Pleural Space Elastance and Its Relation to Success Rates of Pleurodesis in Malignant Pleural Effusion / 결핵및호흡기질환

Background@#Pleurodesis fails in 10%–40% of patients with recurrent malignant pleural effusions malignant pleural effusion and dyspnea. This study aimed to assess the values of pleural elastance (PEL) after the aspiration of 500 mL of pleural fluid and their relation to the pleurodesis outcome, and to compare the pleurodesis outcome with the chemical characteristics of pleural fluid. @*Methods@#A prospective study was conducted in Kasr El-Aini Hospital, Cairo University, during the period from March 2019 to January 2020. The study population consisted of 40 patients with malignant pleural effusion. The measurement of PEL after the aspiration of 500 mL of fluid was done with “PEL 0.5” (cm H2O/L), and the characteristics of the pleural fluid were chemically and cytologically analyzed. Pleurodesis was done and the patients were evaluated one month later. The PEL values were compared with pleurodesis outcomes. @*Results@#After 4-week of follow-up, the success rate of pleurodesis was 65%. The PEL 0.5 was significantly higher in failed pleurodesis than it was in successful pleurodesis. A cutoff point of PEL 0.5 >14.5 cm H2O/L was associated with pleurodesis failure with a sensitivity and specificity of 93% and 100%, respectively. The patients with failed pleurodesis had significantly lower pH levels in fluid than those in the successful group (p<0.001). @*Conclusion@#PEL measurement was a significant predictor in differentiating between failed and successful pleurodesis. The increase in acidity of the malignant pleural fluid can be used as a predictor for pleurodesis failure in patients with malignant pleural effusion.

Prevalence of and attitudes to waterpipe smoking among Saudi Arabian physicians

Background: Tobacco smoking kills more than 5 million people annually and it is the most important cause of preventable death. Waterpipe smoking is common in the Middle East and is prevalent among young people. There is a misconception that it is less harmful than cigarette smoking. Physicians are considered role models in the community and their behaviours and attitudes towards smoking can have direct effects on cessation.

Aim: The aim of this study was to estimate current prevalence, attitudes and associated factors in regard to waterpipe smoking among Saudi Arabian physicians.

Methods: Using a self-administered questionnaire, we conducted a cross-sectional study among 454 male and female physicians from 3 specialties, and of various levels of training working in 4 hospitals in Riyadh.

Results: The prevalence of waterpipe smoking was 45%, greater in men than in women [58% vs 18%; P . 0.001] and in surgical than in medical specialists [58% vs 38%; P . 0.001]. More non-smokers than smokers believed that physicians should serve as role models [79% vs 60%; P . 0.001]. Physicians who were waterpipe non-smokers had received more formal training about cessation than smokers [50% vs 36%; P . 0.001].

Conclusions: Waterpipe smoking among Saudi Arabian physicians is frequent and is associated with low exposure to information about the hazards and cessation during medical education

applicability of the Greulich and Pyle Atlas for bone age assessment in primary school-going children of Karachi, Pakistan

To assess the degree of applicability of bone age calculated by Greulich and Pyle Atlas in estimation of chronological age for therapeutic and medico legal purposes. Two Hundred and Twenty children [139 males, 81 females] between ages of 56 and 113 months [4.5 to 9.5 years] were randomly selected from 4 primary schools of Shireen Jinnah and Clifton, Karachi. Digital images of hand and wrist radiographs were obtained by a computed radiography at Ziauddin Hospital Clifton. Bone ages were computed using Greulich and Pyle Atlas by radiologists at Ziauddin Hospital, North Nazimabad, Karachi. On average, the Greulich and Pyle Atlas underestimates chronological age by 6.65 +/- 13.47 months in females and 15.78 +/- 12.83 months in males [p-values < 0.001]. High correlation was found between chronological age and bone age in both genders [Females r=0.778; p-value < 0.001, Males r=0.816; p-value < 0.001]. Bone age calculated by Greulich and Pyle Atlas should not be used for estimating chronological age in children of ages 56-113 months in situations where high accuracy is required [e.g. medicolegal cases]. However, serial measurements of bone age by this atlas can be used in management of growth related endocrine disorders in these children

Bone age assessment methods: a critical review

The bone age of a child indicates his/her level of biological and structural maturity better than the chronological age calculated from the date of birth. Radiography of the hand and wrist is the commonest modality used to calculate bone age. Automated methods for evaluation of hand and wrist radiographs are also being developed which reduce inter rater variability compared to manual methods. Non radiation based techniques of visualizing hand and wrist bones such as ultrasonography for bone age calculation have been theorized but are not as accurate as radiographic methods. By the age of 18 years, bone age cannot be computed from hand and wrist radiographs, therefore the medial end of the clavicle is used for bone age calculation in individuals aged 18-22 years. CT visualization of the clavicle has been extensively studied but requires a high dose of radiation. MRI based methods are being developed but require more research. Dental age is an alternate form of bone age determination, which also gives an estimate of skeletal maturity. The iliac bone and femoral head have also been studied for computation of bone age but no standardized methods have yet been generated. As different modalities of bone age estimation provide different results and their applicability differs in different ethnicities, we need to design studies in order to compare them and select the method best suited to Pakistani children. Recent articles published between years 2004-2013 obtained from online search engines Pubmed and Google Scholar were used in preparation of this review

Assessment of the effect of implementation of global initiatives for asthma [GINA] guidelines in the outcome of asthma exacerbation in the Emergency Department

Asthma is a continuous significant health problem. Strategies for treating exacerbations are best adapted and implemented at a local level. Severe exacerbations are potentially life threatening, and their treatment requires close supervision. The severity of the exacerbation determines the treatment administered. Indices of severity, particularly peak expiratory flow [PEF], pulse rate, respiratory rate, and pulse oximetry should be monitored during treatment. The aim of this work was to assess the effect of the implementation of the Global Initiative for Asthma [GINA] guidelines in the prognosis and the outcome of asthma exacerbation in the emergency department. The study was conducted on one hundred asthmatic patients. All patients were informed about the study and gave their consents. Patients were subjected to full history taking and clinical evaluation. Investigations were done in the form of peak flow rate [PFR] measurement, pulse oximetry assessment, ABG analysis [for only 17 patients], chest X-ray [it is not routinely recommended] and complete blood count [if needed]. Then patients were classified according to their attacks. All patients were managed according to GINA guidelines. Older patients were significantly suffering from severe to life threatening attacks than younger patients. We found that 12% of patients had occupational related asthma in relation to 88% of patients had non-occupational related asthma. There were no statistical significant differences between classification of severity of current attack and previous emergency department [ED] visits/year. There were no statistical significant differences between the studied groups regarding temperature. Systolic and diastolic blood pressure had statistically significant lower values in patients with severe to life threatening attacks than those with mild to moderate attacks. Severe to life threatening group had respiratory rate higher than mild to moderate group. Mild to moderate group had PEF and SaO2% higher than severe to life threatening group. PEF was statistically higher post treatment than pre treatment. Three patients of 17 had PaCo2 >45 mmHg with hypoxemia and respiratory acidosis and they admitted to the intensive care unit [ICU]. All patients in ED were assisted to determine the severity of asthma concomitant with administration of initial treatment [plan A], which is oxygen to achieve O2 saturation >/= 92%, inhaled B2 adrenergic bronchodilator and an oral or intravenous dose of corticosteroids. Five patients met a good response so they enter in [plan C1]. Seventy-five patients met with the criteria of moderate episode they go to plan B1, 68 patients of them [about 90%] had a good response within 2 h so go to plan C1 and the rest 7 patients [10%] had an incomplete response go to plan C2. Twenty patients met with criteria of severe episode, 17 of them [85%] with incomplete response move to plan C2, and the rest 3 patients [15%] had a poor response and moved to plan C3, no improvement noticed so they were admitted to the ICU. Hospitalization was done to 11 patients who met a poor response [plan C2], 86 patients were discharged from the ED [73 patients from plan C1 and 13 patients from plan C2]. Severe to life threatening group stayed in ED longer than mild to moderate group. All patients presenting in the emergency department with asthma exacerbations should be evaluated and triaged immediately and must be treated according to their severity of classification using GINA guidelines. Measurements of airflow obstruction, using peak expiratory flow, can help to guide therapy for acute asthma. Continuous monitoring of oxyhaemoglobin saturation by pulse oximetry should be undertaken for all patients with acute exacerbation of asthma. We must; educate patients in ED about the nature of asthma and its therapy, educate patients how to use inhalers, encourage patients to use spirometer at home and discharge each patient with ED-asthma discharge plan

CT guided renal biopsy: Safety and efficacy, a study in Pakistan

Percutaneous renal biopsy [PRB] of native kidney with automated spring loaded device is performed with various techniques to improve efficacy and safety .This study was performed to evaluate[1] the safety and efficacy of PRB performed under CT guidance[2] time to develop complications to see whether this procedure can be performed as outpatient[3] diagnostic yield of the specimen. The study was conducted at the Department of Nephrology of Dr. Ziauddin Hospital, on all patients admitted for renal biopsy between 1[st] January 2009 to 31[st] December 2011. PRB was performed on native kidneys by experienced nephrologist under CT guidance with a 18 guage automated spring loaded biopsy gun. Patients were included if they fulfilled the inclusion criteria. All patients were observed for 24 hours post biopsy for major complications like gross hematuria, drop in hemoglobin requiring transfusion, or requiring surgical or radiological intervention and minor complications like transient hematuria, spontaneously resolving perinephric hematoma and their timing of development. In addition, information was gathered regarding diagnostic yield of the specimen. 100 consecutive biopsies were performed. There were no major complications in 98% of the biopsies. 2% patients developed gross hematuria and significant hematoma with a drop in hemoglobin that required blood transfusion. 2% of patients developed minor complications. 100% of the specimen had adequate tissue for making the diagnosis. All major complications developed within 12 hours of procedure. The minor complication occurred at 18 hrs. PRB under CT guidance is a safe and effective procedure; however recommendations can not be made to perform it on outpatient basis

Comparative accuracy single sequence MRI brain scan vs complete MRI brain scanning

This is a cross-sectional and prospective study, which was conducted to compare accuracy between single pulse sequence MRI examination [limited MRI brain scanning] with the complete MRI brain scanning [consist of multiple pulse sequences]. Material and Method: This is a prospective study of 100 patients and male to female ratio is 1.4:1 [fifty-nine males and forty-one females]. Their ages ranged from 1 to 85yrs and maximum cases were in the age group 35 to 54yrs. Headache was the most common presenting complaint followed by hemiparesis and seizures. Result: There was 100% positive predictive value of [limited study] for hydro cephalus, brain edema, cerebral and cerebellar mass lesion, Age related atrophy and extracerebral mass.Positive predictive value of [limited study] is 92% for infarction, 75% for hemorrhage, 70% for ischemic lesion, 67% for pituitary mass. Limited study shows no positive predictive value for empty sella and cystic lesion. For white matter lesion, [limited study] shows 20% positive predictive value. Complete MRI study is comprehensive, reliable and accurate method of diagnosing different brain pathologies and anything less cannot takes its place. But considering the lesser time needed, lesser cost and convenience to patient as proved in this study the limited MRI brain study, which constitute only important sequences is clinically useful especially for brain screening

Response to combination therapy in hepatitis virus C genotype 2 and 3

To determine Sustained Viral Response [SVR] to Interferon [IFN] and ribavirin therapy in chronic hepatitis C patients of genotype 2 and 3. The Garden Clinic, Lahore, from June 1997 to August 2007. All patients of both genotypes 2 and 3 receiving combination therapy were included. Standard IFN with ribavirin was started in 648 [90%] patients of genotype 2 and 3, whereas 73 [10%], all genotype 3 received pegylated IFN. Outcome parameters including End of Treatment Response [ETR] [negative PCR at the end of therapy], sustained viral response [SVR] [negative PCR both at the end of treatment and 6 months later] and relapse [PCR negative at the end of treatment but positive 6 months later] were determined. Data were analyzed using student's t-test and Chi-square. A total of 721 patients of genotype 2 and 3 were evaluated with male to female ratio of 1.78:1 and mean age 39.8 +/- 9.17 years. Twenty six [3.6%] patients were of genotype 2, while 695 [96.4%] had genotype 3. Six hundred and ten patients [84.6%] completed therapy, as per protocol, whereas 58 [8.04%] had therapy beyond 6 months. SVR was 72.7% with better outcome in genotype 2 [80%] than in 3 [72%] and in those on pegylated IFN and ribavirin [85%] than patients on standard IFN-based therapy [71.1%] Relapse was seen in 116 [16.1%] and 80 [11.1%] were non-responders. Patients with baseline ALT 2-4 x UNL had better SVR than patients with ALT < 2x UNL [p-value 0.01]. Genotype 3 was the predominant type of virus in the studied patients. SVR patients was 72.7%. Outcome was better with high baseline ALT and pegylated interferon combination therapy