Sofa score and outcome: experience at a public sector hospital ICU

Objective: The objective was to find a cut off value of at admission SOFA score that best predicts outcome in critically ill patients admitted to ICU of public sector health care facility

Study Design: Cross-sectional, descriptive study

Place and Duration of Study: Medical ICU, Holy Family Hospital, Rawalpindi from February to April 2013

Material and Methods: One hundred and one patients were included. At admission SOFA score of each patient was noted. Data regarding age, gender, at admission SOFA score and outcome in terms of expired or improved [discharged/shifted from ICU] was sought. Receiver Operator Characteristics Curve [ROC] was drawn for SOFA score and poor outcome. Based on the coordinates of SOFA score and outcome ROC curve, best cut off value of SOFA scores with corresponding highest sensitivity and specificity was calculated. Outcome of patients above and below the cut off value was correlated employing Chi-square test

Results: Of the 101 patients, 39 [38.6%] improved and 62 [61.3%] expired. Mean initial SOFA score of patients who improved was 5.87 +/- 4.17 and who expired was 10.98 +/- 4.65. Coordinates of the curve showed that SOFA score cut off value 7.5 had best corresponding sensitivity [0.774] and specificity [0.744]

Based on this finding, patients were categorized to Group I [SOFA score <7], and Group II [SOFA score >8]. 32.6% of the Group I and 82.8% of the Group II patients expired [p-value 0.0000001]

Conclusion: Higher initial SOFA scores in critically ill patients is associated with higher mortality. Initial SOFA scores [<7 and >8] are best predictor of outcome in these patients

Effect of previous exposure to HBV on liver histology and treatment response in CHC patients

To analyze the influence of previous exposure to HBV on liver histology and treatment outcomes in chronic hepatitis C [CHC] patients. Case control study. Rawalian Liver Clinic, Department of Medicine, Holy Family Hospital, Rawalpindi, from January 2011 to December 2012. Medical records of CHC patients attending the Rawalian Liver Clinic were retrospectively analyzed. Virological and treatment responses along with histological changes were compared between cases [anti-HBc positive] and controls [anti-HBc negative]. Significance was determined through chi-square test at p < 0.05. Among the 592 CHC patients, 254 [42.9%] had serological evidence of a positive anti-HBc [cases] and 338 [57.1%], patients had negative anti-HBc [controls]. No significant difference was found between ETR, SVR and treatment responses [n=220] between the two groups. Out of 65 patients whose liver biopsy data was available, cases were more likely to respond in the absence of fibrosis [63.2%, [n=24] vs. 36.8%, [n=14], p=0.001]. The controls responded more in the presence of fibrosis [100% [n=9] vs. 0, p=0.001]. There was no significant effect of anti-HBc positivity on grades of inflammation and consequent treatment response [p=0.14]. There are a significant number of CHC patients with markers of previous HBV infection in Pakistani population. Previous HBV [anti-HBc positive] does not seem to have an adverse effect on liver histology and treatment responses in HBV infection

Dengue hemorrhagic fever: comparison of patients with primary and secondary infections

Dengue hemorrhagic fever [DHF] is considered to be associated with secondary dengue infection. This study was conducted to note frequency of primary and secondary dengue infection in DHF patients. Additionally these patients were compared in terms of age, gender, laboratory parameter, diseases severity and outcome. In this cross sectional observational study DHF patients fulfilling DHF criteria of Dengue Expert Advisory Group [DEAG] were included and divided into groups based on dengue specific IgG positivity and ratio of IgM to IgG. Group I, patients with secondary dengue infection were IgG positive or their ratio of IgM to IgG was <1.2. Group II, primary dengue infection patients were IgG negative or their ratio of IgM to IgG was >1.2. The two Groups were compared for statistically significant association in terms of age, gender, laboratory parameter [at admission hematocrit [HCT], platelet, white blood cell [WBC] counts, alanine aminotransferase [ALT] value], severity [DHF or dengue shock syndrome], and outcome [recovered or expired]. Two hundred thirty-four DHF patients were included. 66.2% was male and 33.8% female. Mean patient age was 28.8 +/- 12.4 years. Based on dengue markers results, 61.5% patients were categorized to Group I, and 38.5% to Group II. Statistically significant association between the two Groups was noted in terms of at admission platelet count, and ALT value, P value <0.05. Primary dengue infection is frequently associated with DHF. Patients with DHF caused by secondary dengue infection have lower at admission platelet counts and higher ALT value

Safety of non-anaesthesiologist-administered propofol sedation in ERCP

Propofol is increasingly being used for sedation purposes during endoscopic retrograde cholangiopancreatography [ERCP]. This study aimed to evaluate the safety of nonanaesthesiologist administration of propofol [NAAP] during therapeutic ERCP. Patients, who underwent ERCP at Centre for Liver and Digestive Diseases, Holy Family Hospital, Rawalpindi, were included in the study. Propofol sedation was administered by a physician who was a non-anaesthesiologist certified in basic and advanced cardiac life support. The total study duration was 6 months. The primary outcome variable was the frequency of any sedation-related complication. A total of 156 patients [41% males and 59% females] were enrolled in the study. The mean propofol dose used during the procedure was 201 +/- 132 mg. The mean propofol dose, when adjusted to weight and duration of procedure, was 0.05 +/- 0.04 mg kg[-1] min[-1]. According to the American Society of Anesthesiologists [ASA] classification. 136 [87%] patients were placed in ASA class I and II and 20 [13%] patients were of ASA class III. Only two patients developed sedation-related complication: one minor requiring bag-mask ventilation and other major requiring mechanical ventilation via endotracheal intubation. Both were managed by the trained non-anaesthesiologist and gastroenterologist at the pIace of procedure. No patients required cardiopulmonary resuscitation and admission to the intensive care unit. There were no sedation-related deaths. NAAP sedation can be considered safe for low-risk patients [ASA class I and II] undergoing ERCP. The presence of a trained anaesthetist is advisable in high-risk patients [ASA class III and higher] with significant co-morbidities

Obesity related compications in 100 obese subjects and their age matched controls

To note obesity related complications in subjects of age range 50-59 years. A case control study was conducted at Medical Unit of District Headquarters Hospital, Rawalpindi for 6 months. Hundred obese subjects in the age range 50-59 years and their age matched non-obese 100 controls were included consecutively from general population. Obese subjects had body mass index [BMI] >30Kg/m2. Controls had BMI of 18.5-22.9Kg/m2 and normal waist hip ratio. Obesity related complications i.e., hypertension, diabetes mellitus, ischemic heart disease, stroke, hyperlipidemia, gall stones, varicose veins, psychological problems, sleep related problems, and degenerative arthritis, were sought in all subjects. Waist hip ratio was noted as measure of central distribution of body fat in obese subjects. Of the 200 subjects, 59% [n=118] were female and 41% [n=82] male. Of the obese subjects 74% and 44% of non-obese controls were female. Mean age of obese subjects and their controls was 54.4'3.22 and 54.57'3.54 years respectively. Central obesity was noted in 84% of obese subjects. Hyperlipidemia [87%], hypertension [71%], diabetes mellitus [65%], gallstones [57%], ischaemic heart disease [49%], osteoarthritis [46%], and sleep disorders [35%] were significant [p<0.05] obesity related complications. Hyperlipidemia, hypertension, diabetes mellitus, gallstones, ischaemic heart disease, osteoarthritis and sleep disorders are common obesity related complications in subjects of age range 50-59 years

Characteristic features of 50 NAFLD patients

Objective: To note characteristic features of patients with nonalcoholic fatty liver disease [NAFLD] diagnosed on ultrasound basis

Design: Descriptive

Place and duration of study DHQ Teaching Hospital, Rawalpindi, from January to June 2003

Materials and Methods: Fifty NAFLD patients diagnosed on ultrasonographic findings were inducted consecutively. Patients with conditions associated with secondary NAFLD were excluded. Clinical and laboratory evaluation of each patient was done to note presence or absence of obesity, hepatomegaly, cholesterol and triglyceride levels, and diabetes mellitus. Obtained data was analyzed using statistical program, SPSS version 10

Results: Of the 50, 54% were female and 46% male. Mean patient age was 42.78 +/- 12.29 years. 66% patients were obese, 56% had hepatomegaly, 28% had elevated cholesterol, 72% had hypertriglycedemia, and 44% were diabetic. All of these features except for hypercholesterolemia were common in females

Conclusion: Obesity, hepatomegaly, diabetes, and hypertriglycedemia are characteristic features of our NAFLD patients that are more common in females

12 years audit of upper gastrointestinal endoscopic procedures

Evaluation of upper gastrointestinal [GI] endoscopy in terms of indications, diagnostic efficacy, and diseases diagnosed. Design: Retrospective, observational case series. Place and Duration of Study: DHQ Teaching Hospital, Rawalpindi, from March 1990 to December 2001. Subjects and Patients who underwent upper GI endoscopy in 12 years were included. Upper GI endoscopies were performed according to standard protocol. Endoscopic diagnoses were based on widely accepted criteria. Of the 8481 patients, 4935 [58.2%] were female and 3546 [41.8%] male. Mean patient age was 40.5 years. Dyspepsia [42.6%], upper GI bleed [32.8%], and evaluation of chronic liver disease [10.2%] were common indications of the procedure. An endoscopic diagnosis was possible in 82.6% patients. Varices, gastritis, duodenitis, and combined lesions were common endoscopic diagnosis. Gastritis and duodenitis were most frequent causes of upper GI bleed. We noted more gastric ulcers compared to duodenal ulcers. Females had significantly more normal endoscopies, p-value= 0.02. Upper GI endoscopy is an effective procedure. Dyspepsia evaluation is commonest indication for upper GI endoscopy in our patients. Etiology of upper GI bleed, and incidence of duodenal ulcer compared to gastric ulcer in our patients are different than described in literature. Females have significantly more normal endoscopies

Retrospective study of 10-cases of peripartum cardiomyopathy

In order to characterize the features of peripartum cardiomyopathy, clinical, electro-cardiographic and echo cardiographic data obtained from ten patients [mean age 36.7 years +/- 7,2] who fulfilled peripartum cardiomyopathy diagnostic criteria were analysed [1]. All were multiparous. Eight [80%] developed heart failure 6.1 weeks +/- 2.2 after delivery and two [20%] in last trimester. Six [60%] patient were in NYIIA functional class III and two [20%] in class IV. Cardiothoracic ratio was increased in all patients on chest X-Ray. Two dimensional echocardiography showed increased internal diameter of left ventricle with poor systolic function in all patients