Diabetic ketoacidosis associated with tacrolimus in solid organ transplant recipients

Diabetic ketoacidosis in patients receiving tacrolimus in the post-transplant setting is rare. We describe two such cases in solid-organ transplant recipients. The first patient, a 17-year-old male, presented with severe diabetic ketoacidosis and was managed with intravenous fluids and insulin infusion. He was a known case of Laurence-Moon-Bardet-Biedl syndrome and had received a renal transplant 2 years ago and was receiving tacrolimus since then. Although diabetic ketoacidosis resolved in 24 hours, large doses of subcutaneous insulin (upto 130 units per day) were needed to keep serum glucose within the normal range. Substitution of tacrolimus with cyclosporine obviated the need for insulin or oral hypoglycaemics. The second patient, a 55-year-old woman, presented with a history of polyuria for 3 days. She had received a hepatic transplant 2 years ago and tacrolimus was being used since then. Mild diabetic ketoacidosis was managed with fluid resuscitation and subcutaneous insulin. Her insulin requirement after an uneventful recovery has been 54 - 70 units per day. Clinicians should be cognizant of the possibility of hyperglycaemic crisis presenting as sudden onset of diabetic ketocidosis in patients receiving tacrolimus. Use of an alternative calcineurin inhibitor may provide a safer solution to minimize future morbidity in such patients

Essays on retail pricing

Most empirical literature on Walmart Supercenters quantifies the price effect of Supercenter entries using lower frequency data (annual or monthly) and does not take into account finer geographical detail of retail markets experiencing Walmart entries. There is also very little empirical research on quantifying the impact of secondary entries by Walmart Supercenters in retail markets. We fill this gap by quantifying the price effect of secondary Supercenter entries into a specific retail market: Columbia, Missouri. We make use of hand-collected weekly price data spanning four time periods from 2006 to 2008 and do not find any evidence of negative price effect either in immediate term or in medium term following the opening of the two Walmart Supercenters in Columbia, Missouri. This result holds for all types of products and for grocery stores of all sizes. There is a dearth of economic literature that quantifies price pass-through following minimum-wage changes. We fill this gap by using a dataset of U.S minimum-wage histories from 1993-2012 along with micro-level price data on specific food products in the fast-food industry during the same time period. We find evidence that minimum-wage increases are associated with statistically significant increases in fast-food prices. However, we also find evidence that minimum-wage hikes are in fact endogenous to prevailing costs of living and correlated with the error term. This endogeniety bias suggests that that actual minimum-wage price elasticity may be much smaller than as estimated in earlier empirical literature on the subject

Knowledge, attitudes and practices survey on organ donation among a selected adult population of Pakistan

Background: To determine the knowledge, attitudes and practices regarding organ donation in a selected adult population in Pakistan. Methods: Convenience sampling was used to generate a sample of 440, 408 interviews were successfully completed and used for analysis. Data collection was carried out via a face to face interview based on a pre-tested questionnaire in selected public areas of Karachi, Pakistan. Data was analyzed using SPSS v. 15 and associations were tested using the Pearson\u27s Chi square test. Multiple logistic regression was used to find independent predictors of knowledge status and motivation of organ donation. Results: Knowledge about organ donation was significantly associated with education (p = 0.000) and socioeconomic status (p = 0.038). 70/198 (35.3%) people expressed a high motivation to donate. Allowance of organ donation in religion was significantly associated with the motivation to donate (p = 0.000). Multiple logistic regression analysis revealed that higher level of education and higher socioeconomic status were significant (p \u3c 0.05) independent predictors of knowledge status of organ donation. For motivation, multiple logistic regression revealed that higher socioeconomic status, adequate knowledge score and belief that organ donation is allowed in religion were significant (p \u3c 0.05) independent predictors. Television emerged as the major source of information. Only 3.5% had themselves donated an organ, with only one person being an actual kidney donor. Conclusion: Better knowledge may ultimately translate into the act of donation. Effective measures should be taken to educate people with relevant information with the involvement of media, doctors and religious scholars

Corporate Social Responsibility Reporting: Towards a framework for Pakistan

Corporations disseminate Corporate Social Responsibility Reporting (CSRR) to discharge accountability and transparency to their stakeholders and achieve corporate legitimacy in society. Originating from the developed countries, CSRR practices have been mainly dominated by the ideas and practices from the United States, United Kingdom, Germany, and Australia, etc., which have influenced CSRR practices in developing countries. Several scholars argue that CSRR is a context-specific concept, and therefore it should incorporate the contextual factors including the socio-economic, political, religious, and cultural factors of the country, and should be based on the perspectives of local stakeholders. The call to incorporate contextual factors provides the impetus for this study to develop a context-specific CSRR framework and to evaluate current CSRR practices of public listed companies in Pakistan. The three interrelated objectives of the study are, (a) to construct a stakeholder-based CSRR index for Pakistani corporations, (b) to evaluate the extent and quality of CSRR practices of Pakistani listed companies, and (c) to examine the factors influencing CSRR practices in Pakistan. To achieve the objectives of the study, a sequential mixed-methods approach was employed and the investigation was completed in three stages. In the first stage, a CSRR index consisting of 70 items was developed in consultation with 50 Pakistani stakeholders from eight groups representing corporate managers, customers, religious clerics, investors, auditors and accountants, corporate employees, government regulators, and academicians. In the second stage, the stakeholders-based CSRR index was applied to the annual reports of 25 listed Pakistani corporations to evaluate the extent and quality of CSRR practices in Pakistan. Finally, statistical techniques, including the correlation and multiple regression analysis, were employed to determine the impact of twelve company-specific factors on the CSRR practices of the Pakistani corporations examined. To provide insights on the findings, the study adopts an integrated theoretical framework including stakeholder theory, legitimacy theory, institutional theory, signaling theory, and agency theory. The interpretation with reference to the theoretical framework provides insights into the CSRR practices of Pakistani corporations. In addition, the study also examines the theories in light of the empirical findings. The findings of the study suggest a considerably low extent and quality of CSRR practices in Pakistan. It points to a significant information gap between the expectations of Pakistani stakeholders and the actual CSRR disclosed by the Pakistani corporations. It is argued that low stakeholders’ activism, the weak influence of normative and coercive forces, and the absence of context-specific CSRR framework and guidelines lead to the low extent and quality of CSRR observed in this study. The regression analysis reveals that firm size, industry, the board size, family ownership, and government ownership significantly influence the CSRR practices in Pakistan. However, this association was not evident with respect to profitability, financial leverage, audit type, firm age, independent and women directors, and foreign ownership. The empirical findings, which are interpreted through the theoretical lenses adopted in this study, indicate that CSRR in Pakistan is used for reputational and impression management, window-dressing, and greenwashing purposes rather than to discharge accountability and transparency to the extended stakeholder groups. The study makes several contributions to the field of CSRR from multiple perspectives. First, the study contributes in the form of a CSRR framework that would guide the CSRR practices and enable the regulatory authorities to make policies and statutory recommendations for the enforcement of CSRR in Pakistan. Second, it contributes to the extant literature by suggesting a systematic method and approach to construct a CSRR index and evaluate CSRR practices in line with the stakeholders’ perspectives and contextual factors. Third, this study highlights the implications of CSRR practices in an Islamic context and therefore contributes to the Islamic scholarship on CSRR. Finally, the study provides new empirical insights on CSRR theories in light of the specific context of a predominantly Islamic country

Efficacy and safety of quinine loading dose in patients with severe falciparum malaria at a tertiary care hospital in Pakistan

OBJECTIVE: To compare the clinical outcomes of a loading dose regimen of quinine with a uniform dose regimen in patients with severe falciparum malaria. METHODS: A retrospective chart review of 315 patients admitted with severe falciparum malaria and treated with quinine at a tertiary care teaching hospital of Karachi, Pakistan during 1999-2006 was conducted. Group A with 103 patients (32.7%) was given an initial loading dose of quinine while group B with 212 patients (67.3%) did not receive the loading dose. The two groups were compared in terms of reduction of parasite load, resolution of fever, recovery of consciousness and incidence of adverse effects. Outcome parameters were measured on the third day of therapy. RESULTS: More individuals in group A (62.1%) were afebrile as compared to group B (54.7%) at day 3 of therapy. Patients in group B showed greater reduction in parasitaemia (47.2% at baseline to 4.7% on day 3) as compared to group A (56.3 % at baseline to 9.7% on day 3). Following therapy, fewer patients in group B had altered consciousness (7.1% at baseline to 4.7% on day 3) as compared to patients in group A (7.8% at baseline to 5.8% on day 3). However, these associations were not statistically significant. The incidence of thrombocytopenia was higher in Group A (5.8%) as compared to Group B (0.9%). CONCLUSION: Although quinine loading dose may be more effective than uniform dose in rapid fever clearance; it also appears to be associated with higher toxicity. Uniform dose of quinine may be prescribed in severe falciparum malaria in view of its better safety profile

Giant adrenal endothelial cyst associated with acute and chronic morbidity in a young female: a case report

Adrenal cysts are rare clinical entities that can present as acute abdomen through rupture and internal hemorrhage as well as chronic symptoms such as gastrointestinal disturbances. A 20-year-old girl presented to our hospital with a 4-years history of abdominal pain and diarrhea. Ultrasound of the abdomen revealed a cystic area measuring 10 × 10 cm between the spleen and left kidney. Computed tomography scan showed a large cystic, homogeneous mass measuring 12.8 × 9.5 × 9.4 cm in the left hypochondrium with most likely origin from the left adrenal gland. Limited work up for hormone hypersecretion was negative. The patient was then encountered in the emergency room with an acute abdomen secondary to intracystic hemorrhage. A laparotomy with left adrenalectomy was performed. Final pathology showed a benign adrenal endothelial cyst. Post-operatively, the patient's long standing complaints of diarrhea and abdominal pain completely resolved. Surgical resection appears a safe and reasonable management strategy in a patient with intracystic hemorrhage of adrenal cyst

Phakomatoses and Their Tumors: Genetics and New Treatment Options

In addition to sporadic primary neoplasms of the central nervous system, several genetic syndromes associated with CNS tumors have been identified. Tuberous sclerosis, neurofibromatosis-1 and -2, and von Hippel–Lindau syndrome belong to a collection of disorders called phakomatoses, which include both CNS tumors and cutaneous manifestations. The underlying genetics of these disorders are being elucidated and offer novel therapies for intervention

Pathogenesis, diagnosis and management of primary melanoma of the colon

<p>Abstract</p> <p>Background</p> <p>Melanomas within the alimentary tract are usually metastatic in origin. On the other hand, primary melanomas of the gastrointestinal tract are relatively uncommon. There are several published reports of melanomas occurring in the esophagus, stomach, small bowel, and anorectum. The occurrence of primary melanoma of the colon has, however, only been rarely reported. The optimum modus operandi for the management of primary colonic melanoma remains nebulous due to the limited number of reports in literature.</p> <p>Methods</p> <p>A comprehensive search of Medline, Cochrane and Highwire was performed using the following keywords: 'melanoma', 'malignant melanoma', 'primary melanoma', 'colon', 'gastrointestinal tract', 'alimentary tract', 'digestive tract', and 'large bowel'. All patients with primary melanoma localized to the colon were included in the review. Patients with metastatic melanomas to the gastrointestinal (GI) tract and primary melanomas localized to the GI tract in anatomic locations other than colon were excluded.</p> <p>Results</p> <p>There have been only 12 reported cases of primary melanoma of the colon to date. The average age of patients on presentation was 60.4 years without any significant gender predilection. Right colon (33%) and cecum (33%) were the most common sites for the occurrence of primary colonic melanoma while abdominal pain (58%) and weight loss (50%) were the most common presenting complaints. Colonoscopy is the most reliable diagnostic investigation and offers the additional advantage of obtaining tissue for diagnosis. S-100 and HMB-45 are highly sensitive and specific for the diagnosis of this malignancy. For primary colonic melanomas that have not metastasized to any distant parts of the body, surgical resection with wide margins appears to be the treatment of choice. Although the management was individualized in every case, most of the authors preferred traditional hemicolectomy as the favored surgical approach. Chemotherapeutic agents including interferons, cytokines, biological agents and radiation therapy for brain metastases have been reported as adjuvant and palliative options while considering malignant melanomas in general. The average recurrence-free interval was 2.59 years. Nine of the 12 reports documented follow-up in their patients. Two of these 9 (22.2%) patients died.</p> <p>Conclusions</p> <p>Primary melanoma of the colon is a rare clinical entity. Whenever a seemingly primary melanoma is detected in an atypical location such as the colon, it is prudent to conduct a thorough clinical investigation to consider the possibility of metastatic disease. Further studies are needed to document the long term follow-up, survival advantage and safety of the management approaches employed in patients with primary colonic melanoma. Based on current data, surgical resection appears to be appropriate management for primary colonic melanomas; unless the disease has metastasized to distant sites where surgery may have a limited palliative role.</p