We conducted a systematic international review of tobacco smoking habits among medical students. Particular attention was paid to countries where smoking rates have been historically well-documented in local journals, but were less often included in larger international review articles. The methodology involved a search of relevant medical subject headings, after which the reference lists of journal papers were also examined to find additional publications. A total of 66 manuscripts met the inclusion criteria. The most common countries previously studied included India, the United States, Australia, Japan, Pakistan, Turkey and the United Kingdom. Overall, our review suggests that the prevalence of smoking among medical students varies widely amongst different countries and also between male and female students within the same areas. Consistently low smoking rates were found in Australia and the United States, while generally high rates were reported in Spain and Turkey. Given their important future role as exemplars, more effective measures to help reduce tobacco smoking among medical students are clearly needed worldwide.

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Background: Papillary thyroid microcarcinoma (PTMC) is a relatively common entity in the general population. Aim: To present our experience with papillary thyroid microcarcinoma of the thyroid as an incidental finding in patients treated surgically for presumably benign thyroid disease. Settings and Design: Histology reports of patients treated surgically with a preoperative diagnosis of benign thyroid disease were reviewed to identify patients with PTMC. Patients with a preoperative diagnosis of thyroid cancer were excluded from this study. Materials and Methods: The files of 380 patients who underwent surgery for presumably benign thyroid disease in our hospital from 1990 to 2002 were reviewed. Data regarding patient's demographics, pathology findings, management and outcomes, were retrieved. Statistical Analysis Used: The findings are expressed as absolute numbers and as percentages (with reference to the total number of patients of this study). Results: Twenty-seven patients with PTMC diagnosed incidentally following thyroid surgery for presumably benign thyroid disease (27/380 or 7.1%) (multinodular goiter = 20 patients, follicular adenoma = 6 patients, diffuse hyperplasia of the thyroid = 1 patient) are presented. Mean diameter of PTMC was 4.4 mm. In 11 patients (40.7%) the tumor was multifocal and in about half of them tumor foci were found in both thyroid lobes. In two patients the tumor infiltrated the thyroid capsule. Total/near-total thyroidectomy was performed in all these patients (in three as completion thyroidectomy). All patients received suppression therapy and 20 of them underwent adjuvant radioiodine therapy. Follow-up (mean 4.56 years, range 1-12 years) was completed in 25 patients; all these patients were alive and disease-free. Conclusions: PTMC is not an uncommon incidental finding after surgery for presumably benign thyroid disease (7.1% in our series). The possibility of an underlying PTMC should be taken into account in the management of patients with nodular thyroid disease; total/near total thyroidectomy should be considered, at least in selected patients with presumably benign nodular thyroid disease.

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Context: There is limited data regarding the use of activated recombinant factor VII (rFVIIa) in anticoagulated patients requiring reversal. Aims: To identify and describe characteristics of subjects who received rFVIIa as part of emergency treatment aimed at improving hemostasis. Settings and Design: Data was obtained from an international peer-reviewed registry haemostasis.com. This registry contains data reported by physicians, who had elected to use rFVIIa to control bleeding in an emergency clinical situation. The contributors' approval for inclusion in the study was obtained and they were requested to validate and update information. Materials and Methods: Database review of cases receiving rFVIIa to manage bleeding coherent with the use of anticoagulant therapy. Statistical Analysis: The Wilcoxon signed rank test was used to compare requirements for blood products and crystalloids/colloids during the 24h preceding and following rFVIIa administration, as well as changes in the levels of clotting factors during that period. Results: Eighteen patients were treated with rFVIIa (median dose: 87.35 µg/kg; range: 20.0-106.0 µg/kg) for bleeding. Anticoagulants requiring reversal included low-molecular-weight heparin (n = 6), unfractionated heparin (n =8), coumarin (n =3) and warfarin (n=1). All patients had failed to respond to traditional antidotes and blood products. Following administration, bleeding stopped in 10, markedly decreased in five and slowed in the remaining three. Amongst 12/16 patients, a response was observed within 2.0 h of first administration. The requirement for blood products and crystalloids/colloids decreased ( P <0.05) after rFVIIa administration. rFVIIa was well tolerated. Conclusions: rFVIIa may play a role in control of untoward bleeding in subjects receiving anticoagulation therapy.

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Psoriatic arthritis (PsA) is a chronic systemic inflammatory disease characterized by joint inflammation associated with cutaneous psoriasis. For many years, the amount of attention directed to PsA had been less than that for various other arthropathies. With the advances in understanding its pathogensis, it is now recognized as a distinct disease entity with characteristic features. Psoriatic arthritis has a greater tendency towards asymmetric oligoarticular involvement, distal interphalangeal involvement and spondylitis. Associated features such as enthesitis and dactylitis are more common. Specific radiological features include ankylosis and bone resorption. With the availability of potent new therapeutic agents for psoriasis and PsA, interest in research and clinical care for these conditions has been reinvigorated. Anti-TNF therapy has achieved encouraging efficacy in both the joints and skin disease, improving function and quality of life and inhibiting radiological progression measured in patients with PsA and psoriasis. Biologic agents may have the potential in addressing the unmet medical need in patients with PsA.

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Background: No reports have been published about age-related sperm malformations in varicocele patients. Aim: To investigate the distribution of abnormal sperm characteristics in adolescents, adults and older men with varicocele. Setting and Design: Records of semen analysis of 143 men aged 14 to 53 years who had evident left-sided varicocele detected by physical examination and confirmed by doppler sonography were selected. Materials and Methods: Sperm concentration, vitality, motility, morphology, hypoosmotic swelling test (HOST) and morphology were measured in adolescent males aged 14 to 20 years (n=31), men 21 to 30 years (n=48), 31 to 40 years (n=40) and older men over 40 (n=24) and compared with a control group of fertile men with no varicocele (n=27) and with a group of infertile men with varicocele (n=26). Statistical Analysis: One-way analysis of variance and the Kruskal-Wallis test were used to compare varicocele groups. Comparisons with the control group and infertile group were performed using the unpaired t-test and the Mann-Whitney test. The discriminating ability of significant sperm characteristics in evaluating the sperm quality of varicocele men was also analyzed using receiver operating characteristics curve to select the cut-off level providing the best combination of sensitivity and specificity. Results: Varicocele men displayed similar impairment of vitality, motility and HOST. Sperm morphology analysis revealed a prevalence of small head, slightly and severely amorphous head and particularly combined anomalies in the study groups. Sperm concentration fell within the normal range of the World Health Organization manual. Differences were not significant between the study groups and when compared with infertile group ( P >0.005). However, a comparative study of the varicocele groups and the infertile group with the control group revealed significant differences in sperm vitality, motility, HOST, morphologically normal sperm, pin-headed, tapered and combined anomalies. Morphologically normal sperm and combined anomalies showed higher accuracy in identifying poor sperm quality in varicocele men (83.7% and 77.9%, at cut-off levels of 9% and 38%, respectively). Conclusions: Varicocele harms equally the sperm characteristics of adolescents, adults and older men. Apparently, it affects sperm quality more adversely than it does sperm production.

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The hyponatremic hypertensive syndrome is a rare but serious complication of reno-vascular disease. The syndrome is characterized by hypertension and profound natriuresis, leading to body sodium and water depletion. Hypertension is typically refractory to treatment. We report an 82-year-old patient with this syndrome and describe the results of an audit of the clinical records of patients admitted to a teaching hospital over a two-year period with confirmed renal artery stenosis and hyponatremia. The syndrome should be suspected in patients in whom severe hypertension is associated with hyponatremia without other apparent cause, especially in the presence of reno-vascular disease.

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Duloxetine is a newly introduced drug. It is being prescribed for the management of diabetic neuropathic pain and major depressive disorder. The most frequently observed adverse events with duloxetine are nausea, dry mouth and somnolence, constipation, diarrhea, decreased appetite, weight loss, feeling of fatigue, dizziness, somnolence, hypohidrosis, decreased libido and erectile dysfunction. One of the patients being prescribed the drug developed bleeding gums on being started with the drug which resolved on stopping it. We hereby report this case.

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Micro-invasive bone grafting is to deliver bone graft materials to the desired site through local puncturation and injection. It has many advantages such as little injury, simple procedures and high efficiency of osteogenesis. Limited sources of graft materials and complicated procedures are the main factors affecting the development of the technique. Therefore, to prepare a stable, economical, efficient and easy-to-use liquid graft material is crucial for the development of the technique. Purpose: The potential efficacy of an injectable calcium phosphate cement's handling properties and scaffold for bone repair performance was evaluated in a rabbit femoral condyles model. Study Design: A comparative study was conducted between a new cement and a commercially available calcium phosphate cement. Materials and Methods: The new cement and commercially available calcium-phosphate cements were compared in terms of the setting time, injection pressure, particle size and compressive strength. Then the cements were delivered to rabbit femoral condyles through local injection and then degradation of cements and bone formation were observed regularly after operation. Results: The new injectable cement was superior to currently used cements in terms of permitted manipulation time, injection pressure, particle size, postoperative degradation and efficacy of scaffold for bone repair; nevertheless, the new cement was slightly inferior to currently used cements in compressive strength and the final setting time. Conclusions: The new injectable cement is more suitable for the clinical study of micro-invasive bone grafting. It allows a brand new bone grafting procedure and provides a new graft material and thus merits further development and wider application.

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Pharmacoeconomics plays a pivotal role in clinical practice. High medicine prices can adversely affect a patient's finances and compliance. The Indian pharmaceutical industry has become a cornucopia of medicines with wide variation in prices for the same medicine marketed under different brand names. Price list of available antimicrobial brands was procured from a commercial drug directory. Average price of widely prescribed oral antimicrobials was found and price variation between different brands was calculated. The variation in medicine prices was found to be from 95% lower to more than 350% higher than the average price. Implications of price variation in clinical practice are discussed and remedial measures suggested.

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Background: The diagnosis of reactive arthritis is a challenging clinical problem in daily practice. Although there are many triggering infectious agents for reactive arthritis, Toxoplasmosis, a worldwide parasitic infection has not been reported. Aim: We investigated the serologic evidence of Toxoplasma gondii ( T. gondii ) infection in patients with newly diagnosed reactive arthritis after six weeks of the onset of the first symptom but no demonstrable triggering agent for reactive arthritis. Setting and Design: Clinical controlled study. Materials and Methods: We screened serologically the serum toxoplasma IgM and IgG antibody (Ab) titers which revealed toxoplasma infection in 50 patients with reactive arthritis (40 female, 10 men) and no demonstrable triggering agent and control subjects (32 female, 8 male). Statistical Analysis: SPSS 10.0 software package program was used. Results: The mean age of the patients and controls was similar (41.3± 12.0 vs. 39.6±11.8 years) respectively. The prevalence of IgG Ab titers of T. gondii in patients and controls were found to be 52% and 47.5%, respectively. Mean serum Toxoplasma IgG Ab levels were found to be 16.5±14.5 IU/ml, and 16.9±13.8 IU/ml in patients and control subjects respectively ( P >0.05). We did not find any Toxoplasma IgM Ab titer demonstrating the acute or sub-acute infection in the serum of patients or controls. Conclusion: Although past Toxoplasma infection was prevalent in both groups, we did not find any subject with acute Toxoplasma infection in patients with newly diagnosed reactive arthritis and healthy controls. Despite the fact that our study group was small, we suggest that T. gondii does not seem to be a triggering agent for reactive arthritis and past infection may be a coincidental finding.

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Idiopathic rupture of the urinary bladder is an uncommon condition and represents less than 1% of all bladder rupture cases. In most of the cases the main etiological factor was heavy alcohol ingestion. A combined injury of the spleen and bladder is a very rare condition that is almost often associated with trauma and foreign bodies. In this paper we present the extremely rare clinical course of acute abdomen caused by a combined spontaneous intraperitoneal injury; spontaneous rupture of the urinary bladder and spleen. According to our opinion, spontaneous bladder rupture caused by bladder distension due to alcohol ingestion led to urinary ascites and abdominal distension. Finally, repeated minor abdominal blunt trauma during everyday life, to a moderately distended abdomen caused a spontaneous splenic rupture in the patient with abnormal coagulation studies.

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Context: The confluence theory of intelligence by Zajonc and Markus emphasizes that individual intellectual difference of children manifests itself in the context of family configuration. Instead of assuming its generalizability, careful scientific work is required before applying the model to South Asian cultures where, predominantly, an extended family type exists. Aims: To assess the role of extended family configuration on the child's intellectual development in a South Asian setting. Settings and Design: A cross-sectional study was conducted on 4-5-year-old preschool children residing in Karachi, Pakistan. Materials and Methods: Three hundred and forty-two child and mother dyads were assessed through a validated cognitive psychometric tool and through a structured questionnaire. Children who were registered at the main Mother and Child Health Centres (MCH) of the Aga Khan Health Services, Pakistan (AKHSP) Karachi and who were born between July 1st 1993-June 30th 1994 with traceable birth records at the maternity homes, were considered for this study. Statistical Analysis: Multivariate linear regression models were used to identify the individual effect of family configuration on the intellectual scores. Results: Family configuration variables such as number of co-residents ( P < 0.05) and the number of siblings ( P < 0.01) in the house were significantly correlated with the psychometric score. Even after controlling for gender, socio-economic status, birth order and birth intervals, significant differentials were observed in favor of an extended family system on a child's intellectual development. Conclusion: The findings suggest the positive role of co-residents of an extended family environment on the intellectual development in early childhood.

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