussusception, particularly after rotavirus vaccination.

Outcome of inadvertent high dose BCG administration in newborns at a tertiary care hospital, Karachi- Case series.

Bacillus Calmette-Guérin (BCG) vaccine is given to newborns soon after birth. BCG vaccine overdose has been rarely reported. Here we report the outcome of newborns who accidently received high dose BCG at a tertiary care hospital, Karachi. We reviewed records of 26 newborns, who accidentally received intradermal high dose BCG, used for the treatment of urinary bladder cancers and 80 times higher dose than the BCG used for routine vaccination. The incident happened from 14-16th April, 2016 at Aga Khan University Hospital, Karachi. Analysis was carried out using SPSS. A total of 23/26(88.5%) newborns were followed for atleast 3 months and 11/26 (42.3%) were followed for atleast one year. 13/26 (50%) were male. All 26 patients were prescribed isoniazid and rifampicin for 3 months. 3/26 (11.5%) were lost to follow-up before completion of anti-tuberculous drugs (ATT). Lesions at the BCG site were observed in 16/26 (61.5%) infants, of which 15 (93.8%) had a papule, 3 (18.8%) developed a pustule, 3 (18.8%) had skin induration and 2 (12.5%) had skin erythema. Axillary lymphadenopathy was observed in 1/26 (3.8%) patient. Coagulation was deranged in 3/26 (11.5%) of babies. Intracranial bleeding was observed in 1/26 (3.8%) case. Localized skin lesions were the most common adverse events. None of them developed clinical tuberculosis. Chemoprophylaxis for inadvertent high dose BCG administration should be given for atleast 3 months. Furthermore, vigilant follow-up, transparency and disclosure are the vital steps in the management of any medical error.

Fungal osteomyelitis in a patient with chronic granulomatous disease: Case report and review of the literature.

Chronic granulomatous disease (CGD) is the most common of the primary immunodeficiency in children. It is caused by single gene defect resulting in dysfunctional nicotinamide adenine dineucleotide phosphate (NADPH) oxidase complex causing recurrent bacterial and fungal infections. Here we present the case of a 9 year old boy who was a known case of CGD since three years of age. He presented with recent history of fever, left sided pain in the scapular region and difficulty in breathing. Chest imaging revealed developing left upper lobe consolidation and erosion of the 3rd posterior rib. The child underwent video assisted thoracoscopic surgery (VATS) and biopsy of the lesion. Histopathology revealed fungal hyphae which were confirmed to be Aspergillus nidulans on staining. He was successfully treated with voriconazole therapy. We will also review the literature on fungal osteomyelitis in CGD patients.

Mycobacterium abscessus lymphadenitis in bone marrow transplant patient.

Non-tuberculous mycobacteria (NTM) are acid-fast bacteria categorized into rapidly growing and slow growing mycobacteria. NTM are more common in transplant patients who are immunocompromised. Here we report the case of a post- bone marrow transplant adolescent male presenting with submandibular swelling and fever. The gland was excised and the histopathology showed chronic granulomatous inflammation. Culture grew Mycobacterium abscessus which was sensitive to amikacin, linezolid and clarithromycin. A good response was achieved on therapy.

Single incision laparoscopic cholecystectomy with conventional instruments and ports: Initial experience at tertiary care public sector Hospital.

OBJECTIVE: To find out safety and feasibility of single incision laparoscopic cholecystectomy (SLIC) using conventional instruments. METHODS: This study was conducted at surgical department of LUMHS Jamshoro Pakistan from Jan: 2014 to Dec: 2015. All cases of symptomatic cholelithiasis that consented for laparoscopic surgery were included. The exclusion criteria were acute cholecystitis, acute gall stone pancreatitis, common bile duct stones and patients with co-morbid. A midline 3cm incision made supraumbilically and 10mm port placed. Two 5mm ports placed on either side of umbilicus slightly superior and laterally in or-der to triangulate. A 2/0 prolene suture placed through the infundibulum of the gall bladder to achieve retraction. The rest of the procedure is like standard 4 ports laparoscopic cholecystectomy. RESULTS: Total no of cases were 50. The age ranged from 30-59 years (mean 35.20 years ±4.886.) There were 43(86%) females and 07(14%) males. The mean operating time was 80 minutes (range 50-120 ±16.020). Four (8%) cases were converted to standard four ports laparoscopic cholecystectomy due to bleeding and difficult dissection in Calot's triangle. Minimal blood loss was observed during the procedure with no postoperative complications. The range of hospital stay was 1-2 days (mean 1.08 ±0.274). CONCLUSION: SILC is a safe and feasible procedure with conventional laparoscopic instruments without additional cost of single port and articulated instruments. The cosmetic results are excellent with minimal increase in the operating time.

Recurrent Salmonellosis in a Child with Complete IL-12Rß1 Deficiency.

A 3 year old boy presented with fever, abdominal pain and cervical lymphadenopathy. He had previously been treated empirically with anti-tuberculous therapy twice, at age 9 months and 27 months, for peripheral lymphadenopathy. An older sibling died of suspected tuberculous meningitis. Mantoux test was normal. Bone marrow and lymph node biopsy ruled out lymphoma and absolute neutrophil and lymphocyte counts were normal. Blood and lymph node cultures were positive for Salmonella typhi. The child's symptoms resolved with IV ceftriaxone and he was discharged. Over the next 2 years, the child was admitted every 2-3 months for culture positive S. typhi bacteremia with complaints of fever, abdominal distention and dysentery. HIV workup was negative. A prolonged course of probenicid and high dose amoxicillin increased interval between episodes to 4-5 months only. Cholecystectomy was debated and deferred due to suspicion of immunodeficiency. Blood samples from patient and parents were sent to France for workup and IL-12Rß1 deficiency was found. Parental counseling and subsequent patient management remained difficult in view of financial constraints and outstation residence of family. At age 7 years, the child presented with small bowel obstruction. He was managed conservatively with antibiotics, IV fluids and blood transfusions, but eventually succumbed to endotoxic shock. This case highlights the importance of considering IL-12Rß1 deficiency in children with repeated salmonellosis, a diagnosis which precludes intensive and aggressive monitoring and management of the patient in scenarios where bone marrow transplants are not feasible.

Prevalence, evaluation and management of preoperative anaemia in the elective general surgical patients.

BACKGROUND: Anaemia is the commonest haematological problem in the preoperative patients. Often it is a sign of underlying disease or associated co-morbid condition. A low haemoglobin level is associated with an excess risk in surgical procedure and its outcome. Therefore an understanding of any cause, evaluation and any potential treatment is crucial in the preoperative setting. Our objective was to determine prevalence, evaluation and management of preoperative anaemia in the elective general surgical patients. METHODS: Prospective observational study in Surgical Unit-II, Liaquat University Hospital Jamshoro from July 2008 to June 2009. One hundred and twenty-five anaemic cases were included in the study, with haemoglobin level < 10 g/dl. Their age ranged from 13 to 70 years. They were evaluated for preoperative anaemia in relation to surgical problems and associated any co-morbid conditions. RESULTS: Out of 830 patients during the study period, 125 patients were anaemic with haemoglobin level 2.1-9.9 g/dl. Fifty-six (44.8%) were male and 69 (55.2%) were female, and 68.5% patients were from rural areas. Hypochromic microcytic was seen in 101 (80.8%) cases. Commonest surgical problem associated with anaemia was malignancies (27.2%) followed by haemorrhoids (20%) and tuberculosis of abdomen (14.4%). Majority of patients (52%) were managed on oral iron supplements while 48% received blood transfusions.

Experience of laparoscopic cholecystectomy during a steep learning curve at a university hospital.

BACKGROUND: Cholelithiasis is the most common disease of alimentary tract affecting the adult population globally and our country in particular is no exception to it as a cause of hospitalization. Surgical removal of gall bladder is the main stay of symptomatic cholelithiasis ensuring a permanent cure. The minimally invasive technique of laparoscopic cholecystectomy has gained wide acceptance as a Gold Standard treatment ever since its introduction. The purpose of this prospective observational study was to document our experience of laparoscopic Cholecystectomy during a learning curve in a single unit of a university hospital and compare it with other available data in the literature. METHODS: Total 94 patients underwent laparoscopic cholecystectomy during the learning curve from Jan 2009 to Dec 2010 in the Department of Surgery Liaquat University Hospital Jamshoro. RESULTS: Mean age was 42 years with females (88.29%) preponderance. Majority of the cases were operated by consultants (85.10%) within 25-60 minutes. Postoperative hospital stay was 3 days with return to work in 7 days. Only 6 (6.38%) cases were converted to open technique. Intra-peritoneal drains and Foley's catheter were kept in selected cases only. Eleven patients (11.70%) had intra-operative complications including complete transaction of CBD in only one (1.06%) male patient. Five patients (5.31%) had postoperative complications with two patients having iatrogenic duodenal injury which was not identified during surgery and pseudo cyst pancreas. Four patients (4.25%) died due to multiple organ failure. CONCLUSION: We conclude that Laparoscopic Cholecystectomy is a gold standard procedure and should be learned on virtual simulated models before starting this procedure on human patients.

Giant trichobezoar mimicking gastric tumour.

We present a case of giant gastric trichobezoar retrieved through a long gastrotomy in a 40 years old married women from rural Sindh with unreported psychological disturbance. Trichobezoar almost exclusively occur in females with an underlying psychiatric disorder. It has an insidious development of symptoms which accounts for its delayed presentation and large size at the time of diagnosis. They are associated with trichophagia (habit of compulsive hair eating) and are usually diagnosed on CT Scans or upper GI Endoscopy. They can give rise to complications like gastroduodenal ulceration, haemorrhage, perforation, peritonitis or obstruction with a high rate of mortality. The treatment is endoscopic, laparoscopic or surgical removal and usually followed by psychiatric opinion.

Health related quality of life after burns: are we really treating burns?

BACKGROUND: During the last few decades management of burns has undergone positive revolutionary change. Today, over 50% of all patients with burns involving 80% of their total body-surface area can survive. Although the objective assessment by attending physician can well define a patient's degree of health, the patient's subjective perceptions and expectations that can influence burn survivors experience of their life is much more important. METHODS: Adult burn patients of both sexes admitted to burn unit with major burns either by size or site who required reconstruction for burn injury were the subjects of this study. The health related quality of life was assessed using SF-36v2, questionnaire. RESULTS: The mild to moderate pain complaint by 87 (88%) of all burn survivors, badly impact role physical and general health with resultant decrease in physical component summary. What was more difficult to explain was the decreased mental health which is evident soon after the incidence and persisted throughout the period of follow-up, showing statistically insignificant improvement when compared from basal score (p = 0.008). Longitudinal decline in HRQoL had strong relationship with female sex, involvement of prime area, hospital admissions, hospital stay and sessions of surgery. Sex, occupation, involvement of prime area and hospital admissions, were the important predictors for decrease in physical component summary of burn survivors. Involvement of prime area and hospital admissions were important determinant for decrease in mental component summary. CONCLUSION: The level and quality of multidisciplinary rehabilitation that these victims needs is very low as compared to developed countries. These patients need long-term professional, psychological, and social support.

Prospective basic clinical audit using minimal clinical data set.

BACKGROUND: Audit is a means of quality control for medical practice by which the profession should regulate its activities with intention of improving overall patient care. Objective of this study was to report 1 year basic clinical audit of a general surgical ward and comparison of results with available data. METHODS: All patients admitted and managed in Department of Surgery Unit-II, Liaquat University Hospital, Jamshoro/Hyderabad from January to December 2007 were included in the study for basic clinical audit. Data of all surgical patients admitted during this period were retrieved from the departmental register. Details of surgical procedures and complications were recorded from the patients' charts. RESULTS: Total number of patients was 1434, out of which 844 (58.85%) were males and 590 (41.14%) were females. Majority (70.02%) of the patients were between 16 to 50 years of age. Elective surgeries were performed in 487 (33.74%) and emergency surgeries in 430 (29.79%) cases, whereas rest of the 526 patients (36.28%) were managed conservatively. Consultant was the primary surgeon in less than 50% of the procedures compare to post graduate trainees and registrars. The most common surgeries performed in elective wing were inguinal hernia repairs (25.66%) and cholecystectomies (22.99%). In emergency wing, most of the surgeries were exploratory laparotomies (38.13%) and appendicectomies (22.79%). Average duration of hospital stay in elective wing was 1-10 days and in emergency wing it was 2-21 days. There was an overall complication rate of 6.3% and a mortality rate of 2.44% respectively. CONCLUSION: We conclude that surgical audit has potential benefits for patients, clinicians, and provision of services for a continuous education, research and improved practice habits and should be perform on yearly basis. We also recommend the proper computerised audit programs and committees for its monitoring and evaluation.

Extra osseous primary Ewing's sarcoma.

The case of 20 years old boy with an extra osseous Ewing's sarcoma is described. He was initially diagnosed as a case of infiltrative malignant tumour of left suprarenal gland on the basis of preoperative workup but postoperative biopsy of surgically excised specimen confirmed Extra-osseous Ewing's Sarcoma (EES) suprarenal gland with no evidence of malignancy on skeletal scintiscan, bone marrow aspirate and histopathology Suprarenal location of primary EES is unknown and probably has not been reported in literature. We report a unique case of EES.

Outcome of the rubber band ligation with Milligan Morgan haemorrhoidectomy.

BACKGROUND: Haemorrhoids is a common anorectal disease seen in our society. Conservative management is usually adopted for 1st and 2nd degree haemorrhoids. Patients who do not respond to above management are the candidates for other modalities of treatment which includes sclerotherapy, rubber band ligation, cryosurgery and stapler gun or open haemorrhoidectomy. The purpose of study was to compare the outcome of the Rubber band ligation with Milligan Morgan haemorrhoidectomy in patients with 2nd and 3rd degree haemorrhoids. METHODS: Hundred diagnosed admitted patients of uncomplicated 2nd and 3rd degree piles were treated either with rubber band ligation (RBL) or open method of Milligan Morgan (OH) for the period from January 2007 to December 2007 were included in the study. Both procedures were evaluated regarding effectiveness, safety, complications after procedures, hospital stay and return to work on a written Performa. Patients with 1st and 4th degree haemorrhoids, below the age of 12 years, bleeding diathesis, associated local anorectal conditions requiring surgery, complicated haemorrhoids, recurrent and secondary haemorrhoids were excluded from the study. Follow up of all these patients was done in OPD to assess any complication and recurrence. Data was analysed through SPSS-16.0. RESULTS: One hundred indoor patients with 2nd and 3rd degree haemorrhoids were treated either with rubber band ligation or open technique. Most (> 90%) of the patients were males. Majority of the patients were in 30-33 years age group. Fresh bleeding (90%) and constipation (45%) were the commonest symptoms followed by prolapsed, discharge and irritation. Second degree was more common than 3rd degree haemorrhoids. Intensive pain was the commonest complain after both the procedures, however faecal incontinence was not reported in either group. Hospital stay was longer in open technique (70%) compare to few hours to one day in rubber band ligation group. Return to work was earlier in patients treated with rubber band ligation. CONCLUSION: Rubber band ligation is safe and effective method compare to open technique in 2nd and 3rd degree symptomatic haemorrhoids.

Open cholecystectomy without intraperitoneal drainage.

BACKGROUND: Cholecystectomy through laparotomy with or without intra-peritoneal drain has been the standard operation for the gall bladder disease for the last 100 years. It implies removal of gall bladder and is performed mainly for symptomatic gall stones. The Objectives was to analyse the outcome of open cholecystectomy without drain in term of complications. METHODS: Patients who underwent open cholecystectomy without drainage from January 2005 to December 2008, at Department of Surgery, Liaquat University Hospital, Jamshoro, Pakistan were included in the study. This was a 4 years prospective analysis of open cholecystectomy performed without drainage on 212 patients. Patients were randomly allocated for the procedure who presented with uncomplicated Cholelithiasis. Exclusion Criteria included carcinoma gall bladder, empyema gall bladder, Choledocholithiasis and porcelain gall bladder. All these patients underwent open cholecystectomy under general anaesthesia through various incisions. Operative time, post operative complications and hospital stay were recorded on a performa and analysed using SPSS-13. RESULTS: Two hundred and twelve patients, 199 females (93.9%) and 13 males (6.13%), age range 15 to 70 years, underwent open cholecystectomy without drainage for uncomplicated cholelithiasis. The most common complication observed includes seroma (5.66%), followed by surgical site infection both superficial and deep (3.30%) and bile leakage (1.14%). However biliary peritonitis, sub hepatic abscess and Wattman Walter's syndrome were not observed in any case. Mean operating time was 35 minutes. Mean hospital stay was 1.5 days with no mortality during the period of hospitalisation. The overall complications rate and hospital stay was significantly less when compared to open cholecystectomy with intra-peritoneal drain. CONCLUSION: In selected cases with a dry gall bladder bed, routine use of intra peritoneal drainage is unnecessary.

Hepatitis B and hepatitis C in Pakistan: prevalence and risk factors.

BACKGROUND: Pakistan carries one of the world's highest burdens of chronic hepatitis and mortality due to liver failure and hepatocellular carcinomas. However, national level estimates of the prevalence of and risk factors for hepatitis B and hepatitis C are currently not available. METHODS: We reviewed the medical and public health literature over a 13-year period (January 1994-September 2007) to estimate the prevalence of active hepatitis B and chronic hepatitis C in Pakistan, analyzing data separately for the general and high-risk populations and for each of the four provinces. We included 84 publications with 139 studies (42 studies had two or more sub-studies). RESULTS: Methodological differences in studies made it inappropriate to conduct a formal meta-analysis to determine accurate national prevalence estimates, but we estimated the likely range of prevalence in different population sub-groups. A weighted average of hepatitis B antigen prevalence in pediatric populations was 2.4% (range 1.7-5.5%) and for hepatitis C antibody was 2.1% (range 0.4-5.4%). A weighted average of hepatitis B antigen prevalence among healthy adults (blood donors and non-donors) was 2.4% (range 1.4-11.0%) and for hepatitis C antibody was 3.0% (range 0.3-31.9%). Rates in the high-risk subgroups were far higher. CONCLUSIONS: Data suggest a moderate to high prevalence of hepatitis B and hepatitis C in different areas of Pakistan. The published literature on the modes of transmission of hepatitis B and hepatitis C in Pakistan implicate contaminated needle use in medical care and drug abuse and unsafe blood and blood product transfusion as the major causal factors.

Epidermoid inclusion cyst of the perineum--a rare case report in a 50 years old male.

A 50 year old male presented with a history of mid line painless swelling in the perineum for last 4 years. The patient's only concern was a perineal swelling which was gradually increasing in size. Clinical examination mimics subcutaneous lipoma with soft lobulated surface with positive slip sign. The base line investigations were within normal limits. Complete surgical excision of the cyst performed. Histopathology confirmed epidermal inclusion cyst with no evidence of malignancy. Patient discharged on next day. The follow-up visits were un-remarkable. Perineal epidermal inclusion cyst is a rare entity and only few cases have been reported.