A Critical Review of Amalaki- (Emblica Officinalis Gaertn.) in Classical Texts and Promote its Use in Our Life

The drug Amalaki (Emblica Officinalis Gaertn.) belongs to family Euphorbiaceae, is used since ancient time for therapeutic purposes. It has been used in the traditional Indian medicine of ‘Ayurveda’ for the treatment of a variety of diseases. Amalaki has five Rasa (taste) except Lavana (salt), It is mainly Amla Ras Pradhan. Its Vipaka (taste after digestion) is Madhura (sweet) and Veerya (potency) is Sheeta (cool). Because of these qualities, the plant performs various pharmacological actions such as anti-inflammatory activity, antioxidant activity, immunomodulatory activity, anti-tussive, antiulcer activity, anticancerous activity, anti-diarroheal and spasmolytic, antidiabetic, in reducing cholesterol and dyslipidemia, antimicrobial, anti-asthmatic. It helps to improve physical and mental health, prevents degeneration, extends youth and delays aging or rather reverse the aging process. Various parts of Amalaki has been described in morphology like root, stem, leaf, seed, flower and fruit. Synonyms and their interpretation, Vernacular names, Rasapanchaka and Karma of Amalaki in various Nighantus (Dhanwantri Nighantu, Shodhal Nighantu, Madanpal Nighantu, Bhavprakasha Nighantu, Kaiyadeva Nighantu and Raj Nighantu) has been described. Classical categorization of plant Amalaki in Charaka Samhita, Sushruta Samhita and Ashtanga Hridaya has been explained according to its Karma and this paper presented a comprehensive review of Emblica Officinalis Gaertn

Clinical characteristics and outcome of budd-chiari syndrome at a tertiary care hospital in Pakistan

Objective: To determine the clinical characteristics of Budd-Chiari syndrome [BCS], its causes and outcome at a tertiary care hospital

Study Design: An observational study

Place and Duration of Study: The Aga Khan University Hospital, Karachi, from 2004 to 2014

Methodology: A retrospective analysis of data was conducted. A predesigned questionnaire was filled from medical records of patients with BCS. Clinical features, etiology, management and outcome was noted from 2004 to 2014. Descriptive statistics were determined

Results: Forty-five patients' charts were reviewed; 26 [57.8%] were male patients. The median [IQR] age at diagnosis was 26.0 [20.5 to 34.5] years. Primary BCS was seen in 27 [60.0%] patients. The most frequent clinical features included ascites [82.2%], abdominal pain [55.6%], and hepatomegaly [31.1%]. A combined hepatic vein/inferior vena cava block was found in 25 [55.6%] patients. Out of the 28 tested patients protein C and protein S deficiencies were detected in 22 [78.6%] and 17 [60.7%] patients, respectively. Antithrombin III deficiency was detected in 14 [58.3%] of those tested patients. Anticoagulants were used in 24 [53.3%] patients. TIPS was done in 11 [24.4%] patients. Mortality was 6.7% [n=3]

Conclusion: Congenital thrombophilia was a major causal factor. Age, clinical features, biochemistry and management are important factors in survival

Primary hepatic carcinoid tumor with poor outcome

Primary Hepatic Carcinoid Tumor [PHCT] represents an extremely rare clinical entity with only a few cases reported to date. These tumors are rarely associated with metastasis and surgical resection is usually curative. Herein, we report two cases of PHCT associated with poor outcomes due to late diagnosis. Both cases presented late with non-specific symptoms. One patient presented after a 2-week history of symptoms and the second case had a longstanding two years symptomatic interval during which he remained undiagnosed and not properly worked up. Both these cases were diagnosed with hepatic carcinoid tumor, which originates from neuroendocrine cells. Case 1 opted for palliative care and expired in one month's time. Surgical resection was advised to the second case, but he left against medical advice

Hereditary hemochromatosis

To describe the clinical and laboratory features of hereditary hemochromatosis associated liver disease in a tertiary care hospital. Observational study. The Aga Khan University Hospital, Karachi, from January 2002 to October 2012. Charts of patients with Hereditary Hemochromatosis [HHC] were reviewed. Data collected and analyzed consisting of clinical presentations, liver function tests, serum ferritin, transferring saturation, hepatic imaging and histology in patients with HHC. A total of 22 patients were identified as having hemochromatosis. All subjects were men with a mean age of 53 +/- 9.2 years at the time of diagnosis. The most common presentation was skin pigmentation seen in 17 [77%], followed by loss of libido/ impotence in 11 [50%] and then arthralgias in 10 [45%] and weakness in 6 [27%]. Eleven [50%] subjects had diabetes mellitus and one subject had concomitant cardiac involvement. Patients with diabetes were diagnosed earlier as compared to those without it. Eighteen [81%] subjects had cirrhosis at the time of diagnosis. Serum iron was 164 +/- 53 ug/dl, ferritin 3391 +/- 1960 ug/L, TIBC 202 +/- 61 ug/dl and transferrin saturation 76.8 +/- 14%. Liver biopsy was done in 10 [45%] and using Pearls' stain histopathological features were consistent with hemochromatosis and none had carcinoma. Only 3 [14%] patients had regular phlebotomy. Hemochromatosis is not a rare disease in Pakistan and should be looked in those subjects whose liver function tests are deranged

How to avoid the impact of environmental mycobacteria towards the efficacy of BCG vaccination against tuberculosis?

Bacillus Calmette-Guerin [BCG] remains the only widely used vaccine against tuberculosis [TB]. Consistent efficacy has been proved in infants but not in adults from developing countries. Epidemiological and experimental studies have pointed out that, prior exposure to prevailing environmental mycobacteria could be responsible for the poor efficacy of BCG as an anti-TB vaccine in adults living in developing countries. Sensitization by environmental mycobacteria may down-modulate the immunologic behavior of BCG on the one hand and may mask its efficacy on the other hand. Some of the important deciding factors for poor efficacy of BCG, due to exposure of the subjects to prevailing environmental mycobacteria, are thought to be [i] Life stage: neonatus versus adolescence; [ii] shared antigens between prevailing environmental mycobacteria and BCG; and [iii] generation of cross-reactive T-regulatory cells against environmental mycobacteria and BCG. In this communication, some novel strategies have been discussed for countering the down modulating impact of environmental mycobacteria towards performance of BCG as an anti-TB vaccine.

Wilson's disease: experience at a tertiary care hospital

Wilson's disease [WD] is a rare autosomal recessive disorder of copper metabolism. Data regarding WD is not available from Pakistan. A cross-sectional study was conducted at The Aga Khan University Hospital, Karachi, and all patients admitted with primary and secondary diagnosis of Wilson's disease were added. A total of 47 patients were seen; 68% [n = 32] were male. The mean age was 26.6 +/- 9.97 years. Most of the patients presented with hepatic, [n = 22, 46.8%], neurological, [n = 17, 36.2%] and psychiatric [n = 8, 17%] symptoms. Mean ceruloplasmin level was 0.17 +/- 0.13 g/dl; it was < 0.25 g/dl in 39 [86.6%] patients. Serum copper [Cu] was reduced in 32 [68.1%] patients and 24-hr-urinary Cu was raised in 22 [47.6%] patients. Slit lamp examination for Kayser-Fleischer [KF] rings was done on 15 [31.9%] patients and 9 [60%] of them had KF rings. Mean serum aspartate transaminase [AST] / alanine transaminases [ALT] ratio was 1.92 and median alkaline phosphatase / total bilirubin ratio was 79.30 [IQR 35.05; 166.50]

Size or the number of portal tracts: which matters in a liver biopsy core in chronic hepatitis C?

Liver biopsy has an important role in staging of fibrosis [SoF] and grading of inflammation [GoI] in chronic hepatitis C [CHC] patients. The effect of size and number of portal tracts [NoP] on grading and staging of liver biopsy was evaluated. A total of 150 consecutive liver biopsy core [LBC] of patients with CHC were obtained. There were 98 [65.3%] males. Mean length of LBC was 1.45 +/- 0.48 cm. Mean number of portal tracts [NoP] was 11 +/- 4.6. Mean length of LBC was greater [1.60 +/- 0.45 cm] in stage 4 [n=41; 27.3%] and lesser [1.28 +/- 0.39] in stage 1 [n=23; 15%, p=0.04]. The mean NoP were 8.5, 10.6 and 13.1 in GoI 1, 2 and 3 respectively [p < 0.001]. The mean NoP were 7.6, 11.1, 11.3 and 14.5 in SoF 1, 2, 3 and 4 respectively [p < 0.0001]. There was a good correlation between number of portal tracts and length of LBC [r[2]=0.56]

Emergency evaluation of acute chest pain

To determine the sensitivity and specificity of initial clinical assessment about the diagnosis of acute coronary syndrome [ACS] in patients presenting with acute chest pain by a cardiology resident in the emergency room and assess the 30-day outcome of patients with ACS and non ACS. Cohort study. The study was conducted in the emergency department and cardiac care units of the Aga Khan University in 2006-07. A total of 202 patients, who presented to the emergency room with chest pain, were given an initial ECG and troponin check. Patients were assigned to initial ACS and non-ACS groups by the cardiology resident. After cardiac workup, patients were assigned to final ACS/final non ACS group. They were followed for outcome after 30 days of initial presentation. Sensitivity and specificity, if initial workup was determined, keeping final assessment after cardiac workup as the gold standard. Out of the 202 patients, 61.9% were males. Their mean age was 54.05 +/- 13 years. Sixty eight percent were placed in the initial ACS group and 30.7% were placed in the initial non ACS group. After workup, 36% were placed in the final ACS group and 28.7% in the final non-ACS group and 35% were undecided. The sensitivity of initial assessment of ACS by the cardiology resident was 100%. However, the specificity was 54.2%. In the 30-day outcome, one patient [1.3%] died in the ACS group due to myocardial ischemia while no patient died from the non ACS group. Initial assessment about ACS by cardiology resident based on character of chest pain, ECG and troponin I is highly sensitive. However, the specificity is low

concept and epidemiology of DHAT syndrome

Culture bound syndromes refer to prevalence of some syndromes in specific cultures. Dhat syndrome [semen loss related psychological distress] is a culture- bound entity seen in natives of Indian sub-continent. Due to its clinical significance, it has been included in ICD-10. It is suggested that such a perception is reflective of the unusual emphasis placed on the qualities of semen in ancient holy treatises. The clinical picture includes symptoms of hypochondriacal quality, with or without psychosexual dysfunction. The symptoms usually disappear if the misconceptions about semen loss are effectively dealt with proper sex education and relaxation exercises. It is expected that with increasing literacy and progress in sexual knowledge among the general population of this region, the syndrome will become less common