Journal of the College of Physicians and Surgeons--Pakistan: JCPSP

Published by College of Physicians and Surgeons Pakistan
Online ISSN: 1681-7168
Publications
Article
Objective: To determine the re-recurrence and the postoperative complications in recurrent pterygium cases treated by intraoperative 0.02% Mitomycin C (MMC) and conjunctival autograft (CAG). Study design: Quasi-experimental. Place and duration of study: Department of Ophthalmology, Liaquat University of Medical and Health Sciences, Jamshoro, Hyderabad and Chandka Medical College Hospital, Larkana, from January to December 2010. Methodology: Cases with recurrent pterygium were included in this study. Cases with history of first time pterygium and pterygium with conjunctival scarring, dry eye, glaucoma and vitreoretinal disease were excluded. After topical and subconjunctival anaesthesia, pterygium was excised in single piece. Intraoperative 0.02% MMC was applied on bare sclera for 2 minutes. CAG was excised from supero-temporal conjunctiva, and implanted on bare sclera. All cases were followed-up for 6 months. Re-recurrence was defined as postoperative fibrovascular re-growth of 1.0 mm or more crossing the corneo-scleral limbus. Data was analysed as descriptive statistics. Results: A total of 65 eyes of 65 cases were studied having mean age of 43.26 ± 12.81 years. Among those, 41 (63.1%) were males and 48 (73.8%) belonged to rural area. The size of pterygium on cornea was 2-3 mm in 44 (67.7%) cases and 4-5 mm in 21 (32.3%) cases. Re-recurrence of pterygium was seen in 3 (4.6%) cases. Postoperative complications included conjunctival granuloma in 2 (3.1%) cases, graft necrosis in 2 (3.1%) cases, graft oedema in 3 (4.6%) cases and graft displacement in 3 (4.6%) cases. Conclusion: The intraoperative application of 0.02% MMC with CAG markedly reduces the risk of re-recurrence of pterygium and postoperative complications.
 
Article
To assess and compare the effectiveness of topical 0.2% glycerl trinitrate (GTN) and topical 2% diltiazem (DTZ), in the management of chronic anal fissure. Comparative, descriptive study. Department of Surgery, Liaquat University of Medical and Health Sciences, Jamshoro/Hyderabad from September 2004 to August 2005. Patients with chronic anal fissure were treated with topical 0.2% GTN (50 patients) and 2% DTZ (47 patients) application for 8 weeks, three times a day at peri anal area. Symtoms, recurrence, wound healing and side effects were compared. Data was analyzed using SPSS version 10 employing X2 test. A p-value below 0.05 were considered statistically significant. There were 53 females and 44 males with a mean age of 30 years. Patients who received topical diltiazem (DTZ) showed statistically significant difference than those who were prescribed topical glycerl trinitrate terms of wound healing and side effects mainly the headaches (p=0.02 and 0.003 respectively). Improvement in symptoms (p=0.345) and recurrence rates (p=0.612) turned to be statistically insignificant although recurrence rate was lower with DTZ. Chemical sphincterotomy is an effective first line management for chronic anal fissure. Both GTN and DTZ are equally effective in managing the chronic anal fissure. DTZ has fewer side effects, a better healing response and low recurrence rates.
 
Article
Objective: To assess the effectiveness of recombinant human (rh) IL-11 to increase platelets count in patients suffering from Dengue fever (DF). Study design: Randomized double blind placebo control study. Place and duration of study: Farooq Hospital, Lahore, from July to October 2011. Methodology: Forty hospitalized patients suffering from Dengue fever having platelets count ² 30000 per micro liter were randomly categorized into two groups, rhIL-11 (test) and distilled water (placebo) groups. The efficacy outcomes (as indicated by step up in platelets count at 48 hours) for the treatment group were compared with the outcomes for the placebo group. Results: The data revealed that the increase in platelet response with recombinant human interleukin 11, 1.5 mg subcutaneously is significantly more brisk than the placebo group. The platelets response in patients with severe thrombocytopenia was greater in the treatment group (50%) at 48 hours as compared to the placebo group (20%) (p=0.047). Response rate was slightly greater among males (6/10, 60%) than females (8/16, 50%); moreover, three-fourth (75%) female responders were in the placebo group, compared to half (50%) male responders in the treatment group. Conclusion: Results of the study suggest that treatment of severe thrombocytopenia accompanying DF with recombinant human interleukin11 may be a useful therapeutic option.
 
Article
To assess the oral hygiene knowledge, attitude and practices among school children and evaluate their DMFT (Decayed/Missing/Filled Teeth) scores. Cross-sectional study. A private school of Karachi from March to April 2008. Convenient sample comprising 300 students of grade 6 within the age group of 11-12 years was selected. A knowledge, attitude and practices survey questionnaire based on quantitative indicators was filled by the students. Clinical examination was done for DMFT. Data analysis was done by using SPSS version 11. Associations were assessed using chi-square test and a p-value of < 0.001 was considered significant. There were 160 males and 140 females in the target group. The mean DMFT was found to be 1.27. The children had satisfactory knowledge of oral health's effect on general health and the problems associated with poor dental hygiene. However, 50.3% children did not have positive attitude towards importance of a dentist's role in maintaining their dental health. Only a few students (11.3%) had familiarity with dental floss. A statistically significant association was found between frequency of brushing and children's knowledge of the problems related to irregular tooth brushing (p < 0.001). The attitude of school children towards dental health and dental service utilization is determined by certain social and cultural factors. The mean DMFT of 1.27 showed that there must have been some poor oral practices that are contributing towards a higher mean.
 
Article
Breast cancer, the most common malignancy in females, has an estimated 5-10% hereditary predisposition. BRCA1 is a tumor suppressor gene and is known to be responsible for breast cancer and breast-ovarian cancers running in families. In breast caner patients, several mutations in BRCA1 have been reported throughout the gene. This report describes identification of a mutation in BRCA1 gene using protein truncation (PTT) assay in a patient with medullary carcinoma of breast who also had a family history of breast cancer. Following DNA sequencing, the mutation was confirmed as substitution of thymine at position 1123 with guanine of exon 11 (1123 T>G). This mutation can be added to the pool of known BRCA1 mutations in Pakistani population, which will help in developing a local screening panel of BRCA1 mutations.
 
Article
Objective: To evaluate the correlation between Cancer Antigen-25 (CA-125) levels with the amount of ascites in patients with liver cirrhosis. Study design: Observational, analytical study. Place and duration of study: Shifa International Hospital, Islamabad, from March 2012 to February 2013. Methodology: A total of 130 patients with liver cirrhosis (with and without ascites) had serum CA-125 levels measured. The amount of ascites was classified according to physical examination and ultrasound (USG) findings. CA-125 levels were compared and correlated with amount of ascites. Results: Majority of patients (57%) had hepatitis C virus and 60% were in class Child Pugh C. There was moderate correlation between amount of ascites and CA-125 levels (r = 0.642, p < 0.001) with significant raised levels of CA-125 in patients with ascites (p < 0.001). Conclusion: There was a moderate correlation between CA-125 levels and presence and amount of ascites.
 
Article
A 13-year-old unmarried female presented with severe colicky lower abdominal pain, radiating to left side, not associated with fever. Ultrasound examination showed a dilated left fallopian tube with minimal free fluid in pelvis, and diagnosis of pelvic inflammatory disease was suggested. MRI of the pelvis showed a complex intensity mass in left adnexa, suggesting a germ cell tumour. Patient underwent diagnostic laparoscopy and laparoscopic removal of left fallopian tube. Histopathology finally established the diagnosis of left fallopian tube torsion.
 
Frequency of H. pylori infection in three age groups of subjects (p-value represents χ 2 test among all groups). 
Article
High frequency of Helicobacter (H.) pylori infection has been reported in Pakistan mainly for dyspeptic patients, while the published data is inadequate regarding asymptomatic population. The non-invasive 13C urea breath test (UBT) was used to determine the frequency of H. pylori infection in 516 asymptomatic individuals and to find out its association with gender and age. Overall prevalence was 74.4% (384/516) while 63.5% (113/178) children were positive for 13C-UBT and the percentage increased with age in both the genders with significantly higher prevalence in adolescents (p=0.003) and adults (p < 0.001). Moreover, there was non-significant difference between the prevalence of H. pylori infection in males and females in all age categories. The reported high frequency of H. pylori infection warrants further studies to identify epidemiological and environmental risk factors.
 
Article
To compare the sensitivity, specificity and Positive Predictive Value (PPV) of histology, Campylobacter-Like Organism (CLO) test, culture and 13C-Urea Breath Test (UBT) for the diagnosis of Helicobacter pylori infection. Descriptive study. District Headquarter Hospital, Rawalpindi, Military Hospital, Rawalpindi and Pakistan Institute of Science and Technology (PINSTECH), Nilore, Islamabad from June 2002 to 2003. Three mucosal biopsy specimens were obtained during endoscopy of 90 symptomatic patients. Histology, CLO test and culture were performed on these specimens. Breath samples for 13C-UBT were collected and sent to RIAD, PINSTECH on the same day for isotope ratio mass spectrometry. For analysis purpose, each of the tests was fixed as the gold standard in turn and the others were then compared against it. In addition, any two as well as any three positive tests were then set as the gold standard and the other tests compared against them to calculate the sensitivity, specificity, accuracy and PPV of other tests. Urea breath test had the highest sensitivity, ranging from 95 to 100%, against all the gold standards with specificity ranging from 55 to 100%, whereas the sensitivity of histological examination was around 98% but it had comparatively lower specificity (49-89%). The CLO test had a sensitivity range of 86-100% and specificity of 67-100%. Culture had the minimum sensitivity (59-70%) but had highest specificity (96-100%) against all the gold standards. Age and gender had no effect on p-value of each test or in combination. The urea breath test has shown the highest ability to detect the organism with 95-100% sensitivity in symptomatic individuals and specificity, which is comparable to other tests.
 
Article
To study the clinical profile of amblyopia in children age 3 to 14 years. A cohort study. The study was conducted over a period of two years from June 2001 to June 2003 at Khyber Institute of Ophthalmic Medical Sciences, Hayatabad Medical Complex, Peshawar, Pakistan. This study included 316 children. Visual acuity was tested with Snellen type and Lea symbols chart according to the level of cooperation of the children. Cycloplegic refraction and orthoptic assessment was performed on all children. One hundred and eighty-two children were between 3 to 8 years age and 134 were between 8 to 14 years. Mean age was 8 years. One hundred and twenty children had strabismic amblyopia, 136 children had anisometropic amblyopia, while 60 children had combined mechanism amblyopia (strabismus and anisometropia both). The results indicate the importance of screening school-going children for refractive error and amblyopia and the importance of a future prospective study on the magnitude, cause and treatment of amblyopia at more treatable age.
 
Article
Objective: To aspirate breast abscess through a wide bore (14-gauge) intravenous (I/V) cannula and determine its efficacy in terms of the number of recurrences and number of aspirations. Study design: Case series. Place and duration of study: Dow University of Health Sciences and Civil Hospital and Bantva Hospital, Karachi, Pakistan, from January 2009 to December 2011. Methodology: Patients with breast abscesses confirmed on ultrasound without skin ulceration were selected. The soft area of breast abscess with positive fluctuation was marked and fixed with index finger and thumb. A 14-gauge cannula was inserted. Pus was aspirated through a 50 cc syringe, repeated till no aspirate could be obtained. All patients were followed weekly for 4 weeks, clinically for size of lump, local tenderness and temperature, while complete resolution was confirmed on ultrasound, as resolution of the lesion. Results: A total of 55 patients were included in this study. Mean age was 29 ± 5.58 years while ranging from 20 - 40 years. Complete resolution of abscess was seen in 31 (56.4%) cases by single aspiration. Second aspiration was required in 24 (43.6%) patients and third aspiration in single setting was required in one case only. Recurrence after the second aspiration occurred in 08 (14.5%). Incision drainage was required in 7 (12.7%) patients. Conclusion: Percutaneous aspiration of breast abscess through a wide bore (14-gauge) I/V cannula is a simple alternative to incision and drainage.
 
Article
Objective: To determine the effect of estradiol treatment on serum corticosterone levels in Oophorectomized (OVX) female Sprague Dawley rats exposed to chronic restraint stress. Study design: Experimental study. Place and duration of study: Department of Physiology, Army Medical College, Rawalpindi and National Institute of Health, Islamabad, from January to December 2008. Methodology: A total of 90 female Sprague Dawley rats (age: 90 ± 10 days), were divided into three groups, each having 30 rats. Group-I comprised of healthy control female rats whereas group-II and III were experimental female rats exposed to chronic restraint stress after bilateral Oophorectomy and called estradiol treated and vehicle treated groups. Estradiol treatment of Oophorectomized rats was done once daily for 2 weeks. At the end of experiment, the rats were sacrificed and intracardiac blood sampling was done to measure serum corticosterone levels by enzyme linked immunosorbent assay (ELISA) kit. Results: The restraint stress to estradiol treated rats for 2 weeks revealed that serum corticosterone levels were significantly increased (31.32 ± 5.46 ng/ml, p < 0.05) as compared to the healthy controls (17.48 ± 4.14 ng/ml). Conclusion: Chronic restraint stress results increases the serum corticosterone levels in Oophorectomized Sprague Dawley rats. Estradiol treatment increases the responsiveness of adrenal cortex of Oophorectomized female rats.
 
Article
Congenital adrenal hyperplasia (CAH) refers to autosomal recessive diseases resulting from deficiency of enzymes involved in the production of cortisol by the adrenal glands. This study was designed to determine the frequency of suspected congenital adrenal hyperplasia patients by evaluating the laboratory data of blood 17-OHP. The study was conducted at Chemical Pathology Section of Department of Pathology at the Aga Khan University, Karachi. The basic demographic data of 2282 subjects was recorded, screened for blood 17-OHP levels from January 2007 to December 2010. A cutoff of ³ 4 ng/ml was considered as suggestive of CAH. The results showed 17-OHP levels ³ 4 ng/ml were found predominantly among infants (14.4%) and in females (18.2%).
 
Article
To determine clinical manifestations of depressive disorder among cases below 18 years. Cross-sectional study. Carried out at NMI (Neurospinal Medical Institute), Karachi, over a period of 3 years (October 2001 to 2004). Four hundred consecutive cases, below the age of 18 years, were evaluated. One hundred cases were inducted in this study based on detailed history and interview by psychiatrists. The diagnostic criteria of ICD-10 (International classification of diseases in its tenth revision) of WHO was used. Results based on clinical features were tabulated and analysed with SPSS-10. Fisher s exact test/Chi-square test were used for comparison between male and female cases. A total number of 400 consecutive cases, below the age of 18, who approached for psychiatric consultation, were evaluated. After applying the ICD-10 diagnostic criteria, a 100 (25%) of them were found to be suffering from depressive disorder. Among them, 54 were girls and 46 boys, giving a male to female ratio of 1:1.32 and statistically insignificant gender difference. Instead of mood disturbance, the most frequent presenting complaints included pain (55%), insomnia (33%), fear (16%), weakness (14%) and aggression (13%). Depression is a common psychiatric disorder among the pediatrics and adolescents. The clinical presentation was usually found to be atypical.
 
Publication trends for top three SAARC countries.  
Publication trend (slope) for each SAARC country.  
Article
Objective: To conduct a geographical analysis of biomedical publications from the South Asian Association for Regional Cooperation (SAARC) countries over the past 25 years (1985-2009) using the PubMed database. Study design: A qualitative study. Place and duration of study: Web-based search during September 2010. Methodology: A data extraction program, developed by one of the authors (SFS), was used to extract the raw publication counts from the downloaded PubMed data. A search of PubMed was performed for all journals indexed by selecting the advanced search option and entering the country name in the 'affiliation' field. The publications were normalized by total population, adult illiteracy rate, gross domestic product (GDP), secondary school enrollment ratio and Internet usage rate. Results: The number of PubMed-listed papers published by the SAARC countries over the last 25 years totalled 141,783, which is 1.1% of the total papers indexed by PubMed in the same period. India alone produced 90.5% of total publications generated by SAARC countries. The average number of papers published per year from 1985 to 2009 was 5671 and number of publication increased approximately 242-fold. Normalizing by the population (per million) and GDP (per billion), India (133, 27.6%) and Nepal (323, 37.3%) had the highest publications respectively. Conclusion: There was a marked imbalance among the SAARC countries in terms of biomedical research and publication. Because of huge population and the high disease burden, biomedical research and publication output should receive special attention to formulate health policies, re-orient medical education curricula, and alleviate diseases and poverty.
 
Article
To monitor pre and postsynaptic receptor responsiveness and consumption of ethanol following the repeated administration of a selective serotonin-1A receptor agonist, 8-hydroxy-2-di-n-propylaminotetralin (8-OH-DPAT), to ethanol treated rats. The experimental protocol was designed to administer ethanol orally to rats for three weeks and 8-OH-DPAT during the 3rd week. The experiments were performed in the department of Biochemistry, Karachi University. Samples collected after three weeks of treatment were analyzed within a week. The study was conducted on 24 males albino Wistar rats treated with ethanol for three weeks. 8-OH-DPAT at a dose of 1mg/kg or saline was injected to ethanol treated rats from day 1 to day 5 during the 3rd week to monitor the effects on ethanol consumption. Pre and postsynaptic responses to 8-OH-DPAT were monitored by injecting the drug on the 6th day to a group of 5-day saline and a group of 5-day 8-OH-DPAT injected animals. Control animals of the two groups were injected with saline. Before the injection of 8-OH-DPAT, weekly intakes of ethanol were highly comparable in the two groups. Administration of 8-OH-DPAT, from day 1 to day 5, decreased ethanol intake. Pre and postsynaptic serotonin-1A receptor dependent responses monitored on the 6th day were higher in 5-day saline than 5-day 8-OH-DPAT injected animals. A decrease in the effectiveness of negative feedback control over the synaptic availability of serotonin following 5-day administration of 8-OH-DPAT is involved in the decreases of ethanol consumption.
 
Article
This review focuses on the role of the cytokine interleukin-1alpha (IL-1alpha) in the testis; elaborating upon its importance during the complex process of spermatogenesis while relating this cytokine to some of the pathophysiological states affecting the testis. IL-1alpha, a proinflammatory cytokine, is expressed constitutively by the intact adult rat testis where it acts on germ, Sertoli and Leydig cells to regulate germ cell proliferation and steroidogenesis. The sequence identity of testicular IL-1alpha matches with the one secreted by activated macrophages in systemic immunity. The classical macrophage IL-1alpha is produced as 32 kDa precursor protein which is processed to mature 17 kDa IL-1alpha and a 16 kDa propiece. The rat testicular IL-1alpha, mainly secreted by Sertoli cells, was found to have molecular heterogeneity that can be observed both at the transcriptional and the translational levels. In the rat testis, two transcripts were found to be expressed with 941 bp and 767 bp (that lacks 174 bp) which were translated into 32 kDa and 24 kDa precursor proteins, respectively. The 32 kDa precursor protein is processed to the 17 kDa mature IL-1alpha. Identical transcripts are also shown to be present in cat, dog and pig. Most of the functional role is assigned to the mature 17 kDa IL-1alpha isoform. However, functional analysis of recombinant rat IL-1alpha isoforms showed that there was a clear biopotency difference between these forms in order of 17 kDa IL-1alpha>32proIL-1alpha>24proIL-1alpha. Furthermore, the mature 17 kDa tIL-1alpha has also been implicated in pathologies such as orchitis, relapse of acute lymphoblastic leukemia (ALL) in the testis and infertility disorders in men. Thus, tIL-1alpha may play an important functional role both in coordination of normal testicular physiology as well as in contributing to the disease states in the testis.
 
Gestational age specific % survival curves (Qatar 2008, VON 2007 14 and UK 2006 15 ).  
Article
To analyze and compare the current gestational age specific neonatal survival rates between Qatar and international benchmarks. An analytical comparative study. Women's Hospital, Hamad Medical Corporation, Doha, Qatar, from 2003-2008. Six year's (2003-2008) gestational age specific neonatal mortality data was stratified for each completed week of gestation at birth from 24 weeks till term. The data from World Health Statistics by WHO (2010), Vermont Oxford Network (VON, 2007) and National Statistics United Kingdom (2006) were used as international benchmarks for comparative analysis. A total of 82,002 babies were born during the study period. Qatar's neonatal mortality rate (NMR) dropped from 6/1000 in 2003 to 4.3/1000 in 2008 (p < 0.05). The overall and gestational age specific neonatal mortality rates of Qatar were comparable with international benchmarks. The survival of < 27 weeks and term babies was better in Qatar (p=0.01 and p < 0.001 respectively) as compared to VON. The survival of > 32 weeks babies was better in UK (p=0.01) as compared to Qatar. The relative risk (RR) of death decreased with increasing gestational age (p < 0.0001). Preterm babies (45%) followed by lethal chromosomal and congenital anomalies (26.5%) were the two leading causes of neonatal deaths in Qatar. The current total and gestational age specific neonatal survival rates in the State of Qatar are comparable with international benchmarks. In Qatar, persistently high rates of low birth weight and lethal chromosomal and congenital anomalies significantly contribute towards neonatal mortality.
 
Article
To assess the spectrum and management of head injuries among earthquake victims. Case series. Place and Duration of Study: The study was conducted at Surgical Ward II, Combined Military Hospital, Rawalpindi, from October 2005 to December 2006. Three hundred consecutive cases of head injury, secondary to earthquake were included in the study. Plain X-rays of skulls were undertaken in clinically stable patients with head injuries. Cases with altered level of consciousness and compound depressed fractures were advised CT scan of head. Pus swabs were taken from open wounds. Proformas were maintained for every patient. Head injury was classified as mild, moderate and severe, and each patient was treated accordingly. One hundred and twenty three (41%) patients were children under 10 years of age. Adults below 55 years were 69 (23%) and above 55 years were 108 (36%). Mean age was 32.2 years (SD + 6.7). Female to male ratio was 1.1:1. One hundred and sixty five (55%) cases were of mild head injury, 103 (34.3%) patients had moderate head injury and 32 (10.7%) patients had severe head injury. Majority (48.7%) of patients was managed conservatively. Minor surgeries were done in 17% of patients and major surgeries were done in 34.3% of patients. Glasgow Outcome Scale assessment was made at the end of 6 months and 1 year. Mortality increased from 3.3% to 7% in one year time. Patients at the extremes of age are more vulnerable to trauma and should be given timely attention in disaster management plans. General and trauma surgeons should be well-versed with the techniques and indications of burr hole evacuation of life threatening intracranial haematomas in situations, where early evacuation is unattainable.
 
Article
To determine the clinical characteristics in adults with confirmed pandemic influenza A (H1N1) infection 2009. A case series. The study was carried out at the Department of Pulmonology and Critical Care, Military Hospital, Rawalpindi, from 1st December 2009 to 30th May 2010. Thirty six adults with confirmed 2009 pandemic H1N1 infection by reverse transcriptase polymerase chain reaction (RT-PCR) were included in the study. All patients were followed in-hospital and clinical features, laboratory and radiological investigations and management data was collected on a pre-designed patient data collection form. Mean age was 34.24±13.92 years with 61.1% females. Seventeen (47.2%) had at least one risk factor for complications with 2009 H1N1 infection; namely obesity in 19.4%, pregnancy in 8.3%, COPD in 5.6%, cardiac failure in 5.6%, chronic liver disease in 5.6%, Diabetes mellitus in 5.6%, immunosuppression in 2.3%, smoking in 25%. Fever (97.2%), cough (97.2%), rhinnorhea (80.6%), and shortness of breath (58.3%) were the commonest symptoms. Radiographic abnormalities were interstitial/reticular infiltrates (30.6%), patchy consolidations (11.1%) and reticular shadows with areas of consolidation (25%). PaO2/FiO2 ratio was less than 200 in 27.8% cases. Thirty six percent cases had creatinine kinase (CK) levels greater than 400 U/L and lactate dehydrogenase (LDH) levels higher than 1000 U/L. Twenty seven percent cases were managed in ICU and 16.7% cases died during hospital stay. The 2009 pandemic H1N1 virus infection had a wide clinical spectrum with a potential to cause high morbidity and mortality. Early empirical antiviral therapy for hospitalized suspected influenza A (H1N1) is vital to prevent the rapid disease progression.
 
Article
Objective: To describe the frequency and outcome of dengue haemorrhagic fever (DHF) cases and determine the association of clinical and laboratory parameters with haemorrhagic complications. Study design: A descriptive study. Place and duration of study: Combined Military Hospital, Lahore, from August to November 2011. Methodology: Clinical profile and outcome of 640 adult patients hospitalized with a strong clinical suspicion of dengue fever (DF) was evaluated. Based on serological confirmation, these patients were divided into confirmed DF and probable DF cases. They were also categorized according to severity into dengue fever (DF), dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS) cases according to WHO guidelines. After detailed clinical evaluation, blood samples were taken for a complete blood count, urea, creatinine, sodium, potassium, bilirubin, alanine aminotransferase (ALT), prothrombin time (PT) and activated partial thromboplastin time (APTT). Patients were managed according to standard protocols with intravenous fluids and symptomatic treatment. SPSS 18 was used for statistical analysis of clinical data. Comparison of features among the groups was made using chi-square or t-test with significance at p < 0.05. Results: There was 359 probable DF and 281 confirmed DF cases. The development of DHF, neurological manifestations and overall mortality was more frequent in confirmed DF group. Comparison between DHF/DSS and DF cases revealed a significant difference in vomiting (p = 0.04), purpuric rash (p < 0.001), systolic blood pressure (p = 0.002), serum ALT (p < 0.001), hospital stay (p < 0.001), neurological involvement (p < 0.001) and coagulopathy (p < 0.001) between the two groups. Among 159 DHF patients, 108 (67.9%) had bleeding from gums and oral cavity, 73 (45.9%) had haemetemesis and 82 (51.5%) malaena, 41 (25.8%) had epistaxis, 12 (7.5%) developed intracranial bleeding, 18 (11%) had hematuria, 12 (7.5%) had fresh bleeding per rectum and 37 (23%) developed haemoptysis. Overall mortality was 3%, but mortality in DHF/DSS cases was 6% and 41.6% for DSS cases. Logistic regression analysis showed that abdominal pain, purpuric rash, ascites, thrombocytopenia, coagulopathy and raised ALT had a statistically significant predictability for developing DHF. Conclusion: A variety of manifestations including that abdominal pain, purpuric rash, ascites, thrombocytopenia, coagulopathy and raised ALT had a statistically significant predictability for developing DHF. A knowledge and understanging of these complictions would be useful for the management of patients if such outbreaks of DHF are encountered again.
 
Article
The aim of this study was to detect an 811 bp filaggrin (FLG) gene fragment known to carry a mutation 2282del4 which causes ichthyosis vulgaris. Seven clinically examined ichthyosis vulgaris families were included in this study. An 811 bp FLG gene fragment was targeted in the genomic DNA of all the members of the seven families by PCR amplification using known primers RPT1P7 and RPT2P1. Successful amplification of an 811 bp FLG gene fragment in all the families suggested the possible role of the 2282del4 mutation in causing ichthyosis vulgaris in Pakistani population.
 
Article
To determine the efficacy of 12 weeks therapy with conventional interferon and ribavirin in chronic hepatitis C genotype 2 and 3 naive patients. A randomized clinical trial. Postgraduate Medical Institute, Lady Reading Hospital, Peshawar, from January 2005 to October 2006. Two hundred and twenty seven patients with chronic hepatitis C genotype 2 or 3 naive patients were enrolled in the study. All the patients were started on conventional Interferon 3 MIU, S/C, three times a week plus Ribavirin 800 to 1200 mg in divided doses daily. HCV-RNA qualitative PCR was determined after 4 weeks. In case of undetected PCR, patients were randomized to Group-I (where antiviral therapy was given for 12 weeks, n=81) or Group-II (where antiviral therapy was given for 24 weeks, n=81). In case of detected PCR, patients were given 24 weeks antiviral therapy, n=65 (Group-III). HCV-RNA PCR was determined at the end of respective therapies and after 6 months later on. Efficacy was defined as number of patients who achieved Sustained Virological Response (SVR) i.e. HCV-RNA PCR remained undetected 6 months after the end of antiviral therapy. SVR was achieved in 66 patients (81.48%) in Group-I, 64 patients (79.01%) in Group-II, and 49 patients (75.35%) in Group-III. SVR rate was better in genotype 2 than genotype 3 in all the three groups (p=0.031, OR = 1.52). Conventional Interferon and Ribavirin combination therapy remains an effective therapy in chronic hepatitis genotype 2 and 3 naive patients in our region. Determination of HCV-RNA qualitative PCR at 4 weeks seems to be an important predictor of SVR and should be used to tailor antiviral therapy to 12 or 24 weeks.
 
Article
The effect of month of Ramadan on the mortality in hemodialysis patients, and to compare it with that in all other Islamic months. A descriptive study. Hemodialysis Unit, The Kidney Center, Karachi, from January 1989 to December 2012. All those patients who were diagnosed to have end stage kidney disease and on maintenance hemodialysis for more than 3 months, regardless of underlying cause of kidney failure were included. Patients with acute kidney injury were excluded. Status of the patients was recorded at the end of the study period. The fasting status of the patients was not mentioned. The deaths of the patients were further evaluated and frequencies of death in all twelve Islamic months were calculated. A total of 1,841 patients were registered, out of whom 897 (48.7%) died, and 269 (14.6%) survived till the end of the study. One thousand and fifty six (57.3%) were males, 651 (35.4%) were diabetic. Total number of 143 (7.76%) events occurred in Ramadan, out of which 94 patients died which make nearly 11% of the total deaths distributed in 12 Islamic months. Frequency of death was higher in Ramadan when compared with other months. Ramadan reflected a higher frequency of death. Therefore, there is a need to evaluate the risk factors in a prospective study so that the dialysis patients can be better managed during this period.
 
Article
To determine association between patient's symptoms and incidence of arrhythmia on 24-hour electrocardiographic Holter monitoring. A cross-sectional descriptive study. The Cardiology Department, Liaquat National Hospital, Karachi, from January to June 2007. Patients above 15 years of age, of either gender, referred for Holter monitoring with symptoms of palpitations, dizziness and syncope were evaluated for arrhythmia. The symptoms were documented by the patients in their symptom diaries (historical logs) during Holter monitoring. Patients who had permanent pacemaker implants were excluded. Descriptive statistics were used to calculate the frequencies and percentages of different symptoms, different arrhythmias were noted on Holter monitoring and the age of patients was noted. Chi-square test was applied to calculate p-values with significant at value less than 0.05. The mean age of patients was 53.71 +/- 15.52 years. There were 54% females and 46% males. Eighty two percent had documented arrhythmias on their Holter monitoring reports. The complaints for which patients were referred included dizziness in 24%, palpitations in 61% and syncope in 15%. On analysis of the historical logs of patients only 64% had symptoms during Holter monitoring and 23% had concurrence of their symptoms with an arrhythmia. Patients who had sinus exit block (p=0.02) and sinus arrest (p=0.002) had significant association with arrhythmia. Twenty percent patients with dizziness, 50% patients with palpitations and 12% of patients who presented with syncope had documented arrhythmias. Twenty four hour Holter monitoring is an important investigation for evaluation of patients with palpitation, dizziness and syncope. Arrhythmias were detected frequently in both symptomatic and asymptomatic patients. One must be careful to avoid attributing a symptom to an arrhythmia until a close temporal relationship is demonstrated.
 
Article
To determine the changes produced in serum 25OHD and iPTH levels after 600,000 IU of injection cholecalciferol in volunteers. Interventional study. Section of Chemical Pathology, Department of Pathology and Microbiology, the Aga Khan University Hospital, Karachi, from June 2009 - June 2010. Volunteers of either gender aged 18-40 years with known 25OHD, calcium (Ca), creatinine (Cr) and phosphorous (P) levels were included in the study. Subjects on therapy like vitamin D and calcium supplements, corticosteroids or anti-epileptic medicines, primary hyperparathyroidism and hypercalcaemia, with co-morbidity like renal failure, liver disease and history of malabsorption, diarrhea or hyperthyroidism were excluded. All volunteers were given an intramuscular injection of vitamin D3 (cholecalciferol, 600,000 IU). After 8 weeks, serum 25OHD, iPTH, Ca and P levels were determined again. For 25OHD level, cut-off of ² 50 nmol/l was defined as deficient, 50-75 nmol/l as insufficient and ³ 75 as optimal level. Mean 25OHD and iPTH levels were 35.06 ± 16.6 nmol/l and 81.15 ± 76.78 pg/ml respectively at baseline. Seventeen volunteers were 25OHD deficient. Five had high iPTH levels (25%) (mean 156 ± 123.7 pg/ml). 25OHD and iPTH showed a significant inverse correlation at baseline (< 0.01). After 8 weeks of injection vitamin D 25OHD levels became optimal in 6 subjects (35%) [mean 92.9 ± 16.6 nmol/l]. It remained low in 5 volunteers (25%) [mean 41.6 ± 9.6 nmol/l] while insufficient levels were seen in 9 volunteers (40%) [mean 63.3±5.8 nmol/l]. Follow-up mean Ca, P and iPTH were 2.25 mmol/l (± 0.09), 1.1 (± 0.1) and 47.52 pg/ml (± 22.56) respectively. A significant increase in mean 25OHD level was seen at follow-up (p < 0.01), while the change in PTH was insignificant (p=0.05). Single mega-dose of cholecalciferol achieved optimal levels of 25OHD in 35% of subjects after eight weeks of supplementation.
 
Article
Objective: To determine the threshold photodynamic therapy parameters, required for choroidal vessel closure, with the photosensitizer, Lambda 27, in Dutch belted rabbits, using fluorescein angiography and histopathology. Design: A pre-clinical experiment. Place and duration of study: Department of Ophthalmology at the Tulane University Health Sciences Center, between June 2001 - July 2002. Patients and methods: Dutch belted rabbits were divided into two groups. The first group was injected intravenously with an aqueous solution of Lambda 27 at 1mg/kg. Saline was injected intravenously into the second group (controls). Approximately 5 minutes after injection of Lambda 27, a diode laser, mounted on Zeiss 30 SL-M slit lamp, emitting light at a wavelength of 719 nm was used to apply photodynamic therapy to the fundus. Lesions were placed on the choroid of the rabbits at a fixed spot size of 1.5 mm, using powers ranging from 50 to 120 mW, for a duration of 5 to 80 seconds. Choroidal vessel closure was documented by fluorescein angiography, the following day, and by light microscopy, after the animals were sacrificed. Results: Choroidal vessel closure was documented using fluorescein angiography for all of the lesions placed at fluence of 22.7 J/cm2 and above. Histopathology also confirmed this finding. No choroidal vessel closure was seen in the rabbits treated with fluences less than 22.7 J/cm2 or in the control group. Conclusion: This experiment establishes threshold parameters for choroidal vessel closure using the photosensitizer, Lambda 27.
 
Article
To compare the side effects, cost, end treatment response (ETR) and Sustained viral response (SVR) with combination therapy of either interferon alpha 2a or 2b in combination with Ribavarin. Randomized Control Clinical Trial (RCCT). The study was conducted at Sarwar Zuberi Liver Centre (SZLC), Civil Hospital Karachi (CHK), from May 2004 to July 2009. Patients positive for qualitative HCV ribonucleic acid (RNA) by Polymerase chain reaction (PCR) and genotype 3 were included. Patients with decompensated cirrhosis, severe depressive illness, autoimmune hepatitis, hyperthyroidism, pregnancy, heart failure, uncontrolled diabetes, obstructive pulmonary disease, children less than three years and patients who had previously received treatment were excluded. Single blind randomization using computerized randomization list was done and patients divided into groups A and B, those requiring treatment were given injection Interferon 3 million units (MU) subcutaneously (SC) three times/week and Ribavarin 1000 mg per day (weight ≤ 75kg) and 1200 mg/day (weight > 75kg) orally with either interferon alpha 2a (group A; FDA approved products) or alpha 2b (group B; non FDA approved product). Demographics, side effects, ETR and SVR were noted. ETR was defined as absence of virus at the end of treatment and SVR was taken as absence of HCV RNA at 6 months after completion of treatment. There were a total 310 patients with mean age of 34.07 +/- 9.38 years including 52.4% males, (n=162). Majority of the patients were from North Pakistan. There were 155 patients each in group A and group B respectively. The cost of treatment for interferon alpha for a single patient for 6 months was Rs 60,000, while for Interferon alpha 2b was Rs 30,000. Side effects (fever initially, followed by fatigue, headache, musculoskeletal pain, depression, alopecia, insomnia, and anorexia) were more prominent in group B when compared with group A. In group A, ETR was 83.8% (130/155) while in group B was 83.2% (129/155). While SVR available in group A was 61/70 (87.1%) and in group B was 60/72 (83.3%). Response to combination therapy for HCV was 83%. ETR and SVR were similar for both interferon alpha 2a and 2b. Side effects though minor are more with alpha 2b (non FDA approved products).
 
Article
Cystic fibrosis is a multi-system genetic disorder caused by mutation in the cystic fibrosis conductance transmembrane regulator (CFTR) gene located on chromosome 7. In United Arab Emirates (UAE), pattern of CF causing gene mutations is different than rest of the Arabs in the region and 95% of CF in Emirati families has been found due to two mutations only - -p.S549R(T>G) and p.F508del. We report the case of a homozygote for a mutation 3120 +1G-->A in the Emirati population detected in a young boy referred to CF and Respiratory Clinic at Tawam Hospital (Al Ain, UAE) for screening CFTR gene.
 
Article
We report a case of bilateral loss of pupillary light reflex and accommodation following 360° peripheral retinal laser therapy. A 24 years old male underwent prophylactic laser barrage for peripheral retinal lattice degenerations. Soon after the procedure, he developed bilateral loss of pupillary light reflex and accommodation. The patient faced difficulty while doing near work. On instillation of 0.125% pilocarpine, both pupils demonstrated the phenomenon of denervation supersensitivity. Damage to the short ciliary nerves was the most likely mechanism responsible for this adverse outcome.
 
Article
Aspiration of foreign bodies into the tracheobronchial tree is extremely rare in adults without an underlying predisposing factor. A high index of suspicion is the most important factor leading to a diagnosis of tracheobronchial foreign body aspiration. Unless the patients give a clear history of aspiration, a foreign body may remain occult for years. To our knowledge, the longest bronchial foreign body retention in an adult recorded in English literature is 40 years. We present a case of coexisting pulmonary tuberculosis and unsuspected foreign body which remained in the bronchus of an adult for 42 years before the diagnosis.
 
Article
Giant cell tumour is a locally aggressive tumour of long-bones of epiphyseal region commonly occurring in adults aged 20 - 40 years. Most common location is distal femur, proximal tibia and distal radius. Different treatment options being used are curettage with bone graft or bone cement, resection with arthrodesis, reconstruction, radiation and chemotherapy. We are reporting a case of giant cell tumour of proximal radius in a 48 years old lady. It is very rare and only 4 cases have been reported in literature. It was treated by wide margin resection without reconstruction.
 
Article
In routine coronary angiography, bifurcation lesion is not uncommon. Current practice of dealing with type 4a coronary bifurcation lesions (lesions of main branch without significant lesions of the side branch) may lead to true bifurcation lesions after stenting due to axial plaque redistribution. This series describes an experience with Greek technique for treatment of type 4a bifurcation lesions in 18 patients for primary stenting of main vessel with simultaneous kissing balloon of side branch in an effort to avoid snow plough effect.
 
Article
ABO iso-immunization is the most frequent haemolytic disease of the newborn. Treatment depends on the total serum bilirubin level, which may increase very rapidly in the first 48 hours of life in cases of haemolytic disease of the newborn. Phototherapy and, in severe cases, exchange transfusion are used to prevent hyperbilirubinaemic encephalopathy. Intravenous immunoglobulins (IVIG) are used to reduce exchange transfusion. Herein, we present a female newborn who was admitted to the NICU because of ABO immune haemolytic disease. After two courses of 1 g/kg of IVIG infusion, she developed necrotizing enterocolitis (NEC). Administration of IVIG to newborns with significant hyperbilirubinaemia due to ABO haemolytic disease should be cautiously administered and followed for complications.
 
Article
To identify the criteria for performing a spinal tap in neonates with suspected sepsis and compare the findings in infants under and over the age of 72 hours. Analytical. Neonatal Ward of Taleghani Medical Centre, Shaheed Beheshti University of Medical Sciences, Evin,Tehran. Study period was of one year, from March 2003 to February 2004. All newborns subjected to a lumbar puncture during the first 24 hours of admission were enrolled in the study. Results of cerebrospinal fluid analysis were scrutinized. There were 380 neonates in the study. Majority i.e. 248 infants were aged<72 hours. Meningitis was diagnosed in 22 cases, (5.8%). There was no significant difference in the incidence of meningitis between neonates under and over 72 hours of age, (6.9% vs. 3.8%, p-value>0.5). Comparison of risk factors, clinical manifestations, and routine laboratory investigations revealed no significant difference in babies with or without meningitis. The findings of this series do not support a selective approach for performing a lumbar puncture in a possibly septic newborn. A lumbar puncture is recommended in all neonates with suspected sepsis regardless of age, risk factors, or specific neurological manifestations.
 
Article
To compare the efficacy of storage of amniotic membrane at -20 and -80 degrees centigrade. Interventional quasi-experimental study. Department of Ophthalmology, Unit 1, Dow University of Health Sciences and Civil Hospital, Karachi, from January 2009 to December 2010. Amniotic membrane was obtained from patients undergoing elective Caesarean section screened for HIV, Hepatitis B and C and gave informed consent. It was washed with solutions containing benzyl penicillin, streptomycin and amphotericin B and frozen at -20 degrees centigrade for upto 6 weeks or at -80 degrees centigrade for upto 6 months. Fisher's exact test was used to check significance. P-value less than 0.05 was considered as significant. Amniotic membrane was stored at -20 degrees centigrade on four occasions and was used in 25 (48.07%) patients. On 3 other occasions it was stored at -80 degrees centigrade and was successfully used in 27 (51.92%) patients. The association between different degrees of storage of graft and type of cases is insignificant (p = 0.99). Compared to use of fresh amniotic membrane use of amniotic membrane stored at -20 and -80 degrees is safe and cost effective. It also excludes the chances of disease transmission. Although freezing at both temperatures is equally efficacious, freezing at -80 degrees centigrade can preserve the graft upto 6 months compared to -20 degrees centigrade which can be used only for 6 weeks.
 
Top-cited authors
Nasir Khokhar
  • Shifa International Hospitals Ltd.
Sahibzada Nasir Mansoor
  • Armed Forces Institute of Rehabilitation Medicine AFIRM, Rawalpindi,Pakistan
Farooq Azam Rathore
  • Armed Forces Institute of Rehabilitation Medicine
Muhammad Omar Qureshi
  • Shifa International Hospitals Ltd.
Fareeha Farooq
  • Riphah International University