Clinical characteristics of pulmonary tuberculosis in adult Pakistani patients with co-existing diabetes mellitus.

A review was made of the records of all patients with pulmonary tuberculosis and diabetes mellitus admitted over a 5-year period to a teaching hospital in Karachi, Pakistan. Among 42358 patients, the total number with both tuberculosis and diabetes was 173. The prevalence of tuberculosis in diabetic patients was 10-times higher than in non-diabetic patients and prevalence increased with duration of diabetes. The lower lung field was most frequently involved, followed by the upper and middle. Bilateral involvement was seen in half and an associated pleural effusion in one-third of the patients. Cavitating lesions were seen in 32% of men and 15% of women.

Clinical characteristics of pulmonary tuberculosis in adult Pakistani patients with co- existing diabetes mellitus

A review was made of the records of all patients with pulmonary tuberculosis and diabetes mellitus admitted over a 5- year period to a teaching hospital in Karachi, Pakistan. Among 42358 the total number with both tuberculosis and diabetes was 173. The prevalence of tuberculosis patients, in diabetic patients was 10- times higher than in non- diabetic patients and prevalence increased with duration of diabetes. The lower lung field was most frequently involved, followed by the upper and middle. Bilateral involvement was seen in half and an associated pleural effusion in one- third of the patients. Cavitating lesions were seen in 32% of men and 15% of women

Medical interns knowledge of TB in Pakistan.

Of 460 interns from five Pakistani teaching hospitals surveyed, only 22% correctly identified the estimated number of new TB cases in Pakistan. The majority (96%) knew that droplet infection was the usual mode of transmission. Only 38% considered sputum smears for acid-fast bacilli as the best test for diagnosis of pulmonary TB and 43.5% for follow-up during TB treatment. The recommended four-drug anti-TB regimen was prescribed by 56.5% in the initiation phase and the recommended two-drug combination in the continuation phase by 52%. Most interns (82%) were unable to identify a single component of directly observed treatment short course (DOTS) strategy. Our study reflects poor awareness of and low compliance to the World Health Organization/National Tuberculosis Programme guidelines among interns. For effective control of TB, immediate action to improve undergraduate and continuing medical education is essential, with special emphasis on national guidelines.

Trends in hospital-based management of acute asthma from a teaching hospital in South Asia.

The aim of this study is to evaluate the hospital-based management of acute asthma in south Asia and to compare practices over a 10-year period. Adult patients (n = 102) admitted at a teaching hospital with acute asthma were studied. Documentation of precipitating factors, family history and physical signs were inadequate in more than half of patients. Pulse oximetry was documented in 95 (93%) patients, but peak flow monitoring was performed only in 50 (49%) patients. Ten-year trend showed deterioration in history and physical examination skills, under use of peak flow readings, and poor pre-discharge instructions. Some aspects of improved care included frequent use of pulse oximeter, preference of inhaled over systemic bronchodilators and increased use of systemic steroids. Significant deficiencies were identified in hospital-based management of acute asthma. Most aspects of asthma care continued to fall short of asthma guidelines.

Smoking prevalence, knowledge and attitudes among medical students in Karachi, Pakistan.

A survey of smoking prevalence and attitudes was made among medical students randomly selected from classes at the Aga Khan University, Karachi, Pakistan. Of 271 respondents, 14.4% were current smokers (22.0% male and 3.8% females) and 3.3% ex-smokers. A majority of students recognized the dangers associated with active as well as passive smoking although only 55% of current smokers planned to quit in the near future. Most smokers (96%) believed that they as well as other health professionals needed training on smoking cessation and 95% of all students believed that doctors should play a role model in smoking cessation by not smoking themselves. Specific training and counselling should be a part of the required curriculum at medical schools.

Smoking prevalence, knowledge and attitudes among medical students in Karachi, Pakistan

A survey of smoking prevalence and attitudes was made among medical students randomly selected from classes at the Aga Khan University, Karachi, Pakistan. Of 271 respondents, 14.4% were current smokers [22.0% male and 3.8% females] and 3.3% ex-smokers. A majority of students recognized the dangers associated with active as well as passive smoking although only 55% of current smokers planned to quit in the near future. Most smokers [96%] believed that they as well as other health professionals needed training on smoking cessation and 95% of all students believed that doctors should play a role model in smoking cessation by not smoking themselves. Specific training and counselling should be a part of the required curriculum at medical schools

Massive pleural effusion and marked increase of CA-125.

The tumour associated CA-125 antigen is widely used in monitoring ovarian carcinoma. In women with a massive pleural effusion and ascites, markedly increased CA-125 levels may lead to an erroneous diagnosis of ovarian cancer. Very high levels of tumour markers may be present in patients with benign pleural effusion, ascites, and chronic liver disease. Raised levels of tumour markers in serum or pleural fluid, in the absence of positive cytology, should be interpreted with caution.

Asthma management by general practitioners in Pakistan.

SETTING: Teaching university hospital in Karachi, Pakistan. OBJECTIVES: Asthma management guidelines have been developed to assist practising physicians in treating asthma patients. The objective of this study was to evaluate if the prescribing habits of practitioners in Karachi were consistent with the published asthma guidelines. DESIGN: A questionnaire survey was conducted among practitioners attending a pulmonary continuing medical education (CME) programme. Three case scenarios of asthma were given, and the doctors were asked to write a prescription for each case. Doctors were asked about their views on inhaler therapy and dietary restrictions in asthma. RESULTS: Of 120 doctors, 100 (83%) responded. Thirty different regimens of short acting beta2-agonist and 16 regimens of steroid therapy were prescribed by the practitioners. Only 35% of the doctors prescribed corticosteroids for persistent asthma symptoms. The great majority of doctors were not aware of treatment options for persistent symptoms despite the use of preventive therapy (8% prescribed long-acting beta2-agonists, 6% high-dose inhaled corticosteroids and 13% theophyllines). Misconceptions about inhaler therapy and diet were found in 20 and 50 doctors, respectively. CONCLUSION: General practitioners in Pakistan did not follow asthma management guidelines. There was serious lack of knowledge about asthma medications coupled with misconceptions about inhaler therapy and dietary factors.

Clinical characteristics of 110 miliary tuberculosis patients from a low HIV prevalence country.

SETTING: A university teaching hospital in Karachi, Pakistan. OBJECTIVE: To define the clinical characteristics and outcome of miliary tuberculosis (TB) patients from a low human immunodeficiency virus (HIV) prevalence country. DESIGN: Review of adult miliary TB patients admitted between 1994 and 2001. Clinical characteristics of those dying from miliary TB were compared with those of the survivors. RESULTS: Most of the 110 cases reviewed were middle aged or elderly, with a female preponderance. An underlying medical condition was present in 47%. Presenting symptoms were of several weeks' duration, and mostly constitutional (fever and weight loss). Common laboratory findings included anaemia (62%), lymphopaenia (71%), hyponatraemia (74%), elevated serum alkaline phosphatase (57%) and hypoalbuminaemia (92%). Typical miliary pattern was observed in 77% of radiographs. Sputum smear and culture were positive in respectively 36% and 52% of those tested. Biopsy was performed in selected patients. Mean hospital stay was 8.8 days, and mortality was 30%. Those who died were significantly older than survivors and had a more fulminant course. Presence of altered mental status, lung crackles, leucocytosis, thrombocytopaenia and the need for ventilation were associated with increased mortality. CONCLUSION: Miliary TB carries a high mortality. It should be considered in patients who present with prolonged systemic symptoms. A positive TB culture or biopsy is needed to establish a diagnosis.

Overnight home oximetry: can it identify patients with obstructive sleep apnea-hypopnea who have minimal daytime sleepiness?

BACKGROUND: Overnight home oximetry is being widely used as a case selection technique for patients with suspected obstructive sleep apnea-hypopnea (OSAH). In the absence of excessive daytime sleepiness (EDS), patients with snoring and/or witnessed apnea are considered to have low probability of OSAH. METHODS: Patients suspected to have OSAH, who denied EDS, and had a normal overnight home oximetry were studied by polysomnography for presence of significant OSAH (apnea/hypopnea index (AHI) > 15/h). RESULTS: Twelve (40%) of the 30 patients studied had significant OSAH. All had a 2% oxygen desaturation index of less than 10/h. The sensitivity of oximetry increased at lower desaturation indices butthis was associated with decreased specificity. Review of oximetry waveform pattern, by experienced physicians, did not improve the diagnostic accuracy. Combining oximetry with a clinical prediction rule would have reduced the need for polysomnography by 30%. CONCLUSION: Many patients, who present with snoring and/or witnessed apnea and are referred to a sleep disorder clinic for suspected OSAH, may have significant OSAH even if they deny EDS. Overnight home oximetry did not help discriminate between those patients with or without OSAH.

Tuberculosis diagnosis and treatment practices of private physicians in Karachi, Pakistan.

In a densely populated urban area of Karachi, Pakistan, a questionnaire survey was made of the knowledge and practices of 120 private general practitioners about the diagnosis and treatment of tuberculosis (TB). The majority knew that cough, fever and weight loss were the main symptoms of TB, but less than half knew that blood in sputum, poor appetite and chest pain were associated with the disease. Only 58.3% of physicians used sputum microscopy for diagnosing TB and 35.0% used it as a follow-up test. Only 41.7% treated TB patients themselves, the remaining referring their patients to specialists. Around 73.3% of the doctors were aware of the 4 first-line anti-TB drugs. Efforts to improve the knowledge of private practitioners, and strategies to enhance public-private collaboration forTB control in urban areas are urgently required.

Tuberculosis diagnosis and treatment practices of private physicians in Karachi, Pakistan

In a densely populated urban area of Karachi, Pakistan, a questionnaire survey was made of the knowledge and practices of 120 private general practitioners about the diagnosis and treatment of tuberculosis [TB]. The majority knew that cough, fever and weight loss were the main symptoms of TB, but less than half knew that blood in sputum, poor appetite and chest pain were associated with the disease. Only 58.3% of physicians used sputum microscopy for diagnosing TB and 35.0% used it as a follow-up test. Only 41.7% treated TB patients themselves, the remaining referring their patients to specialists. Around 73.3% of the doctors were aware of the 4 first-line anti-TB drugs. Efforts to improve the knowledge of private practitioners, and strategies to enhance public-private collaboration for TB control in urban areas are urgently required

A hospital based preliminary report on sleep disordered breathing in Pakistani population.

BACKGROUND: Sleep Disordered Breathing is an important medical condition leading to significant morbidity and mortality. Western studies have shown its prevalence in middle age to be 9% in women and 24% in men. The aim of this study was to have a preliminary assessment on the frequency of Sleep Disordered Breathing in Pakistani subjects. METHOD: Patients attending a medical clinic were surveyed. A sleep questionnaire elicited information about snoring, witnessed apnea, nocturnal choking and excessive daytime sleepiness. Data were recorded for age, height, collar size and weight. Epworth Sleepiness Scale was used to assess excessive daytime sleepiness. Statistical analysis was by chi square test, t-test and Fisher's exact test. A p-value less than 0.05 was considered significant. RESULTS: A total of 123 subjects (M:F = 2:1) were included in the study. The frequency of snoring was found to be 46%. Snoring with apnoea was reported in 7% and snoring with apnoea and excessive daytime sleepiness in 3%. Snorers were more obese (p < 0.001), older (p < 0.003), with higher body mass index (p < 0.001) and larger collar size (p < 0.006) than non-snorers. Hypertension was more common in patients with sleep disordered breathing (35%) as compared to those without (16%). CONCLUSIONS: This is the first preliminary data on sleep disordered breathing from Pakistan that reflects that the prevalence is similar to that seen in the West. The risk factors and association with hypertension are also comparable.

Is there a value of mantoux test and erythrocyte sedimentation rate in pre-employment screening of health care workers for tuberculosis in a high prevalence country?

SETTING: Pre-employment screening of health care workers (HCWs) is practiced widely. Research needs to be carried out to evaluate the screening procedure in developing countries. OBJECTIVE: To evaluate the efficacy of Mantoux test and erythrocyte sedimentation rate (ESR) for the diagnosis of active tuberculosis (TB), in pre-employment screening of HCWs, in a high prevalence country. DESIGN: Pre-employment screening of all new employees was reviewed from June to September 2000. The screening consisted of history, physical examination, blood and urine tests, Mantoux test and a chest radiograph. Patients with clinical, laboratory or radiological features suggestive of active TB were referred to a specialist. RESULTS: Out of 207 employees, a Mantoux reaction of > or = 10 mm and ESR of > or = 25 mm/first hour was noted in 90 (43.5%) and 21 (10.1%), respectively. One person had symptoms suggestive of TB and was already on anti-tuberculosis therapy at the time of screening. All other employees were asymptomatic. Based on radiographic findings, four (2%) cases were referred and one was given anti-tuberculosis therapy. An additional 48 (23.1%) employees were referred on the basis of positive Mantoux or elevated ESR; none were found to have active TB. CONCLUSION: In high prevalence countries use of Mantoux test and ESR in pre-employment screening of HCWs is not recommended for detection of active TB.

Heterogeneity of the memory CD4 T cell response: persisting effectors and resting memory T cells.

Defining the cellular composition of the memory T cell pool has been complicated by an inability to distinguish effector and memory T cells. We present here an activation profile assay, using anti-CD3 and antigenic stimuli, that clearly distinguishes effector and memory CD4 T cells and defines subsets of long-lived memory CD4 T cells based on CD62 ligand (CD62L) expression. The CD62L(low) memory subset functionally resembles effector cells, exhibiting hyper-responsiveness to antigenic and anti-CD3 mediated stimuli, high proliferative capacity, and rapid activation kinetics. The CD62L(high) memory subset functionally resembles resting memory cells, exhibiting hyporesponsiveness to anti-CD3 stimuli, lower proliferative capacity, and slower activation kinetics. Our results indicate that the memory CD4 T cell pool is heterogeneous, consisting of persisting effectors and resting memory T cells.

[Atypical endometrial hyperplasia. Prognosis and course]. / Atypisk hyperplasi i endometriet. Prognose og forløb.

The treatment of patients with the diagnosis atypical endometrial hyperplasia has been disputed during the last decades. The aim of the study was to evaluate the treatment of these patients and analyse the progression rate to invasive carcinoma of the endometrium. Fifty-seven patients with atypical hyperplasia were examined and treated from 1976 through 1991. The medical records were examined retrospectively and the pathology slides were revised by one pathologist in accordance with the 1975 WHO recommendations. Thirty-one (54%) patients were on oestrogen treatment as monotherapy at the time of diagnosis. Forty-two patients had a hysterectomy performed within five months, and five patients had a hysterectomy performed 10 to 61 months after diagnosis. A total of 18 out of 57 patients (31.6%) had or developed endometrial carcinoma all with myometrial invasion: 14 stage I with < or = 50% myometrial invasion, three stage I with > 50% myometrial invasion, and one stage IV. There was no significant difference in age, body mass index, parity or hormone replacement treatment between the group with endometrial carcinoma and the group without endometrial carcinoma. We conclude that unopposed oestrogen treatment and nulliparity are the main risk factors for atypical hyperplasia and that hysterectomy is the appropriate treatment for patients with atypical hyperplasia of the endometrium.

Effector CD4 T cells are biochemically distinct from the memory subset: evidence for long-term persistence of effectors in vivo.

Memory T cell responses are believed to be mediated by long-lived memory T cells that arise directly from a subset of short-lived, activated effector T cells that have reverted to the resting state. Although widely accepted, definitive proof that memory T cells arise from effectors is lacking because of the inability to reliably distinguish these subsets based on known phenotypic or functional parameters. We have used a biochemical approach to distinguish effector and memory CD4 T cell subsets and follow the differentiative fate of effector cells in vivo. When examined biochemically, effector and memory CD4 T cells are strikingly distinct and exhibit qualitative and quantitative differences in tyrosine phosphorylation. These effector-specific patterns were identical in effectors derived either from naive CD4 T cells (primary effectors) or memory CD4 T cells (memory effectors). To monitor the fate of effector cells in vivo, Ag-activated CD4+ TCR-transgenic T cells were transferred into irradiated BALB/c mice. These TCR-transgenic CD4 T cells persisted in adoptive hosts for several months, gave a recall response to Ag, yet exhibited effector-specific biochemical profiles. These results suggest that a subset of effector CD4 T cells can persist in vivo and contribute to long-term immunity by mediating secondary immune responses.

Pneumothorax: a review of 146 adult cases admitted at a university teaching hospital in Pakistan.

OBJECTIVE: There is a lack of data on the etiology and outcome of pneumothorax among the Pakistani population. Our aim was to review the etiology, clinical course, management and outcome of patients presenting with pneumothorax. PATIENTS AND METHODS: All adult cases with pneumothorax admitted to a University Teaching Hospital in Karachi, between January 1992 and June 1996, were reviewed and analyzed. RESULTS: A total of 146 patients were reviewed. Their mean age was 46.3 years (SD +/- 17.8 years) with a male to female ratio of 3.7:1. Secondary pneumothorax was the commonest type seen (45%), followed by traumatic (21%), iatrogenic (18%) and primary (16%). Tuberculosis (47%) and COPD (45%) were most common lung diseases associated with secondary pneumothorax. Pneumothorax secondary to TB presented at an earlier age than that with COPD (49.6 vs. 60.1 years). Similarly, patients with primary pneumothorax were significantly younger than patients with secondary pneumothorax (42.3 vs. 51.7 years). Rib fracture was the most common cause of traumatic pneumothorax. Coronary artery bypass grafting, transthoracic fine needle aspiration and neck vein cannulations were the leading iatrogenic causes. The commonest symptoms of pneumothorax were dyspnea (68%) and chest pain (40%). Most cases (81%) were successfully managed by intercostal tube drainage. CONCLUSION: In our study population, secondary pneumothorax was the commonest variety seen. TB was the commonest cause of secondary pneumothorax, closely followed by COPD. Nearly 40% of pneumothorax were either traumatic or iatrogenic. Intercostal tube drainage remains the treatment of choice for pneumothorax.