unusual case of hypoalbuminemia

This report describes a female patient of 45 years with progressive pallor and malaise. Clinically patient was thin built, jaundiced, with palmar erythema and splenomegaly. Her hemoglobin was 4.2g/dL, mean corpuscular volume was 69.2f/ land serum albumin was critically low i.e. 12g/ L. Hypoalbuminemia is a feature of decompensated cirrhosis of liver however such a low level of albumin without peripheral signs of edema has not been reported to the best of the authors' knowledge. It is hereby reported as the first case of its kind

Accuracy of anti-tissue transglutaminase IgA antibody in the diagnosis of paediatric celiac disease

Objective: to determine the accuracy of anti-tissue transglutaminase IgA [TTG] antibody titer in the diagnosis of celiac disease, taking small intestine histopathology as the gold standard

Study Design: cross-sectional analytical study

Place and Duration of Study: department of Paediatrics, Benazir Bhutto Hospital, Rawalpindi, from February to July 2013

Methodology: sixty patients aged 2 - 13 years, admitted in the Paediatric Department of Benazir Bhutto Hospital, Rawalpindi, having at least 3 features from chronic diarrhea, malnutrition, short stature, anemia, abdominal distension and clubbing, were included. Age, gender, weight and height were recorded. Abdominal distension and clubbing were clinically noted. For hemoglobin, blood complete picture was done. For determination of nutritional status and short stature, standard centile charts were used. TTG titer upper GI endoscopy, duodenal biopsy, and histopathology were done in all cases

Results: there were 60 patients; 32 males, 28 females with mean age of 5.85 +/- 3.36 years. Frequency of CD was 63.33% in study population. Sensitivity of TTG was 86.84%, with 81.82% specificity, 89.19% positive predictive value, and 78.26% negative predictive value for diagnosing CD. TTG titre more than 50 iu/ml had a 100% positive predictive value

Conclusion: TTG is an excellent screening test for the diagnosis of paediatric CD. TTG value > 50 IU/ml has 100% positive predictive value

Comparison of effectiveness and cost of patent ductus arteriosus device occlusion versus surgical ligation of patent ductus arteriosus

Objectives: Comparison of effectiveness and cost of transcatheter occlusion of patent ductus arteriosus [DA] with surgical ligation of PDA

Methods: This retrospective comparative study was conducted in the pediatric cardiology department of Ch. Pervaiz Elahi Institute of Cardiology Multan, Pakistan. Data of 250 patients who underwent patent ductus arteriosus [PDA] closure either surgical or trans-catheter closure using SHSMA Occluder having weight >5 kg from April 2012 to October 2015 were included in this study. SPSS version 20 was used for data analysis. Quantitative variables were compared using independent sample t-test. Chi-square test and fishers exact was used for qualitative variables. P-value <0.05 was considered statistically significant

Results: There were one hundred and twenty [120] patients who underwent transcatheter occlusion of PDA using SHSMA occluder [PDA Device Group] and one hundred and thirty [130] patients who underwent surgical ligation of PDA [Surgical Group]

Incidence of residual shunting was two [1.5%] in surgical group and 0 [0.0%] in PDA Device group for one month follow up period

There were 4 [3.1%] major complications in surgical group. The rate of blood transfusions were high in surgical group [p-value 0.04]

Hospital stay time was significantly less in PDA Device group [P-value <0.001]

Total procedural cost was 110695+1054 Pakistani rupees in PDA Device group and 92414+3512 in surgical group [p-value <0.001]

The cost of PDA device closure was 16.52% higher than the surgical ligation of PDA

There was no operative mortality

Conclusion: The transcatheter closure of PDA is an effective and less invasive method as compared to the surgical ligation. There is a lower rate of complications and the cost is not much high as compared to surgical PDA ligation

Determinants of maternal mortality in Pakistan at a glance

Maternal mortality refers to the death of a woman who dies during pregnancy or within six weeks after delivery. A number of factors contribute to the high maternal mortality ratio around the globe, particularly, in underdeveloped countries. Pakistan has the highest mortality ratio [260 per 100,000 live births] in the region and is one of the developing countries which have committed to decrease maternal mortality by 2015, according to the millennium developing goals [MDG] 5. However, there are number of factors which made Pakistan unable to achieve the MDG 5 by 2015. In Pakistan there are many factors such as biological, socio-economic, cultural and poor quality of Reproductive Health Services [RHS], which contribute to the alarming figure of Maternal Mortality.. This paper aimed to do an in-depth analysis of the determinants of maternal mortality in Pakistan

Satisfaction of patients with peritonsillar abscess with permucosal needle aspiration versus incision and drainage

To assess the efficacy and safety of Permucosal Needle Aspiration of Peritonsillar abscess with the Incision and Drainage. Prospective, descriptive study. This study was conducted at Benazir Bhutto Shaheed Teaching Hospital, Abbottabad from July 2011 to June 2014. This study was conducted on 62 patients, suffering from Peritonsillar Abscess. Patients were divided into 02 groups, group A, patients who were treated by Needle aspiration and group B, patients who were treated initially by incision and drainage. Patients were assessed for relief of pain, hospital stay, complications of the procedure, recurrence of the disease and success rate of the procedure. Of the 62 patients, 38 [61.29%] were male and 24 [38.70%] were female . The age range was from 08 years to 57 years. Duration of symptoms prior to hospital admission was 06 days. The return to semi solid food was 02 days in group A and to solid food 04 days. Where as in group B 88 % return to semisolid in 02 days and to solid in 04 days. 75% the patients in group A were pain free after 05 days as compared to 78 % in group B. The hospital stay was 3-9 days in group A and 4 -10 days in group B patients. The over all success rate was 90 % in group A and 93 % in group B. This study indicates that most patients with peritonsillar abscess can be treated successfully and safely by per mucosal needle aspiration

Efficacy of 5 % lignocaine ointment in reducing the post-operative pain due to intra-nasal packs

To determine the efficacy of 5% lignocaine ointment in reducing the post-operative pain following nasal surgery with bilateral intra-nasal packs. Randomized, Prospective, Control study. This study was conducted at the ENT Department, Benazir Bhutto Shaheed Teaching Hospital Abbottabad from July 2011 to June 2012. A total of 120 patients, who underwent Septoplasty were included in the study .Patients were separated into Group A [n- 40], these patients were having intranasal packs soaked with Liquid paraffin. Group B [n- 40], these patients were packed with 5% lignocaine ointment ,and Group C, [n -40],in this one side of the nasal cavity was packed with liquid paraffin [Cl] and the other side with 5% lignocaine ointment [C2] .In all three groups the intranasal packs were removed after 24 hrs. The severity of post operative pain and the amount of analgesics required by each group calculated. In group B [n-40] the mean VAS was 5.60+-2.40 as compared to 7.27+-1.881 in group A and 7.40+-1.033 [C1], 6.62+-1.764[C2].in group C at 6hrs post operatively. The mean VAS at 24 hrs post operatively in group B was 6.63+-1.125, significantly lower than group A [7.15+-1.252] and group C1 [6.07+-1.023].,C2[4.90+-1.236]. The mean time to first request for rescue analgesia was significantly prolonged in group B, 220.S3+-42.12 min as compared to 148.32+-32.45 min.[group A], and 190.61+-35.45 min. [group C]. The total analgesia [Diclo fenac sodium] required post-operatively was 175.32+-14.13mg in group B , as compared to 225.14-f-25.73mg [group A] and 200.16+-41.89mg [group C].Topical use of lignocaine ointment is safe and may have a significant role in the relief of pain due to post- operative nasal packing

Frequency of hepatitis B and C in young asymptomatic males

To understand the latest trends of hepatitis B and C viruses frequency by detecting Hepatitis B surface antigen and hepatitis C antibodies in young asymptomatic males. Descriptive study. This study has been carried out at the Department of Pathology Combined Military Hospital, Risalpur and Department of Virology, Armed Forces Institute of Pathology, Rawalpindi from 1st March 2010 to 30th September 2010. One thousand and forty two physically fit candidates between 17 to 23 years of age, reporting to Engineer Centre Risalpur, from Punjab and Khyber Pakhtunkhwa for induction in Armed Forces, were enrolled in the study by non-probability convenience sampling. They were screened for HBsAg and anti HCV by Immuno-chromatographic rapid test devices, at Pathology Department Combined Military Hospital Risalpur. All positive samples were confirmed from Department of Virology, Armed Forces Institute of Pathology Rawalpindi by Enzyme Linked Immuno-sorbent assay. Out of 1042 study subjects, screened during the period, 31 [2.97%] were found to be positive for HBsAg and 16 [1.53%] for anti HCV. As per available information, 876 study subjects belonged to rural areas and 166 belonged to urban areas. Mean age was 20 +/- 1.4 years and range was 17 to 23 years. Province wise 987 individuals belonged to Punjab, out of which 30 cases [3.0%] were positive for HBsAg and 15 cases [1.5%] were positive for anti HCV, which indicates that the predominant part of the study subjects were from Punjab and their positivity percentage is almost same as given in the study, whereas 55 individuals belonged to Khyber Pakhtunkhwa. Frequency of Hepatitis B and C in asymptomatic young males of Punjab is 3% and 1.5% respectively and that for Khyber Pakhtunkhwa is 1.8% for both viruses

To assess the morbidity associated with the use of intra-nasal splints and its role in the prevention of nasal adhesions

To assess the morbidity associated with the use of intra-nasal splints and its role in the prevention of nasal adhesions. Prospective study. This study was conducted at Benazir Bhutto Shaheed Teaching Hospital Abbottabad, from July 2010 to August 2011. Randomized prospective clinical method compared between patients with and without nasal splints. The author observed 256 patients operated on for Septoplasty in the Benezir Bhutto Shaheed Teaching hospital Abbottabad. They were assessed for the complications and discomfort of splints. The group with the nasal splints, observed poor quality and the recovery was not well tolerated by majority of them. This group also observed sever pain during the removal of splints. In contrast in patients without the nasal splints the complications were minimum with good quality. Although the nasal splints are widely used, it does not provide maximum protection to prevent adhesions formation. Furthermore morbidity associated with the splints does not justify its regular use

Modified posterior sagittal ano-rectoplasty: a new approach for the management of ano-rectal malformations in children

To introduce a technical modification in Posterior Sagittal Ano-rectoplasty [PSARP], commonly known as Pena's procedure, and to analyse the outcome of such modified procedure in terms of fecal continence and other relevant complications in children with ano-rectal malformations. It was a prospective and descriptive study, conducted at the department of pediatric surgery, Lady Reading Hospital Peshawar from January 2004 to December 2006. Forty patients were studied. All children of either sex with ano-rectal malformation who presented first to our department were included in our study excluding others treated some where else. Relevant investigations were performed in all patients. Diverting colonic or small bowel stoma was created in all patients at presentation to our department. The technique was performed at or after six months of age, depending upon the clinical condition of the patient. After discharge, all patients were examined and monitored in the out-patient department over a period of two years. Out of 40 patients 25[62.5%] were male and 15 [37.5%] were female age range from 6-12 months. On 35 [87.5%]. Isolated PSARP while on 5 [12.5%] patients modified PSARP with abdominal approach were performed. Anal stenosis was found in 3[7.50%] patients, rectal mucosal prolapse in 4[10%], faecal soiling and faecal incontinence in 17[43.58%] and 7[17.05%] patients were respectively. Faecal continence was good, fair and poor in 15[38.46%], 17[43.58%] and 7[17.94%] patients respectively. Our results of the present series suggest that this procedure is a valuable alternative to PSARP for the treatment of anorectal malformations

Estimated reference interval of ionized [free] calcium

To determine the reference values of Ca++ in whole blood in our setup. The Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology, Rawalpindi from Jan 2008 to June 2008. Three hundred healthy individuals were included in the study after obtaining written consent. Out of these 76 individuals were excluded from the study after clinical assessment and collection of laboratory data. One hundred and fourteen were males with mean age 35 +/- 12 years and 110 were females, with mean age 28 +/- 9 years of age. Their Ca++ was estimated by ion selective electrode [ISE] method in heparinized whole blood [WB]. The mean and SD of whole blood Ca++ was calculated separately for the females and the males. The results showed that in our setup males have Ca++ levels of 1.12 +/- 0.05 [mean +/- SD] mmol/l and females have Ca++ levels of 1.12 +/- 0.04 [mean +/- SD] mmol/l. The study revealed that estimated reference range of Ca++ of the studied population was lower than the reference range published for the western population that is used by our physicians for the interpretation and comparison of results

Comparison of role of serum- ascites albumin gradient and ascitic fluid total protein in liver cirrhosis patients

To compare the diagnostic sensitivity of serum/ ascites albumin gradient and ascitic fluid total protein in liver cirrhosis patients, using ultrasonography as gold standard. Validation Study. Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology, Rawalpindi and Department of Radiology CMH/ MH Rawalpindi from 15 Jul 2007 to 15 May 2008. Seventy three patients of liver cirrhosis were enrolled in the study by non-probability convenience sampling. Liver cirrhosis was confirmed on ultrasound abdomen. Ascitic fluid and 3 ml of blood were obtained simultaneously for analysis of serum albumin, ascitic fluid albumin and total proteins. Sensitivity of serum ascitic albumen gradient [SAAG] and serum ascitic fluid total protein [AFTP] was calculated by comparing with liver ultrasonographic findings [gold standard]. Among 73 patients, 52 [71%] were males and 21 [29%] females. Mean ages was 57 years. Age range was 30-80 years. It was observed that sensitivity of SAAG in liver cirrhosis was 97% and that of AFTP was 53% only. Diagnostic sensitivity of SAAG in liver cirrhosis is significantly higher than AFTP in workup of ascites related to portal hypertension

Effect of chronic immobilization stress on vermal cerebellar cortex of young male rats

The objective of this study was to observe the morphological changes in vermal cerebellar cortex of young male rats with special reference to Purkinje cell after exposure to chronic immobilization stress. An experimental study. Department of Anatomy CPSP Regional Centre, Islamabad, from August 2006 to July 2007. Sixty young male Sprague Dawley rats were taken and divided equally in two groups [n=30 in each]. Group A=control. Group B=experimental. 'Experimental' group was kept in restrainer for 2 hours continuously, for 14 days, one rat per restrainer separately. At the end of the experiment, all the animals of both groups A and B were anesthetized and sacrificed for the removal of cerebellum. It was fixed in 10% formalin. To record data for histological evaluation, the vermal cerebellar cortex of a specified area was selected. It was processed and 5 um-thick sections were cut. Hematoxylin and Eosin stained sections were examined under light microscope. Data was analyzed by SPSS version 10. Significant decrease in total cell count and cell size was found in experimental group as compared with controls. Number of dark cells was found more in stressed animals. Increase in thickness of vernal cerebellar cortex and molecular layer was observed in stressed animals as compared with controls. Chronic immobilization stress can affect the outcome of the cerebellar functions causing damage to the Purkinje cells as a result of cellular metabolic changes by an imbalance between the oxidant and anti oxidant status inside the brain

Steroids in the management of acute myocarditis in children

To compare hospital shy, need and duration of inotropic support, mortality to assess immediate outcome and long term recovery in patients with or without steroids. In acute myocarditis, virus is replicating and steroids can be harmful. This clinical trial was conducted on children admitted to a single centre from February 2003 to September 2004 in the Department of Paediatric Cardiology, the Children Hospital and Institute of Child Health, Lahore. Echocardiography was used to confirm dilated dysfunctioning heart with EF under 45%. 100 consecutive children with myocarditis were studied. Mean duration of symptoms was +/- 7.47 in group-is and +/- 13.01 in group-B. The patients presented in shock and severe CCF requiring inotropic support were 43 [86%] in group-A and 38 [76%] in group-B. mean hospital stay [7.47 days] in group-A and 5.68 in group-B, duration of inotropic support [5.34 and 3.95] in group-A and B], hospital mortality [1 and 3] were analyzed and found insignificant statistically. Full recovery [p patients in group-A and 7 in group-B], partial recovery [16 and 13], no recovery [7 and 9] were compared. There was no significant difference. Results of this clinical trial conclude though steroids in acute myocarditis are not harmful but has no significant effect on immediate outcome and long term recovery

Retrospective analysis of clinical presentation of children with diagnosed intussusception

To know the presenting clinical features of intussusception in children up-to the age of twelve years. The study was conducted at the Department of Paediatric Surgery, Post-Graduate Medical Institute, Lady Reading Hospital, Peshawar, over a period of 18 months. A total of 71 patients with diagnosed intussusception were included. The relevant data, both pre-operative and postoperative, of children who were operated for intestinal obstruction and finally turned out to be suffering from intussusception, was fed into a pre-designed proforma and the information so obtained was analyzed according to objectives of the study. The common presenting features were colicky abdominal pain in 70 [98:59%] cases, vomiting in 67 [94.36%] cases, abdominal distension in 67 [94.36%] cases, constipation in 63 [88.73%] cases, bleeding per rectum in 61 [85.91%] cases, palpable mass per abdomen in 56 [78.87%] cases and fever in 18 [25.35%] cases. In 11 [15.49%] cases there was a mass palpable per digital rectal examination and 05 [07.04%] patients had diarrhoea on presentation. Colicky abdominal pain, vomiting, abdominal distention, constipation, bleeding per rectum, palpable mass per abdomen are the commonest presenting clinical features of intussusception in children

Pattern of pediatric ocular trauma in Hayatabad Medical Complex Peshawar

To determine the pattern and causes of pediatric ocular trauma in Hayatabad Medical Complex, Peshawar. A cross sectional descriptive study Department of Ophthalmology, Khyber Institute of Ophthalmic Medical Sciences, Hayatabad Medical Complex, Peshawar from January 1999 to June 2004. The medical records of 481 children aged upto 16 years who suffered ocular trauma were reviewed retrospectively. Age and gender distribution, nature and source of trauma, presentation and ocular features were analyzed. Pediatric ocular trauma constituted 43.5% of total traumatic ophthalmic admission. Four children were victims of bilateral trauma. Male to female ratio was 3.3:1.Twenty five percent children were below 5 years of age, 47.8% were between 5 to 10 years of age and 27.2% were between 10 to 16 years. About 51% injuries were of open globe type and 37.6% closed globe, superficial non perforating injuries, burns and adnexal pathologies were present in 11.3%. Domestic injuries were more common [47.2%]. At the time of admission 14.6% eyes were infected, 2.3% required evisceration or enucleation. Majority [67.3%] of the children presented late [one week later] to the hospital. Male children were affected more than female by trauma. Half of ocular trauma resulted in open globe injuries and almost 50% of cases were related to domestic injuries. Majority of cases presented late and were secondarily infected

Ferritin levels in patients of beta thalassaemia major

In Beta Thalassaemia Major repeated blood transfusions, ineffective erythropoiesis and increased gastrointestinal iron absorption lead to iron overload in the body. The management of the iron overload in these patients requires the administration of iron chelators continuously and evaluation of serum ferritin levels at regular intervals. In the present study serum ferritin levels, of the patients with beta thalassaemia major registered at two different centers of Rawalpindi and Islamabad, were measured. Majority of the patients revealed very high ferritin levels, with a mean of 3390 ng/ml. 21.34% patients had serum ferritin between 1000 to 2500 ng/ml, while 76% patients had values above 2500 ng/ml. These levels reflect inadequate chelation and vulnerability to develop iron overload related complications. There is a dire need to rationalize the chelation therapy, as at present no chelation, inadequate chelation, improper methods of chelators administration, non availability of infusion pumps, non affordability of patients to purchase pumps and chelators, inappropriate evaluation of iron overload and high levels of serum ferritin gives an overall bleak view