The brachial plexus and subclavian arteries are compressed when the thoracic outlet is expelled, resulting in the clinical disease known as Thoracic Outlet Syndrome (TOS). These disorders have various etiological causes, including cervical rib, and can damage the nervous system or blood vessels. The cervical rib, which develops from the seventh cervical vertebra and is thought to be abnormal, extra, or congenitally overdeveloped, is the main factor contributing to thoracic outlet syndrome (TOS). The transaxillary method developed by Roos, which is conservative and offers great exposure to the neurovascular structures with good aesthetic outcomes, is one of several surgical procedures employed for treating TOS. We present a case of a 43-year-old man with a cervical rib who complained of progressive pain and paresthesias in his left upper limb and presented to us in Ghurki Trust and Teaching Hospital Lahore . We removed the cervical rib and stented the Subclavian to the Brachial artery using a transaxillary approach. Keywords: Cervical Ribs, Transaxillary approach, Thoracic outlet syndrome

Decentralisation is associated with the hope that “bringing government closer to the people” will improve the provision of public services by increasing people’s voice in decision-making, and by making the government more accountable to them. Decentralisation is also associated with the hope that disadvantaged groups of society, including the poor and women, will have better possibilities to exercise voice at the local level. Some countries have combined decentralisation with affirmative action, for example, by reserving seats in local councils for women and other disadvantaged groups. Yet the empirical evidence regarding the impacts of decentralisation has been mixed [Bardhan (2002); von Braun and Grote (2002); Jütting, et al. (2004); Steiner (2005)]. In many cases, political decentralisation has not been associated with fiscal and administrative decentralisation, thus limiting the scope of what local governments can actually do. Building capacity at the local level and overcoming coordination problems has been another challenge. Local elite capture has been identified as a major problem that can prevent positive effects of decentralisation for the poor, especially in societies with hierarchical power structures at the local level [Bardhan (2002)]. With regard to gender, there are concerns that decentralisation—even if associated with affirmative action—will not be sufficient to overcome gender-based discrimination. Again, the empirical evidence is mixed [ADB (2004)]. Chatthobadhay and Duflo (2004) found that that women who were elected as village leaders under the reservation policy in the Indian states of West Bengal and Rajastan invested more in those public goods that more closely linked to women’s concerns, such as drinking water. Baden (1999) showed that it depends on local power structures and on the availability and competition over resources whether or not women benefit from decentralisation. In view of the mixed results, important knowledge gaps remain regarding the possibilities to promote public service provision for the poor and for women through political decentralisation and associated affirmative action.

OBJECTIVES: To determine knowledge, attitude, and practice regarding exclusive breastfeeding among mothers attending tertiary care hospitals.  METHODOLOGY: A descriptive cross-sectional study was conducted at the Department of Pediatrics in Hayatabad Medical Complex, Peshawar. A total of 162 mothers were selected who were practicing breastfeeding of ages between 20 to 35 years, having a full-term baby of age up to 6 months old. The data is collected through a pre-planned questionnaire and then was analyzed using statistics version 24.0. The duration of the study was from 1st June 2020 to 30th October 2020. RESULTS: The results showed that no significant association was found between age groups, socio-economic status regarding knowledge, attitude, and practice (p>0.05). However, there was a significant difference between knowledge, attitude, and practice with respect to educational status (p<0.05). 123 (73.21%) mothers had unsatisfactory; whereas 39 (24.07%) mothers had excellent knowledge regarding breastfeeding. 39 (27.07%) of breast-feeding mothers had a positive attitude towards breastfeeding. 123 (73.21%) women showed a negative response regarding the practice of breastfeeding. CONCLUSION: Most of the mothers didn’t have adequate knowledge of exclusive breastfeeding (EBF) practice. As a result, it is suggested that media can be used as a medium to educate women about the benefits of exclusive breastfeeding (EBF).

Background:Hydroxychloroquine (HCQ) is widely used in the management of rheumatoid arthritis and connective tissue disease. The prevalence of retinopathy in patients taking long-term HCQ is approximately 7.5%, increasing to 20-50% after 20 years of therapy. Hydroxychloroquine prescribed at ≤5 mg/kg poses a toxicity risk of <1% up to five years and <2% up to ten years, but increases sharply to almost 20% after 20 years. Risk factors for retinopathy include doses >5mg/kg/day, concomitant tamoxifen or chloroquine use and renal impairment. The UK Royal College of Ophthalmologists (RCOphth) 2018 guidelines for HCQ screening recommend optimal treatment dosage and timing for both baseline and follow-up ophthalmology review for patients on HCQ, with the aim of preventing iatrogenic visual loss. This is similar to recommendations made by the American Academy of Ophthalmology (2016).Objectives:To determine adherence to the RCOphth guidelines for HCQ screening within the Rheumatology departments in the North-West of the UK.Methods:Data for patients established on HCQ and those initiated on HCQ therapy were collected over a 7 week period from 9 Rheumatology departments.Results:473 patients were included of which 56 (12%) were new starters and 417 (88%) were already established on HCQ. 79% of the patients were female, with median ages of 60.5 and 57 years for new and established patients respectively. The median (IQR) weight for new starters was 71 (27.9) kg and for established patients, 74 (24.7) kg.20% of new starters exceeded 5mg/kg daily HCQ dose. 16% were identified as high risk (9% had previously taken chloroquine, 5% had an eGFR <60ml/min/m2and 2% had retinal co-pathology). Of the high-risk group, 44% were taking <5mg/kg. In total, 36% of new starters were referred for a formal baseline Ophthalmology review.In the established patients, 74% were taking ≤5mg/kg/day HCQ dose and 16% were categorized as high risk (10% had an eGFR less than 60ml/min/m2, 3% had previous chloroquine or tamoxifen use and 2% had retinal co-pathology). In the high-risk group, 75% were not referred for spectral domain optical coherence tomography (SD-OCT). 41% of patients established on HCQ for <5 years, and 33% of patients on HCQ for >5 years were not referred for SD-OCT. Reasons for not referring included; awaiting 5 year review, previous screening already performed and optician review advised.Since the introduction of the RCOphth guidelines, 29% patients already established on HCQ had an alteration in the dosage of HCQ in accordance with the guidelines. In the high-risk group, 16% were not on the recommended HCQ dose.Conclusion:This audit demonstrates inconsistencies in adherence to the RCOphth guidelines for HCQ prescribing and ophthalmology screening within Rheumatology departments in the North-West of the UK for both new starters and established patients. Plans to improve this include wider dissemination of the guidelines to Rheumatology departments and strict service level agreements with ophthalmology teams to help optimize HCQ prescribing and screening for retinopathy.Acknowledgments:Drs. S Jones, E MacPhie, A Madan, L Coates & Prof L Teh. Co-1st author, T David.Disclosure of Interests:None declared

Ongoing monitoring by a practice of its standard of care and willingness to make changes is a fundamental part of good practice. One method of doing this is through audit.