Screening outcomes of household contacts of multidrug-resistant tuberculosis patients in Peshawar, Pakistan

OBJECTIVE@#To assess the profile of TB/multidrug-resistant TB (MDR-TB) among household contacts of MDR-TB patients.@*METHODS@#Close contacts of MDR-TB patients were traced in the cross-sectional study. Different clinical, radiological and bacteriological were performed to rule out the evidence of TB/MDR-TB.@*RESULTS@#Between January 2012 and December 2012, a total of 200 index MDR-TB patients were initiated on MDR-TB treatment, out of which home visit and contacts screening were conducted for 154 index cases. Of 610 contacts who could be studied, 41 (17.4%) were diagnosed with MDR-TB and 10 (4.2%) had TB. The most common symptoms observed were cough, chest pain and fever.@*CONCLUSIONS@#The high incidence of MDR-TB among close contacts emphasize the need for effective contact screening programme of index MDR-TB cases in order to cut the chain of transmission of this disease.

Screening outcomes of household contacts of multidrug-resistant tuberculosis patients in Peshawar, Pakistan

Objective To assess the profile of TB/multidrug-resistant TB (MDR-TB) among household contacts of MDR-TB patients. Methods Close contacts of MDR-TB patients were traced in the cross-sectional study. Different clinical, radiological and bacteriological were performed to rule out the evidence of TB/MDR-TB. Results Between January 2012 and December 2012, a total of 200 index MDR-TB patients were initiated on MDR-TB treatment, out of which home visit and contacts screening were conducted for 154 index cases. Of 610 contacts who could be studied, 41 (17.4%) were diagnosed with MDR-TB and 10 (4.2%) had TB. The most common symptoms observed were cough, chest pain and fever. Conclusions The high incidence of MDR-TB among close contacts emphasize the need for effective contact screening programme of index MDR-TB cases in order to cut the chain of transmission of this disease.

Pattern of indications of flexible bronchoscopy among adult patients in a tertiary care hospital

Background: Flexible fiber optic bronchoscopy is frequently performed procedure in pulmonary medicine

Objective: To determine the Clinico-radiological indications of flexible bronchoscopy in a tertiary care hospital

Materials and Methods: This descriptive study was conducted in the bronchoscopy suit of pulmonology department post graduate medical institute[PGMI], Lady Reading Hospital, Peshawar from Jan 2008 to Dec 2010. This was a retrospective analysis of the well maintained records of patients in whom bronchoscopy was done in the above mentioned duration. All the patients above 15 years were included. All the bronchoscopies were done by expert brochoscopists under local aneasthesia. Data was analyzed by SPSS 13 to find the frequencies and percentages

Results: Total number of patients were 423, with a male to female ratio of 1.6:1, in which 191 had haemoptysis , 115 presented with chronic cough, 42 had shortness of breath [SOB] , 11 presented as superior venacaval [SVC] obstruction, 25 had lobar or full lung collapse on chest x rays and 9 patients had solitary or multiple nodules, 8 were scoped for removal of foreign bodies, 4 for medical fitness and 2 for persisted fever. After analysis of x-rays of proven malignancies out of 60 patients, 20 [33.33%] had right side non-resolving consolidation, 18 [30%] Left side consolidation,08 [13.4%] presented with hilar mass, 03 [5%] with multiple nodules, 04 [6.66%] with mediastinal widening , 03 [5%], with left sided lobar collapse, 02 [3.33%] with right lobar Collapse and 02 [3.33%] had either side full lung collapse

Conclusion: Bronchoscopy is an important tool for the diagnosis of the cause of radiological/clinical findings like haemoptysis, chronic cough, SOB, SVC obstruction, hoarseness of voice and persistent x-ray opacity, or lobar or lung collapse. Heamoptysis and chronic cough are the main indications in our setting. Bronchoscopy is minimally invasive procedure with high diagnostic yield for bronchogenic tumours especially central

Outcome of tuberculosis patients registered during 2007 in major teaching hospitals of Peshawar

To evaluate the efficiency of TB diagnostic centers of teaching Hospitals of Peshawar against the set target of treatment success rate of 85% in the teaching hospitals of Peshawar. This descriptive study on data analysis was carried out in National TB Programme [NTP] Centers in major teaching hospitals of Peshawar, NWFP. The patients included in this study were registered from 01/01/07 to 31/12/07. National TB Program [NTP] registers from the three teaching hospitals i.e. Lady Reading Hospital, Khyber Teaching Hospital, and Hayatabad Medical Complex, were studied. All the patients registered in year 2007 were studied for their outcome. The study included 306 patients. Male were 153 [50%] and 153 [50%] females. 191 [62.4%] patients were below 30 years of age, 87 [28.4] patients were between the ages of 31-60 years of age and 28 [9.2%] patients were above the age of 61 years. 149 [48.7%] patients had pulmonary tuberculosis, whereas 157 [51.3%] patients extra pulmonary tuberculosis. Among the Pulmonary tuberculosis patients 101 [67.8%] were smear positive, while 38 [25.5%] patients were smear negative. Out of these 306 patients, 294 [96.1%] patients were new cases and 12 [3.92%] patients were relapses. All registered patients included in the study were followed for 8 months at monthly intervals. 110 [35.9%] patients were cured, 194 [63.4%] patients completed their treatments. Only in 1 patient treatment failed, 1 died, while none of the patients defaulted. The treatment success rate was 99.4%.The performance of TB Control Programme at three teaching hospitals of Peshawar in year 2007 was excellent, showing treatment success rate of 99.4% which is way above the target set by W.H.O. of 85%

Study of current management of community acquired pneumonia and strategies for improvement

To see that the patients admitted with community acquired pneumonia [CAP] are managed in accordance with British Thoracic society recommendations and guidelines. All patients admitted with Community-Acquired Pneumonia in medical wards admitted in large district general hospital setting in UK, were audited. The study period was between September and October 2002. Permission for the study was taken from the local hospital trust audit department. Seventy one sets of notes were reviewed leaving 38 patients appropriate for inclusion into the study. The findings observed in the record revealed that, Respiratory rate was not recorded in 36.8% [n=14] patients, level of confusion not recorded in 47.4% [n=18], Blood cultures not sent in 42.1% [n=16] patients, sputum not sent for culture in 47.4% [n=18] cases. Inappropriate antibiotics used 18.4% [n=7], treatment time of senior review not documented in 36.8% [n=14], radiographic findings not documented in 13% [n=5] cases. No follow up arrangements were made in 13.2% [n=5]. Average time of senor review was 6 hours and average time of antibiotic given after admission was 2 hours. This audit shows that even in a developed country with well-established guidelines for management of different diseases, guidelines for management of community-acquired pneumonia are not strictly adhered to. More efforts need to be made for dissemination and implementation of these guidelines

Career planning by the doctors in NWFP

To determine the extent to which a doctor in NWFP has the knowledge and opportunity to plan his career at right time and reasonable cost. This prospective descriptive study was conducted at the Postgraduate Medical Institute, Hayatabad Medical Complex, Peshawar from August 2006 to January 2007. Relevant information's were recorded on a questionnaire prepared in accordance with the objectives of the study. This study comprised of 82 individuals who responded to the questionnaire, with age ranging from 25-35 years [mean age 28.13 years, SD +/- 2.8, median 30 years]. Out of 82 respondents, 25 [30.5%] had received some kind of orientation about career planning while 56 [68.3%] had received no orientation so far [one respondent did not answered this question]. Out of 82, sixty-two [75.6%] were either self motivated to attempt a postgraduate exam or were guided by their teachers. In terms of time lost, 29 [35.4%] replied that they had wasted their time in thinking/choosing, while 13 [15.8%] pointed out to have wasted additional time in switching over their career from one field to another. Similarly, in terms of finance, 07 [8.07%] responded to have suffered financially. In NWFP due attention has not been paid to career planning and even the well educated class [doctors] are wasting their precious time and finances due to lack of guidance in career planning field

To study the outcome of patients with Multi-Drug Resistant Tuberculosis and see the effectiveness of second line drugs available in Pakistan in the management of MDR TB

MDR TB is a difficult problem to treat specially in countries like Pakistan, where facilities to treat the patients in hospital for the whole course of treatment are limited and also all the effective second line drugs are not available. This study was aimed to see the effectiveness of second line drugs that are available in Pakistan in terms of sputum conversion and cure rate and to see the resistance pattern of MDR TB. This study was carried out from 1st March 1995 to 31st Dec 2001 in a Chest Clinic in Peshawar. All patients having active Pulmonary Tuberculosis with history of irregular treatment in past were included in the study irrespective of age and sex. Their sputum samples were sent for AFB culture and sensitivity and they were started on second line anti tuberculosis drugs. The pattern of drug resistance was noted from results of culture and sensitivity results, when available. The progress of the patient was monitored by clinical assessment, sputum examination and Chest Radiographs on subsequent follow up visits monthly for first three months and then at 2-3 months intervals until completion of treatment. 70 patients, [40 males and 30 females] were included in the study. 05 patients excluded after their sputum C/S showed that they were not having MDR TB. 38% patients had bacilli resistant to all 06 first line drugs, 20% resistant to 05% drugs, 25% resistant to 04 drugs, 12% resistant to 3% drugs and only 05% were only resistant to 02 drugs i-e Rifampicin and INH. Regimen used was Kanamycin 15 mg/kg, Ofloxacin 400-800 mg/day, PAS 150 mg/kg, Ethionamide 15 mg/kg and Thiacetazone and INH 2.5 and 5 mg / kg respectively. The regimen was modified after C/S report with addition of first line drugs to which the bacilli were sensitive. At the end of 02 months the conversion the conversion rate was 79%. Treatment Outcome: 55% patients were cured, 21% lost, 10% had treatment failure and 2% reported dead. Half of the patients cured have been attending for optional follow up for the period ranging from 1 to 6 years and only two patients have relapsed so for. The second line drugs that are available in Pakistan are effective both in terms of sputum conversion and achieving cure. Large number of patients lost signifies the fact that these patients need to be hospitalized and treated under direct supervision for the whole period of treatment as recommended

Survey of chest specialists and trainees knowledge and practice of TB guidelines

To investigate the fundamental knowledge of TB guidelines and their application in day to day practice by the chest specialists and trainees working in teaching hospitals. A questionnaire-based survey was conducted among the participants of 5th biennial chest conference. The data of 195 doctors was analyzed. 96% of doctors said they were treating their TB patients according to guidelines and categorize their patients for treatment, but only 54% knew the correct number of categories for treatment as recommended by the guidelines. Only 49% knew about the components of DOTS. 85% doctors considered sputum microscopy most important diagnostic test for TB and 61% would use it for monitoring of their patients. 88% would advise sputum AFB culture and sensitivity in suspected cases of suspected drug resistance, 59% doctors would treat MDR TB patients themselves and 33% would refer to specialized centers. 5 declared them incurable. 47% and 30% doctors respectively recommended changes in WHO recommended fixed drug combination FDC during pregnancy and lactation. 58% doctors recommended chemoprophylaxis for tuberculosis in our setting. Overall fundamental knowledge of consultants regarding management of TB was good. Knowledge about DOTS and TB guidelines among all the doctors was average and needs improvement. Management of MDR TB by trainees is alarming in the absence of adequate knowledge and experience

Survey of awareness and management attitudes of chest specialist and trainees towards asthma

The study was aimed at three objectives: i. To know about doctors understanding of pathophysiology of Asthma. ii: To assess the knowledge of treatment of asthma and actual treatment practices by Chest specialists and Postgraduate trainees. iii: To assess the baseline knowledge, attitude and treatment practice in the absence of any local treatment guidelines and then see the effectiveness of the guidelines in changing their practice. A preset questionnaire was distributed among doctors from all over Pakistan, during 5th Biennial Conference on Lung Health in 2002. Each question was followed by a set of answers, of which one was to be tick marked. 66 doctors participated, 14 teaching consultants, 24 chest specialists, 14 postgraduate students, and 14 other doctors. 82% doctors would treat their patients on long-term basis and 18% would treat them acutely. 71% thought asthma was chronic inflammation of the airways whereas 28% thought it was due to bronchoconstriction and mucus plugging. Airways remodeling was considered to be partially or fully reversible by 90% and not reversible by 8%, 2% did not respond. 89% were fully aware of stepwise management of asthma and 11% were little aware. The grading of asthma severity was done by clinical examination 44% and clinical plus spirometery 56%. Inhalers were prescribed always by 35%, frequently by 57% and sometimes by 6%. 78% prescribed steroid inhalers alone or in combination with Beta 2 agonist, whereas 12% used only Beta 2 agonist. 93% would teach inhaler technique by themselves or by trained technician and 7% would leave it to chemists or patients. 88% would check inhaler technique on follow-up visit. 92% used oral drugs with inhalers. The choice of oral drugs varied between steroid [8%], theophylline [28%], Beta 2 agonist [37%], and leukotriene inhibitors [18%], no response [9%]. 47% sometimes and 50% never advised desensitization while 3% recommended it frequently. A significant proportion of doctors lacked a good understanding of pathophysiology of asthma. Although the majority of chest physicians and trainees were fully aware and correctly practiced, a significant number [i.e. one fourth] of doctors were not managing their patients with asthma correctly according to the guidelines

Comparison of the efficacy of 06 months vs 09 months therapy in smear positive pulmonary TB

This study was aimed to assess and compare the efficacy of anti TB treatment for 6 months and 9 months duration. New cases of sputum smear positive TB were randomly allocated to one of the two groups. Both received RHZE [Myrin P] in first 2 months followed by RH for 4 months [Group A] and RH for 7 months [Group B]. Patients were followed at monthly interval for first 2 months and then 2 monthly intervals until completion of treatment and subsequently followed at 6 monthly intervals for 18 months to monitor for relapse. Sputum smears were examined for AFB at every visit and chest x-ray performed at 1, 2, 6 and 9 and then 6 monthly interval

Results: 200 patients were studied, 93 patients in group A [6 months regimen] and 107 in group B [9 months regimen]. At the end of one month, sputum conversion in both the groups together was 89% and at the end of 2 months was 97%. Treatment Out come Group-A: Cured 32.5%, Treatment completed 16.8%, lost to follow up 50.5%, relapse 12.5% and there was no treatment failure. Group-B: Cured 18.07%, treatment completed 25.4%, lost to follow up 55%, relapse none and one patient had treatment failure

Conclusion: Default rate was extremely high in this study, where treatment was not supervised. Sputum conversion of 97% to FDC, RHZE [Myrin P] was impressive. There was no significant difference in the treatment outcome in the two groups, however 12.5% relapse rate in 6 month regimen as compared to none in 9 months regimen is rather alarming