Endoscopic retrograde cholangio pancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) in 2 different sessions, is the widely followed standard sequence of surgical procedures for concurrent gall bladder and common bile duct (CBD) stone disease, across the world. However, being highly technical, skillful and technology dependant, ERCP, sometimes, does not succeed even in the best of hands. This can happen due to abnormal local anatomy (eg. Previous Billroth II gastrectomy, previous surgical scars which distort the duodenum etc.) and unfriendly stone morphology such as a very large stone or a large number of stones. Failure to extract/retrieve bile duct stones at ERCP is an indication for CBD exploration (open or laparoscopic) at surgery. Herein, we present one such case of a 67 year old woman who had previously undergone surgery – laparoscopic cholecystectomy for gall stone disease 3 years back. She presented to us with a common bile duct loaded with multiple large stones. Inspite of undergoing ERCP (2 attempts over 48 hours), a common bile duct access could not be achieved endoscopically, thereby rendering endotherapy unsuccessful. She then underwent a successful totally laparoscopic CBD exploration, using standard laparoscopy instruments, some endoscopy accessories like endo-balloon & dormia basket and intraoperative fluoroscopy.

Objective: Chronic kidney disease is usually associated with anemia and the level of anemia correlates with the severity of the renal failure. The kidneys help in maintaining electrolyte balance and blood pressure. They produce the active form of vitamin D and a substance called erythropoietin, which stimulates production of red blood cells. Chronic kidney disease has adverse consequences on almost all body systems resulting in high rate of complications i.e. anemia, cardiac, vascular pulmonary etc. This study was carried out to evaluate the prevalence of anemia in chronic renal failure patients. Material and Methods: It is across sectional study and the data was collected from department of pathology and dialysis unit of Dr. Akbar Niazi Teaching Hospital, Islamabad from January 2021 to December 2021. All the patients who presented with sign and symptoms of chronic kidney disease were included in the study. Data was recorded in specially designed proforma and statistical analysis was performed using SPSS version 21. Results: Total 89 chronic kidney disease patients were included in the study among them 58 (65%) were males 31 (35%) were females. The average age of patients was 55 ± 16.409. Based on eGFR values the CDK patients that belonged to stage 1-5 were 5% (n=4), 6% (n=5), 9% (n=8), 18% (n=16) and 63% (n=56) respectively. The prevalence of anemia in chronic kidney disease patients was 95.5% (n=85) among which 62% (n=56) were males and 32% (n=29) were females. Normocytic normochromic anemia was the most common type with prevalence of 72% (n=64). Mild anemia was recorded in 41(46%) of the CKD patients while severe anemia was recorded in 3(3%) of patients. Besides CDK, diabetes mellitus was present as a comorbid feature in 4 (5%) of the patients, 16 (18%) had positive history of hypertension and 1 (1%) was positive for cardiovascular disease. Conclusion: Mild degree of anemia was seen in CKD patients. Most common type of anemia was normocytic normochromic. Most of the patients presented at stage 5. Comorbidities associated in CKD patients were hypertension, diabetes mellitus and cardiovascular disease.

The management of type 2 diabetes requires multifactorial approach in terms of diet, lifestyle modification and pharmacological treatment to prevent or delay complications and maintain the quality of life. Several studies have been conducted to enhance the treatment of type 2 diabetes. However, there was a lack of data regarding the prescription pattern of antidiabetics among clinicians. So, a cross-sectional, questionnaire based study was conducted to gather information about the prevalence, risk factors, and management of diabetes within a population. The data was collected from 551 doctors across all over India. About 44% doctors reported that 5-10 patients per week were newly diagnosed with type 2 diabetes. In this study, 66% of the doctors reported cardiovascular events as a major complication and 28% of the doctors reported renal complications in uncontrolled type 2 diabetes patients. 48% of the 551 clinicians used DPP4 inhibitors as an add on, followed by 30% who reported the use of SGLT2 inhibitors. Notably, 92% of the participants reported urinary tract infection as the most common undesirable effect in their patients, with the usage of dapagliflozin. Nearly 30% of the clinicians in our survey have prescribed SGLT2 inhibitors for patients who are at >50% risk of developing chronic kidney disease. The results from our study, stated that most of the clinicians use DPP4 inhibitors and SGLT2 inhibitors as an add on to metformin in patients with a failure to control the glycaemic index. Dapagliflozin is prescribed not only to control the glycaemic index but also to reduce the hospitalization due to heart failure and other cardiovascular and renal co-morbidities.