Primary non-typhoidal Salmonella infection presenting as a splenic abscess in a healthy adolescent male.

Isolated splenic abscess in a previously healthy patient is a rare clinical condition and remains a diagnostic dilemma. Clinical presentation is often non-specific and leads to a delay in diagnosis. Imaging studies help to elucidate the condition. Despite advances in medical diagnostics and therapeutics, splenic abscesses can cause significant morbidity and can be fatal. Although splenectomy was considered the treatment of choice in the past, recent trends have seen a shift towards more conservative management. We present the clinical case of a patient who presented to our emergency room with a chief complaint of left shoulder and left upper quadrant abdominal pain. Abdominal imaging showed an intrasplenic collection suspicious for a hemorrhage or an abscess. Percutaneous drainage was successfully performed, followed by conservative management with intravenous antibiotics. The culture of the fluid drained from the spleen was positive for Salmonella Saintpaul. The patient improved and was discharged. A high degree of clinical suspicion is necessary for early identification of a splenic abscess. Splenectomy can be avoided with the use of interventional radiological drainage.

Conservative surgery for osteoid osteoma of the lumbar vertebrae.

BACKGROUND: We present two patients with osteoid osteomas of the lumbar spine to highlight the delay in diagnosis and the utility of precise radiological localization enabling tumor resection without jeopardizing spinal stability. CASE DESCRIPTION: Two young patients with refractory back pain presented after having undergone a year of conservative treatment for presumed mechanical back pain. The presence of "red-flag" symptoms (e.g. rest and night pain, and transient pain relief with aspirin) led to the performance of an isotope bone scan, and subsequent computed tomography (CT), which were both consistent with the diagnosis of an osteoid osteoma. After accurate CT-based preoperative planning for tumor excision, a customized conservative surgical technique was utilized that included marginal en-bloc surgical resection of the tumors. As the intervertebral facet joints were also carefully preserved along with stability, no accompanying instrumented fusion was warranted. Both patients returned to full function with complete resolution of their long-standing back pain of more than 2 years. CONCLUSIONS: The diagnosis of osteoid osteoma of the spine requires a high index of clinical suspicion. Diagnostic evaluations should include thin-slice CT scan to assist in planning the most restricted/conservative en-bloc surgical resection while preserving vertebral stability with facet preservation, and thus avoiding instrumented fusions. Without the availability of percutaneous radiofrequency ablation, such restricted/conservative approaches to osteoid osteomas are viable options in countries with developing economies.

The study of etiological and demographic characteristics of pterygium recurrence: a consecutive case series study from Pakistan.

To determine the agents of recurrence, the demographic features, and the management and outcomes of pterygium cases treated at Aga Khan University Hospital (AKUH), Karachi. This hospital-based descriptive study included 147 patients with pterygium (147 eyes) from both sexes, who presented at the Ophthalmology Department at AKUH between January 1, 2002 and December 31, 2010. Data regarding their demographic profile and other factors were collected in a well-structured proforma. Data were analyzed using frequencies, proportions, group means, standard deviations, and Pearson's chi squared test. The male to female ratio in our study was 2:1, with factors such as younger age (<50 years) at presentation (P = 0.04, Pearson's chi squared test) and the presence of secondary pterygium (P = 0.050) correlated significantly with the recurrence of pterygium. There was a definite trend of decreased recurrence seen with lower grade of pterygium (P = 0.06). The recurrence rate in our study was 8.8 %. These results suggest that a younger age coupled with a higher grade of pterygium as well as a history of multiple recurrences leads to increased susceptibility of recurrence after surgical excision. Early diagnosis and appropriate management will lead to a better prognosis.

Pterygium recurrence related to its size and corneal involvement.

OBJECTIVE: To establish the usefulness of grading system based on the size and extent of corneal involvement in predicting recurrence in patients undergoing primary pterygium excision with intraoperative use of adjunctive topical Mitomycin-C (MMC). STUDY DESIGN: A case series. PLACE AND DURATION OF STUDY: Section of Ophthalmology, the Aga Khan University Hospital, Karachi, from 2005 till 2010. METHODOLOGY: One hundred and twenty male patients (120 eyes) underwent surgical removal of pterygium using bare sclera method with MMC in concentration of 0.2 mg/ml (0.02%) with exposure time of 3 minutes. Classification of subjects was done according to the grading of pterygium. Patients were followed at 3 months interval for a minimum period of 1 year to record any recurrence. RESULTS: The pterygium recurrence rate was 6.7% at a follow-up of 1 year. There was no significant association of pterygium recurrence with younger age (p = 0.14). A higher level of corneal involvement by the pterygium at presentation correlated significantly with the recurrence (p = 0.01). CONCLUSION: These results suggest that a higher grade of pterygium at presentation in patients leads to increased rate of recurrence after surgical excision. Hence, early excision of pterygium is recommended to decrease its recurrence rate.

The ethical dilemma of embryonic stem cell research.

To determine the knowledge, attitude, and ethical concerns of medical students and graduates with regard to Embryonic Stem Cell (ESC) research. This questionnaire based descriptive study was conducted at the Civil Hospital Karachi (CHK), Pakistan from February to July 2008. A well structured questionnaire was administered to medical students and graduate doctors, which included their demographic profile as well as questions in line with the study objective. Informed consent was taken and full confidentiality was assured to the participants. Data were entered in a Statistical Package for Social Sciences (SPSS version.12) and analyzed. A total of 204 male and 216 female medical students and doctors were administered questionnaires out of which 105 males (51.4%) and 108 females (50%) were aware of the embryonic stem cell research and its ethical implications. Forty percent males and 47% of females were of the opinion that life begins at conception. Forty-six percent males and 39% females were in favor of stem cell research while only 31% males and 28% females supported the ESC research. Less than 1/3 of students supported using frozen embryos for research purposes while more than 2/3 indicated that they were unlikely to support abortion for stem cell research purposes. The majority of the students were in favor of stem cell research with some reservations regarding ESC research. A sizeable number of students withheld their views, reflecting their poor understanding of medical ethics. The result of the study indicates a need for incorporating bioethics into the medical curriculum.

The study of etiological and demographic characteristics of neonatal mortality and morbidity - a consecutive case series study from Pakistan.

BACKGROUND: To determine the etiology, management, bacteriological spectrum and outcome of neonatal patients admitted in Civil Hospital Karachi (CHK) and to examine the factors associated with it. METHODS: This hospital based descriptive study of 1463 patients from both sexes who were admitted to Paediatric department, CHK from 1st January 2008 till 31st December 2010 with an established cause according to modified Wigglesworth classification and fulfilling other inclusion criteria were included in the study. Data regarding their demographic profile and potential risk factors was collected on a well structured proforma. Cases were followed until discharge or expiry. Data was analyzed using descriptive statistics. RESULTS: The male to female ratio in our study was 1.12:1. Seven hundred and thirty-four patients were delivered at home (50.2%) and 1010 were less than 7 days old (69%). Out of the total cohort of expired subjects, 89 participants (74.8%) were < 7 days of life. Mortality was more in neonates born at home in rural areas to illiterate mother; 74 patients (62.2%). Most of the deaths; 57 were in neonates suffering from specific infections (47.9%) followed by 38 deaths in immaturity group (31.9%) and 19 related to asphyxial conditions (15.9%). The most common isolates were Staphylococcus aureus (28.7%) followed by Klebsiella (24.8%) and Pseudomonas aeruginosa (16.6 ). One hundred and nineteen (8.13%) of the neonates died in our study group. CONCLUSIONS: These results suggest that neonates with illiterate mothers with high parity and below average socioeconomic level were more susceptible to mortality in the early neonatal period. Most of the cases of mortality were due to specific infections.

To determine the level of satisfaction among medical students of a public sector medical university regarding their academic activities.

BACKGROUND: An ongoing evaluation system is essential to determine if the academic system in place has worked to produce a better product, hence the objective of our study was to evaluate the satisfaction level among medical students regarding their academic teaching and assessment method and what measures will they suggest for the future to rectify the current situation.This questionnaire based cross sectional study was conducted in a public sector medical university from February to July 2010. A well structured questionnaire was administered to a random sample of 375 final year medical students. However 292 of the students provided informed consent and filled in the questionnaire which included their demographic profile as well as questions in line with the study objective. Data was entered in a Statistical Package for Social Sciences (SPSS version.16) and analyzed using descriptive statistics. FINDINGS: The male to female ratio in our study was 1:2. Most of the students (57.2%) were dissatisfied with the quality of teaching in the university. Fifty-seven percent of the participants believed that the current standard of their institute were not at par with those of international medical universities. BCQ's were the mode of examination questions preferred by the majority of the students. Most of the students (66.1%) wanted the university to conduct career planning seminars to help them plan their career. CONCLUSIONS: These results suggest that the students of public sector medical universities are unsatisfied from current academic facilities and teaching activities. Students recommend increased emphasis on better lectures and practical training as well as a need to incorporate career planning sessions for the students to help plan them their future career paths.

The study of etiologic and demographic characteristics of intracranial brain abscess: a consecutive case series study from Pakistan.

BACKGROUND: To determine the demographics, management, bacteriological spectrum, and outcome of brain abscesses of patients brought to Aga Khan University Hospital (AKUH), Karachi, with a history of neurologic symptoms and to examine the factors associated with it. METHODS: This hospital-based descriptive study included 53 patients from both sexes who presented to the neurosurgery section at AKUH from January 1, 2000, until December 31, 2008, with neurologic symptomatology and fulfilling other inclusion criteria. Data regarding their demographic profile and other factors were collected in a well-structured proforma. Data were analyzed using frequencies, proportions, group means, and standard deviations. RESULTS: The male-to-female ratio in our study was 3.4:1, with Staphylococcus milleri (20.7%) being the most common etiologic agent followed by anaerobic bacteria (15.1%). The triad of headache, fever, and vomiting was present in 62.7% of patients at the time of presentation. The most important factors influencing mortality was the neurologic condition of the patient at the time of admission. Chronic suppurative otitis media was the most common predisposing factor for temporal lobe infections, and the frontal lobe was the most common site of involvement in majority of the patients (67.8%). The mortality rate in our study was 11.3%. CONCLUSION: Findings suggest that patients in the second and fourth decades of life are the most susceptible, both in terms of morbidity and mortality. Early diagnosis and appropriate management, along with rapid access to tertiary care centers, will lead to a better prognosis.

Ultrasound biosafety during pregnancy: what do operators know in the developing world?: national survey findings from pakistan.

OBJECTIVES: The purpose of this study was to evaluate the knowledge and attitudes of ultrasound users toward safety aspects during routine obstetric examinations. METHODS: A self-administered questionnaire was given to all registered participants of the 10th Annual International Radiological Conference in Karachi, Pakistan. RESULTS: A total of 306 participants completed the questionnaire (response rate, 70%), including 170 consultant radiologists (55%), 90 radiology residents (30%), 31 sonographers (10%), and 15 others (5%). The mean sonography experience of the end users ± SD was 5.1 ± 5 years. Around half of the participants (45.5%) reported that there should be limitations on the use of ultrasound during low-risk pregnancy. Overall, safety knowledge was inadequate among the participants. However, those who were concerned about limitations on the use of ultrasound during pregnancy were 2.5 times more likely to be familiar with the mechanical index (P < .001) and 1.8 times more likely to be familiar with the thermal index (P < .001). CONCLUSIONS: Increased training for professionals on safety issues of ultrasound procedures during pregnancy is needed. Furthermore, the concept of the absolute safety of ultrasound procedures without knowledge of safety parameters such as the mechanical and thermal indices needs to be changed, and more clarity is required when defining parameters under which the procedures can be safely performed.

Knowledge, attitudes & practices (KAP) of general practitioners (GPS) regarding sexually transmitted diseases (STDS) and HIV/AIDS in Karachi, Pakistan.

OBJECTIVE: To evaluate the KAP of GPs in Karachi who treat most of the cases of STDs in their private clinics. METHODS: It was a cross sectional survey conducted by interviewing 103 GPs from different towns of Karachi through an interviewer administered questionnaire based on WHO protocol for control of STDs. RESULTS: Regarding organisms transmitted through sexual intercourse, 94.2% knew about Neisseria gonorrhoeae while only 38.8% knew about T.Pallidum. Only 26.2% had heard about WHO syndromic management of STDs. Regarding treatment of a HIV positive patient 40.8% said they referred them to an AIDS control programme. Ninety four percent knew the value of sexual history but 55.3% were aware of the recommended treatment regimen. CONCLUSION: Knowledge and Attitudes of GPs was reasonably good but improvement is required with respect to management of STDs & HIV. Targeted continuing medical education programmes and special training sessions are recommended.

Prevalence of type-II diabetes mellitus and diabetic retinopathy: the Gaddap study.

OBJECTIVE: To determine the frequency of type-II Diabetes mellitus (DM) in the endogenous population of Gaddap town and also to evaluate the status of Diabetic retinopathy (DR) in this group. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Isra Postgraduate Institute of Ophthalmology, Al-Ibrahim Eye Hospital, Karachi, from January 2006 till December 2008. METHODOLOGY: This community based study of subjects of either gender was carried out in the Gaddap town. Three primary eye care centres were established in the existing primary health care (PHC) facilities, to screen the target Population aged 30 years and above, and who met other inclusion criteria for DM and DR respectively. Patients requiring intervention were managed accordingly. Data was entered and analyzed using Microsoft Visual Basic 6 and Microsoft Access. RESULTS: Out of the cohort of 19211 subjects, 1677 patients were found Diabetic, giving the prevalence of DM in Gaddap town at 8.73%, with 1258 (6.55%) known and 419 (2.18%) newly diagnosed cases. DR was seen in 460 (27.43%) of the Diabetic cases with 126 (7.51%) patients requiring urgent intervention for vision threatening complications. CONCLUSION: The result validates the importance of early screening of DR in people suffering from DM for possible management and prevention of sight threatening complications in the early stage of the disease and advocates the inclusion of primary eye care as a part of PHC system.

The study of etiological and demographic characteristics of acute household accidental poisoning in children--a consecutive case series study from Pakistan.

BACKGROUND: To determine the agents of poisoning and demographic distribution of children brought to Civil Hospital Karachi (CHK) with a history of accidental poison intake and to examine the factors associated with it. METHODS: This hospital based descriptive study of first 100 patients from both sexes who presented to Pediatric department, CHK from 1st January 2006 till 31st December 2008 with exposure to a known poisonous agent and fulfilling other inclusion criteria were included in the study. Data regarding their demographic profile and potential risk factors was collected on a well structured proforma, cases were followed until discharge or expiry. Data was analyzed using frequencies, proportions, group means, median and standard deviations. RESULTS: The male to female ratio in our study was 1.2:1, with kerosene (50%) being the most common household agent followed by medicines (38%), insecticides (7%) and bathroom cleaners (5%). Factors such as mother's education level, number of siblings and storage place of poison correlated significantly with the cases of accidental poisoning. Most of the children (70%) presented within 3 hours of ingestion. Dyspnea was the most common symptom observed. The mortality rate in our study was 3%. CONCLUSIONS: Children belonging to age group 2-3 years are the most susceptible both in terms of morbidity and mortality. Preventive strategies need to be adopted at a national level to spread awareness among parents.

The efficacy of spirometry as a screening tool in detection of air flow obstruction.

BACKGROUND/OBJECTIVES: In developing countries, spirometry has not been considered a part of routine medical check-up. The purpose of the study was to establish the usefulness of spirometry as a primary screening tool in detecting air flow obstruction (AFO) during routine medical check-up (RMC). METHODS: This was a hospital based, retrospective, non-randomized case series study of 3696 participants, who presented to hospital for routine medical check-up. All subjects were assisted at the Pulmonary Medicine Department, from January 2003 till December 2008 who, having met other inclusion criteria, underwent spirometry. Data were analyzed using proportion, group means, standard deviations and Pearson Chi Square test. RESULTS: The overall yield from spirometry in detecting AFO was 211 patients (5.7%); 174 males (6.1%) and 37 females (4.4%) (P=0.158, Pearson Chi Square test). Greater age at presentation and BMI correlated significantly with AFO in the target group (P=<0.001; P=<0.005) respectively. Dyspnoea was the most frequent symptomatology observed in those diagnosed with AFO. CONCLUSION: These results suggest that spirometry during RMC for all persons can detect a significant number of patients with AFO particularly among the middle and older age groups with a low BMI.