Beyond the liver! extra hepatic manifestations: assessment of frequency and risk factors among hepatitis b and c related chronic liver diseases

Objectives: The study aimed to determine the frequency and risk factors for Extra Hepatic Manifestations among patients with Hepatitis B and C related Chronic Liver Diseases

Study Design: Cross Sectional Study

Place and Duration of Study: This Study is conducted at the Department of Medicine [Both indoor and outdoor patients] of Civil Hospital, Karachi from 2012 to 2016

Materials and Methods: In this study of 548 patients, who were positive for HBV or HCV, fulfill the selection criteria and were suffering from Chronic Hepatitis, Cirrhosis or HCC were examined for Extra Hepatic Manifestations clinically and if required appropriate tests were done to confirm the diagnosis and finding. Frequency and risk factors were determined for extra hepatic manifestations. Test of statistical significance were applied where p value of <0.05 was considered to be statistically significant cut-off

Results: Majority of patients 432 [78.8%] were HCV Positive and 116 [21.2%] were found to be HBV positive. Overall frequency of extra hepatic manifestations was found to be 54.7 %. Patients with chronic hepatitis C and B. The Extra Hepatic Manifestations of 60.6 % in HCV and 32.8% in HBV respectively. Diabetes Mellitus [DM] is the most common extra hepatic manifestation found in both, chronic HCV [19.0%] and chronic HBV patients [5.2%] whereas hypertension is the second commonest extra hepatic manifestation among HBV patients [12.1%]. Disease duration > 5 years, age> 45 years, Viral PCR, Raised ALT and Hepatocellular Carcinoma associated with chronic HCV and HBV were found to be significant risk factors for extra hepatic manifestations

Conclusion: Extra Hepatic Manifestations are more common in HCV associated liver diseases than HBV. Diabetes and hypertension are the main extra hepatic manifestation among HBV and HCV positive patient. Disease duration > 5 years, age> 45 years, Viral PCR, Raised ALT and HCC associated with chronic HCV and HBV were found to be significant risk factors for Extra Hepatic Manifestation

Hypocholestrolic effect of spent black tea leaves replaced with wheat bran in broiler ration

Black tea leaves [Camellia sinensis] have been known for many years in lowering cholesterol level. The purpose of the present study was to find the effects of spent black tea leaves as a substitute of wheat bran on cholesterol reduction in broiler chicks. For this purpose a total of hundred and fifty [150], day old broiler poultry chicks were purchased from the local market. The spent black tea leaves were collected from tea stalls. Chicks were randomly distributed into 5 main groups according to spent black tea leaves and wheat bran supplementation. Group R[0] was kept as control, containing 120g/kg wheat bran but no spent black tea leaves supplementation; group R30 received spent black tea leaves supplemented feed at the rate of 30g/kg plus 90g/kg wheat bran; group R60 received spent black tea leaves supplemented feed at the rate of 60g/kg plus 60g/kg wheat bran, group R90 received spent black tea leaves supplemented feed at the rate of 90g/kg plus 30g/kg wheat bran and group R120 received the spent black tea leaves supplemented feed at the rate of 120g/kg plus 0 g/kg wheat bran respectively. Each group was carrying three replicate [10 chicks/replicate]. The data was statistically analyzed, using completely randomized design. Mean liver cholesterol per chick on diet R[30], R[60], R[90], and R[120] was 102.22, 93.55, 76.22, 60.78 and 51.55mg/100g. Breast cholesterol per chick on diet R[30], R[60], R[90], and R[120] was 61.89, 51.33, 44.78, 37 and 32.77mg/100g. It was concluded that the addition of spent black tea leaves at the rate of 120g/kg has significant effect on cholesterol reduction and over all performance of broiler chicks and recommended that expensive wheat bran can be effectively replaced by these spent black tea leaves in broiler poultry ration

Developing local guidelines for management of sepsis in adults: sepsis guidelines for Pakistan [SGp] endorsed by global sepsis alliance

The purpose of developing [Sepsis Guidelines for Pakistan] [SGP] is to provide clinicians practicing in local hospitals with a framework to aid timely recognition and management of adult patients in sepsis by adopting evidence-based recommendations of Surviving Sepsis Campaign [SSC] tailored to available resources. These recommendations are not meant to replace the SSC Guidelines. SGP is an initiative of Pakistan Society of Critical Care Medicine [PSCCM]. Four key decision points to be addressed in the guidelines were identified by a thirteen member multidisciplinary committeei.e., grading the hospitals in the country, recognition of sepsis and associated organ dysfunction, essential interventions to manage sepsis, and general measures for provision of a comprehensive care to patients in sepsis according to the level of education and training of healthcare providers and facilities and resources available in different levels of hospitals. The draft was presented at the 3[rd] Sepsis Symposium held on13[th] September, 2014 in Karachi. The final document was approved by a panel of experts from across the country, representatives of relevant societies and Global Sepsis Alliance [GSA]. Hospitals are divided into basic, intermediate and tertiary depending on the availability of diagnostic facilities and training of the medical personnel. Modified definitions of sepsis,severe sepsis, and septic shock are used given the lack of facilities to diagnose sepsis according to international definitions and criteria in Pakistan. Essential interventions include fluid resuscitation,vasopressors to support the circulation, maintaining oxygen saturation >/= 90% with oxygen, non-invasive ventilation or mechanical ventilation with lung protective strategies, prompt administration of antibiotics as recommended by the Medical Microbiology and Infectious Diseases Society of Pakistan [MMIDSP] and early source control. It is recommended to avoid starvation, keep an upper blood glucose 7.20, avoid fresh frozen plasma in the absence of bleeding, transfuse platelets if indicated, not use intravenous immunoglobulins and avoid neuromuscular blocking agents [NMBAs] in the absence of ARDS, target specific titration endpoints when continuous or intermittent sedation is required in mechanically ventilated patients and use continuous renal replacement therapy [CRRT] to facilitate management of fluid balance in hemodynamically unstable septic patients in tertiary care centers. In addition a comprehensive, meticulous and multidisciplinary general care is required to improve outcome of sepsis by reinforcing hand hygiene and other infection control measures, adequate monitoring and documentation tailored to the available resources. Goals of care and prognosis should be discussed with patients and families early and either shifting the patient to a hospital with better facilities or limiting or withdrawing therapy in case of poor prognosis should be considered

Evaluation of the Level of Satisfaction Among Family Physicians of their Undergraduate Dermatology Teaching

To evaluate teaching and learning among undergraduate dermatology trainees and also to suggest measures for improvement. Cross sectional survey. The study was conducted at department of dermatology, Pakistan Railway Hospital Rawalpindi, from July 2011 to Dec 2011. An especially designed Proforma was distributed to family physicians in different cities of Punjab and KPK.Total of 121 doctors were recruited for study and 105 Performa were analyzed, which were filled by graduates from Pakistani medical schools.The Information was collected regarding different aspects of their undergraduate dermatology training e.g. lectures, duration of dermatology rotation and assessment techniques used in examination. In the second part of the proforma, family physician's satisfaction level has been assessed regarding adequacy of training, availability of resources and clinical exposure. The responses were recorded on Likert scale 1- 5.Their proforma was analyzed using SPSS version 16. 91% of family physicians disagreed that their Undergraduate dermatology training was adequate regarding duration and content. 85% disagreed that the faculty and infrastructure for dermatology training were adequate in their teaching institution.About 90% of family physicians agreed that more time allocation, early clinical exposure, problem based learning and more question items for dermatology assessments will improve the training of undergraduates. Majority of the family physicians are dissatisfied with their undergraduate dermatology training. They suggest that more time and resources should be allocated for dermatology undergraduate training

Outcome of open versus laproscopic appendicectomy in department of surgery, lady reading hospital, Peshawar

To compare safety and benefits of laparoscopic versus open appendicectomy in a randomized control clinical trial. Between January 2008 and October 2009 one hundred and twenty patients [86 male and 34 female] with suspected acute appendicitis were assigned either to laparoscopic [n=60] or open [n=60] appendicectomy. Surgical technique was standardized for both laparoscopic and open procedure. The patients were analyzed in terms of the following aspects and findings; operation time, postoperative pain, intra and post operative complications, hospital stay and return to normal daily activities. There was no mortality. Wound infection [8.3%] and intra-abdominal abscess [11.6%] formation rate was significantly higher in open group than in the laparoscopic group [1.6%] and [3.3%] respectively. Postoperative pain scores [assessed by a pain distress variable, indicated on visual linear scale 0 to 10 and a pain activity scale, indicated on visual linear scale 0 to 10] was significantly lower in laparoscopic group. Hospital stay was significantly shorter in laparoscopic group [p<0.0353] and mean operation time was similar in both groups. One patient [1.6%] was converted from laparoscopic to open appendicectomy due to diffuse pelvic adhesions. Though operation time was same but complications, pain and hospital stay was less in the Laparoscopic group

Evaluation of the diagnostic accuracy of serology test kit for detection of h.pylori infection in patients presenting with nonulcer dyspepsia taking histopathology as gold standard

To evaluate the diagnostic accuracy, specificity, sensitivity, positive predictive value and negative predictive value of serological testing in detection of H. pylori infection taking histopathology as gold standard. This study was a cross sectional survey carried out at the Histopathology department of Shaikh Zayed Federal Postgraduate Medical Institute Lahore from 27[th] December 2005 to 23[rd] November2006.A total of 100 adult patients of both genders with complaints of non-ulcer dyspepsia from whom gastric biopsies were taken by endoscopy in the Gastroenterology Department were included in the study. Two tests namely, histopathological identification of H. pylori [gold standard] and serological test were carried out on each patient. The diagnostic accuracy, specificity, sensitivity, positive predictive value and negative predictive value of serological test were calculated. The diagnostic accuracy of serological testing in detection of H. pylori infection was 62% in the present study. The sensitivity was 88.6% and Specificity was 41.07%. Positive predictive value and negative predictive value was 54.16% and 82.1% respectively. This test is useful for detecting a newly infected patient, but it is not a good test for follow up of treated patients because the results do not indicate if this is a recent infection with H. pylori or otherwise

Identification of climate changes in the lower indus basin, Sindh, Pakistan

There are several factors causing impact on the climatic sustainability. Human's intervention in the hydrodynamic cycle is one of them. The research studies, relevant to downstream areas of some world's major river systems like Huang He, Nile and Danube rivers, show drastic climatic changes in response to the large scale hydrological moderation due to the man-made water-flow diverting activities in the upstream areas. Similar climatic changes have been identified in the case of the Indus river. The results of present study show that the trends of 44-years' annual average temperatures, precipitations and humidity parameters are distinctly changing in the lower Indus river basin from 1961 to 2004 and expectedly onward particularly in and around the delta region. In general, the average annual temperatures show the rising trend and inversely the precipitation and humidity are decreasing causing substantial deterioration of the rainfall scenario in and around the study area. Considering the mass water divergence of the Indus River System in upstream areas causing acute depletion of Indus water-flow into the downstream Kotri barrage areas and the fast urban and industrial developments, it is inferred that the present climate changing trends are being more augmented due to the critical depletion of the Indus environmental-flow in the Badin area of the lower Indus basin as compared to the Hyderabad and the Karachi areas where ever-increasing faster urban and industrial growths are also contributing substantial inverse impact on the climatic parameters

Clinical presentation and outcome of patients presenting with guillain barre syndrome

To identify the clinical features and outcome of Guillain Barre syndrome [GBS] in patients presenting to general I. C. U. This descriptive study was carried out on patients with the clinical evidence of GBS admitted in the General Intensive Care Unit of Lady Reading Hospital Peshawar, from January to December 2005. All those patients having sensory loss or in whom only legs were affected were excluded from the study. Each patient had a detailed interview and underwent complete neurological and systemic examination. After the confirmation of diagnosis of GBS, the treatment was started accordingly. In this study 14 patients with GBS were treated. There were 13 [93%] male and 1 [07%] female. Ten [71.4%] were in the age range of 15-60 years. All [100%] patients presented with limb weakness. Numbness and paraesthesia was noted in 9 [64.28%] patients. Four [28.57%] patients presented with respiratory difficulty. Muscle weakness and absent reflexes were present in all patlents. Nine [64.1%] patients were offered conservative treatment and 4 [28.6%] patients were treated with assisted ventilation and 1 [07.1%] patient received lmmunoglobulins therapy. Four [28.6%] patients expired in ICU due to respiratory failure in spite of being on ventilator. One [07.1%] patient was taken to home by the attendant against medical advice. More males are affected than females. Limb weakness, respiratory muscles weakness and absent or diminished reflexes are the commonest clinlcal features. Hlgh mortality in this disease is associated with respiratory failure

Study of post-thoracotomy consumption of morphine in patients undergoing lobectomy

Objective: adult patients undergoing thoracotomy for lobectomy have been studied for post-operative pain management in the Intensive Care Unit of Cardio-thoracic Department, PGMILRH, and Peshawar

Material and Methods: 40 patients were divided in two groups, each comprising of 20 patients. Patients in both groups "A" and "B" were comparable in age and procedure and had received the same pre-medication and anasthesia. Patients in-group "A" received boluses of LV. Morphine 3 mg 4-6 hourly while patients in group "B" received pre-incisional Bupivacaine 0.25% via intercostal infiltration which was repeated 12 hourly, group "B" also received W Morphine when severity of pain demanded so. Pain was scored using Visual Analogue Score [VAS]. Patients were nursed I.C.U. propped up in beds receiving 5 L of humidified 02. Study period extended over 48 hours

Results: mean Morphine consumption in-group "A" was 36 mg [range 35-37 mg] while in-group "B" it was 23 mg [range 20-25 mg]

Conclusion: in conclusion patients of Bupivacaine group consumed less Morphine [36.1%] preserving good oxygenation, and pulmonary functions

Late onset asthma and pulmonary infiltrates

We are discussing a patient who was initially diagnosed and treated as pulmonary tuberculosis, but on follow up the clinical, radiological features and investigations were highly suggestive of pulmonary vasculitis. Pulmonary vasculitis occurs in a number of conditions including polyarteritis nodosa, SLE, and Wegener's granulomatosis. This can be the sole manifestation of these diseases for months to years before other systemic manifestations appear