Yield of closed pleural biopsy and cytology in exudative pleural effusion

Objective: To determine diagnostic yield of Closed Pleural Biopsy [CPB] and Cytology in Exudative Pleural Effusion [PE]

Methods: This prospective comparative study was conducted at Chest Unit-II and Medical Unit-IV of Dow University of Health Sciences, Karachi Pakistan from January 2011 till December 2014

Results: Ninety-four patients with exudative PE were finally included. The mean age [SD] was 44.0 [13.8] years. Overall Specific Diagnosis was reached in 76/94 patients; 46 Tuberculosis PE [TPE] and 30 Malignant PE [MPE]. CPB diagnosed all TPE patients alone and 28/30 of MPE. Cytology diagnosed only 10/30 patients of MPE with 8 patients having both CPB and Cytology positive for malignancy whereas in the remaining two cases only Cytology positive. The sensitivity of CPB in detecting TPE and MPE was 93.9% and 82.4% respectively whereas specificity for both was 100%. The diagnostic yield of cytology in detecting MPE is only [33.3%]. The diagnostic yield of CPB for TPE and MPE is 100% and 93.3% respectively. The overall specific diagnostic yield of CPB is 78.7%

Conclusion: CPB is better than pleural fluid cytology alone with the later adding little to diagnostic yield when both combined in distinguishing TPE from MPE, the two main differential of exudative PE in a TBEndemic country

Frequency of minimal hepatic encepalopathy inilleterate patients with compensated cirrhosis

Objective: To determine frequency of Minimal Hepatic Encephalopathy in illiterate patients with compensated cirrhosis

Methods: Illiterate patients with compensated cirrhosis with F4 Score on Shear-wave Elastography were selected for study after informed consent. Sample size was estimated at 106. Selected patients were subjected to two tests for detection of MHE, Number Connection Test A and Block Design Test. Patients taking ? 30 seconds were labelled as Positive for MHE

Result: Out of 110 selected patients 10.9% were alcoholics and in 8.2% of patients no hepatic virus infection was detected. HCV was positive in 48.2% patients while HBV was positive in 13.6% of patients. MHE was detected in 72 [65.5%] of patients. Major differences were found in MHE Stage II and III by two tests. Over all BDT detected more cases and gave higher Staging in Stage II and III as compared to NCT-A test

Conclusion: Minimal Hepatic Encephalopathy [MHE] could be detected in illiterate patients using NCT-A and BDT Tests

Hep-net opinion about the management of patients with chronic hepatitis C in Pakistan in the era of available direct acting antivirals

In Pakistan, we have 4.9% prevalence of HCV in general population, with 79% genotype 3. Recently Sofosbuvir has been made available at compassionate price in Pakistan. Management of chronic hepatitis C includes counseling of HCV patients, their proper assessment to select those who need antiviral therapy, initiation of appropriate antiviral agents and duration of therapy, along-with careful monitoring for safety and efficacy. Hepatic status as well as previous history of HCV therapy needs to be taken in the consideration before starting antiviral therapy. Other factors include co-morbid conditions like obesity, DM, NASH, etc. Treatment of special populations like liver transplant patients, patients with HBV co-infection, chronic kidney disease and hemoglobinopathies need special considerations when initiating HCV therapy

Comparison of frequency of insulin resistance in patients with chronic obstructive pulmonary disease with normal controls

Objective: To compare mean homeostatic model assessment of insulin resistance [HOMA-IR] in patients with and without chronic obstructive pulmonary disease [COPD]

Methods: A Case control analytic study was conducted in medical outpatient department of Medial Unit-II of Dow University of Health Sciences from April 2013 to September 2013. All patients with the diagnosis of COPD were included as cases. Controls were age match healthy individuals with minor illnesses. Age, weight, height and forced expiratory volume in one second to forced vital capacity [FEV1/FVC] ratio were documented. Fasting blood glucose and fasting insulin levels were done. Body mass index [BMI] and IR was calculated using the formulas. HOMA-IR was compared between cases and controls

Results: Forty COPD patients were compared with thirty five age match controls. HOMA-IR was found to be higher in cases as compared to controls [2.85 v/s 2.00] with a p value <0.000

Conclusion: COPD is one of the chronic debilitating diseases in our region with various extra-pulmonary complications. We found IR to be present higher in COPD patients compared with healthy controls. Evaluating the pulmonary function as well as systemic metabolic parameters, may contribute to minimizing mortality and morbidity

Insulin resistance in non-diabetic patients of chronic hepatitis C

To determine insulin resistance in non-diabetic chronic hepatitis C patients using Homeostatic Model Assessment of Insulin Resistance [HOMA-IR]. Patients having anti-HCV positive were included in this study. Patients with diabetes mellitus, thyroid disease, hyperlipidemias, hypercortisolism and infective diseases other than hepatitis C were excluded. Age, weight, height and absence of diabetes were documented. Fasting blood glucose and fasting insulin levels were done. Body mass index and insulin resistance was calculated using the formulas. Patients having insulin resistance using formula HOMA-IR>2.5 were labeled as insulin resistant. Data was analyzed using SPSS-18. One hundred and fifty five patients according to sample size estimation were enrolled, in whom HOMA-IR was calculated, the mean value was found to be 2.47 +/- 1.30. A total of 79 [51%] of patients had HOMA-IR more than 2.5 showing insulin resistance. In a third world country like Pakistan, where there is a high prevalence of hepatitis C infection, the consequences of the disease are also very common. Insulin resistance was found in 51% of patients with chronic hepatitis C

Frequency of eosinophilic esophagitis in patients undergoing upper Gl endoscopy

To determine the frequency of Eosinophilic Esophagitis [EoE] in patients undergoing upper Gl endoscopy. Patients undergoing upper Gl endoscopy for any indication were subjected to additional esophageal biopsies for derrnination of eosinophilic esophagitis. The additional biopsy protocol was two each from proximal esophagus, distal esophagus, stomach and duodenum. Presence of >15 eosinophils in one high power field was criteria for diagnosis of EoE. Ninety four patients were included according to sample size estimations. Eosinophilic esophagitis was found in 7 [7.4%] of patients undergoing upper Gl endoscopies. Eosinophilic esophagitis should be considered as active diagnosis in presence of suggestive symptoms

Frequency and pattern of colonization of intravenous cannula in an ICU of public sector hospital

To determine the frequency of colonization of intravenous [IV] cannula by microorganism in patients admitted to intensive care unit [ICU] and to determine the frequency of common organisms involved in colonization of IV-cannula. A total of 369 patients of age more than 12 years, and meeting inclusion criteria of the study were included from in medical ICU after taking informed consent. Staff nurse introduced intravenous cannula of appropriate bore after proper disinfection of the insertion site with povidone iodine solution and alcohol. The cannula was removed for culture within 48 hours of insertion if clinical signs i.e. redness and swelling was present. Mean age was 41 [ +/- 16.7] years. Male to female ratio was 1.07:1. Presence of colonization in IV-cannula was seen in 31 [8.4%] cases. Coagulase-Negative Staphylococci was the most common microorganism seen in 24 [77.4%] patients. The incidence of IV cannula colonization is low in this study. Bacterial colonization occurs in the indwelling intra vascular cannula despite, adequate precautions. Coagulase-Negative Staphylococci and S. Aureus were the common organisms

Frequency of depression in chronic Hepatitis C naive patients

To determine frequency of depression in chronic hepatitis C na‹ve patients before interferon therapy using CES-D questionnaire. Patients testing positive antibodies to HCV by EIA of more than 6 months duration and who have not taken interferon therapy previously were included after taking informed consent. Patients who had co-infections such as hepatitis B and D virus or human immunodeficiency virus, or patients with other coexisting chronic liver disease like primary biliary cirrhosis, chronic autoimmune hepatitis and Wilson disease were excluded from study. Urdu version of CES-D a self-reporting questionnaire in public domain was administered. A score of >/= 10 was taken consistent with depression. Ninety-six patients were included and 59.4% were depressed. These included 57.9% males and 42.1% females. Highest frequency was seen in under-graduates and positive correlation was seen with duration of hepatitis C infection. This study showed that 59.4% of patients with hepatitis C have depression before initiation of therapy and this should be evaluated and treated if necessary before starting interferon therapy

Estimation of body mass index in students of a public sector medical college in Pakistan

To determine the BMI status of the students of Dow Medical College and to calculate frequency of different BMI categories. A cross-sectional questionnaire based study was carried out in Dow Medical College, Dow University of Health Sciences, Karachi. Body weight and height were measured and body mass index [BMI] values were calculated by dividing weight with [height]2. Overweight and obesity were defined using WHO international standard BMI cut-offs. The overall prevalence of underweight students was 29.9% out of which 9.6% fell under the category of severely underweight [BMI of < 16.5]. In overweight category there were 8%. The frequency of students falling in Obese Class I, II and III was 2.7%, 0.6% and 0.0% respectively. It was found that more female students compared to male students were underweight. In the overweight and obese categories there was a preponderance of male students. A positive correlation was found between perception of obesity amongst parents and overweight obese students. According to this study, underweight, especially in girls, should be considered a serious health problem among adolescent students which needs to be addressed. Obesity on the other hand does not seem to be a major issue amongst them

Frequency of acute hepatitis C after needle stick injury and its treatment outcome

To determine the frequency of acute HCV infection after needle stick injury and its treatment outcome. Patients with HCV positive needle stick injury and reporting within 72 hours of incident were selected. Co-infections with HBV, HDV, HIV, hematological disorders and depression were excluded. Anti-HCV was done at presentation and those testing positive were excluded. HCV RNA was done after two weeks or anti-HCV after six weeks of incident. Those testing positive were kept under observation for 16 weeks for spontaneous resolution. After this period HCV RNA and Genotype were done and therapy with Peg-interferon was started. Rapid, early and sustained virological responses were checked. Two hundred eight patients with HCV positive needle stick injury were selected, 10 [4.8%] developed acute HCV infection out of them one [10%] had spontaneous recovery during the observation period of 16 weeks. seven [77.8%] achieved rapid virological response and eight [88.9%] achieved sustained virological response. Acute HCV is an uncommon disease to diagnose; it has favorable response to therapy if initiated early after a strict surveillance of patients for 8-16 weeks

Frequency of sensory neuropathy in foot of asymptomatic type2 diabetic patients using semmes-weinstein monofilament

To detect neuropathy in diabetics who are clinically asymptomatic, using SW monofilament and to correlate the frequency of detected neuropathy with the duration of diabetes. Known patients of type 2 diabetes that do not have symptoms of peripheral neuropathy were included. Height, weight and duration of diabetes were measured and BMI calculated. SW monofilament was pressed perpendicular to the test site with enough pressure to bend it for one second. Comparison of frequency of SW monofilament test among gender was done by x2 test. Bivariate correlation of SW monofilament test result with duration of diabetes was done by Kendall's test. A total of 700 patients including 324 males and 376 females were examined. Asymptomatic neuropathy was detected in 14.4% of patients. The mean age of males was significantly more [50.4 +/- 9.0 vs 46.7 +/- 8.4 yrs; P < 0.0001] but BMI was lower than females [24.4 +/- 2.8 vs 26.2 +/- 4.2; P < 0.0001]. No correlation of asymptomatic neuropathy with duration of diabetes was detected [P = 0.995]. Asymptomatic neuropathy is prevalent in our diabetic population and it does not correlate with the duration of diabetes. Diabetics should be actively screened for asymptomatic neuropathy by SW monofilament

Appraisal of the knowledge of internet users of Pakistan regarding hepatitis using on line survey

Hepatitis B and hepatitis C are global health care problems causing morbidity and mortality. Much of it could be prevented by better education of the masses regarding its spread. The study was conducted to assess the knowledge base of internet users of Pakistan to help in formulating education strategies. A survey questionnaire consisting of 20 close ended questions was designed and hosted on a website. The responses submitted at the website were auto-emailed to the author. A total of 1024 complete responses were included. The survey shows increased level of awareness according to the educational status. The knowledge status of lowest education level was also adequate possibly due to access to internet to these respondents. Internet users in Pakistan have adequate core knowledge regarding hepatitis

Triple hepatitis: frequency and treatment outcome of co/super-infection of hepatitis C and D among patients of hepatitis B

To determine the frequency of hepatitis C and D in patients of chronic hepatitis B and the treatment response of hepatitis B in such patients. Case series. Civil Hospital and Lyari General Hospital, Dow University of Health Sciences, from July 2003 to June 2005. All patients of hepatitis B presenting during the study period were screened for triple infection by carrying out anti-HBc [IgG], anti-HCV and anti-HDV. Patients who were positive to all three were included in the study. Complete Blood Count [CBC]; HBsAg; HBeAg; anti-HBc IgM; anti-HDV; anti-HCV; HBV DNA PCR; HCV RNA PCR; serum albumin; SGPT; serum bilirubin and ultrasound abdomen were acquired in all patients. All patients received pegylated interferon-alpha 2a 180 mcg sc weekly x 48 weeks. Patients who were also positive for HCV RNA also received ribavirin 1000-1200 mg/d po x 24 weeks for genotype 3 and 48 weeks for genotype 1. Descriptive statistics were used for describing the data. Out of the 246 patients of HBV, 29 [11.8%] patients were also positive for anti-HBc IgG, anti-HDV and anti-HCV. After 48 weeks of therapy, the respective viral undetection by PCR was 4 [13.8%] in patients having only HBV DNA, 3 [10.3%] in patients with only HCV RNA and in patients who had both HBV DNA and HCV RNA positive, simultaneously HCV was cleared in 2 [6.9%] while HBV was not cleared in any case. In patients coming with one hepatic infection, other infections should be sought as they share a common mode of spread and may affect the overall response to treatment

Patterns of acute poisoning and its outcome reported at civil hospital Karachi

To determine frequently used agents in acute poisoning, mode of poisoning, influencing factors, time interval between intoxication and hospital arrival outcome. The study was conducted in the department of Medicine, Civil Hospital Karachi in year 2006. It was a Descriptive and observational study. All cases of acute poisoning admitted in medical unit IV were included in this study. In all the cases a previously prepared Performa was filled, the Performa included patient's demographic patterns, agent used for poisoning, various influencing and precipitating factors of acute poisoning, route of poisoning, time interval between intake and arrival in hospital, past history of such episode, psychiatric history and outcome. Total of 118 cases of acute poisoning admitted during the study period. Sixty two [52.85%] were female and fifty six [47.15%] were males. Oral route was used in all cases. Mode of poisoning was suicidal [61.02%], deliberately self harm [22.03%], accidental [11%] and homicidal [5.08%]. Common reasons for poisoning in males were financial constraints [48%] and unemployment [40%]. Common reason for poisoning in females was family conflictions [68%]. Fifteen patients [12.54%] had previously attempted the poisoning as well. Previously known psychiatric illness was found in five [4.24%] of patients. Most of the patients [102] reached within eight hours, only six arrived within two hours. Eleven patients [9%] expired in which six were females and five were males. Organophosphorus compounds were found to be the commonest incriminating agent in poisoning. Family conflictions and financial constraints were the main reasons behind poisoning. Most of the patients are reaching late in hospital, Majority of the deaths are occurring immediately after arrival and within two days. Reattempt of poisoning was found in significant number of patients which were although preventable. Mortality in cases of poisoning is still high

Corrlation of adjusted blood requirement index with treatment intervention and outcome in patients presenting with acute variceal bleeding

To determine the correlation of ABRI with treatment intervention and outcome as discharged or expired in patients of acute variceal bleed. Cross-sectional study Records of all the patients admitted in Medical Unit-IV, Civil Hospital Karachi with acute variceal bleeding during January 2004 to October 2006 were retrieved. Use of vasoactive agents [Terlipressin/Octreotide], endoscopic band ligation [EBL] and outcome [Discharged/Expired] were noted. ABRI was calculated by the following formula: ABRI= Blood Units Transfused/ [[Final Hematocrit - Initial Hematocrit] + 0.01] Mean ABRI were compared by Student's 't' test according to vasoactive therapy, EBL and outcome. Correlation of ABRI with the same variables was also studied by plotting Receiver Operative Curves [ROC]. Seventy six patients fulfilling inclusion criteria were selected. No statistically significant difference was observed in the mean ABRI scores when compared according to vasoactive drug administration, EBL and outcome. Significant correlation with mortality was seen on ROC plot with significantly larger area under the curve. ABRI correlated significantly with mortality in this study. Larger prospective studies with appropriate power are required to evaluate its association with other variables

Hyperglycemia: an unusual cause for hemichorea-hemiballism

Hemichorea - hemiballism is a rare neurologic disorder due to oxidative stress leading to neurodegeneration of the dentate nuclei and striata. It is rarely observed in diabetes. One such case occuring in an adult female diabetic is described

Unusual presentation of an unusual hepatitis

Autoimmune hepatitis is an uncommon cause of chronic hepatitis in Pakistan. One such case is described occurring in an adult female cirrhotic diagnosed on raised serum IgG and LKM-I

Hepatitis D: a review

Hepatitis D has been shown to be reducing in frequency in the Western countries commensurate with HBV decline while recent reports from Pakistan are indicating a rising frequency. This review describes the management and prevention of this often overlooked cause of hepatitis

Correlation of quality of life in patients of cirrhosis of liver with etiology and disease severity using disease-specific quality of life questionnaire

Quality of Life has an important status in patient management suffering from chronic disease like cirrhosis and health related quality of life has significant impact on patient management. This study was conducted to evaluate the correlation of health related quality of life with disease severity in patients of cirrhosis of liver. This cross-sectional study was conducted at Medical Unit-IV, Dow University of Health Sciences, Karachi, during the period January 2006 to October 2006. All patients of cirrhosis of liver admitted during the study period were selected. Patients with encephalopathy, hepatocellular carcinoma were excluded. The 29 item chronic liver disease questionnaire [CLDQ] was administered to the patients by a postgraduate trainee. Internal validity of responses was checked statistically and correlation of responses was done with disease severity by Child-Pughs Criteria. 109 patients were selected with 72 males and 37 females. Patient classification according to Child class A, B and C was 30, 38 and 41 respectively. The mean CLDQ score in the patients was 89.5 +/- 30.4. It correlated significantly with Child Class but did not correlate with the gender, age and etiology of cirrhosis. Health related CLDQ scores correlate with the severity of liver disease

Treatment outcome in patients of hepatitis B with hepatitis D: experience of 4 years at a tertiary care centre in Pakistan

To determine HBV suppression in patients with dual HBV and HDV infection after 48 weeks with 10.0 MID of interferon-a 2b. Quasi experimental study. Civil Hospital, Karachi and Lyari General Hospital, Karachi, from July 2003 to June 2005. All HBsAg positive patients were screened for anti-HDV, all positives were included. Baseline investigations, liver chemistries and HBsAg; HBeAg; anti-HBcore IgM; HBV DMA quantitative PCR were done. Patients with hepatocellular carcinoma and decompensated cirrhosis were excluded. Patients were treated with Interferon-a 10.0 MID sc t.i.w. for 48 weeks. HBeAg and quantitative HBV DNA was done at week 0, 24 and 48 while CBC and SGPT were done monthly. HBV suppression was defined as levels <400 copies/ml. Fifty-two patients were selected for intervention, including 34 males and 18 females. At the end of therapy after 48 weeks, HBV DNA suppression was achieved in 51.9% and HBeAg became undetectable in 53.8% of patients. Twenty -one patients with HBV suppression still had raised SGPT. HDV should be screened in all patients eligible for HBV treatment