Radiological presentation of post primary tuberculosis in adult sputum smear positive patients

Background: Pulmonary Tuberculosis [TB] is traditionally classified into primary and post primary tuberculosis; both have distinct characteristics on radiology. Adetailed knowledge of different radiological patterns is helpful in diagnosis of TB

Objective: To determine the frequency of various radiological presentation of post primary tuberculosis in adult sputum smear positive patients

Methodology: This cross sectional study was carried out at Department of Pulmonology, Sheikh Zayed Medical College / Hospital, Rahim Yar Khan on adult sputum smear positive pulmonary TB patients. A total of 250 new cases of pulmonary TB with no previous history of Anti-Tuberculosis treatment were included in this study. Socio demographic data and findings of X -ray Chest from each sputum smear positive patient were collected and recorded on a predesigned performa. The data was entered and analyzed by using SPSS version 17

Result: Out of 250 patients, 146 were male and 104 were female with mean age of 35.76 +/- 16.25 years. Left lung was most affected in 40.4% cases, right lung in 35.6%, while 24% has bilateral involvement. Duration of illness prior to diagnosis was 3 +/- 1.66 months. Among the radiological presentation, cavitation was seen in 49.2% cases, alveolar consolidation in 42.4%, nodular pattern in 3.2%, reticulonodular pattern in 3.2% and reticular pattern in 2% cases. There was significant association of alveolar consolidation with male gender [0.03] while reticulonodular pattern was significantly seen in female gender [0.007]. Majority of the patients were young; 42.8% were below the age of 30 years and 82% patients were below the age of 50 years and there was a delay of > 03 months in the diagnosis

Conclusion: According to this study, cavitations and alveolar consolidation were the commonest radiological presentations of post primary TB. Majority of patients were young and there was a considerable delay in diagnosis

Prevalence of resistance to 1[st] line anti tuberculosis drugs at Rahim Yar Khan

Background: tuberculosis is an important infectious health issue and its control strongly rely upon effective treatment. The drug resistance and its pattern are important determinant of the treatment regimen, its duration and outcome

Objective: to determine the frequency and pattern of drug resistance among 1[st] line anti tuberculosis treatment

Methodology: it was a cross sectional study carried on 100 cases of smear positive TB. This study was conducted from 1[st] January 2010 to 30 June 2011. Detailed demographic data and history of ATT was taken and their sputa were sent for drug susceptibility testing on LJ media. The cases with drug resistance and no previous history of ATT were labeled as primary while those with previous history of ATT were labeled as secondary resistant cases. The data was entered and analyzed by using SPSS version 15

Results: out of 100 patients enrolled, drug susceptibility report was available for 87 isolates as sputum failed to grow any organism in 13 patients. Out of these 87 cases, 48 [55.17%] were males and 39 [44.83%] females with age range of 9-91 years. Seventeen out of 87 patients [19.5%] had previous history of ATT. Out of 87 isolate, 62 [71.26%] were sensitive to all 1[st] line drugs [R, H, E, Z, S] while 25 [28.74%] were resistant to one or more drugs. Primary resistance was seen in 17 [24%] out of 70 cases in contrast to secondary in 8 [47%] out 17. The difference between primary and secondary resistance among various drugs was statistically significant for isoniazid [p value 0.003] and pyrazinamide [p value 0.036] while the difference to streptomycin, ethambutol and rifampicin was insignificant with p values of 0.20, 0.35 and 0.09 respectively. There was no case of primary MDR-TB and 5.9% of secondary MDR-TB. None of the sociodemographic parameter was significantly associated with drug resistance

Conclusion: resistance to 1[st] line anti-tuberculosis drugs at Rahim Yar Khan is still common. There are good number of patients in which this resistance pattern compromise the currently recommended regimens. However, larger surveillance studies are needed to strengthen this evidence

Susceptibility pattern of 2[nd] line anti tuberculosis drugs at Rahim Yar Khan

Background: Pakistan has a high burden of drug resistant TB. Effective management of these cases needs the inclusion of 2[nd] line anti-tuberculosis drugs. A comprehensive knowledge of susceptibility pattern to these drugs is mandatory to formulate the best possible regimen

Objective: to determine the susceptibility pattern of 2[nd] line anti tuberculosis drugs

Methodology: this cross sectional study was carried out at Department of Pulmonology, Sheikh Zayed Medical College / Hospital, Rahim Yar Khan on smear positive cases of PTB. This study was conducted from 1[st] March 2010 to 30[th] April 2011. A total of 64 smear positive tuberculosis patients of any age and sex regardless of previous treatment with 1[st] line ATT and no history of prior exposure to 2[nd] line ATT were included. Sociodemographic data like age, sex, marital status and income were recorded. Early morning sputum samples were cultured on LJ medium at a reference lab. Drug susceptibility testing [DST] was done for ethionamide, amikacin, kanamycin, capreomycin and ofloxacin to determine the presence of resistance. The data was analyzed on SPSS version 15

Results: in this study, out of total 64 cases, 36 [56.25%] were males and 28 [43.75%] females with age range of 9 to 76 years. Thirteen cases [20.31%] had previous exposure to 1[st] line ATT. Twelve [18.8%] were resistant to one or more drugs. Resistance was highest for ofloxacin [14.1%] followed by ethionamide [6.3%], capreomycin [3.1%], amikacin [1.6%] and kanamycin [1.6%]. Sociodemographic characteristics also did not show any statistically significant association with drug resistance

Conclusion: there is high frequency of resistance to ofloxacin and ethionamide. To avoid addition of further resistance, DST should be available as early as possible by conventional methods or by rapid genotypic methods at the start of treatment

Early intervention in psychosis [EIP] services, UK: a critical analysis of the evidence

The UK mental health reforms have attracted major government funding. This has been used to commission specialized community teams for people with severe mental illness. The reforms include changes to services for first-episode psychosis, which have gained huge consumer support. The UK service reforms are continuing, with the aim of providing services fit for the 21st century. In this article, we have reviewed the evidence which led to the establishment of early intervention services in the UK by using a selected review methodology. The review includes the historical background to EIP [Early Intervention in psychosis], what is EIP, where it originated from, what was the evidence leading stake holders to push the government to incorporate it in the National Health Policy. What policy reforms took place, and how the government went about implementing these services. We have discussed the current situation of the service. Furthermore we have discussed the gaps in the policy which have been identified. We end the paper with recommendations to policy makers

Which antipsychotics would mental health professionals from a low income country choose for themselves?

To determine which antipsychotics mental health professionals from a low income country would choose for themselves. Cross-sectional study. This study was conducted in 8 cities in Pakistan from February to August 2008. Responses from 268 mental health professionals, including psychiatrists and nurses were obtained using a semi-structured questionnaire. All together 80% of doctors chose an atypical antipsychotic; risperidone was the most popular choice. Half of nurses did not know which antipsychotic to choose and the remaining chose haloperidol [21%] and risperidone [19%]. Efficacy and safety were the two most important factors influencing their decision. Both doctors and nurses in Pakistan considered efficacy and safety/tolerability to be important factors for choosing an antipsychotic; this is in line with National Institute of Clinical Excellence [NICE] guidelines 2009. Mental health training for nurses was identified as a major service deficiency

Primary perisplenic hydatid cyst

Splenic parasitic cysts due to flat worm Ecbinococi resuling in hydatid disease are a rare presentation as primary site even in the endemic regions. Primary splenic parasitic cysts have an incidence of 0.5-4%. A 21-year-old male with pet dogs at home, presented with 3 months history of gradually increasing discomfort in the left hypochondrium and tender splenomegaly. He had marked eosinophilia with normal liver function tests and positive serum IgM Echinococcus antibodies. Ultrasonography showed a cyst in the hilar region of spleen having septations with internal echos. An upper midline laparotomy was performed and a perisplenic cyst was removed along with spleen from the sub-diaphragmatic location. Histopathological examination confirmed acellular fibrous wall of hydatid cyst with germinal layer and scolices in the centre. Postoperatively, patient was continued on oral Albendazole for one month

Open extraperitoneal mesh repair for abdominal wall hernias in females

To determine the outcome of treatment in terms of infection and recurrence using open extraperitoneal mesh repair technique. Quasi-experimental study. The department of General Surgery, Combined Military Hospital, Bahawal Nagar Cantonment, from February 2006 to November 2008. Female patients with abdominal wall hernias with defect of 4 cm or more were studied. A history of previous surgery along with clinical findings on examination like size of defect and previous scar were noted. At surgery, hernial sacs were carefully opened and omental and intestinal adhesions were carefully separated. Polypropylene mesh was placed over extraperitoneal space and secured with interrupted vicryl 2/0 sutures. Redivac drains were placed over the mesh and the fascial repair. The patients were discharged on the 3rd - 4th postoperative day and were followed-up at 3 monthly intervals for postoperative sequelae like seroma, haematoma, infection and recurrence. There were 32 cases with a mean age of 41.25 +/- 10.79 years. The mean follow-up period was 15.78 +/- 9.02 months. Previous abdominal surgical intervention was found in 16 [50%] cases. Out of those, 14 [43.7%] had defects through the previous scar. A history of multiple caesarean sections alone, or in combination with either hysterectomy or laparotomy in the last 5 years was present in 7 patients. There were 12 [37.5%] cases of paraumbilical hernia, 4 [12.5%] of a recurrent paraumbilical hernia, 5 [15.6%] epigastric hernia, 2 [6.2%] mix hernia, 7 [21.8%] incisional hernia and 1 [3.1%] each of Spigelian hernia and postlaparoscopic cholecystectomy portal [paraumbilical] hernia. The mean size of the defect was 4.9 cm in primary paraumbilical hernias and 7.2 cm in recurrent paraumbilical hernias. The mean size of the defect in incisional hernias was 9.4 cm, larger than all other types. Superficial wound infection was seen in only 1 morbidly obese [BMI > 30] patient. No case of seroma, haematoma, deep seated abscess or recurrence was noted in the follow-up period. Abdominal wall hernias are common in female patients, especially those with previous surgical intervention. Open extraperitoneal mesh repair with placement of redivac drains is an effective method for the management of abdominal wall hernias with a smaller complication rate and less recurrence

Ruptured ovarian teratoma presenting as peritonitis

A 55-year-old lady reported to the surgical OPD with clinical findings of acute peritonitis. Emergency laparotomy was performed. The peritoneal cavity was full of purulent material, however, the gut was normal. An 8 x 6 cm thick walled cyst was found in the left ovary with a minute perforation and purulent fluid coming out of it. Thorough peritoneal lavage along with left oophorectomy was performed. The postoperative recovery was smooth. Histopathology confirmed benign cystic teratoma of ovary

Acute acalculous perforated cholecystitis

A case of acute acalculous perforated cholecystitis with acute generalized peritonitis in a middle aged cachectic man, presenting late in a moribund condition, is reported. He underwent emergency laparotomy [subtotal cholecystectomy], went into multi-organ failure and was managed accordingly. The patient recovered in about 2 weeks and was followed-up regularly

Pierre Robin sequence as birth asphyxia in a new born

A new born baby boy presented with birth asphyxia and respiratory distress. He went into cardiac arrest twice but was resuscitated. On detailed evaluation, he had low set ears and micrognathia with glossoptosis consistent with features of Pierre Robin sequence. Episodes of apnoea disappeared, on nursing, the baby in prone position and later on tongue-lip retention suture were applied. Prompt diagnosis and efficient airway management by following the principles of airway resuscitation can save the lives of such babies without specialized care

Prevalence of functional GI disorder in the adult population of Arafat town, Karachi

To find out the prevalence of functional gastrointestinal disorders in the adult population of a low socioeconomic community in Pakistani population. A sample of 500 adult individuals was selected through a simple random sampling technique using simple random table. The Study conducted in 2004 based on a questionnaire comprising of 38 close ended questions as per ROME II criteria. The diagnosis established through the same criterion after analyzing the data on SPSS 10.0. The Study on 500 individuals revealed that a major proportion of the studied population 80.2% [401/500] were having one or more than one functional gastrointestinal disorders ranging from mild to server conditions, while only 19.8% [99/500] of them were free from any disorder. Out of these diseased individuals, the majority 77.8% [312/401] suffering from Multiple Gastrointestinal Symptoms, while 22.2% [89/401] were with that of Single Gastrointestinal Symptoms. Functional gastrointestinal disorders are prevalent in our community. These disorders found in individuals are of both Single and Multiple in nature. Although these are not fatal but may cause discomfort ranging from inconvenience to deep personal distress which may lead to great decline in their quality of life

Cholecysto-hydatid cyst fistula

We present a case of recurrent hydatid cyst liver in a 32-year-old female. Previous surgery was performed 8 years ago elsewhere. Pre-operative assessment at presentation revealed a 110 x 105 mm hydatid cyst in the right lobe of the liver. On exploration, a 5 mm fistulous communication was found between the hydatid cyst and the gallbladder. Patient was subjected to endocystectomy [partial cystectomy], cholecystectomy and closure of the fistula followed by obliteration of the cavity with omentum. Postoperative recovery was uneventful

Retroperitoneal masses: different clinical scenarios

We present two cases of retroperitoneal masses with different presentations and outcomes. The first case was a 22 years old primigravida lady who underwent emergency caesarean section for preterm premature rupture of membranes with breach. On the operating table, a large retroperitoneal mass was identified and the biopsy confirmed Burkitt's lymphoma. Post operative chemotherapy did not have a favourable result and the patient had a fatal outcome. The other case was a 15 years old boy who had a progressively increasing retroperitoneal mass. Exploratory laparotomy revealed a hard, fixed, unresectable tumour extending into the mesentery of the small gut, biopsies were taken which showed tuberculosis. Post operative antituberculosis treatment had a marked response and the tumour disappeared after 6 months