improved record system for tracing outcome of [transferred-out] DOTS patients

This study in Pakistan aimed to develop an improved record-keeping mechanism for the DOTS programme to establish the final treatment status of patients recorded as [transferred -out]. In an intervention study in 40 DOTS diagnostics centres in Punjab province, a modification was made to the existing TB03 register. DOTS facilitators were trained to keep proper records of patients who transferred-out and transferred-in. Among 4442 registered cases, 104 patients [2.3%] transferred out of reporting centres. Correct matching of [-out and -in] patients was achieved for 74 [71.2%] patients; the remaining 30 [28.8%] were untraced. By tracing transferred-out cases, the adjusted outcome success rate increased in the intervention period from 89.6% to 90.9%

Large-scale physical disabilities and their management in the aftermath of the 2005 earthquake in Pakistan

The October 2005 earthquake in Pakistan created a new generation of [persons with disabilities] [PWDs] in the affected districts. A total of 741 people suffered spinal injuries while 713 underwent amputations. A comprehensive response was launched jointly by the Ministry of Health, Earthquake Reconstruction and Rehabilitation Authority and the World Health Organization involving rescue and recovery, hospitalization, surgical interventions, building of infrastructure, development of technical guidelines to improve quality of care, human resource deployment and training. The first national megaproject for institutional and community-based rehabilitation [CBR] services was launched in the earthquake-affected areas. The institutional management of PWDs is now carried out alongside the CBR programme. This intervention also led to the concept of a national CBR programme. The study aims to identify the post-earthquake situation regarding the magnitude and type of physical disabilities and to highlight the rehabilitative interventions undertaken

Superficial extraconal blockade for vitreoretinal surgery

Needle length plays an important role for the success of ophthalmic block. The standard practice is to use 25 mm needles length; however, unnecessarily long needles may increase the risk of complications especially in the presence of staphyloma or previous scleral buckle. This work was designed to compare the efficacy of using 15 and 25 mm needle in performing extraconal block for patients undergoing vitreoretinal surgery. Prospective randomized double blinded study. A total of 120 patients were enrolled in this study and were divided in two groups. In group [1] extraconal block was performed using 25 mm needle, while in group [2] 15 mm needle was used. After primary injection, assessment of the block was done by an anesthesiologist who was unaware of the needle used. If satisfactory akinesia was not achieved a supplementation was provided. At the end of the procedures, patients and surgeons were asked to assess their pain and satisfaction with the anesthetic technique. The sample size calculation using N-Quary version 4. Numerical and categorical data were analyzed using an independent sample, a two-tailed t-test, and chi-square test, respectively. The volume of primary injectable was significantly higher in group 2. The two groups were comparable as regards total volume of local anesthetic, supplementation rate, akinesia, pain score, and surgeon satisfaction. Using 15 mm needle length to perform extraconal blockade for posterior segment procedures is equally effective to 25 mm needle

Anodic stripping voltammetric determination of silver in anti-infective creams using carbon paste electrode

A new method for anodic stripping voltammetric determination of silver [I] using unmodified carbon paste electrode is described. In this method, the silver sample containing 10% phthalic acid solution is pre-concentrated on the electrode at -400 mV for 30 s. The deposited metal is then oxidized by anodic stripping voltammetric sweep. Chemical and electrical parameters affecting the voltammetric measurements are optimized. The peak current is proportional to the Ag [I] concentration over the range 0.5-50 ng/ml [r = 0.997], and the detection limit is 0.2-ng/ml. The relative standard deviation is 2% for 50 ng/ml [four replicates]. Satisfactory results are obtained on applying the proposed method to the determination of Ag [I] in digested samples of topical creams containing 1% silver sulphadiazine. No interference due to many cations is observed. In contrast, 10-fold excess of Cu ions has been shown serious interference, but on adding either 0.2 mM 4-[pyridyl-2-azo] resorcinol [PAR] or thiocyanate, the overlapped peaks can be separated into two well-defined peaks and consequently both cations, Ag and Cu can be determined simultaneously

Endovascular aneurysm repair in a patient with horeshoe kidney and impaired renal function

We present the case of an 80 year old female with a three week history of lower backache and a pulsatile mass in the epigastrium. CT angiogram confirmed the presence of an infrarenal abdominal aortic aneurysm [AAA] co-existent with a horseshoe kidney [HSK]. Due to associated co-morbidities of hypertension, moderate renal failure, chronic obstructive pulmonary disease [COPD] and morbid obesity, she underwent endovascular repair of the abdominal aortic aneurysm. The presence of the horseshoe kidney poses significant difficulty during open repair of AAA, which can be circumvented in favourable cases by endovascular repair, though the latter procedure is not risk-free

Effect of nutritional regimen for moderate burn patients on graft take

Early and individually estimated nutritional care plan is considered to be an important component of therapy for burn healing and graft take. This study aimed to determine the effect of nutritional regimen for moderate burn patients on graft take. It was carried out at the Burns Units of the Main University Hospital in Alexandria. Fifty recent moderate burned patients within 12 hours post burn were included. Included patients were divided sequentially into a control [n=30] and an experimental [n=20] groups and they were uncomplicated with any condition or disease that recommends special dietary regimen. Four tools were developed and used for data collection. A nutritional assessment sheet, food intake record, graft checklist, and dietary plans were done individually for the experimental group. Weekly modifications were done as required. Calculations of caloric requirements were based on Curreri formula [25 Kcal x weight [Kg]] + [40 Kcal x% TBSA]. Adequate level of caloric intake was attained by all patients of the experimental group versus only 20% of patients of the control group. Half of the control group reached the satisfactory level, however the intake of the rest percentage [30%] was unsatisfactory. The majority of both control and experimental groups [90% and 100%] respectively reached the adequate level of fat intake. Unsatisfactory level of fat intake was recorded by only 10% of the patients of control group. Adequate level of food intake-especially calories and proteins, showed significant relationship with graft take among burned patients despite the deterioration which was noticed in the nutritional indicators as anthropometric measurements and laboratory investigations

Carotid endarterectomy at Punjab institute of cardiology, Lahore: Mid term postoperative results

This study was designed to review postoperative results of the carotid endarterectomy [CABG/CEA] performed at the Punjab Institute of Cardiology, Lahore. Cconsecutive 10 patients with coexisting severe ischemic cardiac and carotid artery disease were operated on during 1-year period ending December 2003 at Punjab Institute of Cardiology, Lahore. The mean age of the study population was 60.20 +/- 7.56 years, among theses 9 were male and 1 female patient. Four [40%] patients with carotid artery stenosis were asymptomatic. Previous stroke occurred in 2 [20%] patients: two [20%] patients presented with a history of blackouts and two [20%] with a transient ischemic attack. The mid term results with regard to 30-day postoperative mortality, stroke and major postoperative complications were significantly low in terms of post operative infection as only one [10%] patient had chest infection and there was no in-hospital mortality. Combined interventions of CE and CABG can be performed with an acceptable morbidity and mortality when severe carotid stenosis is associated with advanced, symptomatic ischemic heart disease. The introduction of routine preoperative carotid duplex scanning resulted in higher diagnostic rate for asymptomatic carotid artery disease among the patients scheduled for combined CABG/CE procedure

Multi-drug resistant tuberculosis in northern Pakistan

To determine the resistance pattern of Mycobacterium tuberculosis isolates in Rawalpindi-Islamabad. The study was carried out at the Department of Microbiology, Armed Forces Institute of Pathology, Rawalpindi between September 2000 and August 2002. We examined 1359 pulmonary and extra-pulmonary specimens from suspected cases of tuberculosis. The radiometric Bactec 460 TB system was used for culture and antimicrobial susceptibility testing. Mycobacterium tuberculosis was isolated from 325 clinical specimens. Antimicrobial susceptibility of the isolates was tested against the four first-line anti-tuberculous drugs [rifampicin, isoniazid, streptomycin and ethambutol]. Fifteen% of the isolates were resistant to a single drug, 28% were multi-drug resistant including 7% which were resistant to all the four drugs. The overall resistance against individual drugs was rifampicin 32%, isoniazid 37%, streptomycin 19% and ethambutol 17%. The increasing level of drug resistance among mycobacterial isolates in our population is most alarming. Strict implementation of control measures is required to combat this unfolding crisis

Mammographic criteria for determining the diagnostic value of microcalcifications in the detection of early breast cancer

Objective: To evaluate the importance of microcalcifications in the detection of breast carcinoma in conventional mammography

Material and Methods: This prospective study was carried out at Aga Khan University Hospital [AKUH]. Mammograms of 68 patients with microcalcifications were evaluated. Craniocaudal and oblique views of both breasts were acquired on routine basis with cone compression and magnified views when required

Results: Among 68 patients with microcalcifications, 61 [89%] had clustered microcalcifications while 7 patients [10.29%] had scattered microcalcifications. Microcalcifications can occur in benign and malignant diseases. While evaluating clustered microcalcifications, few criteria have been established to determine malignant clustered microcalcifications, these include specific and nonspecific criteria. Among specific and statistically significant criteria for malignant microcalcifications, which were identified in this study, were irregularity of size, irregularity of density, linear or branched shape and Le Gal's type V distribution. In a cluster total number of >30 microcalcifications and at least 10 microcalcifications/cm2 of a cluster are also important in diagnosing a malignant cluster, but are included in nonspecific criteria because they can be present in benign diseases also. Scattered bilateral microcalcifications are usually present in benign breast diseases, but in this study, two patients with breast cancer had profuse bilateral scattered microcalcifications

Conclusion: This study shows that specific and statistically significant criteria for malignant microcalcifications, are irregularity of size, irregularity of density, linear or branched shape and Le Gal's type V distribution. Scattered bilateral microcalcifications are usually present in benign breast diseases, but irregular shape and development of new calcifications among diffusely scattered bilateral calcifications, on follow up study, should also raise suspicion for being malignant

S100-beta and cytokines as early markers to predict outcome after moderate head injury

The aim of this study was to evaluate the potential role of S-100[beta] protein, 1L-1[beta], IL-6 and TNF-alpha as early predictive markers of the severity and outcome after moderate head injury. Twenty-four patients with moderate head injury with Glasgow Coma Scale score "GCS score" [9-12], who, required admission to the intensive care Unit[ICU] were included in this study. Routine ICU monitoring was applied e. g. heart rate, mean blood pressure, continuous ECG, capnography, SaO[2], and CVP. Parameters assessed included GCS at admission, 30 minutes, 60 minutes, 4 hours and then every 12 hours till the end of the study. Ten ml of blood was taken from the internal jugular cannula and another ten mil from the radial artery cannula at admission then at 24, 48, 72 hours for analysis of S-100[beta] protein and interleukin-1 beta;, interteukin-6 and tumour necrosis factor-alpha. A single venous blood sample was taken from 24 healthy volunteers to be considered as a control for the laboratory work. The serum concentrations of S-100[beta] protein, IL-1[beta] IL-6 and TNF-alpha were found to be significantly increased in the arterial and the venous samples at admission, then gradually declines over the next three days with management suggesting that there is a significant brain release of S-100[beta], IL-1[beta], IL-6 and TNF alpha with head injury. The jugular venous concentrations were significantly higher than the arterial concentration all over the time of the study. There were significant inverse correlations between GCS score and both arterial and venous concentrations of S-100[beta] and IL-6 throughout the study period. Also, there were significant inverse correlations between aterial venous concentrations of interleukin-1 beta, TNf -alpha and GCS score at admission and at 24 hours and this correlations became insignificant thereafter. The present study has demonstratred that S-100[beta], interleukin-1 [beta], and tumor- necrosis factor-alpha were increased after head injury. However, S-100 [beta] and interleukin-6 appeared to be the most sensitive predictors and their significant correlations with GCS score make them helpful as prognostic tools in assessing the severity and predicting the outcome after moderate head trauma

Ischemic stroke subtypes in Pakistan: the Age Khan University stroke data bank

Frequency of ischemic stroke subtypes is influenced by ethnic and geographic variables. Our objective was to identify various stroke subtypes and its determinants at a tertiary care hospital. We prospectively collected data on ischemic stroke subtypes admitted to The Aga Khan University Hospital in Karachi. A total of 596 patients were enrolled in 22 months in the Aga Khan Universtiy Stroke Registry. These included 393 patients with Ischemic stroke, 126 patients with intracerebral hemorrhage, 50 patients with subarachnoid hemorrhage and others. The ischemic stroke group was classified according to the TOAST criteria and comprised of lacunar 168/393 [42.7%]; large artery atherosclerosis 106/393 [26.9%]; cardioembolic 24/393 [6.1%]; undetermined 80/393 [20.3%]; and other determined types 15/393 [3.8%]. The high proportion of lacunar strokes in our population may be due to high burden of inadequately treated hypertension and diabetes. Clear cut cardioembolic stroke was relatively infrequent in our population. Lacunar stroke is the most common subtype of stroke in our patient population. This is most likely secondary to uncontrolled hypertension

An outbreak of cholera in Karachi following monsoon rains 2003

An epidemic of acute gastroenteritis was observed in the province of Sindh following a heavy monsoon season in July-August 2003. In Karachi, a mega-metropolitan city, large numbers of patients were evaluated for gastroenteritis and many were severely dehydrated and needed hospitalization. This study was carried out to describe epidemiologic features of the epidemic of gastroenteritis and investigate the causative agents responsible. We reviewed the medical records of all the pediatric patients admitted to the Aga Khan University [AKU] Hospital, Karachi, with the diagnosis of "Acute Gastroenteritis" over a 3 month period [1st June 31st August 2003], and analyzed their demographic and stool culture results. Epidemiological and clinical observations were recorded and the findings were correlated with the onset of the monsoon rains. A total of 327 pediatric patients were sick enough to be hospitalized with acute gastroenteritis to the AKU hospital over the 3-month period. A 3-fold increase in the number of patients admitted with gastroenteritis was noted in the period coinciding with heavy rains [mid-July to mid-August] compared to the baseline period before the onset of rains [June 2003]. Of the 327 patients hospitalized, 134 [41%] patients had stool cultures performed. Of these 134 patients, 53 [40%] had a positive stool culture. Vibrio cholerae were isolated from 34 of the 53 [64%] positive stool cultures with an overall isolation rate of over 25% from all stool samples submitted for culture. There was a significant increase in the number of cases of gastroenteritis, specifically cholera following a heavy monsoon season in Karachi. Adequate public health measures to prevent the occurrence of outbreaks of cholera and to educate the public about the dangers of drinking contaminated water are urgently needed

Role of hepatitis viruses in egyptian patients with chronic unexplained elevation of serum transaminases

In some patients with persistent alteration of liver enzymes, the cause of [the disturbance cannot be established on the bases of clinical and analytical data. The significance and prevalence of occult viral infections in cryptogenic liver disease remains controversial. The aim of this study was to clarify our lack of knowledge about the exact pathogenic role of known hepatitis viruses in Egyptian patients with chronic unexplained elevation of serum transaminases. Seventy six patients with liver disease of unknown cause were enrolled in this study. In these patients the exact aetiology could not be defined from clinical, biochemical, and serological data. For every patient and before performing the liver biopsy, hepatitis B virus [HBV]-DNA, HCV-RNA and HGV-RNA were assayed in serum by polymerase chain reaction [PCR]. Liver biopsies from these patients showed non specific changes in 23.7%, fatty liver changes in 15.8%, chronic hepatitis in 48.7% and mixed cirrhosis in 11.8%. HBV-DNA and HCV-RNA were detected in serum of 11.8% and 32.9% of patients with cryptogenic disease respectively. Only one patient [1.3%] showed positivity for both viral genomes. Also, only one patient [1.3%] was found to be positive for HGV-RNA. Viraemia was found in 38.9% of patients with pathological non-specific changes, in 33.3% of those with fatty liver, in 51.4% of those with chronic hepatitis, and in 66.7% of subjects with mixed cirrhosis. The results of this study highlight the dominance of chronic viral hepatitis over other forms of liver disease in our country. Also, the routine use of PCR test will pick up most of missed cases of viral infection

EParasite density and morbidity in relation to serum levels of thrombomodulin and E-selectin in the acute phase of plasmodium vivax malaria

Standardized questionnaires, clinical examination and parasitological diagnosis were performed on 40 patients in the acute phase of vivax malaria from the out patient clinics, El Abbassia Fevers Hospital. Serum levels of Thrombomadulin [TM], E-selectin and creatinine were determined in inrolled patients and also in 20 healthy controls. The results, based on multivariable analysis, showed that the clinical diagnosis of malaria including history of fever, rigors, headache, myalgia and palpable spleen was strongly associated with the presence and density of P. vivax malaria even in patients with parasite densities less than l000/micro l of blood and significantly increased the odds of the clinical diagnosis. Results revealed also that the patient's mean +/- SD serum levels of TM and E-selectin were 12.8 +/- 3.67 and 125 +/- 61.4 [u/micro l] respectively, significantly greater than in the controls [TM, P<0.001, E-selectin, P<0.001]. However, no significant differences were identified between patients and controls for serum creatinine values. On the other hand, there was a high significant correlation between levels of parasitemia and serum levels of TM and E-selectin

Comparison of end-tidal carbon-dioxide with arterial carbon-dioxide during laparoscopic cholecystectomy

In laparoscopic cholecystectomy, insufflation of C02 into the peritoneal cavity brings about changes in cardiovascular and respiratory systems due to compression of inferior vena cava, abdominal aorta, splinting of diaphragm and hypercarbia due to absorption of C02 from peritoneum into circulation. This study was designed to compare the PaC02 and PETC02 and evaluate the predictability of PETC02 as an index of PaC02 Thirty patients of either sex, receiving general anaesthesia were studied. PaC02 and PETC02 were determined before insufflation of C02 into the peritoneal cavity and then at 30 minutes intervals until the end of the procedure Before insufflation of C02, PaC02 ranged from 32-38.7 mm of Hg and PETC02 from 30-35 mm of Hg. Both the parameters at various intervals have shown parallel changes. The difference between PaC02 and PETC02 at all times during surgery had a definite upward trend which is statistically highly significant [P<0.0001]. It has been concluded from results of this study that PETC02 is a reliable predictor of PaC02 during laparoscopic cholecystectomy

Is biliary manometry a useful alternative of preoperative cholangiography in CBD stones?

Biliary pressure and flow rates were recorded during cholecystectomy to determine their predictive value about the presence of bile duct stones in a prospective series of 30 patients, using peroperative Cholangiography as control. Biliary pressure more than 15cm of saline and flow rate less than l0 ml/min of saline have sensitivity of 66.6% and 100% respectively and specificity of 92.5% each, comparable to those of peroperative Cholangiography. Thus biliary pressure and flow rate may be useful adjunct to decision making about bile duct exploration during cholecystectomy

Status of oxidant stress in Parkinson's disease and Friedreich's ataxia, clinical and biochemical evaluation

The status of oxidant stress was determined in 27 patients with PD and 21 age matched controls as well as 17 patients with FA and 12 age matched controls. This was achieved by the determination of plasma, RBCs and CSF, superoxide dismutase [SOD], lipid peroxides in the form of thiobarbituric acid reactive substance [TBARS], plasma and RBCs total thiols, plasma and CSF nitrites and nitrates as a measure of NO* plasma ceruloplasmin, vitamins A, E, C and carotenoids. The study also determined plasma level of vitamin B6, triglycerides and cholesterol. The study revealed significantly increased oxidant stress in patients with PD and FD as reflected by significantly increased NO and LPER. Also, there was decreased antioxidant enzymes superoxide dismutase [SOD] and ceruloplasmin as well as non-enzymatic antioxidants total thiols together with chain breaking antioxidant vitamins A, E and C besides beta-carotene. These changes would suggest a role of increased oxidant stress in the etiopathogenesis of these diseases. Besides, the study supported the importance of supplementing these patients with antioxidant therapy

Preclinical detection of lead toxicity neurophysiological, radiological and biochemical study

Exposure to lead, especially among workers in the industries including lead as a main component, is still a serious occupational hazard even in highly developed countries. Early detection and early treatment are very important for such subjects. The aim of this study is the early detection of lead toxicity among workers in printing offices before the appearance of any clinical signs or symptoms and the determination of sensitive and cheap tests for detection of early lead poisoning in subjects at risk. Therefore, 39 workers in the printing offices of Assiut University who had no clinical symptoms or signs suggestive of lead toxicity were included in this study. They were subjected for neurophysiological, radiological and biochemical investigation together with 10 age and sex matched controls. The study clarified a significant [P < 0.0006] delay of distal latency of the right radial nerve. Significantly decreased RBCs levels of NAD synthetase, pyrimidine 5'-N, PHI and LDH as well as total thiol among patients were compared with controls. Abnormal radiological findings were recorded in 33.3% bands across the upper metaphysis of both tibial shafts were observed in patients who had abnormal radiological findings