Publications by authors named "Muhammad Shoaib Khan"

37 Publications

Incremental prognostic value of visually estimated coronary artery calcium in patients undergoing positron emission tomography imaging.

Open Heart 2021 May;8(1)

Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA

Objective: Visually estimated coronary artery calcium (VECAC) from chest CT or attenuation correction (AC)/CT obtained during positron emission tomography (PET)-myocardial perfusion imaging (MPI) is feasible. Our aim was to determine the prognostic value of VECAC beyond conventional risk factors and PET imaging parameters, including coronary flow reserve (CFR).

Methods: We analysed 608 patients without known coronary artery disease who underwent PET-MPI between 2012 and 2016 and had AC/CT and/or chest CT images. We used Cox regression to estimate the association of VECAC categories (≤10, 11-400, >400 Agatston units (AU)) with the primary outcome of all-cause death, acute coronary syndrome or stroke (mean follow-up 4.3±1.8 years). C-statistics assessed the relationship between PET parameters and VECAC with the primary outcome.

Results: Mean age was 58±11 years, 65% were women and 67% were black. VECAC ≤10, 11-400 and >400 AU was observed in 68%, 12% and 20% of subjects, respectively. Compared with VECAC ≤10, VECAC categories 11-400 (HR 2.25, 95% CI 1.24 to 4.08) and >400 AU (HR 3.05, 95% CI 1.87 to 4.98) were associated with the primary outcome after adjusting for traditional risk factors, MPI findings and CFR. Adding VECAC to a model that included PET-MPI, CFR and clinical risk factors improved the prognostic value for the primary outcomes (c-statistic 0.71 to 0.75 with VECAC, p=0.01).

Conclusions: VECAC is a potent predictor of events beyond traditional risk factors and PET imaging markers, including CFR. These data further support the importance for routine VECAC implementation.
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http://dx.doi.org/10.1136/openhrt-2021-001648DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8108688PMC
May 2021

The Novelty of Icosapent Ethyl in the Management of Hypertriglyceridemia and Alleviating Cardiovascular Risk.

J Lipids 2021 12;2021:6696915. Epub 2021 Jan 12.

Division of Cardiac MRI, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA.

Hypertriglyceridemia is believed to be independently associated with an elevated risk of cardiovascular disease (CVD) events. Lifestyle changes and dietary modifications are recommended for individuals with high serum triglyceride (TG) levels (150-499 mg/dl), and pharmacological therapy in addition to lifestyle modification is recommended when serum TG levels ≥ 500 mg/dl. A residual cardiovascular risk remains even in statin appropriate treated patients with CVD risk factors, and in this patient population, hypertriglyceridemia poses an independent and increased risk of ischemic events. In December 2019, the US FDA approved icosapent ethyl (IPE) as an adjunct to a maximally tolerated statin to reduce the risk of CVD events in adults with serum triglycerides > 150 mg/dl and have either established cardiovascular disease or diabetes and two or more additional CVD risk factors. Since IPE significantly decreases total ischemic events in the aforementioned patient population, it would be intriguing to know whether IPE alone added an advantage to lifestyle modification in the low-risk population, who has serum triglyceride between 150 mg/dl and 499 mg/dl.
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http://dx.doi.org/10.1155/2021/6696915DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7815393PMC
January 2021

Diagnostic accuracy of SPECT and PET myocardial perfusion imaging in patients with left bundle branch block or ventricular-paced rhythm.

J Nucl Cardiol 2020 Oct 20. Epub 2020 Oct 20.

Division of Cardiology, Department of Medicine, Hospital of the University of Pennsylvania, 3400 Civic Center Blvd, 11-154 South Pavilion, Philadelphia, PA, 19104, USA.

Background: The difference in diagnostic accuracy of coronary artery disease (CAD) between vasodilator SPECT and PET myocardial perfusion imaging (MPI) in patients with left bundle branch block (LBBB) or ventricular-paced rhythm (VPR) is unknown.

Methods: We identified patients with LBBB or VPR who underwent either vasodilator SPECT or PET MPI and subsequent coronary angiography. LBBB/VPR-related septal and anteroseptal defects were defined as perfusion defects involving those regions in the absence of obstructive CAD in the left anterior descending artery or left main coronary artery.

Results: Of the 55 patients who underwent coronary angiography, 38 (69%) underwent SPECT and 17 patients (31%) underwent PET. PET compared to SPECT demonstrated higher sensitivity (88% vs 60%), specificity (56% vs 14%), positive predictive value (64% vs 20%), negative predictive value (83% vs 50%), and overall superior diagnostic accuracy (AUC .72 (95% CI .50-.93) vs .37 (95% CI .20-.54), P = .01) to detect obstructive CAD. LBBB/VPR-related septal and anteroseptal defects were more common with SPECT compared to PET (septal: 72% vs 17%, P = .001; anteroseptal: 47% vs 8%, P = .02).

Conclusions: PET has higher diagnostic accuracy when compared to SPECT for the detection of obstructive CAD in patients with LBBB or VPR.
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http://dx.doi.org/10.1007/s12350-020-02398-5DOI Listing
October 2020

Parvimonas micra bacteremia in a patient with colonic carcinoma.

Caspian J Intern Med 2019 ;10(4):472-475

Department of Internal Medicine, Marshfield Clinic Health System, Marshfield, Wisconsin, USA.

Background: is a gram-positive anaerobe and a part of the normal commensal flora of the gastrointestinal tract. Factors predisposing to anaerobic bacteremia include malignant neoplasms, periodontal disease, immune deficiencies, chronic renal insufficiency, decubitus ulcers and perforated abdominal viscus. Cases of Parvimonas bacteremia in a patient with esophageal carcinoma and in a patient following ERCP procedure have been reported but to our best knowledge no case has been reported yet in which a patient had colonic carcinoma.

Case Presentation: We present a rare case of a 94-year-old male who presented with chief complaint of fever and constipation. Complete blood count revealed normal white blood cell count anemia. Urinalysis came out to be unremarkable for any evidence of infection. Two blood cultures grew and and patient was later switched to ampicillin-sulbactam as per blood culture susceptibility results. Echocardiogram came negative for any evidence of infective endocarditis. CT abdomen/pelvis showed soft tissue mass in the ascending colon just superior to the ileocecal valve (fig.1, 2). Colonoscopy showed non-obstructing eccentric mass (fig. 3). Biopsy of the mass revealed moderately differentiated adenocarcinoma. Because of lack of distant metastasis, surgical resection of the mass as definitive curative treatment was done.

Conclusion: Immune deficiency is a risk factor for anaerobic bacteremia. Apart from immediately starting the patient on antibiotics, a thorough search for malignancy may be considered when a patient presents with anaerobic bacteremia, especially, when the source of infection is not known. Identifying malignancy in earliest stages may improve treatment outcome.
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http://dx.doi.org/10.22088/cjim.10.4.472DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6856917PMC
January 2019

Treatment of cardiac nocardiosis in a post-renal transplant patient of systemic nocardiosis.

J Cardiovasc Thorac Res 2019 28;11(2):161-163. Epub 2019 May 28.

Tulane University, New Orleans, USA.

In general, nocardia infects immunosuppressed patients, however, sometimes it can also infect immunocompetent individuals. Nocardia infection can disseminate to any organ system of the body but the pulmonary system is the most commonly involved system. In some rare cases, the heart can also be involved and the resulting cardiac mycetoma can be treated successfully with antimicrobials without the need of surgery, unlike fungal cardiac mycetomas wherein surgery may be required in addition to antimicrobial therapy. We present an interesting case of post-renal transplant cardiac nocardiosis, which was treated successfully with a course of antibiotics.
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http://dx.doi.org/10.15171/jcvtr.2019.27DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6669421PMC
May 2019

Single or Combined Applications of Zinc and Multi-strain Probiotic on Intestinal Histomorphology of Broilers Under Cyclic Heat Stress.

Probiotics Antimicrob Proteins 2020 06;12(2):473-480

Department of Veterinary Medicine, University of Bari "Aldo Moro", Valenzano, BA, Italy.

Two-hundred-eighty-day-old broiler chicks were divided into seven groups. The groups were designated as T1, thermoneutral zone; T2, heat stressed (HS); T3, HS + zinc (Zn) supplementation (30 mg/kg); T4, HS + Zn (60 mg/kg); T5, HS + probiotic (0.1 g/kg); T6, HS + probiotic (0.1 g/kg) + Zn (30 mg/kg); and T7, HS + Zn (60 mg/kg) + probiotic (0.1 g/kg). Significant decrease (p < 0.05) was observed in villus height (VH), VH to crypt depth ratio, and villus surface area of all intestinal segments in the T2 group when compared with the T1 group. The same parameters had significantly higher (p < 0.05) values in the jejunum and ileum of the Zn- and probiotic-supplemented groups (alone + combination) when compared with the T2 group. The birds exposed to HS showed fewer (p < 0.05) intraepithelial lymphocytes (IELs) in the jejunum and ileum than the T1 group, while their count increased in the jejunum and ileum with dietary treatments. In conclusion, Zn and probiotic positively modulated the intestinal microstructures of broilers kept under high environmental temperature.
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http://dx.doi.org/10.1007/s12602-019-09561-6DOI Listing
June 2020

Lansoprazole Determination in Pharmaceutical Formulations by Flow Injection Coupled with Acidic KMnO-Quinine Chemiluminescence System.

Anal Sci 2019 Aug 12;35(8):861-867. Epub 2019 Apr 12.

Department of Chemistry, University of Balochistan.

A simple and rapid flow injection chemiluminescence (FI-CL) method based on the reaction of potassium permanganate (KMnO) and quinine was established for the determination of lansoprazole in pharmaceutical formulations. A linear calibration curve was achieved over the range from 0.01 to 20.0 mg L LNP (R = 0.9997 (n = 8); RSD = 1.1 - 3.7% (n = 4)) with a limit of detection of 3.0 × 10 mg L (S/N = 3) and injection throughput of 150 h. By applying the Student t-test (calculated t-test value: t = 1.059907664, and tabulated t-distributed (95%) = 2.200985) it was found that the proposed method and reported spectrophotometric method were not significantly different. The LNP was efficiently extracted and the recovery of LNP from the spiked pharmaceutical formulations was in the range of 91.0 - 105.9% (%RSD = 1.6 - 3.6, n = 4). No significant interference activity was detected from the excipients commonly found in the drug samples analyzed. The possible chemiluminescence emission mechanism is discussed briefly.
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http://dx.doi.org/10.2116/analsci.19P039DOI Listing
August 2019

An approach to enhanced stability: Formulation and characterization of derived lycopene based topical emulgel.

Saudi Pharm J 2018 Dec 20;26(8):1170-1177. Epub 2018 Jul 20.

Department of Pharmaceutical Sciences, Abbottabad University of Science and Technology, Abbottabad, Pakistan.

Focus of the study was to design a novel and cost effective extraction technique for the lycopene from L. fruit and to develop and characterize a stable emulgel formulation containing lycopene as an active ingredient as well as to design an analytical method to determine lycopene concentration in emulgel. Emulgel formulation was prepared and evaluated for its stability at different storage conditions, 8 °C, 25 °C, 40 °C, 40 °C + 75% relative humidity (RH) and 50 °C, for 6 months. Results were statistically analyzed using two way ANOVA, Post-Hoc test and paired sample -test at 5% significance level. Designed extraction technique presented comparable yield, 154.83 mg/Kg of tomato fruit, with all recoveries in the range of 145-156 mg/Kg of tomato. "P-values" calculated for different levels of stability parameters were <0.05, except at 50 °C and time points of 60th day and later. Analytical method designed was having linear range of lycopene 1-10 µg/mL with limit of detection 0.11 µg/mL and limit of quantification 0.34 µg/mL. All inter-day and intra-day recoveries were in the range of 94-105% while in all measurements RSD % was ≤5.36. It can be concluded that the extraction technique was cost effective with comparable results and analytical method was simple, robust, specific and sensitive enough to be used for lycopene concentration determination in emulgel formulation. Furthermore, designed formulation was stable even at high temperature of 40 °C and RH 75%.
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http://dx.doi.org/10.1016/j.jsps.2018.07.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6263630PMC
December 2018

Fatal Hypermagnesemia: an acute ingestion of Epsom Salt in a patient with normal renal function.

Caspian J Intern Med 2018 ;9(4):413-415

Department of Internal Medicine, Marshfield Clinic, Marshfield, USA.

Background: Generally, it is very rare for clinically significant hypermagnesemia to develop in an individual with normal renal functions as the renal handling of serum magnesium is a very potent process and it has the capacity, under conditions of hypermagnesemia, to completely block Mg (magnesium) reabsorption from the thick ascending limb of Henle. Therefore, hypermagnesemia usually arises in the setting of renal failure.

Case Presentation: We present a very rare case of a 40-year-old African American obese female with prior normal renal functions, who presented post-cardiac arrest following accidental overdose of Epsom salt. The patient was initially given supportive therapy and was later considered for the dialysis despite normal renal functions, as serum Mg levels kept on creeping up and clinical status kept on deteriorating continuously.

Conclusions: Seemingly harmless magnesium containing (over-the-counter) (OTC) can potentially be lethal, and such consequences must always be taken into account when using such medications for a prolonged period of time.
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http://dx.doi.org/10.22088/cjim.9.4.413DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6230454PMC
January 2018

Dynamic cardiac anatomy: the "cypress tree" papillary muscle root.

J Cardiovasc Thorac Res 2018 30;10(3):138-143. Epub 2018 Sep 30.

Department of Cardiac MRI, Allegheny General Hospital, Pittsburgh, USA.

The understanding of gross cardiac anatomy has been relatively stable over the last 80 years, reliant on well-established autopsy findings. The advent of dynamic imaging by cardiac MRI and CT provides a window to view anatomic features in vivo, providing insights typically masked at autopsy due to death. We hypothesize that cardiac magnetic resonance (CMR) with its high spatial and temporal resolution allows detection of anatomic features not previously appreciated at autopsy. Two hundred fifty-five sequential, CMR examinations were retrospectively examined to describe the anatomic features of the LV (left ventricular) PM (papillary muscles). Specifically, the origin of the base of the PM was delineated. The insertion of the PM was seen in 255/255 patients. In 249 out of 255 patients (97.6%), the appearance of the PM was not a uniform muscle arising from the inner face of the LV myocardium, but was a finger-like series of long, slender trabeculae carneae traversing >1 cm before inserting into the main body of PM challenging our previous understanding of PM anatomy. The capabilities of dynamic CMR to view cardiac features in vivo non-invasively provides a useful tool to study cardiac anatomy. Unlike the widely accepted representation of papillary muscles, uniformly arising from the floor of the LV, the base resolves into a 'cypress-tree' root-like structure with multiple thin projections before coalescing into a thick muscle head. Such observations have far reaching clinical implications in areas such as mitral regurgitation, post-MI remodeling and electrical transmission of the His-Purkinje system, and further work is indicated to delineate the role of non-invasive imaging in these areas.
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http://dx.doi.org/10.15171/jcvtr.2018.22DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6203870PMC
September 2018

Plant derived anticancer agents: A green approach towards skin cancers.

Biomed Pharmacother 2018 Jul 7;103:1643-1651. Epub 2018 May 7.

Faculty of Pharmacy and alternative medicine, The Islamia University of Bahawalpur, Bahawalpur 63100, Pakistan. Electronic address:

Plants have been used as medicinal agents since the origin of mankind. High cost and severe side effects associated with conventional chemotherapy has limited their general acceptability and fuel up the search for alternate options. The alternative treatment options like phytochemicals have come up with ease of availability and cost effectiveness. Owing to their general acceptance, safety, low side effects and multistep targeting in signal transduction pathways, plant derived phyto-constituents have promising anti-carcinogenic potential for skin related cancers. This leads to the surge in research of new phytochemicals for the prevention and cure of a variety of skin cancers which are major cause of morbidity and mortality in present world. Although very limited clinical data involving humans is available in literature to demonstrate favorable eff ;ects of phyto-constituents on various types of skin carcinomas yet the topical treatment with these plant derived anticancer phytochemicals is very promising. There are various mechanisms and pathways responsible for antitumor activity of plant derived medicinal compounds such as loss of mitochondrial membrane potential, release of cytochrome-c, Down regulation of Anti-apoptotic proteins and Up regulation of pro-apoptotic proteins, Activation of Caspase, Fas, FADD, p53 and c-Jun signaling pathway, Inhibition of Akt signaling pathway, phosphorylation of ERK, P13K, Raf, survivin gene, STAT 3 and NF-kB. In-vitro testing of skin cancer cell lines models offers the opportunity for identifying mechanisms of action of compounds from plant origin against variety of skin related cancers. This review thus aims at providing an overview of plant derived anti-cancer compounds which have been reported to show promising anti-carcinogenic effects against various skin cancer cell lines and on animal models. Phytochemicals that are discussed in this review include steroids, coumarines, trepenes, essential oils, alkaloids, esters, ethers, resins, phenols and flavonoids. This review also provides information about marketed formulations developed so far from plant derived compounds for skin cancer prevention and treatment.
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http://dx.doi.org/10.1016/j.biopha.2018.04.113DOI Listing
July 2018

Left atrial appendage myxofibrosarcoma: A rare masquerader of myxoma and thrombus-"all that glitters is not gold".

Echocardiography 2018 Feb 27;35(2):278-281. Epub 2017 Dec 27.

Division of Cardiovascular Medicine, Department of Cardiac MRI, Allegheny General Hospital, Pittsburgh, PA, USA.

Left atrial appendage mass can occasionally pose a serious challenge to physicians to identify the nature of the mass with the aid of imaging techniques. We present a case of 67-year-old man, who was evaluated for suspected left atria myxoma. Transesophageal echocardiography revealed a heterogeneous density originating from left atrial appendage, thought to be most consistent with a myxoma. Cardiac magnetic resonance imaging, uncharacteristically, gave an equivocal picture, suggesting the mass to be a myxoma on initial imaging and a thrombus with evidence of liquefaction necrosis following postcontrast enhancement. Surprisingly, histopathology of the mass following its surgical excision yielded a rare diagnosis of myxofibrosarcoma.
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http://dx.doi.org/10.1111/echo.13790DOI Listing
February 2018

Efficacy And Safety Of Interlocked Intramedullary Nailing For Open Fracture Shaft Of Tibia.

J Ayub Med Coll Abbottabad 2016 Apr-Jun;28(2):341-344

Department of Community Medicine, Frontier Medical College, Abbottabad, Pakistan.

Background: Due to increasing population and changing human habits the number of accidents and high energy trauma is rising. Management of open fracture tibia is a complex problem and is a challenge for both orthopaedic and plastic surgeons. The study was carried out to ascertain the efficacy and safety of interlocked intra-medullary nailing for open shaft tibial fractures in patients presenting at or after 24hr of injury.

Methods: In this descriptive case series, over a period of 6 moths, 163 consecutive cases of open fracture of tibial shaft were reviewed in terms of clinical profile, time of presentation, and gender distribution.

Results: In this study mean age was 30±0.02 years. Males comprised 85% of study population while 15% were females. Gustilo-I type fracture and Gustilo-II type fracture was diagnosed in 90% and 10% patients respectively. Thirty three percent patients had wound infection while fracture union was found in 15% cases. Moreover interlocked intramedullary nailing for open fracture shaft of tibia was safe in 80% patients while this procedure was effective in 85%.

Conclusions: Un-reamed, interlocked intra-medullary nailing may be considered as a suitable option for treatment of open fractures of tibia.
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December 2017

Outcome of ilizarov fixator in complex non-union of long bones.

J Pak Med Assoc 2015 Nov;65(11 Suppl 3):S147-51

Department of Orthopedics, Khyber Teaching Hospital, Peshawar and Ayub Teaching Hospital, Abbottabad.

Objective: To evaluate the efficacy of Ilizarov fixator in the management of complex non-union of long bones.

Methods: The retrospective study was conducted at Ayub Teaching Hospital, Abbottabad, and Khyber Teaching Hospital, Peshawar, Pakistan, and comprised data of patients aged 14- 60 years of either gender with complex non-union of long bones between January 2006 and December 2013. Data, including age, gender, mechanism of injury, type of long bone involved, complications of surgery and final outcome, was documented on a pre-designed proforma. Outcome was graded using Association for the Study and Application of Methods of Ilizarov scoring system. SPSS 20 was used for analysis.

Results: There were 45 patients of whom 30(66.7%) were males and 15(33.4%) were females. The overall mean age was 32.20±12.48 years (range: 14-60 years).Of the 45 non-unions, 39(86%) healed successfully, and the mean time to union was 30.69±8.6 weeks (range: 16-52weeks).In terms of outcome, 29(64.44%) patients had excellent bone results, 9(20%) had good results, 2(4.44%) had fair results and 5(11.1%) had poor bone results. There were 32(71.11%) patients with excellent functional result, 8(17.77%) good, 2(4.44%) fair and 3(6.66%) patients had poor results.

Conclusions: Ilizarov fixator gave good and excellent results in complex non-union of long bones by eradicating the infection, filling the defect with bone transport, and correcting the deformity and limb length discrepancy.
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November 2015

Impact of Micronutrient Malnutrition on the Health of Preschool Children: A Cross-Sectional Study.

Int J Vitam Nutr Res 2015 ;85(1-2):31-8

5 Department of Biochemistry, Khyber Medical College, Peshawar, Khyber Pakhtunkhwa, Pakistan.

A cross-sectional study was designed to diagnose the prevalence of serum micronutrient deficiencies in apparently healthy preschool children in Pakistan. Children with any organic illnesses, abnormal blood parameters or genetic disorder were excluded. Amongst the studied samples, 56 % were healthy, 7 % were overweight, 7 % were obese, and 30 % were underweight. The body mass index (BMI) of female children was reduced compared to male children, which was statistically significant (p < 0.05). Similarly, zinc and iron deficiencies, ranging from moderate to severe, were found in 50 % and 25 % of the studied population, respectively. Copper and vitamin A concentrations were insufficient in 7 % and 25 % of the subject children, respectively. Micronutrient malnutrition is a recurrent health problem in children below the age of 5 years worldwide, particularly in developing countries. Serum micronutrient deficiencies and imbalances were more prevalent in children from rural than from urban areas.
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http://dx.doi.org/10.1024/0300-9831/a000221DOI Listing
February 2016

Database Research for Fellows-in-Training and Early-Career Cardiologists.

J Am Coll Cardiol 2015 Sep;66(12):1404-7

Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.

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http://dx.doi.org/10.1016/j.jacc.2015.08.001DOI Listing
September 2015

Knowledge and practices of general surgeons and residents regarding spilled gallstones lost during laparoscopic cholecystectomy: a cross sectional survey.

Patient Saf Surg 2013 Aug 14;7(1):27. Epub 2013 Aug 14.

Civil Hospital, Baba-e-urdu Road, Karachi, Pakistan.

Background: Gall bladder perforation, gallstone spillage and loss are commonly reported from Laparoscopic Cholecystectomy (LC). Though rare, lost gallstones can cause a variety of complications presenting variably from within 1 month to 20 years postoperatively. Our objective was to investigate knowledge and practices of surgeons and surgical residents regarding spilled gallstones lost during laparoscopic cholecystectomy.

Methods: An observational, cross-sectional survey, using a questionnaire based on 13 self-answered close-ended questions, was conducted at 6 different post-graduate centers in Karachi, Pakistan.

Results: Of the 82 participants, 23 (28%) were consultant surgeons while 59 (72%) were general surgery residents. 86% of participants were aware that stones lost during LC can cause complications. Out of the 18 reported complications presented, only 20% participants identified more than 8 complications for which they can consider lost gallstones causal. 28% of participants weren't aware about the expected postoperative duration for presentation of complications. Only 15% of our participants expected complications beyond 5 years of the procedure. 72% of participants will not convert to open cholecystectomy to retrieve lost gallstones. While 88% of participants agreed that lost gallstones should be documented in operative notes, only 70% reported that it's actually done in practice. 55% of participants agreed to have possibility of lost gallstones as part of the informed consent but in practice it's included according to only 31% of participants. 68% of participants believe that patients should be informed if gallstones are lost but in actual practice only 41% participants inform patients when gallstones are lost during procedure.

Conclusions: We conclude that there is a dearth of awareness regarding diversity of complications from lost gallstones and about their variable postoperative duration of presentation. The practices involving lost gallstones management, documentation and patient information were found to vary widely. Proper awareness is imperative as it may compel surgeons to undertake all possible measures to retrieve spilled gallstones and progress towards better and standardized practices in managing lost gallstones.
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http://dx.doi.org/10.1186/1754-9493-7-27DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3751300PMC
August 2013

Changing trends of hepatitis B seromarkers amongst Pakistani population: a laboratory-based review.

J Pak Med Assoc 2013 Jul;63(7):826-30

Department of Pathology and Microbiology, Aga Khan University, Karachi, Pakistan.

Objective: To study the changing trends of hepatitis B markers tested at Aga Khan University Hospital clinical laboratory according to the internationally recognised classification of hepatitis B profile.

Methods: The retrospective study involved analysis of laboratory records of hepatitis B profiles of all patients collected from January 2001 to December 2008 at the Aga Khan University Hospital's clinical laboratory. Patients with complete profile tested were categorised according to the Centre for Diseases Control classification of hepatitis B profile. SPSS 16 was used for statistical analysis.

Results: A total of 185,825 patients had serological markers for hepatitis B tested. Mean-age of reactive hepatitis B surface antigen (HBsAg) patients was 30+/-12.5 years. HBsAg reactivity was significantly higher in males than females (34% vs 12%; p <0.0001). HBsAg showed a slight decline in the percentage reactivity during the 8-year study period, while a gradual increase in hepatitis B surface antibody (HBsAb) reactivity was observed. Of the total, 23% patients belonged to the 'susceptible to infection' category; 39% patients were classified as 'chronically-ill'; 12% patients were categorised as 'immune due to hepatitis B vaccination. 3% patients were classed as 'acutely infected'. Overall, samples received from Peshawar, Quetta and Larkana showed very high reactivity rates.

Conclusion: The study substantiated the general perception that levels of HBsAg is showing a decreasing trend, while levels of HBsAb are increasing perhaps due to better vaccination of population.
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July 2013

Patients' insight of interpreting prescriptions and drug labels--a cross sectional study.

PLoS One 2014 3;8(6):e65019. Epub 2013 Jun 3.

Department of Internal Medicine, Aga Khan University, Karachi, Pakistan.

Background: Errors in consuming drugs are associated with significant morbidity and mortality, besides an impact on the already overburdened health-care system. Misunderstanding drug labels and prescriptions plays an important role in contributing to adverse drug events.

Objective: To evaluate abilities to understand prescriptions and drug labels among patients attending tertiary care hospital in Karachi.

Methods: A cross sectional study was conducted at the Aga Khan University Hospital (AKUH), from January to March 2009. After informed consent, 181 adult patients and their healthy attendants were interviewed at AKUH using a standardized questionnaire, which ascertained patient demographics, factors that might increase exposure to health-care personnel as well as the basic knowledge and understanding of prescriptions and drug labels.

Results: Out of 181, majority 137(76%) had received graduate or post-graduate degrees. 16 (9%) had received no formal education; of which all were females and 89(84%) of the total females were housewives. Overall, 130(72%) followed only a single doctor's prescription. Majority failed to understand various medical terminologies related to dosage. In the high literacy group, 45(33%) understood once daily OD (p = 0.003), 27(20%) thrice daily TID (p = 0.05), 29(21%) twice daily BD (p = 0.01), 31(23%) thrice daily TDS (p = 0.002) and 43(31%) as needed SOS (p = 0.003) as compared to the group with no formal education, who were unable to comprehend the terms. The most common reason for using more than one prescription was decreased satisfaction with the doctor in 19(39%) and multiple co-morbids as responded by 17(35%) of patients. Knowledge regarding various medical terminologies used for dosage and routes of drug administration were also understood more frequently among the English medium respondents. The elderly identified medicine through color (47%, p<0.001), and were less likely to understand drug indications (p = 0.05) compared to younger subjects.

Conclusion: Understanding of drug prescriptions is alarmingly low in the community, even amongst the educated. Care givers need to revisit this often ignored aspect of patient care.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0065019PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3670850PMC
January 2015

APACHE II scores as predictors of cardio pulmonary resuscitation outcome: Evidence from a tertiary care institute in a low-income country.

Saudi J Anaesth 2012 Jan;6(1):31-5

Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan.

Aim: The aim of this study was to demonstrate that APACHE II scores can be used as a predictor of the cardio-pulmonary resuscitation (CPR) outcome in hospitalized patients.

Methods: A retrospective chart review of patients admitted, from 2002 to 2007, at the Aga Khan University Hospital, Karachi, was done for this study. Information was collected on 738 patients, constituting all adults admitted in general ward, ICU, CICU and SCU during this time, and who had under-went cardiac arrest and received cardiopulmonary resuscitation during their stay at the hospital. Patient characteristics, intra-arrest variables such as event-witnessed, initial cardiac rhythm, pre arrest need for intubation and vasoactive drugs, duration of CPR and survival details were extracted from patient records. The APACHE II score was calculated for each patient and a descriptive analysis was done for demographic and clinical features. The primary outcome of successful CPR was categorized as survival >24 h after CPR versus survival <24 h after CPR. Multivariable logistic regression was used to assess the association between the explanatory variables and successful CPR.

Results: Patients with APACHE II scores less than 20 had 4.6 times higher odds of survival compared to patients with a score of >35 (AOR: 4.6, 95% CI: 2.4-9.0). Also, shorter duration of CPR (AOR: 2.9, 95% CI: 1.9-4.4), evening shift (AOR: 2.1, 95% CI: 1.3-3.5) and Male patients (AOR: 0.6, 95% CI: (0.4-0.9) compared to females were other significant predictors of CPR outcome.

Conclusion: APACHE II score, along with other patient characteristics, should be considered in clinical decisions related to CPR administration.
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http://dx.doi.org/10.4103/1658-354X.93053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3299111PMC
January 2012

Clinical characteristics and predictors of positive stool culture in adult patients with acute gastroenteritis.

J Pak Med Assoc 2012 Jan;62(1):20-4

Department of Medicine, Aga Khan University, Karachi, Pakistan.

Objective: To identify the presenting features and spectrum of pathogens in adult patients with acute diarrhoea and to determine the predictors of stool culture positivity.

Methods: A descriptive study was conducted in a tertiary care hospital from April 1, 2005 to March 31, 2006. Medical records of all consecutive adult patients with history of acute diarrhoea were reviewed between June 2006 to December 2006 for clinical characteristics and laboratory investigations.

Results: A total of 454 patients were admitted from April 1, 2005 to March 31, 2006. Stool cultures were performed in 233 (50%) patients, 96 (42%) had positive results. Patients with positive stool culture compared to a negative Culture were found to have a younger mean age (43 vs. 53), greater number of unformed stools (16 vs. 11) and low serum bicarbonate level (16 vs. 20). Vibrio cholerae (86%) was found to be the most prevalent organism followed by Salmonella spp (6%), Campylobacter spp (5.2%), Shigella spp (2%). Ciprofloxacin was given to 97% patients along with fluid administration, and 78% were found to be resistant to quinolones. Most patients recovered before the finalized stool culture results.

Conclusion: Careful selection of the patients based on their clinical presentation and initial laboratory work up can help to decide ordering of stool culture in adults with diarrhoea. Fluid resuscitation remains the main stay of treatment.
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January 2012

Modified Turco's postero-medial release for congenital talipes equino-varus.

J Ayub Med Coll Abbottabad 2008 Jul-Sep;20(3):78-80

Department of Orthopaedics, Lady Reading Hospital Peshawar.

Background: Talipes Equino-Varus (TEV) is one of the most common congenital anomaly. It is managed by various methods, i.e., conservative & surgery. Objective of this study was to determine the efficacy of modified Turco's postero-medical release in children's having congenital TEV.

Methods: This descriptive observational study was conducted from June 2004 to June 2008 in the Orthopaedics Unit of Lady Reading Hospital (LRH) Peshawar. The inclusion criteria were children of age 6 months to 3 years of age having moderate and severe club foot. The exclusion criteria were clubfoot secondary to some other disorders such as cerebral palsy, arthrogryphosis multiplex congenita, myelodysplasia or congenital dislocation of the hip. The deformity was treated by modified Turco's one stage release. Follow-up was for one year. Results were graded according to modified McKay rating system.

Results: A total 70 patients were included in this study with the age range of 6 months to 3 years with moderate to sever deformity. Thirty-eight, were male (54.2%) and 32 patients (45.72%) were female, twenty three patients (32.85%) had bilateral club foot while the rest of 47 patients (67.15%) had unilateral deformity. Positive family history of club foot was in 10 patients (14.2%). Results were concluded on 52 patients who completed one year follow-up. Excellent results were observed in 34 patients (65.38%), good in 9 patients (17.30%), fair in 2 patients (3.84%), and poor in 7 patients (13.46%).

Conclusion: Children up to three years age with congenital TEV can be successfully treated in almost all the cases by modified Turco's one stage postero-medial release.
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August 2009

Outbreak of dengue fever in Karachi 2006: a clinical perspective.

J Pak Med Assoc 2009 Jun;59(6):339-44

Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan.

Objective: This study reports clinical manifestations and spectrum of severity of dengue fever (DF), dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS) in adult patients admitted during 2006 outbreak in Karachi. A rough estimation of cost of care was also calculated.

Methods: A cross-sectional study was done at a tertiary care hospital in Karachi from January to December 2006. Patients suspected of having DF with positive dengue IgM antibodies were included and records were reviewed. Patients were divided into DF, DHF and DSS as per WHO classification, and the severity of clinical manifestations was determined.

Results: A total of 278 (65.72%) of 423 patients admitted with suspected dengue illness had positive IgM titer. Mean age was 31 +/- 12.9 years, with 168 (60%) males and 110 (40%) females. Common presenting symptoms were fever (100%), vomiting (78%), epigastric pain (52%), bleeding tendencies (34%), and erythematous rash (33%). Thrombocytopenia (60%), Leucopenia (45%), elevated transaminases (ALT 71%; AST 88%), and deranged PT (22%) and aPTT (75%) were the predominant. Laboratory parameters: DF was diagnosed in 169 (61%) patients, 82 (29%) were classified as DHF, and 27 (10%) as DSS. Patients with DHF/DSS were younger <30 years (n=60, 55%) and had longer hospital stay (p=0.001). Case fatality rate for DHF/DSS group was 4.6%.

Conclusion: It was estimated that endemicity of DF is on the rise in Karachi and a significant proportion of patients had DHF and DSS. Younger patients develop DHF and DSS and have high case fatality rate.
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June 2009

Antimicrobial resistance profile of methicillin resistant staphylococcal aureus from skin and soft tissue isolates.

J Pak Med Assoc 2009 May;59(5):266-9

Department of Pathology & Microbiology, Aga Khan University Hospital, Karachi, Pakistan.

Objectives: To evaluate resistance rates in methicillin resistant Staphylococcus aureus (MRSA) against clindamycin, cotrimoxazole, tetracycline, fusidic acid, rifampicin and chloramphenicol isolated from skin and soft tissue infections (SSTI).

Methods: Descriptive analysis of SSTI samples yielding MRSA in clinical laboratory of a tertiary care center; receiving specimens across Pakistan from January 2005 to June 2007. MICROBIOLOGICAL METHODS: MRSA were identified using standard microbiological techniques. Susceptibility testing was performed by disc diffusion according to Clinical Laboratory Standards Institute (CLSI) against fusidic acid, tetracycline, cotrimoxazole, clindamycin, rifampicin and chloramphenicol. Minimum inhibitory concentrations (MIC) of rifampicin were determined using agar dilution method according to CLSI.

Results: During the study period 501 MRSA were isolated from SSTI. Overall variable susceptibility pattern with high resistance rates to tetracycline (82%), clindamycin (79%), cotrimoxazole (59%), and rifampicin (50%) were observed. Resistance to chloramphenicol (10%) and fusidic acid (9%) was low.

Conclusion: There is a strong need in resource limited countries to review the utility of conventional antibiotics for the management of MRSA SSTI as new agents are expensive and not available. High resistance rates were observed against cotrimoxazole, tetracycline and clindamycin. Resistance to fusidic acid, rifampicin and Chloramphenicol was low.
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May 2009

Syncope: experience at a tertiary care hospital in Karachi, Pakistan.

Int J Emerg Med 2008 Jun 6;1(2):79-83. Epub 2008 May 6.

Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan.

Introduction: Our aim was to determine the characteristics of patients presenting with syncope at a tertiary care hospital in Karachi, Pakistan.

Methods: A review of medical records was conducted retrospectively at the Department of Medicine, Aga Khan University Hospital, Karachi. Patients aged 16 and above, admitted from January 2000 to December 2005 with the diagnosis of syncope made by the attending physician were included.

Results: A total of 269 patients were included (75% males, mean age: 57.4 years). Neurogenic (vasovagal) syncope was the most common cause (47%), followed by cardiogenic syncope (18%) and orthostatic syncope (9%). A total of 24% were discharged undiagnosed. Twenty patients (7.4%) did not have any prodrome. Common prodromal symptoms included dizziness (61%), sweating (25%), palpitations (19%), nausea/vomiting (19%) and visual symptoms (17%). The distribution of symptoms according to cause of syncope revealed only breathlessness to be significantly associated with cardiogenic syncope (p = 0.002). Most patients with cardiogenic syncope were aged above 40 (98%, p < 0.001), had coronary artery disease (72%, p < 0.001) and abnormal electrocardiogram at presentation (92%, p < 0.001).

Conclusion: Despite differences in burden of diseases, our findings were similar to those of published syncope literature. Further studies are needed to develop a protocol to expedite the evaluation and limit the work-up and admission in low-risk patients.
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http://dx.doi.org/10.1007/s12245-008-0015-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2657236PMC
June 2008

Management of diabetic foot by natural honey.

J Ayub Med Coll Abbottabad 2009 Jan-Mar;21(1):103-5

Department of Orthopaedic Surgery & Traumatology, Liaquat University of Medical & Health Sciences, Jamshoro Sindh, Pakistan.

Background: Many studies have demonstrated that honey has antibacterial activity in vitro, and a small number of clinical case studies have shown that application of honey to severely infected cutaneous wounds is capable of clearing infection from the wound and improving tissue healing. Research has also indicated that honey may possess anti-inflammatory activity and stimulate immune responses within a wound. The overall effect is to reduce infection and to enhance wound healing in burns, ulcers, and other cutaneous wounds. The objective of the study was to find out the results of topical wound dressings in diabetic wounds with natural honey.

Methods: The study was conducted at department of Orthopaedics, Unit-1, Liaquat University of Medical and Health Sciences, Jamshoro from July 2006 to June 2007. Study design was experimental. The inclusion criteria were patients of either gender with any age group having diabetic foot Wagner type I, II, III and II. The exclusion criteria were patients not willing for studies and who needed urgent amputation due to deteriorating illness. Initially all wounds were washed thoroughly and necrotic tissues removed and dressings with honey were applied and continued up to healing of wounds.

Results: Total number of patients was 12 (14 feet). There were 8 males (66.67%) and 4 females (33.33%), 2 cases (16.67%) were presented with bilateral diabetic feet. The age range was 35 to 65 years (46 +/- 9.07 years). Amputations of big toe in 3 patients (25%), second and third toe ray in 2 patients (16.67%) and of fourth and fifth toes at the level of metatarsophalengeal joints were done in 3 patients (25%). One patient (8.33%) had below knee amputation.

Conclusion: In our study we observed excellent results in treating diabetic wounds with dressings soaked with natural honey. The disability of diabetic foot patients was minimized by decreasing the rate of leg or foot amputations and thus enhancing the quality and productivity of individual life.
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May 2011

Infection in orthopedic implant surgery, its risk factors and outcome.

J Ayub Med Coll Abbottabad 2008 Jan-Mar;20(1):23-5

Department of Orthopedic, Ayub Medical College, Abbottabad, Pakistan.

Background: Infection in orthopedic surgery is a disaster both for the patient and surgeon. Although its incidence has been reduced due to modern theatre facilities and aseptic measures but in developing countries its prevalence is still high. It is better to prevent infection rather than to treat it. The objective of this study is to know the frequency of infection in orthopedic implant surgery in a public hospital and to evaluate the risk factors, causative organism, complications and treatment.

Methods: This prospective study was conducted in orthopedic unit-B Ayub Teaching Hospital, Abbottabad, from 1st April 2007 to 30th October 2007. Close fracture cases admitted for internal fixation devices were included. The exclusion criteria were soft tissue surgery, wounds and open fractures needing external fixation devices. The follow up was done for six months.

Results: Infection developed in 6 patients (5.76%), out of which superficial and deep infections were 2 (1.92%) and 4 (3.84%) respectively. There were 2 infection cases in each stage of the infection i.e. early, delayed and late. The staphylococcus aureus was the commonest organism, i.e., 3 (50%) out of 6. The age of the patients was more than 60 years in 3 (2.88%) patients, 30 to 60 years in 2 (1.92%) patients and below 30 year in 1 (0.96%) patient. The smoking history was in 2 (1.92%) patients.

Conclusion: Infection rate in our study was quite high and needs proper measures to control it because it had great financial burden on patient and on hospital resources and could lead to morbidity and mortality in patients. We could not find significant risk factors in our small sample size study although the infection was relatively more common in patients with advanced age, prolonged surgery time, smoking and skin abrasion at fracture site. Commonest organism was Staphylococcus aureus.
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January 2009

Evaluation of results of interlocking nails in femur fractures due to high velocity gunshot injuries.

J Ayub Med Coll Abbottabad 2008 Jan-Mar;20(1):16-9

Department of Orthopaedics, Lady Reading Hospital Peshawar, Pakistan.

Background: Femoral shaft fractures are common in adult population due to vulnerability to road traffic accident and firearm injuries. There are various treatment modalities to treat the femur shaft fracture, i.e., Plating & screws, Intramedullary nailing, External fixator and Interlocking nails. Comminuted fractures due to gun shot injuries are a challenging problem for orthopaedic surgeons. The objective of this study is to evaluate the role of interlocking nailing in the management of femoral fractures due to high velocity gunshot injuries.

Methods: This descriptive study was conducted on 68 patients at Orthopaedic unit Postgraduate Medical Institute, Lady Reading Hospital Peshawar, from March 2002 to March 2004. The patients of each gender from age fifteen years onward having femoral shaft fracture due to high velocity gunshot injuries who had not previous surgical intervention were included in the study. The exclusion criteria were intertrochanteric, supracondylar femoral fractures and those who failed the follow-up. All the patients were treated with close or open interlocking nails. The outcome measures were graded excellent, good and poor according to radiological and clinical results. Follow-up was for eighteen months and in some cases up to thirty months.

Results: Out of 68 patients 64 (94.12%) were male and 4 (5.88%) were female patients. The age range was from 15 to 65 years (average age of twenty nine years. The close interlocking nails were done in 64 patients (94.12%) and open interlocking nails were done in 4 patients (5.88%). The static interlocking nailing was performed in 58 patients (85.29%) while dynamic interlocking nailing was performed in 10 patients (14.71%). Knee flexion contracture in 5 cases (7.35%) and limb shortening of less than 2 Cm in 2 patients (2.94%). Non-union were in 4 cases (5.88%). Excellent results were in 42 patients (61.76%), good in 18 patients (26.47%) and poor in 8 patients (11.77%).

Conclusion: Interlocking nailing is one of the best options for the management of femoral shaft fractures due to high velocity gunshot injuries.
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January 2009

Drug overdose: a wake up call! Experience at a tertiary care centre in Karachi, Pakistan.

J Pak Med Assoc 2008 Jun;58(6):298-301

Department of Medicine, Aga Khan University, Karachi.

Objective: To study the characteristics of patients admitted with drug overdose caused either by accidental overdose of the prescribed medications or as an act of deliberate self harm (DSH) at a tertiary care hospital in Karachi, Pakistan.

Methods: A retrospective case series review was conducted at the Aga Khan University Hospital from January 2002 to October 2006. Three hundred and twenty four adult patients admitted with drug overdose were included in the study.

Results: Our sample group revealed mean age of 36.2 +/- 17.0 years, more females (59%), housewives (34%), and students (20%). Fifty six percent of patients committing DSH were married (p = 0.001), 81% needed in-patient psychiatric services (p = 0.016) of whom a significantly high number (38%) refused it. Domestic and social issues were rated highest among DSH group (p = 0.003), depression among females was common (p = 0.028) and Benzodiazepines (41%) was the most frequently used drug (p = 0.021). Sub-group analysis of accidental overdoses revealed mean age of 45.6 +/- 19.6 years, single (75.4%) and males (54.1%). Drugs used were mainly Benzodiazepines (18%) followed by Opioids (11%), Antiepileptics (10%) and Warfarin (10%).

Conclusion: Our study showed that depressed housewives are at greater risk for DSH. Domestic and social issues were rated highest and Benzodiazepines were the most commonly used agents. Most of our patients refused inpatient psychiatric treatment leading us to believe that general awareness of psychiatric illnesses is imperative in our community. High number of accidental overdoses is alarming in older, single males convincing us to believe that existing pharmacy system needs further evaluation and modification.
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June 2008

Simultaneous analysis of the three hormones involved in spermatogenesis and their interrelation ratios.

Pak J Pharm Sci 2008 Oct;21(4):344-9

Pakistan Medical Research Centre, Hayatabad Postgraduate Medical Complex, Peshawar, Pakistan.

The objectives of this non-interventional descriptive study was to determine the variation in serum levels of luteinizing hormone (LH), follicle stimulating hormone (FSH) and testosterone along with their ratios, among men having abnormal semen and their possible etiological role in male infertility. The study was carried out in the Reproductive Physiology Department of Public Health Laboratories Division, and National Institute of health (NIH), Islamabad during January 2004 to December 2005. Two hundred fifty married men who had presented with a complaint of infertility and who had an abnormal seminal profile on the basis of their prior semen analysis were included in the study. Subjects were classified as azoospermic (50), oligozoospermic (75), asthenozoospermic (50) and normozoospermic (75). In addition (50) normal male subjects, who were known to have fathered children, were included as controls. LH, FSH and testosterone levels were determined in serum by using enzyme immunoassay (EIA), using state-of-art Elecsys-2010 fully automatic immunology analyzer by Roche Diagnostics (USA). The FSH and LH level indicated inverse/negative correlation to sperm concentration in semen, while decreased testosterone levels were associated with depleted sperm concentration. The findings indicate that not only the altered/disturbed concentrations of gonadotrophins and androgenic hormones are responsible for male sub-fertility but also the disturbances in gonadotrophic: androgenic hormones ratios lead to infertility since these all hormones act synergistically.
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October 2008