In 2011-12, the cost-effectiveness of imatinib, dasatinib and nilotinib for 1 st -line chronic myeloid leukaemia in the UK was evaluated by NICE. We discuss three methodological issues which strongly influence the estimated cost-effectiveness of these drugs. These issues are also important for the cost-effectiveness of many other drugs and medical devices. METHODS: We discuss the pros and cons of the following competing methods. 1) Estimation of overall survival: Method A: estimated as the cumulative duration of 1 st -, 2 nd -and 3 rd -lines of treatments. Method B: estimated from the surrogate responses: complete cytogenetic response and major molecular response; 2) Cost-effectiveness of subsequent treatments: the cost-effectiveness of 1 st -line drugs are substantially affected by the cost-effectiveness of subsequent drugs. Method A: traditional method of modelling estimated costs and QALYs of subsequent drugs. Alternatively, minimise impact of costeffectiveness of subsequent treatments by either Method B: setting per patient costs and QALYs of subsequent treatments equal between treatment arms, or Method C: cap the cost-effectiveness ratio whilst on subsequent treatments at the willingness to pay threshold; 3) Future drug prices: This is an important issue given that the patent for imatinib will expire soon, in 2016, after which its price may fall substantially. Method A: use the current list prices of all drugs in the future, as required by NICE. Method B: assume constant drug prices until patent expiry, at which time assume a fixed price cut. Assuming a modest 25% price cut on patent expiry, the ICER for nilotinib vs. imatinib increases substantially, from £36,000 to £54,000 per QALY. RESULTS: The pros and cons of the various methods are discussed. CONCLUSIONS: This study informs important methodological issues which apply to many health technologies. The study ultimately contributes to more accurate assessments of the cost-effectiveness of health technologies, and hence whether a given technology should be publicly-funded.

Objective: The main objective of this study is to determine the prevalence of migraine in pregnant women presented with severe headache. Study Design: Retrospective study Place and Duration: Study was conducted at department of Neurology Ayub Teaching Hospital, Abbottabad for duration of eighteen months(from August 2019 to February 2021). Methods: 120 pregnant women with ages 18-45 years were presented in this study. Patients’ detailed demographics including age, body mass index and gestational age was recorded after taking informed written consent. Patients with severe headache were enrolled and International Classification of Headache Disorders-II criteria were used for diagnosis of migraine. Trimester of pregnancy were assessed in terms of 1st, second and third. Complete date was analyzed by SPSS 20.version. Results: Mean age of the patients was 32.16±6.44 years with mean BMI 25.07±2.44 kg/m2. Most of the patients 70 (58.3%) were from third trimester. Gestational age of the pregnant women was 22.64±11.03 weeks. 75 (62.5%) were from urban areas and mostly had low socio-economic status 80 (66.7%). 45 (37.5%) women were educated. 50 (41.7%) cases diagnosed migraine, 35 (29.17%) cases had tension type headache (TTH) while the rest were showed only severe headache among pregnant women. Most common symptom was nausea 24 (48%), followed by vomiting 16 (32%) and sensitivity to light was found in 10 (20%) women. Conclusion: In this study, we concluded with the prevalent condition for pregnant women of migraine and headache-related impairment. Migraine and headache during pregnancy are critical for diagnosis and treatment. Keywords: Headache, Pregnancy, Migraine, Prevalence

Background and Aim: The most common entrapment neuropathy is carpal tunnel syndrome (CTS). Carpal tunnel syndrome is caused by median nerve compression at the wrist joint. Idiopathic carpal tunnel syndrome is the most common cause. Among the other physiologic causes of carpal tunnel syndrome (wrist trauma, diabetes, hypothyroidism, rheumatoid arthritis, occupation, contraception, and pregnancy), pregnancy is the most common. The objective of the present study was to determine the frequency of local treatment in carpal tunnel syndrome during pregnancy. Materials and Methods: This cross-sectional study was carried out on 45 pregnant women with carpal tunnel syndrome in the departments of Neurology and Gynaecology, Ayub Teaching Hospital, Abbottabad from May 2020 to April 2021. Individuals who met the inclusioncriteria were enrolled in this study. Ethical approval and consent forms were taken from the participants. All the patients were treated with local treatment (dexamethasone acetate 4 mg and lidocaine 0.5 ml) under the carpal tunnel syndrome. Before and after 3 weeks of local injection, median nerve electro physiologic parameters through sensory nerve conduction velocity (SNCV), sensory latency (DSL), pain intensity (visual analog scale or VAS) and distal motor latency (DML) were all noted. Results: The mean age of the patients was 29± 5.3 years while mean weight gain was 13.2 ± 4.9 kg. The third trimester was the mostfrequent pregnancy trimester with carpal tunnel syndrome. Before and after 3weeks, the average pain score of injected dexamethasone acetate was 8.65 ±0.89 and 4.29 ± 0.74 respectively (p-value < 0.005). Additionally, the median nerve SNCV transcarpalwas 32.9 ±7.1 and 25.1 ± 7.2 m/s (p-value = 0.001); while DSL median nerve was4.87±0.81 ms and 4.1±0.62. Lastly, the DML of the median nerve before and after 3weeks of local treatment was 5.2±1.03 and 4.69±0.54 ms respectively. Conclusion: Pain intensity and electrophysiological factors were considerablyimproved after local treatment dexamethasone acetate injection. Encouraging results have been offered for carpal tunnel syndrome with minimum invasive treatment in pregnant women. Keywords: Carpal tunnel syndrome, Pain intensity, local treatment

Background: Epilepsy drug therapy advancements have resulted in an increasing number of childbearing age well-controlled epileptic women. It is not surprising then, that the impact of pregnancy on the progression of epilepsy has sparked renewed interest. Aim: The aim of current study was to evaluate the frequency of fits or seizure in pregnant women with previously controlled epilepsy. Materials and Methods: This cross-sectional study was carried out on 98 pregnancies of 84 epileptic women during the period between August 2019 and August 2021in the department of neurology and gynaecology of Ayub Teaching Hospital, Abbottabad. All the pregnant women with less than three verified epileptic fits, pregnancy ended with abortion and incomplete seizure or fit frequency were excluded. All the patients were referred to Gynaecology and Neurology department for early pregnancy and planning by a neurologist and gynaecologist. Data analysis was done with SPSS version 23 with p<0.05 as statistical significance. Results: The association of fits frequency on pregnancy was studied and monitored in 84 epileptic women out of 98pregnancies. About 49 (50%) pregnancies were not affected by fits frequency. The fits frequency was increased in 36 (37%) pregnancies or puerperium while decreased in 13 (13%) pregnancies. Sleep deprivation or drug regimen on-compliances associated was increased in 30 (30.6%) pregnancies. Out of 19pregnancies, eight (42%) had improvement with sleep deprivation correction during none months pre-gestation. Antiepileptic drugs with low plasma concentration of uncontrolled epilepsy during pregnancy were found in 47%. Conclusion: Sleep deprivation, Non-compliance during pregnancy, and before and after pregnancy inadequate therapy all have a significant impact on the course of epilepsy during pregnancy. With proper medical care, pregnancy appears to have only a minor impact on the course of epilepsy. Keywords: Epilepsy, Frequency fits, Sleep Deprivation.

Objectives: To compare the effect of blunt and sharp incision of uterus at cesarean section on intra-operative haemorrhage. Methods: This trial was conducted at the Department of Obstetrics and Gynaecology, Pakistan Ordinance Factory Hospital, Wah Cantt from 14th January to 13th July 2012. Total 80 women planned for lower segment cesarean section through Pfannensteil incision were randomized to either blunt uterine incision (Group-A, n=40) or sharp uterine incision (Group-B, n=40). The fall in Haemoglobin and HCT was compared in two groups and analyzed with help of SPSS version 10. Results: Both groups were similar in terms of demographic features like age, parity, gestational age and indication for cesarean section. The participants in Group-A reveled significantly less drop of mean Hb concentration as compared to Group-B (1.47±1.08 and 1.95±0.85 respectively, P value 0.031). Similarly, the fall in mean HCT was significantly less in Group-A in comparison to Group-B (3.21±1.3 and 4.21±2.17 respectively, P-value 0.015) Conclusion: Blunt expansion of uterine incision during caesarean section is associated with less fall in Haemoglobin and HCT as compared to sharp expansion. doi: https://doi.org/10.12669/pjms.37.7.4159 How to cite this:Faiza, Sadaf F, Ameena B, Khan NR. Comparison of intra operative hemorrhage by blunt and sharp expansion of uterine incision at cesarean section. Pak J Med Sci. 2021;37(7):---------. doi: https://doi.org/10.12669/pjms.37.7.4159 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.