Accuracy of straight leg raise test in patients with lumbar disc herniation keeping magnetic resonance imaging as a reference standard

Objective: To determine the accuracy of straight leg raise [SLR] test in patients with lumbar disc herniation keeping magnetic resonance imaging [MRI] as a reference

Study Design: Validation study

Place and Duration of Study: Radiology department of Combined Military Hospital [CMH], Quetta, over a period of 16 months from 1st Dec 2012 to 31st May 2013

Material and Methods: Total 225 cases with lower back pain were included through non probability-consecutive sampling. Informed consent was taken. The patients were assessed for positive or negative SLR test. Then all patients underwent MRI of lumbosacral spine. Data was collected through a specially structured proforma. Data was analyzed by SPSS version 10

Results: SLR test was found to be positive in 114 [50.7%] cases while negative in 111 [49.3%] cases. Lumbar disc herniation on MRI was found to be positive in 122 [54.2%] cases while negative in 103 [45.8%] cases. Sensitivity, specificity, positive and negative predictive values of SLR test were found to be 82.8%, 87.4%, 88.6% and 81.1% respectively. Accuracy of SLR test was found to be 84.9%

Conclusion: We concluded that SLR test is accurate enough to diagnose disc herniation with reference to MRI. Now we can advise SLR test for assessment of disc herniation where MRI is not available or unaffordable for the patients

Emerging trends of bloodstream infections: a six-year study at a paediatric tertiary care hospital in Kabul

Objective: To determine the frequency of pathogens causing bloodstream infections and evaluate their trends and antibiogram patterns among in-patients in a paediatric tertiary care centre

Study Design: Descriptive study

Place and Duration of Study: French Medical Institute for Mothers and Children [FMIC], Kabul, Afghanistan in two phases, from January 2010 to December 2015

Methodology: Results of blood cultures from suspected cases of sepsis admitted in the FMIC, from January 2010 to December 2012 [Period-1], and from January 2013 to December 2015 [Period-2] were completed. Standard microbiological methods were followed for blood culture and antibiotic sensitivity testing

Results: Out of total 1,040 cases of culture proven sepsis, 528 [50.77%] Gram-negative bacilli [GNB], 474 [45.58%] Gram-positive cocci [GPC], and 38 [3.65%] Candida species were isolated during the entire study period. Out of 528 GNB isolates, 373 [70.64%] belonged to the Enterobacteriaceae and 155 [29.36%] were non-fermenters. Among Enterobacteriaceae, 168 [31.82%] were Klebsiella species [K. pneumoniae=124, K. oxytoca=44], 70 [13.26%] were Enterobacter species [E. cloacae=52, E. aerogenes=18], 65 [12.31%] were E. coli, 37 [7.01%] were Serratia marcescens and 31 [5.87%] were others. Out of 155 non-fermenters, 88 [16.67%] were Pseudomonas aeruginosa, 39 [7.39%] were Burkholderia cepacia and 18 [3.41%] were Stenotrophomonas maltophilia. There was a drop in the frequency of Enterobacteriaceae from 85% in Period-1 to 58.68% in Period-2. There was an increase in the frequency of nonfermenters from 15% to 41.32%, particularly 18 new cases of sepsis caused by Stenotrophomonas maltophilia during Period-2. Among GPC, there was an overall rise of 16.14% in the prevalence of Staphylococcus epidermidis during Period-2 and a drop of 9.64% in the frequency of Staphylococcus aureus during Period-2. The majority of Gram-negative isolates were multidrug-resistant to commonly used antibiotics. However, most of the isolates were sensitive to amikacin and imipenem [except S. maltophilia]. The frequency of those producing ESBL reduced by 11.22% during the Period-2. Among Gram-positive cocci, the pattern of antibiogram did not show a significant change during both periods, and majority remained resistant to commonly used antibiotics. All Staphylococci were sensitive to vancomycin but resistant to penicillin. There was a substantial decline of 18.87% in the frequency of Methicillin-resistant Staphylococci [MRSA/MRSE] during Period-2

Conclusion: Staphylococci and Klebsiellae remain the most important bacteria responsible for bloodstream infections in a tertiary healthcare facility in Kabul. Yet, there has been an increase in the prevalence of Pseudomonas and Burkholderia cepacia. Moreover, Stenotrophomonas maltophilia emerged as a new hospital acquired pathogen. This study could possibly help in suggesting choices eluding the misuse of appropriate antibiotics

Occurrence of extended-spectrum beta-lactamase producers among enterobacteriaceae in a paediatric tertiary care facility in Kabul

The aim of this study was to determine the occurrence of extended spectrum beta-lactamase [ESBL]-producing species of Enterobacteriaceae to control their spread, from March 2008 to June 2012. A total of 411 ESBL-producing isolates were reported belonging to the family Enterobacteriaceae. There were 235 [57.18%] hospital-acquired infections [HAIs] and 176 [42.82%] community-acquired infections [CAIs]. Out of total isolates, majority were E. coli [n=165, 40.15%], followed by 38.93% Klebsiella spp. [n=161], 9.97% Enterobacter spp. [n=41] and 6.33% Serratia spp. [n=26]. Amongst HAIs, most frequent i.e., 111/235 [47.23%] were Klebsiella spp, whereas, amongst CAIs, majority i.e., 96/176 [54.55%] were E. coli. The frequency of ESBL-producing isolates from different sites was blood [37.71%], urine [29.93%], respiratory tract [18.49%] and other sites including pus/pus swabs, CSF/body fluids and secretions [13.87%] respectively. Majority of blood stream infections were caused by ESBL-producing Klebsiella species which accounted for 55.48% of all cases who had septicaemia, whereas E. coli was responsible for causing majority of urinary tract infections [UTIs] and accounted for 78% of all UTIs cases. Intensive Care Unit [ICU] was the place where majority of infections [55%] were observed, followed by 29% in the Medical Unit and 16% in the Surgical Unit

Frequency of infantile pyloric stenosis and ocular abnormalities in Turner's syndrome in Bahawalpur city

Turner's syndrome is one of the most common of all chromosomal abnormalities. Pyloric stenosis is the most common pediatric surgical disorder of infancy that requires surgery for associated emesis.4 Ocular abnormalities are common in Turner's syndrome, but are under estimated and often neglected. The study that was hospital - based observational, was conducted from September 1[st], 2005 to August 31, 2011 in the Al-Noor Hospital Yazman [Bahawalpur] in collaboration with ophthalmology department, Bahawal Victoria Hospital Bahawalpur. Laboratory investigations including electrolytes, blood gas analysis, and osmolality were done in pathology department, Quaid-e-Azam Medical College Bahawalpur. Frequency of pyloric stenosis in infants from 0 - 6 months 64.95% and infants 6 - 12 months is 35.09%, the ocular abnormalities amblyopia 19%, strabismus 23%, phoria only 43.5%, epicanthus 10%, hypertelorism 3%, ptosis 1%, nystagmus 0.5%. There is a high frequency of ocular abnormalities and pyloric stenosis in infants with karyotype XO. Timely diagnosis may save from devastating effects of ocular complications leading to blindness and life threatening alkalosis due to pyloric stenosis in infants below one year of age

Hyperuricaemia and the risk of ocular complications in tuberculous patients during therapy

Objective: To determine the risk of ocular complications due to hyperuricaemia in tuberculous patients during therapy. Material and Methods: The study was canducted in chest ward and eye ward BVH, Bahawalpur in collaboration with Department of Chemical Pathology, QMG, Baharvalpur from July 2009 to July 2011 One thousand and fifty tuberculous patients [850 males and 200 females, aged 18 - 70 years] receiving four standard drugs i.e; rifampicin. pyrazynamide, ethambutol, and isoniazid, were included in the study. Approved and fixed dose combination of four drugs of proven bio equivalency was used Serum uric acld and creatinlne levels were estimated on fujly automated chemistry analyzer SELECTRA-XL [Merck Diagnostics] using Merck reagents. before the commencement of treatmenl. Ophthalmic examination of all the patients included in the study was also done by funduscopy and on slit lamp before starling therapy. At 8-1 2 weeks after commencement of therapy serum uric acid and crealinine levels were measured along with fundoscopic and slit lamp examination on all patients under srudy subjects to diagnose any ocular complication by an ophthalmologist. Results: All patients study subjects had hyperuricaernia [mean=9.60 mg/dl +/- 3.4 SD] and ncrmal creatinine. Syrnploms of visual blurring from the corneal haze or foreign body sensation due to epithelial breakdown were found in 86% of study subjects. Uveitis was found in 2 percent of the patients. Scleritis and Episcleritis was seen in 4% of the patients. Corneal deposits of urates were found in 0.5% subjects whiie conjuntiual urate crystals were found in 8.5% of the subjecls Conclucian: Hyperuricaemia is an important risk factor for ocular complications and starts almost after 8-12 weeks of cornmcncement of antituberclosis treatment. If it is left undiagnosed, sight-threatening effects can occur

study of doppler waveform pattern of hepatic veins in patients of acute viral hepatitis in comparison with control population

The objective of this study was to evaluate hepatic vein flow patterns in adults with acute viral hepatitis and to compare the findings with a control group of healthy people using Doppler ultrasound. Cross-sectional comparative study Radiology Department Military Hospital and Combined Military Hospital Rawalpindi from 15 May 2007 to 15 November 2007. Eighty patients who underwent doppler ultrasound at Military Hospital and Combined Military Hospital Rawalpindi during the study period were divided into two groups of 40 each. Cases were selected from the Out Patient Departments of Military Hospital and Combined Military Hospital Rawalpindi. Group I comprised patients with diagnosis of acute viral hepatitis based on clinical and laboratory findings. Group II included the control group comprising 40 healthy volunteers. Doppler ultrasound of hepatic veins was carried out in both the groups of patients. Abnormal wave pattern of hepatic veins on Doppler ultrasound was noted in 35 [87.5%] in group I and in 1[0.25%] of group II. One patient having abnormal Doppler wave pattern in group II subsequently developed acute viral hepatitis. Doppler ultrasound assessment of wave pattern in hepatic veins is an accurate method to differentiate a diseased liver from a normal one. Doppler ultrasound of hepatic veins is a good technique to study disease status of liver

Frequency of retinopathy in adult diabetics in Bahawalpur city

To determine the frequency of diabetic retinopathy in adult diabetic population of Bahawalpur city. A cross-sectional population based study was carried out to determine the frequency of diabetic retinopathy among adult diabetics of Bahawalpur City from January 2009 - June 2010 at Ophthalmology Department Bahawal Victoria Hospital, Bahawalpur and Department of Pathology, Quaid-i-Azam Medical College, Bahawalpur. Two thousand sixty diabetics [males=1090, females = 970] aged 18 - 55 years [mean age = 38 years] were included in the study who were residing in Bahawalpur for last 3 years. Anthropometric measurements including weight, height and waist measurement were obtained using standardized techniques. Blood pressure was recorded in the sitting position in the right arm to the nearest 2 mm Hg with a mercury sphygmomanometer. A fasting blood sample was taken after ensuring 8 hours of overnight fasting for estimation of plasma glucose. According to ADA criteria, patients having fasting plasma glucose > 99 mg/dl were considered to have impaired glucose level and OGTT was performed. Those having fasting plasma glucose level >/= 125 mg/dl were considered diabetic. For retinal studies, pupils were dilated in both eyes. The four fields taken were stereoscopic picture of the macula, disc and superior temporal and inferior temporal quadrants. Color photography [35 mm] was used because of better clarity and the stereo effect. The frequency of diabetic retinopathy in study subjects was found to be 34.5%. Occurrence of diabetic retinopathy shows a positive correlation with duration of diabetes. Frequency of diabetic retinopathy in Bahawalpur City is 34.5% and hyperglycemia, BMI, obesity, hypertension and dyslipidemia are direct association with diabetic retinopathy

Prevalence of impaired glucose tolerance among obese teenagers

Obesity has been accompanied by an increase in the prevalence of type-2 diabetes among adolescents. We determined the prevalence of impaired glucose tolerance in a cohort of 100 obese teenagers. Department of Medicine, BV Hospital, Bahawalpur. From January 2005 to January 2007. All subjects underwent a two-hour oral glucose-tolerance test [1.75 mg of glucose per kilogram of body weight], and glucose levels were measured fasting and during the first 30 minutes after the ingestion of glucose. Impaired glucose tolerance was detected in 21 percent of the 100 obese adolescents [11 to 19 years of age]; silent type-2 diabetes was identified in 4 percent of the obese adolescents. After the body-mass index had been controlled for, insulin resistance was greater in the affected cohort and was the best predictor of impaired glucose tolerance. Impaired glucose tolerance is highly prevalent among adolescents with severe obesity, irrespective of ethnic group. Impaired oral glucose tolerance was probably associated with insulin resistance

Intervention of insulin resistance at two stages in the evolution of type 2 diabetes

The purpose of this study was to compare the impact of treating insulin resistance with a thiazolidinedione drug before versus at the onset of diabetes on as per diagnosed by glucose levels and funduscopy. The study was conducted in Medical OPD, BVH, BWP from January 2001 to January 2007. One hundred twenty six non-diabetic young women who were 18-30 year old, with a history of GDM in the prior 4 year and a total glucose level on a 75-g oral glucose tolerance test [oGTT] above the median for women with gestational diabetes mellitus [GDM]were randomized to troglitazone [early intervention], 400 mg/d, or placebo [later intervention]. Women who developed diabetes were placed on open-label troglitazone. Glucose tolerance, insulin resistance, and funduscopy were measured at randomization, at the diagnosis of diabetes, and 8 months post trial to determine the long-term impact of the two treatments strategies on glucose levels and eye. During a mean follow-up of 4.3 year between baseline and post-trial tests, glucose tolerance [oral glucose tolerance test, P<0.04] and insulin resistance [P< 0.02] worsened more in women randomized to late intervention [n= 69] than to early intervention [n = 57]. Among women in the late intervention group who developed diabetes, retinopathy and cataract deteriorated significantly during development of diabetes on placebo and then did not change significantly [P >0.50] during treatment with troglitazone and post-treatment washout. In high-risk women, amelioration of insulin resistance can stabilize glycemia at the time diabetes develops. These findings highlight the role of insulin resistance in the genesis of progressive evolution of type 2 diabetes and successful treatment of insulin resistance in young, nondiabetic women with recent GDM lowered endogenous insulin requirements and stabilized pancreatic-cell function, thereby preventing type 2 diabetes in later life

Clinical chemical pathology of diabetics at the time of diagnosis at bahawal victoria hospital, bahawalpur

To determine the clinical chemical pathology of diabetes mellitus [DM] in patients at the time of diagnosis at Bahawal Victoria [BV] Hospital Bahawalpur. A hospital -based observational and prospective study. Bahawal Victoria Hospital, Bahawalpur.Jan 2000- Jan 2005. 210 consecutive cases of diabetes mellitus [males=99, females=111, aged 20-80 years] presenting to the out patient department with varying complaints were included. A detailed history with special emphasis on symptoms and signs was conducted and the findings observed were noted on a previously made performa. The diagnosis of diabetes mellitus was made on WHO Criteria as follows: Fasting plasma >=126mg/dl and/or 2hour postglucose load >=200mg/dl. Differentiation between Type 1 and Type 2 was based on age of onset and mode of treatment. Subjects with unequivocal results were further investigated by OGTT. The OGTT and its interpretation was carried out according to the recommendations of WHO Expert Committee on Diabetes. Plasma Lipids were determined all of the study subjects. Only 9.52% of the study population presented with the classical symptoms of diabetes mellitus at BV Hospital Bahawalpur. Most of the diabetics presented to the BV Hospital with symptoms as generalized weakness with aches and pains, numbness of feet, infertility, vulvovaginitus, blindness etc. Although, in total, a high percentage of the patients had complaints of polyuria, polydipsia and decreased body weight but in most of them these were not their presenting complaints.These study subjects did not necessarily have one specific presenting complaint. Different patients had different combinations of complaints. Dyslipidaemia was found in 39% males and 48% females of the study subjects. 33.31% males and 19.82% females had a positive family history for diabetes mellitus 39.29% males and 24.73% females had hypertension, 26.36% males and 26.78% females were obese. On funduscopic examination of the diabetics 1%males and 2% females were found to have retinopathy. Macular edema was noted in one patient. Classical symptoms of Diabetes metlitus may not be present at the time of diagnosis. Dyslipidemia is present in many cases with a high incidence of hypertension and obesity. Due to high morbidity and complications, physicians should be vigilant in making an early diagnosis of diabetes mellitus

Microalbuminuria: incidence in patients of diabetes mellitus at Bahawalpur

To determine the incidence of microalbuminuria in patients of diabetes mellitus.[type 1 and type 2] at Bahawalpur. Comparative, cross-sectional study. Bahawal Victoria Hospital, from September 99 to December. 02. 120 patients [Males=52; Females=68, aged 10-80 years]; with DM [Type 1 or 2] were included in the study. Detection of proteinuria was done by dry chemistry system using Medi-Test [Combi 10-Macherey-Nagel]. Proteinuria was confirmed by repeated testing and by measuring urinary protein excreted in 24 hours. Patients with proteinuria were not screened for microalbuminnuria. Screening for microalbuminuria was done on spot urine samples by dry chemistry systems using Micral -Test [Roche Diagnostic]. If the urine was positive for albumin, the test was repeated on two further occasions, over the next few weeks; if on two of three tests raised, 24- hour collection of urine was done to measured the albumin excretion rate [AER]. If AER was increased monitoring at each review visit was done. Funduscopy of all study subjects was done. Blood pressure was recorded on each visit and if raised, treatment with an ACE inhibitor was started; Baseline GFR was measured. If AER was normal on two of three occasions, AER was re-measured at the next review appointment. Out of 120 diabetics studied, 43.33% were males and 56.67% were females. Fifty percent of the females with DM and 29.1% of the males had microalbuminuria. Twenty [16.7%] of the diabetics had type 1 DM, out of them 50% had microalbuminuria. The duration of diabetes did not affect the incidence of microalbuminuria. Hundred [83.3%] of the studied patients had type 2 DM, 45% of this group was found to have microalbuminuria. Neither the incidence of proteinuria nor that of microalbuminuria was affected by the duration of diabetes. Fifty eight of the diabetics studied were hypertensive. 48.2% of hypertensive diabetics had microalbuminuria and 24.1% proteinuria. Incidence of microalbuminuria [73.9% and 72.72% of patients with type 1 and type 2 diabetes respectively] was common in diabetics with age ranging between 40-69 years. Incidence of microalbuminuria is high on our setup, reflecting poor glycaemic control

Estrogen replacement therapy for depression in perimenopausal women

To determine the effect of a four-week course of oral estrogen therapy on depression in aging women. Quasi experimental. The OPD, Bahawal Victoria Hospital, Bahawalpur, from September 2000 to January 2004. Forty-two depressed women [aged 42-57] who were either perimenopausal [n=20] or postmenopausal [n=22] received open label treatment with oral estrogen tablets[1.25mg/day] for 4 weeks. The Montgomery-Asberg Depression Rating Scale and the Beck Depression Inventory were used to assess depressive symptoms, the Greene Climacteric Scale was used to assess menopause-related symptoms, and the Clinical Global Impression[CGI] was used to assess global clinical improvement in these women at baseline and after treatment. Remission of depression was defined as a score <10 on the Montgomery-Asberg Depression Rating Scale and a score < 2 on the CGI at week 4. The women who completed the study had a median Montgomery-Asberg Depression Rating Scale score of 20 [range= 15-32] at study entry and 11.50 [range= 10-31.0] at week 4 [z = -3.43, p<0.01]. This improvement was consistent with that reported by the women themselves on the Beck Depression Inventory [rs=0.86, n=20, p<0.01]. The improvement measured by CGI scores was also significant [p<0.01]. Remission of depression was noted in 5 of the 40 women [after 1 year] who completed the study. Anti-depressant response was not associated with severity or subtypes of depression at study entry or with concomitant improvement in menopause-related symptoms. Perimenopausal and postmenopausal women benefit from short-term use of estrogen therapy. Antidepressant effect of estrogen therapy is independent of improvement in menopause-related symptoms

Effect of pregnancy on diabetic nephropathy and retinopathy

To determine whether pregnancy worsens renal function in women with diabetic nephropathy and the effect of pregnancy on diabetic retinopathy. Design: Cross-sectional analytical study. Place and Duration of Study: The study was conducted in OPD, Bahawal Victoria Hospital, Bahawalpur from September 1997 to June 2003. Subjects and Thirty-five patients [aged 20-36 years] identified with diabetic nephropathy and moderate to severe renal dysfunction[creatinine [Cr] > 1.4 mg/dl] at pregnancy onset by retrospective chart review. Alterations in glomerular filtration rate [GFR] were estimated. An equal number of non-pregnant premenopausal type I diabetic women with similar degrees of renal dysfunction served as controls for non-pregnant rate of decline of renal function and potential contributing factors. Student's t-test and repeated measures analysis of variance were analyzed. Mean serum Cr rose from 1.8 mg/dl prepregnancy to 2.5 mg/dl in the third trimester. Renal function was stable in 27%, showed transient worsening in pregnancy in 27%, and demonstrated a permanent decline in 45%. Proteinuria increased in pregnancy in 79%.Exacerbation of hypertension or pre-eclampsia occurred in 73% and 71% of these showed acceleration of disease during the pregnancy. All the patients had diabetic retinopathy, though proliferative retinopathy was diagnosed and treated in only 54.5.% prepregnancy. The retinopathy progressed, requiring laser therapy, in 45.4%. Macular edema was noted in 6 of the patients. Other diabetic complications included peripheral and autonomic neuropathy in 8 patients. Pregnancy induced progression is seen in the decline of renal functions. Patients with diabetic nephropathy were found to have a > 40% chance of accelerated progression of their disease as a result of pregnancy. Forty-five% of the patients had permanent decline in GFR in association with pregnancy

Role of chest X-ray in diagnosis and assessment of severity of high altitude pulmonary edema

High-altitude pulmonary edema [HAPE] is a life threatening illness in climbers who rapidly ascend to a high altitude of more than 3000 meters. Accurate diagnosis and assessment of this disorder is a challenge to radiologist at high altitude medical setup where X-ray chest is the only imaging procedure available. A descriptive study was carried out to diagnose and assess the severity of high altitude pulmonary edema on the basis of radiological scoring on chest X-ray. Thirty-one suspected patients of HAPE were evacuated from high altitude >4000 meters to CMH Skardu on basis of clinical features. Poster anterior chest radiographs were taken by X-ray machine [Siemens, Germany]. Each chest X-ray was evaluated in detail for severity of HAVE by radiological score. Ten X-ray chests of persons who did not develop HAPE were included as quality control. Out of these 31 provisionally diagnosed patients of HAPE, 26 [84%] showed radiological finding of high altitude pulmonary edema that varied from fine reticular pattern of interstitial edema to diffuse air space consolidation. X-ray chest of these patients showed mild HAPE in 14 patients [45%] and moderate HAPE in 11 patients [36%]. One patient [3%] had severe HAPE. It was observed that 15 patients [48%] had cleared their pulmonary fluid on the 2nd day while remaining patients showed normal Xray chest on the 4th day of start of symptoms. It is concluded that X-Ray Chest can play an important role in prompt diagnosis of HAPE and assessment of severity of this potentially life threatening illness by radiological scoring system for further management of these patients at high altitude medical setup

Differentiation of pulmonary embolism from high altitude pulmonary edema

To differentiate the high altitude pulmonary edema [HAPE] from pulmonary embolism [PE] by clinical probability model of PE, lactate dehydrogenase [LDH], aspartate transaminase [AST] and D-dimer assays at high altitude. Design: A prospective study. Place and Duration of Study: The study was carried out at CMH, Skardu, from October 2001 to December 2002. Subjects and Consecutive 40 patients evacuated from height > 3000 meters with symptoms of PE or HAPE were included. Clinical pretest probabilities scores of PE, Minutex D-dimer assay [Biopool international] and cardiac enzymes estimation by IFCC approved methods, were used for diagnosis. Mann-Whitney U test was applied by using SPSS and level of significance was taken at [p<0.05]. Out of 40 subjects, 31 HAPE and 9 patients of PE were initially diagnosed on the basis of clinical features, D-dimer assay and V-Q scanning. Out of 9 patients of PE; 3 had plasma D-dimer between 250-500 ng/ml and 6 > 500ng/ml. Plasma D-dimer of 500 ng/ml was considered as cut-off value; 6 [66.7%] patients of PE could be diagnosed and 30 [96.7%] cases of HAPE excluded indicating very good negative predictive value. Serum LDH, AST and CK were raised above the reference ranges in 8 [89%], 7 [78%] and 3 [33%] patients of PE as compared to 11 [35%], 6 [19%] and 9 [29%] of HAPE respectively. Clinical assessment in combination with D-dimer assay, LDH and AST can be used for timely differentiation of PE from HAPE at high altitude where diagnostic imaging procedures are not available