Frequency of acute complications of Hemodialysis in adult age group at a tertiary care center

Objective: To determine the frequency of acute complications of hemodialysis in adult age group at a tertiary care centre

Study Design: Descriptive study

Place and Duration of Study: Department of Medicine, Combined Military Hospital Lahore, from Apr 2012 to Oct 2012

Patients and Methods: We included 100 consecutive patients of chronic kidney disease on hemodialysis with age more than 12 years. Personal profile, comorbidities, intravenous access type and duration, hemodialysis parameters were recorded for each patient. Monitoring of blood pressure, temperature, pulse and history of palpitations, headache, nausea, vomiting, muscle cramps, fever, shivering, chest-pain, bleeding, fits, itching was recorded before and up till one hour post hemodialysis session

Results: In our study population fever was the commonest complication with frequency of 37 percent, followed by nausea and vomiting in 36 percent, muscle cramps in 28 percent, hypotension in 24 percent, headache in 23 percent, shivering in 22 percent, chest Pain in 15 percent, itching in 14 percent, hypertension in 10 percent, cardiac arrhythmias in 8 percent, hemorrhage in 7 percent and Seizures in 7 percent of patients

Conclusion: Infection related complications were more common in our set up as compared to international statistics which depicts that we should improve our antiseptic techniques

Association of serum sparc with insulin resistance in type-2 diabetes mellitus

Objective: To determine the association of serum SPARC with insulin resistance in type-2 diabetes. Study Design: Descriptive study. Place and Duration of Study: Physiology department and CREAM lab, Army medical college, Rawalpindi, in collaboration with Military Hospital Rawalpindi, from Feb 2016 to Oct 2016

Material and Methods: Sixty individuals were recruited in this descriptive study. Thirty diagnosed cases of type2 DM were included, while thirty age and gender matched healthy individuals were included as controls through non-probability purposive sampling. Controls were labelled as group A, while cases were labelled as group B. Patients with type-1 DM, type-2 DM on insulin therapy, hyperglycemic states other than DM and inflammatory disorders were excluded from the study. Data were collected after informed and written consent. Blood samples were withdrawn under strict aseptic measures and serum was stored at -20oC. Serum insulin levels and serum SPARC levels were analyzed by enzyme linked immunosorbent assay [ELISA]. Insulin resistance was determined using homeostasis model assessment of insulin resistance [HOMA-IR], and its value >1.5 was considered significant

Results: Fasting insulin levels were significantly higher in group B as compared with group A, supporting the diagnosis of type-2 DM. HOMA-IR values were greater than 1.5 in group B, thus establishing significant insulin resistance. Serum SPARC levels were significantly higher in group B than group A [17.7 +/- 1.14 vs 8.7 +/- 1.08 ng/ml] with p-value<0.001. Serum SPARC levels showed positive correlation with fasting insulin levels and HOMA-IR values

Conclusion: Our study showed a positive correlation between serum SPARC levels and insulin resistance, which indicates that SPARC plays an important role in the development of insulin resistance in type-2 diabetes mellitus

localized outbreak of cholera due to vibrio cholerae 01, ogawa resistant to tetracyclines

To study the clinical and laboratory parameters of a localized Cholera outbreak and determine the sensitivity pattern of the subtype involved. A descriptive study. Combined Military Hospital, Lahore. Two weeks. The study is about a localized outbreak of cholera in a group of soldiers, who consumed water from a single contaminated source of water. We are presenting here an account of the clinical and laboratory parameters of 39 hospitalized cases of cholera, who presented with profuse watery diarrhoea and vomiting. There vital signs, hydration status and systemic examination findings were recorded. Stool samples were sent for routine and microscopic examination and bacteriological culture. Blood samples were taken for complete blood count, serum sodium, potassium, urea and creatinine examination. SPSS 18 was used for statistical analysis of the results. The average age of thirty nine men studied in this outbreak was 24.9 +/- 6.9 years. There was no statistically significant difference between confirmed and suspected cholera cases on descriptive analysis of the clinical and laboratory parameters. Majority of patients showed pre-renal azotemia which improved within 48 to 72 hours of hospitalization. Stool cultures isolated Vibrio cholerae O1, subtype Ogawa, which was resistant to tetracyclines, cotrimoxazole and nalidixic acid but sensitive to fluoroquinolones and third generation cephalosporins. The outbreak was controlled when the contaminated water source was sealed and rectified. Multiple drug resistance strains of Vibrio cholera are causing large outbreaks which should be controlled by prevention of the disease and avoiding inappropriate use of antibiotics

Current consideration regarding operative versus non-operative outcome of brain contusion patients

Background: Brain contusion surgeries versus conservative treatment are considered to be the typical decisions faced by doctors, resolved usually based on the experience of respective departments. Till date there are no standard guidelines regarding conservative versus surgical management

Objectives: To determine the outcome of the surgical and medical management in posttraumatic brain contusion patients

Methods: The study was conducted on patients having small and large brain contusions admitted in the department were selected through custom Proforma. The 41 patients [31 males 10 females] included corresponded to no specific exclusion criteria. The patients who improved by Glasgow coma score, neurologically or resolution was confirmed by Computed tomography scan brain were categorized under conservative management. While the patients, who deteriorated by Glasgow coma score, neurologically, bradycardia or showed expansion in the size of contusion with mass effect underwent standard decompressive craniotomy or cranectomy and evacuation of contusions along with duroplasty. Complications and improvement of the patients were determined at follow up and monitored by the help of interval brain CT scan during their stay in the department subsequently followed by cranioplasties

Results: There was a male predilection with male to female ratio of 3.1:1. The age group more frequently affected was 20-40 years and the most causative agent was road trauma accident. Complications were found among two patients as intractable seizures, brain abscess formation, hydrocephalus and post operative jaundice in one patient each. Wound infections in four patients. Overall outcome was good in conservative and surgical intervention patients of brain contusions. The total mortality was four patients, two in each group of patients

Conclusion: Therefore we recommend that nonsurgical and surgical management has comparable results, but surgical decompressive craniotomy is the mainstay of treatment based on the essential monitoring tools as repeated interval scanning and neurological evaluation considering the timing of surgery, volume and size of hematoma, conscious status, bradycardia and hypertension

2011 dengue haemorrhagic fever outbreak in Lahore - an account of clinical parameters and pattern of haemorrhagic complications

To describe the frequency and outcome of dengue haemorrhagic fever [DHF] cases and determine the association of clinical and laboratory parameters with haemorrhagic complications. A descriptive study. Combined Military Hospital, Lahore, from August to November 2011. Clinical profile and outcome of 640 adult patients hospitalized with a strong clinical suspicion of dengue fever [DF] was evaluated. Based on serological confirmation, these patients were divided into confirmed DF and probable DF cases. They were also categorized according to severity into dengue fever [DF], dengue haemorrhagic fever [DHF] and dengue shock syndrome [DSS] cases according to WHO guidelines. After detailed clinical evaluation, blood samples were taken for a complete blood count, urea, creatinine, sodium, potassium, bilirubin, alanine aminotransferase [ALT], prothrombin time [PT] and activated partial thromboplastin time [APTT]. Patients were managed according to standard protocols with intravenous fluids and symptomatic treatment. SPSS 18 was used for statistical analysis of clinical data. Comparison of features among the groups was made using chi-square or t-test with significance at p < 0.05. There was 359 probable DF and 281 confirmed DF cases. The development of DHF, neurological manifestations and overall mortality was more frequent in confirmed DF group. Comparison between DHF/DSS and DF cases revealed a significant difference in vomiting [p = 0.04], purpuric rash [p < 0.001], systolic blood pressure [p = 0.002], serum ALT [p < 0.001], hospital stay [p < 0.001], neurological involvement [p < 0.001] and coagulopathy [p < 0.001] between the two groups. Among 159 DHF patients, 108 [67.9%] had bleeding from gums and oral cavity, 73 [45.9%] had haemetemesis and 82 [51.5%] malaena, 41 [25.8%] had epistaxis, 12 [7.5%] developed intracranial bleeding, 18 [11%] had hematuria, 12 [7.5%] had fresh bleeding per rectum and 37 [23%] developed haemoptysis. Overall mortality was 3%, but mortality in DHF/DSS cases was 6% and 41.6% for DSS cases. Logistic regression analysis showed that abdominal pain, purpuric rash, ascites, thrombocytopenia, coagulopathy and raised ALT had a statistically significant predictability for developing DHF. A variety of manifestations including that abdominal pain, purpuric rash, ascites, thrombocytopenia, coagulopathy and raised ALT had a statistically significant predictability for developing DHF. A knowledge and understanging of these complictions would be useful for the management of patients if such outbreaks of DHF are encountered again

Pattern of dermatophytes among dermatological specimens at AFIP, Rawalpindi

To determine the types and prevalence of dermatophytes from the clinical specimens received at Armed Forces Institute of Pathology [AFIP]. Study design is descriptive. The study was carried out at the Department of Microbiology, AFIP Rawalpindi from June 2009 to May 2010. Total of 400 different clinical specimens were dealt during the study period. After direct microscopy, they were inoculated on Sabouraud's dextrose agar with and without antimicrobials. The plates were incubated at 220C and examined twice weekly up to four weeks for any fungal growth. Species identification was done through colony morphology and microscopic examination of lactophenol blue preparation. Out of total specimens, 221[55.25%] yielded fungal growth. The overall yield of dermatophytes from different specimens was in the order of nail [78%], followed by skin [18.3%] and hair [3.3%]. Mycological infections have growing importance because of the increasing population of immune-compromised patients warranting a high index of suspicion

Ambu bag as a source of Acinetobacter baumannii outbreak in an intensive care unit

This case report describes an outbreak of multidrug resistant Acinetobacter baumannii in the intensive care unit of a tertiary care hospital. Three patients were infected on the same day from an Ambu bag which was used on all the patients. The outbreak was immediately identified and the source was traced within one week. Appropriate measures were taken and a continuous surveillance was carried out resulting in reporting of no such case from the intensive care unit in the last 6 months

Factors predicting the recurrence of spontaneous bacterial peritonitis in patients with cirrhosis

To evaluate the frequency of recurrence of spontaneous bacterial peritonitis [SBP] in patients with end stage liver disease and the factors responsible for it. Descriptive study. The Aga Khan University Hospital, Karachi, from November 2008 till November 2009. Patients with cirrhosis who were admitted at AKUH with diagnosis of SBP during the study period were included. Any episode of SBP after resolution of the first index case of SBP within one year was considered as recurrence. Out of 238 cirrhotic patients, 157 [66%] had single, while 81 [34%] had recurrent episodes of SBP. History of using proton pump inhibitors [PPI] and diuretics was found in 113 [47.5%] and 139 [58.4%] patients respectively. Only 58 [24.4%] patients were on prophylactic antibiotic therapy. Univariate analysis revealed that the female gender [52%], and presence of porto-systemic encephalopathy [PSE, 31%] were statistically significant [p=0.03] among those who had recurrent SBP. On multivariate analysis bilirubin level of > 1.0 mg [OR=7.03; 95%CI=1.55-32], protective factor of hepatitis B [OR 0.31; 95%CI=0.13-0.70] and presence of urinary tract infection [UTl] [OR=2.24; 95%CI=0.99-5.09] were significant in patients with recurrent SBP. Recurrent SBP was noticed in 34% patients. Serum bilirubin level of > 1.0 mg, protective factor of HBV and presence of UTl were significant factors present in patients with recurrent SBP

Severe isolated primary hypoparathyroidism in an adult

A man aged 42 years, presented with 3 years history of paraesthesias in hands and feet and muscle cramps off and on, progressing to severe carpopedal spasm, a couple of times, relieved by intravenous calcium gluconate at the emergency reception of the hospital. On examination, Trousseau's sign and Chvostek's sign were positive. Thyroid gland was not enlarged. Right eye showed mature cataract. Total serum calcium, corrected serum calcium, serum phosphate, ionized serum calcium, serum alkaline phosphatase, serum parathormone [PTH] level were deranged favouring hypoparathyroidism. He was diagnosed to be suffering from isolated primary hypoparathyroidism and put on alfacalcidol and oral calcium carbonate, with which he is asymptomatic now

Efficacy of chloroquine monotherapy against plasmodium vivax malaria

To determine the in vivo efficacy of chloroquine monotherapy against Plasmodium [P.] vivax and frequency of relapse/reinfection. Quasi-experimental study. Place and duration of study: Department of Medicine, Combined Military Hospital, Quetta Balochistan, from July 2006 to February 2007. One hundred and ninety one subjects with positive plasmodium vivax slide were included in the study. Mean, median, minimum and maximum values along with standard deviation of age and parasite clearance time were calculated. Frequency of relapse/reinfection was estimated and significance was determined by applying test of significance. Of the 191, 21 developed P.vivax relapse/reinfection in the six months follow up. Mean duration of relapse/reinfection was 37.76 days while mean parasite clearance time was almost 30 hours in both initial infection and relapse. Chloroquine monotherapy is still effective in the management of P.vivax malaria in our set up and antirelapse therapy is not routinely indicated

Frequency of metabolic syndrome in type 2 diabetes and its relationship with insulin resistance

The metabolic syndrome is a cluster of various cardiovascular disease risk factors: diabetes and pre-diabetes, abdominal obesity, hyperlipidaemia and high blood pressure. People with metabolic syndrome are twice as likely to die from and three times as likely to have a heart attack or stroke compared with people without the syndrome. The objective of the study was to observe the frequency of metabolic syndrome [MetS] in patients with type 2 diabetes mellitus and study the relationship of insulin resistance with the metabolic syndrome and its different clinical parameters. The study was conducted at Combined Military Hospital, Malir, in about six months. Hundred and fifty-five patients with type 2 diabetes were included in the study, who were diagnosed after 25 years of age. All those suffering from any liver disease, non diabetic renal disease, thyroid hormonal disorder, advanced cardiac disease and cancers were excluded from the study. Insulin resistance was measured using homeostatic model assessment of insulin resistance [HOMA-IR] and International Diabetes Federation [IDF] criteria were used to diagnose metabolic syndrome. Among 155 type 2 diabetic patients, 66.5% were having metabolic syndrome [MetS] according to IDF criteria. This frequency was significantly higher in women [84.7%] as compared to men [44.3%]. Difference of means of HOMA-IR [Insulin resistance] in MetS present and MetS absent cases was statistically significant in men [p=0.02] but not in women [p=0.57], when compared through independent sample t-test. Insulin resistance [HOMA-IR] was not significantly correlated with waist circumference [r=0.24], BMI [r=0.16], triglycerides [r=0.22], HDL cholesterol [r=0.18] and HbA1c [r=0.35] but showed moderate correlation with fasting plasma glucose [r=0.44]. Among 39 patients belonging to the 4th quartile of HOMA-IR, i.e., the most insulin resistant people, 79% patients had MetS according to IDF criteria, and 21% patients did not have MetS. It is concluded that the frequency of MetS is significantly high in patients with type 2 diabetes. Insulin resistance as measured through HOMA-IR does not show significant correlation with clinical parameters of MetS in type 2 diabetics

Vancomycin resistant enterococcal sepsis in an acute myeloid leu kemic patient

Neutropenic fever is an important cause of morbidity and mortality during therapy of acute myeloid leukemia. Patients with acute myeloid leukemia are at increased risk of acquiring vancomycin resistant enterococcal infection and its treatment remains problematic. Vancomycin therapy for more than 7 days is usually associated with inducible vancomycin-resistant enterococcal infections. We report a case of vancomycin resistant enterococcal sepsis in a patient of acute myeloid leukemia

Frequency and characteristic features of portal hypertensive gastropathy in patients with viral cirrhosis

To determine the frequency and specific characteristic features of portal hypertensive gastropathy [PHG] in cirrhosis due to viral etiology. Cross-sectional descriptive study. The Aga Khan University Hospital, Karachi, from June 2006 till June 2008. Patients with hepatitis B and C cirrhosis were included who underwent screening esophago-gastro-duodenoscopy [EGD] for varices. Baveno III consensus statement was used for diagnosing PHG on endoscopy and divided them into two subgroups i.e. mild and severe. Data related to platelet/spleen ratio, MELD score and Child Turcotte Pugh [CTP] score indicating severity of cirrhosis were recorded in all patients. Findings were compared by using independent sample t-test. Out of 360 patients who underwent screening EGD, 226 [62.8%] were males. Two hundred and eighty one [78%] had hepatitis C while 79 [22%] suffered from hepatitis B related cirrhosis. Three hundred patients [83.3%] had PHG while 71 [24%] had severe PHG. Higher proportion of esophageal varices [89.7%] was present among those who had PHG [p < 0.001]. On univariate analysis lower platelet counts [117 +/- 55 vs. 167 +/- 90; p < 0.001], increased spleen size [14.1 +/- 2.9 cm vs. 12 +/- 2.4cm; p < 0.001] were found in PHG patients as compared to those without it. Similarly, lower platelet/spleen ratio was noted in patients with severe PHG [916 +/- 400 vs. 1477 +/- 899; p < 0.001]. Furthermore, on multivariate analysis CTP score > 8 MELD score > 12 and platelets/spleen ratio < 900 were significantly associated factors with severe PHG. Frequency of PHG was 83% while severe PHG was seen in 24% cases of viral hepatic cirrhosis. MELD score > 12, CTP score >/= 8 and platelets/spleen ratio

Extended-spectrum beta-lactamase production in sbigella flexneri

Emergence of multidrug-resistant strains of Shigella is a growing concern across the globe. Third-generation cephalosporins are used for treating infections caused by multidrug-resistant Shigellae. However, resistance to these cephalosporin antibiotics due to extended-spectrum beta-lactamases, has emerged as a new problem. So far extended-spectrum beta-lactamases producing Shigella has not been reported from Pakistan. We report such a case in Shigella flexneri from an 8-year old girl with acute dysentery

Evaluation of quality and patient satisfaction during endoscopic procedure: a cross sectional study from South Asian country

To assess the quality of gastrointestinal [Gl] endoscopic procedures and patient satisfaction in endoscopy suite of South Asian country. Patients coming to the endoscopic suite of Aga Khan University Hospital [AKUH] were interviewed and assessed in this cross-sectional study. Quality of Gl endoscopic procedures was evaluated using assessment tools as suggested by The American Society of Gastroenterology. Patient satisfaction after the procedure was assessed using a modified GHAA-9 questionnaire. The questionnaire was statistically evaluated using Pareto analysis and Spearman rank correlation. In this study, 323 patients were evaluated with a mean age of 43 +/- 14.36 years. Out of all the procedures 251 [77.7%] were gastroscopies while 72[22.3%] were colonbscopies. Patients undergoing different therapeautic procedures were 121 in number [37.46%]. Pre-procedure education was rated as excellent or very good by 91.3% of the patients. Midazolam was used for sedation with an average dose of 3 mg. Technically successful procedures included 99.2% gastroscopies and 98.6% colonoscopies. Mean score of patients regarding satisfaction on mGHAA-9 questionnaire was 30 +/- 3.965. Patient dissatisfaction calculated In our study was 3.6% with the length of time spent waiting before procedure and length of time waiting to get an appointment for the procedure contributing to 90% of dissatisfaction. Quality of endoscopic procedures at our centre is at par with international standards with acceptable complication rate and good patient satisfaction

Frequency of extended spectrum beta-lactamases [ESBL] producing nosocomial isolates in a tertiary care Hospital in Rawalpindi

To find out the frequency of extended spectrum beta-lactamases [ESBL] producing organisms among Gram negative rods from clinical specimens. This was a descriptive study. The study was carried out in the Microbiology Department of Army Medical College, Rawalpindi from 1 Jan 03 to 31 Dec 03 on clinical samples received from admitted patients in Military hospital, Rawalpindi. It was carried out on clinical specimens of urine, blood, pus, catheter tips, fluids including CSF, sputum, chest tube, HVS and i/v canula/CVP line obtained from admitted patients in Military Hospital, Rawalpindi. The organisms were identified by standard techniques. Confirmation to the species level was done by API 20 E and API NE where required. Sensitivity testing was carried out by Modified Kirby Bauer disc diffusion method on Mueller Hinton agar incubated at 35o C in ambient air for 24 hrs. ESBL producing strains were identified by double disc diffusion method test according to Jarlier et al. Clavulanate was applied as the inhibitor of beta lactamases [AMO/CLAV disc]. The results were tabulated as frequencies. Forty three percent of clinical isolates yielded ESBL producing gram negative rods. Enterobacter cloacae [76%], Klebsiella oxytoca [68%] Acinetobacter baumanni, [63%] and Aeromonas hydrophila [50%] were the most frequent ESBL producing bacteria. Production of ESBL among Gram negative rods is frequent in Military Hospital, Rawalpindi. Infection control measures are required to control their spread

Changing trends in frequency of extended spectrum beta lactamase producing gram negative bacilli in intensive care units of a tertiary care hospital

To determine the frequency of isolation of extended spectrum beta lactamase [ESBL] producing Gram negative bacteria from intensive care units [ICUs] of a tertiary care hospital. Retrospective descriptive study. The study was carried out at the department of microbiology Army Medical College Rawalpindi from Dec 2003 to Nov 2007. This study was carried out from Dec 2003 to Nov 2007. A total of 590 consecutive Gram-negative bacilli were recovered during the four year study period from various samples including urine, blood, pus, sputum, high vaginal swabs [HVS], ascitic fluid, central venous lines [CVP], chest tubes, catheter tips, NBL [nasobronchial lavage], CSF, tissue, endotracheal tube [ETT] tip and pleural fluid in ICUs. Extended spectrum Beta-lactamase detection in these isolates was carried out by Kirby- Bauer double disc synergy method. The frequency of ESBL producing organisms was 84 [66%] [December 03 to November 04], 80[54%] [December 04 to November 05], 80[57%] [December 05 to November 06] and 82 [47%] [December 06 to November 07] [p<0.0001] Our study shows a decrease in the frequency of ESBL producing organisms. However there is an increase in the resistant organisms having same resistance pattern, but not detected as ESBL producers, therefore we need to improve the methods for ESBL detection

Susceptibility pattern and frequency of extended specturm beta-lactamase producers in a tertiary care hospital

Infections with extended spectrum beta-lactamase [ESBL] producing organisms continue to be associated with higher rates of mortality, morbidity and health care costs. This study was carried out to find out frequency and sensitivity pattern of ESBL producers among Gram negative rods [GNRs] from clinical isolates of a tertiary care Hospital. A total of 1430 GNRs were recovered from 2347 clinical samples received from admitted patients in Military Hospital Rawalpindi. All samples were dealt by standard microbiological methods. Extended spectrum beta-lactamase detection in these isolates was done by double disc approximation test of Jarlier et al, 1988. Frequency of GNRs among clinical isolates was 61% and about 33% of these were ESBL producers. Escherichia coli were the most frequent ESBL producers followed by Klebsiella pneumoniae. Most of the ESBL producers were isolated from urine followed by catheter tips and pus. Among all the antibiotics tested, ESBL producers showed highest susceptibility to carbapenems followed by amikacin. Organisms showing resistance pattern similar to ESBLs were also significant. Continued surveillance by clinical microbiology laboratories, judicious use of antimicrobial agents and implementation of infection control measures are recommended to reduce the frequency of ESBL isolates