Postmortem findings in fatal dengue haemorrhagic fever

During recent epidemic of dengue fever in Peshawar, there has been a significant increase in dengue-associated admission in hospitals. We performed a postmortem examination of dengue-related death in our hospital. He was a young man, who was given supportive care at our tertiary care hospital, despite that he died on seventh day of admission. The autopsy findings in this case included multiple organ involvement including heart, lungs, kidneys and brain. There was histopathological finding of microabscesses in heart, lungs, brain and kidneys, which have not been reported in the literature yet. In patients with severe dengue, deaths do occur despite current supportive management. Knowing the pathological processes involved in severe disease, it can help identify early predictors of disease severity and help applying adequate clinical interventions

Association of hypomagnesemia with hyperglycemia and its renal complication in outpatients

Objective: To evaluate the association of hypomagnesemia with hyperglycemia and its renal complication in outpatients

Study Design: Case control study

Place and Duration of Study: Department of chemical pathology and endocrinology, Armed Forces Institute of Pathology, Rawalpindi, from October 2014 to July 2015

Material and Methods: Adults of either gender aged 20 years and above comprising 63 subjects with hyperglycemia and 63 controls with normoglycemia were consecutively inducted in the study. Patients with malabsorption, thyroid dysfunction or adrenal dysfunction, renal impairment, taking mineral supplement, pregnancy, lactation and any acute illness were excluded from the study. Fasting plasma glucose [FPG] and serum magnesium [Mg] level were measured on ADVIA 1800 siemens clinical chemistry auto-analyzer with hexokinase and xylidyl blue methods, respectively. Urine albumin was analyzed by Immunoturbidimetric method and urine creatinine was measured by the Jaffé kinetic assay on same analyzer. Albumin/creatinine ratio [ACR] was calculated. Pearson correlation coefficient "r" was calculated for serum Mg with FPG and ACR. Mean serum Mg levels in hyperglycemic and normoglycemic groups were compared using in dependent sample "t" test. Frequency of hypomagnesemia [serum magnesium

Results: Serum Mg has significant inverse correlation with FPG [r=-0.543, p=0.001] and ACR [r=-0.474; p=0.001].Mean serum Mg was 0.78 mmol/l in hyperglycemics and 0.88 mmol/l in normoglycemics [p=0.001]. The frequency of hypomagnesemia in subjects with type 2 Diabetes Mellitus [T2DM] was found to be 18.8% while no subject with pre-diabetes and normoglycemia had hypomagnesemia

Conclusion: Subjects with hyperglycemia had significantly lower mean serum Mg levels compared with healthy counterparts. Hypomagnesemia was also associated with poor glycemic control and diabetic nephropathy

Insulin resistance and glucose levels in subjects with subclinical hypothyroidism

Objective: To compare insulin resistance and glycemic indicators among subjects with euthyroidism and subclinical hypothyroidism

Study Design: Comparative cross-sectional study

Place and Duration of Study: Department of Pathology and Medicine, PNS Hafeez, Islamabad, in collaboration with the Department of Chemical Pathology and Endocrinology at the Armed Forces Institute of Pathology [AFIP], Rawalpindi, from December 2015 to September 2016

Methodology: Subjects referred for executive screening of apparently healthy population [without any known history of diabetes, hypertension, heart disease or other chronic ailments], were included. Subjects were grouped as euthyroidism and subclinical hypothyroidism

Results: Median [IQR] insulin resistance indices including fasting insulin and Homeostasis Model Assessment for Insulin Resistance in subjects with group-1 [n=176, 87%, Thyroid Stimulating Hormone: 0.5 - 3.5 mlU/L] and group-2 [n=26, 13%, Thyroid Stimulating Hormone: 3.51 -15 mlU/L] were 7.6 [6.70] vs. 11.4 [13.72, p=0.040] and 1.77 [1.79] vs. 2.8 [3.07, p=0.071]

The median differences for fasting plasma glucose were 5.0 [1.0] in group-1 vs. 5.0 [1.47] for Group-2 [p=0.618], and glycated hemoglobin was 5.60 [1.1] vs. 5.60 [1.7, p=0.824]. Homeostasis Model Assessment for beta sensitivity index in paradox showed slightly higher values for group-2 [median [IQR] 86.67 [92.94]] than group-1 [111.6 [189.64, p= 0.040]]

Conclusion: Measures of insulin resistance including Homeostasis Model Assessment for Insulin Resistance and fasting insulin levels were significantly different between subjects with euthyroidism and having subclinical hypothyroidism

Diagnostic accuracy of serum iron and total iron binding capacity [TIBC] in iron deficiency state

Objective: To determine the diagnostic accuracy of serum iron and total iron binding capacity [TIBC] in detection of iron deficiency

Study Design: Descriptive, analytical study

Place and Duration of Study: Department of Chemical Pathology and Endocrinology, from January 2013 to October 2015

Methodology: Data of 1,815 patients with results of serum iron, TIBC and ferritin from January 2013 to October 2015 was retrieved from Laboratory information System [LIMS] of AFIP. Diagnostic Accuracy Studies [STARD] guidelines were followed. Subjects of either gender, aged 1 - 68 years were included. Cases with raised serum ferritin levels [male > 336 ng/ml, female > 307 ng/ml] were excluded. Serum Ferritin was taken as gold standard with specificity of 99% and sensitivity of 80% at concentration of 30 ng/ml. Transferrin saturation was determined by dividing serum iron by TIBC and multiplying by 100

Results: Out of 1,815 subjects, 931 [51.29%] were males and 884 [48.71%] were females. The median age of the patients were 29.1 years [Inter-quartile range, IQR 19.1]. Taking ferritin as gold standard, the sensitivity and specificity of serum iron was 63.5% and 38.6%, respectively; while that of TIBC was 64.5 % and 42.8%, respectively. Ferritin showed poor correlation with iron, TIBC and transferrin saturation

Conclusion: Serum iron and TIBC give no additional information in the diagnosis of iron deficiency anemia and these tests are redundant for the diagnosis of iron deficiency state, if serum ferritin is available

Water precautions and ear surgery: evidence and practice in Pakistan

For otological operations, water is thought to be the most important precipitating factor for inducing infections. This would lead to post surgical healing problems. Water carrying microbes that are pathogenic source of infection for ears .Various methods are used to achieve water free ear after surgery. To determine the current practice of otolaryngological consultants in Pakistan on advice given to patients regarding water precautions after ear surgery. Clinical survey. Questionnaire based survey filled by 300 Otolaryngologists -Head and Neck surgeons from all over Pakistan. A total of 300 questionnaires were completely filled. Reply rate was 100 percent .In all, 50 percent of consultants allow swimming and bathing with ear plugs after tympanostomy tube placement where as 76.67 percent completely restrict patients for diving after grommet placement. In comparison after myringoplasty 66.67 percent avoid swimming and 60 percent avoid diving and 83.33percent allow bathing with earplugs. However after mastoidectomy 61.67percent advice swimming with ear plugs and 84.34 percent allow bathing with ear plugs but 58 percent completely avoid diving. Regarding choice of ear plugs, 42.33 percent preferred cotton and petroleum jelly as ear plugs. This study reveals current national practice among Pakistani otolaryngological consultant. Further national guidelines are required

Epidemiology of vestibular neurinitis in vertigo presenting at tertiary care health care facility in Pakistan

To determine the frequency of vestibular neuronitis in vertigo patients at a tertiary public health care facility in Karachi Pakistan. It is an epidemiological study conducted at Ear Nose Throat, Head and Neck Surgery Department Jinnah Postgraduate Medical Centre [JPMC], a tertiary care hospital in Karachi, Pakistan. The study duration was from Jan 2007 to Dec 2009. The exclusion criteria included hypertension, diabetes mellitus, hearing loss, other cranial nerves deficits, multidirectional non fatiguing nystagmus, long term medication, Truncal ataxia, inflamed tympanic membrane, mastoid tenderness, high grade fever, and nuchal rigidity. Diagnosis of Vestibular Neuronitis [VN] was made on clinical findings. Patients with sudden onset of vertigo with nausea or vomiting, Clinical signs of unsteadiness, Spontaneous and horizontal nystagmus, Absence of other neurological signs and normal otoscopy and normal hearing were included in the study. Four hundred fifty seven patients reported with vertigo. One hundred sixty five were diagnosed as VN and were enrolled for the study. It was found that patients of VN were increasing yearly; younger male population was found to suffer more than others. Highest incidence was between the age group 16 to 30 years. More patients reported during the months of July - August and March - April every year during the change of season i.e. summer to winter or winter to summer. Vestibular Neuronitis was found more in males than females. Younger population was found to suffer more. Peak incidence was noted during the months of July - August every year. Incidence of VN in younger males and during July - August needs more investigation

Use of buccal fat pad for reconstruction of intraoral defects

The aim of this prospective trial is to assess the utility of Buccal Fat Pad for closure of small and medium sized defect following excision of intra-oral lesions. Thirty five cases with intraoral lesions including thirty one cases of Squamous Cell carcinoma and four cases of severe dysplasia, recruited from the outpatient service of the department of ENT-Head and Neck Surgery, Jinnah Postgraduate Medical Centre, Karachi from 2005 till 2007. All these lesions were limited to buccal mucosa. Most these patients were males [28 males and 7 females] with ages ranging from 24 to 70 years. The buccal fat pad filled wound in all the patients showed complete epithelialization within three weeks, except for two cases who had partial dehiscence of the flap. These too were healed spontaneously without any need of secondary suturing. Five patients had some degree of restricted mouth opening but this limitation improved on mouth opening exercises with wooden tongue spatulas. We believe that Buccal fat pad flap is a simple, reliable, and convenient flap, with least of complication and donor site morbidity and should be employed in filling the small and medium size defect of oral mucosa

Prevalence of chronic sinusitis among outdoor psychiatric patients

To assess the prevalence of chronic sinusitis among outdoor psychiatric patients as a number of patients with chronic sinusitis presents with psychiatric symptoms. 5043 cases. Cohort Study. Department of ENT in collaboration with department of Psychiatry, JPMC Karachi. The study duration was six years from January 2002 to December 2007. All cases of psychiatry consultation who agreed, were assessed for history, mental state examination and physical examination with laboratory and radiological investigation. The final diagnosis was based on criteria of ICD-10 for associated psychiatric diagnosis. Out of 5043 cases, 154 [30.05%] cases had chronic sinusitis. Out of 154 cases of chronic sinusitis 85 [55.2%] were male and 69 [44.8%] were female. Majority of the patients 57 [37%] were below primary level of education. As evident from this study, cases with chronic sinusitis can present psychiatric practice as the symptoms resemble or coexist with psychiatric disorders

Outcome of tympanoplasty type - I by underlay technique

Objective: to observe the factors influencing the success of type-I tympanoplasty by underlay technique, in closing tympanic membrane perforation of variable size and location with temporalis fascia graft

Design: prospective study

Place and duration of study: department of Otorhinolaryngology, Head and Neck Surgery, Jinnah Postgraduate Medical Centre, Karachi from April 2004 to November 2006

Patient and methods: hundred [100] consecutive patients of dry tympanic membrane perforation undergoing type-I tympanoplasty were included. Specific inclusion and exclusion criteria were set. Data were collected regarding age, gender, cause, site and size of tympanic membrane perforation, pre and postoperative audiogram results. The data were entered in a set performa and was analyzed using SPSS version 14.0

Results: the male: female ratio was 2:3 with age varying from 18 to 40 years [mean age 31.2]. Overall success rate was 81% [81 out of 100 perforations closed successfully]. There was no significant effect of age, gender and size of perforation on closure. All patients with traumatic perforation had successful closure [100% with a p-value of <0.05]. Out of the 100 patients tested, the mean air conduction threshold was 40db preoperatively and 28 db postoperatively, while the mean bone conduction threshold remained the same pre and postoperatively i.e. 15 db. On postoperative audiometric analysis air bone gap closed completely in 4 patients, 51 ears had a postoperative air-bone gap of 10 db or less, reduced up to 15db in 26 patients, while in the remaining 19 ears there was no uptake of graft

Conclusion: underlay technique for type-I tympanoplasty is an effective method for closure of uncomplicated tympanic membrane perforations. Patients with a traumatic perforation have a high success rate. Postoperatively these patients have record improvement in hearing on pure tone audiogram

Audiolgical results of type I tympanoplasty by underlay technique with temporalis fascia graft

To determine subjective hearing improvement experienced after closing perforation of various sizes with temporalis fascia grafts by underlay type I tympanoplasty. Prospective study. This study was conducted at the department of Ear, Nose, Throat, Head and Neck Surgery, Jinnah Postgraduate Medical Center Karachi from 01.04.2004 to 31.10.2006. 100 consecutive cases of either sex, age ranging from 18 to 40 years [mean age 31.2] of tubo-tympanic type of chronic suppurative otitis media, with dry central tympanic membrane perforation for last six weeks, having good cochlear reserve and air bone gap between 30dB to 40dB, admitted for tympanoplasty were included for this study. Patients with active ear discharge, frequently or recently discharging ear [history of ear discharge of less than 6 weeks] were excluded. Patients associated with upper respiratory tract pathologies including deviated nasal septum, sinusitis, chronic tonsillitis or pharyngitis and patients with only hearing ear were also omitted from the study. Out of the 100 patients tested, the mean air conduction threshold was 40dB preoperatively and 28dB post-operatively, while the mean bone conduction threshold remained the same pre and post-operatively i.e. 15dB. On post-operative audiometric analysis 51 ears had a post -operative air-bone gap of 10dB or less, air bone gap closed completely in 4 patients, reduced upto 15dB in 26 patients, while in the remaining 19 ears there was no improvement noted. Type-I tympanoplasty underlay technique using the temporalis fascia graft has good functional results in young patients with dry central perforation. For good hearing results, selection of cases has prime importance

Flexible nasopharyngo-laryngoscopy in comparison with direct laryngoscopy

Flexible nasopharyngo-laryngoscopy is a valuable tool in the diagnosis of nasopharyngeal, laryngeal and hypopharyngeal pathologies. Previously, the same pathologies were detected by doing examination under general anaesthesia which requires admission and theatre involvement in a busy hospital like Jinnah Post Graduate Medical Centre, this results in delay of the procedure and put extra burden on already constraint resources. This study was conducted to determine the accuracy of flexible pharyngolaryngoscopy in recording the site and extent of abnormality in outpatient clinic notes when compared to the findings at direct laryngoscopy. This study was conducted at ENT department, Jinnah Postgraduate Medical Centre from 1[st] January 2006 to 31[st] December 2007. Prospective study. 148 patients included in this study were selected with the complains of hoarseness, dysphagia, odynophagia, difficulty in breathing and neck nodes. Flexible nasopharyngo-laryngoscopy done in all cases than patients were admitted in ENT department had undergone direct laryngoscopy under general anaesthesia. The findings of both procedures were compared. Accuracy was found to be 87% when the readings of flexible endoscopy were matched with that of direct laryngoscopy

Role of toluidine blue in early detection of oral cancer

Oral cancer is one of the ten most common cancers in the world with marked geographic incidences in occurrence. The range of frequency of this dreadful cancer varies form negligible in Japan to 45% in Sir Lanka, Nepal, India and Pakistan when compared with the over all incidence of all bodily cancers. In Pakistan oral cancer constitute 10% of all malignant tumors standing second to bronchogenic carcinoma in males and breast carcinoma in females. The more early it is diagnosed the better is the prognosis. This prospective study was planned to use Toluidine Blue as a diagnostic material for early diagnosis of oral cancer. Patients with oral lesions having no clinical evidence of oral cancer, but presenting as non-healing oral ulcers more than 6 months or raised margins were selected. They belonged to both sexes and all age groups. Toluidine Blue [ORA SCAN] was used to stain the lesion and biopsy was taken from stained area, 30 patients which in some cases was more than one place. These patients were randomly selected. Histopathology revealed squamous cell carcinoma in twelve patients and dysplasea in five patients. Tuluidine Blue can be used as early diagnostic aid in cancer of oral mucosa

Maxillary Sinus Carcinoma: a prospective series of 45 cases

To study the epidemiology, etiology and management of maxillary sinus tumors, using parameters like age, sex, socio-economic status, extent of spread, treatment offered and survival rate, and observe if there were any disease outcomes i.e. prognostic factors.Retrospective, descriptive study from Oct. 1997 to Sept. 2003.Dept. of ENT-Head and Neck Surgery, Jinnah Postgraduate Medical Centre, Karachi.45 cases with Maxillary Sinus Carcinoma.The data of all the patients was collected and analyzed.This study revealed that out of the 45 cases, 66% were in the 5th and 6th decade of life. Two-thirds of cases were males, with main presenting symptoms of cheek swelling and nasal obstruction. Most patients presented in Stage 3 with no nodes. Treatment with combined modality i.e. surgery followed by radiotherapy gave a 50% two year survival rate in these cases

Fine needle aspiration cytology: application to children with neck masses

Fine needle aspiration cytology is widely used to screen neck masses in adult population. Our present series of 40 fine needle aspiration cytology performed during January 2001 to December 2002, on 40 children with clinically significant neck masses. These fine needle aspiration cytology were confirmed by subsequent surgical biopsies, or follow up of patient for 18 months. Out of the 40 aspirations performed 32 required no subsequent surgical biopsy whereas those of 8 tumors identified, 6 were malignant. In 4 of these cases, metastatic tumors were diagnosed and appropriate therapy provided. Two false negative and one false positive result were obtained. No delay in treatment occurred because of false negative result and no radical treatment resulted from the false positive diagnosis. The sensitivity was 93.8% and the specificity was 94.4. The usefulness and cost effectiveness of fine needle aspiration is stressed

Diagnostic significance of serum protein electrophoresis

Serum protein electrophoresis is a simple, reliable and specific method of separating different protein fractions. A study was carried out in 1556 symptomatic cases reported to Department of Chemical Pathology, Army Medical College fbr serum protein electrophoresis. Aims and objectives were to see the diagnostic significance of protein electrophoresis especially in comparison to other related investigations like serum protein estimation and albumin: globulin [A: G] ratio etc. Deluxe electrophoresis chamber and sample applicator were used. Gelman DCD-16 digital computing densitometer was used for quantification. Results revealed that protein electrophoresis was essential for diseases like paraproteinaemia, immunodeficiencies and a-antitrypsin deficiency. It is helpful along with other investigations in liver disease, nephrotic syndrome, collagen disease and malignancy. Three hundred and sixty five cases had subacute/ chronic infection, 340 had normal electrophoretic pattern, 250 cases were of congestive cardiac failure, 152 cases of nephrotic syndrome, 90 cases of hepatic cirrhosis, 53 cases of chronic renal failure and 25 cases of paraproteinaemia were identified Its sensitivity and specificity were more than serum protein estimation by dye methods. It is recommended that full use of this diagnostic technique should be made for better diagnostic sensitivity and specificity

Pre-operative evaluation of ovarian mass: risk of malignancy index

To evaluate the risk of malignancy index [RMI] for pre-operative diagnosis of ovarian mass. Design: Observational study. Place and Duration of Study: Department of Chemical Pathology and Endocrinology at Armed Forces Institute of Pathology [AFIP], Rawalpindi from January 2001 to January 2002. Subjects and The study consisted of 100 female patients consecutively admitted for surgical exploration of ovarian mass. Pre-operatively ultrasonic evaluation of ovarian mass, menopausal status and serum cancer-associated antigen 125 [CA 125] levels were carried out. Postoperatively histopathology of the resected ovarian mass was done to confirm the diagnosis. To increase the sensitivity and specificity of CA 125 for early detection of ovarian cancer, a combination of serum CA 125 with ultrasonography and menopausal status, designated as risk of malignancy index [RMI] for each patient, was calculated. The sensitivity and specificity of CA 125 alone for the diagnosis of ovarian cancer, at cutoff level of 35 U/ml, were 83% and 82% respectively. Using RMI, at cutoff level of 125, the sensitivity was 87%, and specificity was 88%. Receiver operating characteristic [ROC] curves reveal that RMI was a better discriminant than CA 125 alone for differentiating between benign lesions and malignant ovarian tumors. The risk of malignancy index [RMI] is a better diagnostic marker as compared to CA 125 alone because of its high specificity and sensitivity in differentiating ovarian cancer from ovarian benign lesions. It is a simple scoring system and, therefore, its application is recommended to evaluate ovarian masses in clinical practice

Management of laryngeal cancer

This is a retrospective study of 625 cases of laryngeal cancer seen over a period of ten years from 1989 to 1998 at the Department of ENT, Jinnah Postgraduate Medical Centre, Karachi. Most of the patients belonged to low socio-economic group and were in advanced stages of the disease. Nodal involvement was surprisingly low as compared to available international data. Different treatment options were used, that is laser surgery, total laryngectomy, near total laryngectomy, radio-therapy and chemo-therapy. The prognosis was not bad for the laryngeal cancer and the 5 year survival rate was around 80 percent

Pattern of disease and treatment of allergic rhinitis in Karachi

This study was conducted on 100 patients visiting Jinnah Postgraduate Medical Centre Karachi, over a period of three years [1996 to 1999] to gain an insight in the problem of nosed allergy in Karachi It was found that perennial rhinitis is more common in Karachi and the response to treatment with antihistamines and local steroid was much better as compared to antihistamines alone

decade of experience in the management of oral cancer

A retrospective study of 374 cases of Oral Cancer seen over a period of ten years and findings compared with international data. In the U.K. and U.S.A malignant tumour of the Oral. Cavity accounts for less than 2% of all malignancies, whereas in India they account for more then 40%[1,2] followed by 35% in Srilanka, whereas in Pakistan the incidence was second highest after bronchogenic carcinoma in males and breast carcinoma in female population[3]. The disease most commonly occur after fourth decade of life and our study showed females are slightly more commonly affected then males in contrast to report from U.K. where male female ratio is 8 : 1[4]. Most of the patients reporting were in advance stage-of disease, belonging to low socio economic group and pan chewing was the most common etiological factor compared to smoking and alcohol in the west[5,6]. The incidence of involvement of mandible and regional lymph nodes is strangely low despite advanced stage of disease. Different modes of treatment have been offered as Laser surgery, surgical excision, radiotherapy and chemotherapy. Reconstruction of different forms are undertaken from simple split thickness skin grafting to K-wire, and axial and random flaps.The prognosis on the whole for oral cancer is poor, and worst for carcinoma of the floor of mouth, less then 15% survival in 3 years time[7]