Throtoxic crisis and acute hepatitis: first and co-existent presentation of thyroid disease and hepatitis E viral infection

Thyroid crisis, also known as thyroid storm and thyrotoxic cns1s, is a life threateningcondition and usually results after sustained and poorly controlled thyrotoxicosis. It may bean- initial presentation in undiagnosed children or neonates.it carries a high mortality rate .We present a unique case of a young male with no previous diagnosed medical illness, who underwent an elective orthopedic operation but developed thyroid storm during operation along with acute hepatic injury with positive serology for HEV. He was treated in intensive care unit on treatment principles of both diseases along with mechanical ventilation and rest of the supportive management. The fortunate patient survived and his hepatic injury was recovered. The diagnosis of Grave's disease was confirmed after his recovery

Lumbar Interverterbral Disc Prolapse (PLID) Surgery and Our Experiences.

Background: Back pain and sciatica are very common in adult persons. These cause a great loss of working hours with financial loss of individual and the nation. Very careful evaluation must be done to treat these patients. Injudicious treatment, whether medical or surgical, may aggravate the sufferings. Objective: To study immediate and long term effect of the prolapsed intervertebral disc surgery. Materials and Methods: This observational study was done in Enam Medical College & Hospital, Savar, Dhaka during January 2007 to June 2011. Sixty four patients operated during this period for prolapsed lumbar intervertebral disc were included in the study. Fifty six (88%) were male and 8 (12%) were female. Age range was 30 to 50 years. Most of the patients presented with back pain and sciatica with no definite history of trauma or weight lifting. Diagnosis was confirmed by MRI. Results: Sixty (94%) patients had no pain after surgery and only 4 patients had occasional pain. Conclusion: Maintenance of strict criteria for the surgery yields very good result.

Interferon-induced central retinal vein thrombosis

A middle-aged lady presented with sudden onset of unilateral central retinal vein thrombosis after completing 6 months course of interferon and ribavirin for chronic hepatitis C infection. She had no risk factors and all her thrombophilia workup was normal, however, she was found to be dyslipidemic which may have contributed to atherosclerosis and predispose to thrombosis. Despite anticoagulation, her visual acuity deteriorated. This case illustrates the possibility of unpredictable visual complication of interferon. Frequent eye examination should be undertaken in patients having underlying risk factors like diabetes, hypertension or dyslipidemia undergoing interferon therapy

Predictive value of Body Mass Index [BMI] AND Waist Circumference [WC] for Coronary Artery DISEASE [CAD] and clinical outcomes using gated myocardial perfusion imaging

Obesity is generally considered as a risk factor for coronary artery disease [CAD] and cardiac deaths but some reports suggest better survival in obese with CAD. The objective of this study was to find out predictive value of body mass index [BMI] and waist circumference [WC] for CAD and its outcome using gated myocardial perfusion imaging [GMPI]. This was a prospective study conducted at Nuclear Cardiology Department of Karachi Institute of Heart Diseases [KIHD], Karachi, Pakistan from August 2011 till May 2013. 400 patients who qualified study criteria were included and were divided in [a] to Obese [BMI30 Kg/m[2]] and Non-obese [BMI<30 Kg/ m[2]] and [b] Low-WC group [male<90 cm and female < 80 cm] and High-WC group [male 90 cm and female 80 cm]. Rest and stress GMPI using Tc-99m MIBI was performed in all patients and abnormal GMPI was followed by coronary angiogram. These patients were followed for 12-18 months regarding fatal and non-fatal events. Non-Obese group included 281 patients [Male: Female = 131:150] with a mean age of 58 +/- 12 years and mean WC 100 +/- 15 cm. Obese group included 119 patients [Male: Female = 36:83] with a mean age of 55 +/- 11 years and mean WC 101 +/- 13 cm. Normal GMPI was found in 172 non-obese and 85 obese patients [p<0.05]. GMPI was abnormal in 109 non-obese and 34 obese patients [p<0.05]. WC was not found independent predictor of abnormal GMPI but high WC was found to a significant predictor of CAD in non-obese females [Odd ratio 8.04; 1.041 - 62.127]. At 18 months event-free survival in normal GMPI group for non- fatal MI was 99.4% in non-obese group and 94.1% for obese [significant P value]. For fatal MI, event-free survival was 99.4% in non-obese and 100% for obese [non-significant P value]. In patients with abnormal GMPI event-free survival for non-fatal events was 95.4% in non-obese group and 82.3% in obese group [significant P value]. While event-free survival for fatal MI was 96.3% in non-obese group and 98.1% for obese [significant P value]. We conclude that CAD was found less prevalent in obese group and High-WC predicted CAD in non-obese females only and was not found an independent predictor. A normal GMPI predicted very high event free survival for fatal events in obese and non-obese but significantly lower for non-fatal events in obese group. Obese group with abnormal GMPI had lower risk for cardiac deaths but higher risk for non-fatal events than non-obese patients with abnormal scans

Double lumen intubation; reliability of auscultatory method?

Auscultation is well established and most commonly used method for checking of correct placement of Double Lumen Tube[DLT]. Now with widespread availability of fibre optic bronchoscope, confirmation of DLT placement by fibre optic bronchoscope is recommended by many and considered mandatory by some anaesthetist. To discuss method of insertion and reliability of auscultatory method to confirm correct placement of double lumen tubes. Observational. Combined Military Hospital Rawalpindi from 16th Nov 2003 to 13th July 2007. We have performed about one thousand one hundred and fifty double lumen intubation without use of fibreoptic bronchoscope. 85% of patients did not need any tube adjustment during surgical procedure. Only 15% cases required tube adjustment intra-operatively. None of procedures were abandoned due to double lumen tubes problems. We conclude that auscultation is not that unreliable though not perfect method of DLT placement. Use of fibreoptic bronchoscope is recommended but not mandatory for DLT placement. Anatomical malpositioning detected by fibre optic bronchoscope which according to some studies is 70 to 80% does not necessarily translate into physiological malfunctioning

clinical and etiological profile of urinary tract infection

To study clinical profile of urinary tract infection [UTI] and to document the common microorganisms causing UTI in admitted patients and to test their sensitivity pattern. We did a hospital based descriptive study in the department of Medicine Khyber Teaching Hospital, Peshawar from December, 2005 to July, 2006. The data of total 50 patients above 13 years of age with signs and symptoms suggestive of UTI was collected on a structured proforma. The clinical presentation, the common causative organisms and their sensitivity pattern was documented. The results were compared with other national and international studies. In this study 47/50 [94%] cases were culture positive with a colony count >105/ml. Overall male to female ratio was 1:2 table. 1. Among the culture positive cases, the commonest pathogens found were E. coli in 25 cases [53.1%] followed by citrobacter in 8 cases [17.02%]. The commonest organisms E.coli and citrobacter showed maximum sensitivity to Amikacin, ofloxacin, ciprofloxacin and ceftriaxones, in decreasing order of frequency. The most common symptom found in all age groups was fever while the commonest sign was anaemia. UTI should be considered in any patient with fever without focus beyond three days. E Coli is the commonest organisms and amikacin is the drug of choice

Epilepsy: a family physician' perspective

Epilepsy is characterized by the occurrence of at least two unprovoked seizures. Seizures occur due to abnormal hypersynchronous discharges of cortical neurons and the clinical features depend upon the location and extent of the propagation of the discharging neurons. Family physician should be able to initiate management, alleviate misunderstandings and refer appropriately when required. For this review, literature search was done on PubMed. Only those articles which were related to the family physicians need were selected. They were further reviewed by the authors and data concerning common problems faced by family physicians was extracted and synthesized. This article reviews the definition of common terminology to describe seizures, classifications, clinical manifestations and complications along with the evaluation and management of epileptic seizures

Frequency of hepatitis B and C seropositivity in prisoners

This study was conducted on prisoners of Central Jail, Bahawalpur and on blood donors at Blood Bank Bahawal Victoria Hospital [BVD], Bahawalpur from Ist August 2005 to 30th November 2005. The intension was to study the seroprevalence of hepatitis B and C in prisoners and to note risk factor if any predisposing to the infection. All the prisoners of central jail Bahawalpur present during the study period, aged more than 18 years of either sex were included as the study group and a comparative group was blood donors presenting to blood bank BVH, Bahawalpur during this period. All the cases in study group [2086] as well as control group [9714] were screened for hepatitis B [HBs Ag] and hepatitis C [anti-HCV] infection detected on serum by One Step Test Device. All the positive cases were confirmed by Enzyme Linked Immunosorbant Assay. After an explanation, verbal consent was taken and a questionnaire was filled before taking samples from all the study group cases. On the basis of screening, prisoners were de vided into seropositive group and sero-negative group. The different variable applied on both the groups were age, sex, occupation, residence, marital status, self shaving / by barber, family history of [H/o] jaundice, H/o blood trans-fusion, operation, tattooing and body piercing, drug abuse, same sex/ extramarital sex and hepatitis B vaccination status. Total prisoners screened were 2086. Out of them 2072 were males [99.3%]. Mean age was 34 years. Total seropositive cases were 249 [11.9%] While during the same period seropositivity in blood donors [control group] was 5.9%. Seropositivity of HBV was 5.6% in study group and 3.1% in control group [p<0.001], HCV was 6.3% Vs 2.8% [p<0.001], statistically very significant difference. Risk factors analysis among prisoners revealed that drug abuse was significantly associated with seropositivity [27% Vs 12%, p value <0.001]. Among drug abusers, very high percentage of intravenous drug users was positive [89.2%, 25 out of 28]. Prisoners shaved by barber were also a t higher risk than self shaving [p value <0.001]. H/o operation [p<0.02] and rural origin [p<0.02] were other significant risk factors. Other risk factors evaluated were not statistically significant. Seroprevalence of hepatitis, both B and C is more in prison inmate than healthy blood donors. Main risk factor in them i is drug abuse, especially intravenous. Other significant risk factor is shaving by barber. There s a need to make some strategy to reduce the risk factors

Rupture of sinus of valsalva presenting with acute left ventricular failure

Rupture sinus of Valsalva is a relatively rare condition. We report a case of ruptured sinus of valsalva presenting as acute left ventricular failure. The patient underwent successful repair of ruptured sinus of valsulva with closure of fistula. During Ventriculotomy the defect was repaired using Teflon butterrressed 5/0 prolene interrupted sutures. After dramatic relief of symptoms patient was discharged on sixth postoperative day

frequency of HBV, HCV and HIV in patients undergoing percutaneous mitral valvuloplasty

Objective: Determine the frequency of Hepatitis B, C and HIV in patients undergoing mitral valvuloplasty with multitrack balloon catheters

Methods: This was a cross sectional study in which 100 consecutive patients of both sexes underwent percutaneous Mitral Valvuloplasty with multi track balloons catheters at the National Institute of Cardiovascular Diseases Karachi from January 2003 to December, 2004. The Viral markers of Hepatitis B Surface Antigen and Antibodies against Hepatitis C and HIV was done in all patients undergoing PTMC prior to procedure

Results: Out of 100 patients undergoing PTMC with multi track balloon catheters, 78 patients were females while 22 of them were males. Screening of these patients showed that 14% of them were Sero positive for HBV while 8% positive for HCV. None of screened patients were HIV positive

Conclusion: 1] The frequency of hepatitis B, C and HIV in patients undergoing PTMC [14% and 8%], as compared to normal population [2.56% for HBsAg] and [5.31% for anti-HCV] respectively. 2] In our country most of patients are non-affording and we have to reuse balloon catheters, so it should be mandatory to screen hepatitis B, C and HIV before undergoing invasive procedures. Balloon used in seropositive patients should be discarded. 3] National guidelines regarding reuse of various hardwire and other preventive measures are mandatory for patient's safety

Increased levels of erythrocyte glutathione in acute myocardial infarction: an antioxidant defence

Glutathione [GSH] has a central role in the defence against oxidative damage. This study was carried out to investigate any change in erythrocyte GSH levels in a population of patients with acute myocardial infarction [AMI] and compare them with levels in normal healthy subjects. Method: GSH levels were determined in erythrocytes of one hundred and seventy six patients with AMI [age: 30-70 years; 131 males and 45 females] admitted to the National Institute of Cardiovascular Diseases, Karachi. These levels were compared with eryrocyte GSH levels obtained from 95 normal healthy subjects [controls]. Mean ' SD erythrocyte GSH levels in AMI patients and controls were found to be 2.34 ' 0.62 micro mol/ml of packed cells and 2.08' 0.62 micro mol/ml of packed cells, respectively. The two values when compared with one way ANOVA were found to be significantly different [p=0.001]. Age had little effect on erythrocyte GSH levels in both AMI patients and normal healthy subjects. Increased production of reactive oxygen species is a feature of cardiovascular disease, such as AMI and cells can respond to mild oxidative stress by upregulating antioxidant defence in terms of increased production of GSH

Coronary artery disease risk profiles at a specialized tertiary care centre in Pakistan

The aim of our study was to evaluate the prevalence of the different risk factors [diabetes, hypertension, hypercholesterolemia, family history, smoking and obesity] in patients with CAD in our patient population. BACKGROUND: The patients with first episode of acute coronary syndrome [ACD] are assessed. The total of 110 consecutive patients admitted to general ward of the National Institute of Cardiovascular Diseases [NICVD] in the month of April were interviewed. Information regarding their co-morbid status and drug usage was obtained as well as details of their admission and treatment plans. The data obtained was analyzed by statistical software [SPSS] ver 10.0.5] Our sample showed a mean age of 55.39 years with a predominance of male patients [65.5%]. Although there was no significant difference in the mean age of presentation of males versus females, Hypertension was the single most common factor being present in 59.1% of subjects. Female patients were obese, hypertensive, and by perch olesterolemic as compared to their male counterparts; while majority of males were smokers, diabetic and positive family history. It was also seen that females were found to have an average four of the seven risk factor assessed; while males average two. Twenty of the twenty two patients who developed complications [left ventricular failure, bundle branch blocks and arrhythmias] were shown to have two or more risk factors. Although ST elevation MI was the most common diagnosis [as compared to non ST elevation MI or unstable angina]. The type and number of risk factors did not seem to influence this outcome. Coronary artery disease has once again been shown to be more prevalent in males than females. Smoking is the most common risk factor amongst the male population. Female patients with CAD are presenting at a much earlier age and majority are obese, hypertensive, have hypercholesterolemia and a history of angina as compared to males; and have on average more risk factors than their male counterparts

ECG and enzymatic indicators of therapeutic success after intravenous streptokinase for acute myocardial infarction-a pilot study

The effect of intravenous streptokinase [SK] on time course of creatine kinase-MB [CK-MB] release and rapid reduction in ST- segment elevation as two non-invasive markers of reperfusion was prospectively studied in 83 patients with first anterior wall AMI [SK group, n = 61; control group, n = 22]. CK-MB evidence of reperfusion in the SK group was significantly higher than that in the control group [80% versus 32%; P 0.0001]. The rapid resolution of sum of ST segment elevations as an evidence of reperfusion was found in 82% patients in SK group versus 23% in the control group [P 0.0001]. Both CK-MB and rapid resolution of ST segment elevations as evidences of reperfusion were found in 69% patients in SK and 14% in the control group [P 0.0001]. The proportions of patients with non-invasive evidence of reperfusion with half-dose SK [750,000 units] regimen were comparable to that reported in the literature with full dose SK [1.5 million] regimen. Thus, serial CK-MB and ECG analysis in patients with AMI undergoing streptokinase therapy provides a non-invasive means for assessing therapeutic success. A dose of 750,000 units of SK was found clinically satisfactory using previously validated non- invasive markers of coronary reperfusion and produced results previously reported with 1.5 million units of SK