The Karachi intracranial stenosis study (KISS) Protocol: an urban multicenter case-control investigation reporting the clinical, radiologic and biochemical associations of intracranial stenosis in Pakistan.

BACKGROUND: Intracranial stenosis is the most common cause of stroke among Asians. It has a poor prognosis with a high rate of recurrence. No effective medical or surgical treatment modality has been developed for the treatment of stroke due to intracranial stenosis. We aim to identify risk factors and biomarkers for intracranial stenosis and to develop techniques such as use of transcranial doppler to help diagnose intracranial stenosis in a cost-effective manner. METHODS/DESIGN: The Karachi Intracranial Stenosis Study (KISS) is a prospective, observational, case-control study to describe the clinical features and determine the risk factors of patients with stroke due to intracranial stenosis and compare them to those with stroke due to other etiologies as well as to unaffected individuals. We plan to recruit 200 patients with stroke due to intracranial stenosis and two control groups each of 150 matched individuals. The first set of controls will include patients with ischemic stroke that is due to other atherosclerotic mechanisms specifically lacunar and cardioembolic strokes. The second group will consist of stroke free individuals. Standardized interviews will be conducted to determine demographic, medical, social, and behavioral variables along with baseline medications. Mandatory procedures for inclusion in the study are clinical confirmation of stroke by a healthcare professional within 72 hours of onset, 12 lead electrocardiogram, and neuroimaging. In addition, lipid profile, serum glucose, creatinine and HbA1C will be measured in all participants. Ancillary tests will include carotid ultrasound, transcranial doppler and magnetic resonance or computed tomography angiogram to rule out concurrent carotid disease. Echocardiogram and other additional investigations will be performed at these centers at the discretion of the regional physicians. DISCUSSION: The results of this study will help inform locally relevant clinical guidelines and effective public health and individual interventions.

The Pakistan Risk of Myocardial Infarction Study: a resource for the study of genetic, lifestyle and other determinants of myocardial infarction in South Asia.

The burden of coronary heart disease (CHD) is increasing at a greater rate in South Asia than in any other region globally, but there is little direct evidence about its determinants. The Pakistan Risk of Myocardial Infarction Study (PROMIS) is an epidemiological resource to enable reliable study of genetic, lifestyle and other determinants of CHD in South Asia. By March 2009, PROMIS had recruited over 5,000 cases of first-ever confirmed acute myocardial infarction (MI) and over 5,000 matched controls aged 30-80 years. For each participant, information has been recorded on demographic factors, lifestyle, medical and family history, anthropometry, and a 12-lead electrocardiogram. A range of biological samples has been collected and stored, including DNA, plasma, serum and whole blood. During its next stage, the study aims to expand recruitment to achieve a total of about 20,000 cases and about 20,000 controls, and, in subsets of participants, to enrich the resource by collection of monocytes, establishment of lymphoblastoid cell lines, and by resurveying participants. Measurements in progress include profiling of candidate biochemical factors, assay of 45,000 variants in 2,100 candidate genes, and a genomewide association scan of over 650,000 genetic markers. We have established a large epidemiological resource for CHD in South Asia. In parallel with its further expansion and enrichment, the PROMIS resource will be systematically harvested to help identify and evaluate genetic and other determinants of MI in South Asia. Findings from this study should advance scientific understanding and inform regionally appropriate disease prevention and control strategies.

Role of misoprostol for therapeutic termination of pregnancy from 10 -28 weeks of gestation.

OBJECTIVE: To assess efficacy, safety and cost effectiveness of misoprostol (prostaglandin E1 analogue) for termination of pregnancy. METHODS: A descriptive study was conducted from March 2003 to December 2004, at Fauji Foundation Hospital Rawalpindi. A total of 200 patients, at 10-28 weeks of gestation, requiring termination of pregnancy were included. Each woman received first dose of 400 microg of misoprostol vaginally. Second dose of 400 microg of misoprostol was administered after 4 hours, according to the cervical dilatation, softening and uterine contractions. Oxytocin infusion was started after six hours of administration of first dose of Misoprostol, depending upon the uterine contractility. The process of abortion was monitored to assess the outcome measures. RESULTS: Successful abortion was seen in 137 (68%) patients, with induction to delivery interval of 12.2 hours. In 40 (20%) patients surgical evacuation was performed. Out of 40 patients, 27 (13.5%) underwent surgical evacuation due to incomplete abortion and 13 (6.5%) for excessive per-vaginal bleeding. A total of 23 (12%) patients had failure of method for induction of abortion and needed either repeat dose of misoprostol after 24 hours or other methods of induction (besides misoprostol). Side effects included nausea, vomiting, diarrhoea and fever. Mean hospital stay for induction of abortion was 31 hours. CONCLUSION: Misoprostol is safe, efficacious and a cost effective drug for induction of the first and the second trimester abortions.

Radical vulvectomy by two different surgical incisions.

OBJECTIVE: To determine the outcome of radical vulvectomy by two different surgical incisions (butterfly vs triple incision) for the treatment of vulval carcinoma. METHODS: A comparative study was conducted from January 1992 to July 2003 at Military Hospital Rawalpindi and Fauji Foundation Hospital Rawalpindi. A total of 35 patients were included in this study. One patient received supportive therapy at stage IVB. Out of 34 patients, 23 (67.64%) underwent radical vulvectomy by butterfly incision and 11 (32.35%) radical vulvectomy by triple incision technique. Data regarding history, clinical examination, surgical procedures, per-operative complications, post-operative complications, hospital stay, recurrence and mortality was collected and analyzed. RESULTS: The percentages of partial wound dehiscence (86.36% vs. 18.18% p = 0.00), wound induration (100% Vs 72.7%, p = 0.008), infection (22.72% vs: 9.09%, p = 0.637) and lymphoedema (9.0% vs. Zero, p = 0.542) were higher in butterfly incision group as compared to triple incision group respectively. The per-operative blood loss (750 +/- 36.9 ml vs. 381 +/- 14.7 ml, p-value: < 0.01), operative time (136.91 +/- 14.73 min Vs 81.82 +/- 14.71 min, p = 0.00) and hospital stay (19.05 +/- 3.27 days Vs 9.09 +/- 0.7 days, p = 0.00) were significantly higher in butterfly incision as compared to triple incision respectively. The recurrence rate in butterfly incision was comparable to triple incision group (14.28% vs. 18.18%, p = 0.572). In the butterfly group one patient died per-operatively and another patient died within one year after surgery. CONCLUSION: Radical vulvectomy by triple incision has comparable recurrence rate but significantly less mortality and morbidity rates when compared to butterfly incision.