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Epidural anaesthesia is being regularly practised in many clinical settings and there are many documented complications. Here we report the successful management of accidental migration of epidural catheter into the subarachnoid space causing near collapse in a patient.

Background: Dexmedetomidine is an alpha 2-adrenergic receptor agonist that provides sedation, anxiolysis, hypnosis, analgesia, and sympatholysis. The present study is aimed to assess the efficacy of dexmedetomidine in attenuating sympathoadrenal response to laryngoscopy and tracheal intubation and to analyse its effect on intraoperative anaesthetic and analgesic requirements. Methods: Sixty patients were randomized to receive either dexmedetomidine 1µg/kg (Group D) or 10 mL of 0.9% saline (Group S) over 10 minutes before induction of anaesthesia and after standard induction procedure the same study drug infusions were continued. Blood pressure, heart rate (HR) and Ramsay sedation score (RSS) were monitored at fixed time interval after study drug infusion and anaesthesia induction. Results: After study drug administration the changes in HR and blood pressure was statistically significant between the groups (p =

Dilated cardiomyopathy (DCM) is characterized by impaired ventricular contractility and causes concern in anaesthetic management as it may sometimes predispose to malignant arrhythmias. A 77-year-old woman diagnosed to have irreducible umbilical hernia, was posted for emergency laparotomy and hernia repair. On examination, she belonged to American Society of Anesthesiologists (ASA) physical status grade III with a functional status of 4 metabolic equivalents (METs). She was also suffering from DCM with severe left ventricular (LV) dysfunction (LV ejection fraction 25%). This patient was successfully managed by administering general anaesthesia with ProSeal laryngeal mask airway. We report the detailed anaesthetic management of this patient who underwent emergency laparotomy and hernia repair.

Background: Suxamethonium is considered as the “gold standard” for tracheal intubation. Because of innumerable contraindications for the use of this drug, there is a continuous search for other alternatives. Methods: In a prospective, randomized and double-blind study, we compared the intubating conditions and haemodynamic responses during rapid tracheal intubation using either suxamethonium or rocuronium with ephedrine pretreatment. We recruited 50 patients and allocated them into 2 groups (n= 25 each); Group S: received suxamethonium 1.5 mg/kg and Group R: received rocuronium 0.6 mg/ kg with ephedrine 100 µg/kg pretreatment. All patients were induced with 2 mg/kg propofol and intubation was attempted at 60 seconds. Haemodynamic responses and quality of intubating conditions were assessed. Results: Both groups were comparable in respect to age, sex, weight, Mallampati grade, Cormack Lehane grade and duration of laryngoscopy. Although both groups had clinically acceptable intubating conditions (good and excellent), there were more number of patients with better intubation score in Group S compared to Group R (p = 0.014). Conclusion: Suxamethonium still continues to be the “gold standard” for providing ideal tracheal intubation conditions. However, in conditions where suxamethonium is contraindicated, rocuronium-ephedrine combination can be used as an alternative to intubate the trachea at 60 seconds.

Background and Objectives: Silver (Ag) and Copper (Cu) Nanoparticles (NP) are a potential substitute for disinfection during endodontic therapy because of their antibacterial action against an array of pathogens, including resistant strains. This study aimed to assess the antibiofilm efficiency of calcium hydroxide modified with Ag and Cu NP suspension against E. faecalis , using confocal laser scanning microscopy (CLSM) and colony forming units (CFU) analysis., Methods: Dentine blocks were inoculated with Enterococcus faecalis for one week and 1 week-old biofilm of E. feacalis were randomly divided into 4 groups, control, calcium hydroxide, calcium hydroxide +2 % Cu NP and calcium hydroxide +2 % Ag NP. Following the incubation of the specimens with the medicament for 24 h at 37C, CLSM was used to evaluate the reduction in biovolume of the biofilm and the CFU was determined to assess the antimicrobial action of the NP-modified calcium hydroxide., Results: CLSM images revealed a significant reduction in the thickness of biofilm in both Ag and Cu groups compared to calcium hydroxide alone. The CFU results showed that group 4 and group 3 showed significantly less CFU followed by group 2 and group 1 (p < 0.001)., Conclusion: Adding Cu and Ag NP to calcium hydroxide intracanal medication significantly increases its antibacterial activity against E. faecalis ., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2025 The Authors.)

Aim: To assess the coronal and apical microleakage of mineral trioxide aggregate (MTA), Biodentine, and Bioceramic putty when used as coronal and apical seals in endodontically treated teeth., Materials and Methods: The study was conducted on 90 mandibular premolar teeth. The groups were divided into two subgroups. One group assessed the coronal seal ( n = 45), and the other group assessed the apical seal ( n = 45). Coronal and apical 3 mm of the root filling was removed and replaced randomly with MTA, Biodentine, and Bioceramic putty in the three experimental subgroups ( n = 15). All teeth were immersed in methylene blue and after incubation, the degree of dye penetration was assessed under a stereomicroscope of ×10 magnification. Statistical analysis was done using the Kruskal-Wallis test with a p -value set at 0.05., Results: The mean depth of dye penetration for coronal sealing in the MTA group was 2.91 ± 0.66, in the Biodentine group was 2.12 ± 0.50 and in the Bioceramic putty group was 1.51 ± 0.46. The mean depth of dye penetration for root-end sealing in the MTA group was 0.75 ± 0.55, in the Biodentine group was 1.94 ± 0.88 and in the Bioceramic putty group was 0.29 ± 0.20., Conclusion: Within the limitations of this study, it can be concluded that Bioceramic putty exhibited better sealing ability in both coronal and apical barriers of root canals., Clinical Significance: The sealing ability of a material vastly influences the treatment outcome of nonsurgical and surgical root therapy. The study evaluates the coronal and apical seal of three physical variants of Bioceramic material. How to cite this article: Rao MH, Krishnan R, Gopal P, et al. An Ex-vivo Evaluation of Sealability of Three Bioceramic Physical Variants in Coronal and Apical Thirds of Root Canals. J Contemp Dent Pract 2024;25(11):1022-1026.

Background and Aims: Intraperitoneal local anaesthetic instillation (IPLAI) reduces postoperative pain and analgesic consumption effectively but the timing of instillation remains debatable. This study aims at comparing pre-emptive versus post-surgery IPLA in controlling postoperative pain after elective laparoscopic cholecystectomy., Methods: Ninety patients belonging to American Society of Anesthesiologists physical status I or II were randomly assigned to receive IPLAI of either 30 ml of normal saline (C) or 30 ml of 0.5% bupivacaine at the beginning (PE) or at the end of the surgery (PS) using a double-dummy technique. The primary outcome was the intensity of postoperative pain by visual analogue scale score (VAS) at 30 minute, 1, 2, 4, 6, 24 hours after surgery and time to the first request for analgesia. The secondary outcomes were analgesic request rate in 24 hours; duration of hospital stay and time to return to normal activity. Data were compared using analysis of variance, Kruskal-Wallis or Chi-square test., Results: For all predefined time points, VAS in group PE was significantly lower than that in groups C ( P < 0.05). The time to first analgesic request was shortest in group C (238.0 ± 103.2 minutes) compared to intervention group (PE, 409.2 ± 115.5 minutes; PS, 337.5 ± 97.5 minutes;P < 0.001). Time to attain discharge criteria was not statistically different among groups., Conclusion: Pre-emptive intraperitoneal local anaesthetic instillation resulted in better postoperative pain control along with reduced incidence of shoulder pain and early resumption of normal activity in comparison to post surgery IPLAI and control., Competing Interests: There are no conflicts of interest.

Background: Toll-like receptors (TLRs) play a significant role based on innate immune mechanism during viral infection. TLR signaling mechanism designates to protect the cells from invading viruses. The expression of TLRs during dengue virus (DENV) infection not yet well explained. This study evaluates the TLR gene expression from DENV-infected patient's cornea., Methods: Reverse transcriptase PCR was performed for the detection and genotyping of viral nucleic acid from corneal grafts and DENV-infected cell suspension. TLR expression studies were done on DENV-infected cornea by real-time RT 2 Profiler PCR Array., Results: The reverse transcriptase PCR and genotyping confirmed the presence of DENV-3. TLR expression studies revealed the upregulated expression of TLR4, TLR7, TLR9 and TLR10., Conclusion: Molecular testing of DENV reveals that serological positivity induces transmission of the virus through cornea and stimulates the expression of TLR4, TLR7, TLR9 and TLR10, which may lead to up-regulation of innate pro-inflammatory response in the cornea.

Molar incisor hypomineralization (MIH) is a developmental defect affecting teeth. High prevalence rates of MIH and its clinical implications are significant for both the patients and clinicians. A wide variation in defect prevalence (2.4-40.2%) is reported. It seems to differ with regions and various birth cohorts. Some of the recent prevalence studies are tabulated. Patient implications include hypersensitive teeth, rapid progression of caries, mastication impairment due to rapid attrition, and esthetic repercussions. Implications for clinicians include complexity in treatment planning and treatment implementation, poor prognosis of the restorations, difficulty in achieving pain control during treatment, and behavior management problems. Intention of this paper is to review the etio-pathogenesis, prevalence, clinical features, diagnostic features, and eventually present a sequential treatment approach, i.e., in accordance with current clinical practice guidelines.

Objective: To assess knowledge and practices related to dengue management among physicians., Methods: The cross-sectional study was conducted at hospitals in Islamabad, Lahore, Faisalabad, Peshawar, Quetta and Karachi between June and December 2012Physicians from public and private sectors filled a self-administered questionnaire about dengue knowledge and its management practices. A maximum score of 100 was assigned to the knowledge portion. Data was analysed using SPSS 15., Results: A total of 400 subjects participated in the study; 200(50%) each from public and private hospitals. Of them, 223(56%) were males; 268(67%) were in the 21-30 years age bracket. The highest score was recorded in Quetta 67 followed by 65 in Karachi, 62 in Lahore, Faisalabad, Peshawar and 59 in Islamabad. Of the total, 200 (50%) were not aware that leucopenia is a criterion for diagnosing probable dengue. Similarly 140 (35%) did not know the criteria for diagnosing dengue haemorrhagic fever and warning signs of severe dengue. Total of 204 (51%) were not aware of the criteria for discharging of the admitted cases. There was no significant difference between dengue knowledge of the physicians belonging to public and private sectors (p>0.05)., Conclusions: Quite a large number of physicians lacked knowledge of probable diagnosis of dengue and appropriate time to discharge the patients.

Background: Dexmedetomidine and midazolam both modulate spinal analgesia by different mechanisms, and yet, no human studies are available to compare them for postoperative analgesia after neuraxial administration., Objectives: We investigated the addition of dexmedetomidine or midazolam to intrathecal bupivacaine on the duration of effective analgesia and clinical safety profile., Study Design: Prospective, randomized, double blind, placebo controlled study., Setting: University teaching hospital., Methods: The study cohort included a consecutive and prospective series of patients, referred for endourological procedures. The patients were randomly allocated into 3 groups (20 patients each) to receive intrathecally 3 mL of 0.5% hyperbaric bupivacaine in combination with 5 mcg of dexmedetomidine (dexmedetomidine group), 1 mg of midazolam (midazolam group) or 0.5 mL of 0.9% saline (control group). The groups were compared to the regression time of sensory block, duration of effective analgesia (defined as the time interval between administration of intrathecal drug to the time of first analgesic request or a numeric rating scale = 4.0), sedation score, and side effects in the first 24 hours., Statistics: One way-ANOVA, Kruskal Wallis test, and Chi-square test (χ²), significance level: P < 0.05., Results: The duration of effective analgesia (time to first analgesic request) was significantly prolonged in the dexmedetomidine group (286 ± 64 minutes, P < 0.01) when compared with midazolam group (236.9 ± 64.9 minutes) and the control group (212.7 ± 70.2 minutes). Pairwise comparisons among the 3 groups with Bonferroni adjustment revealed that patients from the dexmedetomidine group were more sedated in comparison to the midazolam and control groups at the end of the first 15 minutes after intrathecal injection [χ² (2) = 7.157, P = 0.028], with a mean rank sedation score of 35.58 for dexmedetomidine, 25.00 for midazolam, and 30.93 for control. No significant differences in the side effects were observed during the study period. Midazolam did not lengthen the time of the two segment sensory regression or the time to first request analgesia., Limitation: The study cannot be extrapolated to muscle cutting surgeries under spinal anaesthesia., Conclusions: The addition of dexmedetomidine (5 mcg) to 3 mL of intrathecal hyperbaric bupivacaine (0.5%) significantly prolongs the duration of effective analgesia in comparison to 1 mg midazolam or placebo (0.9% normal saline) with a comparable incidences of side effects.

We announce the draft genome sequence of two extensively drug-resistant Mycobacterium tuberculosis strains, VRFCWCF XDRTB 232 and VRFCWCF XDRTB 1028, isolated from the sputum samples of a patient clinically suspected to have tuberculosis, and we also report novel mutations that confer drug resistance., (Copyright © 2014 Kulandai et al.)

Context: Central venous catheter (CVC) insertion induces pain and discomfort to a conscious patient despite application of a local anesthetic (LA) field block and this pain can be greatly lessened by using additional analgesics., Aim: The aim of this study is to evaluate the efficacy of fentanyl along with LA field infiltration in controlling pain and discomfort associated with CVC insertion., Settings and Design: A prospective, randomized, double-blind, placebo-controlled trial was conducted at tertiary referral center., Materials and Methods: Fifty-four patients scheduled for planned CVC were randomly assigned to receive either fentanyl (2 μg/kg) or 0.9% normal saline. Pain and discomfort using a verbal numeric rating pain scale at 5 times points during CVC insertion were assessed and analyzed., Results: The median interquartile range pain score is worst for placebo group after LAI (5 [3-6]) and in the immediate postprocedure period (5 [4-5]) which was significantly attenuated by addition of fentanyl (3.5 [2-5] and 3 [2-4]) (P = 0.009 and 0.001 respectively). Overall, fentanyl and placebo group were not statistically different with median discomfort score except at T10 (P = 0.047)., Conclusions: Preprocedural bolus fentanyl infusion provides adequate analgesia and can be safely used for alleviating pain during CVC insertion in conscious patients.

Background: Energy drink is a type of beverage which contains stimulant drugs chiefly caffeine and marketed as mental and physical stimulator. Coffee, tea, soft drinks and other caffeinated beverages are not considered as energy drinks. Purpose of our study was to evaluate the awareness of medical students regarding energy drinks and their pattern and reason of energy drinks consumption., Methods: This was a cross sectional and observational study conducted during the period of January - December 2012 at four Medical Colleges (Dow Medical College, Sindh Medical College, Jinnah Medical College and Liaquat National Medical College) of Karachi, Pakistan. Over all 900 M.B.B.S students were invited to participate after taking written consent but viable questionnaire was submitted by 866 students, estimated response rate of 96%. All data was entered and analyzed through SPSS version 19., Result: Out of 866 participants, majority were females 614 (70.9%) and only 252 (28.5%) were males, with a mean age of 21.43 ± 1.51 years. Energy drinks users were 350 (42.89%) and non users were 516 (59.58%). Only 102 (29.3%) users and 159 (30.7%) non users know the correct definition of Energy drinks. Regarding awareness, mostly user and non users thought that usage of energy drinks had been on rise due to its usefulness in reducing sleep hours [users193 (43.9%), nonusers 247 (56.1%) (p < 0.05)], for studying or completing major projects [users184 (45.0%), nonusers 225 (55.0%) (p < 0.05)] and for refreshment purposes [users179 (44.9%), nonusers 220 (55.1%) (p < 0.05)]. Two main reasons of not using energy drinks by non-users were "awareness from its side effects" 247 (47.8%) and "have no specific reason" 265 (51.3%). Most common side effects reported by users were fatigue 111 (31.7%) and weight gain 102 (29.4%)., Conclusion: In sum, the fact that despite serious side effects of weight gaining and fatigue, practice of consuming energy drinks is highly prevalent among medical students, particularly because they are ever ready to boost their energy level and reduce sleep hours due to stress of exams and projects. This warrants the creation of continued public health awareness about the appropriate use of caffeinated beverages, their potential benefits, side effects and correction of wrong perceptions.

Aim: The aim of this in vitro study was to evaluate and the compare antibacterial efficacy of four dentin bonding system against Streptococcus mutans, Streptococcus salivarius and Lactobacillus acidophilus over a period of three months using agar disk diffusion test., Methodology: All the three standard bacterial strains were inoculated into BHI broth and incubated at 37°C for 48 hours. A 100 μl of broth suspension containing aliquots of S. mutans, S. salivarius and L. acidophilus were spread onto M-H agar medium using sterile cotton swabs. The experimental groups were as follows:, Group a: Test conducted for evaluation of antimicrobial efficacy against S. mutans MTCC 497, GROUP B: Test conducted for evaluation of antimicrobial efficacy against S. salivarius MTCC 1938, and GROUP C: Test conducted for evaluation of antimicrobial efficacy against L. acidophilus MTCC 447. For sample preparation, 20 μl bonding agent was dropped with micropipettes on paper disks, and blown dry for 10 seconds. Then it was light-cured at 2 mm for 20 sec using a QTH visible light curing unit. For first reading, the sample disks were placed over the freshly inoculated agar plates and then incubated at 37°C for 48 hours. The rest of the paper disks were stored in dark, submerged in distilled water at 37°C. They were placed on freshly inoculated spread plates after specific time intervals- 1 day, 1 week, 2 weeks, 1 month and 3 months after ageing in PBS. After incubation, the diameters of zones of inhibition around the plates were measured. The experiment was performed twice in triplicate. The data was then statistically analysed using Two way ANOVA test and post hoc., Results: Results showed that Xeno III had the maximum antibacterial efficacy over a period of three months, followed by XP bond. This antibacterial activity was maximum against Streptococcus mutans, followed by Lactobacillus acidophilus and least against Streptococcus salivarius. Adper Easy One and G bond had minimal effect against the test bacteria during the test period., Conclusion: The antibacterial effect decreased over a period of three months for all the dentin bonding systems.

Objective: To determine the risk of PTSD in patients with acute burn incidents., Method: This was an observational prospective cross-sectional study conducted in admitted patients in Burns Ward of Civil Hospital, Karachi during a period of 6 months from January 1 to June 30, 2011. Data was collected through questionnaire having socio demographic variables and the Impact of Event-Scale (IES-R) was used to determine the risk of PTSD., Results: Out of 145 patients, 12 (77.3%) were at risk of PTSD with 75 (66.9%) males and 37 (33%) females. Out of these 112 cases, 50% belonged to age group 16-29 years. All burn patients with more than 60% total body surface area (TBSA) involved in injury were at risk., Conclusion: The study reports an astronomic number of burns patients with PTSD risk. PTSD drastically affects the quality of life. The earlier this disorder is diagnosed and assessed; better chances are there for enhanced treatment and better recovery.

Reduction of ZnCl2 using LiBH4 in mesitylene yielded zinc nanoparticles (Zn-NPs), borane (BH3) and closo-dodecaborate (B12H12)(2-). The BH3 evolved gas was trapped as Ph3P:BH3 adduct while closo-(B12H12)(2-) was extracted by methanol and characterized from spectral data.

Objective: Burns are important contributors toward mortality in trauma related injuries in Karachi, Pakistan. The aim of the present study was to delineate the factors contributing to the duration of hospitalization and mortality in such patients., Methods: We performed a single center retrospective study of patients admitted during a 2 year period (January 2009 till December 2010) in Burns Center, Karachi. Patients with incomplete record were excluded. Variables included were age and gender of the patient, the percent total body surface area (%TBSA) burn, the cause of the burn and the body parts affected along with the micro-organisms isolated from the burn wounds. The relationship of these variables with the duration of hospitalization and the outcome of patients was assessed by means of Pearson Chi Square test in SPSS version 14., Results: Mean age of patients was 26.64 years (± 13.430). More males (56.6%) were admitted than females (43.4%), giving a male to female ratio of 1.3:1. Mean percent total body surface area (%TBSA) burnt and mortality were 24.69% and 26.38% respectively with both having higher values in females (p<0.001). Males had a mean longer duration of hospitalization compared to females (35.94 days vs. 27.63 days). The most common micro-organism colonizing the wounds was found to be Staphylococcus aureus. Factors significantly (p<0.05) associated with increased duration of hospitalization and mortality include the age and gender of the patient, the cause of burn, inhalation injury, the region affected and %TBSA burnt., Conclusion: The relationship of age and gender of the patient, the cause of burn, inhalation injury, the region affected and %TBSA burnt are important factors in determining the duration of hospitalization of the patients and whether the patients will survive or succumb to injuries., (Copyright © 2012 Elsevier Ltd and ISBI. All rights reserved.)

Background: Treatment of acute post-thoracotomy pain is particularly important not only to keep the patient comfortable but also to minimize pulmonary complications., Aim: This study was designed to test the effect of pre-induction administration of clonidine, given as a single intravenous dose, on post-operative pain scores and fentanyl consumption in patients after thoracic surgery., Setting and Design: Tertiary referral centre. Prospective, randomised, double-blind, placebo-controlled trial., Methods: Sixty patients were randomly allocated to receive clonidine (3 mcg/kg) or saline pre-operatively before induction of anaesthesia. The primary endpoint was pain on coughing (visual analogue scale (VAS) 0-100 mm) 120 min after surgery, time to first analgesic injection in the post-anaesthesia care unit (PACU) and 24-h fentanyl consumption., Statistical Analysis: For between-group comparisons, t-test and U-test were used as appropriate after checking normality of distribution. The incidence of complications between the groups was compared by Fisher's exact test., Results: The post-operative VAS for the first 120 min and the fentanyl consumption at 24 h was significantly greater in the placebo group compared with the clonidine group (P<0.05). The sedation score was increased in the clonidine group during study drug infusion, but did not differ significantly on admission to the PACU., Conclusions: A single intravenous dose of clonidine (3 mcg/kg) given before induction of anaesthesia significantly reduced the post-operative VAS score in the initial period and fentanyl consumption during 24 h after thoracic surgery.

Background: Rocuronium produces faster neuromuscular blockade compared with other neuromuscular blocking drugs. It produces comparable intubating conditions to that of succinylcholine, but does not have the short intubation time of the latter. Hence, it may not be preferable for rapid sequence intubation, but rocuronium with priming may produce comparable intubating time and conditions to that of succinylcholine. Rocuronium with priming may be an alternative to succinylcholine in rapid sequence intubation in conditions where succinylcholine is contraindicated. The present study was conducted to compare the intubating conditions and intubation time of rocuronium with and without priming., Methods: Sixty patients of ASA physical status I and II, aged between 18 and 60 years, of both sexes, were divided into priming and control groups of 30 each. Patients in the priming group received 0.06 mg/kg of rocuronium and those in the control group received normal saline. All patients received fentanyl 1 μg/kg, followed by thiopentone 5 mg/kg for induction. Intubating dose of rocuronium 0.54 mg/kg in the priming group and 0.6 mg/kg in the control group were administered 3 min after priming. Onset time of intubation was assessed using a Train of Four stimuli, and the intubating conditions were compared by the Cooper scoring system., Results: The onset time of intubation was 50.67±7.39 s in the priming group and 94.00±11.62 s in the control group, with excellent intubating conditions in both the groups and without any adverse effects., Conclusions: Priming with rocuronium provides excellent intubating conditions in less than 60 s with no adverse effects.

Objectives: To compare the statistical methods, types of article and design of studies used in 1998 and 2007 articles of leading indexed and non-indexed medical journals of Pakistan., Methods: Six leading medical journals of Pakistan: (1) JCPSP, (2) JPMA, (3) JAMC, (4) PJMS, (5) PJMR and (6) PAFMJ, were selected for this study. Articles reviewed were 1057 to achieve the above mentioned objective., Results: The articles reviewed for 1998 and 2007 were 366 and 691, respectively. Original articles contributed the maximum percentage of 65.6%, followed by case reports with 24.8%. The contribution of case reports in 1998 was 20.5% which increased to 27.1% in 2007. There was no statistically significant difference between 'indexed' and 'non-indexed' journals for different type of statistical methods in 1998 or 2007. In total, 749 articles were categorized as 'original articles' or 'short communication'. Among them, 51% articles mentioned study design and 67.3% of them were correct for the respective methodology. In 1998, 202 (74%) articles did not use any statistics or indicated only descriptive statistics, while in 2007, 239 (50.2%) articles did the same. The reader who was familiar with t-test and contingency tables in 1998 could have understood 97.4% of the scientific articles. However, this percentage dropped to 83.0% in 2007., Conclusions: Quality of elaborating methods and usage of biostatistics in 6 leading Pakistani medical journals improved from 1998 to 2007, but has still to come up as compared to other western medical journals.

Objectives: To determine the effectiveness of the circumcision by Plastibell technique with comparison of complications among neonate and infant age groups., Methods: A retrospective, descriptive study was conducted in all the plastibell circumcisions performed by the first author, during the period October 2006 to December 2008 at a private hospital Karachi. The record of all the cases fulfilling the inclusion criteria were obtained and analyzed for determining the outcome and complications if any in neonates and infants and to compare it with in these two groups., Results: Overall 245 cases of neonates and infants were selected. Mean age of neonates and infants was 14 +/- 2 days and 3 +/- 0.5 months respectively. The plastibell circumcision was done in all the cases i.e. 90 neonates and 155 infants. Out of these, the successful rate of plastibell circumcision without any complication was recorded as 196 cases (80.00%) whereas, 49 cases (20.00%) developed complications. In neonates it was recorded as 04.44% cases, whereas this ratio was 29.03% in infants. Most common complications were delayed separation of the ring in 17 cases (6.93%), bleeding in 12 cases (4.89%), localized superficial infection in 12 cases (4.89%), and proximal migration of ring in 07 cases (2.85%)., Conclusion: The ratio of complications of circumcision by plastibell is significantly higher in infants as compared to neonates. However it is an easy, quick and safe technique. Outcome of this procedure is encouraging while infants are more prone to develop post operative complications than neonates.

Background: To study the clinical presentation, pulmonary functions and outcomes in subjects who were accidentally exposed to chlorine gas., Methods: Prospective observational study of 64 patients who sustained acute accidental exposure to chlorine gas during a leak in the chlorination system of the public bathing pool of a temple., Results: The major presenting symptoms and signs included acute dyspnoea (100%), chest discomfort (100%), cough (97%), eye irritation (88%), giddiness (72%), vomiting (46%), and heaviness in the head (44%); tachycardia (100%), tachypnoea (96%) and polyphonic wheezing (28%). All patients were managed in the emergency room with humidified oxygen inhalation and beta-2 agonist nebulisation and 52 were discharged within six hours. Twelve patients were severely affected and required hospitalisation; three of them were admitted into the intensive care unit. Three patients developed pulmonary oedema six to eight hours following admission. Pulmonary function testing (n = 12) at presentation revealed obstructive defect in eight and mixed obstructive-cum-restrictive defect in four patients. The mean duration of hospital stay was 5.1 +/- 2.1 days. None of the patients died. Reactive airway dysfunction syndrome (RADS) was observed in three of the 12 hospitalised patients, who complained of manifested persistent cough that lasted for three months period following discharge. Serial pulmonary functions recovered to normal range by the end of the six months in all patients and remained so at one-year follow-up., Conclusion: Acute exposure to chlorine gas is an uncommon, but important public health hazard and can cause RADS, acute lung injury and pulmonary function abnormalities, which are reversible on prompt and appropriate management.

Objective: To assess the safety and acceptability of a single dose of vitamin-D versus the efficacy of injectable Vitamin-D versus oral vitamin-D., Study Design: Case control., Place and Duration of Study: It was carried out at the Department of Paediatrics, Kharadar General Hospital, Karachi, from August 2003 to April 2004., Methodology: Children of the age of 6 months to 3 years with clinical, biochemical and radiological evidence of vitamin- D deficiency rickets were included. The history, clinical examination, complete blood picture, serum calcium. Phosphorus, alkaline phosphatase and X-ray of wrist joint were done. The children were divided into two groups A and B. Group A was given oral vitamin-D and group B was given intramuscular injection of vitamin-D on the first day and then they were followed for two more visits at 30 and 90 days with clinical, biochemical and radiological examinations to assess the outcome., Results: There were 50 confirmed cases of rickets in each group. The mean age was 10.9+5.1 months and 14.7+8.1 months in group A and B respectively. In these children, clinical features were weakness, difficulty in walking, frontal bossing, ribcage deformity and widening of wrist were seen. After one dose of vitamin-D (cholecalciferol), there was appreciable gain of weight and height and raised levels of alkaline phosphatase became normal during follow-up. Radiological florid rickets and non-florid rickets in both groups healed clinically during follow-up period. Oral and injectable forms of vitamin-D (cholecalciferol) were effective but injectable form was shown to be statistically significant. There were no undesirable side effects and both forms of treatment were well-tolerated.

Summary: Prolonged ventilation leads to a higher incidence of ventilator associated pneumonia(VAP) resulting in ventilator dependency, increased costs and subsequent weaning failures. Prevention and aggressive treatment of VAP along with patient friendly newer modes of ventilation like adaptive support ventilation go a long way in successful management of these cases.

Poisoning with Cleistanthus collinus frequently causes cardiac manifestations such as rhythm disturbances and also results in other manifestations such as metabolic acidosis and hypokalemia. We present the case of a patient who presented with a rare myasthenic crisis-like syndrome requiring assisted ventilation due to Cleistanthus collinus poisoning, which responded to treatment with neostigmine.

Enantiopure (3S,5S,6R,8S)- and (3S,5S,6S,8S)-6-hydroxypyrrolizidinone 3-N-(Boc)amino 8-methyl carboxylates (6R)- and (6S)-1 were synthesized in seven steps starting from (2S)-alpha-tert-butyl N-(PhF) aspartate beta-aldehyde (10). Carbene-catalyzed acyloin condensation of beta-aldehyde 10 followed by acetylation provided a separable mixture of diastereomeric (2S,5RS,7S)-diamino-4-oxo-5-acetoxysuberates (13). Reductive amination and lactam annulation of the respective alpha-acetoxy ketones 13 provided hydroxypyrrolizidinones (6R)- and (6S)-1 with retention of the C6-position stereochemistry. The X-ray crystallographic study of (6R)-1 indicated dihedral angles constrained within the heterocycle that were consistent with the ideal values for the i + 1 and i + 2 residues of a type II' beta-turn. Hydrogen-bonding studies on N'-methyl-N-(Boc)aminopyrrolizidin-2-one carboxamides (6R)- and (6S)-21 in DMSO-d6, demonstrated different NH chemical shift displacements and temperature coefficients for the amide and carbamate protons, indicative of solvent shielded and exposed hydrogens in a turn conformation. 6-Hydroxy pyrrolizidinone amino carboxylate 1 may thus find application as a constrained alaninylhydroxyproline dipeptide mimic. In addition, alkylation of the hydroxyl group provided orthogonally protected pyrrolizidinone amino dicarboxylate (6R)-25, demonstrating potential for expanding the diversity of these rigid dipeptide surrogates for the exploration of peptide conformation-activity relationships.

Background: Severe acute exacerbation of chronic obstructive pulmonary disease (AE-COPD) is a common reason for emergency room (ER) visit about which little has been documented from India., Methods: Prospective study of the clinical presentation and predictors of outcome in 116 patients presenting with severe AE-COPD requiring admission to the medical intensive care unit between January 2000 and December 2004., Results: Their mean age was 62.1 +/- 9.8 years. There were 102 males. Mean duration of COPD was 7.2 +/- 5.8 years. All males were smokers (22.3 +/- 11.2 pack years); 35.2% smoked cigarettes and 64.8% smoked bidis. All women were exposed to domestic fuel. Associated co-morbid illnesses were present in 81 patients (69.8%); 53(45.7%) had one co-morbid illness and the remaining 28 (54.3%) had two or more co-morbid illnesses. Evidence of past pulmonary tuberculosis (PTB) was present in 28.4% patients; 5 patients who also had type II diabetes mellitus had active PTB. Arterial blood gas analysis revealed respiratory failure in 40 (33.8%) patients (type I 17.5% and type II 82.5%). Invasive mechanical ventilation was required in 18 patients. Sixteen (13.7%) patients died. Stepwise multivariate logistic regression analysis revealed need for invasive ventilation (OR 45.809, 95% CI 607.46 to 3.009;p < 0.001); presence of co-morbid illness (OR 0.126, 95% CI 0.428 to 0.037;p < 0.01) and hypercapnia (OR 0.114, 95% CI 1.324 to 0.010;p < 0.05) were predictors of death., Conclusion: Co-morbid conditions and metabolic abnormalities render the diagnosis of AE-COPD difficult and also contribute to mortality. High prevalence of past PTB and active PTB in patients with AE-COPD suggests an intriguing relationship between smoking, PTB and COPD which merits further study.

Oligomers of a new class of sugar amino acids (SAA) using a xylofuranoic acid has been shown to generate a robust 14-helix. The design involved the use of xylofuranose with a cis arrangement between the amine and carboxyl groups to promote the adoption of a 14-helix instead of a mixed 12/10-helix observed in a sugar oligomer using a ribofuranoic acid and beta-Ala. The observation of a stable right-handed 14-helix in a cis-SAA is unprecedented.

This study reports the photoelectrocatalytic oxidation of benzoic acid in a three-electrode photoelectroreactor. The effects of the anode bias potential, the atmosphere of reaction and the basis material for photocatalyst preparation on the removal efficiency of benzoic acid were researched. The photoelectrocatalysis was compared with photolysis, photocatalysis and electrolysis. The results of the experiments indicated the removal efficiency of benzoic acid after the photoelectrocatalytic oxidation process for 1 h could be more than 85%, much higher than the efficiency of photolysis (48%), photocatalysis (30%) and electrolysis (nearly having no effect). The synergetic effect of the photoelectricity was obvious. The working electrode and the counter electrode were arranged as two concentric columns whose diameters were different. The results showed that this kind of arrangement mode was very effective. In nitrogen atmosphere the removal efficiency of benzoic acid could be 98% when TiO2/Ti acted as the anode of the photoelectrocatalytic oxidation process for 1 h, much better than the TiO2/Al did (85%). While in oxygen atmosphere the two kinds of electrodes were both effective and the removal efficiency of benzoic acid could approach 100%.

We retrospectively reviewed the case records of 82 patients with severe left ventricular dysfunction (ejection fraction < 30%) who underwent coronary artery bypass grafting between March 1993 and February 2000. They were aged 28 to 76 years (mean, 60 years), and 66 of them were male. Significant comorbid factors included hypertension (93%), diabetes mellitus (85%), and hypercholesterolemia (49%). The number of grafts used ranged from 1 to 3. The majority of the patients (91%) belonged to the Canadian Cardiovascular Society angina class III. Coronary angiography revealed single-vessel (in 16% of the patients), double-vessel (52%), and triple-vessel disease (32%), and left main stem disease (18%). Seven patients (9%) died within 48 hours after surgery. The mean duration of hospital stay was 7 +/- 2 days. The 75 patients who survived were followed up for 3 months to 7 years. At the 1-year follow-up, 61 of the 68 patients (90%) who were alive moved up from angina class III to class I. Our observations suggest that coronary bypass carries an acceptable mortality risk and may offer a better quality of life in patients with poor ventricular function.

Objective: To determine the deficiencies in the existing record keeping system (ERKS) in government teaching hospitals of Karachi., Study Design: Descriptive, qualitative study to determine the deficiencies in the ERKS in government teaching hospitals of Karachi., Setting: The study was conducted in four government teaching hospitals of Karachi from 1.1.1998 to 1.11.1998., Methods: A total of 9725 pre-coded proformas were filled from 136 units of all hospitals including out patient departments (OPD), wards and emergency units., Results: Majority of the records (52.2%) were retrievable within one hour. The mean +/- S.D of patients seen per day at all hospitals were 122.49 +/- 92.25 (57 OPDs), 30.04 +/- 16.24 (75 wards) and 186.25 +/- 145.80 (4 emergencies). In majority of units (57.4%), the stationary for record keeping system was either not provided or was not enough. Only 39.0% units have 75% or more required information on records. The important information (except age) i.e. temperature, pulse rate, blood pressure, diagnosis, weight, history of patient, laboratory findings, previous record and discharge report and prescribed doses of medicine were lacking., Conclusion: The ERKS in the government hospitals of Karachi is inadequate. It is therefore essential that uniform OPD, ward and emergency slips should be developed having all-important queries. So that data could be utilized for research purposes along with better planning and management of the hospital and procurement plan for the government.

Several cyclic analogues of renin inhibitors, based on Glu-D-Phe-Lys motif have been investigated by NMR spectroscopy and molecular dynamics calculations (MD). The 15 membered macrocycle, resulting from Glu and Lys side-chain cyclization, exhibits conformational preference. The structural evidence from NMR shows the presence of hydrogen bond between Lys NH and Glu side-chain carbonyl, resulting in a 10 membered pseudo beta-turn-like structure. The structure of the cyclic moiety is similar in all the peptides, which takes at least two conformations around Calpha-Cbeta in Glu side chain. The restrained MD calculations further support such observations and show that the macrocycle is fairly rigid, with two conformations about the Glu Calpha-Cbeta bond. The linear peptide appendages, which are essential for activity in cyclic peptides, show an extended structure in the beta-region of Ramchandran plot. These calculations also demonstrate that for the most active peptide, two major conformers each exist about the Calpha-CO bond of the Lys, D-Trp and Leu residues. In this peptide, the cyclic moiety presents a negatively charged surface formed due to the carbonyl oxygens, which are thus available to form hydrogen bonds with the receptor. The linear fragment presents further binding sites with a surface which has the hydrophobic side chains of D-Trp, Leu and D-Met on one side and carbonyls on the other side.

In an effort to explore the effect of ring size on the biologically active conformation of cyclic analogs of the mating pheromone alpha-factor (WHWLQLKPGQPMY) from Saccharomyces cerevisiae, eight cyclic tetrapeptides corresponding to the KPGQ portion of alpha-factor were synthesized. These N-alpha-acetyl/carboxyl amide terminal cyclic tetrapeptides were prepared on a 4-methylbenzhydrylamine resin using orthogonal Boc, Fmoc, OFm and OtBut protecting groups and HOBt-DIPC accelerated active esters or urethane-protected N-carboxyanhydrides. On-resin cyclization of the side-chain amino and carboxyl groups of the first and fourth residues, respectively, was performed with the BOP reagent to generate lactams containing 14-18 atoms. HF cleavage resulted in two products, the desired cyclic tetrapeptide and a major side product. All peptides were purified to near homogeneity (> 99%) by using reversed-phase HPLC and were characterized by FBMS and 1H NMR. Certain constrained cyclic tetrapeptides appear to be a mixture of isomers at room temperature as evidenced by HPLC and NMR. The major side product has been identified as a cyclo dimer, obtained as a consequence of interchain cyclization on the resin. CD analysis in several solvents gives evidence that some of the cyclic tetrapeptides exist in beta-turn conformations.

Immunization status of children and their mothers and reasons for their failure to be immunized were studied. The study lasted for two months, i.e., August and September, 1993 at the Paediatric Outpatient Department of Civil Hospital, Karachi. Three groups of patients were targeted. Six hundred and twenty-four children under 1 year of age, 955 children between the ages of 1 to 5 years and 1579 mothers were registered. These women were questioned regarding their immunization status and that of their children. In the group below 1 year of age, BCG, DPT and polio (3 doses) and measles were given to 75%, 35% and 23% respectively. Tetanus toxoid (2 doses) was given to 47% of their mothers. In the group of children between 1-5 years, BCG, DPT and polio 3 doses and measles were given to 84%, 63% and 58% respectively. Tetanus toxoid (2 doses) were given to 64% of their mothers. The main reasons for not vaccinating were lack of information and lack of motivation.

We have examined the effects of antisense oligomers (AOs) of various lengths, sequences and chemistry on the proliferation of eight different cell lines, five derived from patients with chronic myelogenous leukemia (CML) and three from other sources. In general, phosphodiester AOs were inactive, presumably due to degradation by nucleases present in fetal calf serum. Both BA2 and B3A2 phosphorothiolate AOs (but not corresponding sense oligomers) significantly inhibited the proliferation of three CML cell lines (BV173, LAMA84, and KYO1), but the effect was independent of the type of breakpoint expressed by each cell line, suggesting that the inhibition was sequence dependent but not sequence specific. The CML cell lines tested showed different sensitivities to inhibition of proliferation by AOs--lines with defective expression of the normal ABL protooncogene (e.g. BV173) were more readily inhibited than lines with a normal ABL message (e.g. K562). We conclude that further studies are necessary to delineate the precise mechanism(s) by which CML cell proliferation is inhibited by AOs.