Masters in Public Health, London School of Hygiene and Tropical Medicine, Public Health
B of Medicine and B of Surgery, Aga Khan Univ Of Medical Sciences (2010)
Purpose: To report a case of presumed bilateral chorioretinitis secondary to alendronate therapy.Observations: A 71-year-old female presented to the clinic in July 2017 with six months history of difficulty in reading along with floaters in both eyes which were more severe in the right eye. Past medical and surgical history revealed a history of hypertension, gout, hyperthyroidism, osteoporosis, and humerus fracture. She was started on alendronate three months before developing ocular symptoms. On ocular examination, best corrected visual acuity was 20/30 in the right and 20/25 in the left eye. Slit-lamp examination demonstrated normal anterior chamber examination in both eyes. Dilated fundus examination revealed geographic chorioretinal lesions around the optic nerve head in both eyes, more extensively in the right eye; and superior and temporal to the macula in the right eye. Past ocular records in February 2015 did not reveal any such findings. Fundus autofluorescence demonstrated hyper-autofluorescence in the peripapillary lesions in both eyes. The lesion adjacent to the macula in right eye displayed mixed hyper and hypo-autofluorescence. Fluorescein angiography showed combined hyper- and hypo-fluorescence compatible with window defect, staining and blockage. However, no leakage was appreciated in the macula, peripapillary, and peripheral lesions in both eyes. Optical coherence tomography scan showed septate hyporeflective intraretinal spaces in the right eye.Conclusion and importance: The index report underscore the importance of considering alendronate as an etiologic cause of chorioretinitis, especially in subjects with atypical lesions developing after alendronate therapy. We, therefore, recommend discontinuation of this medication in subjects who develop chorioretinitis after employing this medication.
View details for PubMedID 30809598
PURPOSE: The aim of this study is to evaluate the differences in the fundus autofluorescence (FAF) signal between the blue light autofluorescence (BAF) from Spectralis (Heidelberg, CA) and green light autofluorescence (GAF) 200TxTM (OPTOS, UK, in normal subjects and in patients with retinochoroidopathies (RC).METHODS: In this prospective study, FAF was performed using BL (lambda=488nm) and GL (lambda=532nm) on normal subjects and patients with RC. The corresponding pairs of BAF and GAF images from both groups were analyzed using Photoshop. The strength of the FAF signal was measured on a gray scale, where optic disc was a standard to indicate absence of AF. In addition, gray values obtained from three identical points (foveal center, and points of hypo and hyper autofluorescence) in the corresponding BAF and GAF images of normal and RC subjects were divided by the optic disc value to calculate autofluorescence signal ratio (R). The R values at fovea (R1), hypoautofluorescent point (R2), and hyperautofluorescent point (R3) were compared between BAF and GAF modalities, in normal and in RC subjects separately.RESULTS: One hundred six pairs (106 eyes) of FAF images analyzed (37 pairs: normal and 69 pairs: RC subjects). In normal subjects, the mean R1, R2, and R3 values for BAF were (1.5±0.88, 1.23±0.58, and 4.73±2.85, respectively) and for GAF were (0.78±0.20, 0.78±0.20, and 1.62±0.39, respectively). Similarly, in subjects with RC, the mean R1, R2, and R3 values for BAF were (1.68±1.02, 1.66±1.15, and 7.75±6.82, respectively) and for GAF were (0.95±0.59, 0.79±0.45, and 2.50±1.65, respectively). The mean difference in the R1, R2, and R3 ratios between BAF and GAF in normal and in RC subjects was statistically significant (p<0.001). The strength of the correlation (r) between ratios for BAF and GAF was weak or not statistically significant in both normal and RC subjects (p>0.05).CONCLUSION: The distribution and intensity of the AF signal differ in BAF and GAF and cannot be used interchangeably. In BAF, optic disc signal is always weaker than in other areas, which was not true for GAF where optic disc signal was stronger than fovea and hypoautofluorescent point in both groups.
View details for PubMedID 30617430
View details for Web of Science ID 000442932807084
View details for Web of Science ID 000442912505014
View details for Web of Science ID 000442912508138
View details for Web of Science ID 000442912501050
Background: Vessel flow density (VFD) may provide important information regarding perfusion status. Diurnal variation in VFD of choriocapillaris has not been reported in literature. In the index study, optical coherence tomography angiography (OCTA) was used to assess the diurnal variation of the VFD in the choriocapillaris of subjects with no known ocular disease.Methods: Fifty eyes with no known ocular disease (25 subjects) were included. OCTA images were acquired using AngioVue (Optovue, Fremont, CA, USA) at two different time points on a single day: 9:00 AM and 6:00 PM. Macular cube scan protocol (3*3mm) centered on the fovea was used. Automatic segmentation of the retinal layers and choriocapillaris was performed using ReVue software, which was also used to measure the choriocapillaris VFD. Horizontal line scan passing through fovea was obtained by the device at both time points to measure the subfoveal choroidal thickness (CT). Linear measurement tool of software was used to measure subfoveal CT according to a standardized reproducible method. Wilcoxon signed-rank test was used to assess the differences in choriocapillaris VFD and subfoveal CT at the two time points. Correlation between change in choriocapillaris VFD and subfoveal CT at the two time points was assessed using the Pearson correlation coefficient (r).Results: The mean age of the subjects was 31.96±11.23years. Choriocapillaris VFD was significantly higher at 9:00 AM compared to 6:00 PM (P<0.0001) with mean choriocapillaris VFD of 68.74±4.80% at 9:00 AM and 67.57±5.41% at 6:00 PM, with a mean diurnal amplitude of 1.17%. Mean subfoveal CT was 287.74±61.51m at 9:00 AM and 270.06±60.73m at 6:00 PM. Subfoveal CT was also significantly higher at 9:00 AM compared to 6:00 PM (P<0.0001) with a mean diurnal amplitude of 17.68m. Change in choriocapillaris VFD correlated with change in subfoveal CT (r=0.87, P<0.001).Conclusion: OCTA demonstrated significant diurnal change in choriocapillaris VFD in subjects without any ocular disease with VFD being higher in the morning and lower in the evening. Decrease in choriocapillaris VFD in the evening correlated with a reduction in subfoveal CT.
View details for PubMedID 30338130
To report the primary endpoint analyses of the safety and efficacy of 2 different doses of intravenous (IV) infusions of tocilizumab (TCZ), an IL-6 inhibitor, in eyes with noninfectious intermediate uveitis, posterior uveitis, or panuveitis.Randomized, controlled, multicenter clinical trial.STOP-Uveitis is a randomized, open-label safety, efficacy, and bioactivity clinical trial conducted at 5 clinical centers across the United States. The study evaluated the role of TCZ in patients with noninfectious uveitis (NIU). Thirty-seven patients with NIU were randomized into one of 2 treatment groups in a ratio of 1:1. Group 1 received IV infusions of 4 mg/kg TCZ and group 2 received IV infusions of 8 mg/kg TCZ. Infusions were given every 4 weeks in both groups until month 6 (primary endpoint). Primary outcome measure was incidence and severity of systemic and ocular adverse events through month 6. Secondary outcome measures included mean change in visual acuity (VA), vitreous haze (VH), and central macular thickness (CMT) at month 6.A total of 37 patients were randomized in the study. At month 6, 43.5% of patients who had the potential for a 2-step decrease in VH demonstrated a 2-step decrease (40% in Group 1 and 46.1% in Group 2). Mean change in CMT was -83.88 ± 136.1 ?m at month 6 (-131.5 ± 41.56 ?m in Group 1 and -38.92 ± 13.7 ?m in Group 2). Mean change in VA was +8.22 ± 11.83 ETDRS letters at month 6 (10.9 ± 14.6 in Group 1 and 5.5 ± 7.8 in Group 2). Repeated infusions of TCZ were well tolerated.Repeated IV administrations of TCZ are well tolerated. TCZ (both 4 and 8 mg/kg) is effective in improving VA and reducing VH and CMT in eyes with noninfectious intermediate uveitis, posterior uveitis, and panuveitis.
View details for PubMedID 28887113
View details for Web of Science ID 000432170302324
View details for Web of Science ID 000432176306066
View details for Web of Science ID 000432170304106
View details for Web of Science ID 000432170305054
View details for Web of Science ID 000432170302173
View details for Web of Science ID 000432170305315
To assess normal vessel flow density (VFD) in macular and peripapillary regions of eyes with no known ocular pathology using optical coherence tomography angiography (OCTA).AngioVue (Optovue, Fremont, CA, USA) was used to capture OCTA images. A 3 × 3 mm grid and a 4.5 × 4.5 mm grid was used to scan parafoveal and peripapillary regions, respectively. ReVue software was utilized to measure VFD in five sectors within the inner two circles of ETDRS grid in macular region and correlated to retinal thickness of same sectors. At optic disc, VFD was calculated in six sectors based on Garway-Heath map. Area and morphology of foveal avascular zone (FAZ) was correlated with VFD in central 1 mm. The influence of myopia on mean VFD was also assessed.Twenty-four eyes (mean age: 30 years) were analyzed. Mean VFD in macular sectors was 43.5 (±4.5) and 45.8 (±5.0) % in superficial and deep retinal plexuses, respectively. Mean VFD was significantly higher in deep retinal plexus compared to superficial retinal plexus in all sectors except central 1 mm (p < 0.05). Mean VFD in central 1 mm increases with an increase in central retinal thickness in both superficial and deep retinal plexuses (p < 0.001). Mean parafoveal VFD at level of both superficial and deep retinal plexuses decrease with an increase in spherical equivalent in myopics (p < 0.05). Mean VFD in myopics was found to be significantly lower in parafoveal region of deep retinal plexus (p < 0.05). Mean area of FAZ was 0.33 (±0.15) and 0.47 mm2 (±0.15) in superficial and deep retinal plexuses, respectively. Area of FAZ decreases with an increase in central 1 mm thickness and foveal VFD (p < 0.001).OCTA may be used to measure VFD in macular and peripapillary regions. Vessels in the parafoveal region are more densely packed in the deep retinal plexus leading to higher VFD compared to superficial plexus. Thicker retina in fovea translates into higher foveal VFD due to more compact arrangement of retinal layers and continuity of inner nuclear layer (INL). Myopia is associated with lower VFD in parafoveal region at level of deep retinal plexuses which may explain thinning of INL in myopics.
View details for PubMedID 28781889
View details for PubMedCentralID PMC5535290
View details for DOI 10.1055/s-0037-1603626
View details for Web of Science ID 000394210204381
Elasticated retractors, a recent advancement in surgical techniques, provide an enhanced and effective way of retraction during head and neck surgeries. These have been used for a number of procedures and are known for their effective retraction and minimizing surgical time span. This article highlights the authors' experience and the pros and cons of this technique.
View details for Web of Science ID 000377769100019
View details for PubMedID 27225152
Emergency general surgery (EGS) has emerged as an important component of frontline operative care. Efforts in high-income settings have described its burden but have yet to consider low- and middle-income health care settings in which emergent conditions represent a high proportion of operative need. The objective of this study was to describe the disease spectrum of EGS conditions and associated factors among patients presenting in a low-middle income context.March 2009-April 2014 discharge data from a university teaching hospital in South Asia were obtained for patients (?16 years) with primary International Classification of Diseases, 9(th) revision, Clinical Modification diagnosis codes consistent with an EGS condition as defined by the American Association for the Surgery of Trauma. Outcomes included in-hospital mortality and occurrence of ?1 major complication(s). Multivariable analyses were performed, adjusting for differences in demographic and case-mix factors.A total of 13,893 discharge records corresponded to EGS conditions. Average age was 47.2 years (±16.8, standard deviation), with a male preponderance (59.9%). The majority presented with admitting diagnoses of biliary disease (20.2%), followed by soft-tissue disorders (15.7%), hernias (14.9%), and colorectal disease (14.3%). Rates of death and complications were 2.7% and 6.6%, respectively; increasing age was an independent predictor of both. Patients in need of resuscitation (n = 225) had the greatest rates of mortality (72.9%) and complications (94.2%).This study takes an important step toward quantifying outcomes and complications of EGS, providing one of the first assessments of EGS conditions using American Association for the Surgery of Trauma definitions in a low-middle income health care setting. Further efforts in varied settings are needed to promote representative benchmarking worldwide.
View details for DOI 10.1016/j.surg.2015.08.004
View details for Web of Science ID 000367869400031
View details for PubMedID 26361098
Central line-associated bloodstream infections (CLABSI) are one of the leading causes of death in the USA and around the world. As a preventable healthcare-associated infection, they are associated with significant morbidity and excess costs to the healthcare system. Effective and long-term CLABSI prevention requires a multifaceted approach, involving evidence-based best practices coupled with effective implementation strategies. Currently recommended practices are supported by evidence and are simple, such as appropriate hand hygiene, use of full barrier precautions, avoidance of femoral lines, skin antisepsis, and removal of unnecessary lines. The most successful and sustained improvements in CLABSI rates further utilize an adaptive component to align provider behaviors with consistent and reliable use of evidence-based practices. Great success has been achieved in reducing CLABSI rates in the USA and elsewhere over the past decade, but more is needed. This article aims to review the initiatives undertaken to reduce CLABSI and summarizes the sentinel and recent literature regarding CLABSI and its prevention.
View details for DOI 10.1007/s11908-015-0491-8
View details for Web of Science ID 000356540100003
View details for PubMedID 26031963
Aspiration during any kind of injection is meant to ensure that the needle tip is at the desired location during this blind procedure. While aspiration appears to be a simple procedure, it has generated a lot of controversy concerning the perceived benefits and indications. Advocates and opponents of aspiration both make logically sound claims. However, due to scarcity of available data, there is no evidence that this procedure is truly beneficial or unwarranted. Keeping in view the huge number of injections given worldwide, it is important that we draw attention to key questions regarding aspiration that, up till now, remain unanswered. In this review, we have attempted to gather and present literature on aspiration both from published and non-published sources in order to provide not only an exhaustive review of the subject, but also a starting point for further studies on more specific areas requiring clarification. A literature review was conducted using the US National Institute of Health's PubMed service (including Medline), Google Scholar and Scopus. Guidelines provided by the World Health Organization, Safe Injection Global Network, International Council of Nursing, Center for Disease Control, US Federal Drug Agency, UK National Health Services, British Medical Association, Europe Nursing and Midwifery Council, Public Health Agency Canada, Pakistan Medical Association and International Organization of Standardization recommendations 7886 parts 1-4 for sterile hypodermics were reviewed for relevant information. In addition, curricula of several medical/nursing schools from India, Nigeria and Pakistan, the US pharmacopeia Data from the WHO Program for International Drug Monitoring network in regard to adverse events as a result of not aspirating prior to injection delivery were reviewed. Curricula of selected major medical/nursing schools in India, Nigeria and Pakistan, national therapeutic formularies, product inserts of most commonly used drugs and other possible sources of information regarding aspiration and injections were consulted as well.
View details for DOI 10.12688/f1000research.1113.3
View details for PubMedID 28344770
Tuberculosis (TB) is a global health problem with predominance in resource-poor countries. Extrapulmonary TB constitutes approximately 10% of the cases and can present as different forms depending on the route of entry. Cutaneous TB is a small subset of the extrapulmonary TB. Cutaneous TB can either be of primary origin or secondary origin or it can be a part of a systemic infection. TB verrucosa cutis (TBVC) is the exogenous reinfection of TB in a previously sensitised patient. Routine cultures do not have a high yield in TBVC due to the paucibacillary nature of the organism. Here we are presenting a rare case of a patient who developed in a keloid over the right ear lobule following ear piercing. This has only been presented once in the previous literature and for the first time in the head and neck region.
View details for DOI 10.1136/bcr-2013-010294
View details for PubMedID 23845683
View details for PubMedCentralID PMC3736208
The aims of this study were to assess how closely cardiologists in Pakistan followed published recommendations for lipid management and to identify the factors associated with such behavior.A cross-sectional survey was delivered in person between September and December 2007 to all cardiologists practicing in 4 major cities in Pakistan (Karachi, Lahore, Quetta, and Peshawar). A standard questionnaire was used to obtain information from cardiologists. Adherence to the guidelines established by the 2004 National Cholesterol Education Program Adult Treatment Panel III was computed based on answers to 14 questions; each correct answer (ie, the answer that followed the guidelines) was assigned 1 point, for a maximum cumulative score of 14. Multivariable linear regression was performed to determine the factors independently associated with guideline knowledge.A total of 295 cardiologists were approached; 239 consented to participate (overall response rate, 81.0%). The median score was 9 out of a maximum of 14 (interquartile range, 8-11). There were important points of divergence from practice recommendations, including suboptimal targets for low-density lipoprotein cholesterol (LDL-C) (< or = 70 mg/dL was the target used by only 16.7% of respondents [40/239]), undertreatment of revascularized patients (31.4% [75/239]), cessation of statin therapy once LDL-C targets were achieved (20.9% [50/239]), and use of different treatment thresholds for patients aged >65 years (41.8% [100/239]) and female patients (46.4% [111/239]). In the adjusted analysis, experienced physicians, interventional cardiologists, and those who pursued continuing medical education activities (journals and conferences) had higher scores (P = 0.005, P = 0.041, P = 0.008, and P = 0.001, respectively).We found important self-reported departures from recommended lipid-management guidelines among cardiologists in Pakistan.
View details for DOI 10.1016/j.clinthera.2009.07.020
View details for Web of Science ID 000269335600012
View details for PubMedID 19695410