Clinicohematological parameters and outcomes in a cohort of chronic lymphocytic leukemia patients with Deletion 17p from Pakistan

BACKGROUND: Chronic lymphocytic leukemia (CLL) exhibits profound heterogeneity in its clinical course. Its clinicohematological and cytogenetic features play a significant role in determining the clinical course and in predicting the treatment response and prognosis. In this context, 17p deletion is known to predict a poor prognosis, as these cases are refractory to conventional therapy. This study aimed to evaluate the clinicohematological characteristics, outcomes, and prognostic factors among CLL patients with and without del 17p in Pakistan. METHODS: This prospective observational study was conducted at the Department of Haematology, Armed Forces Institute of Pathology (Rawalpindi, Pakistan) between January 2013 and December 2017. Patients were diagnosed based on the International Workshop on Chronic Lymphocytic Leukaemia IWCLL criteria, their clinicohematological parameters were recorded, and cytogenetic analyses were performed. The time from diagnosis to treatment and the 2-year overall survival rate were also evaluated. RESULTS: We evaluated 130 CLL cases, including 24 patients (18.5%) with del 17p, who included 18 men (75%) and 6 women (25%). The median age was 68 years. Binet stage C was detected at the presentation in 16 patients (67%). Treatment was administered to 14 patients (70%) at a median interval of 11 months (range, 0–28 mo) after diagnosis. The overall response rate was 64.3%, the median event-free survival was 9 months (range, 1–23 mo), and the 2-year overall survival rate was 65%. CONCLUSION: Del 17p is relatively common in Pakistan, and patients harboring this deletion had poor treatment response and survival outcomes.

Role of HRCT and 3D MRI in children with congenital sensorineural hearing loss

Background: Congenital hearing loss sensorineural variety is one of the most common birth defects. Imaging is very important to determine the underlying pathology of such cases

Objective: To assess the various cochlea vestibular bony and nerve anomalies by HRCT scan of temporal bone and MRI scan with 3D reconstruction images of inner ear

Methodology: A total of 140[280 ears] children with congenital deafness [88 males and 52 females], between 1 January 2012 to 30 September 2014 were included in this cross sectional study. All patients were assessed radiologically by HRCT scan of temporal bone and MRI with 3D scan of inner ear. This study was conducted at Al Razi Health Care Hospital, Lahore and Sheikh Zayed Medical College/Hospital, Rahim Yar Khan. The frequency of cochlear, vestibular aqueduct anomalies were noted. The data was entered an analyzed by using SPSS version 15

Results: We found various congenital anomalies of bony labyrinth and vestibulocochlear nerve in this study. Out of 280 inner ears we found 37 [13.2%] anomalous inner ears. Out of these 37 inner ears 25 [67%] has cochlear anomaly, 30 [83.1%] has anomalous vestibule, 19 [52.2%] has abnormal vestibular aqueduct and 9 [24.9%] has abnormal cochlea vestibular nerves

Conclusion: The study showed that most common ear anomaly in congenital sensorineural loss was cochlear vestibular, internal auditory canal anomalies. This study shows the outcome of preoperative inner ear assessment by radiological imaging mainly HRCTof temporal bone and MRI with 3D reconstruction

Frequency of thrombocytopenia in plasmodium vivax malaria

To determine the frequency of thrombocytopenia in Plasmodium vivax [P.vivax] malaria cases at two hospitals. Cross-sectional descriptive study. The study was conducted at the departments of Pathology, Combined Military Hospitals Malir and Sibi, Pakistan from Jul 2011 to Mar 2012. A total of 2709 samples were collected from febrile patients for detection of malaria parasite [944 from CMH Malir and 1765 from CMH Sibi]. Cases having infection with P. falciparum alone or having mixed infection with P. vivax and P. falciparum were excluded from the study. Both thick and thin film microscopy and immunochromatographic method [OptiMAL-IT] were used for detection of malarial parasite. Platelet counts were done using automated haematology analyser [Sysmex KX 21] with re-evaluation of low counts with manual methods. Total of 170 patients were found positive for P. vivax malaria [44 from CMH Malir and 126 from CMH Sibi]. Platelet counts ranged from 21 - 457 x loyi with a mean of 134 x loyi. Ninety five [2.1%] from CMH Malir and 4.2% from CMH Sibi out of 170 patients had thrombocytopenia, and the difference in thrombocytopenia at the two hospitals was insignificant [0.017]. Thrombocytopenia in patients with P. vivax infection is equally prevalent in the two hospitals, representing a widely different geographical area and should prompt a more thorough search for malarial parasite

Pramipexole induced recurrent pleural effusion

Recurrent pleural effusions are relatively uncommon and as clinicians we keep drug induced pleural effusion lower in our list of differentials. Pramipexole induced recurrent pleural effusion can be life threatening if not recognized early and has been reported in literature only a few times. A 44 years old man with history of traumatic brain injury presented with pneumonitis and p leural effusion which was tapped. Patient returned with pleural effusion within 2 weeks and a careful analysis of all the risk factor and drugs revealed that the most likely etiology was chronic use of Pramipexole leading to recurrent pleural effusion and early pulmonary fibrosis. Pramipexole induced recurrent pleural effusion can cause significant morbidity and should be recognized early. Physician prescribing this medication should be aware of this rare side effect of the medication

Management of ureteric calculus renal failure: a cost effective and decision making analysis with and without percutaneous nephrostomy

Background: Calculus acute renal failure is a urological emergency. Prompt treatment in the form of either temporary urinary diversion, or definite treatment can save the patients from developing chronic renal failure

Objectives: To compare the management of patients with obstructive uropathy with and without percutaneous nephrostomy

Patients and methods: A prospective interventional study conducted at SIMS/ SZMC, 2007-10. Twenty patients of ureteric calculus presenting with acute renal failure were included in our study. Patients were divided into two groups. Age, sex, duration of anuria and biochemical profile like serum creatinine and serum potassium levels were noted in both groups. In group A, a preliminary percutaneous nephrostomy tube was placed as a temporary diversion. On normalization of clinical and biochemical profile, definite treatment in the form of ureterorenoscopy/ lithoclast was performed. In group B, all the patients underwent definite treatment in the form of ureterorenoscopy/ lithoclast without preliminary temporary urinary diversion. The duration of normalization of renal function test, efficacy of URS lithoclast, hospital stay and cost effectiveness in both the groups were noted

Results: A total of 20 patients with 75% male and 25% female were included. Duration of anuria in group A was one day in 1 patients and 2-3 days in 6 patients. The duration of anuria in group B was 102 days in 8 patients. Mean normalization of serum creatinine level in group A was 5.9 days while it was 5.2 days in group B. The mean hospital stay was 10 days in group A while it was 4.7 days in group B. The mean cost of treatment in group A was Rs. 12300 and Rs. 4800 in group B

Conclusion: In patients with deranged renal functions but otherwise clinically normal can be offered definite treatment without temporary diversion in the form of PCN. This not only decreases the morbidity associated with PCN but also comforts the patients in term of shorter hospital stay and cost effectiveness

Diagnostic value of b-scan ultrasound in ophthalmic tumors

Background: Ophthatamic ultrasonography is a useful diagnostic tool for intraocular evaluation

Objectives: The objective of this study was to detect and characterize the ocular and orbital tumors with the help of B-scan ultrasound

Patients and Methods: This was a prospective descriptive study conducted in Sheikh Zayed Medical College/Hospital, Rahim Yar Khan, for a period of two years from January 2009. Contact B-scan methodology with 7.5 MHZ linear probe was used in which probe was directly placed on closed eyelids. Scanning was performed in longitudinal as well as transverse planes and with eye movements in all directions. 51 consecutive patients of either sex and age were examined, referred from different ophthalmology centers and clinics having clinical suspicion of orbital masses

Results: Total 51 cases were examined, 27 [53%] were males and 24 [47%] were females. Right eye was involved in 51% cases, left was in 43% cases and both eyes were involved in 6% cases. Out of 51 cases, 88% cases were diagnosed to be extra ocular orbital tumors and 12% were intra ocular tumors. Among all tumor types, pseudo tumor was commonest variety and was 26%

Conclusion: Ultrasonography of eyes [B-scan] is non invasive, relatively cheaper and easily available method to diagnose orbital tumors

Trauma of the eyes in medico legal cases presented at a tertiary care hospital

Background: Ophthalmaic injuries in medicolegal cases in rarely studied and reported. These case are usually encountered in medicolegal practices

Objectives: The aim of the study was to elaborate the ophthalmic medicolegal cases presented in Sh. Zayed Medical College / Hospital, Rahim yar khan, with emphasis on the incidence, type of assault / weapon used and to determine the types of wounds according to Qisas and Diyat ordinance Pakistan

Design: Descriptive study

Place and duration of Study: Total 120 cases were included who were presented in three years [from Aug.2008 to Aug.2011] in Emergency Department of SZMC Rahim yar khan. Out of which 110, cases were referred to Department of Ophthalmology Sh. Zayed Hospital Rahim yar khan by Causality Medical Officers, and 10 patients [12.5%] were re-examined by constituting Medical Board by the order of the courts for expert opinion

Material and Methods: 120 cases of ophthalmic injuries presented for medico legal opinion in Sh. Zayed Medical College / Hospital, Rahim yar khan, during this period. These were grouped according to age, sex, weapons of infliction, mode, and the gravity of vision loss, which was classified according to; total loss of vision or percentage of vision lost. Nature of loss of vision whether reversible on treatment or not was determined. Types of wounds according to Qasis and Diyit Ordinance were also determined. Help of X-Rays, CT-Scan and Ultrasound [B-Scan] was taken where required

Results: Out of 120 persons, only 12 were female [10%] and remaining [90 %] were male. The age group most commonly involved was 21- 40 years [54.1 %], 06 patients [05%] had self inflicted type of injury around the eye. Blunt weapons / assault [60%] were the predominant mode of infliction. Injuries have been categorized according to Qisas and Diyat Ordinance; Shajjah-e Khafifah were 72 [60 %], Shajjah-e-Mudihah were 24 [20 %], patients with corneal ulcer / abrasion leading to permanent scar were 20 [16.7 %] and they were categorized as Itlaf-e-Salahiet-Udw. Those patients who were undergone surgical intervention and had lost their both eye balls were categorized as Itlaf-e-Udw and were only 04 [3.3%]

Conclusion: In our study, only two patients gave proper subjective vision, other patients were malingering for their vision loss, so objective method of vision assessment must be applied. Self inflicted type of injury around the eye to get benefit must be kept in mind that was not vision depriving, only type of wound was modified. Eye Surgeons and the medico legal officers should be very vigilant to make Medico legal reports

Hepatocellular carcinoma in cirrhotic patients: frequency, seroprevalence of hepatitis B and C and patient profile

Objective: to find out frequency of hepatocellular carcinoma in cirrhotic patients and to determine seroprevalence of hepatitis Band C and profile of these patients

Material and Methods: this study was done in Sheikh Zayed Medical College/Hospital, Rahim Yar Khan from February to August 2009. One hundred cirrhotic patients admitted in medical wards were evaluated for demographic and clinical features, Seroprevalence of hepatitis B and C and Child Pugh score and class. Those having focal defect in liver on ultrasound were further investigated for serum alpha-fetoprotein, CT scan abdomen and fine needle aspiration for histopathological examination

Results: eighteen patients were found to have HCC with mean age of 53 years, 78% of these patients were male. Eighty three percent were anti-HGV positive, 6% were both HBs Ag and anti HGV positive and 11 % were seronegative. Mean Child score of these patients was 9.16. Main presenting symptoms were massive ascites, hematemesis/melena, hepatic encephalopathy and jaundice

Conclusion: HCC is a common complication of hepatitis C associated cirrhosis

Epidural anaesthesia; single-shot for day-case knee arthroscopy using a 50-50 mixture of lignocaine and bupivacaine

To compare the benefits and adverse effects of three different drug combinations when used for single-shot epidural anaesthesia for day-case arthroscopy. Prospective, random, double-blind study. A 250 bedded secondary care hospital. From October 2005 to Feb 2007. We studied 75 adult male patients, aged between 23 to 63 years, weight <100 kg, ASA physical status I or II undergoing elective knee arthroscopy as day-case procedure/Patients were randomly divided into three groups [25 patients in each group] and single-shot epidural anaesthesia was performed using a total of 20 ml epidural lignocaine 2% [Group 1] bupivacaine 0.5% [Group 2] or a mixture containing lignocaine 2% and bupivacaine 0.5%, 10 ml each [Group 3]. Time to achieve maximum height [in minutes] was similar in group-1 and group-3 [10 +/- 4 and 11 +/- 2], but it was significantly longer in group-2 [20 +/- 3]. Block time was comparable in group-2 and 3 [130 +/- 25 and 118 +/- 37] but it was significantly shorter in group-1 [60 +/- 20]. Post-operative discharge time was longest in the group-2, and comparable in group-1 and S.The incidence of complications like bradycardia, hypotension, nausea and vomiting were more in group-2 and less in group-1 and group-3. Inadequate anaesthesia was more in group-1 and least in other two groups. Four patients of group-1 needed rescue analgesia and two from same group needed general anaesthesia as compared to none in group-2 and group-3. In 4-point patient satisfaction scale, maximum patients from Group-3 rated it perfect while most patients from group-1 were not satisfied with the quality of anaesthesia. The results of our study show that a 50-50 mixture of lignocaine and bupivacaine with fentanyl 50 pg when used for single-shot epidural anaesthesia for day case knee arthroscopy, provides better quality of analgesia, with fewerincidences of side effects and more patient satisfaction as compared to lignocaine or bupivacaine alone

Asymptomatic bacteriuria in pregnancy: assessment of frequency and risk factors

To determine the frequency and risk factors of asymptomatic bacteriuria during pregnancy. Hospital based cross sectional study. This study was undertaken at outpatient department of Obstetrics and Gynecology at Jinnah Medical College Hospital Karachi from May 1, 2008 till September 30, 2008. Two hundred pregnant women who met the inclusion criteria were included in the study after informed consent and evaluated for bacteriuria. Data collected was analyzed utilizing statistical programme for social sciences [SPSS] version 10. Out of Two hundred antenatal mothers screened, 12 had significant bacteriuria giving frequency of 6%. Out of them 3 [7.8%] patients were below 20 years, 7[5.78%] were between 20 and 30 years and 2 [4.87%] women were aged above 30 years [p=0.842]. Regarding parity 3[4%] primigravida and 9[7.2%] multigravida had asymptomatic bacteriuria [p=0.275]. It was observed that prevalence was highest, 9% in lower socioeconomic class as compared to 2.24% in lower middle and upper middle class. The difference was found to be statistically significant [p=0.041].Regarding education status 10.97% of women were uneducated and only 2.54% were educated [p=0.016]. The study revealed high incidence in [58.33%] in women with previous history of urinary tract infection [p=0.000]. The frequency of asymptomatic bacteriuria among pregnant women was 6%. It was associated with lower socioeconomic status, illiteracy and past history of urinary tract infection

Anaesthetic risks in children with obstructive sleep apnea syndrome undergoing adenotonsillectomy

To determine the frequency of anaesthetic risks in children having Obstructive Sleep Apnea Syndrome [OSAS], undergoing adenotonsillectomy. A case-control study. Department of Anaesthesiology, Armed Forces Hospital, Najran, Saudi Arabia from November 2006 to January 2008. The study was carried out in 60 children scheduled to undergo adenotonsillectomy and divided into two equal groups of 30 each. Group-1 had obstructive sleep apnoea syndrome and group-2 had children without it. Both groups were given a standard general anaesthesia and frequency and rate of complications and medical interventions taken in such children were studied. P-value and odds ratio were determined. The age ranged from 3 to 10 years. The frequency of difficult intubation was higher in the group-1 than in the control group [16.6 vs. 3.3%, odds ratio 5.8]. At the time of induction of anaesthesia desaturation was higher in group-1 [33.3 vs. 6.6%, p=0.021, odds ratio 7]. At the time of extubation, desaturation was significantly higher in group-1 [43.3 vs. 6.6%, p=0.002, odds ratio 10.70]. The complications at extubation, for example cough, laryngospasm and postoperative nausea and vomiting were higher in group-1 but not statistically significant. In the postanaesthesia care unit, the frequency of complications and medical interventions were also higher in group-1. More patients of group-1 required oxygen [63.3 vs. 10%, p < 0.001, odds ratio 15.54] and insertion of an oropharyngeal airway [20% vs. nil, p=0.023] respectively. Children with OSAS, operated for adenotonsillectomy, are at significant risk of certain life-threatening perioperative anaesthetic complications. These results may be used as a guideline for safe and successful anaesthetic management of these children

autopsy study of asphyxial deaths

The study includes autopsy examination of 132 cases of asphyxial deaths, brought by the police at Department of Forensic Medicine, K.E.M.U., Lahore during the year 2002, 2003 and 2004. The study revealed that the female to male ratio was 2:3 and individuals in the third decade of life are maximally involved. The ligature was a single loop in 77.7% of the cases and multiple in 22.3% of the cases. The most frequent non-specific asphyxial signs were congestion [72.7% of the cases] and petecheal haemorrhages [78%] cases. The hyoid bone was fractured in 22.7% cases. The associated injuries found were, physical and sexual in nature in 65% of the cases examined

Incidence of homicide by sharp edged weapon at Lahore

To find out the most frequently targeted site of the body in sharp force homicidal injuries, defence wounds, age, associated weapon use, gender incidence and cause of death. Department of Forensic Medicine and Toxicology, King Edward Medical University, Lahore. 2002, 2003 and 2004. Proforma was designed for retrospective study, relevant information was gleaned from the available record .A three year period was selected, spreading over 2002, 2003 and 2004, was scrutinised for 232 cases autopsied at this facility. Male to female ratio was 2.26: 1. Maximum number of victims belonged to the 20-29 years age group. Single injuries were present in 18.54% of the cases and multiple were present in 81.46% cases. The commonest associated weapon used was blunt. Death was caused by haemorrhage in 46.5% cases and damage to vital organs proved to be the cause of death in 53.5% cases. Defence injuries were seen in 26.7% cases. The commonest infliction site was the neck in females while the area most targeted in male victims was the chest. The most targeted site is neck. Approximately one in four victims had defence injuries. Most injuries are on trunk [chest and abdomen]. Commonest regions for males was chest and in females. Damage to vital organs was the major cause of death. Amongst females teenager are more vulnerable, as this group had the maximum number of victims

Frequency predisposing factors and fetomaternal outcome in uterine rupture

To determine the frequency and to analyze the predisposing factors, maternal and fetal outcome of uterine rupture. Cross-sectional study. The Department of Gynaecology and Obstetrics, Jinnah Postgraduate Medical Centre, Karachi from February 1997 to January 2000. All cases of ruptured uterus, who were either admitted with or who developed this complication in the hospital, were included in the study. Demographic data, details regarding the most probable predisposing factor, type of rupture, the management and maternal and fetal outcome were taken into consideration for analysis. During three years, total number of deliveries was 18668, and there were 103 cases of uterine rupture [0.55%].Out of these, only 13 [12.62%] patients were booked. Most of the patients presented between the ages of 26-30 years [42.71%]. Majority of ruptures occurred in para 2-4[44.66%]. Fiftyfive cases [53.39%] had a previous caesarean section scar. In 68 [66.01%] cases, the tear was located in lower uterine segment. In 93 [90.29%] cases, anterior uterine wall was involved. Rupture was complete in 79 [76.69%] cases. Repair of uterus was done in 79 [76.69%] cases. Hysterectomy was performed in 24 [23.30%] cases. There were 8 [7.76% or 77.66/1000] maternal deaths and 85 [81.73% or 825 / 1000] perinatal deaths. This study confirms high frequency of such serious preventable obstetrical problem which can lead to high fetomaternal mortality. Rupture of caesarean section scar was the most common cause of uterine rupture found in this series

Graft versus host disease in allogeneic stem cell transplantation - 3 l/2 years experience

To evaluate the frequency and outcome of graft versus host disease after allogeneic stem cell transplant in haematological disorders at Armed Forces Bone Marrow Transplant Centre, Rawalpindi from July 2001 to December 2004. Eighty-six patients with various haematological disorders namely aplastic anaemia [n=32], b-Thalassaemia [n=25], CML [n=22] ALL [n=3], AML [n=l] Fanconi's anaemia [n=2], and Gaucher's disease [n=l], underwent allogeneic stem cell transplantation. All patients received cyclosoprin, prednisolone and short course of methotrexate as GvHD prophylaxis. The patients who developed acute GvHD > grade-II or chronic extensive GvHD received steroids at a starting dose of 2 mg/kg body weight along with gradual increase in cyclosporine dosage [max dose 12.5 mg/kg]. The overall incidence of acute GvHD grade-II to IV was 44.2% [n=38/86] where as the incidence of chronic extensive GvHD was 14% [n=12/86]. Acute GvHD was 68% [n=17/25] in B-Thalassaemia, 50% [n=ll/22] in CML, 50% [n=2/4] in Acute Leukaemias and 25% [n=8/32] in Aplastic Anaemia. Chronic GvHD was 25% [n=l/4] in Acute Leukaemias, 18.8% [n=6/32] in Aplastic Anaemia, 18.2% [n=4/22] in CML and 4% [n=l/25] in B-Thalassaemia. The overall survival in acute GvHD was 84.2% [n=32] where as the overall survival in chronic GvHD was 50% [n=6]. The overall mortality in acute GvHD was 15.8% [n=6] and 50% in chronic GvHD [n=6]. The morbidity and mortality due to severe acute and chronic GvHD remains high despite standard prophylaxis against GvHD. New strategies are needed to prevent and treat GvHD

Posttransplant Guillain Barre Syndrome

This case report describes a patient with severe aplastic anaemia, who developed Guillain Barre Syndrome [GBS] 10 weeks after allogeneic haematopoietic stem cell transplantation [HSCT] from HLA-matched siblingíyounger sister. GBS was preceded by pneumonia, herpes labialis and oral candidiasis a week earlier. Treatment with ventilatory management, intravenous human immunoglobulin [IVIg] and antimicrobials resulted in smooth recovery in thirty-one days

Graft versus host disease in allogeneic stem cell transplantation - 3 1/2 years experience

To evaluate the frequency and outcome of graft versus host disease after allogeneic stem cell transplant in haematological disorders at Armed Forces Bone Marrow Transplant Centre, Rawalpindi from July 2001 to December 2004. Eighty-six patients with various haematological disorders namely aplastic anaemia [n=32], b-Thalassaemia [n=25], CML [n=22], ALL [n=3], AML [n=1] Fanconi's anaemia [n=2], and Gaucher's disease [n=1], underwent allogeneic stem cell transplantation. All patients received cyclosoprin, prednisolone and short course of methotrexate as GvHD prophylaxis. The patients who developed acute GvHD > grade-II or chronic extensive GvHD received steroids at a starting dose of 2 mg/kg body weight along with gradual increase in cyclosporine dosage [max dose 12.5 mg/kg]. The overall incidence of acute GvHD grade-II to IV was 44.2% [n=38/86] where as the incidence of chronic extensive GvHD was 14% [n=12/86]. Acute GvHD was 68% [n=17/25] in