A prospective study of N-acetylcysteine treatment in drug-induced fulminant hepatic failure

Background: Acute liver failure (ALF) is a rare but severe, life-threatening, complex, multisystemic gastroenterological emergency. Its rapid progression and high mortality demand early diagnosis and expert management. Drug-induced ALF (DI-ALF) remains the uncommon cause of ALF in India. To date, there is no established treatment for DI-ALF other than liver transplantation and little is known about the use of N-acetylcysteine (NAC) in DI-ALF. A prospective case-control study was carried with the aim to determine the effect of NAC on mortality of DI-FHF patients and also to evaluate the safety and efficacy of NAC use.Methods: A total of 18 patients with a diagnosis of DI-FHF were included in the study. 10 patients received NAC infusion for 72 hours whereas the control group received placebo. The variables evaluated were demographic, signs and symptoms, biochemical parameters, outcome and length of hospital stay.Results: Out of 18 DI-FHF patients, 13 (72.2%) had anti-tuberculosis therapy (ATT) induced FHF and 5 (27.8%) patients had ayurvedic induced FHF. The two groups were comparable for the various baseline characteristics (age, INR, alanine aminotransferase, creatinine, albumin, grade of encephalopathy, etc.). The mortality decreased to 20% with the use of NAC versus 75% in the control group (P=0.023). Use of NAC was associated with a shorter length of hospital stay of survived patients (P=0.043). Moreover, the overall survival was improved by NAC (P=0.023) in DI-FHF. ATT induced FHF showed better outcome as compared to ayurvedic induced FHF use (P=0.019).Conclusions: Author recommended the use of NAC along with conventional treatments in patients with DI-FHF in non-transplant centers while awaiting referrals. ATT induced FHF showed better outcome as compared to ayurvedic induced FHF with NAC administration and its use was safe.

Comparison of cardiac autonomic response in different ABO blood groups of young adults

Background: ABO blood group has been associated with various disease phenotypes, particularly cardiovascular disease. Abnormal autonomic response also plays a role in cardiac morbidity. Increasing attention is being focused on the role of autonomic nervous system in health and disease. The literature lacks data on the association of blood groups and cardiac autonomic function. The aim of the study was to find out the association between different blood groups and cardiovascular autonomic functions in young adults.Methods: 150 healthy young students of MMU aged 18-25 years, divided into four groups based on ABO blood grouping, determined by agglutination test (group A, group B, group O and group AB). Various autonomic function tests done were lying to standing test, Valsalva maneuver, Hand grip test (HGT) and Cold pressor test (CPT).Results: The mean baseline heart rate was significantly higher in group O as compared to group A. No parasympathetic alteration between different ABO blood groups was seen. Blood pressure response to HGT and CPT was not statistically significant between different blood groups.Conclusions: Present study revealed no alteration in cardiac autonomic function with regards to ABO blood grouping in young adults.

Etiological profile and clinical characteristics in fulminant hepatic failure in North India

Background: Acute liver failure (ALF) is a rare but severe, life-threatening, multisystemic medical emergency. ALF of duration <8 weeks in a patient is considered as fulminant hepatic failure (FHF). Its rapid progression and high mortality demand early diagnosis and expert management. Clinical and etiological profile varies with geographical area and time. The objective of this prospective study was to determine the clinical characteristics and etiological profile of FHF.Methods: A total of eighty consecutive patients with a diagnosis of FHF were included in the study. The variables evaluated were demographic, signs and symptoms, biochemical parameters (bilirubin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), prothrombin time (PT), internal normalization ratio (INR) etc.) and etiological profile.Results: Most of the patients were <35 years of age and males. Viral hepatitis 35 (43.8%) was the most common cause of FHF but the majority of the patients 25 (31.2%) had undetermined etiology. Among viral causes, acute hepatitis E was most common followed by hepatitis B and A. Drug or toxic induced liver failure (18.8%) also contributed a significant proportion of cases. The three groups (viral, drug-induced and indeterminate) were comparable for the various baseline characteristics (bilirubin, alanine aminotransferase, INR, creatinine, albumin, grade of encephalopathy, MELD score etc.).Conclusions: Like the rest of India, viral hepatitis was the common cause of FHF but the majority of the patients 25 (31.2%) had undetermined etiology. Our study highlights the differences in the profile of FHF from other earlier studies in India and the west. Each different etiology leads to a similar final common pathway. Trying to determine etiology is essential, however, as outcomes and the use of antidotes depend on the identification of the causative process.

Clinical features, laboratory characteristics and outcome of patients with drug-induced acute liver failure

Background: Acute liver failure (ALF) is a rare medical emergency. Its rapid progression and high mortality demand early diagnosis and expert management. Drug-induced ALF (DI-ALF) remains the uncommon cause of ALF in India. Clinical and etiological profile varies with geographical area and time. A prospective study of DI-ALF was carried with the aim to determine the clinical features, laboratory characteristics, outcome and hospital course.Methods: A total of 15 patients with a diagnosis of DI-ALF were included in the study. The variables evaluated were demographic, signs and symptoms, biochemical parameters [bilirubin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), prothrombin time (PT), internal normalization ratio (INR) etc.], outcome and course during hospitalization.Results: Out of 15 DI-ALF patients, 12 had Anti-tuberculosis therapy (ATT) induced ALF and 3 patients had ayurvedic induced ALF. Majority of the patients were females (73.3%) and middle-aged (42.60±14.30 years). Coma grade at the time of admission showed that majority of patients (66.8%) had grade I and II encephalopathy. Depending on the pattern of liver injury, hepatocellular pattern was most common (53.3%) followed by mixed and cholestatic pattern. 40% of patients died with DI-ALF complications of which ATT induced ALF contributed 41.7%. Mean AST was more increased as compared to ALT. Development of ascites (P = 0.030) and mannitol use (P = 0.025) was significantly more common in non survived group than survived group. Length of hospital stay was significantly more in non survived group than survived group (P = 0.009).Conclusions: ATT was the class of drugs most frequently associated with DI-ALF. DI-ALF disproportionately affected middle-aged women. Most DILI ALF patients had hepatocellular injury pattern. 40% of patients died with DI-ALF complications. Development of ascites, mannitol use and length of hospital stay was significantly more in non survived group than survived group.

A comparative study of RapidArc and intensity-modulated radiotherapy plan quality for cervical cancer treatment

Background: RapidArc therapy, a complex form of intensity-modulated radiotherapy (IMRT), is now widely used to treat cancer patients. Aims: This study aimed to investigate and compare the plan quality of IMRT and RapidArc techniques using various dosimetric indices to find the better treatment modality for treating patients with cervix cancer. Materials and Methods: Thirteen cervical cancer patients treated with IMRT were selected for analysis and original plans were subsequently re-optimized using the RapidArc technique. Plans were generated such that dose of 5000 cGy was delivered in 25 equal fractions. Inverse planning was done by Eclipse (Varian Medical Systems, Palo Alto, CA) treatment planning system for 15 MV photon beams from computed tomographic data. Double arcs were used for RapidArc plans. Quality of treatment plans was evaluated by calculating conformity index (CI), homogeneity index (HI), gradient index (GI), coverage, and unified dosimetry index (UDI) for each plan. Results and Conclusion: RapidArc resulted in better planning target volume (PTV) coverage as is evident from its superior conformation number, coverage, CI, HI, GI, and UDI. Regarding organs at risk (OARs), RapidArc plans exhibit superior organ sparing as is evident from integral dose comparison. Difference between both techniques was determined by statistical analysis. For all cases under study, modest differences between IMRT and RapidArc treatment were observed. RapidArc-based treatment planning is safer with similar planning goals compared to the standard fixed IMRT technique. This study clearly demonstrated that favorable dose distribution in PTV and OARs was achieved using RapidArc technique, and hence, the risk of damage to normal tissues is reduced.

Diagnosis of urinary tract infection: medical imaging or laboratory based

Urinary tract infection [UTI] affects women more than males mainly due to smaller urethra and feminine genital anatomy. Symptoms of UTI includes painful micturaition, flank pain, fever etc while its signs are pyuria, bacteriuria and tenderness in flank. In order to rule out UTI, laboratory tests are primarily performed, most important are urine routine examination, urine culture and sensitivity test. Radiological evaluation of urinary system is also done to determine the underlying causes of infection and the extent of damage caused to the renal system by the infection

Role of different functional parameters in gratification of denture wearing patients

Objective:To assess the overall satisfaction and to evaluate complications in removable denture patients, during different functional movements

Materials and Methods: This descriptive study was done on 180 patients who were restored with removable complete and partial prosthesis. They were analyzed on the basis of a specific questionnaire related to the use of denture and post-insertion follow-ups. For each patient, relevant history was recorded along with oral and a thorough examination of prosthesis they were using. A four-grade scale criteria was used for evaluation and standardization of the study, in terms of different functions and level of comfort

Result:Most of the examined patients showed their satisfaction from their prosthesis.The degree of satisfaction seemed to be directly related to the duration of denture wearing that is the older the denture got, more satisfactory the results were shown.Patients with shorter duration of treatment or those who were recently given the prosthesis, presented with more dissatisfaction and complain about their functional abilities with dentures, while the complains were gradually resolved with passage time as patients got used to them

Conclusion:Majority of the patients showed their gratification with their dentures, which were judged as satisfactory by the dentist. There was a difference between the retention of the upper and lower dentures however in a level of satisfaction with their dentures in different functions like chewing and speaking

effect of anemia on pregnancy and fetal outcome: GMC hospital, Ajman, UAE

Objective: Anemia in pregnancy is a major public health problem globally. The aim of this study is to assess the effect of anemia on pregnancy and its effect on fetal outcome in mothers attending OPD in GMC Ajman, UAE

Materials and methods: A cross-sectional study was conducted from the records of 100 mothers with anemia and 100 non-anemic mothers who had delivered in the past 2 years at GMC Hospital, Ajman. Details of the mother and the newborn were collected in data extraction forms. Chi square test was done for associations. T-test est was done to compare mean values. P value <0.05 was considered as significant

Results: Anemia was more common among women

Conclusion: This study demonstrated that there are more cases of mild anemia, the rate of caesarian section was higher and the mean birth weight of the baby is lower in anemic mothers. It is recommended that cases of anemia should be diagnosed early and be undergoing immediate management to prevent any further complications

Phytochemical analysis of Hibiscus caesius using high performance liquid chromatography coupled with mass spectrometry

Various species in genus Hibiscus are traditionally known for their therapeutic attributes. The present study focused on the phytochemical analysis of a rather unexplored species Hibiscus caesius [H. caesius], using high-pressure liquid chromatography coupled with mass spectrometry [HPLC-MS]. The analysis revealed five major compounds in the aqueous extract, viz. vanillic acid, protocatechoic acid, quercetin, quercetin glucoside and apigenin, being reported for the first time in H. caesius. Literature suggests that these compounds have important pharmacological traits such as anti-cancer, anti-inflammatory, anti-bacterial and hepatoprotective etc. however, this requires further pharmacological investigations at in vitro and in vivo scale. The above study concluded the medicinal potential of H. caesius

Effect of concept maps on knowledge retention in dental students

To determine the effect of Concept Maps on Knowledge Retention in Dental students. Randomized study. study was conducted at the Jinnah Medical and Dental College, Karachi. A randomized controlled trial was conducted on fifty students of BDS first year at the Jinnah Medical and Dental College, Karachi. The students were randomly divided into two groups. Initially the whole class was taught thefirst unit of Biochemistry [Carbohydrates] by the conventional method. It was followed by a Multiple Choice Questions test which established the equivalence in the mean scores of the two groups. The Intervention group now attended a workshop on [Concept Maps]. In the next two units [Proteins and Lipids], the Intervention group made Concept Maps while the Control group continued with the conventional method. Each unit ended with an MCQ test. The score of the Unit test was taken as an indicator of short term retention of knowledge. Two months later, an unscheduled Retest was given consisting of all the MCQ given in the three Unit tests. The difference between the scores of the Unit tests and Retest was taken as an indicator of long term retention of knowledge. The mean scores of the two groups were compared using Independent samples t-test. No significant difference was found in the mean scores of the Intervention and Control groups in the Unit tests. But in the Retest the Intervention group performed significantly better [p < 0.01] than the Control group. Learning through Concept Maps improves long term retention of knowledge

Partial edentulism based on Kennedy's classification

The aim of this study is to investigate the distribution of the partial edentulism in general population according to Kennedy's classification. Cross Sectional Study This study was conducted Isra Dental College OPD in Hyderabad from Feb 2010 to July 2011. This is a cross sectional study carried out on 395, subjects, both males and females and belonging to age groups 35-50 years, completed during the period of one and half year. All patients' personal history was taken regarding their age and socioeconomic condition. Partial edentulism was recorded by visually examining the study sample. The results include the visual examination of 395 individual in which majority were males 246 [62%], mostly belonging to the poor class, 231 [59%] and in early forties 181[46%]. There is high prevalence of Kennedy's class IV, 128[32%] among sample then followed by Kennedys Class I 92[23.3%], II 76[19.2%] and III 50[12.7%]. The association between partial edentulism according to Kennedy's classification with socio- demographic profiles of the sample is statistically significant [68, 17%; p=0.04]. In our study there is significant difference between gender and partial edentulism as more male patients visit the dental clinic for partial denture belongs to low income status and in 41-45 years age group

Courvoisier's law revisited

According to Courvoisier's law; if gallbladder is palpable in a jaundiced patient, it is unlikely to be due to gallstones, because stones would have given rise to chronic inflammation and subsequently fibrosis of gallbladder therefore, rendering it incapable of dilatation. Conversely, the causes other than stone [principally tumours], would result in the distension of gallbladder, felt on abdominal palpation. However, in Courvoisier study of 109 cases of dilatation of gallbladder, 17 were due to impacted stones. Therefore, Courvoisier concluded that dilatation of gallbladder was rare with stones obstructing the common bile duct. Despite this fact it is always assumed that the palpable gallbladder is due to malignancy [pancreatic or periampullary etc.]. Here, we report a rare case of palpable gallbladder in a jaundiced patient due to multiple cholelithiasis and a large choledocholithiasis causing obstruction of CBD

Changing trend in topography of peptic ulcer perforation

Objective: to find out the changing trends in topography of peptic ulcer perforation

Design: retrospective

Setting: department of Surgery, Unit II Chandka Medical College Teaching Hospital Larkana

Duration: from July 2004 to June 2007 [3 years]

Patients and methods: the age, sex, clinical presentations, treatment options and operative findings of patients, who presented with perforated peptic ulcer were studied from their case files, and data were analysed

Results: out of 86 patients, 81 were males and 5 were females with a male to female ratio of 16.2:1. The prevalence of perforation was highest in patients of 40-59 years of age. Seventy-six patients underwent emergency explorative laparotomy. Among these, 70 patients had gastric and 6 had duodenal ulcer perforation, resulting in duodenal to gastric ulcer ratio of 1:11.5. Repair with Omentopexy was the procedure employed

Conclusions: peptic ulcer perforation is most common in the stomach of middle aged man

Pattern of firearm injury and outcome

Objective: to study the pattern and outcomes of firearm injuries at Department of Surgery during 3 years

Design: retrospective study

Setting: department of Surgery, Unit II, Chandka Medical College Teaching Hospital Larkana

Duration: three years, from July 2004 to June 2007

Patients and methods: record of all firearm injury cases, who presented during study period, was analyzed. Data were collected on printed proforma from indoor patient record [case file] and operation theatre record. Demographic data, clinical presentation, site and frequency of injuries, investigations including radiology, operative findings, and postoperative course were the variables of study

Results: out of 282 firearm injured patients, 258 were males and 24 were females, with male to female ratio of 10.7:1. The age ranged 12-80 years. Ninety-nine [33.68%] patients had injuries to abdomen only and 72 [25.53%] to chest only, while 72 [25.53%] patients had multiple injuries including injuries to abdomen. One-hundred and twelve [39.71%] patients underwent Laparatomy [including patients with multiple injuries], 66 [23.40%] required chest intubations. Twohundred and forty-four [86.52%] patients were cured and discharged. Seven [2.48%] patients were referred to other departments like Orthopaedic and Neuromedicine and 14 [4.96%] to other hospitals with advanced patient care facilities. Mortality rate was 6%

Conclusion: the firearm injury is common in 20-39 year old males. The most common site of injury is abdomen. The commonly injured intra-abdominal organ is bowel followed by liver and kidney, while most commonly injured extra-abdominal organ is lung

Spectrum of diseases in patients with non-traumatic acute abdomen

Objective: To identify the spectrum of diseases leading to acute abdomen in local population, presenting in a surgical unit. Design: Retrospective study. Setting: Department of Surgery Unit-II Chandka Medical College Teaching Hospital Larkana. Duration: A period of three years, from July 2004 to June 2007

Patients and Methods: All patients presenting with non-traumatic acute abdominal pain were included in the study. Patients presenting with gynecological and urological causes were excluded. Their presentation, diagnosis and management were recorded from their case files and OT registers

Results: During the period under review, a total of 586 patients presented with non-traumatic acute abdomen; of which there were 412 [70.30%] males and 174 [29.69%] females, with a male to female ratio of 2.3:1. The highest incidence of acute abdomen 163 [27.81%] was found in patients of 21-30 years age group, followed by under 20 age group 150 [25.59%] and 30-40 years age group 101 [17.23%]. The most common cause of acute abdomen was acute appendicitis accounting for 205 [35%] admissions. These patients were mostly young males in teens and twenties. Intestinal obstruction was second leading cause accounting for 167 [28.5%] cases and this affected more commonly the middle aged persons. Five hundred and twelve [87.37%] patients were treated successfully and discharged home while 3% left against medical advice. Mortality was 9.55% and it was highest in patients presenting with perforation peritonitis

Conclusion: The most common cause of acute abdomen in this study was acute appendicitis affecting young population. This was followed by intestinal obstruction and gut perforation. Acute cholecystitis commonly affects the middle aged, post-menopausal women. Pancreatitis is a rare cause of acute abdomen in this area

Maternal plasma Homocysteine level, 24-Hour urinary protein and hemoglobin in pre-eclamptic patients: Is there any relationship?

Background: Anaemia is very common in developing countries especially during pregnancy. Hyperhomocysteinaemia can result from genetic or nutrient-related disturbances in the transsulfuration or remethylation pathway for homocysteine metabolism. Inadequate intake of vitamin B ,B or folate may underlie some cases of elevated homocysteine levels. The aim of this 12 6 study was to investigate the possible relationship between plasma homocysteine level, haemoglobin level and 24-hour urinary protein in pre-eclamptic patients. Folic acid deficiency is one of the major causes of hyperhomocysteinemia which is one of the major risk factor for preeclampsia [PET]. Severe proteinuria of several grams/day occurs in pre-eclamptic toxaemia

Methods: A cross-sectional comparative study was carried out on 90 primigravida attending the "antenatal clinic" of Services Hospital, Lahore

Results: Out of these 60 primigravida 30 were mildly preeclamptic and 30 were severely pre-eclamptic at 30-38 weeks of pregnancy.30 primigravida [30- 38 weeks of pregnancy] having uncomplicated pregnancy were taken as control

Conclusion: The results show that in mild PET and in severe PET, the plasma homocysteine level shows a significant relationship with 24-hour urinary protein and haemoglobin level. Anaemia [folic acid defeciency] is one of the important risk factor in the causation of hyperhomocysteinemia which is one of the major chronic risk factors for eclampsia

Multi-drug resistant typhoid in adults

A total of 100 clinically suspected cases of typhoid fever were studied during the period January 1993 to December 1994. Blood and bone marrow cultures were done to find out the pattern of anti-microbial sensitivity of Salmonella; 44 cases were culture positive. Salmonella typhi was isolated in 81.8% of the cases [n=36] while Salmonella para typhi A was isolated in 18.1% of the cases [n=8]. Salmonella paratyphi B and C were not isolated. All isolates of Salmonella typhi were resistant to conventional anti-typhoid drugs i.e. chloramphenicol, amoxycillin and co-trimoxazole, and were sensitive to aminoglyco-sides-gentamycin, third generation cephalosporin cefexim, cefotaxime, ceftazidime and ceftriaxone and to quinolones i.e. ofloxacin and glomefloxacin. All isolated of Salmonella paratyphi A were sensitive to conventional as well as the newer antibiotics mentioned above. It is concluded that, in view of the alarming increase in the incidence of multi-drug resistant salmonella typhi to conventional antibiotics, typhoid fever must be treated very cautiously, and newer antibiotics must only be used when they are indicated so as to prevent the development of microbial resistance against them