comparative analysis of the association of chronic inflammation versus no inflammation on the nutritional status of patients on chronic maintenance hemodialysis

To assess the association of chronic inflammation on the nutritional status of patients on Chronic maintenance hemodialysis. This cross-sectional comparative study was performed at department of Medicine Fauji Foundation Hospital Rawalpindi. Patients having chronic renal failure who were on regular maintenance hemodialysis for more than 6 months were included in the study. Ultrasound examination was done to confirm the presence of renal parenchymal disease and shrunken kidneys. The level of C-reactive protein was measured as indicator of inflammation and serum albumin, cholesterol level, mid-arm circumference, triceps skin fold thickness, subscapular skin fold thickness and body mass index [BMI] were used as the assessment tools to evaluate the influence of inflammation on the nutritional status in patients. Patient in two groups with positive or negative CRP were compared regarding the effects of inflammation on nutritional parameters. Out of 30 patients, 13 [43.3%] had evidence of inflammation with positive CRP and a mean BMI of 19.2 +/- 3.3 whereas the CRP negative group had a mean BMI of 24.9 +/- 1.5. Regarding nutritional parameters, Triceps Skin Fold Thickness, Subscapular Skin Fold Thickness, mid-arm circumference and serum albumin were also statistically low in CRP positive patients although serum cholesterol levels did not differ significantly in our study. The CRP positive patients therefore were malnourished as compared to the CRP negative group. Patients with end stage renal disease on chronic dialysis with evidence of inflammation are more at risk of malnutrition. Although there is no standardized strategy for the treatment of chronic inflammation in these patients so far but this area needs further research to improve outcome in these patients

Disposal of syringes, needles, and lancets used by diabetic patients in Pakistan

To assess the use, handling and disposal of insulin injection equipment by diabetic patients in Pakistan. We conducted a cross-sectional study at diabetic clinics in five tertiary centers in Pakistan. All diabetic patients [type 1/type 2] who were on insulin for more than 1 month, were included. An Urdu [local language]-translated questionnaire was used to collect information on insulin administration equipment, the site and frequency of needle use, insulin syringe/pen/lancet disposal, sharing of needles and knowledge about diseases that are spread by sharing contaminated needles. Of 375 patients, 58% were female. The mean [SD] duration of diabetes was 12.3 [7.3] years, and the duration of insulin use was 4.4 [4.3] years. The majority of the patients used syringes [88.3%] for insulin administration. Additionally, the majority of the patients disposed of used devices [syringes, 92%; pens, 75%; and lancets, 91%] in the household garbage collection bin. About half of the patients [n = 185] reported being educated by their physicians about the disposal of sharps. Those who were educated by a physician [adjusted odds ratio [adjOR]: 0.36; 95%CI: 0.16-0.81] or could read/write English [adjOR: 0.32; 95%CI: 0.11-0.92] were less likely to dispose of syringes and needles in the household garbage. The common disposal of sharps in the household garbage has implications for disease transmission. Education on the safe disposal of sharps may improve the disposal practices

Mediastinal tuberculosis presenting with sternal osteomyelitis and discharging sinus

Involvement of the mediastinum and sternal bone leading to osteomyelitis is a very rare presentation of tuberculosis even in countries where tuberculosis is endemic like Pakistan. Frank presentation as discharging sinus is even more uncommon. We describe a case where a patient presented with constitutional symptoms of fever, loss of appetite, significant weight loss and an erythematous tender lesion over the sternum with a discharging sinus without any features of pulmonary tuberculosis. The case was initially not diagnosed by routine laboratory tests and the lesion was just considered as a boil until presented to tertiary care hospital as discharging sinus. Plain Radiographs showed lytic lesion on the inner aspect of sternum and histopathology of the aspirate from the lesion confirmed the presence of epithelioid granulomas and acid fast bacilli on staining. Patient responded very well to 12 months of antituberculosis treatment

Her-2/neu gene overexpression in breast carcinoma and its association with clinicopathological characteristics of the disease

To assess the frequency of Her-2/neu gene amplification in breast cancer and its association with clinicopathologic characteristics of the disease. Cross-sectional comparative study. Study was carried out at Surgical Unit I, Holy Family Hospital, Rawalpindi, from January 2005 to December 2006. A total of 50 patients diagnosed of having breast cancer on biopsy of breast lump were included in the study. All patients underwent mastectomy and samples were submitted to AFIP [Armed Forces Institute of Pathology, Rawalpindi] for histopathology and determination of estrogen and progesterone receptors and Her-2/neu gene amplification. Moreover, association of Her-2/neu amplification to other characteristics like tumor size, node involvement, histological grade and presence of estrogen and progesterone receptors were also studied. Out of 50 patients, 18 [36%] were positive for Her-2/neu over expression. Among the various prognostic factors, age showed a statistically significant relation to Her-2/neu positivity [p=0.001]. The Her-2/neu positive cancers were larger in size [mean size of 7.9 +/- 3.615 and 5.4 +/- 1.906 cm in Her-2/neu positive and negative cases respectively; p=0.002]. Her-2/neu positive cases had statistically significant relation to number of involved lymph nodes [mean number of 9.9 and 4.4 lymph nodes in Her-2/neu positive and negative cases respectively; p=0.001]. Tumor grade and nuclear grade had no statistically significant relation to Her-2/neu status [p=0.19 and 0.434 respectively]. Both estrogen and progesterone receptors are inversely related to Her-2/neu positivity [p=0.028 and 0.006 respectively]. The pathological and clinical characteristics of Her-2/neu positive and negative subsets differ, and Her-2/neu over. expression was associated with other poor prognostic factors of age, tumor size and number of nodes involved. There was an inverse relation of Her-2/neu status and hormone receptor

Risk of development of chronic kidney disease in patients with type 2 diabetes having metabolic syndrome

To measure the relation of creatinine clearance in type-2 diabetic patients with different components of metabolic syndrome and to quantify the relationship of frequency of incident CKD with increasing number of metabolic syndrome components while controlling for age, gender and duration of diabetes. Cross-sectional descriptive study. Diabetes Clinic, Fauji Foundation Hospital, Rawalpindi, from January to August 2006. Patients having type-2 Diabetes for more than 5 years were enrolled. Information regarding age, gender, duration of diabetes, type of diabetes, treatment taking, complete fasting lipid profile, fasting blood glucose, Body Mass Index [BMI], 24 hours urinary proteins and creatinine clearance, co-existent risk factors like hypertension and ischemic heart disease was taken. Patients were divided into groups having one to all five metabolic syndrome traits. Progressive increase in the metabolic syndrome traits was compared with decline in creatinine clearance. Pearson correlation test and multiple logistic regression were applied to determine correlation with significance at 'r' and 'p'

Frequency of depression and anxiety in patients attending a rheumatology clinic

This study was done to find out the frequency of anxiety and depression among patients with common rheumatic disorders and determine the possible relationship of different demographic and clinical variables with anxiety and depression. Cross-sectional, analytical study. The study was carried out at Fauji Foundation Hospital, Rawalpindi, during April to August 2006. Patients attending the rheumatology outpatient department, with more than 2 years duration of rheumatic disorder were selected. A proforma regarding the demographic details was filled for all the patients. A physician made the assessment regarding the rheumatological disorder. Urdu version of Hospital Anxiety and Depression Scale [HADS] was used to assess anxiety and depression. Clinical assessment was done by two psychiatrists according to International Classification of Diseases-10 [ICD-10]. Data was analyzed on SPSS10 and p-value was calculated using Chi-square test as test of significance. There were 108 patients mostly females [90%], mean age 44.7 +/- 11 years, majority [72%] were married and 51% were uneducated. Almost 80% of the patients had rheumatoid arthritis. Two-third of the patients had persistent symptoms. According to the HADS, scoring 56% of the patients had more than the cut off score for depression and 65.7% patients had scores falling in the category of cases. Regarding the clinical diagnosis, 42% of the patients were found to be depressed. Considering the factors which might be associated with depression or anxiety; only gender was found to be significantly associated with depression [p=0.03]. Depression and anxiety is high in patients being treated for chronic rheumatological disorders. A close liaison between rheumatologist and mental health professionals could prove beneficial for these patients

Evaluation of risk factors of non alcoholic fatty liver disease [NAFLD] in a tertiary care hospital at Rawalpindi, Pakistan: a local experience

To document the frequency of risk factors for nonalcoholic fatty liver disease, such as gender, diabetes mellitus, hypercholestrolemia, hypertriglyceridemia, obesity and metabolic syndrome. This descriptive study was carried out at Department of Medicine Fauji Foundation Hospital Rawalpindi from January 2007 to December 2007 One hundred nonalcoholic patients with elevated ALT and negative viral serology and diagnosed as having fatty liver on ultrasound were evaluated for the presence of diabetes, hypercholestrolemia, hypertriglyceridemia, obesity and metabolic syndrome. Patients with suspected autoimmune hepatitis, hemochromatosis and Wilsons disease were excluded. The mean age was 45.39 years. Out of 100 patients, 63% were females and 37% were males. Sixty six percent patients were obese. Other risk factors included hypertriglyceridemia in 48%, diabetes mellitus in 34%, hypercholesterolemia in 28% and metabolic syndrome in 28% cases. Nonalcoholic fatty liver disease is associated with a high prevalence of obesity, hypertriglyceridemia, hypercholestrolemia, diabetes and female gender

Evaluation of knowledge and practices of foot care in patients with chronic type 2 diabetes mellitus

To evaluate the knowledge and practices of foot care in patients with diabetes mellitus and to stress upon the importance of such knowledge and practices in decreasing morbidity associated with diabetic foot disease. One hundred patients of either sex from three tertiary care hospitals with a 5 year history of Diabetes Mellitus were selected in this study and were asked to fill out a questionnaire about their knowledge and practices about daily foot inspection, foot cleaning, appropriate nail care, and use of footwear in the form of shoe material, open or closed forepart and nature of heel. Out of 100 patients [36 males and 64 females], 34% patients inspected their feet daily and 78% of the respondents knew about care of callosities, minor injuries and cuts, 52% of patients didn't know about correct technique of cutting nails. Eight [22.2%] male and 28 [43.8%] female patients were using open shoes while 24 [66.7%] male and 38 [59.4%] female patients had shoes with narrow forepart. Ten [27.8%] males were using shoes made of hard material as compared to 20 [31.3%] of female patients. Twenty two [34.4%] of our female diabetic patients were using shoes with high heel. Only 68% of the patients were on regular follow up. This simple quality initiative concludes the notion that patients with diabetes who are at risk for the development of diabetic foot ulcers should receive ongoing foot-specific patient education

Malignant hypertension in a patient with end of stage renal disease [ESRD] treated by renal transplant

Control of hypertension is often a problem in the management of end stage renal disease [ESRD]. Multiple modalities of treatment are required to prevent cardiovascular and cerebrovascular mortality and morbidity. These include fluid and salt restriction, multidrug regimes and dialysis. We report a case of young 25 years old patient, admitted with chronic renal failure, complicated by malignant and refractory hypertension, not responding to hemodialysis and antihypertensive agent. During stay in hospital, patient also had intracerebral hemorrhage, fits due to uncontrolled hypertension requiring ventilatory support followed. Renal transplant was considered to be the final therapeutic modality. After gradual recovery, a successful live-related renal transplant was performed. As soon as good graft was established, the blood pressure settled and 4 of the 5 antihypertensives were withdrawn. After 2 weeks, patient was discharged in a stable condition with a total stay of about 2 months

Renal transplant in a patient with augmentation cystoplasty

A 20 years old girl, had undergone surgery for meningocele six weeks after birth, suffered from neurogenic bladder dysfunction. She underwent an augmentation ileocystoplasty and was trained to perform clean intermittent self catheterization [CISC]. After two years she developed renal failure secondary to recurrent urinary tract infections and she was started on chronic hemodialysis. On account of repeated line sepsis, a live related donor renal transplant was performed. About three months after renal transplantation she reported in emergency with an episode of graft rejection secondary to severe infection and later on complicated by leakage of urine from the renal pelvis of the allograft into the peritoneal cavity suggestive of a rent. A percutaneous nephrostomy of the allograft was performed which facilitated healing of the rent in the renal pelvis. The nephrostomy was withdrawn and patient started voiding through urethral catheter and gradually returned to CISC