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Background: Legg-Calve-Perthes (LCP) disease, or idiopathic avascular necrosis of the femoral head occurs during early childhood and is caused by impaired circulation in the femoral head. Varus derotation osteotomy (VDO) was described over half a century ago, and is now a popular method for the operative treatment of Perthes disease. Objective: To find out the clinical and radiological outcome of varus derotation osteotomy for containment of femoral head in advanced Perthes disease. Materials and Methods: This observational study was conducted in the Department of Orthopaedic Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Shahbag, Dhaka from March 2015 to September 2017. Total 20 cases of advanced Perthes disease were enrolled. Pre- and post-operative period were evaluated by interview and clinical examination by using a semi-structured questionnaire. Demographic and clinical information were recorded. All patients had a pre- and post-operative x-rays. We used visual analog scales (VAS) for scoring pain; Wiberg’s central edge angle, epiphyseal extraction index, neck shaft angle and Larson (Iowa) hip score were used to assess the outcome of VDO. Comparison of continuous variables between the two groups was made with Student’s t-tests. Comparison of proportions between Herring groups B and C were made with chi-square tests. p

Tuberculosis (TB) is a communicable systemic infectious disease with high morbidity and mortality associated with it. Resistance to medications used to treat tuberculosis has been on the rise in recent years. (multidrug-resistant tuberculosis) (MDR-TB) is a significant challenge to (TB) control around the world. An observational research was conducted in a tertiary care teaching hospital to determine the interim pharmacological and microbial results of Rifampicin resistance TB patients. Data from Santhiram Medical College and General Hospital, Nandyal, Kurnool Dist. Andhra Pradesh were obtained from Aug 2020 to Feb 2021, after receiving ethical approval from the Institutional Ethics Committee. The effects of the regimen are determined in terms of cure, finished treatment, treatment failure, number of patients moved to MDR-TB, number of patients who died in long-term MDR-TB regimen patients. Microsoft Excel 2007 was used to analyse the data. There were 82 male and 23 female out of 105 patients included in the study. Of these 75 patients were from rural areas and 40 from urban areas Using the Chi-square test and X2=12.1026, p=0.0005, which was important, the correlation between geographical spread and treatment result was determined. Out of 115 patients, 99 (86.09 percent) were cured of their disease, 06 (5.22 percent) died, 10 (8.69 percent) developed MDR-TB, and 2 (1.74 percent) were deemed medication errors. Males between the ages of 51 and 70 are more vulnerable to TB than females, according to our results. Compared to females of the same age, male patients over 40 years of age are more vulnerable to MDRTB. this was not part of the research objectives, emphasis should not be placed on this as either conclusion or recommendation.

Polycystic Ovary Syndrome (PCOS) is the most common, yet complex, endocrine disorder affecting women in their reproductive years and is a leading cause of infertility. This disease appears to be multifactorial and polygenic in nature involving multisystem dysfunction, namely reproduction, endocrine and metabolic. Hyperandrogenism and insulin resistance appear to be central cause to the pathophysiology of the disease. The glucose and insulin metabolism pathways have been studied and debated to understand whether Insulin Resistance is due to a defect in insulin action or a primary defect in β-cell function or decreased hepatic clearance of insulin, or a combination of all these factors. Numerous studies have demonstrated that obese, normal weight and thin women with PCOS have a form of insulin resistance that is unique and intrinsic to the disorder. Moreover obese women with PCOS possess an additional burden of insulin resistance resulting from their excess adiposity. Hyperinsulinemia leads to increase in androgen production directly by acting as a co-gonadotropin, augmenting Luteinizing Hormone activity within the ovary, and indirectly by increasing serum LH pulse amplitude. Whereas Androgens may in turn contribute at least partially to the insulin resistance state linked with PCOS. In this review, we will briefly study the role of insulin resistance in polycystic ovary syndrome. Keywords: Polycystic ovary syndrome, insulin resistance, Hyperandrogenism.

Objective: To determine the frequency, pattern and outcome of early complications after endoscopic third ventriculostomy (ETV) in Obstructive hydrocephalus. Material and Methods: The study included 160 patients from Neurosurgery department, Lady Reading Hospital Peshawar and private clinics over a period of twelve months. After performing ETV under general anesthesia by a single expert neurosurgeon, the patients were followed up for seven days post operatively for the CSF leak, wound infection, meningitis, seizures, bleeding and in hospital death. Results: Eighty five percent of the patients had no untoward complications, while 15% showed complications including CSF leak (5%), wound infection (3%), meningitis (2%), seizures (2%), bleeding (2%) and in hospital death (1%). Conclusion: Due to the less invasive nature, endoscopic third ventriculostomy is favored for treating obstructive hydrocephalus in select patient population as it is safe and have better outcomes.

Introduction - Current research provides strong evidence that intradermal Bacillus Calmette-Guerin (BCG) vaccination improves glucose metabolism by a mechanism of switching oxidative phosphorylation to aerobic glycolysis inducing a state of high glucose utilization. We present a case that demonstrates improvement in blood sugar levels upon administration of a series of intravesical BCG instillations. There is no research, in current literature, correlating blood sugars lowering after intravesical administration of BCG vaccines. Case Description - An 81 years old male with a medical history of type 2 diabetes mellitus, coronary artery disease, and bladder cancer underwent a series of BCG instillations, as therapy for his bladder cancer. He underwent BCG treatments according the Southwest oncology protocol for bladder cancer. During his BCG treatments, the patient was on Humalog 75/25, 30 units twice a day. Upon completion of his treatments, the patient experienced an episode of hypoglycemia that required hospitalization. His insulin regimen was decreased from 30 to 25 units BID. His A1C at the time of diagnosis was 8.7% and after insulin adjustments declined to 8.1%. We are reviewing a list of type II diabetic patients with bladder cancer who were treated with BCG and analyzing blood sugars before and after BCG exposure. We hypothesize that BCG vaccination precipitated the improvement in his blood sugars. Conclusion - Additional studies on BCG vaccinated, diabetic, bladder cancer patients are needed for confirmation of this effect. Our case illustrates a probable reduction in blood sugars attributable to his BCG vaccinations. Research suggests that intradermal BCG switches cellular metabolism from oxidative phosphorylation to early aerobic glycolysis. Another effect of BCG is the increasing levels of tumor necrosis factor (TNF) that leads to elimination of self-reactive white blood cells and inducing regulatory T cells. More research is needed to confirm whether intravesical administration of BCG has the same effect as intradermal BCG vaccination, which would have a potential impact on the clinical management of both type 1 and type 2 diabetic patients.

Objectives: To compare mean pain score between skin traction versus withoutskin traction in cases presenting with hip fracture. Study Design: Multi-randomized controlledstudy. Setting: Department of Orthopaedics, Chandka Medical College Hospital Larkana andQazi Hussain Ahmad Medical Complex, Nowshera. Period: 1st October 2016 to 31st March2017. Materials and Methods: A total of 100 cases (50 in two groups) between 18-60 years ofage including both genders presenting with unilateral femur fracture within 72 hours of injurywere enrolled in this study. They were divided in two groups i.e. study and control group, studygroup was allotted to the cases undergoing traction while control was those without using skintraction. Intramuscular diclofenac sodium injection (75 gm) was used in all participants andfollowed up for two tablets of paracetamol (500 mg) on 8 hourly basis. Visual analogue scaleto record pain score, 0 was no pain and 10 was the severe pain, it was recorded at 24 hoursof application of traction and second measurement was recorded just few minutes before thesurgery is done. Results: In this study, mean age was calculated as 48.74+9.12 years, agerange was 18-60 years. Male participants were in majority by calculating 64% (n=32) in Studyand 58% (n=29) in control group while female cases were 36% (n=18) in cases and 42%(n=21) in control group. Mean pain score at 24 hours of traction in study and control group wasrecorded as 4.60+0.70 in study group and 5.30+0.82 in control group (P = 0.0553), showsa significant difference. Conclusion: Mean pain score is significantly reduced during first 24hours of application of skin traction as compared to those without it in cases with hip fractures,however, it has no significant effect on pain after 24 hours of application.

Elevated blood pressure (BP) is a growing burden worldwide, leading to over 10 million deaths each year. May Measurement Month (MMM) is a global initiative aimed at raising awareness of high BP and to act as a temporary solution to the lack of screening programs worldwide. Hypertension is a global health concern for developing countries. In Pakistan, apart from few population-based studies which evaluated the prevalence of hypertension, there is no current nationally representative study (the latest nationwide survey was conducted more than two decades ago). Pakistan Hypertension League, in accordance with the International Society of Hypertension directive under the banner of the May Measurement Month 2017 (MMM17) campaign, carried out a nationwide cross-sectional survey of volunteers aged ≥18 in May 2017 through its 14 regional chapters. Blood pressure measurement recorded through digital apparatus, the definition of hypertension (≥140/90 mmHg or being on BP-lowering treatment) and statistical analysis followed the standard MMM protocol. A total of 5333 individuals were screened during the MMM17 campaign with mean age 45.0 (11.6). Males had a higher rate (66.3%, n = 3536) in those screened than females (33.0%, n = 1757). A total of 55.2% (n = 2943) people had hypertension. This result shows very high rates of hypertension in Pakistani people. Therefore, there is an urgent need for federal implementation of BP screening as well as awareness programs across the nation.

Introduction: Thyroid nodules are very common. They occur more commonly in women with an increased prevalence of thyroid nodules reported in pregnancy. Most thyroid nodules diagnosed during pregnancy are benign. Pregnancy causes major physiological changes including changes in the levels of thyroid hormones and the elevation of thyroid binding globulin. Thyroid nodules may also occur in people with abnormal thyroid function tests manifesting as hyperthyroidism or hypothyroidism. We present a unique case of a new diagnosis of a large thyroid nodule that has significantly decreased in size after 20 months postpartum. Case description: Patient is a 31 year old female with past medical history of anxiety and white coat hypertension who was diagnosed with a 3.3 x 2.3 x 2.1 cm thyroid nodule a month following delivery. Patient did not have any abnormalities in her thyroid function tests before, during, or after pregnancy. She remained euthyroid throughout the pregnancy and in the postpartum period. Fine needle aspiration biopsy of the nodule showed atypia of undetermined significance (Bethesda Category III). The specimen was further analyzed by afirma testing that confirmed benign pathology. Twenty months postpartum, the thyroid nodule significantly decreased in size to 1.9 x 1.4 x 1.2 cm. Conclusion: Thyroid hormone levels physiologically change during pregnancy and this may affect the growth of thyroid nodules. We just presented a patient who exhibited a significant decrease in the size of her thyroid nodule. Sahin et al. showed that while the size of the thyroid nodule increases during pregnancy the number of nodules remains unaffected. Kung et al. showed that pregnancy is associated with an increase in the size of preexisting thyroid nodules as well as the number of newly developed thyroid nodules. Vanucchi et al. showed that although the thyroid gland becomes larger, particularly in late pregnancy, the sizes of any preexisting thyroid nodules remained unchanged and patients’ thyroid gland size returned to normal after delivery. The current literature provides conflicting data on this topic. The true association between pregnancy and thyroid nodules is unknown. Contemporary literature is ambiguous on this topic and more scientific studies are required to find the true association between pregnancy, the formation of thyroid nodules, and increase in the size or number of thyroid nodules.

Introduction: Diabetes is one of the most prevalent diseases in the world. We recognize the three most common types of diabetes: type1, type2 and gestational diabetes. It is estimated that around 425 million of people worldwide have diabetes and about 90% of those represent type 2 diabetes. The most common types of diabetes are polygenic -- they are caused by a defect in multiple genes. Monogenic diabetes is caused by a mutation in a single gene. We currently have over 10 different types of monogenic diabetes called MODY (Maturity Onset Diabetes of the Young). Sun et al. states that over the past few years, 30 different insulin gene mutations were reported to cause a new syndrome called MIDY (Mutant INS-gene-induced Diabetes of Youth). Most of these mutations lead to proinsulin misfolding in the endoplasmic reticulum. We present a rare case of a young obese female with an elevated proinsulin level and low C-peptide level diagnosed with type 1 diabetes requiring therapy with insulin. Case Description: A 21 year old female with past medical history of chronic diarrhea initially presented with a complaint of dry mouth, dizziness, excessive urination, and thirst. She was found to have hyperglycemia of 203 mg/dL, A1C 8.3, and negative ketones. Patient had a strong family history of diabetes. She had a family history of: father with type 1 diabetes; mother with a past medical history of gestational diabetes who became diabetic postpartum; and three of the patient’s grandparents with a history of diabetes. Patient was started on the oral hypoglycemic agents metformin and glipizide, but she only had partial response to these medications. Because of her strong family history and incomplete response to oral hypoglycemic agents, additional testing was performed. Patient was found to have a low C-peptide level (1.6 ng/mL), elevated proinsulin (72.9 pmol/L), positive GAD antibody (10.3 units/mL) and negative islet cell autoantibody. Patient had a very good response to insulin and subsequently became insulin dependent. She is currently on an insulin pump. Conclusion: Sun et al. reports that proinsulin misfolding causes beta cell failure. Increased misfolding occurs under certain pathological conditions that are currently unknown. We think that there might be some increased proinsulin misfolding abnormality that might be occurring in this patient. There are most likely many epigenetic modifiers that would trigger certain individuals to be more prone to this phenomena of misfolded proinsulin. Future research in diabetes may one day yield antibodies that would specifically recognize misfolded proinsulin in the plasma. Further research is required to elucidate how defective proinsulin folding may lead to beta cell dysfunction and subsequent evolution of diabetes mellitus.

Inefficient and irrational use of medicines is a widespread problem at all levels of health care. Lack of discretely documented policies and proce-dures in respect of medicines management in hospitals is unnecessarily straining the meagre resources resulting into poor inflow of benefits to the patients. Per capita wastage from inefficient and irrational use of medicines tends to be greatest in hospitals. Many of these sources of wastage could be reduced if some basic principles of medicine management and use are followed and a comprehensive medicines management policy framework is developed. An efficient and robust medicines management in hospitals ensures rational selection, quantification, procurement, storage, distribu-tion, use and thereby availability of the right drugs in the right quantities, at reasonable prices, and at recognized standards of quality throughout the year without any stock-out periods in between. Effective medicines management is a collaborative process involving many stakeholders that is required for providing the health care system with a road map for con-tinuous improvement in pharmaceutical supply chain including expense containment with specific goals and outcome measures of success. Ex-isting medicines management and supply chain systems within hospitals have several gaps and shortcomings particularly lack of resources and well documented policy framework. Urgent steps are required to assess, evalu-ate, and monitor the functioning of supply chain system for bridging up the gaps and rectification of shortcomings. Priority needs to be accorded towards engaging well-qualified manpower, suitably trained in medicines management across the different levels of care. How to Cite this Article Pubmed Style Mir Javid Iqbal, Mohammad Ishaq Geer , Parvez Ahmad Dar. Medicines Management in Hospitals: A Supply Chain Perspective. SRP. 2017; 8(1): 80-85. doi:10.5530/srp.2017.1.14 Web Style Mir Javid Iqbal, Mohammad Ishaq Geer , Parvez Ahmad Dar. Medicines Management in Hospitals: A Supply Chain Perspective. http://www.sysrevpharm.org/?mno=302644569 [Access: March 28, 2021]. doi:10.5530/srp.2017.1.14 AMA (American Medical Association) Style Mir Javid Iqbal, Mohammad Ishaq Geer , Parvez Ahmad Dar. Medicines Management in Hospitals: A Supply Chain Perspective. SRP. 2017; 8(1): 80-85. doi:10.5530/srp.2017.1.14 Vancouver/ICMJE Style Mir Javid Iqbal, Mohammad Ishaq Geer , Parvez Ahmad Dar. Medicines Management in Hospitals: A Supply Chain Perspective. SRP. (2017), [cited March 28, 2021]; 8(1): 80-85. doi:10.5530/srp.2017.1.14 Harvard Style Mir Javid Iqbal, Mohammad Ishaq Geer , Parvez Ahmad Dar (2017) Medicines Management in Hospitals: A Supply Chain Perspective. SRP, 8 (1), 80-85. doi:10.5530/srp.2017.1.14 Turabian Style Mir Javid Iqbal, Mohammad Ishaq Geer , Parvez Ahmad Dar. 2017. Medicines Management in Hospitals: A Supply Chain Perspective. Systematic Reviews in Pharmacy, 8 (1), 80-85. doi:10.5530/srp.2017.1.14 Chicago Style Mir Javid Iqbal, Mohammad Ishaq Geer , Parvez Ahmad Dar. "Medicines Management in Hospitals: A Supply Chain Perspective." Systematic Reviews in Pharmacy 8 (2017), 80-85. doi:10.5530/srp.2017.1.14 MLA (The Modern Language Association) Style Mir Javid Iqbal, Mohammad Ishaq Geer , Parvez Ahmad Dar. "Medicines Management in Hospitals: A Supply Chain Perspective." Systematic Reviews in Pharmacy 8.1 (2017), 80-85. Print. doi:10.5530/srp.2017.1.14 APA (American Psychological Association) Style Mir Javid Iqbal, Mohammad Ishaq Geer , Parvez Ahmad Dar (2017) Medicines Management in Hospitals: A Supply Chain Perspective. Systematic Reviews in Pharmacy, 8 (1), 80-85. doi:10.5530/srp.2017.1.14

Introduction - Postpartum thyroiditis (PPT) is a rare medical condition occurring after pregnancy. Postpartum thyroiditis is a syndrome of transient or permanent thyroid dysfunction occurring in the first year after delivery. It can present as clinical thyrotoxicosis, followed by hypothyroidism and subsequent recovery of thyroid function or it may present as an isolated thyrotoxicosis or hypothyroidism. An estimated 20-40% of women develop permanent hypothyroidism; usually during the 3 to 10 year interval following an episode of PPT. PPT is the most common thyroid disease in the postpartum period with an incidence between 5-9%. The condition is most common in patients with positive thyroid antibodies (TPO), type 1 diabetes or prior history of PPT. We present a unique case of postpartum thyroiditis with postpartum hyperthyroidism, with markers of Graves’ disease, in a patient with a maternal history of Graves’ disease. Case description - An 18 year old female, without prior medical history, presented with thyrotoxicosis following delivery of her first child. Initially, she responded to therapy with propranolol; however, when her thyroid function became increasingly symptomatic, therapy was augmented with methimazole. Methimazole was selected because of the corresponding clinical features of Graves’ disease coupled with a positive thyroid stimulating immunoglobulin (TSI = 431) and family history of Graves’ disease. Thyroid scan and uptake showed homogenous thyroid without discrete nodule with normal thyroid uptake. Unfortunately, methimazole precipitated urticaria and pruritus, without any liver abnormalities, necessitating its’ discontinuance. Propranolol monotherapy subsequently provided effective symptomatic relief. The patient’s thyroid levels eventually peaked following delivery (fT4 -4.32) before trending downward (fT4 = 1.79), paralleling the resolution of her symptomatic biochemical thyrotoxicosis and resolution of her goiter. Conclusion - Literature review revealed lack of similar case report. Our patient benefitted from symptomatic therapy with propranolol. Women with preexisting thyroid disorders are at high risk for developing postpartum thyroiditis and should be closely monitored for one year post-partum. We hypothesize that our patient most likely had preexisting Grave’s disease that was exacerbated after her delivery. Reference - Pearce EN. Thyroid disorders during pregnancy and postpartum. Best Pract Res Clin Obstet Gynaecol. 2015;29(5); 700-706.

Background: Osteoarthritis is more common in females because inpostmenopausal state, it is linked with high body weight, higher subcutaneous fat, deficiencyof calcium and weakness of muscles associated with changes in harmones. Objectives: Toassess the outcome of high tibial osteotomy in unicompartmental osteoarthritis of knee in termsof pain and improvement in function. Study Design: Prospective study. Setting: King AbdullahTeaching Hospital, Mansehra. Period: 1st January 2016 to 31st December 2017. Materialsand Methods: Two hundred and forty eight cases were included in which twenty cases wereoperated by the use of modified coventry technique, twenty cases were operated by openwedge osteotomy with non locking plates as well as bone graft and remaining 208 cases wereoperated by medial open wedge osteotomy and iliac graft secured by locking plate. In all casesat eight weeks, six weeks and third post operative day respectively allowed full weight bearing.Post-operative changes in tibio femoral angle included in radiographical analysis. 2 years meanfollow-up of all these cases. Results: Function score and pain of knee improved considerably asthe p value

Introduction Hospital-based adverse drug reaction (ADR) monitoring and reporting studies are conducted to identify, quantify and minimize such risks associated with the use of drugs particularly on long-term basis. Kashmir province of Indian state of Jammu and Kashmir presents a huge market for medicines that runs into millions of rupees. Yet there was no provision to monitor these drugs for their adverse effects prior to this study in any of the leading hospitals of the province. As such the present study, which was first of its kind in the valley, was undertaken to assess the frequency, preventability, category, severity, causality, extension of hospital stay and costs of drug-related adverse effects in Kashmiri patients at a Srinagar-based tertiary care hospital. Methods A prospective, observational, cohort study on 5482 patients was undertaken over a 270 day period. Adult patients admitted in Internal Medicine in-patient department (IPD), presenting to the Internal Medicine out-patient department (OPD) and those visiting the Accident and Emergency Department of the study hospital were included in the study. Patients belonging to both the sexes were screened and monitored on a daily basis for the occurrence of any ADRs. Definition of ADR given by the World Health Organization (WHO) was used and causality of suspected ADRs was determined using Naranjo's algorithm whereas severity was assessed using modified Hartwig's scale and preventability was determined using Hallas methodology. Costs of ADRs and extension in hospital stay were calculated as per Lagnaou and Nicholas methodology respectively. Results ADRs accounted for 6.23% of adult Kashmiri patients visiting the tertiary care hospital under study, either for referral or hospitalization, with the majority (81.57%) of these ADRs being preventable; 23.68% of patients had mild ADRs, 69.29% had ADRs of moderate severity, and 7.01% had severe ADRs. Four classes of drugs most frequently suspected in admissions due to ADRs were anti-infective agents (40.92%) including anti-tubercular drugs (13.15%), steroids (14.03%), anti-coagulants (8.77%), and NSAIDs (7.89%). Increasing age and female gender were identified as risk factors. The total cost to the hospital due to hospitalization of patients presenting with ADRs over the 9-month period in the internal medicine IPD was found to be USD 22469 at the time of this study. Discussion/conclusion The present work is the maiden pharmacovigilance study conducted on Kashmiri patients, especially at a tertiary care teaching hospital that has provided baseline information about the prevalence of ADRs and their distribution among different age groups, genders, organ systems affected, and therapeutic classes of medicines. The data collected will be useful for long term and more extensive ADR monitoring on Kashmiri patients and will also be useful in framing policies toward the rational use of drugs. This study led to the establishment of a full-fledged pharmacovigilance centre and initiation of pharmaceutical care services in the study hospital.

Background: Vitamin D deficiency in children is an important medical entity commonly diagnosed during early childhood. Prevalence and incidence of vitamin D deficiency in children is underestimated and can have far reaching consequences as per the latest evidence. Children at high risk should be identified and treated accordingly to avoid the treatable misadventures of future life. Aim: The purpose of this review is to provide summary of the latest research in particular to the practical aspects of vitamin D deficiency in children. Methods: A literature search in PubMed, Medline, Embase, Scopus, Google Scholar, and DOAJ was conducted, regarding pediatric vitamin D deficiency related research and review articles in English language, using keywords or phrases such as bones; childhood allergy; calcium; children; diabetes mellitus type 1; respiratory infections; rickets; failure to thrive, 25-OH vitamin D. Conclusion: Despite major advances in unfolding the classical and non-classical role of vitamin D in various health related events in children, yet most of the pediatric population is vitamin D deficient even in countries like India with ample sunlight. DOI: http://dx.doi.org/10.3126/ajms.v6i1.10199 Asian Journal of Medical Sciences Vol.6(1) 2015 1-7

The handicrafts of Kashmir are famous throughout the world. Kashmiri willow wicker items are losing market due to the negligence from the stakeholders of the state. This craft needs to be revamped in order to preserve our cultural heritage. The present study is a small effort in this regard and attempts to show how the culture can be preserved in this modern age with the help of electronic media. A detailed survey was conducted to find out the products made by willow wicker. All the product-related information to these products was accumulated in the form of a digital library. In this study, Greenstone Digital Library (GSDL) software was used to gather the documents containing information related to each item of willow wicker for easy retrieval using various access points.

Universal health coverage has recently been listed on top of the worldwide health agenda backed by multilateral and donor organizations. Unless and until the concept is clearly understood, “universal coverage” (or universal health coverage i.e. UHC) can be used to define practically any health financing reform or scheme. All countries are concerned to provide better equity in the use of health services, service quality and financial protection for their people. Hence, the achievement of UHC is relevant to every country. It is the duty of ever nation to provide free and universal access to quality health-care services to its citizens irrespective of causing any economic burden on them. India as a country continues to be among the countries of the world that have a high burden of diseases. In a developing country like India, 39 million people are being impoverished because of Out-of-pocket health expenditures each year and a major share of these expenditures are contributed by hospitalization. Out-of-pocket expenditures are huge even after the financial protection given by a number of health insurance programs. These pose challenges along with a global discourse to achieve universal health coverage (UHC) – increasing access to quality healthcare services at affordable cost, by all people; and in times of fast economic growth in India. The Indian people deserve and demand an efficient and equitable health system which can provide UHC. UHC in India could only be achieved by increasing spending on health sector, if the primary health care facilities receive a minimum of 70% of health spending, public spending on the purchase of medicines increase from 0.1% to 0.5% GDP, and all the health facilities in India are upgraded to match the Indian Public Health Standards. This paper unfolds all the aspects related to policy and practice of achieving Universal Health Coverage in India.

Background Pulmonary hydatid cysts are recognized to have high rate of rupture compared to those in other affected organs. To identify risk factors associated with endobronchial rupture, we prospectively assessed 32 patients with hydatid cysts. There were 21 males and 11 females, with a mean age of 32 ± 15 years (range 9 to 65 years). Methods All patients undergoing thoracotomies for hydatid cysts were included. Demographic data, site, size, and whether cysts were ruptured or intact, were reviewed. Intraoperatively, bronchial fistula diameters were measured. A stepwise multiple logistic regression model was used to analyze the results. Results Seventeen (53.1%) patients presented with ruptured cysts (group 1) and 15 with intact cysts (group 2). There was a significant difference in mean fistula diameter between groups: 6.16 ± 2 mm in group 1 vs. 0.34 ± 0.19 mm in group 2 ( p ≤ 0.0001), which was identified as the only significant risk factor associated with cyst rupture. Conclusion At the fistula site, the intracystic pressure is unopposed, leading to herniation of the endocyst membrane, disruption of its integrity, and rupture. Therefore, we postulate that this scenario in combination with other coexisting factors could be the possible mechanism for cyst rupture in group 1. This concept may also explain the pathogenesis of the high rate of rupture of pulmonary hydatid cysts. Accordingly, we consider these cysts a naturally occurring model for rupture, which should be treated surgically as soon as the diagnosis is made, to avoid complications.

Background Out-of-hospital cardiac arrest (OHCA) is one of the leading causes of death and disability worldwide. Overall survival after an OHCA has been reported to be poor and limited studies have been conducted in developing countries. We aimed to investigate the rates of survival from OHCA and explore components of the chain of survival in a developing country. Methods We conducted a multicenter prospective cohort study in the emergency departments (ED) of five major public and private sector hospitals of Karachi, Pakistan from January 2013 to April 2013. Twenty-four hour data collection was performed by trained data collectors, using a structured questionnaire. All patients ≥18 years of age, presenting with OHCA of cardiac origin, were included. Patients with do-not-resuscitate status or referred from other hospitals were excluded. Our primary outcome was survival of OHCA patients at the end of ED stay. Results During the three month period, data was obtained from 310 OHCA patients. The overall survival to ED discharge was 1.6 % which decreased to 0 % at 2-months after discharge. More than half (58.3 %) of these OHCA patients were brought to the hospital in a non-EMS (emergency medical service) vehicle i.e. public or private transportation. Patients utilizing non-EMS transportation reached the hospital earlier with a median time of 23 min compared to patients utilizing any type of ambulances which had a delay of 7 min hospital reaching time (median time 30 min). However, patients utilizing ambulances with life-support facilities, as compared to all other types of pre-hospital transportation, had the shortest time to first life-support intervention (15 min). Most of the patients (92.9 %) had a witnessed cardiac arrest out of which only a small percentage (2.3 %) received bystander CPR (cardio pulmonary resuscitation). Median time from arrest to receiving first CPR was 20 min. Only 1 % of patients were found to have a shockable rhythm on first assessment. Conclusion This study showed that the overall survival of OHCA is null in this population. Lack of bystander CPR and weaker emergency medical services (EMS) leading to a delay in receiving life-support interventions were some of the important observations. Poor survival emphasizes the need to standardize EMS systems, initiate public awareness programs and strengthen links in the chain of survival. Electronic supplementary material The online version of this article (doi:10.1186/s12873-016-0093-2) contains supplementary material, which is available to authorized users.

� ABSTRACT� Introduction: An organized and systematic drug procurement process based on well-established scientific principles effectively ensures the availability of right medicines in the right quantities, at reasonable prices, and at recognized standards of quality. It ensures 'value for money' and 'economies of scale' to the best possible extent. Methods: This study was carried out to evaluate various drug procurement and tendering practices prevalent at three tertiary care public health facilities of District Srinagar, the summer capital of J&K state. One children's tertiary care hospital (CH), one Govt. Medical College Hospital (MCH), one district hospital (DH) was selected for the study. Two different pharmaceutical supply chains were involved in procurement of medicines for the study hospitals. A set of 149 qualitative and 15 quantitative indicators were developed to evaluate drug procurement practices in these healthcare settings. Results: Qualitative indicator based assessment revealed that a centralised procurement and decentralised distribution practice was being followed by both the supply chains studied. Procurement funds were found to be grossly inadequate whereas pre-qualification of suppliers was undertaken. Competitive e-tendering method was followed using double envelope system. However, rate contracts were not regularly updated and there were no means available to check and determine the quality of drugs effectively. Available pool of human resource was found to be inadequate and there were no standard procedures in place to monitor the performance of procurement and supply system on regular basis. Conclusion: Appropriate measures need to be taken for proper selection, quantification, forecasting and procurement of medicines in accordance with well established guidelines to make the supply chain more efficient. Allocation and disbursement of funds for procurement should also be sufficient and timely to cater to the needs of individual hospitals across all levels of care.

In the present study, coal from Chakwal (Pakistan) was leached with an aqueous solutions of iodine monochloride (ICl) and diethylenetriamine pentaacetic acid (DPTA) of different concentrations. The effect of stirring time, concentration and pH was studied on the leaching of different metals from coal. The physicochemical parameters indicated that the coal was of reasonably good quality. The results indicated that with increase in time duration, the extraction of metals increased. In most of the cases, metal concentration increased in the leachate with increasing the concentration of the leaching agents. DPTA was found to be the best leaching agent for most of the metals. Higher extraction of metals from coal fly ash indicated that coal organic matter has a pronounced effect on the leaching. Higher concentration of metals was extracted from virgin coal and coal fly ash at low pH (p > 0.00) as compared to high pH. DPTA extracted metals in higher concentration from virgin coal and coal fly ash at low pH as compared to ICl. Based on the present study, the most leached metals were Fe, Cu, Mn and the least were Pb, Ni, Cd and Cr.

Different clays collected from local sources, including Kaolinite, Montmorollinte, Palygorskite and Vermiculite have been utilized for the selective adsorption of sulphur compounds prevailing in petroleum products i.e. crude oil, kerosene and diesel oil. The desulphurization activity of the clay was compared with the charcoal, ion exchange resins and with each other. Desulphurization was performed in batch operation at different time intervals i.e 1, 3 and 6 hrs at 40 ºC temperature. Out of different adsorbents used, Kaoilinte exhibited the maximum desulphurization yield of 60 %, 76 % and 64 % at 6 hrs adsorption incase of crude oil, kerosene and diesel oil respectively. All the mineral clays adsorbents were characterized by surface area, SEM and EDX analysis. The FT-IR study of the desulphurized fractions revealed that mostly high molecular weight thioles and thiophenic compounds were depleted during adsorption process.

This paper reports the adsorption of phosphate ions on coal, charcoal, and coal ash. The influences of factors such as contact time, and initial adsorbate concentration have been studied. Adsorption of phosphate ions on virgin coal was significant compared to charcoal, coal and coal ash evacuated at 200°C. The significant adsorption capability of coal is due to the porosity as well as due to organic carbon and inorganic elements present in coal. The evacuation of coal proved to be ineffective in enhancing its capability for phosphate ions retention. The adsorption behaviors of all the three adsorbent used was conformed using Freundlich’s adsorption model. The results suggest that coal could be used as an efficient adsorbent for removing phosphate ions from wastewater.

Many trials on the use of hormone replacement therapy (HRT) have provided contradictory results on its risks and benefits in post-menopausal women. The use of HRT declined globally following publication of the first data from the Women’s Health Initiative (WHI) trial in 2002, with the revelation that there was an increased risk of breast cancer and coronary heart disease (CHD) in postmenopausal women taking HRT. Following this, other leading studies published results that were consistent with these findings, which reduced enthusiasm for HRT use. However, recent publications from the International Menopause Society indicate that HRT is the first-line and most effective treatment for menopausal symptoms. Moreover, when the full results of the WHI trial were subsequently published, it appeared that HRT may confer benefits for CHD prevention below age 60. The statements from the British Menopause Society and the International Menopause Society (IMS) published in 2008 also supported this opinion. These revelations renew interest in HRT use. This paper analyzes the effects of combination versus unopposed HRT on osteoporosis, breast and CHD, endometrial cancer induction, venous thromboembolic disease, lipids and lipoproteins, neuroprotection, and cognitive function in post-menopausal women.

Objective: To review clinical presentations and associations in patients suffering from Retinitis Pigmentosa. Design: Descriptive study. Period: January 2005 to December 2009. Setting: KTH Peshawar, DHQ Hospital Karak and Group of Teaching Hospital Bannu. Materials and Methods: A proper performa was made for documentation of patients. After informed consent, history was taken properly. Ocular examination regarding visual status, anterior and posterior segment examination with direct, indirect ophthalmoscope and slit lamp bimicroscopy was done. IOP was checked with applanation tonometer. For systemic examination and associations opinion of physician was asked if needed. Results: Total 83 patients were examined out of which 49(59.03%) were male and 34(40.96%) were female. Regarding age factor 1(1.20%) patients were in age group up to 10 years, 3(3.61%) in age group 11 to 20 years, 12(14.45%) in age group 21 to 30 years, 21(25.30%) in age group 31 to 40 years, 27 (32.53%) in age group 41 to 50 years, 12(14.45%) in age group 51 to 60 years, and 7(8.43%) patients were in age group 61 to 70 years. In 79(95.18%) patients there was family history of R.P while in 4 (4.81%) patients no family history was present. All the patients have involvement of both eyes. 61(73.49%) patients presented with complaints of night blindness, 56(67.46%) patients with defect in visual acuity with range from 6/9 to perception of light, out of which 24 patients had refractive error and 32 patients had no refractive error. 21(25.30%) patients presented with field defect. Fundoscopy revealed, bone spicule pigments configuration in 83(100%) patients, attenuated blood vessels in 23(27.71%) patients and, waxy pallor disc in 12(14.45%) patients. Regarding associations, in systemic association group 82(98.79%) patients had no association while 1(1.20%) patients had bardet biedle syndrome. In ocular association group 24(28.91%) patients had myopia, 14(16.86%) patients had cataract. Primary open angle glaucoma was present in 3(3.61%) patients while 2(2.40%) had cystoid macular oedema. Keratoconus was present in 1(1.20%) patients. Conclusions: Retinitis Pigmentosa is a grave disease with irreversible loss of visual functions. Mostly it is bilateral. Severity increases with age. Familial onset is more.

Removal of industrially important Tartrazine dye from aqueous solution was carried with virgin and variously activated coal samples at room temperature. The morphological study indicated that the number of coal particles was increased when the coal was evacuated at 200°C while aggregated form was observed at 400°C evacuation temperature. The coal particles were again formed at 600°C evacuation temperature. The coal, which was evacuated at 400°C, adsorbed less Tartrazine than the coal samples which were evacuated at 200 and 600°C. This might be caused by the aggregation of the coal particles at 400°C (because of the plastic range of coal swelling), which results in a decrease of the coal surface area. The obtained adsorption data were also fitted to Langmuir and Freundlich isotherms, which followed both Langmuir and Freundlich isotherms models.

The influence of a group of metal oxide, hydroxide and chloride catalysts on the yields of liquefied products has been identified. The results of hydrogenation experiments performed with varying coal to catalyst ratio for a slurry of lignite coal in toluene demonstrated that metal loadings even as low as 1% proved effective for enhancement of yields. Among the catalysts employed, halide catalysts proved to be the most effective in terms of high yields of desirable liquefied products.

This paper demonstrates the thermal and catalytic pyrolysis of some whole plastics and plastic–coal mixtures with and without solvent in an inert atmosphere of N 2 using a micro autoclave. The temperature was varied between 300 and 400 °C. The effect of some catalysts, i.e., AlCl 3 and Co–Mo, on the liquid yield was also studied. The results demonstrate that temperature has a promising effect on the yield; however high temperature, as well as high catalyst loading, caused a decline in liquid yield. The effect of the solvent was found to be significant. None of the catalysts show an impressive effect on the yield of the desired products. Among the plastics studied, high density polyethylene (HDPE) and polypropylene (PP) gave high yields even in the absence of a solvent and catalyst. The results are quite promising in terms of resource recovery, both from coal as well as plastics. The idea will also help in combating the environmental problems associated with plastics and coal.

This paper reports the demineralization of coal with EDTA, citric acid, HCl, HNO3, acid mixture and CH3COONH4. The residual coal from each treatment was analyzed using Scanning Electron Microscopy. All the micrographs are bright field and reveal several features correspond to the mineral grains comprised of lithophiles like aluminum, potassium, and sodium; sidrophiles like iron and chalcophiles like copper and germanium. The absence of some morphological features correspond to inorganic elements in residual samples confirms demineralization. It is evident from the results that amongst the leachants used; acid mixture and EDTA have caused significant removal of mineral phases.

Influence of pretreatments, i.e., demineralization and pre-soaking in some solvents on the yields of liquefied products obtained from hydro-depolymerization of Pakistani coal in a pool of hydrogen has been discussed. Results of hydrogenation experiments demonstrated that demineralizing the coal sample prior to liquefaction caused the yields to decrease compared with the virgin coal samples. The contribution of mineral matter of coal has been evaluated by comparing the yields of liquid products of virgin and leached samples. Increase in the yields obtained from the hydrogenation experiments of swollen coal samples was not satisfactorily significant.

A Pakistani coal was de-polymerized/liquefied in toluene in a 1000 mL micro autoclave. Experiments have been performed in a pool of hydrogen under varying operating conditions of temperature, residence time, hydrogen pressure (cold), coal/solvent ratio and coal particle size. A pronounced effect of all these process variables has been noted on the yields of liquefied products, i.e., THF solubles, n-pentane solubles, and n-pentane insolubles. Extraction temperature of 450 °C, residence time of 1 hour, hydrogen pressure of 30 kgf/cm 2 , coal/solvent ratio of 1:2 and coal particle size of 53-45 μm were found optimum for maximum conversion of Pakistani coal into liquefied products.

Characterization of liquefied products (oil and asphaltene) of Pakistani coal was performed using 1 H and 13 C nuclear magnetic resonance (NMR) spectrometry. It was noticed that bands corresponding to aliphatic protons and carbons were sharp and well pronounced in all the profiles. Peaks corresponding to aromatic hydrogens and carbons were featureless, which is suggestive of the presence of configurations like aliphatic carbon chains and some alkyl substituents and absence of configurations like hydro-aromatics, biphenyls, phenanthrene and anthracene in both of these extracts.

The effects of cropping systems and management practices on soil properties provide essential information for assessing sustainability and environmental impact. Tillage and fertilizer rates were evaluated for their effects on soil bulk density (BD), penetration resistance, soil organic carbon (SOC) concentration and availability of macronutrients on a sandy clay loam (fine-loamy, mixed, hyperthermic Typic Haplargids, USDA; Luvic Yermosol, FAO) in a semi-arid region of Pakistan. Wheat (Triticum aestivum L.) and cotton (Gossypium hirsutum L.) were double-cropped from 1996 to 1998. Tillage treatments were minimum till (MT), conventional till (CT), and deep till (DT). Low, medium and high fertilizer rates were applied to wheat and cotton. BD was affected neither by tillage nor fertilizer rates. Soil penetration resistance was lower for DT than CT and MT. Tillage methods affected soil P concentration but did not affect N and K concentrations. However, fertilizer application significantly increased soil P and K concentrations. Concentrations of N, P, K and SOC were greater in the plough layer than sub-soil. Grain yield of wheat was significantly negatively correlated with penetration resistance and was positively correlated with soil P and K concentrations. Yield of cotton was significantly negatively correlated with soil BD. These data provide an experimental basis to re-evaluate recommendations for fertilizer rates and tillage methods for production of wheat and cotton in Punjab. Further, there is a strong need to establish long-term experiments to study agronomic and environmental effects of tillage methods, fertilizer rates, and cropping systems on productivity and environment quality.

Appropriate tillage and fertilizer management practices need to be developed for sustainable crop production without jeopardizing the quality of soil and the environment. Effects of tillage and fertilizer were studied for 4 years on wheat ( Triticum aestivum L.) and for 2 years on cotton ( Gossypium hirsutum L.) from 1995–1996 to 1998–1999. The experiments were conducted on a sandy clay loam (fine-loamy, mixed, hyperthermic Typic Haplargids, USDA; Luvic Yermosol, FAO) in semi-arid region of Pakistan. Effects of three tillage methods as main plots and three fertilizer rates as sub-plots were studied in a split plot configuration. Tillage treatments were minimum till (MT), conventional till (CT), and deep till (DT). Three rates of NPK fertilizer (kg ha −1 ) were 60-20-25 (F 1 ), 120-40-50 (F 2 ), and 180-60-75 (F 3 ) for wheat; and 85-19-25 (F 1 ), 170-38-50 (F 2 ), and 255-57-75 (F 3 ) for cotton. Tillage treatments had significant effect on grain yield of wheat in 2 out of 4 years. Considering average yield over all fertilizer treatments and four seasons, mean wheat yield was 3.4 Mg ha −1 for MT, 5.0 Mg ha −1 for CT and 3.6 Mg ha −1 for DT. Mean grain yield based on the average of all tillage treatments over four seasons was 3.2 Mg ha −1 for F 1 , 3.7 Mg ha −1 for F 2 , and 3.9 Mg ha −1 for F 3 . A similar trend was observed for wheat straw yields. Deep ploughing significantly increased seed cotton yield compared to MT and CT treatments. Averaged over all fertilizer treatments and two seasons, mean seed cotton yield was 2.3 Mg ha −1 for MT, 2.4 Mg ha −1 for CT and 2.5 Mg ha −1 for DT. Similarly, the mean seed cotton yield was 2.1 Mg ha −1 for F 1 , 2.5 Mg ha −1 for F 2 and 2.6 Mg ha −1 for F 3 . For both crops the interaction of tillage and fertilizer treatments was significant. Tillage systems did not significantly affect the plant tissue elemental contents of wheat (at tillering) and cotton (at flowering). However, the increasing rates of N, P and K caused a corresponding increase in tissue contents of N, P and K of wheat and cotton. Tillage and fertilizer treatments had a positive effect on nutrient uptake by wheat. CT and DT increased N, P and K uptake compared to MT treatment.

Objective: To develop and validate an indicator based assessment tool for carrying out an in-depth assessment of drug selection practices prevalent at various public health facilities.Methods: The study was designed across the different levels of healthcare settings. One super specialty children’s tertiary care hospital (CH), one government medical college hospital (MCH), one district hospital (DH), one sub-district hospital (SDH) and one primary health center (PHC) was selected for the study. A set of 29 qualitative and 7 quantitative indicators was developed and validated to evaluate and assess drug selection practices in these public healthcare facilities.Results: All the surveyed healthcare facilities managed and stored essential medicines except solid oral dosage forms, contraceptives, antiretrovirals and anti-tubercular drugs. The selection process for medicines was not carried out at SDH and PHC level. National List of Essential Medicines (NLEM), manufacturer’s information, and expert faculty opinion were used as basic tools for carrying out a selection of drugs. None of the facilities were found to have Drugs and Therapeutics Committee (DTC) in place or its own Hospital Formulary (HF). Insufficient and irregular disbursement of funds was found to be the main constraint in selecting drugs for procurement. None of the facilities had any policy and procedural manual or standard operating procedures for governing their drug selection and quantification processes. Quantitative assessments showed that disbursement of the budget was fragmented. On the basis of NLEM children’s hospital was found to have highest medicines percentage availability of eighty percent (80%) with the lowest at SDH and PHC of twenty percent each (20%). Facility wise percentage adherence to various indicators for policies and procedures was found to be 50% in MCH, CH, and DH respectively and 66.6% adherence for NLEM indicator was recorded in MCH, CH and DH respectively.Conclusion: Drug selection process for public health facilities is a highly technical and professional activity that can only be achieved efficiently by having a well-defined document containing Standard Operating Procedures (SOPs) and comprehensive policy framework for drug selection, quantification, procurement, storage, distribution, and use besides having suitably qualified, adequately trained, sufficiently skilled manpower both at managerial and ground level.

Supraphysiological concentrations (SPCs) of triiodo-L-thyronine (T3) have been used in the treatment of a number of nonviral diseases. However, the signaling mechanisms that regulate the function of T3 at these concentrations and their role in modulating cellular stress pathways and antiviral responses are unknown. Here, we have investigated the effects of SPCs of T3 on integrated stress response (ISR) signaling pathways and the replication of vesicular stomatitis virus (VSV). T3 amplified Poly IC-induced activation of RNA-dependent protein kinase, induced phosphorylation of eIF2α, stress granule (SG) formation, IRE1α phosphorylation, XBP1 splicing, and the expression of stress markers. T3 inhibited VSV replication by modulating SG formation and the expression of stress response markers. ISR activator guanabenz also inhibited VSV replication and amplified T3-induced anti-VSV response. To summarize, we have uncovered novel functions of T3 at SPCs as an activator of ISR signaling pathways and an inhibitor of VSV replication. This study offers a proof of principle of the concept that ISR activating agents like SPC of T3 and guanabenz can be potential antiviral agents.

The purpose of the present study was to find out the sources of mercury and arsenic pollution of water in the industrial area of Peshawar, the capital of Khyber Pakhtunkhwa, Pakistan. Samples of effluents, mud, and water were collected from the target area (industrial area of Peshawar), the area of water supply source, and from the less polluted area, the Lower Dir district, as the control. Hg was determined by the cold vapor generation technique, while arsenic was determined using the electrothermal atomic absorption technique. Data of the water from the industrial area were compared with that of the source area, control area, as well as with the WHO and some international drinking water quality standards. The results show that some parameters, i.e., TDS, DO, pH, and hardness, were more than the permissible limits. Textile and glass industries were found to be the major sources of Hg and As pollution. Downstream dilution of these contaminants was also observed.

Desulphurization of jet fuel, diesel oil, heavy residue and commercial furnace oil is carried out through extraction with aqueous solutions of sodium chloride, barium chloride, sodium hydroxide, mercury chloride, arsenic trioxide, potassium iodide, lead acetate, calcium hydroxide, zinc chloride, aluminum chloride, hydrochloric acid and sulphuric acid. Among the solutions used, HgCl2 and Ca(OH)2 were found to be the most efficient for the removal of sulphur compounds from the fractions understudy at 40 °C temperature and 30 min of shaking time. The total sulphur depletion of 60 % and 58 % has been achieved in case of jet fuel oil, 71 % and 62 % in case of diesel oil, 68 % and 67 % in case of heavy residue and 67 % and 69 %in case of commercial furnace oil with 10% HgCl2 and 5% Ca(OH)2 aqueous solutions, respectively.

Environmental pollution is one of the burning issues of the world. In developed countries, there are lot of awareness about the environment and the impact of various industries on their life and surroundings. A little has been done in this direction in developing countries. In Pakistan, a big problem is the rapid conglomeration of the brick kilns in the outskirts of nearly all the urban centers to cope with the rapid construction work in big cities. A huge amount of low-grade coal or rubber tires is used as fuel in a very non-scientific manner. The purpose of the present study was to look into the impact of the brick kilns on the different aspects of environmental pollution caused by these kilns. Concentration of metals Cu, Co, Zn, Pb, Cr, Ni, Cd, and Mn were measured on 36 soil samples collected from the area and the same number of plant samples in order to establish the distribution of heavy metals in the area and to determine the effect of this distribution on the surrounding atmosphere and the possible effects on human life.

1 BRICS Medicines Alliance 2 Federal University of Goias, Brazil 3 University of Brasilia, Brazil 4 Kazan Federal University, Russia 5 Christian Medical College, India 6 University of Kashmir, India 7 National Hospital Administration of MOH, China 8 West China Second University Hospital, Sichuan University, China 9 University of Kwazulu-Natal, South Africa 10 Management Sciences for Health, South Africa

All around the world many digital library initiatives have taken place, which look after the digitised content. In India, such an effort known as Digital Library of India (DLI) has been started. Many digitisation centres have been located around the country, which submit the digitised content to the DLI, which are funded by The Ministry of Communication and Information Technology (MCIT), Government of India. The initial target of the mission is one million books. So far much development has occurred and this paper tries to peep into this development.

The minimal inhibitory concentration of prostaglandin E1 (used as a probe for prostacyclin [PGI2]) needed to inhibit platelet aggregation (36 +/- 16 nM) in normal volunteers (n = 40) increased (64 +/- 30 nM) in patients (n = 46) with acute coronary artery disease. Bolus injection of insulin in 20 patients, 0.1 U/kg body weight 4 times a day (every 6 hours) for 7 days decreased the minimal inhibitory concentration of prostaglandin E1 from 64 +/- 30 to 26 +/- 12 nM (p less than 0.001). Twenty other patients who received only saline solution had no decrease in minimal inhibitory concentration of the prostanoid. The bolus injection of insulin also increased the plasma level of PGI2 (9 +/- 2 pM) two-fold in these patients (28 +/- 10 pM). Administration of aspirin inhibited the insulin-induced increase of plasma prostanoid level. Patients in the placebo group had no increase in plasma PGI2 level. The bolus injection of insulin administered only once to another group of patients (n = 6) demonstrated that the hormonal effects were maximally increased within an hour of insulin administration, and were directly related to the increased insulin level in plasma. These results indicated the feasibility of using physiologic quantities of insulin for controlling of platelet aggregation through resensitization of platelet response to prostaglandin and increased synthesis of PGI2 in vivo in acute coronary artery disease.