Procedural determinants of fluoroscopy time in patients undergoing cardiac catheterization

Background and Objective: Due to increase in number of cardiac catheterization procedures safety concerns is an issue nowadays. Multiple diagnostic modalities use radiations, which also put a patient at higher cumulative radiation exposure. Therefore steps should be taken to minimize radiation exposure during cardiac catheterization. Hence determination of factors which prolong FT will result in better understanding of problem.This retrospective study was undertaken to determine factors responsible for prolong fluoroscopy time in patients undergoing coronary artery catheterization

Methods: This retrospective study was conducted at catheterization Laboratory National Institute of Cardiovascular Diseases, Karachi from June 2014 to June 2015. Patients of either gender, aged between 18 to 90 years undergoing cardiac catheterization procedures were included. Radiation exposure time was measured in terms of fluoroscopy time

Results: A total of 957 patients were included in this study out of which 731 were of diagnostic Coronary Angiograms [CA] and 226 were of Percutaneous Coronary Intervention [PCI]. The mean age of the study participants was 54.12+/-10.89 years and majority 734[76.6%] were male. Mean fluoroscopy time [FT] in the patients subjected to PCI was 9.61+/-6.07 minutes while in cases for CA 4.17+/-4.13 minutes. FT for CA was observed significantly dependent on procedural access, operator's experience, and LV angiogram. While FT for PCI was found dependent on number of stents deployed during the procedure

Conclusion: For invasive coronary angiographic procedures radial route increased fluoroscopy time. For percutaneous coronary intervention femoral and radial route fluoroscopy time were not significantly different

Application of BiPAP through endotracheal tube in comatose patients with COPD exacerbation

Objective: To evaluate the effectiveness and safety of using BiPAP through endotracheal tube in comatose Chronic Obstructive Pulmonary Disease [COPD] patients with hypercapnic respiratory failure

Methods: This is a prospective study done at Department of Chest Medicine, Jinnah Postgraduate Medical Centre, Karachi, during March to June 2017. It included all comatose COPD patients with hypercapnic respiratory failure who had a poor functional status prior to the illness and who did not meet the criteria to be kept on mechanical ventilator. Patients with apnea and other causes of coma were excluded. These patients were applied BiPAP through endotracheal tube and its response on blood gases and neurological status was evaluated

Results: The success rate of BiPAP through endotracheal tube was 70.5% [31/44]. Improvement in Glasgow Coma Scale [GCS] score [p<0.01], pH [p<0.01], and PaCO2 [<0.01] was observed among the responders following two hours and 24 hours of therapy. No significant difference was found in response with regards to gender, smoking status, prior use of noninvasive ventilation or duration of disease. No complications were observed during the therapy

Conclusion: In resource poor settings, the use of BiPAP through endotracheal tube can be an effective and safe intervention for comatose COPD patients with hypercapnic respiratory failure

Management of community acquired pneumonia by Family Physicians

Background and Objective: Community Acquired Pneumonia [CAP] is a major burden on health system with significant mortality and morbidity. Family Physicians [FPs] can play important role. To determine management strategies and prescription of FPs regarding CAP

Methods: A multicenter cross sectional survey was done in 10 cities of Pakistan from November 2014 to January 2015. Self-administered questionnaire was filled by 110 Family Physicians

Results: Of total 71% of FPs reported to work in high prevalence areas for respiratory ailments. Only 32% of FPs used PSI and 34% CURB 65 for assessment of severity. It was alarming to note that only 58% of FPs treats severe pneumonia with Intravenous antibiotics while rests were comfortable with oral route

The overall use of quinolones to treat CAP, irrespective of severity, in combination or as single agent was > 60%

Duration of antibiotics for severe pneumonia was sub optimal [<10 days]. Only 52.8% patients came back for follow-up so true outcome cannot be anticipated

Conclusion: Major deficiencies were treatment of severe pneumonia in community, inappropriate use of quinolones and poor knowledge of recent guidelines. This can lead to emergence of resistant bacteria and high mortality and morbidity

Frequency of depression in chronic obstructive pulmonary disease [COPD] patients

To determine the frequency of depression in Chronic Obstructive Pulmonary Disease [COPD] patients. We conducted cross sectional study between June 2008 to April 2009 in Department of Chest Medicine, Jinnah Hospital Karachi. All adult patients presenting with sign and symptoms of COPD confirmed by Global Initiative for Chronic Obstructive Lung Disease [GOLD] criteria giving informed consent following inclusion and exclusion criteria were consecutively included. The primary outcome of the study was prevalence of depression measured through Hamilton Depression Rating Scale [HAM-D]. The score was classified into 10-13= mild; 14-17= moderate and >17 = severe. The sample size was [n=63]. The mean age of the sample was 60.87 +/- 10.93 years. There were 50 [80%] males and13 [20%] females. The severity of COPD in 6 [9.52%] patients was mild, 22 [35.02] moderate, 27 [42.90] severe and 8 [12.70%] were very severe. The mild to moderate depression was found in 10 [15%] of patients. We found that ten [15%] of COPD patients were also suffering from depression. It is lower than what international studies have shown. We recommend that all COPD patients should also be screened for depression in order to reduce the morbidity associated with depression and COPD

Knowledge, Attitude and misconceptions regarding tuberculosis in Pakistani patients

To assess knowledge of patients with tuberculosis; about their disease and misconceptions regarding TB. A cross sectional study was conducted at Out-patient clinics of two teaching hospitals [private and public] in Karachi, Pakistan. A questionnaire was filled for the purpose. A total of 170 patients were interviewed, 112 from private and 58 from a public sector hospital. Cough, fever, bloody sputum and chest pain were recognized as the common symptoms of TB. Eleven [7%] patients thought TB was not an infectious disease and 18 [10.6%] did not consider it a preventable disease. Contaminated food was considered the source of infection by 81 [47.6%] and 96 [57%] considered emotional trauma/stress the causative agent of TB. No counseling about preventing spread was received by 81 [50%] patients and 97 [57%] considered separating dishes as an important means of preventing spread. Thirty one [18%] patients would have discontinued their medications following relief of symptoms. Thirty nine [23%] of the respondents thought that TB could lead to infertility and 66 [38.8%] believed that there were reduced chances of getting married following infection. Misconceptions concerning TB are common in Pakistani patients. Lack of knowledge on Tuberculosis is alarming

Diagnostic yield of fast plaque TB TM Test for rapid detection of mycobacterium in tuberculosis suspects

To compare the diagnostic yield of FAST Plaque TB' test with the conventional methods for detection of mycobacterium tuberculosis in sputum of Tuberculosis suspects at Jinnah Postgraduate Medical Center Karachi Pakistan. A comparative study of diagnostic yield of FAST Plaque TB' test with the culture and ZN staining, conducted from January to June 2004. The study was completed on 48 samples, 31 [64.58%] male and 17 females [35.42%]. Half of the cases were sputum positive. Culture positive was in 17 [35.41%] and negative in 28 [58.3%] wereas 3 [6.25%] were contaminated. FAST Plaque TB' test was positive in 16 [33.33%] and negative in 32 [66.6%] specimens. Out of 17 culture positive, 2 [11.7%] were negative and in 28 culture negative, 1 [3.57%] specimen was positive for FAST Plaque TB' test. Out of 24 smear positive, 11 [45.83%] were negative and in 24 smear negative, 3 [12.5%] were positive, for FAST Plaque TB' test. Compared to culture it has sensitivity of 86.23% and specificity of 96.42%, positive predictive value of 93.75% and negative predictive value of 93.1%. FAST Plaque TB' test is a simple test that can detect viable mycobacterium in 2 days. It has a good sensitivity and specificity. The cost is three times less than the other available tests like PCR. Thus it can be useful in the diagnosis of tuberculosis as an adjunct to sputum microscopy in endemic countries

Proportion of gastroesophageal reflux symptoms in patients with chronic obstructive pulmonary disease

To determine the proportion of gastroesophageal reflux symptoms in patients with chronic obstructive pulmonary disease and its association with the severity and worsening of the symptoms of chronic obstructive pulmonary disease [COPD]. A prospective, questionnaire based, case control, analytical study was conducted in the Department of Pulmonology, Jinnah Postgraduate Medical Centre, Karachi during June 2002 to January 2005. Gastroesophageal reflux symptoms were compared between 100 chronic obstructive pulmonary disease patients who fulfilled the inclusion criteria and 150 control subjects. Both groups were interviewed according to modified version of Mayo clinic GER questionnaire. Chronic obstructive pulmonary disease patients were divided into two groups according to pulmonary function tests [PFTs] results into FEV1 <50% and FEV1 >50%. Chronic obstructive pulmonary disease patients had more frequent gastroesophageal symptoms than controls [25% vs. 9.33% respectively; p=0.001], heartburn/acid regurgitation [70% vs. 43.33% and 56% vs. 30.66% respectively; p-value=0.001], dysphagia [15% vs. 4%; p-value=0.002] and chronic cough [89% vs. 29.33%; p-value=0.001]. Twenty six COPD patients reported respiratory symptoms associated with reflux, whereas control subjects denied such association. Of the 11 patients with frequent gastroesophageal symptoms, 10 patients increased their inhaler use [p=0.001]. Frequent gastroesophageal symptoms had shown a significant association with decreased FEV1 [25% vs. 0% p-value 0.001]. In contrast Pulmonary function test results were similar among chronic obstructive pulmonary disease patients with and without gastroesophageal symptoms [48.13+20.81 vs. 50.94+23.33]. Anti-reflux medication proton pump inhibitor and H2-blockers were utilized more by COPD patients as compared to control subjects. A higher proportion of frequent gastroesophageal symptoms were noted by COPD patients than control subjects and higher proportion of gastroesophageal symptoms was present in severe COPD patients

Role of intravascular ultrasound [IVUS] in evaluating optimal inflation and size of stents and balloon in patients undergoing percutaneous coronary interventions [PCI]

Objective: To evaluate the size of balloon and stent and inflations given to patients undergoing PCI before and after IVUS. Design: A retrospective study. Place and duration of study: This retrospective study was conducted at department of catheterization laboratory National Institute of Cardiovascular Diseases [NICVD] Karachi from 1998 to 2001

Subjects and Methods: All patients who have undergone PCI in catheterization laboratory NICVD from 1998 to 2001 were included. These patients include those who have undergone IVUS in between year 2000 and 2001

Results: IVUS study and use of stents and balloon in four years showed that mean diameter of stent in males used increased from 3.05 mm to 3.13 mm and mean length reduced from 18.32 mm to 15.22 mm with inflations ranged from 9.30 atm to 13.4 atm. For Balloons mean diameter decreased from 2.7 mm to 2.6 mm and mean length reduced from 20.9 mm to 19.24 mm with inflations that increased from 5.04 atm to 6.4 atm. In females stent used with mean diameter that increased from 2.96 mm to 3.08 mm and mean mean length decreased from 18.33 mm to 15.47 mm and inflation increased from 9.33 atm to 12.69 atm. Balloon used with mean diameter that decreased from 2.9 mm to 2.6 mm with length that decreased from 20.8 mm to 19.04 mm and with inflations 6.20 atm to 5.80 atm

Conclusion: This study showed that IVUS demonstrated a significant increase in stent expansion after IVUS. Mean length of stent and balloon used decreased yearly. Mean diameter of stent used were increased while that of balloon decreased after IVUS

Clinical and morphological evaluation of tuberculous peripheral lyphadebnopathy

To analyze clinical presentations in patients of tuberculous peripheral lymphadenopathy. Design: A descriptive observational study. Place and Duration of Study: Department of Chest Medicine, Jinnah Postgraduate Medical Centre and National Institute of Child Health from January to June 2002. Subjects and Patients presenting with peripheral lymphadenopathy with the confirmed diagnosis of tuberculous were included in the study. The diagnosis of tuberculosis was made on finding acid fast bacilli on smear examination and / or histological demonstration of caseating epithelioid cell granulomas in the specimen obtained by fine needle aspiration cytology [FNAC] or excision biopsy. Patients in whom definite diagnosis of tuberculosis was not established on the basis of microscopy or histopathology examination were excluded from the study. History and physical examination findings were recorded on pre-designed proforma. The maximum number of patients [68.75%] was in pediatric age group. The duration of illness was more than a year in 43.75% of the patients. Cervical region was the commonest affected in 70.83% patients. In majority of cases [89.58%] glands were multiple and in 66.7% glands were matted. In 83% cases diagnosis was achieved by FNAC subjected for cytology and acid fast bacilte [AFB] smear examination. In local setting tuberculous etiology should be strongly suspected in a young patient presenting with peripheral lymphadenopathy, with prolonged duration of illness, and involvement of cervical glands with multiple and matted appearance. FNA is a reliable tool of diagnosis

BCG vaccination of children upto 12 years age: does it protect against tuberculosis?

To review the set criteria for the use of BCG vaccination as part of National immunization programme. To determine the protective effect of BCG vaccination in the prevention of tuberculosis [children oge upto 12 years]. To find out the risk factors for the causation of tuberculosis among cases to that among controls. Matched case control study done on 600 individuals with case to control ratio 1:1, age, sex and socio-economic status taken as matching factors. National Institute of Child Health, Karachi. The study shows that BCG is not protecting our population [children age upto 12 years] from tuberculosis. Among vaccinated cases 67.14% were suffering from pulmonary tuberculosis, 10% from haematogenous form of tuberculosis and 22.86% from glandular tuberculosis while among non-vaccinated the proportion was 62.5, 20% and 1 7.5% respectively. Low educational status of mother and history of tuberculosis in the family are two risk factors for causation of tuberculosis. The reason for non-effectiveness of BCG vaccination in our population is perhaps because they are exposed to TB infection in their families at an earlier age before BCG vaccine can provide immunity

review of 52 cases of empyema of thorax in adults [etiology, microbiology and management]

Fifty two cases of empyema of thorax were admitted in Chest Medicine Unit, JPMC from January 1995 to August 1997. There were 39 male and 13 female, with average age of 42 years [14 to 70 years]. 70% [36] had empyema secondary to bronchopulmonary infection, 5.76% [2] had ruptured liver abscesses and 13.46% [7] had iatrogenic empyema. The most common clinical manifestation was fever 82%, cough and chest pain [59%], dyspnoea [32%] and weight loss [19%]. The commonest organism isolated was Pseudomonas aeurogenosa [13%], followed by E. coli and Staph, aureus 11% each. Therefore it is necessary that Bronchopulmonary infection should be adequately managed to prevent Empyema Thoracis

Complications associated with combined thoracentesis and pleural biopsy

In order to determine the spectrum and frequency of complications associated with thoracentesis alongwith pleural biopsy, we analysed 80 procedures of pleural aspiration and biopsy during a 9-month period from January 1996 to September 1996 in the department of Thoracic Medicine, Jinnah Postgraduate Medical Centre Karachi. A special proforma was designed that included all relevant details. All junior doctors working in the department were asked to attend a lecture demonstrating the technique of performing thoracentesis and pleural biopsy. Every procedure was observed by a senior doctor who was responsible for recording and filling the proforma during and after the procedure. A total of 44 [55%] procedures had complications, 11 [13.5%] procedures had major complications while 39 [48%] had minor complications. Six of those with major complications also had minor complications. We conclude that thoracentesis with pleural biopsy carries a significant morbidity therefore if it is performed by the junior doctor it should be done after proper training and preferably under the supervision of a senior doctor

audit of 191 fiberoptic bronchoscopes

The result of 191 fiberoptic bronchoscopies which were performed in the Department of Thoracic Medicine from January 1995 to June 1996 were analyzed retrospectively to determine the diagnostic yield and results of bronchial washing, brushing and biospy. Indications for bronchoscopy were multiple but mostly [61% cases] it was done on suspicion of malignancy; 67.5% cases were confirmed on histopathological and cytological grounds. Definite endobronchial growths were observed in 46.5% cases. Plumonary tuberculosis was diagnosed in 15 patients [7.85%] by bronchial washings and endobronchial biopsy in whom sputum was either negative or the patient was not expectorating at all. Fiberoptic bronchoscopy in mediastinal mass was non-conclusive. Fiberoptic bronchoscopy in patients presenting with haemoptysis having a normal chest radiograph is reported to be unrewarding but in this series 16.6% had malignancy as compared to 3% cases reported in the literature. Fiberoptic bronchoscopy gave a positive diagnosis in 64% of patients

Fiberoptic bronchoscopy in suspected cases of bronchogenic carcinoma

Retrospective analysis of the role of fiberoptic brochoscopy in 117 cases of suspected malignancy was done. Of findings, histopathological and cytological confirmations were analysed. In 89 cases [79.06%] definite endobronchial growths were seen, while in 79 cases [67.52%] histopathologic and cytologic diagnosis was successfully achieved. In our opinion fiberoptic bronchoscopy is a useful tool for the diagnosis of suspected cases of malignancy, however team work of bronchoscopist, histopathologist and cytologist is required for a maximum yield