Insulin resistance in non-diabetic patients of chronic hepatitis C

To determine insulin resistance in non-diabetic chronic hepatitis C patients using Homeostatic Model Assessment of Insulin Resistance [HOMA-IR]. Patients having anti-HCV positive were included in this study. Patients with diabetes mellitus, thyroid disease, hyperlipidemias, hypercortisolism and infective diseases other than hepatitis C were excluded. Age, weight, height and absence of diabetes were documented. Fasting blood glucose and fasting insulin levels were done. Body mass index and insulin resistance was calculated using the formulas. Patients having insulin resistance using formula HOMA-IR>2.5 were labeled as insulin resistant. Data was analyzed using SPSS-18. One hundred and fifty five patients according to sample size estimation were enrolled, in whom HOMA-IR was calculated, the mean value was found to be 2.47 +/- 1.30. A total of 79 [51%] of patients had HOMA-IR more than 2.5 showing insulin resistance. In a third world country like Pakistan, where there is a high prevalence of hepatitis C infection, the consequences of the disease are also very common. Insulin resistance was found in 51% of patients with chronic hepatitis C

Health seeking behavior of adult patients attending OPDS of public sector hospitals in Karachi

To determine health seeking behavior pattern and factors associated with it in adult patients attending OPDs of public sector hospitals in Karachi. Cross-sectional hospital based survey conducted on 384 adult patients attending OPDs of two major public sector hospitals in Karachi, selected using convenient sampling technique. Structured questionnaire was used which included age, gender, language spoken, educational and socio-economic status, beliefs regarding illness, autonomy of the patients, symptoms, duration, severity of the illness and type of care sought. Data was analyzed on SPSS version 15; chi-sq was used at 0.05 alpha level for statistical significance. Out of 384 patients, 53%[202] were from Civil Hospital and 47% [182] from Jinnah Post Graduate Medical Centre, Karachi. Overall, there were 54%[209] males and 46%[175] females with 52% cases [199] 31-60 years old. Almost 94%[361] patients believed that headache, common cold and low grade fever are mild illnesses and do not require treatment whereas 96%[369] perceived hypertension, diabetes mellitus, numbness and fits as a serious illness which required treatment. Doctor was the first preference to seek treatment by 89%[341] with 23%[89] using home remedies and 5%[19] treated the disease themselves. About 52%[198] had free will to select their health care providers. About 84%[322] patients preferred going to public sector hospitals due to its free medicines and laboratory tests while 87%[335] used public sector hospital due to more qualified doctors and 77%[295] due to free medicines. In case of emergency 51%[195] preferred private doctors due to less waiting time from doctors visit to start of treatment. Overall 98%[375] said that they sought appropriate medical care, 1%[4] inappropriate and 1%[5] prompt care for their illness. Socio-economic status and health expenditure were two important determinants for health seeking behavior over-riding age, gender and ethnicity. Misconceptions' regarding illness existed among the patients. Government should introduce reforms in health sector especially in health financing, expenditure, and consumer behavior for the benefit of poor people

Frequency of eosinophilic esophagitis in patients undergoing upper Gl endoscopy

To determine the frequency of Eosinophilic Esophagitis [EoE] in patients undergoing upper Gl endoscopy. Patients undergoing upper Gl endoscopy for any indication were subjected to additional esophageal biopsies for derrnination of eosinophilic esophagitis. The additional biopsy protocol was two each from proximal esophagus, distal esophagus, stomach and duodenum. Presence of >15 eosinophils in one high power field was criteria for diagnosis of EoE. Ninety four patients were included according to sample size estimations. Eosinophilic esophagitis was found in 7 [7.4%] of patients undergoing upper Gl endoscopies. Eosinophilic esophagitis should be considered as active diagnosis in presence of suggestive symptoms

Frequency and pattern of colonization of intravenous cannula in an ICU of public sector hospital

To determine the frequency of colonization of intravenous [IV] cannula by microorganism in patients admitted to intensive care unit [ICU] and to determine the frequency of common organisms involved in colonization of IV-cannula. A total of 369 patients of age more than 12 years, and meeting inclusion criteria of the study were included from in medical ICU after taking informed consent. Staff nurse introduced intravenous cannula of appropriate bore after proper disinfection of the insertion site with povidone iodine solution and alcohol. The cannula was removed for culture within 48 hours of insertion if clinical signs i.e. redness and swelling was present. Mean age was 41 [ +/- 16.7] years. Male to female ratio was 1.07:1. Presence of colonization in IV-cannula was seen in 31 [8.4%] cases. Coagulase-Negative Staphylococci was the most common microorganism seen in 24 [77.4%] patients. The incidence of IV cannula colonization is low in this study. Bacterial colonization occurs in the indwelling intra vascular cannula despite, adequate precautions. Coagulase-Negative Staphylococci and S. Aureus were the common organisms

Frequency of depression in chronic Hepatitis C naive patients

To determine frequency of depression in chronic hepatitis C na‹ve patients before interferon therapy using CES-D questionnaire. Patients testing positive antibodies to HCV by EIA of more than 6 months duration and who have not taken interferon therapy previously were included after taking informed consent. Patients who had co-infections such as hepatitis B and D virus or human immunodeficiency virus, or patients with other coexisting chronic liver disease like primary biliary cirrhosis, chronic autoimmune hepatitis and Wilson disease were excluded from study. Urdu version of CES-D a self-reporting questionnaire in public domain was administered. A score of >/= 10 was taken consistent with depression. Ninety-six patients were included and 59.4% were depressed. These included 57.9% males and 42.1% females. Highest frequency was seen in under-graduates and positive correlation was seen with duration of hepatitis C infection. This study showed that 59.4% of patients with hepatitis C have depression before initiation of therapy and this should be evaluated and treated if necessary before starting interferon therapy

Assessment of injection practices in public sector expanded programme of immunization clinics in Karachi

A safe injection is defined as one that does not harm the receipent, expose the health worker to avoidable risk or result in waste that is harmful to others. To assess injection practices in Public Sector Expanded Programme of Immunization [EPI] clinics in three urban towns of Karachi and see if these clinics meet the necessary requirement for staff competence, supply of vaccines, injection equipment and their disposal. This was a health centre based cross-sectional survey conducted in 49 Public Sector EPI clinics from June 2008 to March 2009. These clinics were selected using random table from three urban towns i.e. Saddar, Lyari and Jamshed town of Karachi. Variables of the study were socio-demographic characteristics of the vaccinators including their training qualifications, staff competence, information regarding supply of vaccines, injection equipment, puncture proof safety boxes, maintenance of cold chain and vaccination/medical waste disposal. WHO tool for the assessment of injection safety was used as a questionnaire for the collection of data and it was analyzed on computer package SPSS version 11. Data showed that 35 [71%] vaccinators were males and of the total, 38 [78%] vaccinators were less than 30 years of age, 45 [92%] were trained dispensers but also trained for vaccinations and 4 [8%] staff nurses. It was observed that in all clinics disposable syringes were used for BCG and AD syringes were used for DPT, Measles and Hepatitis vaccination. Adequate amount of vaccines, injection equipment and puncture proof safety boxes were available, cold chain for the preservation of vaccines was well maintained, used syringes/needles were not re-used, families did not bring their own syringes for vaccination. Recapping of used syringes was observed in 20% clinics, skin barrier [piece of gauze under the thumb] while breaking vaccine bottles was not practiced in any EPI clinic. All used syringes and needles were thrown in puncture proof safety boxes. There was no history of needle prick injuries among vaccinators. Policy Document for safe injection practice and waste disposal was not found in any EPI clinic and the staff was ignorant about it. The study concludes that in all 49 EPI clinics, injection practice was safe except its method of waste disposal, sufficient amount of vaccines, injection equipment, and puncture proof safety boxes were available and staffs of these clinics were well trained. The policy document for safe disposal of sharp waste/vaccination waste should be available at all clinics and hospitals and staff should be trained for its use

Frequency of acute hepatitis C after needle stick injury and its treatment outcome

To determine the frequency of acute HCV infection after needle stick injury and its treatment outcome. Patients with HCV positive needle stick injury and reporting within 72 hours of incident were selected. Co-infections with HBV, HDV, HIV, hematological disorders and depression were excluded. Anti-HCV was done at presentation and those testing positive were excluded. HCV RNA was done after two weeks or anti-HCV after six weeks of incident. Those testing positive were kept under observation for 16 weeks for spontaneous resolution. After this period HCV RNA and Genotype were done and therapy with Peg-interferon was started. Rapid, early and sustained virological responses were checked. Two hundred eight patients with HCV positive needle stick injury were selected, 10 [4.8%] developed acute HCV infection out of them one [10%] had spontaneous recovery during the observation period of 16 weeks. seven [77.8%] achieved rapid virological response and eight [88.9%] achieved sustained virological response. Acute HCV is an uncommon disease to diagnose; it has favorable response to therapy if initiated early after a strict surveillance of patients for 8-16 weeks

Frequency of sensory neuropathy in foot of asymptomatic type2 diabetic patients using semmes-weinstein monofilament

To detect neuropathy in diabetics who are clinically asymptomatic, using SW monofilament and to correlate the frequency of detected neuropathy with the duration of diabetes. Known patients of type 2 diabetes that do not have symptoms of peripheral neuropathy were included. Height, weight and duration of diabetes were measured and BMI calculated. SW monofilament was pressed perpendicular to the test site with enough pressure to bend it for one second. Comparison of frequency of SW monofilament test among gender was done by x2 test. Bivariate correlation of SW monofilament test result with duration of diabetes was done by Kendall's test. A total of 700 patients including 324 males and 376 females were examined. Asymptomatic neuropathy was detected in 14.4% of patients. The mean age of males was significantly more [50.4 +/- 9.0 vs 46.7 +/- 8.4 yrs; P < 0.0001] but BMI was lower than females [24.4 +/- 2.8 vs 26.2 +/- 4.2; P < 0.0001]. No correlation of asymptomatic neuropathy with duration of diabetes was detected [P = 0.995]. Asymptomatic neuropathy is prevalent in our diabetic population and it does not correlate with the duration of diabetes. Diabetics should be actively screened for asymptomatic neuropathy by SW monofilament

Appraisal of the knowledge of internet users of Pakistan regarding hepatitis using on line survey

Hepatitis B and hepatitis C are global health care problems causing morbidity and mortality. Much of it could be prevented by better education of the masses regarding its spread. The study was conducted to assess the knowledge base of internet users of Pakistan to help in formulating education strategies. A survey questionnaire consisting of 20 close ended questions was designed and hosted on a website. The responses submitted at the website were auto-emailed to the author. A total of 1024 complete responses were included. The survey shows increased level of awareness according to the educational status. The knowledge status of lowest education level was also adequate possibly due to access to internet to these respondents. Internet users in Pakistan have adequate core knowledge regarding hepatitis

Triple hepatitis: frequency and treatment outcome of co/super-infection of hepatitis C and D among patients of hepatitis B

To determine the frequency of hepatitis C and D in patients of chronic hepatitis B and the treatment response of hepatitis B in such patients. Case series. Civil Hospital and Lyari General Hospital, Dow University of Health Sciences, from July 2003 to June 2005. All patients of hepatitis B presenting during the study period were screened for triple infection by carrying out anti-HBc [IgG], anti-HCV and anti-HDV. Patients who were positive to all three were included in the study. Complete Blood Count [CBC]; HBsAg; HBeAg; anti-HBc IgM; anti-HDV; anti-HCV; HBV DNA PCR; HCV RNA PCR; serum albumin; SGPT; serum bilirubin and ultrasound abdomen were acquired in all patients. All patients received pegylated interferon-alpha 2a 180 mcg sc weekly x 48 weeks. Patients who were also positive for HCV RNA also received ribavirin 1000-1200 mg/d po x 24 weeks for genotype 3 and 48 weeks for genotype 1. Descriptive statistics were used for describing the data. Out of the 246 patients of HBV, 29 [11.8%] patients were also positive for anti-HBc IgG, anti-HDV and anti-HCV. After 48 weeks of therapy, the respective viral undetection by PCR was 4 [13.8%] in patients having only HBV DNA, 3 [10.3%] in patients with only HCV RNA and in patients who had both HBV DNA and HCV RNA positive, simultaneously HCV was cleared in 2 [6.9%] while HBV was not cleared in any case. In patients coming with one hepatic infection, other infections should be sought as they share a common mode of spread and may affect the overall response to treatment

Practice of informed consent for the treatment of tuberculosis

To find out the practice of informed consent obtained and opinion for seeking it, from patients enrolled under direct observation treatment short course for the treatment of tuberculosis in three public sector chest clinics of Karachi and recommendations accordingly. A cross-sectional hospital based survey. This survey was conducted on 138 patients selected by systematic random sampling method from Lyari, Nazimabad and Malir chest clinics of Karachi. Independent variables of this study were age, gender, educational level, socio-economic status, place of residence and habits of the patients enrolled in direct observation treatment short course. Dependent variables of this study were information about the diagnosis of the disease, drug's dose, duration, intake method, its side effects and voluntary consent/approval for enrolling in the treatment regime prescribed by the health care provider. Inclusion criteria of this study were confirmed diagnosed case of tuberculosis according to criteria set by the said clinic, in the initial intensive phase of the treatment. Exclusion criteria were patients of tuberculosis given treatment on trial basis or patients in the continuation phase of treatment. It was found that 100% patients had no knowledge of informed consent. Patients were informed only verbally about their diagnosis, drugs required to treat their illness, its dose, duration, intake method and side effects by the health staff. Thirty percent patients were unable to recall which part of their body was affected by the disease; 90% remembered the duration of therapy without understanding the difference of initial intensive or continuation phase of the treatment, 57% were taking drugs in the presence of a responsible person; 48% recalled the reason for direct observation of drug intake and 72% were found to be in favor of seeking consent before enrolling themselves in direct observation treatment short course. In this study it was found that the practice of obtaining informed consent was below the standard level of international and ethical acceptability in the studied public sector chest clinics of Karachi

Patterns of acute poisoning and its outcome reported at civil hospital Karachi

To determine frequently used agents in acute poisoning, mode of poisoning, influencing factors, time interval between intoxication and hospital arrival outcome. The study was conducted in the department of Medicine, Civil Hospital Karachi in year 2006. It was a Descriptive and observational study. All cases of acute poisoning admitted in medical unit IV were included in this study. In all the cases a previously prepared Performa was filled, the Performa included patient's demographic patterns, agent used for poisoning, various influencing and precipitating factors of acute poisoning, route of poisoning, time interval between intake and arrival in hospital, past history of such episode, psychiatric history and outcome. Total of 118 cases of acute poisoning admitted during the study period. Sixty two [52.85%] were female and fifty six [47.15%] were males. Oral route was used in all cases. Mode of poisoning was suicidal [61.02%], deliberately self harm [22.03%], accidental [11%] and homicidal [5.08%]. Common reasons for poisoning in males were financial constraints [48%] and unemployment [40%]. Common reason for poisoning in females was family conflictions [68%]. Fifteen patients [12.54%] had previously attempted the poisoning as well. Previously known psychiatric illness was found in five [4.24%] of patients. Most of the patients [102] reached within eight hours, only six arrived within two hours. Eleven patients [9%] expired in which six were females and five were males. Organophosphorus compounds were found to be the commonest incriminating agent in poisoning. Family conflictions and financial constraints were the main reasons behind poisoning. Most of the patients are reaching late in hospital, Majority of the deaths are occurring immediately after arrival and within two days. Reattempt of poisoning was found in significant number of patients which were although preventable. Mortality in cases of poisoning is still high

Corrlation of adjusted blood requirement index with treatment intervention and outcome in patients presenting with acute variceal bleeding

To determine the correlation of ABRI with treatment intervention and outcome as discharged or expired in patients of acute variceal bleed. Cross-sectional study Records of all the patients admitted in Medical Unit-IV, Civil Hospital Karachi with acute variceal bleeding during January 2004 to October 2006 were retrieved. Use of vasoactive agents [Terlipressin/Octreotide], endoscopic band ligation [EBL] and outcome [Discharged/Expired] were noted. ABRI was calculated by the following formula: ABRI= Blood Units Transfused/ [[Final Hematocrit - Initial Hematocrit] + 0.01] Mean ABRI were compared by Student's 't' test according to vasoactive therapy, EBL and outcome. Correlation of ABRI with the same variables was also studied by plotting Receiver Operative Curves [ROC]. Seventy six patients fulfilling inclusion criteria were selected. No statistically significant difference was observed in the mean ABRI scores when compared according to vasoactive drug administration, EBL and outcome. Significant correlation with mortality was seen on ROC plot with significantly larger area under the curve. ABRI correlated significantly with mortality in this study. Larger prospective studies with appropriate power are required to evaluate its association with other variables

Effects of community noise on urban population

Community noise or environmental noise is a noise produced by various activities except the one produced by industry. Its main sources are transportation [air, road and rail], construction, public works and human activities. The indoor source of community noise is ventilation system, neighbors, office machines, home appliances and leisure activities. Health effects caused by noise include hearing loss, sleep disturbance annoyance besides many others. To find out the range of effects of community noise [sleep, fatigue and irritation] on housewives of urban population and see its association with age, education and other factors. This was a Questionnaire based exploratory community based cross-sectional survey conducted on 252 housewives selected at random from six localities of three towns i.e. Saddar, Lyari and Jamshed town of Karachi. Data was analyzed on computer package SPSS version 10. In this study 39% housewives were immigrants from India [muhajir], 28% Sindhi, 14% Punjabi, 9% Pashto and 6% were other ethnic groups, mean age of housewives was 35.3 years. It was found that majority 81.01% of housewives were able to listen to television programs in normal volume while 16.0% were listening the same programs at high volume. Similarly most [83.11%] housewives were able to listen to telephonic conversation easily in their homes, 22[8.7%] housewives had been treated for ear problems in the past, 20 [7.9%] gave history of impaired hearing and 1 was using a hearing aid. About 95.2% housewives were speaking in normal volume and 54[21.4%] were using various kinds of medications for chronic medical illnesses. Three point Lickert scale was used to measure the effect of noise for sleep disturbance, fatigue and irritation and it was seen that 34.1% housewives experienced severe sleep disturbance, and about the same percentage 33.3% felts severe fatigue and 33.7% irritation due to noise. All these issues were more frequent in women age over 30 years then those aged less then 30 years. The most common cause of noise pollution was human activities. Housewives were avoiding exposure to noise by moving to quiet corners of their homes and keeping the doors and windows closed. The study showed that almost 33% housewives experienced severe sleep disturbances, fatigue and irritation due to community noise. The problem was more pronounced in housewives who were over 30 years of age. Commonest cause of community noise is the one produced by human activities followed by traffic noise

Hyperglycemia: an unusual cause for hemichorea-hemiballism

Hemichorea - hemiballism is a rare neurologic disorder due to oxidative stress leading to neurodegeneration of the dentate nuclei and striata. It is rarely observed in diabetes. One such case occuring in an adult female diabetic is described

Unusual presentation of an unusual hepatitis

Autoimmune hepatitis is an uncommon cause of chronic hepatitis in Pakistan. One such case is described occurring in an adult female cirrhotic diagnosed on raised serum IgG and LKM-I

Correlation of quality of life in patients of cirrhosis of liver with etiology and disease severity using disease-specific quality of life questionnaire

Quality of Life has an important status in patient management suffering from chronic disease like cirrhosis and health related quality of life has significant impact on patient management. This study was conducted to evaluate the correlation of health related quality of life with disease severity in patients of cirrhosis of liver. This cross-sectional study was conducted at Medical Unit-IV, Dow University of Health Sciences, Karachi, during the period January 2006 to October 2006. All patients of cirrhosis of liver admitted during the study period were selected. Patients with encephalopathy, hepatocellular carcinoma were excluded. The 29 item chronic liver disease questionnaire [CLDQ] was administered to the patients by a postgraduate trainee. Internal validity of responses was checked statistically and correlation of responses was done with disease severity by Child-Pughs Criteria. 109 patients were selected with 72 males and 37 females. Patient classification according to Child class A, B and C was 30, 38 and 41 respectively. The mean CLDQ score in the patients was 89.5 +/- 30.4. It correlated significantly with Child Class but did not correlate with the gender, age and etiology of cirrhosis. Health related CLDQ scores correlate with the severity of liver disease

Treatment outcome in patients of hepatitis B with hepatitis D: experience of 4 years at a tertiary care centre in Pakistan

To determine HBV suppression in patients with dual HBV and HDV infection after 48 weeks with 10.0 MID of interferon-a 2b. Quasi experimental study. Civil Hospital, Karachi and Lyari General Hospital, Karachi, from July 2003 to June 2005. All HBsAg positive patients were screened for anti-HDV, all positives were included. Baseline investigations, liver chemistries and HBsAg; HBeAg; anti-HBcore IgM; HBV DMA quantitative PCR were done. Patients with hepatocellular carcinoma and decompensated cirrhosis were excluded. Patients were treated with Interferon-a 10.0 MID sc t.i.w. for 48 weeks. HBeAg and quantitative HBV DNA was done at week 0, 24 and 48 while CBC and SGPT were done monthly. HBV suppression was defined as levels <400 copies/ml. Fifty-two patients were selected for intervention, including 34 males and 18 females. At the end of therapy after 48 weeks, HBV DNA suppression was achieved in 51.9% and HBeAg became undetectable in 53.8% of patients. Twenty -one patients with HBV suppression still had raised SGPT. HDV should be screened in all patients eligible for HBV treatment

Waste disposal of government health-care facilities in urban area of Karachi - a KAP survey

Waste produced by health-care facilities can be broadly divided into two categories, non-infectious waste comprises 75% to 90% of the total waste, is non-risk health waste, can be disposed of like other waste in municipal landfills whereas infectious waste comprises10% to 25% consist of syringes, needles, chemicals, body parts, drugs etcs, needs treatment before disposal. To find out knowledge, attitude and practice of personnel involved in waste disposal of health-care facilities. Cross-sectional, hospital based survey conducted on 137 personnel involved in waste management of 68 randomly selected health-care facilities, in urban area of Karachi. Data of 9 hospitals, 11 maternity homes and 29 dispensaries, comprising 137 sanitary workers showed that knowledge of all [100%] workers about hospital waste management was poor whereas attitude of 38% and practice of only 2% was good. The study further showed that 24.5% health-care facilities disposed infectious and non-infectious waste without any treatment into public dustbins, 73.7% sanitary workers carry waste in open buckets for final disposal. None of the sanitary workers have undergone routine medical check-ups except when ill, 67.9% were not provided any protective equipment. It was also found that 96.4% were not interested in health education for the safe disposal of health-care facilities waste rather they were just doing their jobs for their earning. Infectious and non-infectious waste were collected together and disposed off in municipal landfills; while liquid waste is disposed off into the sewerage system without any treatment. The study showed that the knowledge, attitude and practice of personnel involved in health care facilities' waste management are extremely poor and proper facilities for management of hospital waste are almost non-existent in Karachi

Frequency and comparative analysis of hepatitis in patients seeking treatment for hepatitis B

To find the frequency of hepatitis 'D' in patients of hepatitis 'B' seeking treatment and to compare clinical and biochemical features in patients harboring HDV with those who are not. Cross-sectional study. Medical Unit-IV, Civil Hospital Karachi, Medical Unit-VI and Surgical Unit-VII, Lyari General Hospital, Dow University of Health Sciences, Karachi; from July 2003 to June 2005. HBsAg positive patients seeking treatment were enrolled in the study. Anti-HDV was done in all. Patients were split into two groups according to their anti-HDV status into HDV positive and HDV negative groups. Liver biochemistries and viral profile for HCV, anti-HBc IgM and HBeAg were done and compared between the two groups. A total of 246 patients were selected. HDV was positive in 66 [26.8%] patients. No significant difference was observed in the frequency and stages of cirrhosis between the two groups while significant differences were observed in the mean SGPT [95% CI: -381.09 to -110.74; P = 0.001] and albumin levels [95% CI: 1.87 to 7.73; P = 0.007] and in the frequency of HBeAg [P = 0.001], anti- HBc IgM [P = 0.02] and HBV DNA [P < 0.001]. HDV infection was common in patients with HBV in this cohort of patients. All patients of HBV should be screened for HDV before treatment decision for the former is taken