Beyond the liver! extra hepatic manifestations: assessment of frequency and risk factors among hepatitis b and c related chronic liver diseases

Objectives: The study aimed to determine the frequency and risk factors for Extra Hepatic Manifestations among patients with Hepatitis B and C related Chronic Liver Diseases

Study Design: Cross Sectional Study

Place and Duration of Study: This Study is conducted at the Department of Medicine [Both indoor and outdoor patients] of Civil Hospital, Karachi from 2012 to 2016

Materials and Methods: In this study of 548 patients, who were positive for HBV or HCV, fulfill the selection criteria and were suffering from Chronic Hepatitis, Cirrhosis or HCC were examined for Extra Hepatic Manifestations clinically and if required appropriate tests were done to confirm the diagnosis and finding. Frequency and risk factors were determined for extra hepatic manifestations. Test of statistical significance were applied where p value of <0.05 was considered to be statistically significant cut-off

Results: Majority of patients 432 [78.8%] were HCV Positive and 116 [21.2%] were found to be HBV positive. Overall frequency of extra hepatic manifestations was found to be 54.7 %. Patients with chronic hepatitis C and B. The Extra Hepatic Manifestations of 60.6 % in HCV and 32.8% in HBV respectively. Diabetes Mellitus [DM] is the most common extra hepatic manifestation found in both, chronic HCV [19.0%] and chronic HBV patients [5.2%] whereas hypertension is the second commonest extra hepatic manifestation among HBV patients [12.1%]. Disease duration > 5 years, age> 45 years, Viral PCR, Raised ALT and Hepatocellular Carcinoma associated with chronic HCV and HBV were found to be significant risk factors for extra hepatic manifestations

Conclusion: Extra Hepatic Manifestations are more common in HCV associated liver diseases than HBV. Diabetes and hypertension are the main extra hepatic manifestation among HBV and HCV positive patient. Disease duration > 5 years, age> 45 years, Viral PCR, Raised ALT and HCC associated with chronic HCV and HBV were found to be significant risk factors for Extra Hepatic Manifestation

Better prognostic marker in ICU - APACHE II, SOFA or SAP II!

Objectives: This study was designed to determine the comparative efficacy of different scoring system in assessing the prognosis of critically ill patients

Methods:This was a retrospective study conducted in medical intensive care unit [MICU] and high dependency unit [HDU] Medical Unit III, Civil Hospital, from April 2012 to August 2012. All patients over age 16 years old who have fulfilled the criteria for MICU admission were included. Predictive mortality of APACHE II, SAP II and SOFA were calculated. Calibration and discrimination were used for validity of each scoring model

Results:A total of 96 patients with equal gender distribution were enrolled. The average APACHE II score in non-survivors [27.97+8.53] was higher than survivors [15.82+8.79] with statistically significant p value [<0.001]. The average SOFA score in non-survivors [9.68+4.88] was higher than survivors [5.63+3.63] with statistically significant p value [<0.001]. SAP II average score in non-survivors [53.71+19.05] was higher than survivors [30.18+16.24] with statistically significant p value [<0.001]

Conclusion:All three tested scoring models [APACHE II, SAP II and SOFA] would be accurate enough for a general description of our ICU patients. APACHE II has showed better calibration and discrimination power than SAP II and SOFA

Typhidot: a blessing or a menace

Typhoid remain an increasing problem in Third world countries like Pakistan. A reliable, easy and affordable rapid diagnostic test is a need for our clinicians, many of whom consider Typhidot to be promising. Typhidot has been used as the only tool to diagnose typhoid fever by general practitioners and consultants despite its low sensitivity and specificity causing misdiagnosis and treatment. We therefore conducted this study to evaluate the sensitivity and specificity of Typhidot in patients with fever. A retrospective analysis of a total of 145 febrile patients was done. Blood culture and Typhidot along with other relevant investigations had been performed in each case. Sensitivity, specificity and the association of Typhidot to the diagnosis was found using SPSS v16.0. Out of 145 patients, 15 [10.3%] had positive blood culture for Salmonella typhi, 7 [4.8%] had positive culture for salmonella paratyphi and 94 [64.8%] had positive culture for other organisms. Twenty nine [20%] patients had negative culture results. Forty seven [32.4%] patients had only IgM positive on Typhidot, 7 [4.8%] had both IgM and IgG positive and 91 [62.8%] had both IgM and IgG negative. Amongst the 130 patients with diseases other than typhoid, 50 [38.5%] showed a positive Typhidot result. Amongst the 15 patients with typhoid, 11 [73.3%] showed a negative Typhidot result. The sensitivity of Typhidot was found to be 26.7% and the specificity was 61.5%. The Positive Predictive Value [PPV] was 7.4% and the Negative Predictive Value [NPV] was 87.9%. Even though Typhidot is rapid, easy and affordable, its use should be discouraged due to low sensitivity and specificity and insignificant [p=0.067] association to the disease

Pittsburgh sleep quality index: validation of the urdu translation

To translate and validate the Pittsburgh Sleep Quality Index [PSQI], a standardized self-administered questionnaire for the assessment of subjective sleep quality into the Urdu language. Validation study. Mayo Hospital, Lahore, from March to April 2012. The PSQI was translated into Urdu following standard guidelines. The final Urdu version [PSQI-U] was administered to 200 healthy volunteers comprising medical students, nursing staff and doctors. Inter-item correlation was assessed by calculating Cronbach alpha. Correlation of component scores with global score was assessed by calculating Spearman correlation coefficient. Correlation between global PSQI-U scores at baseline with global scores for each PSQI-U and PSQI-E at 4-week interval was evaluated by calculating Spearman correlation coefficient. Moreover, scores on individual items of the scale at baseline were compared with respective scores after 4-week by t-test. One hundred and eighty five [185] participants completed the PSQI-U at baseline. The Cronbach alpha for PSQI-U was 0.56. Scores on individual components of the PSQI-U and composite scores were all highly correlated with each other [all p-values < 0.01]. Composite scores for PSQI-U at baseline and PSQI-E at 4-week interval were also highly correlated with each other [Spearman correlation coefficient 0.74, p-value < 0.01] indicating good linguistic interchangeability. Composite scores for PSQI-U at baseline and at 4-week interval were positively correlated with each other [Spearman correlation coefficient 0.70, p < 0.01] indicating good test-retest reliability. The PSQI-U is a valid and reliable instrument for the assessment of sleep quality. It shows good linguistic interchangeability and test-retest reliability in comparison to the original English version when applied to individuals who speak the Urdu language. The PSQI-U can be a tool either for clinical management or research

Inpatient management of type 2 diabetes mellitus: does choice of insulin regimen really matter?

To assess inpatient management of non-critically ill type 2 diabetics with different insulin regimen. We reviewed the medical records of all non-critically ill type 2 diabetic patients more than 18 years of age in medical department of civil hospital Karachi and Dow University of Health Sciences from January 2011 to December 2012. We collected the data from case records in data collection sheets that fulfill the inclusion criteria and divided the study subjects into three groups according to insulin regimen they received. A total of 416 patients were analyzed out of which 220 were male. Subjects were divided into three groups according to insulin regimen they received. Majority were put on sliding scale of insulin [44.7%], while 33.1% and 22.1% subjects received basal bolus and pre-mixed insulin regimen respectively. Patients treated with basal bolus regimen had greater improvement in glycaemic control with short duration of hospital stay as compared to other two groups. The mean hyperglycaemic events were higher in sliding scale group while mean hypoglycaemic events were higher in basal bolus group. In non-critically ill type 2 diabetic patients the basal bolus regimen is superior to sliding and pre-mixed insulin regimen. Sliding scale should be discouraged in non-critically ill type 2 diabetic patients

Clostridium difficile postantibiotic diarrhoea diagnosis

To study the frequency of Clostridium difficile in postantibiotic diarrhoea in patients admitted to the medical ward of a secondary care hospital. Observational study. Sindh Government Hospital, Liaquatabad, Karachi, from June 2002 to May 2009. Adults of either gender who received antibiotics after admission and subsequently had watery stools at least 2 days after admission were selected. The exclusion criteria were past history of inflammatory bowel disease or any type of malabsorption state and those who did not show WBCs in stools. All variables of these patients along with clinical findings, type of antibiotic received, and number of stool motions per day were recorded. Three samples of the stools were sent for detailed reports to analyze the number of leukocytes per high field and culture, on cycloserine - cefoxitin - fructose agar [CCFA]. All findings were entered into and analyzed by SPSS 16 for statistical analysis. Out of the 473 patients who received antibiotics for any reasons, 191 [40.38%] developed diarrhoea. The mean age was 45.6 +/- 17.73 years and male to female ratio was 1.85:1. The average number of stools passed per day was 4.84 +/- 1.24 and all patients showed leukocytes in stool samples with a mean count of 6.67 +/- 0.89/HPF. The stool culture on CCFA was positive for 57 patients [29.18%], while 134 patients [70.15%] were stool culture negative as well as negative for evidence of any parasites; these samples were labelled benign antibiotic associated diarrhoea [BAAD]. Ampicillin and amoxicillin with clavulanate were the most implicated antibiotics in this study. Clostridium difficile is the main putative agent in postantibiotic diarrhoea. In settings with limited resources, use of specific culture media such as CCFA proves to be highly cost effective, and sensitive for this diagnosis. Macrolides and quinolones are the safest agents to prescribe in this context

Are tremors in old age, really senile? a hospital based study

To study the frequency and severity of tremors in otherwise healthy elderly adults at Sind Government Hospital Liaqatabad, Karachi. This cross-sectional study, was conducted at the Sindh government hospital, Liaquatabad, Karachi from October, 2007-2009. Five hundred otherwise healthy adults of both genders of more than 60 years were selected. After thorough clinical examination, classification and the severity of tremors were assessed by tasks given to the patients by principal investigator which he designed himself. All variables were put in proper register. Data entry and analysis was performed by single researcher on SPSS 16 for biostatistics. The inclusion criteria were adults of more than 60 years of either gender with no history of any systematic or neurological illness and presently not on drugs. The exclusion criteria were disputed age groups and those who cannot sign or write their names because they cannot be assessed by tasks. The mean age was 68.75 years +/- 6.74 with male female ratio of 1.95:1. Out of 500 subjects 84 [16.8%] showed no tremors, 307 [64.4%] had mild tremors only evident on special movements i.e. enhanced physiological tremors [physiological senile tremors] and 109 [21.8%] had moderate to severe tremors evident on movements i.e. kinetic, essential tremors [pathological senile tremors], with family history of 50.45%. Tremors in old age are not part of life. Most of them had enhanced physiological tremors while few were of essential type with strong family history. If these are detected, they should be evaluated and classified and can be managed to make elderly population more useful to their family and the society

Tremors; myths and misconceptions; a 7-year clinical survey 2002-2009

To determine the myths and misconceptions about [Tremors] among those who developed this disorder and their health seeking behavior, and also among those who never had tremors, at the psycho-neurology and medical OPD of Sindh Govt. Hospital, Liaqatabad no. 10, Karachi. A single centre based cross-sectional survey, conducted from year 2002 to 2009 at Sindh Govt. Hospital [SGH] Liaqatabad no.10, Karachi. 403 adult patients of either sex with tremors were selected from medical and psycho-neurology OPD's. For comparison 100 healthy individuals from general population, who never had tremors, of the same area were also included. Questionnaires regarding different myths and misconceptions about tremors were filled by the patients/normal healthy people after obtaining the consent. Out of 403 selected patients [61.53% males and 38.47% females] majority belonged to the urban areas. Out of hundred normal healthy people 73 [73%] were males and 27 [27%] were females. Only 8% of the patients considered tremor was a neurological illness, while 33% of the patients and 41% of the general population related it to magic or witchcraft. Overall, females were more inclined to choose alternative medicine and spiritual therapy than males. Myths and Misconceptions about tremors are present in our society because of strong belief and observations. Provision of primary education, health education and using electronic media can play a key role in abolishing these misconceptions

Clinical profile and management outcome of diabetic foot ulcers in a tertiary care hospital

To determine major risk factors and management outcome of diabetic foot ulcers in order to prevent amputation. Cross-sectional descriptive study. Study was conducted at the Department of Medicine, Civil Hospital Karachi, from January 2005 to December 2006. One-hundred and sixteen consecutive diabetic patients, with foot ulcers of Wagner's grade 1 to 4 were assessed at baseline for demographic information, detailed history, neuropathy, peripheral pulses and frequency of diabetic complication. Glycemic control was determined on the basis of HbA1c levels. Appropriate medical and surgical treatments were carried out and patients were followed-up until healing or for 6 months as end point of study. Outcome was recorded as healed, incomplete healing and amputated. A majority of subjects had type 2 diabetes [95.7%] with male predominance [66%]. The mean age was 54.29 +/- 7.71 years. Most of the patients were overweight, hyperglycemic and had diabetes > 10 years duration. Neuropathic ulcers were found in 91 [78.4%] patients, while rest of the 25 [22.6%] had neuroischemic ulcers. Wound cultures revealed polymicrobial organisms. Foot ulcers of 89 [77.7%] patients healed without amputation and 17 [14.7%] patients had minor or major amputations. Long-duration of diabetes, poor glycemic control and type of foot ulcers had effect on prognosis [p<0.05]. Effective glycemic control, optimal wound care, aggressive medical management and timely surgical intervention may decrease disabling morbidity with better outcome of diabetic foot ulcer

Neuroleptic malignant syndrome: a sixteen years retrospective review

To study demographic characteristics, psychiatric diagnosis, type of neuroleptic drugs administered, course of illness, management and outcome. Retrospective chart review study. This study was carried out for sixteen years [1988-2004] in the Psychiatry unit, Aga Khan University Hospital, Karachi. Sample consisted of 25 cases of Neuroleptic Malignant Syndrome in which 13 were males and 12 were females. The record was taken from the health information management system which keeps a comprehensive chart of each patient. This renders the files retrievable through computer generated search. A specific data collection form was designed for extraction of relevant data. The data was analyzed using SPSS version 13.0. Twenty five cases were identified, of which thirteen were males. Mean age was 45 years [range 20-74 years]. Bipolar affective disorder was the most common diagnosis followed by schizo-affective disorder, schizophrenia, postpartum psychosis, dementia and Parkinsonism. 48% of the patients had previous history of neuroleptic use, while 28% received neuroleptics for the first time. Among neuroleptic users, 20% were on long-acting depot antipsychotics. 52% received per-oral dose [PO], while 32% received intramuscular [IM] dose. 56% patients were on other concomitant medications among which Lithium was the most common [16%]. 96% patients had the cardinal symptoms of fever, rigidity and increased creatine phosphokinase [CPK]. 96% had associated delirium, 80% showed autonomic instability with fluctuation in pulse and blood pressure. Electrolyte disturbance was seen in 84% and diaphoresis with leukocytosis was present in 68% patients. NMS was associated with high ambient temperature with mean temperature of 39.20 C [S.E. 0.3]. Discontinuation of neurolpetic medications and supportive care was carried out in all cases. In our case series we observed mortality rate of 16%. Out of 25 patients, 21 recovered with early diagnosis and adequate management. Risk of NMS can be minimized by use of low potency or atypical antipsychotics, cautious use of concomitant medications and depot preparations and initiation of neurolpetics at lower dose with careful monitoring. With good supportive medical care mortality can be substantially minimized

Correlation of serum cortisol levels and stress among medical doctors working in emergency departments

To assess and correlate serum cortisol levels and self-perceived work-related stress among medical doctors working in emergency departments in different tertiary care hospitals of Karachi. Cohort study. The study was conducted in Section of Chemical Pathology, Department of Pathology and Microbiology, AKUH, from December 2004 to August 2005. A total of 64 doctors participated from one private and two public tertiary care hospitals of Karachi. Thirtyfour doctors were from emergency departments and 30 from non-emergency departments. Serum cortisol levels were measured in the morning [between 8.00-8.30 am] and in the evening [between 8.00-8.30 pm]. Cortisol was measured by Florescence Polarization Immunoassay [FPIA] technique. Two questionnaires, modified mental Professional Stress Scale [PSS] and Aga Khan University Anxiety and Depression Scale [AKUADS] were used to assess stress levels. Emergency room physicians [ERP] were 1.2-year younger than non-emergency room physicians [NERP]. Mean evening cortisol of emergency physicians was 60.72nmol/L higher than non-emergency physicians. The difference between morning and evening cortisol was marginally significant [p = 0.051]. Morning diastolic blood pressure was 3mmHg higher in emergency physicians. Forty-one percent of emergency physicians and 20% of non-emergency physicians had AKUADS more than or equal to 20, the difference was borderline significant [p = 0.068]. Mean value of professional stress scale for emergency physicians was significantly higher than non-emergency physicians. Evening serum cortisol concentration was significantly associated with PSS [p = 0.011]. The sub-scales such as work-load [p = 0.007] and lack of resources were highly significant with evening cortisol [p = 0.005]. In this study, evening serum cortisol levels significantly correlated with work overload and lack of resources, however, there was marginally significant correlation between morning and evening serum cortisol difference. Study suggests that emergency physicians perceive more stress than non-emergency physicians. Work overload and lack of resources are major contributing factors for stress in these doctors

Psychiatric in patient Violence: Use of chemical and physical restraint at a University hospital in Karachi, Pakistan

To study the frequency of inpatient-violence and use of physical and chemical restraints in its management. Descriptive study. The Department of Psychiatry, Aga Khan University Hospital, Karachi between January 2004 and December 2004. Information on socio-demographic characteristics, psychiatric diagnoses, routine and as required psychotropic medications was collected for all patients admitted to psychiatric unit. An incidence reporting form was filled for each patient requiring physical restraint. Out of all the patients admitted [n=393] over the one-year period, 44% [n=175] patients required P.R.N. psychotropic medication. Intramuscular anti-psychotic medication was used in 50% cases, benzodiazepines in 33% while 16% required both. 14% [n=57] required physical restraints. 4-point restrain was used in 31 [54%] cases while 2-point restrain was used in 23 [40%] cases. No serious injury was noticed in any case. According to these two proxy indicators the frequency of violence in this in patients psychiatric setting is estimated to be 14%. Incidence figures of inpatient violence in our psychiatric setting are alarmingly high. This requires systematic research related to the risk factors and determinants of inpatient violence

Gender differences in age at onset of schizophrenia

To evaluate the gender differences in age at onset of schizophrenia. Prospective case control study. Department of Psychiatry, Aga Khan University Hospital, Karachi between January to December 2002. Patients and Sixty patients admitted consecutively to psychiatry ward and meeting the inclusion criteria were enrolled for the study. Age at onset of illness was defined as age at onset of gross psychotic symptoms, age at first contact with psychiatrist and age at index admission. Statistical method included two independent samples t-test. Data was dichotomized into those with family history of schizophrenia versus those without family history of illness and then Chi-square test of association was applied. The mean age of onset of illness was 23.96 years in females and 24.13 years in males. In all other measures used to assess the onset of illness, females were overrepresented at the younger age group. 56.7% patients had a family history of psychotic disorder. Among them the mean ages at onset of illness were 20.59 years in females and 21.85 years in males [c 0.04 df =58]. The illness occurred at a younger age in those with positive family history of schizophrenia [21.22 years] than those without it [25.14 years] with dissipation of gender difference in the former. There was no significant gender difference in age at onset of disorder in this study. Family history of schizophrenia appears to be the most significant factor that eliminates the gender differences in age at onset of schizophrenia

Depression in primary care: difficulties and paradoxes

The presentation of depression in primary care is in many ways different from that seen in psychiatric settings. The process of detection and treatment is also different. This is particularly so in developing countries like Pakistan, which has high prevalence rates of depression but poorly organized primary health care services and primary care physicians [PCPs] who have little psychiatric training, either at undergraduate or postgraduate levels. There is a need to review difficulties faced by primary care physicians in detection and management of depression. It is hoped this would lead to better and more effective management of depression at primary health care level