ROLE OF PAP SMEAR TEST: FROM SCREENING TO CURE IN TERTIARY CARE HOSPITAL

OBJECTIVE This study aims to assess the Pap smear screening method’s accuracy in detecting precancerous lesions. METHODOLOGY After fulfilling the inclusion criteria patients were selected, the patient’s bladder was emptied and put in a dorsal position, and Cusco’s speculum was introduced after lubrication followed by insertion of Ayer’s spatula, applied on the transformational zone, and rotated in 360 degrees. Specimen smeared on glass slides and sent to the laboratory with fulfilled lab pre-requisite form. Patients were requested to follow up with a histopathology report. RESULTS Mean age of the patient was 38.111+9.461 years. Among the 77 patients whose samples were taken 15.4% were asymptomatic, 32.1% with vaginal discharge, 17.9% vaginal discharge,17.0% with intermenstrual bleeding and 16.7% were having lower abdominal pain with p-value=0.087. Histopathology reports were interpreted upon follow-up visit among those 1.3% came out to be positive for malignancy, 76.6% negative for malignancy while 22.1% had an inadequate sample. CONCLUSION The most common method for screening for cervical cancer is the Pap smear, but its efficacy in detecting early precancerous lesions is very low, possibly due to laboratory error or false technique to a gynecologist of sample technique in our tertiary care hospital. Other screening methods should be used instead of conventional Pap smear

Skin Changes in Newly Diagnosed Cases of Hypothyroidism

Introduction: Thyroid disorders are frequent in our population that leads to variety of cutaneous manifestations. Aim of our study was to determine the frequencies of skin changes of hypothyroidism and their association with gender. Methodology: This observational study was conducted at RIHS Islamabad (Ist Jun to 31st Dec 2019) after ethical approval. 105 patients (>18years age) of both genders. Confirmed to have hypothyroidism on the basis of thyroid function tests were included. Secondary hypothyroidism, sick thyroid disease, pregnant women, receiving thyroxin therapy, carcinoma of thyroid, critically ill cases, post-thyroidectomy and iatrogenic thyroid cases were excluded. After informed consent, demographic details were documented. Patients were clinically evaluated and examined in detail including dermatological examination for cutaneous manifestations. Various skin findings are studies with respect to gender. Data was analysed by SPSS version 21 with Chi-square test as a test of significance, significant p<0.05. Results: Among 105 cases of hypothyroidism (62% females and 38% males, mean age was 38.04+12.61 years. Mean TSH level was found to be 32.08 + 33.96 (mean TSH was 35.31+37.31 in females Vs. 26.96 + 27.19 in males; p=0.001). Common skin findings were dry skin in 69.5%, diffuse hair loss in 58%, coarse skin in 57%, pruritis in 51.4%, madarosis 37%, seborrheic dermatitis 34%, coarse scalp hairs 27% and slow nail growth in 23%. The brittle nails, alopecia areata, chronic urticaria, acanthosis nigricans, ivory yellow skin, purpura ecchymosis, ichthyosis, herpes simplex and certain other findings were found in <20% cases. Obesity was observed in 53(50.5%) cases, Type 2 diabetes in 20(19%), hypertension in 23(21.9%), dyslipidaemia in 12(11.4%) and anaemia in 9(8.6%). Obesity, diabetes, dyslipidaemia had no association with gender (p>0.05). However, hypertension and anaemia were significantly frequent amongst females (p<0.05). The dry, coarse skin, diffuse hair loss and seborrheic dermatitis were associated with female gender (p>0.05). Slow nail growth, brittle nails, acne vulgaris, acrochordons, vitiligo, xanthelasma were more common in males however the difference wasn’t statistically significant. Conclusion: Skin acts as an important diagnostic window to diseases affecting internal organs including thyroid disorders. Authors recommend screening for thyroid functions, diabetes, hypertension, dyslipidaemia, obesity and anaemia in patients presenting with suggestive dermatological manifestations irrespective of age and gender. KEYWORDS:  Hypothyroidism.  Thyroid Diseases.  Skin Changes. Thyroid Stimulating Hormone. Thyroid Gland

FUTURE CARDIAC EVENTS IN NORMALLY DIAGNOSED GATED MYOCARDIAL PERFUSION SPECT (GSPECT)

Coronary heart disease (CHD) is a major cause of mortality and morbidity in Europe and USA and its management consumes a large proportion of national healthcare budgets. Many studies had tested the prognostic value of a normal myocardial perfusion scintigraphy; they concluded that a normal MPI study is associated with a very low rate of future cardiac events. In view of the above this study is designed to determine the risk of future cardiac events after normal MPS in local population. Methods: This was a retrospective observational registry performed in a single center in the Kingdom of Saudi Arabia. The data were collected from the nuclear medicine database identifying all the reported normal myocardial perfusion scans between January 2008 and December 2011 . Results: There were 290 patients identified with normal cardiac nuclear scans in the pre-specified time frame. Basic patient demographics were outlined and the patients’ charts were reviewed looking for any major cardiac events such as MI or sudden death. Mean follow up was 14.8 months. There were 2 patients that were admitted with NSTEMI and went on to have diagnostic angiograms. One of those two patients underwent percutaneous coronary intervention with stenting. The other patient had nonobstructive CAD and was advised for medical management only. These findings are consistent with a 0.7% risk of cardiac events after a negative scan Conclusion: The above findings demonstrate that the risk of major cardiac events after a negative nuclear cardiac scan is low and is in keeping with the international statistics available

FUTURE CARDIAC EVENTS IN NORMALLY DIAGNOSED GATED MYOCARDIAL PERFUSION SPECT (GSPECT)

Coronary heart disease (CHD) is a major cause of mortality and morbidity in Europe and USA and its management consumes a large proportion of national healthcare budgets. Many studies had tested the prognostic value of a normal myocardial perfusion scintigraphy; they concluded that a normal MPI study is associated with a very low rate of future cardiac events. In view of the above this study is designed to determine the risk of future cardiac events after normal MPS in local population. Methods: This was a retrospective observational registry performed in a single center in the Kingdom of Saudi Arabia. The data were collected from the nuclear medicine database identifying all the reported normal myocardial perfusion scans between January 2008 and December 2011 . Results: There were 290 patients identified with normal cardiac nuclear scans in the pre-specified time frame. Basic patient demographics were outlined and the patients’ charts were reviewed looking for any major cardiac events such as MI or sudden death. Mean follow up was 14.8 months. There were 2 patients that were admitted with NSTEMI and went on to have diagnostic angiograms. One of those two patients underwent percutaneous coronary intervention with stenting. The other patient had nonobstructive CAD and was advised for medical management only. These findings are consistent with a 0.7% risk of cardiac events after a negative scan Conclusion: The above findings demonstrate that the risk of major cardiac events after a negative nuclear cardiac scan is low and is in keeping with the international statistics available

The Karachi intracranial stenosis study (KISS) Protocol: an urban multicenter case-control investigation reporting the clinical, radiologic and biochemical associations of intracranial stenosis in Pakistan.

Background: Intracranial stenosis is the most common cause of stroke among Asians. It has a poor prognosis with a high rate of recurrence. No effective medical or surgical treatment modality has been developed for the treatment of stroke due to intracranial stenosis. We aim to identify risk factors and biomarkers for intracranial stenosis and to develop techniques such as use of transcranial doppler to help diagnose intracranial stenosis in a cost-effective manner. Methods/Design: The Karachi Intracranial Stenosis Study (KISS) is a prospective, observational, case-control study to describe the clinical features and determine the risk factors of patients with stroke due to intracranial stenosis and compare them to those with stroke due to other etiologies as well as to unaffected individuals. We plan to recruit 200 patients with stroke due to intracranial stenosis and two control groups each of 150 matched individuals. The first set of controls will include patients with ischemic stroke that is due to other atherosclerotic mechanisms specifically lacunar and cardioembolic strokes. The second group will consist of stroke free individuals. Standardized interviews will be conducted to determine demographic, medical, social, and behavioral variables along with baseline medications. Mandatory procedures for inclusion in the study are clinical confirmation of stroke by a healthcare professional within 72 hours of onset, 12 lead electrocardiogram, and neuroimaging. In addition, lipid profile, serum glucose, creatinine and HbA1C will be measured in all participants. Ancillary tests will include carotid ultrasound, transcranial doppler and magnetic resonance or computed tomography angiogram to rule out concurrent carotid disease. Echocardiogram and other additional investigations will be performed at these centers at the discretion of the regional physicians. Discussion: The results of this study will help inform locally relevant clinical guidelines and effective public health and individual interventions

Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial

Background Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy

Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): a randomised, open-label trial

Background: Antiplatelet therapy reduces the risk of major vascular events for people with occlusive vascular disease, although it might increase the risk of intracranial haemorrhage. Patients surviving the commonest subtype of intracranial haemorrhage, intracerebral haemorrhage, are at risk of both haemorrhagic and occlusive vascular events, but whether antiplatelet therapy can be used safely is unclear. We aimed to estimate the relative and absolute effects of antiplatelet therapy on recurrent intracerebral haemorrhage and whether this risk might exceed any reduction of occlusive vascular events. Methods: The REstart or STop Antithrombotics Randomised Trial (RESTART) was a prospective, randomised, open-label, blinded endpoint, parallel-group trial at 122 hospitals in the UK. We recruited adults (≥18 years) who were taking antithrombotic (antiplatelet or anticoagulant) therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage, discontinued antithrombotic therapy, and survived for 24 h. Computerised randomisation incorporating minimisation allocated participants (1:1) to start or avoid antiplatelet therapy. We followed participants for the primary outcome (recurrent symptomatic intracerebral haemorrhage) for up to 5 years. We analysed data from all randomised participants using Cox proportional hazards regression, adjusted for minimisation covariates. This trial is registered with ISRCTN (number ISRCTN71907627). Findings: Between May 22, 2013, and May 31, 2018, 537 participants were recruited a median of 76 days (IQR 29–146) after intracerebral haemorrhage onset: 268 were assigned to start and 269 (one withdrew) to avoid antiplatelet therapy. Participants were followed for a median of 2·0 years (IQR [1·0– 3·0]; completeness 99·3%). 12 (4%) of 268 participants allocated to antiplatelet therapy had recurrence of intracerebral haemorrhage compared with 23 (9%) of 268 participants allocated to avoid antiplatelet therapy (adjusted hazard ratio 0·51 [95% CI 0·25–1·03]; p=0·060). 18 (7%) participants allocated to antiplatelet therapy experienced major haemorrhagic events compared with 25 (9%) participants allocated to avoid antiplatelet therapy (0·71 [0·39–1·30]; p=0·27), and 39 [15%] participants allocated to antiplatelet therapy had major occlusive vascular events compared with 38 [14%] allocated to avoid antiplatelet therapy (1·02 [0·65–1·60]; p=0·92). Interpretation: These results exclude all but a very modest increase in the risk of recurrent intracerebral haemorrhage with antiplatelet therapy for patients on antithrombotic therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage. The risk of recurrent intracerebral haemorrhage is probably too small to exceed the established benefits of antiplatelet therapy for secondary prevention

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020