The Cost Of Dialysis In Malaysia: Haemodialysis And Continuous Ambulatory Peritoneal Dialysis

@#In Malaysia, dialysis-treated end stage renal disease (ESRD) patients have been increasing rapidly. Haemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) use a disproportionately large amount of limited healthcare resources. This study aims to estimate the costs of HD and CAPD from the Ministry of Health (MOH) perspective. One year prospective multicentre study was conducted from October 2016 to September 2017 to assess direct medical costs of 90 HD patients and 73 CAPD patients from five large MOH dialysis centres. A mixed method of activity-based costing and step-down was used. The capital costs included land, building, medical equipment and furnishing. The recurrent costs included staff emoluments, facility utilities, patients’ medical costs and dialysis consumables. One-way sensitivity analysis was performed to investigate variability in the data. One hundred and forty-one patients (82%) completed the study comprising of 77 patients on HD and 64 patients on CAPD. Majority of the patients were between 46-65 years old (n=75, 53.2%). The most common aetiology of ESRD was diabetes mellitus (44.2% in HD and 48.4% in CAPD). Cost per patient per year was RM39,790 for HD and RM37,576 for CAPD. The main cost drivers were staff emoluments (37.6%) and dialysis consumables (70.5%) for HD and CAPD respectively. HD is highly sensitive towards all the variables analysed except for dialysis consumables. In CAPD, there are minimal sensitivities except for the 5% discount rate. Knowledge of the costs of modalities are useful in the context of planning for dialysis services and to optimise the number of kidney failure patients treated by dialysis within the MOH.

Plasmapheresis versus intravenous immunoglobulins in guillain barre syndrome, the therapeutic outcomes

To compare the therapeutic outcomes of plasmapheresis with intravenous immunoglobulins [IVIG] for Guillain Barre syndrome. Randomized controlled trial. Medicine department; PNS Shifa Hospital Karachi from Jan 2011 to Jun 2012. Adult patients admitted to internal medicine department with the diagnosis of Guillain Barre Syndrome [GBS] fulfilling the inclusion and exclusion criteria were included after taking ethical approval and informed consent. They were randomly assigned to plasmapheresis and IVIG treatment groups. Their presenting features, investigations and management plan were followed over 6 months duration. Hughes disability scale for Guillain Barre syndrome was documented and compared at admission, 4 weeks, 12 weeks and 6 months by non-parametric tests via SPSS version 17. Total 36 patients [31 males and 5 females] were included. Mean age was 37 +/- 15 [18-70] years, mean duration of symptoms 11.6 +/- 12.7 days. Plasmapheresis and IVIG groups were comparable with respect to age and gender [p>0.05]. Significant improvement of mean disability score was observed in each group from baseline score [p<0.0005]. At specified intervals, comparison between the two groups in terms of mean improvement in disability scores showed significant improvement at 4 weeks [p<0.05] in IVIG group as compared to plasmapheresis group; however on further observation at 12 weeks and 6 months, mean improvement was comparable between two groups with no significant difference [p>0.05]. There was no significant difference in need for assisted ventilation between two groups [p>0.05]. Variants of GBS observed were AIDP [50%], AMAN [31%] and AMSAN [19%]. Our study suggests that both plasmapheresis and intravenous immunoglobulins are useful and effective modes of treatment for Guillain Barre Syndrome. Significant short term improvement was observed in the IVIG group at 4 weeks of treatment; however no significant difference in therapeutic outcome observed between the two groups on further follow up of 6 months. Thus focusing the need of further large scale regional studies to analyze various factors contributing to this short term but significant improvement with IVIG treatment observed in this study

Etiologic patterns of ischaemic stroke in young adults

To determine the etiologic patterns of ischaemic stroke in young adults. A descriptive study. Department of Neurology, Jinnah Postgraduate Medical Centre, Karachi, from January to December 2010. All ischaemic stroke patients aged 15 - 45 years were included. The etiologic patterns were classified using TOAST [Trial of ORG 10172 in acute ischaemic stroke] classification and comparisons were made between different stroke subtypes with reference to traditional risk factors like age, smoking, hypertension, diabetes mellitus and dyslipidemia. Results were described in percentages. There were 75 cases and higher proportion of patients had ischaemic stroke due to cardiac etiology below the age of 35 years. Nineteen patients had cardioembolic stroke [8 [42.1%] males and 11 [57.9%] females]; 15 patients had large artery atherosclerosis [males 9 [60%], females 6 [40%]]; 17 patients had stroke of determined etiology [SDE], [6 [35.2%] males and 11 [64.8%] females] among whom 47% were due to venous sinus thrombosis. Twelve patients had stroke of undetermined etiology [SUE], [5 [41.6%] males and 7 [58.4%] females] and 12 patients had stroke due to small vessel disease [SVD] [8 males [66.7%] and 4 [33.3%] females. Cardioembolism, venous sinus thrombosis and premature atherosclerosis are common etiologies in young patients with acute ischaemic stroke

Pancytopenia: megaloblastic anemia is still the commonest cause

To find out the frequency of the different causes of Pancytopenia and also to specifically detect the percentage of vitamin B12 deficieny amongst these patients. It is a prospective study carried out in Medical Unit I [Ward 5] of Jinnah Postgraduate Medical Centre Karachi from March to August 2007. A total of 88 patients were included after a detailed history and examinations the information was recorded on Proforma. Findings of aspiration and trephine biopsies were interpreted in the light of history, clinical examination and peripheral blood findings. Out of 88 patients suffering from Pancytopenia, a large number [40.90%] were diagnosed as Megaloblastic Anemia, out of which 77.77% had vitamin B12 deficiency. Aplastic anemia was found in 28 [31.88%] patients followed by other less common causes. Megaloblastic anemia was found in largest number of patients who were found to have Pancytopenia on initial investigations and majority of such patients were found to be deficient in Vitamin B

Malarial hepatopathy in falciparum malaria

To evaluate the clinical, biochemical and sonographic changes in patients with falciparum malaria and jaundice. A case series. This study was conducted at Medical Unit-1 [Ward 5], Jinnah Postgraduate Medical Centre, Karachi, from January 2006 to November 2007. A total of 62 adult patients, regardless of age and gender, with peripheral blood film evidence of falciparum malaria, who had jaundice, were included. Any patient with evidence of infection with Plasmodium vivax or other causes of liver disease [e.g. viral hepatitis, cirrhosis, portal hypertension, amoebic liver abscess, unexplained hepatomegaly, ascites, history of alcoholism, taking hepatotoxic drugs, past history of jaundice] was excluded on the basis of history, relevant clinical examination and investigations. Age of the patients ranged from 13-48 years [mean 26.04 +/- 8.33]. All patients were febrile and icteric, with pallor in 67.7%, hepatomegaly in 30.6%, splenomegaly in 70.9% and impaired consciousness in 20%. Serum bilirubin levels ranged from 3 to 24 mg%. Thirty two [51.6%] had serum bilirubin 3-6 mg%, 20 [32.2%] had 6-10 mg% and 10 [16.1%] had >10 mg%. ALT levels ranged from 20-870 IU/L and AST levels 24-1210 IU/L respectively. INR ranged from 1-1.3. Twenty eight patients [45%] had predominantly conjugated or mixed hyperbilirubinemia and serum transaminases were more than three times normal. Ultrasonography revealed hepatomegaly with decreased echogenicity in 22 [35.4%], splenomegaly in 48 [77.4%] and both hepatomegaly and splenomegaly in 16 [25.8%]. Gallbladder wall thickness was increased in 5 [8.06%] patients. There was no evidence of biliary dilatation. A significant percentage of patients having falciparum malaria with jaundice fulfill the criteria for malarial hepatopathy. It should be considered in patients presenting with acute febrile illness with jaundice so that specific treatment can be given

Management of ectopic pregnancy time for change

Ectopic pregnancy is a common complication of pregnancy leading to considerable maternal morbidity and mortality. Standard treatment has been to first diagnose the condition and then through an open approach either perform salpingectomy linear salpingostomy or to milk out the tube. Ectopic pregnancy can now be managed laparoscopically; one can carry out a salpingectomy or linear salpingostomy through a minimal access approach The laparoscopic approach to the management of ectopic pregnancy has proved to be safe effective, technically feasible and cost effective for health providers as well as for the patient