The Potential Role of Nitric Oxide in Halting Cancer Progression Through Chemoprevention

Nitric oxide (NO) in general plays a beneficial physiological role as a vasorelaxant and the role of NO is decided by its concentration present in physiological environments. NO either facilitates cancer-promoting characters or act as an anti-cancer agent. The dilemma in this regard still remains unanswered. This review summarizes the recent information on NO and its role in carcinogenesis and tumor progression, as well as dietary chemopreventive agents which have NO-modulating properties with safe cytotoxic profile. Understanding the molecular mechanisms and cross-talk modulating NO effect by these chemopreventive agents can allow us to develop better therapeutic strategies for cancer treatment.

Hospital waste management tackling trash as a team

Clinical waste is a major source of infection amongst patients, hospital workers and the community. The Hospital Waste Management committee established in Dr. Ziauddin Hospital has active involvement of Nursing, Housekeeping and Infection Control departments. This multifaceted approach has brought about changes in the form of educational campaigns, involving training sessions and informational posters to improve awareness among hospital workers. This not only decreases the number of injuries and accidents occurring in relation to clinical waste disposal, but proper disposal of hazardous waste is beneficial for the community and the environment we live in. The first step is to target the areas which need the most attention and then to develop a tailor-made plan focusing on the major problems. Effective communication and teamwork help control the issue from all different angles and provide a pro-active approach to improve the waste management facilities of the hospital and serve the community as a whole

Inducible clindamycin resistance in staphylococcus species

To determine the frequency of inducible clindamycin resistance in clinical isolates of Staphylococcus species by phenotypic D-test. Observational study. Ziauddin University Hospital, Karachi, from July to December 2011. Consecutive clinical isolates of Staphylococcus species were collected and identified by conventional microbiological techniques. Antimicrobial susceptibility testing and inducible clindamycin resistance was carried out by performing D-test using CLSI criteria. Methicillin resistance was detected by using Cefoxitin disk as a surrogate marker. Statistical analysis was performed by SPSS version-17. A total of 667 clinical isolates of Staphylococcus species were obtained during the study period. In these isolates, 177 [26.5%] were Staphylococcus aureus, and 490 [73.5%] were coagulase negative Staphylococci. The total frequency of inducible clindamycin resistance among isolates of Staphylococcus species was 120/667 [18%]. Frequency of inducible clindamycin resistance among coagulase negative Staphylococci group and Staphylococcus aureus group were 18.57% and 16.38% respectively. Median age of patients in D-test positive group was 19.5 [1 - 54] years. The frequency of inducible clindamycin resistance among Staphylococcus species may differ in different hospital setup. Clinical microbiology laboratories should implement testing simple and effective D-test on all Staphylococcus species. D-test positive isolates should be reported clindamycin resistant to decrease treatment failure

Fatal primary meningoencephalitis caused by naegleria fowleri

Naegleria fowleri is a free living parasite which habitats in fresh water reservoirs. It causes a fatal nervous system infection known as primary amoebic meningoencephalitis by invading through cribriform plate of nose and gaining entry into brain. We report a case of primary amoebic meningoencephalitis caused by Naegleria fowleri in Karachi, Pakistan, in a 42 years old male poultry farm worker having no history of swimming. Clinical course was fulminant and death occurred within one week of hospital admission. Naegleria fowleri was detected by wet mount technique in the sample of cerebrospinal fluid collected by lumbar puncture of patient. This is a serious problem and requires immediate steps to prevent general population to get affected by this lethal neurological infection

Diagnostic cut-off levels of plasma brain natriuretic peptide to distinguish left ventricular failure in emergency setting

To determine the diagnostic cut-off values of brain natriuretic [BMP] peptide to establish left ventricular failure in patients presenting with dyspnoea in emergency department. Descriptive study. Ziauddin University Hospital, Karachi, from July to December 2011. BMP estimation was done on Axysm analyzer with kit provided by Abbott diagnostics, while the Doppler echocardiography was done on Toshiba istyle [UICW-660A] using 2.5 MHz and 5.0 MHz probes. Log transformation was done to normalize the original BNP values. A receiver operating curve was plotted to determine the diagnostic cut-off value of BNP which can be used to distinguish CHF from other causes of dyspnoea. Statistical analysis was performed by SPSS version 17. A total of 92 patients presenting with dyspnoea in the emergency department were studied. There were 38/92 [41.3%] males and 54/92 [58.7%] females, and the average age of the study population was 64 +/- 14.1 years. These patients had BNP levels and Doppler echocardiography done. The average BNP was found to be 1117.78 +/- 1445.74 pg/ml. In log transformation, the average was found to be 2.72 +/- 0.58. BNP value of 531 pg/ml was found to be the cut off to distinguish between cardiogenic and non-cardiogenic causes of dyspnoea. BNP value of 531 pg/ml can distinguish CHF from other conditions as a cause of dyspnoea in emergency

Correlation of fine needle aspiration cytology, smear and culture in tuberculous lymphadenitis: a retrospective study

Tuberculous lymphadenitis is the commonest form of extrapulmonary tuberculosis. Fine needle aspiration cytology [FNAC] is a simple out-patient diagnostic procedure used for the diagnosis of tuberculous lymphadenitis. Over the last two decades, fine needle aspiration cytology has emerged as a simple outpatient diagnostic procedure for the evaluation of tuberculous lymphadenitis. This has replaced excision biopsy of lymph node. In this study, FNAC was complemented with smear examination and culture for AFB. It was observed that out of the 100 reported cases of tuberculosis on FNAC direct smear positivity on ZN staining was 3/100[3%]. After the inoculation of residual aspirated material on LJ medium the culture yield was 27/100[27%]. Thus FNAC had greater diagnostic efficacy, proved to be a rapid, less time consuming and non-invasive screening test for evaluation of tuberculous lymphadenitis

Settings and Design: A retrospective laboratory based study at, Meezan lab Faisalabad. Material and Methods: 100 patients of lymphadenitis which were diagnosed as cases of granulomatous inflammation on FNAC were included in this study. These cases were reported on cytology by using the Giemsa stain, H and E stain, Gram and Ziehl Neelsen stain. After the smear preparation the part of left over aspirated material was inoculated on LJ medium and were reported on the basis of morphological features by concerned microbiologist

Results: Out of these 100 selected reported cases of tuberculous lymphadenitis culture revealed growth of Mycobacterium on 27 of them. While direct microscopic examination of the ZN stained smears from these aspirates revealed the presence of AFB in only 3 out of 100 cases

Bacteremia due to aeromonas hydrophila in acute lymphoblastic leukemia

Aeromonas hydrophila [A. hydrophila] is a low virulent organism but may cause devastating fatal infections in immunocompromised host especially in liver cirrhosis. It is rarely reported to cause septicemia in a patient with Acute Lymphoblastic Leukemia [ALL]. The mortality rate of septicemia due to A. hydrophila is 29% to 73%. We report a case of 59-year-old female patient who was a known case of ALL, presented with the complaints of fever, lethargy and generalized weakness for one month. After taking blood samples for investigations, empirical antimicrobial therapy was started. She did not improve after 48 hours of therapy. Meanwhile blood culture revealed pure growth of A. hydrophila. After sensitivity report was available, ciprofloxacin was started. Patient became afebrile after 48 hours of treatment with ciprofloxacin. It is very vital to correctly identified and treat bacteremia due to A. hydrophila especially in the underlying leukemic patient.

Non parasitic splenic cyst: a case report

Primary splenic cyst is a rare entity and majority of the cases are classified as epithelial cysts. They are uncommon, comprising only about 10% of benign non-parasitic cysts. Most of the cysts are asymptomatic, and they are incidental findings during abdominal ultrasonography. We report a case of 20 years old male who presented with 1 year history of mild abdominal pain and left upper quadrant fullness. Ultrasound and computed tomography [CT] both were suggestive of splenic cyst. Serological tests were negative for parasitic infection. Splenectomy was done. Histopathological findings are consistent with splenic epithelial cyst

Microalbuminuria in diabetic patients and its correlation with duration of disease and glycemic control

To find out the frequency of microalbuminuria in patients with diabetes mellitus both type 1 and 2 with reference to glycemic control and duration of disease. Study was conducted at Dr. Ziauddin University Hospital North Nazimabad Campus, Karachi. Fifty seven diabetic patients of either sex were included in the study. Patient taking Angiotensin Converting Enzyme [ACE] inhibitors were excluded from the study. Out of 57 diabetic patients, 22 [38.6%] patients had HbA1c less than 7.0% and 35 [61.4%] patients had HbA1c more than 7.0%. Out of 22 patients with optimal glycemic control 8 [36.4%] had microalbuminuria, 3 [13.6%] had clinical albuminuria and 11 [50.0%] had no microalbuminuria. While out of 35 patients with poor glycemic control 10 [28.6%] had microalbuminuria, 9 [25.7%] had clinical albuminuria and 16 [45.7%] had no microalbuminuria. Out of 57 patients; 14 [24.6%] were having disease up to 5 years. Out of them 10 [71.4%] had no microalbuminuria and 4 [28.6%] had micro and clinical albuminuria. Patients with disease duration between 6-10 years were 18 [31.6%], out of which 10 [55.6%] had no microalbuminuria and 8 [44.4%] had micro and clinical albuminuria and 25 [44%] patients were having disease duration more than 10 years, out of these, 7 [28%] had no microalbuminuria and 18 [72%] had micro and clinical albuminuria. Diabetic patients with increased duration of disease are more prone to renal complication irrespective of glycemic control at the time of study. Therefore besides monitoring for their glycemic control, these patients should be monitored for development of nephropathy especially more frequently as the disease duration progresses.

Outcome of the surgical treatment of bullous lung disease: a prospective study

This study aimed at evaluating the outcome of surgery for bullous lung disease by comparing the preoperative and postoperative subjective dyspnea score, pulmonary function and clinical features. This prospective study was conducted from May 2009 to October 2011, on 54 patients operated for bullous lung disease. Follow-up at 3-6 months consisted of taking a comprehensive history, physical examination, radiological work-up, and evaluation of changes in subjective dyspnea score, arterial blood gas analysis [ABG], and pulmonary function test [PFT]. After comparison with preoperative values, the student's paired t-test was used to calculate the statistical significance. With approximately 21.6 cases per year, the most common underlying lung pathology was primary bullous lung disease, followed by COPD. The most common presenting complaint was spontaneous pneumothorax in tall young adults in their fourth decade of life with a history of smoking. Bullectomy, with or without decortication, was done for all cases. Improvement in mean PaO2 [arterial partial pressure of oxygen], SaO2 [arterial oxygen saturation] and PaCO2 [arterial partial pressure of carbon dioxide] was seen in most cases but was statistically insignificant. Improvement in mean FEV1 [forced expiratory volume in 1st second], FVC [forced vital capacity] and FEV1 / FVC was statistically significant, with FEV1 being the most reliable indicator of postoperative progress. Improvement in subjective dyspnea score was statistically significant and showed an inverse correlation with FEV1. Those with diffuse pulmonary parenchymal involvement had poorer baseline values and less significant postoperative improvement. Complications occurred more commonly in those with diffuse disease. Mortality was seen exclusively in those with diffuse disease. We conclude that surgery is required for bullous lung disease more frequently in our community since we have a high number of young patients with primary bullous lung disease and localized parenchymal involvement and these patients have a good surgical outcome. Potentially fatal complications like pneumothorax and recurrent infections can therefore be prevented in them. Those with underlying diffuse disease and severely decreased FEV1 [especially below 1 L] also benefit from surgery but require careful patient selection

Pleural empyema due to salmonella typhi

Salmonella serotypes most often produce gastroenteritis, enteric fever, bacteremia, vascular infection and chronic carrier state. Localized infection may occur at any site after Salmonella bacteremia. Pulmonary involvement due to Salmonella infection is rare. Empyema occurs usually in elderly patients or in patients with underlying diseases such as diabetes mellitus, malignancy, or pulmonary disease. We report the case of an 83-year-old male diabetic patient who presented with fever, productive cough, and difficulty in swallowing. The chest radiographs revealed soft shadowing mild atelactasis and pulmonary abscess on left side. CT-guided aspiration of pus was done. Salmonella enterica serotype typhi was isolated from pus sample. Pleural empyema or abscess usually requires surgical drainage in addition to antimicrobial therapy. After complete course of antimicrobial therapy, the patient improved

Reconstruction of contracted eyelids: outcome of different procedures of surgery

To evaluate the different procedures of the reconstruction of post traumatic eyelids contractures with regards to the functional and cosmetic results. Descriptive case series. Department of Plastic and Reconstructive Surgery at Jinnah Post Graduate Medical Centre [JPMC] Karachi, from 2003 to 2008. All patients admitted with eyelids contractures were included. A detailed history was taken. Examination of eyes were done, which included visual acuity and near vision test. Test for tear formation, staining of the cornea for any ulcer or rupture of cornea due to injury, were also performed. Priority was given to vision restoration. Culture and sensitivity of discharge from eye, if any, was also done. Patients were subjected to different surgical procedures. There were total of 30 patients with 16 males and 14 females. The age of the patients ranged from 7 years to 58 years. Excision of lesion and primary closure was done in two patients [6.6%], rotation advancement flap in two [6.6%], release and medium thickness grafting in thirteen [43.3%], release and Wolfe grafting in eight patients [26.7%] and Z plasty in five [16.7%] cases. Medium thickness skin graft is preferred in up to [3/4th] loss of eyelid thickness and primary closure is appropriate where up to 25% loss is found

Prevalence of HCV genotypes in patients reporting in tertiary health care hospital of Karachi

The present study was designed to see the variables which may affect the conventional treatment outcome by injection interferon in chronic hepatitis "C" patients. Among these variables hepatitis "C" genotype is most important, as it influences the duration and dosage of anti-viral therapy. To determine the frequency distribution of HCV genotypes, a study was conducted in a tertiary care centre of Karachi, the largest metropolitan city of Pakistan, where people of all ethnic origins are found. All the HCV positive patients, including impatient admitted in hospital and outpatients, more than 18 years of age, reported for genotyping of HCV in the clinical laboratory of Dr. Ziauddin Hospital from May 2009 to April 2010 were studied. HCV genotyping was performed on a total of 457 patients who tested positive for presence of Hepatitis "C" viral RNA. The most prevalent genotype was type 3 with 392 [85.8%] cases, followed by type 1 with 51 [11.2%] cases. There were only two cases with a co-infection of type 1 and 3, while genotype 2,4 and 5 were also seen in a few cases. Among the cases studied, there were higher proportion of females 276 [60.4%], dominating the HCV infected population. The present study revealed that genotype 3 was the most common genotype in patients with HCV infection in Karachi. Other genotypes were also present in the patients infected with HCV, but were of lesser frequency. To prevent the treatment failure it is advisable that before commencement of therapy, the genotype of the patient should be established so that appropriate treatment in correct dosage for optimal duration of time of time could be instituted

Frequency of extended spectrum beta lactamase producing enterobacteriaceae among urinary pathogen isolates

To determine the frequency of extended-spectrum beta lactamase [ESBL] producing Enterobacteriaceae in urinary isolates. Observational study. Ziauddin University Hospital, Karachi, from February to October 2008. All members of Enterobacteriaceae isolated from urinary samples of in-patients were included and identified using standard biochemical tests. Urinary samples from out-patients were excluded. Detection of ESBL was carried out by double disk diffusion technique. Statistical analysis was performed by SPSS version 10. A total of 289 isolates of Enterobacteriaceae were identified during the study period. Of those 190/289 [65.7%] of the isolates were found to be ESBL producing. ESBL positivity within individual organism group was highest in Klebsiella species 84.16%, followed by Escherichia coli 68.55%, Enterobacter species 36.84%, and Proteus mirabilis 28.55%. Mean age of patients with ESBL producing organisms was 58.69 +/- 18.97 years. ESBL production was almost similar in all age groups. A high frequency of ESBL producing organisms especially Klebsiella species and Escherichia coli amongst the hospital obtained urinary isolates was documented particularly in the older age group. The data points towards an urgent need for regular screening and surveillance for ESBL producing organisms in this region

Analysis of the prevalence of cancer in Faisalabad: a single centre study

To analyse the prevalence of different types of malignancies presenting to one centre in Faisalabad over a period of 3 years. A retrospective study. The study was conducted at Meezan Lab from January 2007 to December 2009. All the consecutive specimens presenting for histopathology were included in the study. The total number of biopsies dealt with during this period was 3926 out of which 564 were malignant. The male to female ratio was 1:1.19. The peak age for presentation was between 51-70 in males, while it was 31-50 in females. In males the top five tumours involved the lymph nodes 43[16.6%], prostate 40[15.5%], urinary bladder 28[10.8%], skin 24[9.3%] and vocal cords 16[6.2%]. Among females the most frequently seen tumours were breast 101[33.0%], skin 30[9.8%], lymph node 20[6.5%], ovary 19[6.2%] and esophagus 16[5.2%]. The incidence of malignancies appears to be on the rise. This could be due to an increased level of awareness in the patients causing them to present earlier. There is the need to set up a population based tumour registry on a national level to calculate the true incidence

Co-relation of sentinel lymph node metastases with the size of primary breast carcinoma

This is a cross-sectional study designed to explore the co-relation between the tumour size and incidence of metastases in the sentinel lymph node and was conducted at Departments of Pathology, Punjab Medical College, Faisalabad and Sheikh Zayed Hospital, Lahore and Departments of Surgery, Allied and DHQ Hospitals, Faisalabad from July 2002 - June 2003. The sentinel lymph node [SLN] was identified in 80 cases of early [T1 and T2] breast carcinoma by a localization technique using 1% Isosulphan Blue. The maximum size of the tumour was measured on gross examination and the margins were labelled with Alcian blue and fixed in Bouin's fluid. The entire tumour was embedded and the size of the tumour was confirmed on microscopic examination. Similarly the entire SLN was embedded and the microscopic measurement of tumour deposit was made in every case. The SLN was successfully isolated in 80 cases. Right sided carcinoma was seen in 52.5%. Stage T1 was seen in 37.5% and 62.5% were of stage T2. Most of the tumours [65%] were located in the upper outer quadrant. Nearly all [97.5%] were infiltrating ductal carcinomas. The microscopic measurement of the size of tumour varied between 5-70 mm and the size of the metastatic deposit of the tumour in the SLN varied from 2-22mm. It was noted that the involvement of SLN and non sentinel lymph node [NSLN] increased in relation to an increase in size of the primary tumour. The study concluded that as the size of the tumour increases, the chances ofmetastases occurring increases and thus has a linear relationship

Sentinel lymph node; lymphatic mapping in patients with breast carcinoma

To assess the efficacy of a localization technique for the sentinel lymph node in patients with early breast carcinoma using 1% isosulphan blue. Departments of Pathology, Punjab Medical College Faisalabad and Sheikh Zayed Hospital, Lahore and Departments of Surgery, Allied and DHQ Hospitals, Faisalabad from July 2002 - June 2003. 1% Isosulphan blue was used to identify the sentinel node in cases of early [T1 and T2] breast cancer. The dye was injected just before the incision was made. The area was massaged. Mastectomy was done. The sentinel node was identified by following the blue track to the first coloured lymph node. This was removed and submitted separately for histopathology along with the mastectomy specimen. The procedure was performed in 95 cases. SLN were identified in 80 [84%] patients. The mean age was 43.99 years. Majority of the tumours were located in the right breast in the upper outer quadrant. One SLN was identified in 93%, 2 in 3% and 3 were noted in 4% of the cases. Injection of 1% isosulphan blue around the tumour is an effective method for isolation of the SLN in selected cases. It saves the patient of the side effects of axillary clearance in node negative cases

Coexistence of endometrioid adenocarcinoma of the ovary and the uterus

The coexistence of carcinoma of the endometrium and ovaries is uncommon and occurs in about 10% of women with ovarian carcinoma. We are presenting such as a case with a review of the relevant literature

Acute myocardial ischemia following accidental intravenous administration of epinephrine in high concentration.

Inadvertent and accidental epinephrine overdose might result in potentially lethal complications. We present a case of acute epinephrine toxicity resulting in acute myocardial ischemia in a young boy with combined variable immunodeficiency syndrome who developed severe allergic reaction to intravenous immunoglobulin, and was subsequently given epinephrine by mistake intravenously rather than subcutaneously. He developed significant ischemic changes in standard 12-lead electrocardiogram, transiently raised cardiac enzymes, reduced left ventricular systolic function, pulmonary edema and pulmonary hemorrhage. It is suggested that special precautionary measures should be taken regarding the dose and the route while administering epinephrine to avoid mishaps.