Availability And Storage Conditions Of Essential Medicines At Primary Healthcare Facilities In Punjab, Pakistan.

BACKGROUND: Availability of essential medicines is one of the most important universal human right. For one third of the world, unavailability of essential medicines remains a major problem. The objective of this study is to authenticate the availability of essential medicines along with the storage conditions at primary healthcare level, district central warehouses and private pharmacies in the rural areas. METHODS: A community based cross-sectional survey was conducted in five districts of Punjab, Pakistan. Data was collected retrospectively and prospectively, by World Health Organization (WHO) tool, Operational Package for Assessing, Monitoring and Evaluating Country Pharmaceutical Situations. RESULTS: On an average availability of essential medicines in primary healthcare, private pharmacies, and warehouses were 90.32±1.78 (SD), 82.83±2.75 (SD) and 96±0.83 (SD), respectively. Stock out duration of essential medicines in primary healthcare and district central warehouses were 11.56±4.08 (SD) and 10.24±5.95 (SD) respectively. Expired medicines were not found. Storage conditions of medicines in store room in PHC, private pharmacies and district central warehouses were 75.76±1.53(SD), 73.33±2.16 (SD), and 82.0±2.48 (SD) respectively. Storage conditions of dispensing room in PHC and private pharmacies were 66.06±2.52 (SD) and 39.65±4.25 (SD) respectively. CONCLUSION: Availability of essential medicines was below WHO standards. Medicines were found to be stocked out. No expired medicine was found on shelves. Storage conditions of medicines were poor.

COVID-19: lessons for junior doctors redeployed to critical care.

Approximately 4% of patients with coronavirus disease 2019 (COVID-19) will require admission to an intensive care unit (ICU). Governments have cancelled elective procedures, ordered new ventilators and built new hospitals to meet this unprecedented challenge. However, intensive care ultimately relies on human resources. To enhance surge capacity, many junior doctors have been redeployed to ICU despite a relative lack of training and experience. The COVID-19 pandemic poses additional challenges to new ICU recruits, from the practicalities of using personal protective equipment to higher risks of burnout and moral injury. In this article, we describe lessons for junior doctors responsible for managing patients who are critically ill with COVID-19 based on our experiences at an urban teaching hospital.

Lack of Androgen Receptor Expression Selects for Basal-Like Phenotype and Is a Predictor of Poor Clinical Outcome in Non-Metastatic Triple Negative Breast Cancer.

Background: Androgen receptor (AR) has emerged as a significant favorable prognostic indicator in estrogen receptor expressing (ER+) breast cancer (BCa); however, its clinical and biological relevance in triple negative breast cancer (TNBC) and association with cancer stem cell (CSC) markers remain ambiguous. Methods: We examined the immunohistochemical expression of AR in a cohort of stage I-III TNBC cases (n = 197) with a long-term clinical follow-up data (mean follow-up = 53.6 months). Significance of AR expression was correlated with prognostic biomarkers including cancer stem cell markers (CD44, CD24, and ALDH1), basal markers (CK5, CK14, and nestin), proliferation marker (ki-67), apoptotic marker (Bcl-2), and COX-2. Expression of CK5 and nestin was used for the categorization of TNBC into basal (TN, CK5+, and/or nestin+) and non-basal (TN, CK5-, and/or nestin-) phenotypes, and Kaplan-Meier curves were used for estimation of overall survival and breast cancer-specific survival (BCSS). Results: AR expression was observed in 18.8% of non-metastatic TNBC tumors. Expression of AR correlated with lower grade (P < 0.001) and conferred a favorable prognostic significance in patients with axillary lymph node metastasis (P = 0.005). Lack of AR expression correlated with expression of CSC phenotype (CD44+/CD24-) (P < 0.001), COX-2 (P = 0.02), basal markers (CK5: P = 0.03), and nestin (P = 0.01). Basal-like phenotype (TN, CK5+, and/or nestin+) correlated with quadruple-negative breast cancer (QNBC) and showed a significant association with adverse prognostic markers including high proliferation index (P < 0.001), expression of COX-2 (P = 0.009), and CSC phenotype (CD44+/CD24-: P = 0.01). Expression of AR remained an independent prognostic indicator for improved overall survival (P = 0.003), whereas basal-like phenotype was associated with an adverse BCSS (P = 0.013). Conclusions: Assessment of AR and basal markers identified biologically and clinically distinct subgroups of TNBC. Expression of AR defined a low-risk TNBC subgroup associated with improved overall survival, whereas expression of basal markers (CK5 and nestin) identified a high-risk subgroup associated with adverse BCSS. Integration of immunohistochemical analysis of AR and basal biomarkers to the assessment of TNBC tumors is expected to improve the prognostication of an otherwise heterogeneous disease.

Optically selective and electrochemically active chemosensors for Cu (II) ions based on a skeleton of 2-(benzylideneamino)-4,5,6,7-tetrachloro-3',6'-dihydroxyspiro-[isoindoline-1, 9'-xanthen]-3-one.

A new series of fluorescent chemosensors (7a-7f) based on a core skeleton of 2-(benzylideneamino)-4,5,6,7-tetrachloro-3',6'-dihydroxyspiro-[isoindoline-1,9'-xanthen]-3-one was synthesized and characterized by FT-IR, NMR and mass spectrometric techniques. The sensitivity and selectivity of probes (7a-7f) for Cu2+ ions were investigated by colorimetric, UV-vis absorption, fluorescence emission spectral studies and electrochemical analysis. These optical probes exhibited higher sensitivity and selectivity towards Cu2+ ions in DMSO solution over various other metal cations under consideration. Induced changes were observable by naked-eye. Based on fluorescence titration spectra and Job's-plot, it was found that the complexes formed between probes (7a-7f) and Cu2+ ions were in 1:1 stoichiometric ratio. The detection limit for chemosensors (7a-7f) were calculated to be 3.0834 × 10-7-3.6425 × 10-7 M.

Success And Safety Of Misoprostol For Treatment Of Early Pregnancy Failure.

BACKGROUND: Early pregnancy failure is a common complication in pregnancies. It can be managed medically as well as surgically. Lately there has been an emphasis on medical management of early pregnancy failure. Misoprostol, a Prostaglandin E1 analogue has been found to be safe and effective in treatment of early pregnancy failure. METHODS: This was a descriptive cross-sectional study that was conducted at the department of gynaecology and obstetrics, Ayub teaching hospital Abbottabad from Jan 2015 to Dec 2016. A total of 81 pregnant women with early pregnancy failure were enrolled in the study. Misoprostol was administered in a dose of 800 µg PO and repeated every 3 hours for a maximum of three doses if and when required. RESULTS: Misoprostol was effective in 60 (74.07%) patients and it resulted in complete expulsion of products of conception. The remainder needed surgical evacuation. There was a low incidence of side effects with nausea being the most common (4.94%) followed by PV bleeding (3.70%), abdominal cramps (3.70%) and diarrhoea (2.47%). CONCLUSIONS: Misoprostol is a safe and effective treatment option for the management of early pregnancy failure.

Domestic Violence Among Pregnant Women.

BACKGROUND: Domestic violence during pregnancy is an important social & health issue in all societies. In Muslim world and particularly underdeveloped countries, domestic violence is often under reported. It is the need of hour to encourage reporting of such events & implementation of research-based policies for prevention of women abuse & support of the victims of domestic violence (DV). The objective of this study was to highlight this neglected social problem of our society & to identify at risk population. METHODS: This is a cross sectional study conducted at Ayub Teaching Hospital & Benazir Bhutto Shaheed Teaching Hospital, Abbottabad (January 2014 to December. 2016). Pregnant women were inquired regarding history of abuse by husband and sociodemographic characteristics were noted in a Performa to analyse the risk factors for domestic violence. RESULTS: The overall prevalence was found to be 35%. Out of 1000 pregnant women, 270 (27%) suffered from simple violence and 60 (6%) were victims of grievous assault. Violence among pregnant women is found to be more prevalent among residents of urban areas, women of older age being uneducated & belonging to poor socioeconomic status. CONCLUSIONS: Domestic violence during pregnancy is a common & often neglected psychosocial health problem. High risk population needs to be identified so that preventive strategies can be planned & implemented.

Expression of Androgen Receptor and Cancer Stem Cell Markers (CD44+/CD24- and ALDH1+): Prognostic Implications in Invasive Breast Cancer.

BACKGROUND: Androgen receptor (AR) has emerged as a significant prognostic marker in early breast cancer (BCa). Association of AR with cancer stem cell (CSC) markers in BCa is unknown. Aim of the present study was to evaluate the immunohistochemical expression of AR, CD44, CD24 and ALDH1 in a cohort of Pakistani patients diagnosed with invasive BCa and to correlate the expression with 5- year disease free survival. PATIENTS AND METHODS: We evaluated immunohistochemical expression AR, CD44, CD24 and ALDH1 in formalin fixed paraffin embedded archival blocks of 166 cases of primary invasive BCa (stage I-III) and correlated the expression with clinicopathological variables and outcome using univariable and multivariable analysis. Survival data was computed by Kaplan Meier curves. RESULTS: Expression of AR was observed in 62.7% tumors whereas CD44, CD24 and ALDH1 were expressed in 61.4%, 44% and 30.1% tumors, respectively. AR expression was significantly associated with T1-T2 tumors, lower grade, estrogen and progesterone receptor expression (P < .05) and remained an independent prognostic indicator in multivariable analysis (adjusted HR 0.33, 95% CI 0.13-0.81; P = .016). Significant association was observed between concordant expression of AR and CD24 (P = .001) with a favorable impact on survival (P = .007) whereas expression of CSC phenotypes (CD44+, CD44+/CD24- and ALDH1+) did not correlate with adverse outcome (P > .05). However, AR expression retained the association with better prognosis even in patients whose tumors exhibited a CSC phenotype. CONCLUSIONS: Expression of AR and CD24 in stage I-III invasive BCa correlates with favorable clinicopathological features and delineates a subgroup of patients with better disease-free survival.

Diaphonization: a recipe to study teeth.

AIM: There are various techniques to study root canal morphology and diaphonization is one of them. There are various methods of decalcification and diaphonization, cited in literature and the main aim of this paper was to give a brief account of the various techniques and share our experience of the technique at a teaching institution in Karachi, Pakistan. MATERIALS AND METHODS: Diaphonization is one of the oldest methods and is based on decalcification of teeth followed by clearing and dye penetration. The specimen is later studied under microscope without sectioning. RESULTS: After the process of clearing a three-dimensional (3D) structure of the internal canal anatomy was visible with naked eye. CONCLUSION: This paper entails a detailed historical background as well as the author's technique including percentages of various chemicals used and the timing of immersion of teeth into these agents. CLINICAL SIGNIFICANCE: The read out is simple and can be subjected to interpretation by direct observation under microscope and can be helpful for students undertaking research in not only the discipline of dentistry but also in other fields such as botany and zoology.

Effect of teriparatide on bone regenerate after distraction osteogenesis.

OBJECTIVE: To determine the effect of teriparatide on new bone formation in a rat model of distraction osteogenesis. METHODS: The experimental study was conducted at the Aga Khan University Hospital, Karachi, in November-December 2010, and comprised male Sprague-Dawley rats weighing 250gm each who were allocated to two treatment groups, teriparatide and saline, both given subcutaneously for 7 weeks. Femoral distraction was done for 3 weeks at the rate of 0.4mm/day, followed by a further 4 weeks for consolidation. New bone formation was assessed using X-ray scoring system, bone densitometry and histology. RESULTS: The 12 rats in the study were divided into two groups of 6(50%) each. All rats in the teriparatide group showed new bone formation whereas bone formation was present only in 2(33.3%) rats in the saline group. Bone densitometry showed that area (size) of the new bone formed adjacent to the margins of the osteotomy site as well as the total bone mineral content of the new bone was significantly higher (p<0.05) in the teriparatide group. Histological analysis showed larger but statistically insignificant (p>0.05) area of woven and trabecular new bone in the teriparatide group. CONCLUSIONS: The results suggested a promising role of parathyroid analogue therapy in distraction osteogenesis for promoting bone formation and consolidation. This may have strong clinical implications in cases of limb lengthening and bone transport.

Vaginal breech delivery: still a safe option.

BACKGROUND: Elective caesarean section has replaced vaginal delivery for term breech foetuses due to fear of complications of vaginal breech delivery. This increasing rate of caesarean section worldwide is alarming. It has not only led to increase in adverse consequences in subsequent pregnancies and future fertility but also loss of skills for vaginal breech delivery. This study was conducted to determine the safety of vaginal breech birth in terms of maternal and neonatal complications. METHODS: This cross sectional study was conducted at department of Obstetrics/Gynaecology, Ayub Medical College, Abbottabad from January 2004 to December 2011. One seventy-eight women having successful vaginal breech delivery of singleton term foetuses from 2004-2008 were selected. They were studied for neonatal complications like low Apgar score (AS) < 7 at 5 min, birth trauma, admission to neonatal intensive care units and perinatal mortality. Maternal complications including any genital tract trauma and post-partum haemorrhage (PPH) were also noted. RESULTS: There were 11243 deliveries during this period, including 674 breech presentations at term (incidence of breech 6%). Out of 178 successful vaginal breech deliveries, 8 (4.49%) neonates had AS < 7 at 5 min, and 6 (3.37%) neonates needed NICU admission. There were no cases of birth trauma or perinatal morbidity. Maternal complications occurred in only 5 (2.8%) patients, 2 (1.1%) having perineal tears, 2 (1.12%) retained placenta and one (0.56%) case of post partum haemorrhage. CONCLUSION: Vaginal breech delivery can be safely undertaken without compromising maternal and neonatal outcome if strict criteria are met before and during labour.

Clinical audit of foetomaternal outcome in pregnancies with fibroid uterus.

BACKGROUND: Leiomyoma, myoma, leiomyoma or fibroids are synonymous terms. They may be present in as many as 1 in 5 women over age 35 years. If pregnancy is associated with fibroids, it leads to multiple complications. Objectives of this study were to evaluate the maternal and foetal outcome in women having pregnancy with fibroids in uterus and the complications associated with fibroids during the pregnancy. METHODS: This descriptive study was conducted in the Department of Obstetrics and Gynaecology, Ayub Teaching Hospital Abbottabad from March 2009 to March 2010. Data were collected on performa regarding demographic variables, obstetrical history, mode of delivery, maternal outcome, maternal complications, and foetal outcome. Mean and standard deviation was calculated for age, period of gestation, and obstetrical history. Frequency and percentages was calculated for booking status, maternal outcome, maternal complications and foetal outcome. RESULTS: Thirty patients were included in this study who had pregnancy with fibroid. Normal delivery was achieved in 14 (46.66%) patients. Eight (26.67%) patients had caesarean section and eight (26.67%) had miscarriages. Seven (23.33%) patients had no complications while 8 (26.67%) had miscarriages, 8 (26.67%) had postpartum haemorrhage, 10 (33.33%) had preterm delivery, and 3 patients had ante-partum haemorrhage. Two (10%) patients had premature rupture off membranes and 1 patient (3.33%) had pain abdomen and technical difficulty during caesarean section. There were 12 (40%) healthy babies. Five (16.67%) babies delivered with morbidity but recovered. There were 4 (13.33%) intrauterine deaths and one early neonatal death. CONCLUSION: Fibroid in pregnancy, especially multiple intramural fibroids and fibroids larger than 10 Cm, cause miscarriage and preterm labour.

Frequency of maternal mortality and morbidity in pregnancy-induced hypertension.

BACKGROUND: Pregnancy-induced hypertension (PIH) is defines as hypertension in pregnancy, and is sustained blood pressure >140 mm Hg systolic or 90 mm Hg diastolic. Objective of this study was to see the maternal outcome in terms of morbidity and mortality in PIH. METHODS: This descriptive study was conducted in Obstetrics and Gynaecology Unit of Fauji Foundation Hospital, Rawalpindi from January to December 2010. Both booked and un-booked cases were selected after fulfilling inclusion criteria. A detailed history and clinical examination was recorded and relevant investigations were performed. Patients were monitored for rise in blood pressure, development of complications related to hypertensions in pregnancy as well as maternal and perinatal outcome. RESULTS: During this period, 100 patients were admitted with pregnancy-induced hypertension. Majority were un-booked. Primigravida were 60 (60%), and were in age group 21-30 year, remaining were above 30 year. Four patients had placental abruption, 2 pulmonary oedema, 5 HELLP syndrome, 2 severe renal impairment, 20 elevated liver enzyme, 23 uncontrolled blood pressure, 20 server preeclampsia, 10 thrombocytopenia, 3 eclampsia, 10 had impaired coagulation profile, and 1 had maternal death. CONCLUSION: Pregnancy induced hypertension is a major cause of maternal mortality and morbidity. In Pakistan, its incidence and related mortality are high due to lack of adequate antenatal care.

Neonatal outcome in pre-eclamptic patients.

BACKGROUND: Pre-eclampsia (PE) is defined as hypertension (blood pressure of 140/90 mm Hg on two occasion 4-6 hour apart or single reading of diastolic blood pressure of >110 mm Hg) and proteinuria developing after 20 weeks of pregnancy up to 6 weeks post partum in previously normotensive, non-proteinuric women. The aim of this study was to determine the neonatal outcome in babies born ofpre-eclamptic patients. METHODS: It is a cross-sectional comparative study and was carried out in department of Obstetrics and Gynaecology unit C of Ayub Teaching Hospital, Abbottabad from 1st January 2007 to 30th June 2007. The study population included all cases presenting with pre-eclampsia after 20 weeks gestation to emergency and OPD and controls (Normal subject without pre-eclampsia). RESULTS: A total of 73 cases of pre-eclampsia were recorded in study period and were matched for age, gestational age and parity with controls. Neonatal outcome data showed a perinatal mortality of 328 neonates per 1000 total births, major cause being still births and intrauterine death (IUD). Decreased APGAR score was present in 31 cases and 3 controls. CONCLUSION: Pre-eclampsia has great implication on adverse neonatal outcome. The various complications seen are low APGAR score, IUD, low birth weight, intrauterine growth restriction and increased need for admission to Neonatal Intensive Care Unit (NICU).

Comorbid illnesses and chest radiographic severity in African-American sarcoidosis patients.

Sarcoidosis disease expression differs along racial/ethnic lines and black race has been cited as a poor prognostic factor. Besides genetic, healthcare, and socioeconomic factors, comorbid illnesses may influence sarcoidosis disease expression. We set out to investigate the association between comorbid illnesses and chest radiographic severity in a population of African-American sarcoidosis patients. The study was designed as a retrospective database analysis. The hospital and outpatient databases of the Grady Health System were searched to capture adult patients between November 1999 and December 2003 with the ICD-9 codes of 135 or 519.8, along with all associated secondary and tertiary diagnostic codes. Patient electronic pathology and radiographic reports were reviewed for tissue biopsies showing noncaseating granulomas and for chest radiographic Scadding stage. A total of 165 African-American patients were identified (64% female, 43 +/- 10 years old). Ninety percent (149/165) had comorbid illnesses. The most frequent chronic comorbid illnesses were hypertension (39%), diabetes mellitus (19%), anemia (19%), asthma (15%), gastroesophageal reflux disease (15%), depression (13%), and heart failure (10%). Females had increased frequency and clustering of chronic illnesses. Chest radiographic stages were more severe in patients with anemia, depression, and those less than 40 years old. Males, within each chronic illnesses category, had more severe CXR stages compared to females; however, significance was not achieved. We concluded that most adult patients with sarcoidosis have comorbid illnesses and these, in addition to gender differences, may influence sarcoidosis disease expression. Screening for comorbid illnesses should be an important aspect of sarcoidosis patient management.