Emicizumab for acquired hemophilia A: Report of two cases and dosing strategies.

Acquired hemophilia A (AHA) is a rare autoimmune bleeding disorder caused by autoantibodies against FVIII. Severe AHA is life-threatening. Currently, licensed hemostatic agents for the treatment of severe AHA have short half-lives and require intravenous administration, leading to a need for hospitalization, higher costs, and negative effects on quality of life. We present two cases of severe AHA with high inhibitor titers where emicizumab was safely and effectively used with intensive immunosuppression. These reports suggest in vivo efficacy even in high inhibitor environments. The optimal dosing regimen (accelerated vs. standard loading, maintenance frequency) is unknown and we discuss the current approaches.

Catecholaminergic Polymorphic Ventricular Tachycardia and Gene Therapy: A Comprehensive Review of the Literature.

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is an inherited channelopathy. In this review, we summarize the epidemiology, pathophysiology, clinical characteristics, diagnostics, genetic mutations, standard treatment, and the emergence of potential gene therapy. This inherited cardiac arrhythmia presents in a bimodal distribution with no association between sex or ethnicity. Six different CPVT genes have been identified, however, most of the cases are related to a heterozygous, gain-of-function mutation on the ryanodine receptor-2 gene (RyR2) and calsequestrin-2 gene (CASQ2) that causes delayed after-depolarization. The diagnosis is clinically based, seen in patients presenting with syncope after exercise or stress-related emotions, as well as cardiac arrest with full recovery or even sudden cardiac death. Standard treatment relies on beta-blockers, with add-on therapy, flecainide, and cardiac sympathetic denervation as second-line treatments. An implantable cardioverter-defibrillator is indicated for patients who have suffered a cardiac arrest. Potential gene therapy has emerged in the last 20 years and accelerated because of associated viral vector application in increasing the efficiency of prolonged cardiac gene expression. Nevertheless, human trials for gene therapy for CPVT have been limited as the population is rare, and an excessive amount of funding is required.

Chaotic transformation of parotid acinic cell carcinoma to metastatic dedifferentiated high-grade pathology - A rare case with clinical and emotional challenge.

INTRODUCTION AND IMPORTANCE: Acinic cell carcinoma (AciCC) is a rare entity in which high-grade transformation (HGT), formerly dedifferentiation, is uncommon. This case report presents a rare case of AciCC, with rapid transformation to metastatic high-grade dedifferentiated pathology after initial curative treatment. CASE PRESENTATION: A 58-year-old woman presented in the medical oncology clinic with a progressive swelling on the right side of her face. Magnetic resonance imaging revealed a 5 × 5 cm lobulated parotid gland lesion, and fine needle aspiration biopsy was consistent with carcinoma. After informed consent, a Modified-Blair incision was given as a standard approach to the right preauricular area under general anaesthesia, and a right superficial parotidectomy with the removal of the tumor and selective lymph node dissection was performed. Histopathology of the resected mass was reported as parotid AciCC. She was given adjuvant radiation therapy. A repeat PET CT scan ten weeks after the completion of her adjuvant radiation treatment showed local disease recurrence as well as multiple pulmonary deposits. A repeat biopsy was reported as DOG-1 positive dedifferentiated (high-grade) acinic cell carcinoma, and she was offered platinum-based palliative systemic chemotherapy. CLINICAL DISCUSSION: Parotid acinic cell carcinomas with high-grade transformation are rare. This case highlights its critical diagnostic markers, curative and palliative management and long-term follow-up. CONCLUSION: The transformation of parotid AciCC to high-grade, dedifferentiated pathology is unusual and belligerent. Hence, these tumors need intense treatment with a multimodality approach. Close follow-ups with history and physical examination, along with periodic imaging, should be considered for these patients.

The Importance of Sociocultural Factors for Understanding and Managing Genito-Pelvic Pain/Penetration Disorder: The Example of Muslim Societies.

ABSTRACT: Although potentially disabling for couples, genito-pelvic pain/penetration disorder (GPP/PD) is still not well understood. In Muslim countries, this condition reaches high levels, which could be because of the traditional social background. In this study, we aimed to identify the sociocultural determinants leading to GPP/PD in countries in the Middle East/North Africa, the Arabian Peninsula, and Turkey and to discuss the implications on management.This systematic review of quantitative and qualitative studies was conducted on three databases: Medline, Embase, and Google Scholar. The review includes all-time articles that examined the sociocultural factors related to GPP/PD in Muslim societies. The majority of the couples had poor sexual education despite their high educational level. They often visited traditional healers, general practitioners, and gynecologists before being referred to sexologists. With adequate treatment, the majority could achieve penetration rapidly.Muslim countries show high levels of PD, which might be due to their strict religious background. The latter should be integrated into the management for better results.

Updated Outlook of Cerebral Amyloid Angiopathy and Inflammatory Subtypes: Pathophysiology, Clinical Manifestations, Diagnosis and Management.

Cerebral amyloid angiopathy (CAA) is a common untreatable cause of lobar hemorrhages and cognitive decline in the older population. Subset of patients present with its inflammatory subtype with rapid decline in cognitive functions and neurological deficits. Most commonly the underlying pathophysiology of this disease is deposition of insoluble amyloid protein into blood vessel walls which results in vessel fragility leading to local neurotoxicity which may eventually leads to lobar hemorrhages and cognitive decline. The term "Amyloid Spell" encompasses transient focal neurological deficits which is commonly misdiagnosed as seizures or transient ischemic attack in the emergency department. Radiologic findings in these patients may reveal microbleeds, cortical superficial siderosis, white matter hyperintensities, and cerebral edema which support the clinical diagnosis which could be otherwise challenging. CAA diagnostic criteria require CT (Edinburgh Criteria) or MRI imaging, or neuropathology. The diagnosis can be suspected without imaging or neuropathology but cannot be confirmed. This review article provides a critical outlook on different types of presentations, updated diagnostic criteria and management of CAA patients illustrating underlying mechanisms associated with neuronal injury secondary to amyloid deposition.

Sirolimus vs tacrolimus: Which one is the best therapeutic option for patients undergoing liver transplantation for hepatocellular carcinoma?

Liver transplantation (LT) withstands as the most preferred therapeutic option for patients afflicted with hepatocellular carcinoma (HCC) and cirrhosis. To improve prognosis post-transplant, as well as to prevent the occurrence of rejection, a life-long immunosuppression strategy is implemented. The following letter to the editor highlights and provides novel evidence from recently published literature on topics discussed within the review article titled "Trends of rapamycin in survival benefits of liver transplantation for hepatocellular carcinoma" in World J Gastrointest Surg 2021; 13: 953-966. In the recent manuscript, the authors compared immunosuppressive drugs such as the newer option first-generation mammalian target of rapamycin inhibitor, also known as sirolimus, with the most widely used first-generation calcineurin inhibitors, such as tacrolimus (TAC). TAC is commonly known as the most effective immunosuppressive drug after LT, but it has been reported to cause intolerable side effects such as nephrotoxicity, neurotoxicity, diabetes, hypertension, gastrointestinal disturbances, increased risk of infections, and malignancies. It is necessary for physicians to be aware of recent advances in tacrolimus and sirolimus therapies to compare and understand distinctly the effectiveness and tolerability of these drugs. This will assist clinicians in making the best treatment decisions and improve the clinical prognosis of LT recipients with HCC.

Three-dimensional visualization and virtual reality simulation role in hepatic surgery: Further research warranted.

Artificial intelligence (AI) is the study of algorithms that enable machines to analyze and execute cognitive activities including problem solving, object and word recognition, reduce the inevitable errors to improve the diagnostic accuracy, and decision-making. Hepatobiliary procedures are technically complex and the use of AI in perioperative management can improve patient outcomes as discussed below. Three-dimensional (3D) reconstruction of images obtained via ultrasound, computed tomography scan or magnetic resonance imaging, can help surgeons better visualize the surgical sites with added depth perception. Pre-operative 3D planning is associated with lesser operative time and intraoperative complications. Also, a more accurate assessment is noted, which leads to fewer operative complications. Images can be converted into physical models with 3D printing technology, which can be of educational value to students and trainees. 3D images can be combined to provide 3D visualization, which is used for preoperative navigation, allowing for more precise localization of tumors and vessels. Nevertheless, AI enables surgeons to provide better, personalized care for each patient.

Knowledge and perception of Sepsis among Doctors in Karachi Pakistan.

Objectives: To assess knowledge and perception among Pakistani physicians towards sepsis. Methods: This cross-sectional study was conducted in Indus Hospital and Health Networks from September 2020 to March 2021. The International Sepsis Survey questionnaire was adapted, and its link was sent to trainee physicians as well as specialists, and consultants practicing in various hospitals via social media. Knowledge and perception were scored and 50% was considered the cut-off score for adequacy. Data was analyzed using SPSS version 26. Results: Analysis was done on 222 respondents who completed the survey. 37.9% of the participants had adequate knowledge. Knowledge regarding sepsis was significantly associated with specialty, ICU/CCU/HDU, and work experience (P-value <0.0001). More recent trainee physicians and those with more experience in critical care areas demonstrated better knowledge. Over 2/3rd of the respondents strongly agreed that sepsis remains one of the unmet needs in critical care today. Conclusion: A common belief exists that sepsis remains a challenge to treat among doctors. Moreover, there is consensus that it is the most frequently miss diagnosed condition in critical care and a dire need exists for its early diagnosis. Additionally, prompt management of presumed sepsis is imperative to improve outcomes.

Epidemiology of in-hospital cardiac arrest in a Pakistani tertiary care hospital pre- and during COVID-19 pandemic.

Objectives: To determine epidemiology of in-hospital cardiac arrest (IHCA) in a tertiary care hospital, pre- and during pandemic. Methods: This is a cross-sectional study of inpatients who experienced an in-hospital-cardiac arrest at a tertiary care hospital in Karachi between August 2019 and August 2020. Outcome variables were return of spontaneous circulation (ROSC) and survival to discharge (StD) and analysis was also done comparing pre- and during pandemic period. Results: A total of 77 patients experienced at least one IHCA event during the 1-year study period. Comparing pre- and during pandemic, ROSC for women was higher during the pandemic albeit not significant (43% vs 50%) in comparison to men (54% vs 10%, p<0.001). During the pandemic, women with IHCA were significantly younger than men (µ ± sd; 36.8 ± 15.3 vs 55.9 ± 12.7, p=0.001,) whereas pre-pandemic, there was no gender differences in mean age. Non-shockable rhythm was more common (92.2%) than shockable rhythm (6.5%). Pre- and during pandemic, there were significant differences in the cause of IHCA for 4H4T (87% vs 100%) and cardiac (36% vs 9%). The proportion of hypoxic patients increased from 50% during pre-pandemic to 91% during the pandemic period, whereas hypo/hyperkalemia decreased from 53% to 34%. Conclusion: Despite the limitation of a small sample size, our study has provided important information regarding the epidemiology and outcomes of IHCA pre- and during pandemic in a busy Pakistani tertiary care hospital. Our finding that gender differences exist in survival pre- and during pandemic needs to be explored further with more hospitals doing comparative studies.

Atezolizumab plus bevacizumab versus sorafenib or atezolizumab alone for unresectable hepatocellular carcinoma: A systematic review.

BACKGROUND: Despite the use of current standard therapy, the prognosis of patients with unresectable hepatocellular carcinoma (HCC) is poor, with median survival times of 40 mo for intermediate HCC (Barcelona Clinic Liver Cancer [BCLC] stage B) and 6-8 mo for advanced HCC (BCLC stage C). Although patients with early-stage HCC are usually suitable for therapies with curative intention, up to 70% of patients experience relapse within 5 years. In the past decade, the United States Food and Drug Administration has approved different immunogenic treatment options for advanced HCC, the most common type of liver cancer among adults. Nevertheless, no treatment is useful in the adjuvant setting. Since 2007, the multi-kinase inhibitor sorafenib has been used as a first-line targeted drug to address the increased mortality and incidence rates of HCC. However, in 2020, the IMbrave150 trial demonstrated that combination therapy of atezolizumab (anti-programmed death-ligand 1 [PD-L1]) and bevacizumab (anti-vascular endothelial growth factor [VEGF]) is superior to sorafenib, a single anti-programmed death 1/PD-L1 antibody inhibitor used as an anti-cancer monotherapy for HCC treatment. AIM: To conduct a systematic literature review to evaluate the evidence supporting the efficacy and safety of atezolizumab/bevacizumab as preferred first-line drug therapy over the conventional sorafenib or atezolizumab monotherapies, which are used to improve survival outcomes and reduce disease progression in patients with unresectable HCC and non-decompensated liver disease. METHODS: A comprehensive literature review was conducted using the PubMed, Scopus, ScienceDirect, clinicaltrials.gov, PubMed Central, Embase, EuropePMC, and CINAHL databases to identify studies that met the inclusion criteria using relevant MeSH terms. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and risk of bias (RoB) were assessed using the Cochrane RoB 2 tool and Sevis. RESULTS: In the atezolizumab/bevacizumab group, an improvement in overall tumor response, reduction of disease progression, and longer progression-free survival were observed compared to monotherapy with either sorafenib or atezolizumab. Hypertension and proteinuria were the most common adverse events, and the rates of adverse events were comparable to those with the monotherapy. Of the studies, there were two completed trials and two ongoing trials analyzed using high quality and low bias. A more thorough analysis was only performed on the completed trials. CONCLUSION: Treatment of HCC with atezolizumab/bevacizumab combination therapy was confirmed to be an effective first-line treatment to improve survival in patients with unresectable HCC and non-decompensated liver disease compared to monotherapy with either sorafenib or atezolizumab.

Targeting Inflammatory Mediators: An Anticancer Mechanism of Thymoquinone Action.

BACKGROUND: Thymoquinone is a promising anticancer molecule, the chemopreventive role of which is well-known at least in vitro and in the animal model. In this review article, we focused on the anti-inflammatory activities of thymoquinone in cancer cells. METHOD: Research data on inflammation, cancer and thymoquinone were acquired from PubMed, Scopus, Web of Science and Google Scholar. We reviewed papers published since the mid of the last century, and the most cited papers of the last ten years. RESULTS: Studies indicate that thymoquinone possesses immunomodulatory activities, in addition to its chemopreventive role, as thymoquinone can target and modulate inflammatory molecules, like nuclear factor kappa B (NF-κß), interleukins, tumor necrosis factor-α (TNF-α), and certain growth factors. As chronic inflammation plays an important role in cancer development, controlling inflammatory pathways is an important mechanism of an anticancer molecule, and modulation of inflammatory pathways might be one of the key mechanisms of thymoquinone's anticancer activities. CONCLUSION: This article reviewed the role of inflammation on cancer development, and the action of thymoquinone on inflammatory molecules, which have been proved in vitro and in vivo. Much attention is required for studying the role of thymoquinone in immunotherapeutics and developing this molecule as a future anticancer drug.

Renal Injury in All-Comers After Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis.

Background Acute kidney injury (AKI) following aortic valve replacement is associated with poor prognosis. Transcatheter aortic valve replacement (TAVR) is a novel strategy with a percutaneous approach and early recovery time. We conducted this meta-analysis to compare TAVR to surgical aortic valve replacement (SAVR) and their respective renal outcomes. Methods We searched for randomized controlled trials (RCTs) using MEDLINE, PUBMED, and Google Scholar databases from their inception till April 6, 2019, and included eight trials comparing TAVR to SAVR in cases that reported AKIs. Results We found a significant reduction in AKI after TAVR compared to SAVR at 30 days [n = 66 vs. n = 160, respectively; odds ratio (OR) = 0.38, 95% confidence interval (CI) = 0.28-0.51; p: <0.00001, I2 = 0%]. At one year, a trend towards reduced renal failure was noted in the TAVR arm compared to the SAVR arm (n = 74 vs. n = 129, respectively; OR = 0.57, 95% CI = 0.32-1.01; p = 0.05, I2 = 69%). Conclusion Based on our findings and analysis, we have concluded that TAVR is associated with significantly reduced renal injury at 30 days when compared to SAVR.

Combined Wharton's jelly derived mesenchymal stem cells and nerve guidance conduit: A potential promising therapy for peripheral nerve injuries.

BACKGROUND: Peripheral nerve injuries represent a clinical problem with insufficient or unsatisfactory treatment options. Functional outcome with nerve guidance conduits was unsatisfactory in nerve defects with increased gap size. So, cell therapy may benefit as a tool for optimizing the regeneration process. The aim of the present study was to evaluate the impact of combination of cell therapy and nerve guidance conduits on the nerve regeneration and on the expression of the factors aiding the regeneration in a rat model of sciatic nerve injury. METHODS AND RESULTS: Sixty Wistar rats were randomly divided into four groups: Group I: normal control group; Group II: sciatic nerve injury (SNI) with a 10mm long sciatic nerve gap; Group III: SNI with using a nerve conduit (NC) for nerve gap bridging; and Group IV: SNI with using a NC associated with Wharton's jelly derived mesenchymal stem cells (WJ-MSCs). The results showed that the combination therapy NC+WJ-MSCs caused much better beneficial effects than NC alone evidenced by increasing sciatic nerve index and pin-prick score. The histopathological analysis found that the use of the NC combined with WJ[HYPHEN]MSCs resulted in a structure of the sciatic nerve comparable to the normal one with better nerve regeneration when compared with NC only. There was no differentiation of WJ-MSCs into nerve structure. Lastly, there was an upregulation of expression for netrin-1, ninjurin, BDNF, GDNF, VEGF and angiopoitin-1 rat genes in NC+WJ-MSCs group than NC alone. CONCLUSION: The addition of WJ-MSCs to the nerve guidance conduits seems to bring significant advantage for nerve regeneration, basically by increasing the expression of neurotrophic and angiogenic factors establishing more favorable environment for nerve regeneration.

Phytotoxicity evaluation of some commonly used shampoos using Brassica napus L.

Hair shampoos are among the most commonly used chemicals in everyday life. Since shampoos are a major component of domestic and municipal wastewater, they may affect plants when irrigated with wastewater. However, their effects on plants have never been investigated in detail. The present study was aimed to evaluate the effect of some commonly used hair shampoos on seed germination and seedling vigor of Brassica napus. Seeds of Brassica napus were exposed to different concentrations of hair shampoos, i.e., 0 (control), 0.001, 0.01, 0.1, 1.0, and 10 %. The obtained results revealed that germination was not very sensitive to shampoo stress and was significantly inhibited only at the highest tested concentration (10 %) of shampoo except in the case of one shampoo where it was inhibited at concentration of 1 % or above. The other tested parameters of Brassica napus were comparatively more sensitive than germination to shampoo stress. However, at lower concentrations of shampoos, stimulatory effects were also observed in some cases. Although no exact data is available on shampoo concentration in wastewater used for irrigation, it is unlikely that shampoo concentration in irrigation water reach so high and pose adversity to plants.

Regional implementation of newborn screening for critical congenital heart disease screening in Abu Dhabi.

Congenital heart disease (CHD) is the most common birth defect and affects approximately 8 out of every 1,000 infants born each year. Despite antenatal screening and at least one examination before discharge infants with critical CHD (CCHD) are routinely not detected before discharge from the newborn nursery. Newborn screening for CCHD using pulse oximetry is widely endorsed however until recent efforts, CCHD screening programs had only been implemented at the individual hospital level. The purpose of this paper is to describe the implementation of CCHD screening across the entire Emirate of Abu Dhabi. The Health Authority-Abu Dhabi (HAAD), in collaboration with Children's National Medical Center (Children's National), successfully implemented CCHD screening at the emirate level using a "train-the-trainer," two-tiered approach, starting with two pilot hospitals then rolling the program out to all birthing facilities. In the first year, CCHD screening was added as a mandatory test to the HAAD Newborn Screening Standard, has been implemented in most birthing facilities, and occurs for the majority of infants (86 %) in Abu Dhabi. This led to the identification of ten newborns with CCHD. Based on the successful identification and mitigation of barriers to implementation, the approach may be adapted for similar programs in other populations.

Health burden of skin lesions at low arsenic exposure through groundwater in Pakistan. Is river the source?

A significant proportion of groundwater in south Asia is contaminated with arsenic. Pakistan has low levels of arsenic in groundwater compared with China, Bangladesh and India. A representative multi-stage cluster survey conducted among 3874 persons > or = 15 years of age to determine the prevalence of arsenic skin lesions, its relation with arsenic levels and cumulative arsenic dose in drinking water in a rural district (population: 1.82 million) in Pakistan. Spot-urine arsenic levels were compared among individuals with and without arsenic skin lesions. In addition, the relation of age, body mass index, smoking status with arsenic skin lesions was determined. The geographical distribution of the skin lesions and arsenic-contaminated wells in the district were ascertained using global positioning system. The total arsenic, inorganic and organic forms, in water and spot-urine samples were determined by atomic absorption spectrophotometry. The prevalence of skin lesions of arsenic was estimated for complex survey design, using surveyfreq and surveylogistic options of SAS 9.1 software.The prevalence of definitive cases i.e. hyperkeratosis of both palms and soles, was 3.4 per 1000 and suspected cases i.e. any sign of arsenic skin lesions (melanosis and/or keratosis), were 13.0 per 1000 among > or = 15-year-old persons in the district. Cumulative arsenic exposure (dose) was calculated from levels of arsenic in water and duration of use of current drinking water source. Prevalence of skin lesions increases with cumulative arsenic exposure (dose) in drinking water and arsenic levels in urine. Skin lesions were 2.5-fold among individuals with BMI <18.5 kg/m2. Geographically, more arsenic-contaminated wells and skin lesions were alongside Indus River, suggests a strong link between arsenic contamination of groundwater with proximity to river.This is the first reported epidemiological and clinical evidence of arsenic skin lesions due to groundwater in Pakistan. Further investigations and focal mitigation measures for arsenic may be carried out alongside Indus River.

Hyperendemic pulmonary tuberculosis in peri-urban areas of Karachi, Pakistan.

BACKGROUND: Currently there are very limited empirical data available on the prevalence of pulmonary tuberculosis among residents of marginalized settings in Pakistan. This study assessed the prevalence of pulmonary tuberculosis through active case detection and evaluated predictors of pulmonary tuberculosis among residents of two peri-urban neighbourhoods of Karachi, Pakistan. METHODS: A cross-sectional study was conducted in two peri-urban neighbourhoods from May 2002 to November 2002. Systematic sampling design was used to select households for inclusion in the study. Consenting subjects aged 15 years or more from selected households were interviewed and, whenever possible, sputum samples were obtained. Sputum samples were subjected to direct microscopy by Ziehl-Neelson method, bacterial culture and antibiotic sensitivity tests. RESULTS: The prevalence (per 100,000) of pulmonary tuberculosis among the subjects aged 15 years or more, who participated in the study was 329 (95% confidence interval (CI): 195-519). The prevalence (per 100,000) of pulmonary tuberculosis adjusted for non-sampling was 438 (95% CI: 282-651). Other than cough, none of the other clinical variables was significantly associated with pulmonary tuberculosis status. Analysis of drug sensitivity pattern of 15 strains of Mycobacterium tuberculosis revealed that one strain was resistant to isoniazid alone, one to streptomycin alone and one was resistant to isoniazid and streptomycin. The remaining 12 strains were susceptible to all five drugs including streptomycin, isoniazid, rifampicin, ethambutol, and pyrazinamide. CONCLUSION: This study of previously undetected tuberculosis cases in an impoverished peri-urban setting reveals the poor operational performance of Pakistan's current approach to tuberculosis control; it also demonstrates a higher prevalence of pulmonary tuberculosis than current national estimates. Public health authorities may wish to augment health education efforts aimed at prompting health-seeking behaviour to facilitate more complete and earlier case detection. Such efforts to improve passive case-finding, if combined with more accessible DOTS infra-structure for treatment of detected cases, may help to diminish the high tuberculosis-related morbidity and mortality in marginalized populations. The economics of implementing a more active approach to case finding in resource-constrained setting also deserve further study.

Breast cancer risk factor knowledge among nurses in teaching hospitals of Karachi, Pakistan: a cross-sectional study.

BACKGROUND: Breast cancer is the most common cancer among women in both the developed and the developing world. The incidence of breast cancer in Karachi, Pakistan is 69.1 per 100,000 with breast cancer presentation in stages III and IV being common (>or= 50%). The most pragmatic solution to early detection lies in breast cancer education of women. Nurses constitute a special group having characteristics most suited for disseminating breast cancer information to the women. We assessed the level of knowledge of breast cancer risk factors among registered female nurses in teaching hospitals of Karachi. We also identified whether selected factors among nurses were associated with their knowledge of breast cancer risk factors, so that relevant measures to improve knowledge of nurses could be implemented. METHODS: A cross-sectional survey was conducted in seven teaching hospitals of Karachi using stratified random sampling with proportional allocation. A total of 609 registered female nurses were interviewed using a structured questionnaire adapted from the Stager's Comprehensive Breast Cancer Knowledge Test. Knowledge of breast cancer risk factors was categorized into good, fair and poor categories. Ordinal regression was used to identify factors associated with risk knowledge among nurses. RESULTS: Thirty five percent of nurses had good knowledge of risk factors. Graduates from private nursing schools (aOR = 4.23, 95% CI: 2.93, 6.10), nurses who had cared for breast cancer patients (aOR = 1.41, 95% CI: 1.00, 1.99), those having received a breast examination themselves (aOR = 1.56, 95% CI: 1.08, 2.26) or those who ever examined a patient's breast (aOR = 1.87, 95% CI: 1.34, 2.61) were more likely to have good knowledge. CONCLUSION: A relatively small proportion of the nursing population had good level of knowledge of the breast cancer risk factors. This knowledge is associated with nursing school status, professional breast cancer exposure and self history of clinical breast examination. Since only about one-third of the nurses had good knowledge about risk factors, there is a need to introduce breast cancer education in nursing schools particularly in the public sector. Continuing nursing education at the workplace can be of additional benefit.