Low levels of vitamin D[3] in people of Karachi - needs to be readdressed

Objective: The aim of this study is to see the frequency of vitamin D and its impact on the sample population

Study Design: Descriptive / cross sectional study

Place and Duration of Study: This study was conducted at Trauma and General Hospital, Karachi from January 2014 to June 2015

Materials and Methods: 205 patients were included in the study. Participants were assessed according to predesigned questionnaire. All patients were subjected to have complete blood count, serum calcium, phosphorous, albumin, alkaline phosphatase, SGPT, vitamin D and parathyroid hormone levels along with X-rays of hip joint and femur

Results: Out of total 205 patients, 12.7% were males and 87.3% were females. Mean age was 41.32 +/- 15.225 years. 5.9% had normal levels of Vitamin D[3], while 60.5%, 27% and 6.5% showed mild, moderate and severe deficiency. Serum calcium and phosphorous were deficient in 20.4% and 31.9% respectively. Serum alkaline phosphatase and parathyroid hormone were normal in most of the participants. The deficiency of Vitamin D[3] was mostly due to reduced sun exposure and excessive clothing [86.8%] while 8.3% showed malabsorption. This deficiency caused bone pains, and muscle pains in 55.6%, and 17.6% respectively. But none of the patient had any fracture

Conclusion: Levels of Vitamin D[3] are low in most of the people of Karachi but without any gross deformity. It is advisable to readdress the daily requirement of vitamin D bring the awareness among people regarding sun exposure and daily use of vitamin D supplements

Decompensated cirrhosis; thyroid hormone levels in patients

Objective: The objective of the study is to find out, the levels of thyroid hormones in serum of the patients having decompensate cirrhosis and to determine the frequency of signs and symptoms of thyroid dysfunctions in such patients. Study design: Prospective descriptive study. Setting: All medical wards of Civil Hospital and Ojha campus, Dow University of Health Sciences, Karachi, Pakistan. Period: May 2013 to January 2015

Methodology: 76 patients having decompensated liver cirrhosis with various presentations, which were fulfilling the inclusion and exclusion criteria and were admitted in medical wards during the study period, were included in this study. Detailed history and examination of each case was performed. Thyroid hormone levels were performed along with other relative laboratory investigations and the results were obtained

Results: Out of 76 patients 58 patients had low serum T3 levels, whereas 18 had normal T3 levels. 65 patients had normal T4 levels and 11 had low serum T4 levels. The TSH levels were found normal in 74 patients and two patients had raised TSH levels

Conclusion: It is concluded that T3 levels is low in cirrhotic patients but at the same time T4 and TSH levels remains normal in majority of cases and the patients remain euthyroid. As far as the clinical scenario is concern, no significance was found in the frequency of sign and symptoms of thyroid dysfunction. Most of the patients did not show signs and symptoms of hyper and hypothyroids

Frequency of non-alcoholic steatohepatitis on histopathology in patients of type 2 diabetes mellitus with duration of more than 5 years

Objective: to determine the frequency of non-alcoholic steatohepatitis [NASH] on histopathology in patients of type 2 diabetes mellitus with duration of more than 5 years

Study Design: descriptive, cross-sectional study

Place and Duration of Study: department of Medicine, Dow Medical College, Civil Hospital, Karachi, from November 2013 to April 2014

Methodology: patients with type 2 diabetes mellitus of more than 5 years duration having raised alanine transaminases level and fatty liver on ultrasonography were selected. Informed consent was obtained and liver biopsy was performed in all patients by experienced physician of Civil Hospital Karachi. All samples of biopsy were sent for histopathology. Those patients with hepatitis B, C and D and steatosis like alcoholic and hypertriglyceridemia were excluded from the study. Descriptive statistics were calculated on SPSS version 17

Results: out of the 262 cases, 56.49% [148/262] showed non-alcoholic steatohepatitis on the basis of histopathology. The mean age of the patients was 50.72 +/-8.48 years. Median [interquartile] duration of diabetes mellitus of the cases was 9 years [15 - 4]. Out of 148 NASH cases, 56.1% [83/148] were males and 43.9% [65/148] were females

Conclusion: nonalcoholic steatohepatitis is an increasingly important and unrecognized spectrum of chronic liver disease associated with high prevalence of diabetes that is often overlooked and diagnosed with complications. So early recognition of these patients can prevent further complications

Celiac disease; a hidden cause of iron deficiency anemia?

Objective: The aim of the study is to determine frequency of celiac disease in adults with inexplicable iron deficiency Anemia

Study Design: Cross-sectional / observational study

Place and Duration of Study: This study was conducted at all Medical units of Civil Hospital Karachi from December 2009 to June 2010

Materials and Methods: The study included diagnosed cases of Iron Deficiency Anemia on basis of Iron profile without evident reason. They were evaluated for celiac disease on the basis of serological markers i.e. tissue transglutaminase antibodies [TTG] IgA type via standard laboratory procedures

Results: A total of 100 patients with Iron deficiency anemia previously diagnosed on basis of serum levels were included in this study. The average age was 37.12 + 8.2years and 44 [44%] were males.Celiac disease was found via serology in 16 [16%] of the patients. Out of these 16 Celiac disease patients 7 [43.75%] were males and 9 [56.25%] were females with 1:1.28 male to femaleratio

Conclusion: Celiac disease is an important cause of inexplicable Iron deficiency anemia especially in absence of gastro-intestinal symptoms. Serology though less sensitive, but can be an important screening tool for these patients

Sequential organ failure assessment [SOFA]score as a predictor of outcome in patients admitted in a medical ICU

Objective: To assess the efficacy of Sequential Organ Failure Assessment score [SOFA] as a determinant of outcome in critically ill medical patients

Study Design: Prospective observational cohort study

Place and Duration of Study: This study was conducted at Medical ICU of Civil Hospital Karachi from June 2014 to December 2014

Materials and Methods: The study was conducted on 152 patients admitted in the Medical ICU. The SOFA score was calculated on admission and thereafter daily until ICU discharge or death. The primary outcome measure was ICU mortality. The initial SOFA score, the SOFA scores at 48 and 72 hours, the mean and highest SOFA scores and the trend of SOFA score during the initial 48 hours were correlated with mortality

Results: The overall ICU mortality rate was 35.5 % [n=54]. Patients with an initial SOFA score of /= 10 had a mortality rate of 88.2 %. The SOFA scores at 48 and 72 hours also showed significant association with mortality. The mortality rates of patients having a score of /=10 at 48 and 72 hours were 91.3% and 93.8% respectively. A sharp rise in mortality was seen when the Highest SOFA score during the entire ICU stay exceeded 7. Patients having a mean SOFA score of greater than 5 had a mortality rate of 66.7% regardless of length of stay. Univariate Logistic Regression Analysis revealed that the Highest SOFA score had closest correlation with mortality followed by Mean SOFA score, SOFA at 48hours, and SOFA at 72 hours. The biggest area under the receiver operating characteristic curve [AUROCC] was seen for the Highest SOFA score followed by SOFA at 72 hours, Mean SOFA score and SOFA at 48hours. Analysis of the changes in SOFA score during the first 48 hours depicted a mortality rate of 54.9% when the score increased, 27.6% when the score decreased and 23.3% when it did not change

Conclusion: The serial evaluation of SOFA score proved to be a convenient and efficient tool to predict mortality in the critically ill ICU patients

Clinical pattern and outcome of organophosphorus poisoning

Objectives: to determine the clinical presentation and outcome of acute organophosphorus Poisoning

Methods: this case series included 100 cases from various medical wards of Civil Hospital Karachi from February 2008 to December 2008. We included all patients of organophosphorus poisoning who showed either signs of muscarinic or nicotinic involvement. However we excluded those patients in which organophosphorus poisoning was doubtful and who were intoxicated with poisoning other than organophosphates

Results: hundred patients of organophosphate poisoning were admitted among these 68% was males and 32% were females. Modes of poisoning were suicidal in 65% of cases, accidental in 27% and 8% were homicidal. Though the clinical presentation of acute poisoning was variable however the most consistent feature was miosis [98%]. According to W.H.O. classification for severity of organophosphorus poisoning; 60% cases were moderate, 28% were severe and 12% were mild. The mortality rate was 20% and mostly among patients who presented with severe symptoms and presented late

Conclusion: pesticides are the major chemical agents which pose a health threat particularly to young people, depressed individual and farm worker so this fetal condition needs rapid diagnosis and early treatment

Hepatic overlap syndrome: glass of autoimmune mimicry - half empty and half filled

Objective: To unfold the iceberg entity of hepatic overlap syndrome among patient with established chronic liver diseases

Methodology:Forty-one patients were referred from the remote areas of Sindh province during March 2008 to August 2010 to Department of Internal Medicine at Civil Hospital, Karachi, Pakistan. These patients were unresponsive to the treatment[s] being prescribed. The complete biochemical, clinical, serological and histopathological profiles of these patients was assessed. The Chazouilleres criterion was used to diagnose the overlap syndrome cases [according to which an AIH-PBC overlap syndrome would be accepted when 2 out of 3 criteria each of AIH or PBC is fulfilled]. Data were analyzed through SPSS version 16.0. Frequencies and means were calculated. Serological markers were correlated against biopsy patterns by Pearson's, Cramer's V test, Mantel-Haenszel Test to measure the odd of getting the particular biopsy pattern and 2- sided significance level <0.10 was taken as significant

Results: Out of 41 patients, 23 had AIH or PBC [56.09%] and the other 18 [43.90%] were having CLD secondary to Wilson's disease [9 patients], fatty liver [4 patients], Hepatitis B [3 patients] and hepatitis C [2 patients]. Further workup in 23 patients showed that 10 out of 23 were having AIH/PBC overlap. Fatigue was the most common clinical symptom among Overlap syndrome patients [80%]. 3 patients were having Hashimoto's thyroiditis and one male was diagnosed with SLE

Conclusion: We emphasize and recommend for detail investigations to consider such entity for autoimmune chronic liver disease, where initial laboratory investigations do not support the exact diagnosis among CLD patients. Since no work has been done so far on overlap syndrome in our set up, we suggest multicentre prevalence surveys to develop proper treatment guidelines for Indo-Pakistan population

Causes and outcome of patients with fulminant hepatic failure

To identify the causes and outcome of patients with Fulminant hepatic failure among 40 patients. Descriptive case series study Study conducted in an ICU of Medical unit II Civil Hospital Karachi, during October 2004 to October, 2006. 40 consecutive patients of either sex having clinical features and biochemical markers suggestive of acute liver failure without prior history of any liver disease were included in study. All patients assessed from day one of admission in ICU till two weeks both clinically and biochemically and data analyzed on SPSS version 10.0. Out of 40 patients 16 [40%] were presented in hyper acute stage, 20[50%] were in acute stage and 4 [10%] were in sub acute stage of Fulminant hepatic failure. The most common etiology found among 40 patients was viral in origin. 29 patients [72.5%] were having different hepatotrophic viral etiology. In this study out of 40 patients 26 [65%] expired and among them 15 [57.60%] were male and 11 [42.30%] were female patients. Majority of patients died were having viral and drug related etiologies. This clinical descriptive study highlight the facts that Fulminant hepatic failure [FHF], is a well known entity in our Medical ICU and is not uncommon in our country where viral, Falciparum and drug related etiologies are frequently seen. The mortality is high all over the world but cases have also shown improvement in survival rate with aggressive therapy and intensive monitoring .Considering the facts and fatal consequences of this entity, short and long term large-scale studies are still needed to predict overall mortality in our Country

Electrocardiographic changes in patients with acute stroke: an overview

To determine the frequency of ECG changes in patients with acute stroke but without any underlying cardiac disease. Observational study ICU Medical unit II, Civil Hospital Karachi Nov, 2004 to Nov, 2006. All the patients who were admitted in the ICU and had first time stroke were taken in the study. Patients who had TIA, preexisting cardiac disease or on cardiac medication, electrolyte imbalances and brain-stem stroke were excluded from the study. Day one ECG considered in the study and data analyzed on SPSS version.10.0. This was the prospective observational study based on two years. The frequency of ECG abnormalities [n = 64 or was 64%].The most common stroke related ECG abnormality among 100 patients was prolonged QT interval and was found in 64% of the patients with SAH and 56% in ICH and 36% ischemic stroke. Characteristic T-wave inversions were seen commonly in ICH 46% as compared to 33% in SAH and 21% in Ischemic stroke. Electrocardiographic changes are commonly seen in patients with acute stroke, both in ischemic and hemorrhagic variety. Theses changes sometimes create diagnostic and management dilemmas especially with no preexisting cardiac disease. Patients with ECG abnormalities in acute stroke should be advised for long term follow-up to predict outcome as well

Risk factors and outcome in 114 young stroke patients

Incidence of young stroke is increasing world wide and it is important to identify the precipitating factors for prevention of stroke. This study was conducted to identify the risk factors and outcome of stroke in young patients who were admitted to Civil Hospital Karachi. It is a descriptive correlational study. The young stroke patients who were admitted in neurology and all medical units of Civil Hospital Karachi from 2003 to 2005 were evaluated for the factors responsible for stroke and their outcome. 114 young stroke patients were included in this study who were clinically diagnosed as a case of stroke and their lesions were confirmed through CT/MRI of brain .Non-stroke lesions presented as motor neurological deficit were excluded. Detailed clinical history, comprehensive neurological examination, CT/MRI of brain and in certain cases conventional cerebral angiography was done. The sample contained 79 males and 35 females. Hypertension was the most common risk factor: The other risk factors were smoking, hyperlipidemia and family history of stroke. Cerebral infarction was diagnosed in 78[68.4%] patients and intracerebral hemorrhage/sub-arachnoid hemorrhage was seen in 36 [31.6%]. Small vessel occlusion was common than large artery atherosclerosis. Hypertensive intracerebral hemorrhage was the most common sub-type of intra cerebral hemorrhage. 47.3% patients were discharged as independent, 31.6% as dependent and 21.1% died. The frequency of hypertension and hypertensive intracerebral hemorrhage suggests accelerated hypertensive arteriolar damage, possibly due to poor control of hypertension. The causes of stroke among young adults are more diverse than in the elderly and require a thorough diagnostic work up for further prevention of stroke