MicroRNAs: a new paradigm towards mechanistic insight of diseases

In 1993 miRNAs were discovered during a research on Caenorhabditis elegans conducted by Victor Ambros and Gary Ruvkun. The gene lin-4 that played important role in development in C. elgans was observed not encoding any protein but a very small RNA molecule of just 22 nucleotides. Main objective of this review is to highlight the significance of miRNAs in regulating the expression of many genes, which are either directly or indirectly involved in many diseases. One of the major causes of illness and death in developed countries of the world is cardiovascular disease. Some of the miRNAs have certain role to play in heart that are not specified for heart. So miRNAs have been found to be in other tissues like fibroblasts, endothelial cells and smooth muscle cells that are part of physiological study of cardiovascular system. Adult heart has limited capacity of regeneration therefore lost cardiomyocytes due to myocardial ischemia or infarction can result in low performance of heart. miRNAs have been shown to play a role in apoptotic regulation of cardiomyocytes in vivo. Many studies have shown that miR146a and 155 are up regulated in peripheral blood mononuclear cells, synovial fibroblasts, synovial fluid and Th-17 cells from rheumatoid arthritis patients as compared to healthy persons. Several types of miRNAs are playing important roles in type 1 diabetes mellitus including miR-375 and miR-375 with intolerance to glucose and decreased beta cells account due to impaired proliferation. Up regulation of miR-125a in WAT of type 2 Diabetes mellitus have been observed. miRNAs have proved to be the important regulators of cytokines and growth factor expression. Thus, suggested as a good biomarker and target of therapy. miRNA profiling techniques have revealed the role of miRNAs in Multiple sclerosis

Parvo B 19 myocarditis in immunocompetent patient

Parvo B19 virus can cause different diseases in human. It can cause myocarditis which if not treated in time can prove fatal. Here we are presenting a case of 43 years old immune-competent male who was found to be infected with Parvo B 19 virus, which was diagnosed by positive serology and PCR technique. He was successfully treated and ison regular follow up. Every clinician should consider the possibility of PVB 19 in any patient presenting with acute myocarditis

Tetanus; still cannot be prevented, a three year retrospective study in DHQ hospital, Faisalabad

Tetanus still remains a major public health problem in Pakistan like in most other developing countries, with a high morbidity and mortality. To study the demographic profile the clinical profile, the outcome of the tetanus patients and effectiveness of tetanus immunization coverage in district Faisalabad. Retrospective record based study. Surgical unit-5 DHQ Hospital, Faisalabad from January 2010 to December 2012. All data of 198 patients of tetanus of any age and sex, diagnosed clinically was collected, compiled and analyzed from the Medical Records Department of the Hospital. Out of 198 patients of tetanus,138[69.7%] were males and 60[30.3%] were females. Their ages ranged from 1 to 85 years with a mean and a standard deviation respectively of 29.36 and 17.48 years.162 [81.8%] were from rural and36[18.2%] were from urban areas. 47[23.7%] patients were having prior immunization and151[76.3%] were not immunized. The most common presenting symptoms were trismus [47.5%], body stiffness [24.2%],fits[19.2%] and respiratory distress[9.1%]. 23[11.6%] patients were having mild disease,71[35.9%] patients were having moderate disease,71[35.9%] patients were having severe disease and 33[16.7%] were having very severe disease. Overall mortality rate was 41.4%. Respiratory failure was the most common cause of death and there was statistically significant association between mortality and increasing grades of disease. By making expanded programme of immunization [EPI] more effective and removing flaws from out-dated vaccination through incomplete vaccination. By improving awareness in public and complete vaccination through EPI program, we can reduce the incidence of tetanus

Accelerated 2 hour regimen of streptokinase for pulmonary embolism

To assess the safety and efficacy of accelerated 2 hour regimen of streptokinase [SK] in acute massive pulmonary embolism. The primary end point of study was immediate hemodynamic improvement and safe discharge from the hospital. Quasi-experimental study. Armed Forces Institute of Cardiology - National Institute of Heart Diseases [AFIC-NIHD], March 2010 to Sept 2010. Twenty five patients referred to AFIC-NIHD Rawalpindi with recent symptoms [<5 days] suggestive of acute massive pulmonary embolism were considered for entry into the study. On confirmation of acute massive pulmonary embolism, they were thrombolysed with 1.5 million units of streptokinase over two hours followed by unfractionated heparin infusion intravenously at a dose of 1,000 IU/h. They were observed for immediate hemodynamic and clinical improvement and followed up till discharge from the hospital. Safety of Streptokinase was assessed by observing for major bleed [requiring blood transfusion]/fatal bleeding/intracranial haemorrhage confirmed on CT scan or anaphylaxis secondary to accelerated regimen. Mean age of the patients was 55 years [range 24 to 85 years] and 60% [15] were males and 40% [10] were females. CT pulmonary angiogram in all 25 cases confirmed massive pulmonary embolism. Streptokinase 1.5 million units were given to all 25 patients in infusion form over a period of 2 hours followed by unfractionated heparin infusion at 1000 IU/hour. No bleeding complication was observed in any of these cases. Eighteen [72%] patients showed immediate hemodynamic and clinical improvement but 28% [7] expired on the same day. Average hospital stay of the patients was 6 days. Mortality of patients with massive pulmonary embolism is high even after thrombolysis. Accelerated 2 hour regimen of streptokinase can be routinely used in patients with massive pulmonary embolism without obviously compromising efficacy or safety but further randomized controlled trials to compare the two SK regimens are required to better predict the efficacy and outcome of the two regimens

Initial experience of fractional flow reserve in 30 patients with moderate coronary artery lesions at armed forces institute of cardiology

To evaluate our initial experience of Fractional Flow Reserve [FFR] for decision making in coronary revascularization in moderate lesions. A descriptive study. Armed Forces Institute of Cardiology/National Institute of Heart Diseases from August 2009 to August 2010. A total of 30 consecutive patients who underwent FFR at AFIC/NIHD from August 2009 to August 2010. These were the cases in which decision regarding PCI was difficult on visual assessment alone as experienced operators differed in their opinion. A 0.014" FFR wire was used and pressure gradients across the lesions were noted A total of 30 patients with 44 moderate lesions on coronary angiography were evaluated in our initial experience. Amongst these, 27 [61.4%] LAD lesions were studied [20 lesions had an FFR > 0.80 while 7 [15.9%] had an FFR 0.80 or less]. Seven [15.9%] lesions of LCX were evaluated [5 had an FFR > 0.80 and 2 had 0.80 or less]. Seven [15.9%] lesions were of RCA [4 had an FFR >0.80, 3 had 0.80 or less]. One case of LMS lesion was found to be non-critical. Two [4.5%] vein graft lesions were included of which one was found to be angiographically critical, [FFR 0.72]. Out of the total 44 lesions studied 14 [31.82%] lesions were critical with an FFR 0.80 or less, which were stented. Thus 30 stents were saved. This reduced the cost, as well as the un-necessary hazards and risks associated with PCI and the issue of difference in opinion was put to rest. We thus conclude that FFR is a very important tool in guiding the interventionist for planning PCI in moderate lesions

Procedural analysis of patients with stent thrombosis [ST]

To analyze the procedural details of patients presenting as ST and undergoing PCI. Descriptive study. Armed Forces Institute of Cardiology - National Institute of Heart Diseases [AFIC-NIHD] from Jan 2007 to Dec 2010. A descriptive, single center study done at AFIC Rawalpindi from Jan 2007 to Dec 2010. During this period patients with prior stenting who presented to AFIC E/R with acute ischaemic symptoms with ECG changes and had angiographically confirmed ST were studied. Their procedural details [index PCI and ST procedure] were analyzed. Over this four year study period, 7694 coronary angioplasties were carried out and 12871 stents [10633 DES and 2238 BMS] were implanted. Amongst these, 32 patients [28 males and 4 females] later had angiographically confirmed ST and were treated with PCI. Mean age was 51.57 years. Dual antiplatelet therapy [DAPT] non-compliance was not a contributory factor in our study. Coronary distribution involved in ST included 20 cases of LAD, 7 of LCX and 5 of RCA territory. Thirteen [40%] patients had overlapping stents, 11 [34.4%] had direct stenting. Average diameter of stents with ST was 2.86 mm and the average length was 24.17 mm. Incidence of ST was higher in BMS as compared to DES [p0.003]. Of these 32 patients, 14 [43.75%] were treated with further stenting whereas 18 [56.25%] underwent POBA only. Telephonic follow up after second PCI was possible in only 15 cases, out of which five [33.33%] deaths were reported on the day of thrombotic procedure. ST has a high mortality and there was an overall higher frequency of ST in BMS compared to DES. Acute and subacute ST were mainly related to BMS whereas late ST was more common in DES. However PCI technique i.e direct stenting and overlapping stents, was a major predictor of stent thrombosis

Combined urethrolithotomy with vesicolithotomy in an 18-months old boy

We present a case of 18 months old male child who reported with acute urinary retention. He had a urethral calculus along with a vesical calculus. He was subjected to combined external urethrotomy and open vesicolithotomy in one sitting. The patient made a smooth post operative recovery and was followed up for 6 months

Severe recurrent oral ulceration secondary to erosive lichen planus

A case of recurrent progressively severe ulceration secondary to erosive lichen planus is reported. The patient developed marked malnutrition as a result of extensive involvement of the oral cavity. In addition to the oral ulcerations, she also had violaceous spots present over her forearm. Treatment administered in view of histopathological report and clinical presentation, resulted in marked improvement in symptoms and weight gain

three-year audit of rigid oesophagoscopy at lady reading hospital Peshawar

The number of oesophagoscopies performed annually provides an indication of the extent of oesophageal disorders in any particular setting. The present study aimed to provide such data for rigid oesophagoscopy at the only referral centre for this procedure in Peshawar. An audit of all available records of patients undergoing rigid oesophagoscopies from January 2002 to December 2004, at the Lady Reading Hospital Peshawar was performed. A total of 200 cases of rigid oesophagoscopies were performed during this three-year period of study. The ages of patients ranged from 1 to 90 years, with a two fold male preponderance. The main indication was dysphagia with major causes being oesophageal carcinoma [115, 57.5%], reflux oesophagitis [56, 28%], strictures of various aetiologies [19, 9.5%] and foreign bodies [10, 5%]. Successful dilatation was possible in 70% of cases; the morbidity rate was 4.5% due to perforation observed in 9 cases. The mortality rate was 1.5% due to septicemia in 3 cases. A high rate of rigid oesophagoscopies was observed indicating an increased frequency of oesophageal disorders in this setting. The morbidity and mortality rates observed are within acceptable ranges for this procedure

Thrombocytosis: analysis of 329 patients

To find out the nuquency of different clinical conditions causing thrombocytosis in hospitalized patient population. Cross sectional, descriptive study. Combined Military Hospital Attock, 1st Sept 2003 to 1[st] March 2004. All patients referred to haematology department for complete blood counts who had platelet count exceeding 400 x10[9] /L. Out of nine thousand patients, 329 [3.65%] revealed thrombocytosis. The Male to female ratio was 1.4:1, [48%] were adults, ana 52% were children. Platelet count ranged between 403 X10[9]/L and 1365 X10[9]/L In adults, iron deficiency [36%], infections [30%], infections concomitant with iron deficiency [13%], chronic inflammatory disorder [7%], clonal thrombocytosis [5%], haemorrhages [3%]; and in children infections concomitant with iron deficiency [36%], infections [26%], iron deficiency [18%], and acute gastro enteritis [6.5%] were the leading causes of thrombocytosis. Iron deficiency anaemia and infections are leading causes of thrombocytosis in our set up. Clonal thrombocytosis is seen in 5% of adult patients. Relative frequency of different conditions causing thrombocytosis varies with patient age

Frequency of glucose-6-phosphate dehydrogenase deficiency in some ethnic groups of Pakistan

To determine the frequency of G6PD deficiency in young healthy adult males of some ethnic groups in Pakistan. Design: Descriptive study. Place and Duration of Study: Study performed in Combined Military Hospital, Attock in collaboration with Armed Forces Institute of Pathology, Rawalpindi from October 2003 to January 2004. Patients and Asymptomatic and healthy adult males were included in the study. A brief clinical record including age, ethnic group, place of residence, and history of past illnesses including fever, episodes of recurrent jaundice were recorded. Met-hemoglobin reduction test for G6PD screening was performed. Hemoglobin, red cell indices and total leukocyte count of G6PD deficient cases were measured on Sysmex KX 32 hematology analyzer. Three thousand adult males with age between 17 years to 23 years were screened. G6PD deficiency was detected in 1.8%. Deficiency state was 1.07% in Kashmiris, 1.47% in Punjabis, 2.77% in Sindhis, and 3.17% in Pathans. Past history of recurrent jaundice was present in 5.7%. Mild anemia was present in 3.8%. Frequency of G6PD deficiency was 1.8% in young healthy adults with insignificant difference among various ethnic groups except in Pathans

One year experience of treating carcinoma oesophagus

To audit one year of esophageal workload in a Cardiothoracic unit Material and This study was conducted at Cardiothoracic unit Lady Reading hospital peshawer from 1st January to 31st December 2003, and it comprised of 146 patients presenting with spontaneous dysphagia. Barium swallow and endoscopy/biopsy were done for diagnoses; C.T scan was used to stage the disease and offer possible treatment. Ca esophagus constituted 25.84% of total operative work load in one year. Disease was more common in males; mean age at presentation was 56 years. High incidence was found in Afghan nationals. The common presenting clinical features were dysphagia and weight loss. Barium swallow detected the abnormality in almost all advanced cases. C.T scan was found accurate in[36/41] 87.80% cases in staging the disease. In majority of cases disease arose in the lower 2/3 of the organ and most frequently it was sqamous cell carcinoma.[105/146] 71.91% were inoperable; surgery offered good in operable cases. Carcinoma oesophagus is not uncommon in this part of the world; Efforts should be made to diagnose the disease early, as the treatment is possible and give good in the early stage of disease

Clinical assistance of bone marrow examination in a secondary-care hospital

This study was performed to evaluate various clinical situations requiring bone marrow examination and to assess its advantages in a secondary care hospital. One hundred and five bone marrow examinations were performed from 1st April 2002 to 31st March 2003. The age ranged from 4 months to 70 years with a mean age of 32 years, 10 patients were children under the age of 15 years and 95 were adults. Male to female ratio was 3:1. Progressive pallor [26%], visceromegaly [25%], abdominal disturbances [19%], fever of unknown origin [8.5%], bleeding manifestations [8.5%], lymphadenopathy [8.5%] bone pains [5%], and suspected hematological malignancy [8.5%] were the common clinical situations where bone marrow examination was asked. Nutritional deficiency anemia constituted 61% of the bone marrow examination results. Other conditions were anemia of chronic disorder [13.5%], acute leukemia [5%], chronic leukemia [3%], multiple myeloma [2%], myelodysplastic syndrome[2%], congenital sideroblastic anemia[1%], storage disorder[1%] and metastatic bone disease[1%]. Bone marrow examination at secondary care hospitals carries many advantages. About 80% cases can be treated in these centers and do not require referral. The disease is usually at its early stage, marrow is unaffected by any therapy and has better diagnostic value

Thrombocytopenia: analysis of 415 patients

To find out the relative frequency of conditions associated with thrombocytopaenia. Descriptive study Combined Military Hospital Attock in collaboration with Armed Forces Institute of Pathology Rawalpindi, from March 2003 to March 2004. Materials and All patients referred for blood counts. Patients with platelet count below 150x10[9]/L, were registered. Investigations including peripheral blood counts and smear examination, blood/smear for bacterial culture, IgM for Dengue virus, Hepatitis B surface antigen and anti-hepatitis C Antibodies, ultrasound abdomen and bone marrow examination were performed. Out of 18,000 patients, 415[2.3%] revealed thrombocytopaenia [341 adults and 74 children]. In adults, viral anti-body was found in 27.7%, malaria in 17%, bacterial infections in 12.4%, megaloblastic anaemia in 8.2%, bone marrow infiltrates in 7.9%, drug induced thrombocytopaenia in 4.4%, chronic liver disease in 3.5%, hypersplenism in 2.9%, DIC in 2.9%, pregnancy associated thrombocytopenia in 2%, aplastic anaemia in 1.5%, ITP in 1.2% and upper respiratory viral infection in 8%. In paediatric age group malaria was detected in 27%, megaloblastic anaemia in 23%, bacterial infections in 13.5%, leukaemia in 13.5%, neonatal thrombocytopenia in 9.5%, ITP in 2.7%, DIC in 1.4%, aplastic anaemia in 1.4% and upper respiratory viral infections in 8%. Malaria, viral and bacterial infections and megaloblastic anaemia are the most common causes of thrombocytopenia in our setup

Presentation and management of empyema thoracis at lady reading hospital Peshawar

Background: Empyema thoracis remains a common thoracic problem with challenging management strategies. We undertook the present study to outline key aspects of the presentation and management of this condition at our tertiary care hospital

Methods: We analyzed 105 consecutive patients treated for empyema thoracis over a one-year period at Thoracic Surgical unit, Lady Reading Hospital Peshawar Pakistan. The study included patients aged 10-60 years of either sex. Patients were subjected to detailed diagnostic and management protocols with a view to define successful diagnostic and management strategies

Results: The majority of patients [68%] were male, with a mean age of 28.5+/-14.2 years, a majority [42%] being in the 10-20 years age group. Common presentation was with fever [73%], cough [65%] and chest pain [60%]. The mean duration of symptoms was 6.1 weeks. Common aetiologies of empyema were pneumonia [46.7%], iatrogenic [21.9%], traumatic [16.2%] and malignancies [11.4%]. Forty patients [38%] underwent an unsuccessful therapeutic procedure prior to admission to the Thoracic unit. In the unit, 58 patients received closed intercostal drainage [31 of which required further intervention], five patients were treated with repeated thoracentesis and 8 patients were subjected to fibrinolytic therapy. The majority of patients underwent a surgical procedure like rib resection [7], decortication [23], thoracoplasty [3] and other procedures in the first instance with only 4 patients requiring further surgery. Majority of patients [97/105, 92.4%] were cured of their disease. The hospital mortality was 7.6%

Conclusion: Multiple therapeutic options exist for the treatment of thoracic empyema. Optimal therapy requires selection of the most appropriate first procedure for each patient with post procedure imaging to avoid inordinate delays between interventions. Early referral of all empyema patients to thoracic units for definitive therapy is recommended

audit of lobectomy for pulmonary disease at lady reading hospital, Peshawar

The present study was designed to provide data on the role of elective open lobectomies in the treatment of benign and malignant pulmonary diseases in our setting. An audit of patients' records over a two-year period was performed to collect relevant data at the Cardio Thoracic Unit of the Lady Reading Hospital Peshawar Pakistan. A total of 55 lobectomies were performed from January 1999 to December 2000, including 34 males and 21 females. The mean age of patients was 31.23 +/- 14.95 years, with only 7 [12.7%] cases above 50 years of age. Benign pulmonary conditions, particularly chronic lung infections were the major indication for lobectomies [50/55, 90.9%], while lung cancers accounted for only 5/55 [9.1%] of lobectomies. Bronchiectasis was the leading indication with 28 [50.9%] lobectomy cases. Most patients [37/55, 67.3%] had uneventful postoperative recovery, while 18/55 [32.7%] developed some sort of complication. The most common postoperative complication was infection [wound infection and empyema] accounting for 8 patients [14.6%], followed by air leak [5/55, 9.1%]. Mortality was low, with only 2 deaths [3.6%]. Elective open lobectomy is a safe procedure in our setting with significant benefits for patients and acceptable morbidity and mortality

Surgical treatment of pulmonary hydatid disease

To study the outcome of surgical treatment of pulmonary hydatid disease.This study comprised of two hundred patients, operated for pulmonary hydatid disease in Cardiothoracic unit, LRH, Peshawar form 01.07.1990 to 30.06.2000. The preoperative work up, apart from history and examination included FBC, LFTs, Blood grouping, chest X-ray PA and Lateral views, Casoni's test, haemagghitination test. Ultra sound abdomen and chest, and CT thoracic. Patients were operated for cystectomy, lobectomy decortication, thoracoplasty and combined pulmonary and hepatic cystectomy as required. All patients were put on post operatively mebendazole for at least 28 days. Patients were followed up for complication. Two hundred patients underwent surgery for pulmonary hydatid cyst over a ten years period. Operations performed were cystectomy 168, lobectomy 24, [primary 18, revision 6], decortications 13 and 1 thoracoplasty. Mortality was 4/200 i.e. 2%. The main/ major morbidity was air leak for which 9/200 patients were re-explored, with resuturing in 3 cases and secondary lobectomy in 6. Cystectomy, without needle aspiration, was found to be the procedure of choice for pulmonary hydatid