simple integrated primary health care based model for detection of diabetic retinopathy in resource-limited settings in Pakistani population

Objective: To find out prevalence of Diabetic Retinopathy in general population of three districts in Pakistan

Methods:A community based cross-sectional survey was conducted in three large districts of Pakistan namely Rawalpindi in Punjab, Peshawar in Khyber Pakhtoonkhwa and Hyderabad in Sindh between January 2013 and August 2015. Lady Health Workers identified individuals at high risk for diabetes based on predefined criteria. High risk population was tested for dysglycemia. Fundoscopic evaluation for evidence of DR was performed in all individuals with a random blood glucose >190mg/dl. Individuals with the evidence of DR were referred to affiliated tertiary care ophthalmology departments

Results:A total of 42,629 individuals reported at the project sites and 63% [n=26,859] were female. Fifty one percent [n=21,989] individuals met high risk criteria. Out of these 21,989 individuals, dysglycemia was found in 3,869 [17.6%]. Fundoscopy showed evidence of DR in 1,042 [27%] individuals. Amongst high risk population, dysglycemia was significantly more common in females as compared to males. The frequency of DR in dysglycemic patients was comparable across both gender groups

Conclusion:The prevalence of DR in Pakistani population is alarmingly high. This preventable cause of blindness is largely undiagnosed in our population and a simple integrated model based on primary health care facilities can help identify and treat a large population of DR patients

Causes of short stature in Pakistani children found at an Endocrine Center

Background and Objective: Short stature is defined as height below 3[rd] centile. Causes of short stature can range from familial, endocrine disorders, chronic diseases to chromosomal disorders. Most common cause in literature being idiopathic short stature. Early detection and management of remedial disorders like malnutrition and vitamin D deficiency, Endocrine disorders like growth hormone deficiency and hypothyroidism can lead to attainment of expected height. Pakistani data shows idiopathic short stature as the most common cause of short stature. Our study aimed at detecting causes of short stature in children/adolescents at an Endocrine referral center

Methods: A retrospective study was conducted at WILCARE Center for Diabetes, Endocrinology and Metabolism, Lahore on 70 well-nourished children/adolescents. The patients had been evaluated clinically, biochemically and radiologically as needed. Biochemical testing included hormonal testing as well to detect endocrine causes. Data was entered and analyzed in SPSS 20.0

Results: Leading cause of short stature in our population was Growth Hormone [GH] deficiency seen in 48 out of 70 [69%] patients. Second most common endocrine abnormality seen in these patients was Vitamin D deficiency [44 out of 70 patients [63%]]. Primary hypothyroidism; pan-hypopituitarism and adrenal insufficiency were other endocrine causes. The weight for age was below 3rd percentile in 57 [81%] patients, with no association with other major causes

Conclusion: Growth hormone and Vitamin D deficiency constitute one of the major causes of short stature among well-nourished children with short stature in Pakistan

Risk factors for deliberate self-harm in patients presenting to the emergency departments of Karachi

To determine the risk factors for Deliberate Self-Harm [DSH] in patients presenting to the Emergency Departments [EDs] of three tertiary care hospitals of Karachi, Pakistan. Multicentre matched case control study. EDs of the Aga Khan University Hospital, Karachi, Civil Hospital, Karachi and Jinnah Postgraduate Medical Centre, Karachi, from March 2011 to February 2012. A total of 201 cases and 201 matched controls were taken from three hospitals situated in Karachi. All patients of 16 years and above presenting to the EDs of the hospitals with DSH attempt were invited to participate in the study. Controls were ED patients with complaints other than DSH. A control was matched with case for hospital, gender and age. Two questionnaires were used to collect information on the risk factors of DSH. Conditional Logistic Regression [CLR] was used to assess the association of various risk factors with DSH. Risk factors of DSH in Karachi included current history of mental disorder [OR = 4.53, 95% CI = 1.59 - 12.92], not sharing problems with someone [OR = 4.67, 95% CI = 2.4 - 9.0], living in rented houses [OR = 2.58, 95% CI = 1.37 - 4.84], Pathan ethnicity [OR = 5.05, 95% CI = 1.01-25.38] followed by others [OR = 3.88, 95% CI = 0.77 - 19.69] and Urdu speaking [OR = 2.71, 95% CI = 0.59 - 12.45]. Absence of physical illness in the past month had an inverse association with DSH [OR = 0.17, 95% CI = 0.07 - 0.37]. Mental illnesses, low socio-economic status and loneliness were the risk factors of DSH patients presenting to the three EDs of Karachi. Physical illness in the last month was protective against DSH in these patients. Psychiatric evaluation of DSH patients in the ED is important for early diagnosis and management of mental disorders

Profile of psychiatric patients presenting to a tertiary care emergency department of Karachi

This study reviewed the presentations of psychiatric patients admitted through the Emergency Department [ED], The Aga Khan University Hospital, Karachi. Psychiatric patients admitted through the ED to the psychiatry ward were compared to those admitted through the same units other than the psychiatry ward, from 2006 to 2010 using medical records. Psychiatric patients were defined as those in whom psychiatry consult was generated and 1127 cases were included in study. There were 550 [48.8%] female patients. Most common presentations in the ED were sleep-related problems [n=205, 15.9%] followed by aggressive behavior [n=191, 14.8%]. Depression was the most common diagnosis made in the ED [n=331, 29.3%] and at the time of discharge from the hospital [n=354, 29.5%]. Psychiatric patients presenting to the ED had signs and symptoms which one generally disregards. However, these minor indicators can lead to major events in a patient's life

Fast ultrasound; a basic tool to evaluate the blunt abdominal trauma patient and help to decision making for emergency surgery

Fast ultrasound is a basic tool to evaluate the blunt abdominal trauma patient and help to decision making for emergency surgery. Observational study. The King Fahad Hospital Madina Munawara, over a period between 2010 and 2011. This study consisted of 765 patients came in Emergency department The King Fahad Hospital Madina Munawara Level II, or Regional Resource Trauma Center Saudi Arabia. Detailed History was taken from all the patients with special regard to bland abdominal trauma. All patients were brought to a trauma resuscitation area where a trauma team conducted a primary survey, after an airway and adequate oxygenation/ventilation were established. The FAST examinations were performed using 4 windows: subxiphoid, right upper quadrant, left upper quadrant, and suprapubic. The critical areas for intra-abdominal bleeding were the hepatorenal space [Morrison's pouch], the spleno-renal space, and the pelvic pouch of Douglas. The FAST examinations were interpreted on the spot and results Recorded. Results were prepared with help of tables and graphs. Data was analyzed through SPSS software. 73 out of 765 patients who underwent FAST ultrasound in the Emergency Room. 40 [54.79%] cases were road traffic accident [RTA] injuries followed by injury due to fall were in 33[45.20%] cases. Findings are fast ultrasound observed 49 out of 73 patients [67.12%] were considered positive FAST who had fluid [blood] in the peritoneal cavity and these patients shift to Operative Room for surgery. While 24[32.87%] patients with no evidence of intraperitoneal fluid were considered negative for FAST and these patient underwent CT scans for evidence of solid organ injury[Chart No.2]. 5 out of 24 cases of solid visceral trauma found on CT scan abdomen, but had not been detected by FAST then shift to operative room after resuscitation. We conclude that FAST ultrasound is very helpful to assessment of blunt abdominal trauma and to detect intraabdominal fluid. Fast ultrasound can help in the quick decision for surgical intervention within minutes of a patient's arrival at emergency department

Low attendance in lectures at medical colleges of Karachi - a cross sectional survey

To evaluate the attendance of medical students in the lectures and to identify different factors responsible for low attendance. This cross sectional study was conducted at three medical colleges in Karachi, Pakistan during July to September 2012. Medical students of3rd year and above representing different medical colleges were asked to fill out a questionnaire to assess the different reasons why medical students tend to absent themselves from lectures, their views regarding content and quality of lectures. Students having attendance of 50% or more were included in the study. A total of 509 student responded to the survey. Two hundred and eighty two students [having >50% attendance in the last semester] were included in the study. Mean age was 21.14 +/- 1.9 years. There were 110 [39%] males and 172 [61%] females. The two most common reasons for not attending the lectures were; timing of the lectures not adjusted according to the students schedule [n=180; 63.8%] and the students preferred self/group study over lectures [n=198; 70.2%]. On the other hand majority of the students [n=173; 61.3%] were also of the opinion that it is difficult and complex to learn without lectures. There are various reasons for absenteeism from lectures including timing of the lectures and preference for self study. These need to be rectified in order to strengthen the learning process in medical undergraduates

Presence of multiple antimicrobial resistant strains and frequency of pseudomonas aeruginosa in bronchiectasis patients in balochistan

Objective: To discover the frequency and presence of multiple antimicrobial resistant strains of Pseudomonas aeruginosa [P.aeruginosa] in patients with Post tuberculosis bronchiectasis in Baluchistan

Design: A prospective descriptive study

Place and duration: this study was done in Pulmonology and tuberculosis outpatient department [OPD] of Fatimah Jinnah Chest Hospital and Rehan Hospital Quetta Pakistan from 1st October 2011 to 1st April 2012

Methodology: The samples were obtained from post tuberculosis patients [n=60, Age = 40+ years] suspected of bronchiectasis who were subjected to spirometry test, Mueller Hinton sensitivity testing, oxidase test and disk-diffusion method to find out frequency and multiple drug resistance of P. aeruginosa

Results: Our results confirmed the association of chronic P. aeruginosa infection with poor lung function. It is not clear whether P. aeruginosa caused the accelerated decline in lung function or it was just a marker of those whose lung function was already declining rapidly. The antibiotic susceptibility testing confirmed the presence of resistant strains of the P. aeruginosa most of which were mucoid strains. It proved that a single antibiotic therapy is not a good treatment for patients with P. aeruginosa infection in airways

Conclusion: Bronchiectasis is more frequently encountered in middle-aged and elderly persons and resistant strains of P. aeruginosa are highly prevalent in these patients

Various presentation of abdominal tuberculosis in surgical patients

To see the various presentation of abdominal tuberculois in surgical patients. prospective study. This study was carried out in the Surgical Department at civil Hospital Karachi, from Oct 2011 to 31[st] May 2012. Study consisted of twenty six patients. Base line and specific investigations were done in all patients, especially mantoux test, sputum examination x-ray abdomen and ultrasound of abdomen. Inclusion criteria were that all patients diagnosed as case of tuberculosis on the basis of history, clinical examination and investigations. Exclusion criteria included unfit patients for general anesthesia, pregnant ladies due to risk of foetal loss, patients with carcinoma of colon. Data was analyzed through SPSS software. 26 cases of abdominal tuberculosis. 12 males [46.15%] and 14 females [53.84%]. Male to female ratio was 1:1.16. Age ranged from fifteen to seventy years with mean age of patients were 42.1 years. Twelve Patients [46.15%] presented in subacute intestinal obstruction, four patients [15.38%] with acute intestinal obstruction, six [23.07%] with signs of peritonism and four [15.38%] with mass in abdomen. Erythrocyte sedimentation was 2 patients [7.70%] had ESR 20 mm/hr, eight patients [30.77%] between 20 to 40 mm/hr, eleven patients [42.1%] between 40 to 60 mm/hr and five patients [19.23%] between 60 to 100 mm/hr. Liver Function Test was within normal range in all of them. Mantoux Test was found positive in fourteen [53.84%]. Plain x-ray abdomen erect and supine position showed sixteen patients [61.54%] significant findings were observed. Barium meal and Follow through examination was performed in four patients [15.38%]. Three patients [75%] showed narrowing of ileum and irregularities in the caecum and one' patient [25%] had dilated small bowel loops with narrowing of terminal part of ileum while caecum was normal. In one patient [3.84%] small bowel enema revealed delayed emptying of small bowel with dilatation of jejunum, Barium enema was performed in three cases, which revealed, filling defect in caecum and narrowing at ileocecal junction. We conclude that. The clinical features of this disease are usually non-specific, vague and diverse therefore the accurate diagnosis is some times difficult

Non-academic attributes of hidden curriculum in medical schools

To identify the non-academic attributes developed during 5 years of training in medical school. Sequential mixed method. The study was conducted on final year medical students of four medical colleges in the city of Lahore, from March to September 2010. Probability random sampling was employed to identify public sector medical colleges for inclusion in the study through Lottery method. In the first phase, survey was done with the help of questionnaires, distributed amongst 280 students, selected on the basis of convenience sampling. It was triangulated with data collected by in-depth structured interviews on 46 students selected using purposive sampling after formal informed consent. For quantitative data percentages of the categorical variables were calculated through SPSS version 10. For qualitative data, themes and patterns were identified using Content Analysis technique. Majority of the medical students [80%] learn the attributes of integrity, self-reliance, tolerance and independence during their schooling. Sixty five percent students thought that the values of humanity, forbearance, righteous attitude in face of adversities and sympathetic behaviour towards peers and patients helped them in being better medical students. Thirty five percent said they faced the negative influences of gender bias and gender discrimination which has led to their impaired professional growth. Eighty percent of the students believe that the teaching methodology employed is teacher centric which does not let them become problem solvers, team players, reflective learners and hampers development of effective communication skills. Medical schooling in our part of the world helps in developing untaught attributes such as integrity, selfreliance, tolerance, independence, sympathetic attitude and good communication skills which are the same as are developed in the medical students of advanced countries, which can be fostered further by formally addressing them in the curriculum

Bedside manners: do we care?

Teaching bedside manner might prove to be one of the most challenging tasks in medical education as it is not easy to structure or formalise such training. Besides, the rigorous training process for acquiring clinical and technical skills often overshadows the humanistic aspect of medical care. The aim of this study was to assess the perception of final year medical students as well as the faculty regarding the teaching and practice of bedside manner including a brief evaluation of students' bedside manner. A cross-sectional study was conducted involving final year medical students from five medical colleges [n=193] and faculty from a single institution [n=29]. Sample was selected using systematic random or convenient sampling techniques. Data was collected using self administered, anonymous, structured questionnaire. Data were analysed using SPSS-17. While evaluating students' bedside manner, 85% of the students reported they always take consent while interacting with a patient whereas, only 17% of the faculty members agreed with this. Only 3% of the faculty members reported that students take care of privacy of patients and none of them thought that students reassure a patient during an encounter whereas the percentages among students were 76% and 48%, respectively. Though students thought they need to improve, majority [56%] of them was confident of their bedside manner. On the other hand, 83% of the faculty members rated students' bedside manner from fair to poor. A large proportion [69%] of the faculty members were not satisfied with the quality of teaching regarding bedside manner, reporting lack of focus on this particular aspect of medical care as the most important cause. Majority of the students [87%] believed doctors have a better bedside manner in private as compared to public hospitals. Students have an inflated evaluation of their bedside manner but majority felt a need to improve. A sharp contrast exists between students' and faculty's opinion regarding the practice of bedside manner by students. An outright lack of focus on bedside manner was reported as the most important cause for inadequate emphasis on teaching this particular aspect of medical care

Academic misconduct among students in medical colleges of Karachi, Pakistan

To determine the trends of academic misconduct in undergraduate students of different private and government section medical institutes. This cross sectional study was conducted at three medical colleges of Karachi, Pakistan. The students were evaluated by giving a self reported questionnaire containing various questions assessing their educational dishonesty and cheating behaviors. A total of 274 students from different years completed the questionnaire. Mean age was 21.48 +/- 1.89 years. Most of the students were in 4[th] year [n=86; 31.3%]. There were 182 [66.5%] females and 92 [33.5%] males. Majority of the students [n=155; 55.1%] accepted that they have cheated at least once. There was no significant difference regarding acceptance of cheating among different years of study [p=0.23] however females were found to accept cheating more as compared to males [p=0.036]. First year students were found more to ask teachers for answers during OSCE [p=0.01]. A large number of students accepted that they mark proxy for their friends [85.7%] and also ask their friends to mark proxy for them [85.03%]. Nearly half [44.02%] of the students rotating in wards also admitted to write fake histories. A large number of medical students admitted cheating and involvement in other academic misconduct. We need to improve our educational system, formally add professional session and strict disciplinary action should be taken against those who are found guilty

Hepatitis and AIDS fear and misconceptions; Are our students ready for contact with these patients?

Blood born infection is also one of the medical profession hazard which is added due to virus transmission by needles and medical instruments and Hepatitis and HIV viruses are leading viruses in this hazard. Medical students who are actively participating in clinical practices and due to contact with patients, face exposure of patient's needles, instruments, and blood and this exposure starts in clinical posting of third year when their clinical knowledge and professional skills are in early phases. To assess and evaluate the existing level of knowledge about these blood born infections [Hepatitis B, C and AIDS] to ensure their participation in clinical activities during their clinical posting. An observational cross sectional study with prospective data. Dow lnternational Medical College. From 2010 to 2011. This is an observational cross sectional study with prospective data, done through a questionnaire survey on third year MBBS students. 47% of the students have fear about to be infected by patient's examination during clinical posting and majority of students have misconceptions about transmission of these infections. Students have more knowledge about HIV compare to hepatitis but there is no relation in knowledge score and student's fear as shown by p value of 0.3 and 0.73 for HBV and HIV but for HCV [p= 0.035] during this study. Up to half of the students have fear to be infected by these infections during patient's examination and this perceived risk of infection is due to lack of knowledge and these misconceptions and attitude to these patients are the sources to make them reluctant in active participation of clinical activities directly related to patient.

Obstructive uropathy: causes and outcome in pediatric patients

To pinpoint the major causes of obstructive uropathy in children and determine the outcome in terms of renal impairment and mortality. This observational study included pediatric patients presenting with obstructive kidney disease. All consecutive pediatric patients [< 12 years] presenting with signs and symptoms of obstructive uropathy +/- chronic kidney disease [CKD] for the duration of 3 months or more represented by a GFR of < 52 ml/min/m were included while patients with co-morbidities representing independent mortality risk like congenital heart diseases and with non-obstructive causes of renal failure and patients with no evidence of urinary tract obstruction on either ultra sonogram or renal scan were excluded. They were categorized into five segments and the outcome of the treatment at the end of follow up period of 2 years was recorded and categorized similarly to eliminate any bias. Forty three patients were recruited initially but 3 were excluded. The mean age was 5.3 years and there were 33 [82.5%] males. Majority had severe growth retardation. Posterior urethral valve [45%] and nephrolithiasis [35%] were commonest causes. The mean serum creatinine on admission was 6.35 [1.2-22] mg/d and at the end of follow up had reduced to 1.6 [0.4-3.2] mg/dl. [p- 0.0017]. Post treatment 27 [67.5%] patients had no residual renal impairment while only 5 patients [12.5%] patients developed ESRD and were referred for transplant. We conclude that obstructive uropathy is an important cause of preventable renal failure in children

Development of massive pneumopericardium after intubation and positive pressure ventilation

Pneumopericardium is a rare complication of chest trauma, mechanical ventilation and cavitating pneumonia. We report a case of a 7-year-old patient with chronic myeloid leukemia who developed massive pneumopericardium immediately after being electively intubated for a diagnostic radiological procedure in the setting of ongoing Enterococcal pneumonia. As intensive care medicine becomes more prevalent in hospitals, we believe that clinicians need to be aware of this uncommon but potentially fatal condition

Frequency of anti Hepatitis C Virus antibodies amongst sanitary workers in a tertiary care hospital in Pakistan

To determine the frequency of anti Hepatitis C Virus antibodies in sanitary workers at Military Hospital Rawalpindi and to identify additional risk factors in them for hepatitis C infection. Cross sectional study. Department of medicine Military Hospital [M.H.], Rawalpindi Pakistan over six months. All sanitary workers working at Military Hospital Rawalpindi were tested for anti HCV antibodies by third generation ELISA six percent of the study population was found to be positive for anti HCV antibodies. The frequency of anti HCV antibodies is fairly high in sanitary workers working in this tertiary care hospital studied. HCV infection is more frequent in those sanitary workers who have longer duration of service

Multiple carpometacarpal volar dislocation

A case of multiple Carpometacarpal joints volar dislocation in a young man of 25 years of age is reported. He presented with pain and deformity of his left hand immediately after road traffic accident. He was unable to move his left hand. X-rays of the affected hand showed volar dislocation of all four medial Carpometacarpal joints. Dislocated joints were reduced, fixed with K-wires and immobilized in slab. K-wires were removed after 8 weeks. Hand function is satisfactory on the follow-up

Cerebral sinovenous thrombosis in children

Cerebral sinovenous thrombosis in childhood is a serious disease. There are many predisposing and influencing factors which should be unraveled to identify patients at risk and to establish treatment regimens in children. We report two cases, in which the predisposing risk factors for the cerebral sinovenous thrombosis were antithrombin III deficiency in one case, and severe dehydration in the other. In both cases diagnosis was confirmed by standard imaging methods, computerized tomography [CT] followed by magnetic resonance imaging/venography [MRI and MRV]

Primary closure of common bile duct after open choledochotomy

To assess the outcome of primary closure of common bile duct after open choledochotomy. Descriptive case series. Department of surgery, unit II, III and VI, Dow University of Health Sciences and Civil Hospital Karachi from June 2005 to May 2009. Clinical records of all the patients who underwent bile duct exploration followed by primary closure were reviewed. Main outcome measures were operating time, duration of hospital stay and postoperative complication; including bile leakage, subphrenic abscess, biliary peritonitis and postoperative jaundice. The SPSS version 11 was applied to the data for analysis. A total of 38 patients were found from clinical records having male to female ratio of 1:6.6. Mean [ +/- SD] operating time was 95 [ +/- 7] minutes. The overall complication rate was 10.52%. Bile leak was encountered in three [7.89%] patients whereas small subphrenic collection was noticed in one [2.63%] patient who was treated conservatively. None of the patients experienced postoperative jaundice and biliary peritonitis. Mean [ +/- SD] duration of hospital stay was 7.63 [ +/- 1.63] days. Primary repair of common bile duct after open choledochotomy is safe and associated with low complication rate

Chest trauma management: good outcomes possible in a general surgical unit

To determine the predominant pattern of injuries following chest trauma and assess the adequacy of the management strategies employed in a general surgical unit of a trauma care hospital. This Case Series study with prospective data collection was conducted in Surgical Unit-Il ft Unit-VI of Civil Hospital Karachi, from September 2007 to February 2009. One hundred and three consecutive patients with thoracic trauma presenting in emergency department were evaluated. Patients above 12 years of age, who presented with chest trauma either alone or associated with multiple trauma were included. A total of 103 patients were studied for various chest injuries during eighteen months period. As a whole 58% of patients had blunt chest injury as compared to 42% who had penetrating injuries. Thirty patients [29%] had chest wall injuries [rib fracture, mild lung contusion] without haemothorax or pneumothorax, who were managed conservatively. Chest intubation was required in 64 patients [62%] having hemothorax I pneumothorax. Thoracotomy was required in nine patients [9%], in which only two were emergency thoracotomy and seven were elective. Over all mortality rate was 8%.Penetrating injury of chest is rising with time due to gunshot injuries although blunt trauma is still more common. Majority of chest trauma patients can be managed in a general surgical unit satisfactorily and few patients need major operative management