Frequencies of acute intra-dialytic complications: a single centre experience

Objective: To determine frequencies of various acute complications in patients undergoing hemodialysis

Study Design: Descriptive cross-sectional study

Place and Duration of Study: Department of Nephrology Military Hospital [MH] Rawalpindi, from Jan 2016 till Mar 2016

Material and Methods: A total of 150 patients who underwent haemodialysis at MH were enrolled in the study after informed consent on justification of inclusion and exclusion criteria. The patients were evaluated for the frequency of various intra-dialytic complications and data were analysed using SPSS version 19

Results: Out of the 150 enrolled patients, males were 125 [83.33%] and females were 25 [16.67%]. A total of 2520 haemodialysis session were performed. Hypotension was the most frequently observed complication during 318 [12.62%] dialysis sessions, followed by hypertension in 208 [8.25%] and fever in 193 [7.66%] sessions. Other complications were muscle cramps in 116 [4.60%], shivering in 94 [3.73%], headache in 70 [2.78%], nausea/vomiting 60 [2.38%], itching 41 [1.62%], chest pain 37 [1.47%], hypoglycaemia 31 [1.23%], seizures 23 [0.91%] and arrhythmias in 13 [0.52%] dialysis sessions

Conclusion: Haemodialysis, one of the renal replacement therapies, is a life-saving treatment modality but it is not without complications despite the advances in technology. However frequency with which they occur is low and majority are not life threatening

Diagnostic accuracy of clinical methods for detection of diabetic sensory neuropathy

Objective: To determine the accuracy of clinical methods for detection of sensory neuropathy as compared to biothesiometry

Study Design: Cross-sectional analytical study

Place and Duration of Study: 1 Mountain Medical Battalion, Azad Kashmir, from October 2013 to September 2014

Methodology: Patients with type 2 diabetes were enrolled by convenience sampling. Exclusion criteria included other identifiable causes of neuropathy, extensive ulceration of feet, amputated feet, those on treatment for neuropathy and unwilling patients. Average of 3 vibration perception threshold values measured with a biothesiometer on distal hallux was calculated. Ten gm monofilament was used to examine touch sensation over dorsal surfaces of great toes. Vibration sensation was checked over the tips of great toes using 128Hz tuning fork. Ankle jerks were checked bilaterally

Results: Neuropathy [vibration perception threshold > 25 volts] was present in 34 [21.12%] out of 161 patients and 93 [57.76%] were symptomatic. Measures of diagnostic accuracy for monofilament, tuning fork and ankle jerks were: sensitivity 41.18%, 55.88% and 64.71%; specificity 92.91%, 93.70% and 80.31%; positive predictive value [PPV] 60.87%, 70.37% and 46.81%; negative predictive value [NPV] 85.51%, 88.81% and 89.47%; and, diagnostic accuracy 81.99%, 85.71% and 77.02%, respectively. Values for any 1 positive sign, any 2 positive signs or all 3 positive signs were: sensitivity 35.29%, 14.71% and 32.35%; specificity 81.89%, 93.70% and 99.21%; PPV 34.29%, 38.46% and 91.67%; NPV 82.54%, 80.41% and 84.56%; and, diagnostic accuracy 72.05%, 77.02% and 85.09%, respectively

Conclusion: Clinical methods are high accurate and specific diagnosis in picking up symmetric sensory neuropathy in patients with type 2 diabetes, particularly when multiple signs are combined

Thrombocytopenia in malaria: can platelet counts differentiate malaria from other infections?

To determine the accuracy of thrombocytopenia as a diagnostic marker for malaria. Cross-sectional study. Department of Medicine, 1 Mountain Medical Battalion [Bagh, Azad Kashmir] from July to September 2013. Adult patients presenting with a short history of fever without any localizing symptoms or signs were included. Exclusion criteria included patients with fever of > 7 days duration, those in whom an underlying diagnosis could be easily confirmed on the basis of history and physical examination, those on antibiotics/ antimalarials or antiplatelet agents and patients with Dengue fever. Platelet counts in venous whole blood samples were analysed with Sysmex KX-21 Haematology analyzer. Thick and thin peripheral blood smears were then prepared and examined for malarial parasites. Diagnosis of malaria was established on the basis of smear findings. There were 245 patients in total. Out of the 109 patients with thrombocytopenia, 61 had vivax malaria. Platelets count was normal in 136 patients, including 4 with vivax malaria. Falciparum malaria was not seen in any patient. All cases with malaria were uncomplicated. Various measures of accuracy thus calculated were sensitivity 93.85%, specificity 73.33%, positive predictive value 55.96%, negative predictive value 97.06%, positive likelihood ratio of 3.52, negative likelihood ratio of 0.08, diagnostic odds ratio 41.94 and diagnostic accuracy of 78.78%. Thrombocytopenia has an excellent sensitivity and a very good specificity for vivax malaria. Normal platelet counts provide very strong evidence against malaria as the etiology of fever without a focus

Herpes Zoster involving penis and scrotum: an unusual occurrence

Herpes zoster is an infectious vesicular skin rash in a dermatomal distribution caused by Varicella zoster virus. It occurs very uncommonly in sacral dermatomes. We describe a case with rash on penis and scrotum due to involvement of S2 dermatome in a young male. The disease followed an uneventful course and the patient recovered completely without any sequelae or complications. This case is being presented to highlight its unusual location and to discuss differentiation from another viral infection commonly seen at this site

Frequency of Poor Adherence to Antihypertensive Treatment and an Analysis of Clinico-demographic Correlates

This observational study is aimed to determine the frequency of poor compliance to antihypertensive treatment and to identify predictive demographic factors. One hundred and six hypertensive patients, on treatment for more than three months, were enrolled. Demographic characteristics [age, gender, level of education, duration of hypertension and area of residence] were recorded. Number of antihypertensive as well as total medicines, presence of any co-morbid conditions, possible side effects to treatment and financial source for obtaining medications were also enquired. Blood pressure was measured and body mass index was calculated. Compliance was assessed with 4-Item Morisky Medication Adherence Scale. Poor compliance [scores ² 2] was present in 31 [29.25%] patients. Systolic and diastolic blood pressures were higher in poorly compliant patients. Patients with co-morbid conditions were more likely to have poor compliance [OR=4.238; 95% CI 1.161, 15.468]. Other variables did not have a significant association with compliance to treatment. Poor compliance is fairly common in hypertensive patients and should be looked after for more so in patients with co-morbid conditions

Backache due to alkaptonuria in a middle aged man

Alkaptonuria is a rare cause of backache. A 55 years old gentleman, a retired army personal had been having pain and stiffness in the spine for the last 15 years, accompanied by bluish black discolouration of face and hands. Kyphosis and reduced movement of spine were present. Other joints were spared. Osler spots were visible on the sclera. X-rays revealed calcification of intervertebral discs. Asymptomatic renal stone was identified. There was no cardiac involvement. Symptomatic care was provided.

Lipoma in perineum- an unusual location

Subcutanoeus lipomas are rarely seen in the perineum. We describe a 55 years old man with four years history of a 10cm long soft lobulated mass between the scrotum and anus.This was successfully excised and was shown to be a lipoma on histopathological exam

Intralesional ciprofloxacin for cutaneous leishmaniasis: comparison with meglumine antimoniate

Leishmaniasis is quite commonly encountered in Balochistan. Of all the known treatment modalities, only a few are available at our hospital. We carried out this study in search of an effective and easily available agent. This quasi-experimental study was carried out at Combined Military Hospital Sibi in Balochistan from May to Nov 2010. The gross appearance of non healing ulcers and demonstration of parasite in Giemsa stained smears were used to confirm the diagnosis. Thirty nine patients were enrolled and divided into two groups by non- probability convenience sampling. Eighteen patients [having 30 ulcers] received meglumine antimoniate and 21 patients [having 32 ulcers] received 0.2% ciprofloxacin intralesionally every fifth day till re-epithelialization started, up to a maximum of five doses. Side effects of therapy were checked at every visit. Patients were followed up at one week and subsequently one month after completion of treatment to assess complete clinical healing and regression in size of the scar. Two ulcers in meglumine antimoniate and five ulcers in ciprofloxacin group did not heal [response rate 93.33% vs. 84.38%, p: 0.273]. Those treated with meglumine antimoniate required a lesser number of doses [mean 3.83 and 4.27; p: 0.039]. Reduction in scar size was equal in both groups [58.46% and 57.21%; p: 0.087]. Intralesional ciprofloxacin is an effective, cheap and safe treatment for cutaneous leishmaniasis

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

Effect of glycemic control on diabetic dyslipidemia

To determine whether good glycemic control has an effect on lipid profile in diabetics. Cross- sectional study. Department of Medicine, Combined Military Hospital Lahore; June to December 2007. After taking relevant history and physical examination, serum urea, creatinine, thyroid stimulating hormone, bilirubin, alanine transaminase and HbA1c were measured. Blood samples for determination of fasting plasma glucose, serum total cholesterol, triglycerides, HDL and LDL levels were collected in a fasting state. Patients were divided into two groups based on HbA1c levels. They were compared using SPSS 13. 42 patients had good glycemic control and 58 had poor control. The two groups were age and weight matched. 43 patients had abnormal lipid profiles. Serum total cholesterol and triglycerides were lower and HDL levels higher in the good control group but serum LDL levels were equal. Good glycemic control improves lipid profile in patients with type 2 diabetes mellitus

Peripheral arteriovenous malformations

Arteriovenous malformation [AVM] is an anomaly characterized by abnormal vascular communications between arteries and veins in the different organs of the body. It may be congenital or acquired. Microsurgical resection, endovascular embolization and radiosurgery [irradiation] are the three effective modes of treatment currently available. However, no objective criteria have been established for which mode[s] of treatment should be selected for individual patients with AVMs