Efficacy and Safety of the RBD-Dimer-Based Covid-19 Vaccine ZF2001 in Adults.

BACKGROUND: The ZF2001 vaccine, which contains a dimeric form of the receptor-binding domain of severe acute respiratory syndrome coronavirus 2 and aluminum hydroxide as an adjuvant, was shown to be safe, with an acceptable side-effect profile, and immunogenic in adults in phase 1 and 2 clinical trials. METHODS: We conducted a randomized, double-blind, placebo-controlled, phase 3 trial to investigate the efficacy and confirm the safety of ZF2001. The trial was performed at 31 clinical centers across Uzbekistan, Indonesia, Pakistan, and Ecuador; an additional center in China was included in the safety analysis only. Adult participants (≥18 years of age) were randomly assigned in a 1:1 ratio to receive a total of three 25-µg doses (30 days apart) of ZF2001 or placebo. The primary end point was the occurrence of symptomatic coronavirus disease 2019 (Covid-19), as confirmed on polymerase-chain-reaction assay, at least 7 days after receipt of the third dose. A key secondary efficacy end point was the occurrence of severe-to-critical Covid-19 (including Covid-19-related death) at least 7 days after receipt of the third dose. RESULTS: Between December 12, 2020, and December 15, 2021, a total of 28,873 participants received at least one dose of ZF2001 or placebo and were included in the safety analysis; 25,193 participants who had completed the three-dose regimen, for whom there were approximately 6 months of follow-up data, were included in the updated primary efficacy analysis that was conducted at the second data cutoff date of December 15, 2021. In the updated analysis, primary end-point cases were reported in 158 of 12,625 participants in the ZF2001 group and in 580 of 12,568 participants in the placebo group, for a vaccine efficacy of 75.7% (95% confidence interval [CI], 71.0 to 79.8). Severe-to-critical Covid-19 occurred in 6 participants in the ZF2001 group and in 43 in the placebo group, for a vaccine efficacy of 87.6% (95% CI, 70.6 to 95.7); Covid-19-related death occurred in 2 and 12 participants, respectively, for a vaccine efficacy of 86.5% (95% CI, 38.9 to 98.5). The incidence of adverse events and serious adverse events was balanced in the two groups, and there were no vaccine-related deaths. Most adverse reactions (98.5%) were of grade 1 or 2. CONCLUSIONS: In a large cohort of adults, the ZF2001 vaccine was shown to be safe and effective against symptomatic and severe-to-critical Covid-19 for at least 6 months after full vaccination. (Funded by the National Science and Technology Major Project and others; ClinicalTrials.gov number, NCT04646590.).

Effectiveness of early pharmaceutical interventions in symptomatic COVID-19 patients: A randomized clinical trial.

Objective: We assessed the effectiveness of oral Hydroxychloroquine (HC), Azithromycin (AZ) and Oseltamivir (OS), alone or combined, among patients hospitalized with mildly symptomatic coronavirus infectious disease (COVID-19). Methods: Following the approval of the National Bioethics Committee and prospective registration (clinicaltrials.gov NCT04338698), a multicenter randomized clinical trial of adaptive design was conducted at 10 multispecialty hospitals in Pakistan. Patients were randomized into seven treatment groups. Starting April 15, 2020, consenting, eligible, otherwise healthy adult patients or those with co-morbidities under control, were recruited if they presented with mildly symptomatic COVID-19 (scored 3 on a 7-point ordinal scale anchored between 1 = not hospitalized, able to undertake normal activities, to 7 = death) confirmed by quantitative Real-Time Polymerase Chain Reaction (qRT-PCR). Two primary outcomes were assessed by day seven: Turning qRT-PCR negative; and clinical improvement of two points from the baseline. Outcome rates were compared using a chi-square test. Multiple imputations were applied to handle missing data. An interim data analysis was carried out on July 19, 2020, following which the study continued without treatment group changes. Data Safety and Monitoring Board advised to stop recruitment due to its futility on January 18, 2021. Results: Of 471 patients randomized, a total of 426 (90.4%) completed the follow-up for primary outcomes. Based on imputed data analyses at day seven: Total qRT-PCR negative cases were 137/471 (29%, 95% CI 25.0 - 33.4). By day seven, a total of 111/471 (23.5%, 95% CI 19.8 - 27.6) showed clinical improvement. No serious or non-serious adverse event was reported. Conclusions: Among patients with mild COVID-19, there was no statistically significant difference in the effectiveness of oral antimalarial, antiviral, or antibiotic treatments.Clinicaltrials.gov ID: NCT04338698.

Metadherin (MTDH) overexpression significantly correlates with advanced tumor grade and stages among colorectal cancer patients.

BACKGROUND: Colorectal cancer is the 4th leading cause of cancer related deaths affecting both men and women worldwide. In the present study, any probable role of MTDH mRNA expression in CRC tumorigenesis was explored using both discovery and validation cohorts. METHODS AND RESULTS: After prior ethical and biosafety approvals, tumor tissue samples along with their adjacent controls were collected for this study from Pakistani patients diagnosed with colorectal cancer. RNA was isolated using Trizol reagent, followed by cDNA synthesis. Transcript analysis of MTDH was performed by using qPCR. Moreover, genome-wide expression of MTDH was also determined through micro-array data analysis using BRB-array tools software. MTDH expression was significantly high in tumor tissue samples (p < 0.05) compared to their respective controls. Likewise, results of microarray analysis also revealed overamplification of MTDH in tumor samples as compared to controls. Expression of MTDH was also found to be positively correlated with KI-67 index (p < 0.05) and were observed to be significantly upregulated in advance tumor grade (p < 0.05) and stage (p < 0.05). However, no association of MTDH overexpression with age and gender could be established. CONCLUSION: Hence, it can be concluded that MTDH is a core element that plays a pivotal role in colorectal tumorigenesis irrespective of patient's age and gender. Molecular insight into the tumor microenvironment revealed MTDH as a niche, representing distinctive framework for cancer progression, thus, making it an innovative target strategy for colorectal cancer treatment.

Influence of ABCB1 gene polymorphism on concentration to dose ratio and adverse effects of tacrolimus in Pakistani liver transplant recipients.

OBJECTIVE: To evaluate the possible association of ABCB1 single nucleotide polymorphism (SNPs) of the ABCB1 gene with tacrolimus dosages, concentration-to-dose ratios (CDR) and adverse effects in Pakistani liver transplant recipients. METHODS: This observational study was conducted at Shifa International Hospital, Shifa Tameer-e-Millat University, Islamabad and Basic Medical Sciences Institute, Karachi from September 2016 to July 2020. Eighty-one liver transplant recipients were included. Demographics, clinical data, tacrolimus trough levels and doses were monitored. Electrochemiluminescence immunoassay (ECLIA) was used to measure tacrolimus trough levels. Transplant recipients were genotyped for three ABCB1 SNPs (rs1045642, rs2032582 and rs1128503). Acute cellular rejection (ACR), sepsis and other adverse events were monitored. RESULTS: ABCB1 rs1045642 CC genotype showed lower tacrolimus CDR as compared to CT and TT genotype in the first week of the post-transplantation period (p=0.02). There was a significant association of polymorphisms in rs1045642, rs2032582 and rs1128503 with psychosis, sepsis and ACR respectively. CONCLUSION: Identification of ABCB1 rs1045642 polymorphism may shorten the time to achieve optimum levels of tacrolimus during dose titration. ABCB1 polymorphism rs1045642, rs2032582 and rs1128503 may predict adverse effects in liver transplant recipients receiving tacrolimus.

WhatsApp an informal learning and communication tool: Perception of medical officers working in low resource setting: A Focus Group Discussion.

OBJECTIVE: To assess if WhatsApp communication improves clinical knowledge and to explore the perception of its use among medical officers at a secondary care facility. METHODS: The mixed method study was conducted at the Department of Obstetrics and Gynaecology, Aga Khan Hospital for Women and Children, Kharadar, Karachi, from May to July,2018, and comprised medical officers working at the secondary care facility. All the officers were added to a WhatsApp group with a consultant. Information regarding patient condition and management were exchanged in the form of messages, images related to patient care along with consultant feedback. A pre-test to assess prior knowledge was done followed by a post-test after three months of WhatsApp communication to see improvement in knowledge. To inquire about participant's WhatsApp experience and perception, a focus group discussion was conducted. SPSS 19 was used for data analysis. RESULTS: There were 10 medical officers in the study. A total of 520 communications were recorded. Of them 352(67.6%) were text messages, 117(22.5%) were images followed by 15(2.88%) web links and 36(6.9%) social messages. The pre-test mean score was 29.8±2.65 while the post-test score was 41.3±2.83 with a mean improvement in knowledge of 11.50±2.46 (p<0.0001). The focus group discussion indicated that the participants felt it was a valuable tool for prompt communication and effective patient care, and enhanced their clinical knowledge. CONCLUSIONS: WhatsApp was perceived as an effective tool for good communication as well as for improving clinical knowledge among medical officers working in low-resource setting.

Sweat Gland Carcinoma With Lymphadenopathy.

Sweat gland carcinoma is a rare tumour, being almost 1% of primary skin lesions. The tumour has tendency to spread to regional lymph nodes and distant metastases has also been reported. Their exact incidence in Pakistan is not known. Treatment options are also not clearly defined though surgery is the initial treatment approach as adjuvant treatment has not been properly explored. We report a case of sweat gland carcinoma with lymphadenopathy.

Traumatic Right Diaphragmatic Hernia; A Delayed Presentation.

Diaphragmatic rupture following blunt or penetrating thoraco-abdominal trauma is frequently missed. It presents years later with herniation of abdominal viscera. Surgical treatment should be sought for when diagnosed. A 56 year old female presented to emergency with traumatic right diaphragmatic hernia, road traffic accident 8 years ago when she sustained multiple rib fractures on the right side. Upon diagnosis, successful primary hernia repair was performed. Non-specific clinical and radiological features of diaphragmatic hernia (diminished breath sounds, respiratory distress, orthopnoea, dyspnoea, hydro-pneumothorax, and mediastinal shift and lung collapse) lead to delayed or missed diagnosis. Patients present months to years later with complications. By including it in the differentials while managing a trauma patient along with collaboration of the radiology department, the chances of missing this finding would be lowered substantially.

Students Dreem From Pre-Clinical To Clinical Years-A Cross Sectional Analysis From Rehman Medical College, Peshawar.

BACKGROUND: Educational environment is a key indicator of student learning and reflects quality of education and curriculum. With the boom of medical colleges in the private sector, parents put great stress on education and educational environment. The purpose of this study was to investigate the difference in perceptions regarding educational environment between pre-clinical and clinical year MBBS students and to determine year wise strengths and weaknesses of the MBBS program. METHODS: The study utilized the cross-sectional study design and employed, "Dundee Ready Educational Environment Measure (DREEM) questionnaire. The survey included 142 pre-clinical (1st and 2nd year MBBS) and 185 clinical students (3rd to Final year MBBS). RESULTS: The total DREEM score for the program was 119/200. Total score for pre-clinical years was 120/200 and that for clinical years was 118/200. There was no statistically significant difference between students' perceptions of pre-clinical and clinical years. When the sub scale analysis was done, perceptions of learning (POL) (p=0.007), perceptions of teachers (POT) (p=0.003) and social self-perception (SSP) (p=0.025) scales showed statistically significant difference between pre-clinical and clinical years. Academic self-perception (ASP) and perceptions of atmosphere (POA) showed no statistically significant difference. CONCLUSIONS: About the educational environment perception students regarded it as more positive than negative. Pre-clinical students were more satisfied than clinical students except for SSP scale. Students pointed out weaknesses in the curriculum especially for teaching and learning and in the atmosphere, more so for clinical students than pre-clinical students. Findings of this study guide that emphasis shall be put on teaching development and CME activities and regular feedback mechanisms for both students and faculty members.

Application of Artificial Intelligence in Vascular Surgery.

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Immunoinformatics-Based Proteome Mining to Develop a Next-Generation Vaccine Design against Borrelia burgdorferi: The Cause of Lyme Borreliosis.

The tick-borne bacterium, Borrelia burgdorferi has been implicated in Lyme disease-a deadly infection, formerly confined to North America, but currently widespread across Europe and Asia. Despite the severity of this disease, there is still no human Lyme disease vaccine available. A reliable immunoinformatic approach is urgently needed for designing a therapeutic vaccine against this Gram-negative pathogen. Through this research, we explored the immunodominant proteins of B. burgdorferi and developed a novel and reliable vaccine design with great immunological predictability as well as low contamination and autoimmunity risks. Our initial analysis involved proteome-wide analysis to filter out proteins on the basis of their redundancy, homology to humans, virulence, immunogenicity, and size. Following the selection of proteins, immunoinformatic tools were employed to identify MHC class I & II epitopes and B-cell epitopes, which were subsequently subjected to a rigorous screening procedure. In the final formulation, ten common MHC-I and II epitopes were used together with a suitable adjuvant. We predicted that the final chimeric multi-epitope vaccine could invoke B-cell responses and IFN-gamma-mediated immunity as well as being stable and non-allergenic. The dynamics simulations predicted the stable folding of the designed molecule, after which the molecular docking predicted the stability of the interaction between the potential antigenic epitopes and human immune receptors. Our studies have shown that the designed next-generation vaccine stimulates desirable immune responses, thus potentially providing a viable way to prevent Lyme disease. Nevertheless, further experimental studies in a wet lab are needed in order to validate the results.

In silico screening, SAR and kinetic studies of naturally occurring flavonoids against SARS CoV-2 main protease.

The Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2) pandemic has become a global challenge based on its replication within the host cells that relies on non-structural proteins, protease (Mpro). Flavonoids, an important class of naturally occurring compounds with medicinal importance, are frequently available within fruits and vegetables. Herein, we report the in silico studies on naturally occurring flavonoids consisting of molecular docking studies and evaluation of theoretical kinetics. In this study, we prepared a library of nine different classes of naturally occurring flavonoids and screened them on Autodock and Autodockvina. The pharmacokinetic properties of most promising compounds have been predicted through ADMET SAR, inhibition constants, ligand efficiency and ligand fit quality have been worked out theoretically. The results revealed that naturally occurring flavonoids could fit well in the receptor's catalytic pocket, interact with essential amino acid residues and could be useful for future drug candidates through in vitro and in vivo studies. Moreover, MD simulation studies were conducted for two most promising flavonoids and the protein-ligand complexes were found quite stable. The selected natural flavonoids are free from any toxic effects and can be consumed as a preventive measure against SARS CoV-2.

Comparison of Different Molecular Subtypes with 14% Ki-67 Cut-off Threshold in Breast Cancer Patients of Pakistan- An Indication of Poor Prognosis.

BACKGROUND: Ki-67 is a proliferation marker that is used not only to categorize patients in luminal A and B subtypes of breast cancers, but also to determine the aggressiveness of the disease in triple negative and human epidermal growth factor 2 (HER2) over expressed molecular subtypes. The present study was designed to evaluate the role of Ki-67 with cut off value of 14% in molecular subgroups and its association with patient prognosis. METHODS: Immunostaining was performed on histopathologically confirmed sections (n = 278) to assess expression of Ki-67, estrogen receptor (ER), progesterone receptor (PR) and HER2. Immunoreactivity of molecules was recorded as percentage scoring. RESULTS: Adopting a cut off value of 14%, Ki-67 was high in 88%of the cases included in the study. High Ki-67 was significantly associated with pathological parameters including histological grade, advanced stage and nodal/distant metastasis. Immunoexpression of ER, PR and HER2 also showed strong correlation with high expression of Ki-67. Based on the St. Gallen classification, the cases were categorized into luminal A (10%) and luminal B (51%), triple negative (20%) and HER2 enriched (18%). Ki-67 index was also significantly high in 98% of HER2 enriched and 95% of TNBC patients. Interestingly, Ki-67 score with cut off value of 14% proved to be significant in deciphering prognosis in luminal patients. Moreover, high expression of Ki-67 also proved to be a marker of poor prognosis, especially in triple negative patients. CONCLUSION: We suggest that utilization of IHC4 status i.e. ER, PR, HER2 and Ki-67 along with pathological findings and molecular subtyping can considerably affect clinical as well as therapeutic decisions.

Targeted Inhibition of Fibroblast Growth Factor Receptor 1-GLI Through AZD4547 and GANT61 Modulates Breast Cancer Progression.

The underlying mechanism of fibroblast growth factor receptor 1 (FGFR1) mediated carcinogenesis is still not fully understood. For instance, FGFR1 upregulation leads to endocrine therapy resistance in breast cancer patients. The current study aimed to identify FGFR1-linked genes to devise improved therapeutic strategies. RNA-seq and microarray expression data of 1,425 breast cancer patients from two independent cohorts were downloaded for the analysis. Gene Set Enrichment Analysis (GSEA) was performed to identify differentially expressed pathways associated with FGFR1 expression. Validation was done using 150 fresh tumor biopsy samples of breast cancer patients. The clinical relevance of mRNA and protein expression of FGFR1 and its associated genes were also evaluated in mouse embryonic fibroblasts (MEFs) and breast cancer cell line (MDA-MB-231). Furthermore, MDA-MB-231 cell line was treated with AZD4547 and GANT61 to identify the probable role of FGFR1 and its associated genes on cells motility and invasion. According to GSEA results, SHH pathway genes were significantly upregulated in FGFR1 patients in both discovery cohorts of breast cancer. Statistical analyses using both discovery cohorts and 150 fresh biopsy samples revealed strong association of FGFR1 and GLI1, a member of SHH pathway. The increase in the expression of these molecules was associated with poor prognosis, lymph node involvement, late stage, and metastasis. Combined exposures to AZD4547 (FGFR1 inhibitor) and GANT61 (GLI1 inhibitor) significantly reduced cell proliferation, cell motility, and invasion, suggesting molecular crosstalk in breast cancer progression and metastasis. A strong positive feedback mechanism between FGFR1-GLI1 axis was observed, which significantly increased cell proliferation and metastasis. Targeting FGFR1-GLI1 simultaneously will significantly improve the prognosis of breast cancer in patients.

Clinical and genetic characterization of congenital lipoid adrenal hyperplasia.

Disorders of steroid synthesis are a group of anomalies caused by defects in any step of conversion of cholesterol into steroid hormones. The disorders are characterized by defects leading to abnormalities of salt-water balance and/or sexual differentiation. Congenital lipoid adrenal hyperplasia (CLAH) is the most severe form of steroid synthesis disorder caused by the accumulation of cholesterol in the outer mitochondrial membrane due to steroidogenic acute regulatory protein (StAR) deficiency. Pathogenic sequence variants in the gene STAR encoding StAR protein leads to CLAH. In the present study, a Pakistani family was clinically diagnosed with the LAH phenotype. Sanger sequencing of STAR in the family revealed a novel homozygous nonsense mutation [c.295G>T, p.(Glu99*)] in the living affected individual. The study was designed to assist in carrier testing and prenatal diagnosis within the affected family. In addition, searching for common variants in the STAR gene would help in designing low-cost targeted variation testing in other patients.

Sequence variants in three genes underlying leukodystrophy in Pakistani families.

Leukodystrophies (LDs) are a heterogeneous group of rare and progressive genetic diseases that affect brain, spinal cord, and often the peripheral nerves. They are characterized by abnormal development or destruction of the myelin sheath of the brain. This study was aimed to search for the causative variants in three unrelated consanguineous families presented with LD. Detailed clinical investigations were carried out on probands in three unrelated consanguineous families of Pakistani origin. Targeted gene sequencing and Whole Exome Sequencing (WES) were performed for variant identification. Candidate variants were checked for co-segregation with the phenotype using Sanger sequencing. Public databases including ExAC, gnomAD, dbSNP, and the 1,000 Genome Project were searched to determine frequencies of the alleles. Conservation of the missense variants was ensured by aligning orthologous protein sequences from diverse vertebrate species. Targeted gene sequencing identified a novel homozygous missense mutation [c.2135G > A, p.(Arg712His) in the ATP Binding Cassette Subfamily D Member 1 (ABCD1; OMIM# 300371) in three affected siblings in family A.WES followed by validation by Sanger sequencing revealed previously reported homozygous missense variants [c.162C > A; p.(Asn54Lys)] in ASPA (OMIM# 608034) in family B and [c.361G > C,p.(Gly121Arg)] in ARSA (OMIM# 607574) in family C. Investigation of three families underlies importance of WES as an amazing diagnostic tool for conclusive determination of a specific type of LD. Further, the study would assist in carrier testing and prenatal diagnosis of the affected families. In addition, searching for common variants in the genes causing LD would help in designing low-cost targeted variation testing in patients.

Abdominal compartment syndrome among critically ill surgical and traumatised patients: experience at Pims, Islamabad.

BACKGROUND: Raised intra-abdominal pressure (IAP) accompanied by evidence of organ dysfunction constitutes abdominal compartment syndrome (ACS). The ACS is now becoming an increasingly recognised fatal entity in the critically ill surgical and traumatized patients receiving critical care. The objectives were to determine the frequency of abdominal compartment syndrome (ACS) in critically ill surgical and traumatised patients and to identify the risk factors associated with its development in our patients. METHODS: This descriptive study was conducted at Department of Surgery, Pakistan Institute of Medical Sciences (PIMS), Islamabad from July 2004 to February 2005. Two hundred critically ill adult surgical and traumatised patients who needed catheterisation were included in the study. Patients who had cardiac tamponade, tension pneumothorax, status asthmaticus, bladder outflow obstruction, pre-existing end organ failure and those not consenting to participate in the study were excluded. Diagnosis of the underlying surgical condition was made by history, physical examination and necessary investigations. The main diagnostic tool employed for detecting ACS was the measurement of intra-cystic pressure (ICP) which was taken as an indirect measure of intra-abdominal pressure (IAP). It was measured four hourly by employing simple fluid column manometry method. Blood pressure, pulse rate, temperature, respiratory rate and urine output were recorded 4 hourly. Arterial blood gases (ABGs) and renal function tests (RFTs) were performed daily. ACS was diagnosed on the basis of raised IAP of >10 mmHg coupled with evidence of one or more end organ failure. A variety of risk factors that lead to ACS were studied among the patients. RESULTS: Out of 200 patients, six had ACS. The overall frequency was thus 3%. The M:F was 2:1. Most of the patients were in the age range of 31-40 years. Severe peritonitis, severe gut oedema, SIRS and tense ascites were recognised as statistically significant risk factors for the development of ACS. All patients with ACS had features of multiorgan dysfunction. There was 80% in-hospital mortality among the ACS sufferers. CONCLUSION: ACS develops in a significant number of critically ill and traumatised patients developing quickly and proving fatal without ACS specific interventions. All such high risk patients should undergo serial ICP measurements as a screening test for early detection of ACS.

Treating infected diabetic wounds with superoxidized water as anti-septic agent : a preliminary experience.

OBJECTIVE: To evaluate the effectiveness of superoxidized water (MicrocynTM) in diabetic patients with different wounds. STUDY DESIGN: Single-centre single blinded randomized controlled trial. PLACE AND DURATION OF STUDY: Department of General Surgery, Orthopaedics and General Medicine at Pakistan Institute of Medical Sciences, Islamabad, from April to June 2006. PATIENTS AND METHODS: One hundred known diabetic patients were enrolled. Half were randomized to the intervention group (those whose wounds were managed with superoxidized water) and half to the control group (whose wounds were treated with normal saline) using a table of random numbers. The two groups were matched for age, gender, duration of diabetes and category of wound. All patients received appropriate surgical treatment for their wounds as required. Local wound treatment was carried out daily using superoxidized water soaked gauzes on twice daily basis in the intervention group and normal saline in the control group. The treatment was continued until wound healing. The main outcome measures were duration of hospital stay, downgrading of the wound category, wound healing time and need for interventions such as amputation. RESULTS: Statistically significant differences were found in favour of the superoxidized water group with respect to duration of hospital stay, downgrading of the wound category and wound healing time. CONCLUSION: Although the initial results of employing superoxidized water for the management of infected diabetic wounds are encouraging, further multicentre clinical trials are warranted before this antiseptic is recommended for general use. It may offer an economical alternative to other expensive antiseptics with positive impact on the prevailing infection rates, patient outcomes and patient satisfaction.

Sentinel node localization in breast carcinoma.

OBJECTIVE: To determine the success rate of sentinel node dissection and the sensitivity of sentinel node to determine the presence of axillary node metastasis in women with clinically node negative breast cancer. DESIGN: Case series. PLACE AND DURATION OF STUDY: The study was conducted at Department of General Surgery Pakistan Institute of Medical Sciences, Islamabad (PIMS) and Nuclear Oncology and Radiotherapy Institute, Islamabad (NORI) from January 2002 to December 2003. PATIENTS AND METHODS: A total of 15 patients of early carcinoma breast were recruited in the study. Five patients were injected with radiocolloid and later with isosulfan blue in the subareolar region. Ten patients were given isosulfan blue only. All the patients were subjected to standard axillary clearance after sentinel node biopsy through separate incisions. Sentinel node was examined by intra-operative frozen section and all of the dissected lymph nodes were examined histopathologically for tumour deposits. RESULTS: Sentinel lymph node was successfully excised in all the cases 15/15 (100%). In 14 of the patients the sentinel node pathology was truly predictive of axillary nodal status. Sensitivity of the test was 93.33% and the positive predictive value was 100%. CONCLUSION: Sentinel node biopsy should be followed by standard axillary lymph adenectomy until the results of multiple prospective randomized trials define the role of this technique in the management of carcinoma breast.

Postpancreatitis Abscess of Falciform Ligament: An Unusual Presentation.

Pathologies of the falciform ligament are extremely rare entities ranging from cyst and hematoma to abscess and gangrene. Intestinal obstruction, secondary to extensive falciform ligament abscess, has not been reported to date. On account of being rare, diseases of falciform ligament have perplexing presentations leading to unwanted delays in diagnosis and management. These may present with abdominal wall ecchymoses (Cullen's sign - pancreatitis, portal hypertension), an abdominal mass, features of abscess, intestinal obstruction or peritonitis. Abscess may be an indicator of underlying liver or biliary pathology. Appreciating these as important differentials while working up patients with similar features, would markedly reduce missed diagnoses and improve surgical management. We present the case of a 40-year Pakistani gentleman who had duodenal obstruction owing to the presence of falciform ligament abscess resulting from a rather ignored episode of pancreatitis, mimicking malignancy.