Management of Lupus Nephritis: An Update

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease, and lupus nephritis (LN) is associated with increased morbidity and mortality. Renal biopsy is essential and the gold standard to diagnose LN. Extra-glomerular involvement is seen in up to 60% of patients with LN and is associated with poor outcomes. The revised International Society of Nephrology/Renal Pathology Society classification for LN has changed the parameters for activity index scoring, redefined crescent and highlighted the significance of extra-glomerular involvement. Repeat renal biopsy is done for resistant disease or during a flare, usually when atypical features are present or when the baseline biopsy showed non-proliferative histology. Protocol repeat biopsy may prove to be valuable as a monitoring tool in patients with LN. Newer modalities of therapy like multitargeted therapy and biological agents may pave a way for better outcomes with minimal adverse effects to the patients.

Asymptomatic urinary tract infection among diabetic patients admitted at a tertiary care hospital of Karachi

Objective To determine frequency of urinary tract infection among asymptomatic diabetics, the etiological agents, antibiotic sensitivity and the pattern of antibiotic resistance to that organism

Methodology This cross-sectional study was conducted at Taj Medical Complex, Hamdard University Hospital, and Karachi. A total of 395 patients with Diabetes Mellitus were enrolled in our study. All data were transformed in a structured Performa. All lab analysis plus Urine C/S were done with written consent from the patients. Data was maintained and analyzed on SPSS version 20

Result Among the 395 included patients, 44 % [174] were females and 56 % [221] were males. 362 were taking oral hypoglycemic agents [OHA], 9 were under insulin and 24 were taking both insulin and OHA. The mean HbA1c was 8.08 +/- 1.29. Out of 395 samples of urine C/S of asymptomatic diabetic patients, 242 samples showed growth of organisms more than 105 CFU [colony forming units]. The most common organism in 160 [66.11%] cases was E.coli. The other organisms isolated were klebsiella in 37 [15.28%] cases, staph aureus in 30 [12.4%], proteus in 7 [2.3%], enterococcus in 8 [3.3%] case. UTI was found more common in those patients who were taking oral hypoglycemic agents as compared to those who were taking insulin. E-coli- was sensitive to ciprofloxacin in 88.75%, ceftriaxone in 67.9% and imipenum in 100%. Klebsiella was 100% sensitive to ciprofloxacin. It was also 100% sensitive to imipenum. Staph aureus was sensitive to ciprofloxacin in 70%cases and 77% sensitive to ampicillin. E.coli was resistant to ampicillin, cefixime and gentamycin. Klebsiella was resistant to ceftriaxone and pimpedic acid. Staph aureus was resistant to co-trimoxazole. Proteus was resistant to imipenum in 100% cases and enterococci were resistant to amikacin in 100% cases

Conclusion The study concluded that the prevalence of UTI is higher in females as compared to males in asymptomatic diabetic patients. E.coli was the foremost etiological agent of UTI. It was also observed that the diseases incidence increases with increasing age and vice versa. Because of the frequency and severity of UTI in diabetes, prompt diagnosis and early treatment is compulsory to prevent consequent complications

clinical experience of patients with heat stroke at Karachi during a devastating heat wave in 2015

Objectives: To review the clinical presentations, management and outcomes of heat stroke patients presented to Hamdard University Hospital, Karachi in summer 2015

Study Design: Observational / descriptive study

Place and Duration of Study: This study was conducted at the Hamdard University Hospital [Taj Medical Complex], Karachi from 15[th] to 30[th] June 2015

Methods: A retrospective analysis of database of 51 patients presented with high grade fever [>1040F] and altered sensorium was performed. All data were transferred to proforma which included patient's demographic features [name, age and sex], clinical and laboratory parameters, treatment given, duration of hospital stay, outcomes [death or alive] and reasons of mortality. The SPSS version 19 was used for statistical analyses

Results: Majority of the patients [63%] were between 61-80 years of age group with mean +/- SD age was 69.24 +/- 11.28 years. Males were affected more than females [60.7% vs. 39.3% respectively]. Out of 51, 41 [80.4%] had co-morbidities and were on regular medications. The mean +/- SD Glasgow Coma Scale at the time of presentation was 10.29 +/- 4.33. The major laboratory derangements were hyponatremia [68.6%], elevated blood urea [52.9%], serum creatinine [41.2%] and alanine transferase [15.6%]. Standard treatment strategies were provided to all patients. Out of 51, 19 [37.3%] patients were expired as a result of multi-organ failure, shock, arrhythmias and rhabdomyolysis

Conclusion: Heat stroke is common in older males especially those who had co-morbidities. It carries a significant mortality due to multiorgan failure and shock

Gartland type III supracondylar fracture humerus; surgical management

Objectives: the purpose of present study is: 1. To know the results of surgical intervention of Garland type III fracture Humerus in children.2. To know the early and late complication of surgical intervention

Study Design: prospective interventional study

Setting: department of Orthopedic Unit-II, Civil Hospital Karachi

Period: February 2010 to January 2012

Methods: 200 male and female patients with Gartland type III supracondylar fracture of humerus presenting within 24 hour of injury, with age limit varying between 1- 12 years were included in our study. The anteroposterior and lateral view X-rays were taken and evaluated for displacement and angulation, medial/ lateral displacement and angulation and rotation of distal fragment. After all aseptic measures, patient under general anesthesia, through posterior approach skin was incised, subcutaneous tissue dissected along the line of incision. Triceps apponeurosis was splitted and interposed soft tissue was released and fracture reduced and fixed with K-wire on both medial and lateral sides parallel to the long axis of humerus in lateral view and an angle of 30 degree - 40 degree in A/P view. Wound closed in layers, aseptic dressing applied and well-padded back slab with elbow in appropriate angle of flexion was applied and pulses were checked. Postoperatively the hand was held elevated. Plaster of parries black slab was removed after four weeks; the wires were removed after six weeks. The follow-up ranged from 3 to 6 months. All the Data regarding patient were entered on well-designed proforma. The criteria for assessing the results were based on healing period, anatomical appearance, function and radiographic appearance

Results: excellent results according to Mitchell-Adam's criteria were observed in 60%. [120/200] cases, good results were observed in 27% [54/200] cases. Overall excellent to good results were observed in 87% of cases

Conclusion: it is concluded that outcome of surgical treatment of supracondylar fractures of humerus [Gartland type III] fixed with medial and lateral placement of k- wires were excellent to good and it achieves stable fixation. As both wires were placed under vision so risk of ulnar nerve and radial nerve injuries were decreased as compared to closed reduction and percutaneous k-wiring. As this method is techinically easy, less demanding and effective for stabilization and can be applied for patients with these fractures

Curcumin sensitizes lung adenocarcinoma cells to apoptosis via intracellular redox status mediated pathway.

The present study demonstrates that curcumin acts as pro-oxidant and sensitizes human lung adenocarcinoma epithelial cells (A549) to apoptosis via intracellular redox status mediated pathway. Results indicated that curcumin induced cell toxicity (light microscopy and MTT assay) and apoptosis (AnnexinV-FITC/PI labeling and caspase-3 activity) in these cells. These events seem to be mediated through generation of reactive oxygen species (ROS) and superoxide radicals (SOR) and enhanced levels of lipid peroxidation. These changes were accompanied by increase in oxidized glutathione (GSSG), reduced glutathione (GSH) and -glutamylcysteine synthetase (-GCS) activity, but decrease in GSH/GSSG ratio. The induction of apoptosis and decrease in GSH/GSSG ratio was also accompanied by sustained phosphorylation and activation of p38 mitogen activated protein kinase (MAPK). On the other hand, addition of N-acetyl cysteine (NAC), an antioxidant, blocked the curcumin-induced ROS production and rescued malignant cells from curcumin-induced apoptosis through caspase-3 deactivation. However, L-buthionine sulfoximine (BSO), a GSH synthesis blocking agent, further enhanced curcumin-induced ROS production and apoptosis in A549 cells. Decreased GSH/GSSG ratio seems to be a crucial factor for the activation of MAPK signaling cascade by curcumin. The study therefore, provides an insight into the molecular mechanism involved in sensitization of lung adenocarcinoma cells to apoptosis by curcumin.

Referral pattern of patients with end-stage renal disease at a public sector hospital and its impact on outcome.

Background. Late referral of patients with chronic kidney disease (CKD) to a nephrologist has been shown to be associated with greater morbidity and adverse clinical outcomes. Methods. We did a prospective cross-sectional study of 2490 consecutive, newly diagnosed patients with end-stage renal disease (ESRD) referred to the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh over 2 years. The referral pattern was classified on the basis of the interval between first visit to a nephrologist and initiation of renal replacement therapy (RRT). If the patient reported later to a nephrologist, the disease would have progressed more, and the time interval to initiation of RRT would thus be shorter. A time interval of <3 months was classified as late referral (LR), 3–12 months as intermediate referral (IR) and >12 months as early referral (ER). The demographic and clinical characteristics and co-morbid conditions were compared, and factors associated with LR and outcomes were evaluated. Results. About 75% of patients were referred late. Poor socioeconomic status, low level of education and reduced access to reimbursement of treatment costs contributed to LR. The aetiology of ESRD could not be established in a larger number of LR patients as compared to the other groups. LR patients had a higher prevalence of uraemic complications and required emergency dialysis more frequently. A higher proportion of LR patients were lost to follow up because they could not afford to continue dialysis. Early mortality was higher in the ER group than in the other groups. ER patients were older, more likely to have diabetic nephropathy and a higher burden of co-morbid conditions. They were also more likely to choose continuous ambulatory peritoneal dialysis or undergo transplantation. Only 28% of all patients continued RRT beyond 3 months. Conclusion. A large majority of patients with ESRD in India seek medical attention late, usually in advanced stages of CKD with uraemic complications. LR is more frequent in younger patients and those with non-diabetic kidney disease, and is associated with poor socioeconomic status, lack of education and poor outcomes.

Hepatotoxicity with antituberculosis drugs: the risk factors

To assess the severity and frequency of hepatotoxicity caused by different antituberculosis [ATT] drugs and to evaluate whether concurrence of risk factors influence the antituberculosis drug induced hepatotoxicity. This prospective cohort study was conducted in Medical Unit-V and OPD department of Civil Hospital Karachi from July 2004 to July 2005. A total of 339 patients diagnosed of active tuberculosis infection with normal pretreatment liver function were monitored clinically as well as biochemically. Their data were collected on proforma and patients were treated with Isonized, Rifampicin and Pyrazinamide. Duration after which derangement in function, if any, occurred and time taken for normalization was noted. Treatment was altered as needed, with exclusion of culprit drug. Finally data was analyzed by SPSS version 10.0. ATT induced hepatotoxicity was seen in 67 [19.76%] out of 339 patients. Females were more affected as compared to males [26.3% vs. 19.7%]. BMI [kg/m2] of 91% of diseased group were less than 18.5 [p<0.01] most of them were anemic having low albumin level suggestive of lean body mass. Hepatotoxicity was more severe in AFB smear positive patients. Concomitant use of alcohol, paracetamol and low serum cholesterol were proved as predisposing factors. Isoniazid [37 patients [55.21%], p<0.01] was the main culprit followed by Rifampicin [23 patients, 34.21%] and Pyrazinamide [7 patients, 10.5%]. Most of the patients [61%] developed the hepatotoxicity within two weeks of starting antituberculosis therapy with mild to moderate alteration in ALT and AST. ATT-induced hepatitis is significantly more frequent and more severe in patients with hepatotoxicity risk factors

Falciparum malaria: various presentations

This study was conducted to evaluate the modes of clinical presentations of falciparum malaria. Descriptive study. Medical Unit 5, Civil Hospital Karachi and Ankle Sria Hospital Karachi from August 2003 to December 2005. A total of 348 patients admitted with fever were screened with peripheral blood smear for malarial parasite. One hundred and twenty two patients were smear positive. One hundred and eight were positive for plasmodium falciparum, which were included in this study. Eleven patients were positive for plasmodium vivax and three patients had co-infection with plasmodium falciparum and P.vivax which were excluded. Critically ill patients were given injectible Quinine sulphate, rest of them were given either Halofantrine or Artemether orally. Out of 108 P. falciparum smear positive patients, males were 74 [68.51%] and females were 34 [31.48%]. Fever was present in all patients. Jaundice was observed in 39 [36.11%], vomiting in 32 [29.62%], abdominal pain in 23 [21.29%], altered state of consciousness in 26 [24.07%], diarrhea in 9 [8.33%], cough in 8 [7.40%] and seizures in 2 [1.85%] patients. Out of 108 patients 22 [20.37%] patients presented with cerebral malaria, 8 [7.40] with picture of respiratory tract infection, 9 [8.33%] patients presented with acute gastroenteritis, 9 [8.33%] with acute abdomen simulating the picture of acute pancreatitis but serum amylase and ultrasound abdomen excluded the diagnosis of acute pancreatitis. Six [5.55%] presented with the picture of acute hepatitis and 4 [3.70%] presented with fulminant hepatic failure with raised serum ammonia levels and hepatocellular jaundice with negative viral markers for hepatitis B, C and E. Three [2.77%] patients presented with a picture of acute renal failure. Apart from these, many patients were seen with various presentations of acute abdomen, clinical picture of lower respiratory tract infection, acute hepatitis with Fulminant hepatic failure being notorious. Falciparum malaria should be considered as a possibility in all febrile patients even with various presentations for malaria

Hypokalemic quadriparesis with normotensive primary hyperaldosteronism

This case report describe a 45 years old female who presented with hypotonia, hyporeflexia, and motor weakness of all four limbs with bilateral flexor planter response due to severe hypokalemia. The patient was finally diagnosed as a case of normotensive primary aldosteronism. Her CT scan abdomen was done which excluded adrenal adenoma. Aldosterone antagonist led to excellent response and recovery