Clinical and laboratory profile of dengue fever patients admitted in combined military hospital Rawalpindi in year 2015

Objective: The purpose of this study was to determine the pattern of clinical presentations, haematological and biochemical abnormalities, and outcome of dengue fever patients admitted in Combined Military Hospital [CMH] Rawalpindi in year 2015

Study Design: A descriptive cross sectional study

Place and Duration of Study: Department of Medicine, CMH Rawalpindi, from January 2015 to December 2015

Material and Methods: Patients meeting the inclusion criteria were admitted at CMH Rawalpindi and blood serology was done to confirm the diagnosis of dengue fever. Cases with positive dengue serology were included in the study. Clinical symptoms, signs, investigations and outcome of these patients were recorded on a pro forma. Blood samples were taken for analysis. Chest X-Ray and ultrasound abdomen were done on required basis

Results: Out of forty confirmed cases of dengue fever, there were 25 [62.5%] males and 15 [37.5%] females. Mean age was 40 years. There were 39 cases [97.5%] of dengue fever and one case [2.5%] of dengue shock syndrome. There was no case of dengue haemorrhagic syndrome. Maximum cases were seen in the month of October 2015. The clinical features noted were: headache and myalgias 62.5%, chills and rigors 57.5%, retro-orbital pain 42.5%, vomiting 35.0%, pruritus 27%, skin rash 20%, abdominal pain 20%, diarrhoea 10%, bleeding 2.5%, ascites and pleural effusion 2.5%, and hepatomegaly 15%. The laboratory findings were: leucopenia 85% and thrombocytopenia 92.5%. Serum alanine transaminase [ALT], urea, and creatinine were raised in 30%, 2.5% and 7.5% cases respectively. Mortality was 2.5%

Conclusion: This study showed that patients admitted to CMH hospital had a milder presentation of dengue fever in the year 2015

Changes in P-wave amplitude and axis after treatment of chronic obstructive pulmonary disease exacerbation

To compare the change in P-wave amplitude and axis before and after 24 hours of the treatment of chronic obstructive pulmonary disease exacerbation.Quasi-experimental study. Department of medicine, PNS Shifa Karachi from Dec-2010 to June-2011 [six months]. A total of 93 subjects were included in the study. Their pre-treatment and post treatment ECGs were evaluated by measuring P-wave amplitudes in leads II and aVF and P-wave axes were calculated. The differences in terms of changes in P-wave amplitude and axis were compared. Mean age of patients was 53.09 +/- 7.20 years. Before treatment P-wave amplitude in lead II was 2.36 +/- 0.34 mm and after treatment it was 1.73 +/- 0.29 mm [p < 0.001]. P-wave amplitude in lead aVF before treatment was 2.446 +/- 0.334 mm while after treatment it was 1.556 +/- 0.329 mm [p < 0.001]. P-wave axis before treatment was 72.67[degree] +/- 4.67[degree] and after 24 hours of treatment it was 63.75[degree] +/- 3.95[degree] [p < 0.001]. Sigruficant changes in terms of reduction of P-wave amplitude and left ward rotation of P-wave axis occur after effective treatment of acute exacerbation of COPD. These findings provide valuable objective evidence in evaluating patient's response to treatment and recommended to be used in clinical practice

Perceptions of faculty and health care managers about managerial skills and training needs of doctors working as house officers in medical institutions

Objective: To find out the perceptions of faculty and health care managers about the managerial skills of house officers, areas in which they are deficient and the learning strategies to improve these skills

Study design: Cross sectional study

Place and Duration of Study: The study was carried out in affiliated institutions of Armed Forces Postgraduate Medical Institute Rawalpindi, Pakistan Institute of Medical Sciences, Islamabad, and Holy Family Hospital Rawalpindi, from 15[th] December 2014 to 15[th] February 2015

Material and Methods: Questionnaire was used for data collection. It consisted of three sections. It assessed the respondents' perceptions of house officers' managerial skills, areas in which they were deficient and learning strategies for these skills. A probability convenience sample of faculty members and health care managers of institutions affiliated to Army Medical College, Pakistan Institute of Medical Sciences and Holy Family Hospital Rawalpindi was selected

Results: A total of 106 health care managers and faculty members were approached, of which 88 responded. Respondents were equally divided among health care managers and faculty members. The following skills of house officers received the lowest ratings by the respondents, 'Skills of using evidence based guidelines for allocating health care resources', 'how to function in their position as a leader', 'how the Pakistan healthcare system is organized and financed'. Respondents were unanimous that medical graduates need training in managerial skills and majority [93%] of them preferred lectures as the teaching strategy

Conclusion: Health care managers and faculty members in Rawalpindi/Islamabad region perceive the managerial skills of house officers as inadequate. They believe that training is required at undergraduate level to improve these competencies

Early asymptomatic decline in left ventricular ejection fraction in adult cancer patients receiving doxorubicin

To determine the frequency of doxorubicin induced early asymptomatic decline in left ventricular ejection fraction by serial echocardiography and to identify risk factors associated with cardiotoxicity. Quasi-experimental study. Oncology Department, Combined Military Hospital, Rawalpindi from January 2012 to December 2012. Patients who were started on doxorubicin-based chemotherapy during the study period and had completed at least 300 mg/m[2] cumulative dose were included in this study. Electrocardiography, chest X-ray and echocardiography were done at baseline and one to three months after completion of chemotherapy. All patients were evaluated for the presence of the following risk factors: pre-existing coronary artery disease, diabetes mellitus, hypertension, chest wall irradiation and a cumulative dose exceeding 400 mg/m[2]. Asymptomatic cardiac dysfunction was defined as ejection fraction [EF] fall greater than 10% on follow-up echocardiography with minimum or no symptoms. Significant change was observed in ejection fraction after completion of chemotherapy. Out of 54 patients, 27.8% showed 5%, 13% showed 10% decline, 16.7% had 15% decline, one [1.9%] patient had 20% decline in EF after completion of chemotherapy while 40.7% had no change in ejection fraction. Thirty one percent of the patients developed > 10% decline, in left ventricular ejection fraction with the use of doxorubicin in the cumulative dose range of 300-400 mg/m[2]. Pre-existing coronary artery disease, hypertension and a cumulative dose exceeding 400 mg/m[2] are identifiable risk factors in this study. This entails regular monitoring for cardiac dysfunction by echocardiography during doxorubicin treatment

Pattern of extranodal involvement in non hodgkin's lymphoma

To study the anatomical and histomorphological pattern of extranodal non hodgkin's lymphoma [NHL]. Descriptive study. The study was carried out at oncology department combined military hospital rawalpindi during July 2012 to April 2013. All newly diagnosed patients of NHL with extranodal involvement were included in the study.They were categorized as primary extranodal or secondary extranodal lymphomas. Histological pattern and site of involvement were studied. The male to female ratio was 2.2:1 [Male 31, Female 14], and the mean age was 48.16 years[SD=13.40]. Primary extranoal involvement was seen in 55.6% of patients. Secondary extranodal involvement was seenin 44.4patients. Diffuse large B-cell lymphoma [DLBCL] was the most common type of NHL observed in both primary and secondary extranodal involvement. Gastrointestinal tract was the most common site for primary extranodal involvement and bone marrow was the most common site for secondary extranodal involvement.High freqency of primary extranodal involvement was noted in our study. DLBCL was the most common morphological type observed.Gastrointestinal tract and secondary bone marrow involvement were the most common anatomical sites for primary and secondary extranodal involvement respectively

Hepatotoxicity of ATT

To determine the frequency of hepatotoxicity with standard ATT. Descriptive. Department of Medicine, Combined Military Hospital Lahore. Feb 2007 to April 2008. 250 patients aged 18 years or greater having pulmonary TB were selected through non-probability convenience sampling technique. All patients were given four drugs for two months indoors, followed by two drugs for four months in outdoor. Symptoms suggestive of hepatotoxicity were enquired from the patients regularly. Serum bilirubin and ALT were measured on monthly basis and finally on completion of therapy. Hepatotoxicity was defined as a five fold rise in serum ALT. In patients developing hepatotoxicity, treatment was modified accordingly. This study was done on 189 male and 61 female patients [total: 250]. Hepatotoxicity developed in 13 [5.2%] patients, mostly during the initial phase of treatment [84.6% incidence during the first month]. Risk factors included: age [4 out of 156 young patients and 9 out of 94 older patients; p: 0.016] and nutritional status [8 malnourished patients and 5 well nourished patients; p: 0.031]. Hepatotoxicity was not related to the gender [9 males and 4 females; p: 0.585] or the results of baseline sputum smears [7 out of 102 smear positive cases and six out of 148 smear negative cases; p: 0.064]. Hepatotoxicity with ATT is fairly common, especially in the elderly, malnourished patients and during the initial phase of treatment

Hepatitis C; frequency of thrombocytopenia patients treated with interferon

To determine the frequency of thrombocytopenia and its manifestations in patients with Chronic Hepatitis C Virus infection treated with interferon and ribavirin. In door and out door patients. Case series. Department of Medicine PNS Shifa Hospital Karachi, from 1[st] August 2006 to 1[st] July 2007. A Proforma was designed to enter the data of 100 patients fulfilling the inclusion criteria included in the study. Adult patients between the ages of 18 and 50 years of both gender were selected. Presence of anti HCV antibodies, elevated serum alanine transaminase, a positive polymerase chain reaction for hepatitis C ribonucleic acid and compensated liver disease were prerequisites. All patients were treated with combination of interferon and ribavirin. Blood counts, alanine transaminase and prothrombin time were done at baseline and at 2, 4 and 8 weeks intervals after starting interferon. A drop in platelets count below 100,000/cmm was taken as interferon induced thrombocytopenia. In our study thrombocytopenia occurred in 1 1% patients. Grade 3 thrombocytopenia [platelet counts < 50,000] occurred in 01 patient out of hundred in which there was severe gum bleeding and purpura so antiviral treatment was discontinued. Grade 2 thrombocytopenia [platelet counts between 50,000-75,000] was observed in 03% patients but there were no bleeding episodes, 50% reduction dose was done in these patients. Grade 1 thrombocytopenia [platelet counts between 75,000- 100,000] was noticed in 07% patients but there were no bleeding manifestations and dose reduction was not done. Combination therapy is well tolerated, however, it can cause life threatening complications like bleeding episodes in a few patients. Bleeding complications and manifestations as a result of thrombocytopenia are uncommon

Hepatic encephalopathy; Precipitating factors in patients with cirrhosis

gujri@hotmail.com Hepatic encephalopathy is a common complication of cirrhosis. Its development heralds a poor prognosis. Hepatic encephalopathy is often precipitated by an identifiable factor. Prompt diagnosis of precipitating factors is the key to management of this reversible complication of cirrhosis. To determine the frequency of precipitating factors for hepatic encephalopathy in patients diagnosed with cirrhosis. Descriptive Study. The study was carried out at Combined Military Hospital Lahore from 18.6.07 to 18.12.2007. Eighty Consecutive patients, 18 years and above of both genders suffering from hepatic encephalopathy were included in the study. Precipitating factors of hepatic encephalopathy were identified with the help of clinical examination and investigations. Majority of patients [63.8%] had one precipitating factor; more than one factor was found in 27.5%. Upper gastrointestinal bleed [56%] and infections [27%] [spontaneous bacterial peritonitis and urinary tract infections] were the leading precipitating factors. Use of diuretics/ electrolyte imbalance and constipation were found in 19% and 7% of patients respectively. No precipitating factor was detected in 9% of patients. In majority of patients with hepatic encephalopathy, precipitating factor/ factors could be easily identified

Chronic diarrhea; large gut causes

To determine the frequency of large bowel causes of chronic diarrhea in adult Pakistani patients. Cross sectional study. Medical unit 1 at Combined Military Hospital Lahore, Pakistan. Six months [from 01-11-2007 to 30-4-2008]. Fifty adult patients with chronic diarrhea, irrespective of their gender were selected by non probability convenient sampling. Patients already diagnosed with diseases known to cause diarrhea and those with toxic mega colon were excluded from the study. All patients were subjected to fiberoptic colonoscopy and findings were recorded. Biopsies were taken from suspected lesions or from normal looking mucosa. Diagnosis was made with colonoscopic and histopathologic findings. Thirty two [64%] patients had abnormal findings visible on colonoscopy. Histopathology was normal in 18 [36%]. Twenty [40%] patients had ulcerative colitis, seventeen [34%] had IBS, five [10%] had CA colon and three [6%] patients had crohn's disease. Other diagnoses included non specific colitis, tubulovillous adenoma and infection. Twenty three out of 24 patients [95%] who had blood in stools had a visible abnormality on colonoscopy whereas colonoscopy was positive in only 33% of patients who did not have blood in stools. Most causes of large gut chronic diarrhea can be identified by colonoscopy and biopsy. Colonoscopy has a very high yield in chronic diarrhea and should be recommended for its work up. Its yield is even higher in patients with bloody diarrhea

comparative study of three brands of biosynthetic human insulin

To compare the activity of three brands of regular biosynthetic human insulin [BHI] in healthy normal subjects with the glucose clamp technique. A comparative study. CMH Lahore from May 2007 to July 2007. Thirty healthy normal male volunteers who met the inclusion criteria were tested. Each insulin preparation was sequentially infused through intravenous route at 0.02 U/kg/h for 2 hour, 0.032 U/kg/h for 2 hour and finally at 0.05 U/kg/h for 2 hours. A simultaneous 25% glucose infusion was maintained and the amount the glucose consumed was calculated. All subjects were studied on three different occasions with the three brands' of insulin. Blood glucose was monitored at regular intervals and its level was kept constant [clamped] at a baseline. The amount of glucose infused was calculated for each insulin dose for the three brands of BHI. Mean values of glucose administered during the six hour infusion period for the three brands ranged between 162 to 190g. The mean glucose consumed with 0.02 units/kg/hr of Zansulin, Actrapid and Humulin were 26.7gm, 30.6gm and 31.2gm respectively Similarly the mean glucose consumed with 0.032 units/kg/hr of Zansulin, Actrapid and Humulin were 53gm, 59.7gm and 62.1gm respectively and a similar pattern of glucose consumption was observed for insulin dose of 0.05 units/kg/hr. Glucose administered during the 6 hour infusion differed significantly among the three brands of insulin, [p<0.05]. Post hoc test for multiple comparison showed significantly more glucose consumption with Humulin R and Actrapid as compared to Zansulin R [p value <0.05].There was no significant difference in biological activity of Humulin R and Actrapid [p value >0.05] Humulin R and Actrapid had greater biological activity as compared to Zansulin R when glucose consumption was measured for each using glucose clamp technique

Seroprevalence of HBsAg and HCV antibodies in hospital workers compared to aged matched healthy blood donors

As study was planned to document the seroprevalence of HBsAg and HCV antibodies in hospital workers compared to age-matched volunteer healthy blood donors. The study was conducted at PNS Shifa Hospital Karachi from November 2001 to October 2003. Study group comprised of 305 voluntary hospital workers including 60 doctors, 101 female nurses and attendants, 116 male nurses and attendants and 18 sweepers. Control group comprised of 300 aged matched volunteer blood donors, 90 males and 30 females. A performa was designed to record various findings. Sera of subjects were tested by a standard method for the presence of HBsAg and HCV antibodies. Study group comprised 70 [23%] doctors, 60 males and 10 females. HBsAg was positive in 1[1.43%] and HCV antibodies in 2[2.85%]. Among 101[33%] of the female nurses and attendants, HBsAg was positive in 03 [3%] and HCV antibodies in 8[8%]. Among 116 [38%] male nurses and attendants, 04 [3.44%] were HBsAg positive and 07 [6.03%] HCV antibodies positive. Among 18[6%] khakrobs and sweepers 1[5.56%] was HBsAg positive and 2[11.11%] were HCV antibodies positive. In total 10[3.27%] hospital workers were found positive for HBsAg and 18 [5.90%] positive for HCV antibodies. In voluntary blood donors, HBsAg was detected in 2.4% and HCV antibodies in 3.2%. It is conduced that the seroprevalence of HBsAg is marginally higher in hospital workers while seroprevalence of HCV antibodies is reasonably higher in hospital workers compared to general healthy population

effects of exposure to crude oil on the health of workers involved in clean up operation

An oil tanker carrying crude oil was grounded near Karachi coastline. This observational non-interventional study was carried out to study the effect on health of workers who were involved in the clean-up operation. First fifty consecutive naval personnel who came in close contact with the spilled crude oil in the sea were evaluated. Their symptoms, physical signs and lung function tests were recorded before and then on daily basis for 2 weeks. All the 50 subjects had developed symptoms. The most frequent symptom was redness of eyes [60%] followed by headache [52%], nausea [50%], throat irritation [48%], dry cough [10%], tightness in the chest [8%], blurring of vision [8%] and other minor symptoms [18%]. None of the subjects was asked to stop the work because of the severity of toxic symptoms. Reversible obstructive airway disease was seen in only 4 subjects, all of them had dry cough before exposure. The data suggests that exposure to volatile products of crude oil leads to development of neurological, respiratory and eye symptoms. Mild reversible obstructive airway disease may only manifest in few individuals who already had respiratory symptoms before exposure

Prevalence of anti - hepatitis C antibodies and hepatitis B surface antigen in healthy male naval recruits.

Hepatitis B virus [HBV] and hepatitis C virus [HCV] are the commonest causes of chronic liver disease the world over including Pakistan. Various studies done in the past show wide variation in the results. Freshly inducted healthy recruits selected in Pakistan Navy were tested for hepatitis B surface antigen [HBsAg] and anti-hepatitis C antibodies [anti-HCV]. This study was carried out in PNS Shifa hospital Karachi. The prevalence of anti-HCV was 2.2% [95% CI:1.3-3.1%] and HBsAg was 3.2% [95% CI:2.1-4.3%]. There was variation in prevalence of anti-HCV and HBsAg in different cities. This study indicates that there is a considerable HBV and HCV threat to our population