Prothrombotic markers in Thalassemia major patients: A paradigm shift.

BACKGROUND: It is being increasingly recognised that thalassemia major patients, like intermedia, have increased propensity for thromboembolism. Deficiency of natural anticoagulants is more recently defined finding contributing to the hypercoagulable state. The aim this study is to determine natural anticoagulants levels and their correlation with maternal characteristics, haematological and biochemical markers. METHODS: This is a prospective case-control study. We registered 80 patients and 60 healthy controls from Jan 2009 to Dec 2013. Complete blood counts, prothrombin time, activated partial thromboplastin time, protein C, protein S, antithrombin, serum ferritin, liver enzymes; HbsAg and Anti- HCV were evaluated. RESULT: There were 42 males and 38 females with mean age of 12.30±5.50 years. The mean protein C, protein S and antithrombin in patients and control were 58.25±22.5 versus 110.67±22.60, 67.90±19.58 versus 98.70±21.54 and 89.73±18.09 versus 104.0±10.98 (p<0.001) respectively. Protein C was predominantly deficient in 65% followed by protein S and antithrombin in 35% and 20% respectively. Protein C deficiency divulged positive correlation with protein S deficiency (p = 0.035) and antithrombin deficiency with hemoglobin of ≤8gm% (p<0.0025). No significant correlation of prothrombotic markers was established with maternal characteristics, hepatic dysfunction, hepatitis and serum ferritin. CONCLUSION: Substantial decrement in prothrombotic markers, primarily protein C, may be implicated in elevated thrombosis; however follow-up data is required to establish definitive thromboembolic events.

Primary care referral practice, variability and socio-economic deprivation in colorectal cancer.

AIM: The reasons for pre-hospital delay of the diagnosis of cancer are multifactorial, but include a physician-related component. Urgent cancer pathways and direct-to-test approaches have been implemented, but the emergency presentation of colorectal cancer (CRC) remains little changed over recent years. We examined the variability between primary care providers in referral patterns and its effect on outcome. METHOD: A retrospective analysis was performed of a prospectively maintained database for 2009-2014 in a UK district hospital providing bowel cancer screening and tertiary rectal cancer services. RESULTS: Of 1145 CRC patients, 937 (81.8%) were diagnosed with a symptomatic cancer; 229/937 (24.4%) initially presented as an emergency. Between 44 primary care providers, emergency presentation varied between 8.3% and 57.1%. Patients of providers with high levels of emergency presentations (HV) had more advanced cancers than those of providers with medium (MV) or low levels (LV) [103/253 (40.7%), 154/461 (33.4%), 65/223 (29.1%); P = 0.025] and a lower 3-year overall survival (50.2%, 57.8%, 65.6%; P = 0.013), but with no difference in case-mix or deprivation levels. In adjusted analysis, this difference remained significant (advanced disease, OR 1.663, P = 0.011; 3-year hazard ratio 1.479, P = 0.010; comparing HV with LV). Conversely, elective suspected cancer referrals were less often used amongst diagnosed cancers [LV 136/223 (61.0%), MV 228/461 (49.5%), HV 114/253 (45.1%), P < 0.001] with limited evidence for a more selective approach in the use of the 2-week rule amongst all 2-week rule referrals [LV 136/2508 (5.4%); MV 228/4239 (5.4%); HV 115/1526 (7.8%); positive cancer diagnosis, P = 0.005]. CONCLUSION: Significant variability in emergency presentation of CRC requires local audit and examination of the reasons for delay in diagnosis and targeted measures to improve performance in non-emergency referral pathways.

Unabsorbed dura patch removed eight years after pituitary surgery.

The Codman ETHISORB Dura Patch is a synthetic, absorbable material whose absorption is complete within approximately 90 days. We report the first case of an unabsorbed Codman Dura patch, in which a patient was presented with nasal obstruction and epistaxis 8 years after pituitary surgery for Cushing's disease.

Unani treatment and leech therapy saved the diabetic foot of a patient from amputation.

Every 30 seconds, a lower limb amputation is carried out due to diabetes throughout the world. The mortality rate due to diabetic foot gangrene is just next to that of cancer. As tissue death cannot be reversed, surgical removal of the affected tissue (debridement) or amputation of the limb is the only treatment option left when gangrene has advanced. The present case study illustrates an option to treat poorly healing diabetic wounds with Unani medicine (blood purifier and deobstruent) besides hirudotherapy. The study was performed on a 60-year-old woman suffering from diabetic foot (on the left) grade 5 and facing the prospect of imminent amputation. The patient was having severe pain (80 mm on a 100 mm visual analogue scale) in the gangrenous foot and foul-smelling with necrosed areas. Wound dressing was done with unripe papaya as it has a very good role in clearing necrotising area and hirudotherapy was also used in poorly healing wounds. The pain score decreased to 0-10 mm on a 100 mm visual analogue scale within 20 days and no further pain relieving medication was required. Over a time interval of nearly 3·5 months, necrotic areas disappeared and the wound was completely healed.

Current trends of seroprevalence of transfusion transmitted infections in Pakistani ß-thalassaemic patients.

BACKGROUND: Though regular blood transfusion improves the survival, it carries the unavoidable risk of transfusion transmitted infections (TTI) in ß-thalassaemic patients. Owing to the lack of uniformity in blood screening practices in Pakistan, TTI is still a major challenge. OBJECTIVES: To study the current trends of TTI in regularly transfused ß-thalassaemics and their correlation with age, number of transfusions, hematological and biochemical markers. METHODS: We carried out a prospective case-control study. 100 ß-thalassemic patients and 200 healthy donors were recruited from June 2011 to June 2014. HCV antibodies, Hepatitis B surface antigen and human immunodeficiency virus antibodies (I & II) were evaluated. Complete blood counts, LFTs and serum ferritin were tested on all patients. RESULTS: Mean age of patients and controls was 11.18±5.07 and 20.5±1.87 years respectively. In patients, 54% and 46% were males and females respectively. Anti-HCV antibody and HbsAg were positive in 27% versus 3% and 3% versus 2% in patients and controls respectively. None of the patients and controls was HIV reactive. Seropositivity of Anti-HCV was significantly higher in patients than that of controls (P<0.001). Anti-HCV positively correlated with age above 10 years, numbers of transfusions (≥150 units), high serum ferritin, elevated ALT and alkaline phosphatase (P<0.001). CONCLUSIONS: Over the decade, TTI magnitude has significantly reduced, but hepatitis C is still a main hazard. Further preventive measures including nucleic acid testing, voluntary donation and stringent donor selection will be required for reducing TTI in ß-thalassaemics.

Insight into the electronic, elastic, structural, thermal, and optical characteristics of potassium magnesium fluoride KMgF3 with isotropic external stress.

The demand for increasingly fine detail in optical lithography for semiconductors necessitates the use of lower-wavelength lithographic light. This drives the need for lenses in optical lithography steppers made of vacuum ultraviolet-transparent (VUV-transparent) materials. In this work, the density functional theory (DFT) study of potassium magnesium fluoride KMgF3 is presented. Total energy was calculated with correlation functional generalized gradient approximation (GGA). The ground state quantities such as bulk modulus and lattice parameters have been evaluated. The material's cubic structure is scrutinized under various stress levels (0-100 GPa), revealing that KMgF3 starts to deform at 128 GPa. The C11, C12, and C44 independent elastic constants were used to analyze the structural stability of the KMgF3. The densities of states and electronic band structures have also been computed. According to electronic calculations, when stress is applied to KMgF3, the band gap increases for all values of stress (0-100 GPa). Mechanical parameters, including elastic constants and ratios, indicate the material's remarkable ductility and stability. Phonon density of states and thermal characteristics exhibit shifts and variations with increasing stress, providing insights into the material's behaviour below its melting point. The thermodynamic properties of KMgF3, such as enthalpy, free energy, entropy, heat capacity, and Debye temperatures at various temperatures ranging from 0 K to 1000 K, have also been examined to explore their basic properties. These findings contribute to a comprehensive understanding of KMgF3, opening avenues for its application in advanced technologies, particularly in the realms of semiconductors and optoelectronics.

A social enterprise model for TB detection and treatment through the private sector in Pakistan.

BACKGROUND: Existing models to increase TB case notifications from the private sector in Pakistan are financially unsustainable and have achieved modest success due to limited coverage. OBJECTIVE: To evaluate the impact of a social enterprise model (SEM) intervention on TB case detection in Karachi, Pakistan, and to assess its financial sustainability. METHODS: Purpose-built centres were established within the private sector that integrated TB screening, diagnostics and treatment and operated 12 hours per day with convenient locations to improve access. TB services were offered free of cost, and revenue generation took place through user fees from other diagnostics. Private providers with a focus on the informal sector were engaged through community workers to generate screening referrals. RESULTS: Overall 171,488 people were screened and 18,683 cases were notified, including 197 individuals with drug-resistant TB. Annual TB notifications in Karachi increased from 18,105 in 2014 to a maximum of 25,840 (40% increase). The proportion of cases in Karachi notified by the centres grew to 27% in 2020. Commercial revenue reached USD288,065 and enabled operating cost recovery of 15%. Average cost per TB case notified was USD203. CONCLUSION: The SEM intervention contributed a large proportion of notifications in Karachi and achieved modest cost recovery.

CONTEXTE: Les modèles existants visant à augmenter les notifications de cas de TB par le secteur privé au Pakistan ne sont pas viables financièrement et n'ont obtenu qu'un succès modeste en raison d'une couverture limitée. OBJECTIF: Évaluer l'impact d'un modèle déntreprise sociale (SEM, pour l'anglais « social entreprise model ¼) sur la détection des cas de TB à Karachi, au Pakistan, et évaluer sa viabilité financière. MÉTHODES: Des centres spécialisés ont été créés dans le secteur privé. Ils intègrent le dépistage, le diagnostic et le traitement de la TB et fonctionnent 12 heures par jour dans des lieux adaptés afin dén faciliter l'accès. Les services de lutte contre la TB étaient gratuits et les recettes provenaient des frais d'utilisation des autres diagnostics. Des prestataires privés, axés sur le secteur informel, ont été engagés par l'intermédiaire d'agents communautaires pour orienter les patients vers les services de dépistage. RÉSULTATS: Au total, 171 488 personnes ont été dépistées et 18 683 cas ont été notifiés, dont 197 personnes atteintes de TB résistante aux médicaments. Les notifications annuelles de TB à Karachi sont passées de 18 105 en 2014 à un maximum de 25 840 (augmentation de 40%). La proportion de cas à Karachi notifiés par les centres est passée à 27% en 2020. Les recettes commerciales ont atteint 288 065 USD et ont permis un recouvrement des coûts déxploitation de 15%. Le coût moyen par cas de TB notifié était de 203 USD. CONCLUSION: L'intervention SEM a contribué à une grande proportion de notifications à Karachi et a permis un modeste recouvrement des coûts.

Effects of isotropic stress on the band structure elastic, optical, thermal, and x-ray diffraction properties of TiSnO3.

BACKGROUND: Cubic perovskite titanium stannous oxide (TiSnO3) is a promising material for various applications due to its functional properties. However, understanding how these properties change under external stress is crucial for its development and optimization. METHOD: This study employed density functional theory calculations to investigate the structural, electronic, optical, thermal, and mechanical properties of TiSnO3 under varying degrees of external static isotropic stress (0-120 GPa). RESULTS: The study reveals a significant decrease in the bandgap of TiSnO3 with increasing stress due to lattice modifications and the formation of delocalized electrons. Partial density of states analysis indicates that Sn and O states play a key role in shaping the electronic band structure. TiSnO3 exhibits increased light absorption with stress, accompanied by a blue shift in absorption peaks, whereas, both polarizability and refractive index decrease with increasing stress. Mechanically, all elastic moduli (bulk, shear, and Young's) show an increase under stress, signifying a stiffening response of the material under stress. Similarly, the Pugh ratio suggests a transition from ductile to brittle behaviour at elevated stress levels. Phonon dispersion calculations indicate the instability of the cubic phase at 0 K. However, a phonon gap emerges at 30 GPa and widens with increasing stress. X-ray diffraction further supports these findings by demonstrating a shift in diffraction peaks towards higher angles with increasing stress, consistent with the applied stress. CONCLUSION: In conclusion, this computational study offers a thorough understanding of how external stress influences the properties of TiSnO3, providing valuable insights for potential applications in various fields.

The International Consensus for Early TB framework (ICE-TB): Implications from a low-incidence setting.

In recent years, there has been increasing recognition of the public health significance of the spectrum of TB disease presentation, and the existing classification systems of asymptomatic infection and symptomatic TB have been limited in terms of explanatory power. Accordingly, in 2022-2023, a new International Consensus framework for Early TB (ICE-TB) was developed, categorising the spectrum of TB infection and disease into five states based on the presence or absence of macroscopic pathology, host infectiousness, and symptoms and signs.We used the ICE-TB framework to re-analyse existing notification data for 2022 within a low-incidence setting to explore the potential utility and future challenges for its public health application.Existing notification data were sufficient to allow substantial reclassification of currently recognised active disease states, but did not systematically capture Mycobacterium tuberculosis infection or subclinical TB. Fifty percent of existing TB notifications would be classified as 'Clinical, infectious', with the potential need to consider further subclassification.Our exploration highlighted limitations in existing classification systems and diagnostic approaches and should encourage researchers and programmatic implementers to emphasise person-centred and programmatic needs in the development of new tools for TB management..

Development and validation of HPLC method for simultaneous estimation of piperine and guggulsterones in compound Unani formulation (tablets) and a nanoreservoir system.

An attempt has been made to develop and validate a simultaneous HPLC method for novel approach of drug release via oil-in-water (o/w) nanoemulsion formulation and Habb-e-Khardal Unani tablet containing piperine and guggul sterones E and Z as main ingredients. Nanoemulsion was prepared by titration method using sefsol-218 as an oily phase, cremophor-EL as a surfactant, transcutol as a co-surfactant and distilled water as an aqueous phase. The formulation was optimized on the basis of thermodynamic stability and dispersibilty test. The nanoformulation was evaluated for particle size, surface morphology, electrical conductivity and viscosity determination. The in vitro dissolution was carried out by dialysis bag method. Drugs were quantified using an HPLC method developed in-house with a C(18) column as stationary phase and acetonitrile and water as mobile phase at λ(max) of 240 nm. The optimized formulation showed higher drug release, lower droplet size and less viscosity as compared with the conventional Habb-e-Khardal Unani tablet. The present study illustrated the potential of nanoemulsion dosage form in improving biopharmaceutic performance of piperine and guggul sterone. The HPLC method was also found to be quite sufficient for the routine quality control of formulations containing piperine and guggul sterone E and Z as ingredients and also for in vitro drug release studies.

A systematic overview of the medicinal importance of sanguivorous leeches.

Leeches are a class of segmented invertebrates, known for their blood-feeding habits and used in phlebotomy to treat various ailments since antiquity. In Europe, medicinal leeches have recently been rediscovered and are used by maxillofacial and other microsurgeons to aid salvage of compromised venous engorged tissue and amputations, such as digits, ears, and nasal tips. Because of their important salivary components, blood-sucking (sanguivorous) leeches, such as Hirudo medicinalis and related species, have engendered great interest from pharmaceutical companies searching for anticoagulants to prevent blood clotting during microsurgeries. Scientific research reveals that the beneficial effects of leeching, in addition to decongestion, include injection of a cocktail of several medicinally useful bioactive molecules present in their saliva. Owing to its therapeutic potential, the research is continuing as many new salivary compounds are being isolated and synthesized.

Morphological control of porous SiC templated by As-synthesized form of mesoporous silica.

Porous silicon carbide with fiber like morphology was successfully prepared via a hard templating approach using as-synthesized form of mesoporous silica SBA-15 as template and sucrose as carbon precursor. The obtained materials have been characterized by various sophisticated techniques such as XRD, nitrogen adsorption, HRTEM, HRSEM, FT-IR and TGA. The XRD and the nitrogen adsorption results revealed that the materials are highly crystalline and exhibit porous structure with excellent textural characteristics. It has been demonstrated that the morphology of the materials can be finely controlled from rod shaped morphology to fiber like nanostructures by the simple adjustment of the reaction time from 5 to 12 h at the reaction temperature of 1300 degrees C. The reaction time of 12 h at 1300 degrees C was found to be the best condition to obtain highly crystalline nanofiber like morphology. The obtained materials display beautiful nanofiber morphology which has the diameter of 20 to 60 nm and a length of 7 to 10 microm which is much longer than the previously reported SiC nanofibers.

Synthesis of superacid-functionalized mesoporous nanocages with tunable pore diameters and their application in the synthesis of coumarins.

Here we demonstrate for the first time the preparation of a triflic acid (TFA)-functionalized mesoporous nanocage with tunable pore diameters by the wet impregnation method. The obtained materials have been unambiguously characterized by XRD, N(2) adsorption, FTIR spectroscopy, and NH(3) temperature-programmed desorption (TPD). From the characterization results, it has been found that the TFA molecules are firmly anchored on the surface of the mesoporous supports without affecting their acidity. We also demonstrate the effect of the pore and cage diameter of the KIT-5 supports on the loading of TFA molecules inside the pore channels. It has been found that the total acidity of the materials increases with an increase in the TFA loading on the support, whereas the acidity of the materials decreases with an increase in the pore diameter of the support. The acidity of the TFA-functionalized mesoporous nanocages is much higher than that of the zeolites and metal-substituted mesoporous acidic catalysts. The TFA-functionalized materials have also been employed as the catalysts for the synthesis of 7-hydroxy-4-methylcoumarin by means of the Pechmann reaction under solvent-free conditions. It has been found that the catalytic activity of the TFA-functionalized KIT-5 is much higher than that of zeolites and metal-substituted mesoporous catalytic materials in the synthesis of coumarin derivatives. The stability of the catalyst is extremely good and can be reused several times without much loss of activity in the above reaction.

Ultrafast microwave assisted synthesis of mesoporous SnO2 and its characterization.

Mesoporous SnO2 was prepared by a high temperature microwave assisted process using a low cost polymeric surfactant, poly(ethylene glycol). The obtained material has been characterized by several sophisticated techniques such as XRD, nitrogen adsorption, HRTEM, UV-Vis DRS, HRSEM and photoluminescence. The characterization results reveal that the obtained material exhibits a high surface area with a spherical morphology, crystalline walls and narrow mesopores. In addition, microwave process requires only a short time for the formation of mesoporous SnO2. SnO2 with no porous structure was obtained when hydrothermal technique was used. We also found that the band gap of the mesoporous SnO2 is much smaller than that of the nonporous bulk SnO2 and showed excellent photoluminescent properties.

Training workshops in problem-based learning: changing faculty attitudes and perceptions in a Pakistani medical college.

BACKGROUND: Problem-based learning (PBL) has over the years become a learning strategy established for teaching students in medicine. In order to use PBL as a teaching tool, faculty must be familiar with PBL and comfortable with the role transition from 'teacher' to 'facilitator'. This transition is critical for the success of PBL. This article describes the faculty development process undertaken in Pakistan at the onset of introduction of PBL in the curriculum. METHODS: At the Foundation University Medical College (FUMC), we initiated a faculty development program in PBL. The program consisted of two-day, hands-on facilitator training workshops conducted five times over the year and led by in-house faculty. A total of 180 faculty members completed these workshops. The workshops consisted of interactive sessions on the philosophy of PBL, small group dynamics, the role of the facilitator, an introduction to case design, wrap-up PBL sessions and assessment in PBL. Participants were provided with pre-workshop reading material in the form of 'PBL Handbooks', which contained details of the PBL process and specific responsibilities of the facilitator. Participants were also given a chance to experience the role of the facilitator by facilitating the faculty-learner group through a PBL session and receiving feedback. A retrospective pre-post survey was conducted to gauge changes in participants' perceptions of PBL. RESULTS: The faculty reported a significant increase in their regard for PBL as an instructional paradigm (p=<0.001). They also generally became more interested in empowering students with self-directed learning using PBL as a teaching tool and showed a greater desire to be facilitators (p=<0.001). CONCLUSION: This evaluation reveals that facilitator training workshops can help not just to improve the facilitation skills of participants but also to stimulate interest amongst faculty to use PBL in the curriculum. Such workshops can be run in Pakistan at minimal cost: the only cost we incurred was for photocopying the reading material. How much difficulty the faculty will actually have serving as facilitator in the PBL process will only become evident when they lead PBL groups over the coming year.

Comparative Fingerprint Profiling of Unani Polyherbomineral (Safoof-e-Pathar Phori) Formulation by HPTLC, HPLC, and GC-MS.

BACKGROUND: Standardization of Unani formulations is essential to assess the quality and safety of drugs to establish their acceptance internationally as well as in nationally. Safoof-e-Pathar phori is a polyherbomineral formulation that contains six different plant and mineral constituents: Didymocarpus pedicellata, Dolichos biflorus, Rheum emodi, Raphanus sativus, potassium carbonate, and potassium nitrate. OBJECTIVE: The objective of the study is to develop and establish the quality of Safoof-e-Pathar phori, used for antilithiatic activity using chromatographic analysis. METHODS: This study involves comparative fingerprint profiling of an Unani polyherbomineral formulation with its plant constituents by high-performance TLC (HPTLC), HPLC, and GC-MS. The authenticity of the Unani polyherbomineral formulation using comparative HPLC and GC-MS fingerprint profiling was achieved by comparing the retention time of peaks matching with plant drugs. RESULTS: In HPTLC, comparative fingerprinting was done on the basis of retardation factor values of compounds separated on HPTLC plates of the formulation and the single drugs. The relative retention times of the characteristic peaks in the HPLC fingerprinting were established for identification of the Unani poly-herbo-mineral formulation, whereas GC-MS was used for comparative fingerprint profiling of different compounds present in single drugs and in formulation through the National Institute of Standards and Technology and Wiley libraries using mass by charge ration (m/z) of detected compounds. CONCLUSIONS: The fingerprint analysis approach is the most potent tool for quality control of polyherbal medicines because of its accuracy and reliability, and it also helps in identification and authentication and prevents adulteration. HIGHLIGHTS: The developed chromatographic methods enable the quality and safety profile of the products.

Endoscopic training-is the future three-dimensional?

BACKGROUND/OBJECTIVES: Endoscopic surgery has a distinct disadvantage compared to direct vision: loss of binocular vision. Three-dimensional endoscopy has been welcomed due to the promise of improving stereopsis. METHODS: Prospective randomized study of junior doctors with minimal endoscopic experience, using both two-dimensional and three-dimensional, zero-degree, 4-mm Storz endoscopes. Data was collected using validated, standardized training models, both objectively and subjectively. Paired comparisons between variables relating to the endoscopes were performed using Wilcoxon's tests. Operators were then split into groups based on their endoscope preference, with comparisons made using Mann-Whitney tests for Likert scale responses, Kendall's tau for ordinal variables, and Fisher's exact tests for nominal variables. RESULTS: Reduction of field of vision of three-dimensional endoscopy by 2%. Significant findings included decreased past-pointing, improved depth and perception and image quality. CONCLUSION: The use of an endoscopic endonasal approach with three-dimensional technology has measurable advantages for novice users, and highlights potential tailoring of future surgical training. LEVEL OF EVIDENCE: 1b.

Impact of scaling up Xpert® MTB/RIF testing for the detection of rifampicin-resistant TB cases in Karachi, Pakistan.

SETTING: Pakistan ranks fourth among the countries with a high burden of multidrug-resistant tuberculosis (MDR-TB), with only 19.2% of the 15 000 estimated incident cases being notified. Increasing treatment coverage for MDR-TB is a key priority for Pakistan's National Tuberculosis Programme. The World Health Organization recommends the use of the Xpert® MTB/RIF assay as the first-line diagnostic test for individuals with presumed TB. OBJECTIVE: To describe a multifaceted case-finding intervention targeting public and private sector health care facilities that used the Xpert assay as a frontline diagnostic test for individuals with presumptive TB, in Karachi, Pakistan, and its impact on case notifications of MDR-TB. DESIGN: Cross-sectional study. RESULTS: A total of 51 168 individuals were tested using Xpert, of whom respectively 7581 and 1534 people were diagnosed with TB in the public sector (reverse public-private mix) and private sector (social business model) arms; 574 (6.3% of all TB cases) were identified as having rifampicin (RMP) resistance. A total of 517 (90.1%) people with RMP-resistant TB (RR-TB) identified through the project were initiated on second-line treatment. The intervention resulted in 194 additional cases of RR-TB, an increase of 43% over the baseline. CONCLUSION: This project, one of the largest Xpert testing programmes conducted at city level, resulted in significantly increased detection and treatment of MDR-TB.

Patho-epidemiology of Cancer Cervix in Karachi South.

INTRODUCTION: The present study was conducted with the objective of examining descriptive epidemiological and pathological characteristics of cancer cervix in Karachi South, an all urban district population of Karachi, Pakistan. METHODOLOGY: A total of 74 cases of cancer cervix, ICD-10 (International Classification of Diseases 10th Revision) category C53 were registered at the Karachi Cancer Registry, for Karachi South, during a 3 year period, 1st January, 1995 to 31st December 1997. RESULTS: The age standardized incidence rate (ASR) world and crude incidence rate (CIR) per 100,000 were 6.81 (5.2, 8.43) and 3.22 (2.49 to 3.96). Cancer cervix accounted for approximately 3.6% of all cancers in females and was the sixth malignancy in hierarchy. The mean age of the cancer cases was 53.27 years [standard deviation (SD) 11.6; 95% confidence interval (CI) 50.58, 55.96; range (R) 32-85 years)]. The distribution by religion was Muslims (90.5%), Christians (8.1%) and Hindus (1.4%). There were no cases reported in Parsees. The frequency distribution by ethnicity was Urdu speaking Mohajirs (20.3%), Punjabis (17.6%), Gujrati speaking Mohajirs (4.1%), memon Mohajirs (8.1%), Sindhis (10.8%), Baluchs (8.1%), Pathans (5.4%) and Afghan migrants (2.7%). The ethnicity was not known in approximately a fourth (23.0%) of the cases. The socio-economic distribution was 27.0% financially deprived class, 24.4% lower middle class and 48.7% upper middle and affluent classes. The majority of the women were married (86.5%); a smaller number were unmarried (2.7%) or widows (10.8%). The age-specific curves showed a gradual increase in risk from the fourth up till the seventh decade, followed by an actual apparent decrease in risk after 64 years of age. The peak incidence was observed in the 60-64 year age group. The morphological categorization was squamous cell carcinoma (86.5%), adenocarcinoma (10.9%) and adenosquamous carcinoma (2.6%). The majority of cases presented with moderately differentiated or grade 2 lesions (45.9%). There were no in-situ cases. Approximately half the cancers (58.1%) had spread regionally and 8.1% to a distant site at the time of diagnosis. Odds ratios (OR) were calculated for socioeconomic residential categories, religion, ethnicity, age groups and education. The OR for socioeconomic residential categories ranged between 0.69 and 2.9 with a marginally higher risk in the lower [OR 2.09 (95% CI .97; 4.49)] and lower middle class [OR 2.08 (95%CI 0.95; 4.58)]. Hindus [OR 1.2 (95% CI 0.18; 2.2)] had a slightly higher risk then the Muslims [OR 0.14 (95% CI 0.17; 1.2)]. A higher risk was also observed for Christians [OR 7.76 (95% CI 1.74; 34.5)]. CONCLUSION: The incidence of cervical cancer in Karachi South (1995-97) reflects a low risk population with a late presentation and a high stage disease at presentation. It is suggested that cervical screening if implemented should focus on once a life time methodology involving 36-45 year old women. This should be combined with HPV vaccination for the young and public health education for all. A regular cervical screening program would require mobilization of considerable financial, structural and human resources along with training for personnel. This may burden the already stretched health resources of a developing country.

Ilaj bil hijamah (cupping therapy) in the Unani system of medicine: anecdotal practice to evidence based therapy.

BACKGROUND: Cupping (Hijamah) therapy is very well documented as a result of several thousand years of clinical experiences in Unani medicine. In this procedure, suction is created by various means either with or without bloodletting. Though this therapy is being widely practiced across the globe for treating many chronic and intractable ailments but many reports reveal its unscientific and improper practices which results in many complications. Therefore to develop standard operative procedures and to propose protocols of cupping therapy in various diseases is the need of hour. MATERIALS AND METHODS: A thorough literature review of relevant journals and textbooks was performed to gather the maximum available data on cupping therapy. CONCLUSION: This paper seeks to introduce the general concepts of cupping therapy in Unani medicine and other traditional systems of medicine, shortcomings and limitations of the currently published studies and suggest ways to improve these technical/methodological flaws. In addition, the authors have also attempted to provide the cupping related materials, hypotheses, observations which will provide the researchers the base for evaluating their usefulness in future clinical trials.