Economic burden of dengue in four major cities of Pakistan during 2011

To assess the economic burden of dengue infection by calculating cost per patient and disability adjusted life years lost. The cross-sectional study was conducted in Islamabad, Lahore, Faisalabad and Karachi from July 2012 to March 2013. Residential addresses and telephonic numbers of dengue patients were taken from the records of Pakistan Institute of Medical Sciences, Islamabad, Mayo and Ganga Ram Hospital, Lahore, Civil Hospital, Karachi, and Allied Hospital, Faisalabad. A total of 250 dengue confirmed cases - 50 from each hospital - were randomly selected. Information regarding duration of illness and out-of-pocket expenses were collected to estimate the direct cost, while indirect cost [number of work days missed by the patient] was calculated from disability adjusted life years using Murray's formula. Overall, there were 162[65%] men and 88[35%] with a mean age of 30.4 +/- 13.5years. More than half 138[55%] were below 30 years of age. Socio-economically, 145[58%] belonged to low, 70[28%] middle and 35[14%] to high socioeconomic groups. Of the total, 210[84%] cases had dengue fever followed by 32[12.8%] dengue haemorrhagic fever and 8[3.2%] dengue shock syndrome cases. Average duration of illness was 32 +/- 7.1 days. Overall direct cost per patient was Rs.35, 823 [US$358] and average pre-hospitalisation, hospitalisation and post-hospitalisation was Rs.6154, Rs.21, 242 and Rs.8, 427 respectively. The overall disability adjusted life years per million population was 133.76. Although the government had provided free treatment for dengue in public-sector hospitals, still patients had to pay Rs.21, 242 during hospital stay, resulting in substantial burden which needs to be addressed

Persistence of dengue symptoms among discharged dengue cases of Lahore, Pakistan

The signs and symptoms of acute dengue infection are well defined and characterized. However, little data is available about the persistence of these symptoms which depends upon the disease management and patient care. This study was conducted to determine the persistence of dengue symptoms in admitted cases who were discharged from hospital. Data of dengue cases who were admitted in 2 public sector hospitals was retrieved along with their complete addresses. Patients were approached and interviewed after getting the written informed consent. A pre-designed questionnaire was used to collect information about the persistence of dengue symptoms in the patients after they were discharged from hospital. Of 41 cases interviewed, 31 were males and overall mean age was 31 years. The case record showed that 15 cases had dengue shock syndrome, 14 dengue hemorrhagic fever and 12 dengue fever. The average period of illness after getting discharged was 19 days which was significantly higher in females [23 days] as compared to males [18 days]. Majority of the cases [except 04] reported persistence of dengue symptoms in which joint pain [29 cases], itching [17 cases] and exhaustion [14 cases] were more common. The persistence of joint pain after discharge was significantly associated with dengue shock syndrome. The current study showed significant association between joint pain and DSS which could be overcome through proper case management. Furthermore there is a need to follow admitted dengue cases after getting discharged from the hospital to avoid any complications

Screening for tuberculosis among household contacts of index patients

Household contacts of sputum positive pulmonary TB cases are at a high risk of getting infected with tuberculosis therefore symptomatic or vulnerable individuals should be screened and treated early. To determine the prevalence of pulmonary tuberculosis in the households contacts of index patients having pulmonary tuberculosis infection using standard diagnostic tests and refer the positive cases to DOTS program for treatment. This national descriptive study was conducted in seven Centers of PMRC throughout Pakistan form November 2010 to March 2012. A total of 580 index adult patients suffering from pulmonary tuberculosis, being treated at DOTs Centers of major tertiary care hospitals of Karachi, Lahore, Multan, Peshawar and Quetta living within 5-8 kilometers of the hospital, who consented to participate in the study were selected from the DOTs centres. Generally one but occasionally two close contacts of these index patients [spouses, parents or siblings] were called to the hospital for screening of TB using chest Xray, smear microscopy and tuberculin skin test. Out of 800 contacts screened, 125 [15.6%] were positive on sputum smear examination while 113 had infiltration on X-rays along with positive tuberculin skin test [Indurations of >10 mm] making a definitive diagnosis of TB. Calcified lesions were seen on X-rays in another 91 cases giving evidence of past infection, however 26 of these were AFB positive indicating either the relapse of disease or active lesion. Low grade fever and weight loss were the most significant findings in contacts that were positive on sputum smear and radiology. Almost 15.6% household contacts of pulmonary tuberculosis patients have pulmonary tuberculosis. Health care providers in general and DOTs staff in particular should be trained to inform all index cases that their close contacts especially those suffering from weight loss and fever should be screened for tuberculosis and treated if required

Pregnancy related medical problems at a tertiary care hospital

To estimate pregnancy related medical problems in cases visiting care hospital for antenatal care tertiary .Retrospective OPD based study done at medical research laboratory of Ganga Ram Hospital, Lahore from January 2011 to December 2011. A total of 1806 pregnant cases visited the biochemistry laboratory out of which 1000 cases fulfilled the criteria and had complete record available and were selected for analysis. Variable including hemoglobin, blood group and Rh factor, fasting and post prandial plasma glucose, viral markers like HBsAg, Anti-HCV and Anti-HIV l/ll and complete urine examination. Data was analyzed using Statistical Package for Social Sciences [SPSS-15]. The mean age of women was 25.4 +/- 4.29 years and 78.1% were between 21-30 years. The mean fasting and post parandial glucose levels were 84.03 +/- 15 mg/dl and 134.30 +/- 23 mg/dl respectively. Gestational diabetes mellitus was found in 96 cases [6.9%]. HBsAg was present in 1.2%, HCV in 8.5% and both B and C were present in 1 case. None had HIV l/ll infection. Blood group 'B' was commonest [34.2%], followed by group 'O' [30.6%], group 'A' [24.5%] and 'AB' [10.7%]. Rhesus factor [Rh] showed 94% Rh-positive cases and 6.0% Rh negative. Overall anemia was present in 61.1% cases with mild anemia in 87.5%, moderate in 12.2% and severe in 0.1%. Urinary tract infection was seen in 10.1 % cases. Anemia was common in pregnancy. Urinary tract infection [10%], hepatitis C virus exposure [8.5%] and gestational diabetes mellitus [7%] were common. Although the screening of HCV is not recommended internationally but the rate of HCV infection is on increase in Pakistan so there is a need of proper screening of HCV along with routine antenatal screening. It will help to identify asymptomatic women, who may benefit from antiviral therapy at a time when they are more receptive to medical intervention

Frequency of iron deficiency anaemia and beta thalassaemia trait at haematology department of children hospital, Lahore

Beta thalassaemia and iron deficiency anaemia are the most common microcytic hypochromic anaemias in Pakistan. Both have a significant impact on the patient, the patient's family and offspring. A descriptive study that was designed to compare the frequency of beta thalassaemia trait with iron deficiency anaemia in children who visited Children's Hospital Lahore. Duration of study was six months from May 2005 to Oct 2005. Comparison was based on red blood cell morphology. Their demographic characteristics were also studied. Three hundred children aged 01 - 16 years who visited Children's Hospital Lahore were included in this study. Duration of study was 6 months. Criteria for selection were voluntary participation and the availability of family members. Venous blood samples were collected into EDTA. Erythrocyte subsets are reported by the Sysmex XE 5000 analyzer. Children receiving blood transfusion were excluded from the study. It was observed that the prevalence rate of iron deficiency is more common [89.7%] as compared to beta thalassaemia trait [10.3%] in children. Male children were more thalassaemic and iron deficient as compared to females. Age range of both groups of children were 1 - 4 years. Thalassaemic patients have more positive family history than iron deficiency. Peripheral blood smear of thalassaemic children showed mild anisopoikilocytosis and fragmentation. Mild to moderate microcytosis and hypochromia was observed in same group of children. On the other hand mild to moderate anisopoikilocytosis, microcytosis and hypochromia was observed in children with iron deficiency. Severe microcytosis, hypochromia and mild fragmentation was observed in the same group of children. It is concluded that the frequency of iron deficiency is more common in age under 5 as compared to thalassaemia trait. Study also concluded that the percentages of iron deficiency in children studied are very high in our country as compared to other parts of the world. Positive family history of BTT may be due to marriage between close relatives, especially first cousins is a very common custom. Red cell differential is useful in distinguishing between thalassaemia and iron deficiency anaemia. In red cell morphology of both groups, fragmentation may be used to differentiate beta thalassaemia trait from iron deficiency

Thyroid status and urinary iodine levels in women of endemic goiter area

To determine the thyroid function tests and urinary iodine levels in women belonging to goiter endemic area. Descriptive study conducted in women of goiter endemic area in Saggian Lahore. Saggian Lahore is a goiter endemic area. A total of 293 women between the ages of 18-45 years residing in the area were clinically screened for goiter. Of them 73 women having goiter were recruited for the study. Information regarding demographic profile clinical presentation and physical examination of the goiter was recorded on a questionnaire. The goiter size was graded according to WHO, UNICEF and the International Council for the Control of Iodine Deficiency Disorder. About 5ml of blood sample was drawn from each women and run for thyroid function tests i.e. T3 T4 and TSH using Elisa kits [Human scientific Co. Germany]. Urinary iodine was checked by chemical method. Mean age of 73 women was 28.5 years. Marital status showed that 48[65.7%] were married and 25[34.3%] were unmarried. Visible diffuse goiter was seen in 56[77%] cases. Pressure symptoms as cough and shortness of breath was seen in 30[41%] and 31[42.5%] women respectively. Among the 73 women 24.6% [18 cases] took treatment for goiter. Adverse pregnancy outcome secondary to goiter was seen in 58% [28 cases] out of 48 married women. Thyroid function tests result showed that 72% [53 cases] were euthyroid, 18% [13 cases] were hypothyroid, and 10% [7 cases] were hyperthyroid. Urinary iodine levels showed that 99% women were iodine deficient. Thyroid functions do not indicate iodine deficiency in all cases of goiter, therefore, Urinary iodine levels need be estimated while investigating goiter cases. Policy message: Iodine deficiency should be diagnosed and treated on priority basis

Association of insulin resistance with obesity in children

Insulin resistance is the primary metabolic disorder associated with obesity. Little is known about its role as a determinant of the metabolic syndrome in obese children. To assess the association of insulin resistance with metabolic syndrome in obese and non obese children. Study type and settings: Cross sectional analytical study conducted among children of ten Municipal Corporation high schools of Data Ganj Buksh Town Lahore. A total of 46 obese and 49 non obese children with consent were recruited for the study. Fasting blood glucose, serum insulin, high density lipoprotein cholesterol, triglycerides, cholesterol, non HDL-cholesterol LDL cholesterol were measured using standard methods. Data were analyzed by using statistical software SPSS-Version 15. A total of 95 children 49 obese and 46 non obese were recruited for the study. A significant association of serum triglyceride [p<0.001], high density lipoprotein cholesterol [p<0.001], fasting blood glucose [p<0.001], and insulin levels [p<0.001], was seen between the two groups. For each component of metabolic syndrome, when insulin resistance increased so did odds ratios for cardio metabolic risk factors. Insulin resistance was seen in 34.7% children. Metabolic syndrome was found in 31.6% children reflecting that obese children are at high risk for metabolic syndrome and have low HDL-cholesterol and high triglycerides levels

Prevalence of dyslipidemia in patients with type-2 diabetes mellitus

The dyslipidaemia associated with type-2 diabetes is associated with raised plasma triglycerides, low high-density lipoprotein cholesterol, high low-density lipoprotein cholesterol and very low-density lipoprotein cholesterol levels and is a risk factor of cardiovascular disease. To assess the lipid abnormalities in patients with type-2 diabetes. A cohort study carried out at Diabetic Clinic of PMRC Research Centre, FJMC, Lahore, Pakistan. Eight years case records of type-2 diabetic patients seen at the research centre from 1999-2006 were reviewed. The research centre is a specialized centre for diagnosing and treating diabetes mellitus. All the patients were recruited for their follow up check up and laboratory investigations for dislipidemia. Adult treatment panel III guidelines for dyslipidaemia were followed. A 12 hours fasting blood sample was collected from each patient for serum total cholesterol, triglycerides, low-density lipoprotein cholesterol [LDL-C], high-density lipoprotein cholesterol [HDL-C], and glucose as well as glycosylated hemoglobin [HbA1c] by using standard methods at Biochemistry laboratory of the research centre. LDL-C/ HDL-C ratios, Very low-density lipoprotein cholesterol [VLDL-C] and body mass index was calculated after anthropometery body mass index [BMI] >/= 25 was considered as overweight while >/= 30 obese. HbA1c<6.1 was considered as poor glycemic control. Data was analyzed by using statistical software SPSS-15. a total of 1200 type-2 diabetes were seen in 8 years. There was poor glycemic control, in 87.5% subjects judged on blood HbA1c levels. These patients had higher total cholesterol, LDL-C and low HDL-C levels in blood. The percentage of patients with high, borderline and near optimal risk LDL-C was 62.7, 26.9 and 10.4% respectively, while HDL-C >40mg/dl were seen in 67%. Raised VLDL-C [above 40 mg/dl] was seen in 32.9% cases. The group with high LDL and VLDL is at risk of developing cardiovascular disease. Hypertriglyceridaemia was found in 55% and hypercholesterolaemia in 45.4% cases. Obesity as indicated by body mass index was found in 53.7% patients. Statistically significant association of hypercholesterolemia, hypertriglyceridemia, hypo HDL cholesterolemia and VLDL-C was found with advancing age while only hypertriglyceridemia and VLDL-C showed a positive association with duration of diabetes. A significant association of hyperglycemia [raised HbA1c] was seen with hypertriglyceridemia and high LDL-C along with high body mass index i.e. obesity. Hypertriglyceridemia, high LDL-C and VLDL-C, low HDL-C levels and obesity were the pattern of dyslipidemia found in our diabetic population

Efficacy of fix dose combination [atorvastatin and amlodipine] in treatment of uncontrolled hypertension and dyslipidemia

Background: The fixed-dose combination containing the antihypertensive agent amlodipine and the statin, atorvastatin, is the first combination of its kind designed to treat two risk factors for cardiovascular disease [CVD], i.e., hypertension and dyslipidemia. In this study, blood pressure an lipid lowering effects of combination of amlodipine and atorvastatin were evaluated in uncontrolled hypertensive patients. Methods: Thirty patients both male and female in the age group 35–60 years attending the Hypertensive Clinic of PMRC FJMC suffering from uncontrolled hypertension wer selected. Baseline blood pressure was checked after half hour rest in sitting and standing position using mercury sphygmomanometer. Blood sample was collected from all patients after overnight fasting for assessment of serum cholesterol, triglycerides, LDL and HDL cholesterol levels. They were prescribed with fixed dose combination of 5 mg amlodipine and 10 mg atorvastatin. Patients were followed for their blood pressure measurement after every 4 weeks up to 12 weeks. At the end of 12 weeks their fasting blood sample was taken again for determination of serum cholesterol, triglyceride, LDL and HDL cholesterol levels. Results: Systolic blood pressure after 4, 8 and 12 weeks was significantly lower at all intervals from baseline. When systolic blood pressure after 8 and 12 weeks was compared with 4 weeks, the effect was again significant [p=0.024, p=0.002 respectively].There was no significant reduction seen in 8 versus 12 weeks [p=0.493]. Diastolic blood pressure at 4, 8 and 12 weeks was significantly lower from baseline. Diastolic blood pressure after 4 and 8 weeks when compared with 8 and 12 weeks was not significantly low [p=0.99 and 0.91 respectively]. Lipid profile of the patients was significantly reduced from baseline after twelve weeks of fixed dose combination of treatment [p<0.000]. Conclusion: Combination therapy proved to be effective in controlling hypertension and dyslipidemia than single pill. It also improved patient's compliance. It is suggested that polypill should be prescribed instead of multiple drugs. Keywords: combination therapy, atorvastatin, amlodipine, uncontrolled hypertension, dyslipidemia

Role of alanine transaminase as an indicator of non alcoholic fatty liver patients with type-2 diabetes mellitus

This study was carried out to see the role of Alanine transaminase [ALT] as an indicator of Non Alcoholic Fatty liver disease [NAFLD] in patients having Type-2 Diabetes Mellitus. This was a descriptive study carried out al PMRC FJMC Lahore. A total of 63 diabetic cases that were diagnosed on ultrasonography as nonalcoholic fatty liver were recruited in this study. Demographic profile of the patients were recorded and all were subjected to lab investigation which included random blood glucose, serum triglycerides and liver function tests including viral marker of the hepatitis. Fatty liver was more prevalent in female patients 47 out of 63 [74.6%] and is more common above 40 years of age, median age being 46 years. The duration of disease was prolonged with median of 6 years. It is seen that 28/63 [44.5%] were hypertensive, 31% had hyperlipidemia and 9.5% were having ischemic heart disease. Majority of patients 28 out of 63 [44.5%] had hepatomegaly. The liver enzymes results showed that 12 of the 63 [19%] were positive for hepatitis B and C and had ALT level raised with mean of 63.00 +/- 40.66. While, among the other 51 patients without hepatitis B and C ALT level were within normal range in 36 [71%] of the cases. While in rest of 29%%15 out of 51 they were only mildly elevated. Thus showing that ALT has no role as an indicator of fatty liver. Alanine transaminase is not an indicator of NAFLD and mild elevation can be due to the metabolic disturbances in type-2 diabetic patients. It is therefore, suggested that ultrasound graph is a good tool to detect the NAFLD in its early stage

Differentiation of common gram negative pathogens by PCR- ribotyping

Gram negative bacteria especially members of family Enterobacteriaceae are among the most frequently isolated organisms from the clinical specimens. Rapid diagnosis of the pathogen in a clinical sample is always very important. Conventional methods are time-consuming. Among molecular techniques, PCR is very useful but unless very specific primers are used, non-specific amplifications are a problem. PCR-ribotying is a technique that gives very specific multiple bands by use of a single primer set. This study was designed to establish patterns for five common pathogens of Enterobacteriaceae, namely Escherichia coli, Salmonella enterica serovar Typhi [Salmonella Typhi], Proteus vulgaris, Klebsiella aerogenes, and Cirtobacter freundii along with another very common and problematic gram negative pathogen Pseudomonas aeruginosa. Each species gave a specific ribotyping pattern. Escherichia coli gave four amplification products of 1200, 850, 800, and 700 bps. Four amplification products of different sizes were also observed in Citrobacter freundii [3000, 850, 700, and 580 bps], Proteus vulgaris [900, 800, 750 and 700 bps], and Klebisella aerogenes [3000, 870, 700 and 520 bps]. More discrimination with five amplification products was seen in Salmonella Typhi [3000, 1200, 900, 850, and 700 bps]. On the other side of spectrum was Pseudomonas aeruginosa only a single amplification product of 750 bps was observed. PCR-ribotyping can very efficiently and specifically differentiate between opportunistic gram negative human pathogens

Cystic lymphangioma of the small-bowel mesentery: case report

Cystic lymphangioma of the small-bowel mesentery is a rare manifestation of an intraabdominal tumor in elderly patients. We present a case of a small-bowel mesentery lymphangioma, causing fever and chills and present clinical and pathologic features. Furthermore, etiology and differential diagnosis of this tumor are discussed

Significant incidence of typhoid in hepatitis C patients

Only proven way of transmission of Hepatitis C is through blood. The origin is unknown in nearly half the cases. Pollution is suspected as a cause but it is impossible to prove this relationship directly. We thought that typhoid being a proven pollution related disease, determination of its confection in Hepatitis C patients representing same Socio-economic group would be of interest. A typhoid in Hepatitis C patients can easily be overlooked because symptoms like fever and abdominal discomfort are present in both diseases. Blood samples were collected from three groups of study as mentioned in materials and methods. These samples were processed for 4[th] generation HCV ELISA. PCR for HCV, PCR for typhoid. Blood culture for typhoid and widal test as required [details are given in methodology]. Finally the data thus obtained was analysed and conclusions were drawn. Health Biotechnology Division, National Institute for Biotechnology and Genetic Engineering [NIBGE] and Millat Laboratory Faisalabad. April 2004 to Oct 2004. The parameters included were PCR, blood culture and widal test. There were three groups of study, PCR and ELISA positive patients of Hepatitis C [105] - further subdivided into two groups, with history of exposure to known causes of spread of HCV in last one year [65] and those without such history [40]; clinically diagnosed cases of typhoid [30]; and healthy controls [50]. In the three groups, PCR was positive in 9.5[7.7 and 12.5], 63.3, and 2.0% cases respectively. Figures for blood culture were 4.7[3.1 and 7.5], 33.3, and 0% in the same order, and the respective figures for widal test were 34.2[33.8 and 35.0], 56.6, and 24.0%. The increase in PCR and blood culture positivity in Hepatitis C cases as compared with normal subjects is statistically significant [P< 0.05]. These results clearly suggest that the source of infection for the two diseases is same in many cases, and therefore, provides a strong indication of a relationship between pollution and Hepatitis C

Xanthogranomatous pyelonephritis [XGPN] with xanthogranulomatous fungal infection: a case report

A case of xanthogranulomatous pyelonephritis with fungal infection is described. The patient was a known case of nephrolithiasis and thalassemia. He had developed pyrexia of unknown origin since two years. On further workup he was found to have hepatomegaly, para-aortic lymphadenopathy, massive left kidney and advanced renal failure with deranged renal function tests. The patient underwent left nephrectomy with the provisional diagnosis of advanced renal failure secondary to nephrolithiasis or renal Koch`s. Histopathological examination revealed XGPN with numerous fungi present both in snore form and septate hyphae. Post operative recovery was un-eventful