CONTEXT: The delineation between selection of surgery and non-surgery residency programmes could provide a pragmatic view of the influences on medical graduates’ careers. This would also help coordinators and educators of residency programmes in surgery to further understand the dynamics of specialty selection. AIMS: To identify the different factors that influence the graduates to select surgical specialties in Pakistan. SETTINGS AND DESIGNS: A cross-sectional survey was conducted in 4 teaching hospitals of Karachi between July 1999 and January 2001. SUBJECTS and METHODS: A total of 455 residents in 1-5 years of residency programmes were contacted. Three hundred and forty-one residents consented to the interview. Residents who were registered both with the College of Physicians and Surgeons of Pakistan (CPSP) and the Post Graduate Medical Education (PGME) office of the selected hospitals were included in this study. STATISTICAL METHOD USED: Logistic regression analysis. RESULTS: Final multivariate analysis identified 4 factors that remained significantly associated with the selection of surgical specialty: deriving gratification from direct patient care (adjusted odds ratio [aOR] = 5.79; 95% confidence interval [CI]: 1.24, 26.99), procedure-based medical practice (aOR = 2.85; 95% CI: 1.23, 6.61), nature of clinical problems (aOR = 3.39; 95% CI: 1.47, 7.84), and lack of consideration of stress during professional work (aOR = 2.27, 95%CI: 1.25, 4.13). CONCLUSIONS: Direct patient care is perceived to be an integral part of surgery residency and immediate patient outcome is a positive influence in selecting surgical specialty. The inclination towards surgery appeared to be determined by the type of procedures and technical skills involved in its practice. The nature of clinical problems is an important determinant of the choice of specialty. Stress was not perceived to be an important influencing factor for those who decided to select surgical specialties.

BACKGROUND: Myoclonic-Astatic Epilepsy (MAE) usually starts before five years of age and is associated with very frequent seizures and is highly resistant to treatment. AIM: To investigate the outcome of adjunctive topiramate (TPM) therapy in children with a diagnosis of MAE syndrome. Subjects AND METHODS: In an outpatient setting, case notes of 27 children who received TPM were retrieved and analysed. RESULTS: Records of 6 children with MAE, who were experiencing 2-8 atonic seizures daily before starting TPM were studied. Improvement was noted after addition of TPM (mean dose at steady-state 7.4±2.5mg/kg/day) to the regimen of 1-3 anti-epileptic drugs they were receiving concurrently. All but one child improved following the titration period: one had 50-80% improvement in the frequency of atonic seizures and three had over 80% improvement. However, one child who showed over 80% improvement and was free of atonic seizures, later developed increased frequency of other seizure types. In one child there was no significant improvement. Improvement has been sustained for over 6 months in three patients and over 4 months in one; three have continued TPM. TPM was stopped in three patients (reduction in seizure control/no improvement). CONCLUSIONS: This study supports the efficacy of TPM in controlling atonic seizures in MAE and indicates that it should be considered as an add-on drug in the management of this ‘difficult-to-treat’ epileptic syndrome.

BACKGROUND and AIMS: Mental stress is considered to be a precipitating factor in acute coronary events. We aimed to assess the association of subjective or ‘perceived’ mental stress with the occurrence of acute coronary events. SETTINGS AND DESIGN: Prospective case-control survey was carried out in a referral teaching hospital. subjects & METHODS: Consecutive patients with acute myocardial infarction and ST elevation on electrocardiogram who were admitted to the Coronary Care Unit of a referral teaching hospital were enrolled in the study as cases. Controls were unmatched and were enrolled from amongst patients with coronary artery disease who did not have recent acute coronary events. Subjective Stress Functional Classification (SS-FC) for the preceding 2-4 weeks was assessed and assigned four grades from I to IV as follows: I - baseline, II - more than usual but not affecting daily routine, III - significantly high stress affecting daily routine and IV - worst stress in life. STATISTICAL ANALYSIS: Proportions of different characteristics were compared using chi-square test with Yates continuity correction. Student’s unpaired t test was applied for mean age. ‘p’ value of < 0.05 was considered statistically significant. RESULTS: SS-FC could be reliably (99%) and easily assessed. Eighty (53%) of the total 150 patients with acute MI reported ‘high’ levels of stress (stress class III and IV). This is in contrast to only 30 (20%) of 150 healthy controls reporting high stress for the same period (p value < 0.001). CONCLUSION: Patients with acute myocardial infarction report a higher subjective mental stress during 2 to 4 weeks preceding the acute coronary event.

BACKGROUND AND AIMS: The anaesthetic potency of volatile anaesthetic agents is measured by the minimum alveolar concentration (MAC) required to suppress response in 50% of subjects. We studied the effect of epidural morphine on MAC of isoflurane in humans. SETTINGS AND DESIGN: A prospective single-blind study designed to study the effect of epidural morphine on MAC of isoflurane. SUBJECTS AND METHODS: Forty-eight patients were randomly divided into two groups – Group I patients received 3 mg morphine in 10 ml saline, and Group II patients received 10 ml saline epidurally. Anaesthesia was induced with isoflurane in oxygen and nitrous oxide. Later nitrous oxide was discontinued and MAC of isoflurane determined using modified Dixon’s method of sequential sampling. RESULTS: Epidural morphine resulted in a significant reduction in MAC of isoflurane, 0.98 vs. 1.14 in control group (p<0.05). CONCLUSIONS: Epidural administration of 3 mg morphine in 10 ml saline decreased the MAC of isoflurane.

BACKGROUND: A retrospective analysis of 28 cases of duodenal tuberculosis (TB) was done to evaluate radiological findings and their value in the diagnosis of the disease. subjects AND METHODS: Upper gastrointestinal and small bowel series of 28 patients with duodenal tuberculosis were analysed for radiological findings. The diagnosis of duodenal TB was confirmed by surgery and biopsy in 18, on the basis of radiological findings and response to treatment in 9, and on the basis of findings on upper gastrointestinal scopy and biopsy in 1 patient. RESULTS: The study included 28 patients (14 males, 14 females). The mean age was 32.1 (range 5-65). Twenty-three (82.2%) patients presented with obstructive symptoms while five manifested with dyspeptic symptoms. Of the latter, 4 had ulcerations in the third and fourth parts of the duodenum. In the remaining patient, the mucosa of the duodenum could not be clearly visualised. Two patients had extrinsic impression at the D2-D3 and D3-D4 segments. In 23 patients with obstructive symptoms, 18 demonstrated luminal narrowing of varying degrees and 5 had a sharp band-like cut-off at the third part of the duodenum. Of the 18 patients with luminal narrowing, 13 had extrinsic compression, 12 had proximal dilatation and 14 had ulcerations mainly in the second and third parts of the duodenum. Biliary involvement was seen in 3 patients without any signs or symptoms directly referable to the biliary involvement. CONCLUSION: Though duodenal TB lacks specific radiological features, barium studies help to localise and define the area of narrowing and ulcerations and help to confirm the presence of lymph nodes causing compression of the duodenum.

BACKGROUND: Malaria is of immense importance amongst the tropical diseases in India. There is a need to develop newer diagnostic aids and research is necessary to identify new prognostic markers for prediction of the course and complications. AIMS: To evaluate the white cell differential count and morphology in Plasmodium vivax and Plasmodium falciparum malaria and study their prognostic utility. SUBJECTS AND METHODS: Two hundred and sixty-four adult patients in the age range of 20 to 65 years presenting to the hospital over a period of 4 months with clinical features of malaria and a positive peripheral smear examination were studied. RESULTS: No statistically significant difference was noted in the white blood cell (WBC) count and neutrophil count in P.vivax versus P. falciparum malaria. Band cells were more frequently noted in P. falciparum malaria than in P.vivax malaria (p < 0.0001). Toxic granulation of the neutrophils was noted in 9.5% of the patients and exclusively in P. falciparum malaria. Presence of toxic granulation of the polymorphs in subjects with P. falciparum malaria was significantly associated with anaemia (p=0.019), jaundice, cerebral involvement, adult respiratory distress syndromes, renal dysfunction and death (p < 0.0001 for all these parameters). CONCLUSION: Band cells were seen in P. vivax and P. falciparum malaria, although in higher numbers in P. falciparum malaria. Toxic granulation of the neutrophils was noted only in the presence of P. falciparum malaria in this study and correlated with severity.

India is a developing country with one of the most diverse populations and diets in the world. Cancer rates in India are lower than those seen in Western countries, but are rising with increasing migration of rural population to the cities, increase in life expectancy and changes in lifestyles. In India, rates for oral and oesophageal cancers are some of the highest in the world. In contrast, the rates for colorectal, prostate, and lung cancers are one of the lowest. Studies of Indian immigrants in Western societies indicate that rates of cancer and other chronic diseases, such as coronary heart disease and diabetes, increase dramatically after a generation in the adopted country. Change of diet is among the factors that may be responsible for the changing disease rates. Diet in India encompasses diversity unknown to most other countries, with many dietary patterns emanating from cultural and religious teachings that have existed for thousands of years. Very little is known, however, about the role of the Indian diet in causation of cancer or its role, if any, in prevention of cancer, although more attention is being focused on certain aspects of the Indian diet, such as vegetarianism, spices, and food additives. Of particular interest for cancer prevention is the role of turmeric (curcumin), an ingredient in common Indian curry spice. Researchers also have investigated cumin, chilies, kalakhar, Amrita Bindu, and various plant seeds for their apparent cancer preventive properties. Few prospective studies, however, have been conducted to investigate the role of Indian diet and its various components in prevention of cancer. From a public health perspective, there is an increasing need to develop cancer prevention programs responsive to the unique diets and cultural practices of the people of India.

The role and functions of antioxidant micronutrients such as ascorbate (vitamin C), a-tocopherol (vitamin E) and carotenoids that are provided through the diet in aging and in the prevention of age-related diseases are discussed in the present work. In general, a healthy lifestyle involving regular exercise and avoidance of tobacco or alcohol abuse are the key to the prevention of several age-related diseases including cardiovascular diseases, dementia and cancer. A balanced and regular nutrition with at least five portions of fruit and vegetables per day is a critical constituent of such a healthy lifestyle.

Parkinson’s disease (PD) and Alzheimer’s (AD) are major progressive neurological disorders, the risk of which increases with advancing age (65 years and over). In familial cases, however, early onset of disease (about 35 years) is observed. In spite of extensive basic and clinical research on PD and AD, no preventive or long-term effective treatment strategies are available. Several studies have indicated that oxidative stress is a major risk factor for the initiation and progression of sporadic PD and AD. Even a-synuclein and b-amyloid fragments that are associated with the PD and AD, respectively, mediate part of their action via oxidative stress. Therefore, reducing oxidative stress appears to be a rational choice for the prevention and reduction in the rate of progression of these neurological disorders. This review provides a brief description of the epidemiology and pathogenesis of PD and AD, and the scientific rationale for the use of multiple antioxidants in the prevention of these neurological diseases.

Malignant fibrous histiocytomas (MFH) as primary renal tumours are rare, with less than 50 cases described in the literature. We report a case of primary renal MFH of giant cell type in a 56-year-old man, who presented with bilateral dull flank pain, intermittent gross haematuria and body weight loss (6 kg in 3 months). Intravenous urography, computerized tomography (CT) and magnetic resonance image (MRI) showed right ureteral stones with mild hydronephrosis, and a solid mass at the lower pole of the left kidney associated with staghorn calculi, as well as tumour thrombi in the left renal vein and inferior vena cava. Left radical nephrectomy and evacuation of tumour thrombi from the left renal vein and inferior vena cava were performed. Histopathologic examination revealed malignant fibrous histiocytoma (MFH) of giant cell type. To the best of our knowledge, this is the first report of primary renal MFH associated with staghorn calculi.

Ankle varus deformity arises due to a number of congenital and acquired causes leading to significant functional debility in the patients, especially children. We report a less commonly used technique, the transphyseal osteotomy of distal tibia, for the correction of varus deformity of the ankle joint in a thirteen-year-old boy. Full correction of the deformity could be achieved using this technique. The patient is fully functional with normal gait. No recurrence was detected at follow-up visit 26 months later.

Hypocomplementemic urticarial vasculitis (HUV) is known to be associated with malignancies. Urticarial vasculitis has been linked to lymphomas, but to our knowledge, the association of HUV and non-Hodgkin lymphoma has not been described so far. A patient with HUV who developed 10 years later a diffuse large B cell lymphoma is reported here.

Wasp stings have been associated with a wide variety of local and systemic reactions including, rarely, tachyarrhythmias. We discuss a case of atrial flutter occurring in a 64-year-old man following a single sting in the absence of anaphylaxis. The pathogenesis is discussed and the literature reviewed.

Clinicians might not always have available the services of a professional medical photographer, but if a standardised approach is followed those who take their own clinical photographs can achieve acceptable results. This article offers guidance to the clinician on consistent lighting, exposure, patient positioning, linear scale, perspective, depth of field, and background. Advice is given on equipment and materials, including digital and conventional cameras, flash (strobe), films, and processing choices. Consistency of approach is emphasised – it is not acceptable to use photographic tricks to enhance the appearance of clinical outcomes. Rather, care should be taken to ensure that the only changes among clinical photographs taken over time are in the patient. Photographs should be stored and presented appropriately for their use and images for publication should be prepared according to the instructions to authors. Digital images for publication should be sized appropriately for the final reproduction size.