Antituberculous Drug-Induced Hepatitis in a Patient With Congenital Adrenal Hyperplasia: A Clinical Challenge.

Pulmonary tuberculosis (TB) is highly prevalent in Pakistan, and immunosuppressed individuals (including those on long-term corticosteroid therapy) are at an especially high risk of infection. Owing to the limited number of effective antituberculous drugs, treating resistant cases or patients who develop unfavorable side effects from the first-line agents becomes a daunting task. We discuss a patient with congenital adrenal hyperplasia (CAH) suffering from pulmonary TB who developed drug-induced hepatitis after being started on recommended first-line anti-TB drugs.

Philosophy of dermatology and the uneven road to realizing it: Perspective from a third-world country.

The philosophy of dermatology involves helping patients who present to dermatologists to realize their full potential by treating them holistically and educating them about the different aspects of their disease(s), while helping the doctors involved to grow professionally and as human beings. In the setting of a burdened health sector of a third-world country like Pakistan, the road to realizing this philosophy is rife with hurdles in the form of low resources, poor health infrastructure, lack of a research culture, a low literacy rate, and sociocultural taboos. The resolution of these issues needs concerted efforts by all the stakeholders, and it can be possible only through selfless leadership, dedicated teamwork, and incessant efforts by the doctors, health authorities, and national as well as international health institutions.

Mite is right: A case of infected scabies masquerading as a blistering disorder.

Scabies classically presents with itching and skin lesions in the interdigital spaces of hands, trunk, and genitals. Rarely, non-classical skin lesions can result in misdiagnosis and inappropriate management of patients.

COVID-19 and Pakistan: a survey assessing the awareness of patients presenting to the outpatient departments of health care centers.

Background: The coronavirus pandemic is one of the most disastrous calamities of modern times. The outpatient departments of health centers have an important role in the appropriate health education of the patients and their attendants regarding disease prevention and control. Objective: The objective of this study was to help the health authorities in devising an effective strategy of educating the vulnerable population at their point of first contact with a health professional. Methods: This descriptive cross-sectional study was conducted from 2 April 2020, to 17 July 2020, in the Punjab province of Pakistan. Data was entered and analyzed using the Statistical Package for Social Sciences (SPSS) version 23.0. A p-value of less than 0.05 was considered significant. Results: Out of 238, 144 were males and 94 were females and the mean age was 34.53 years. Although television was the most common source of information (51.7%) a significant proportion of the people of Shorkot, i.e., 60.3% relied on word of mouth compared to that of other cities (p < 0.001). Almost 60% of the participants recognized all the symptoms correctly. The majority agreed that wearing a mask was effective in limiting transmission (96.6%) and about 80% of the participants considered the decision of the nation-wide lockdown to be a correct measure. In Shorkot, 32% of the people were against the decision of lockdown, which was significantly higher as compared to people from other cities (p < 0.001). Conclusions: Our study demonstrated encouraging data regarding awareness of the included population in terms of COVID-19 symptoms and preventive measures.

A survey of perioperative complications with Clavien-Dindo classification: A cross-sectional study.

OBJECTIVE: To determine the incidence of complications in elective surgeries and to grade them according to the Clavien-Dindo Classification System. METHODS: The cross-sectional study was conducted in the General Surgery Operation Theatre of Holy Family Hospital, Rawalpindi, Pakistan, from February to April 2018, and comprised patients undergoing elective surgeries. Age, gender, region of surgery, type and grade of complications, were recorded using Clavien-Dindo Classification proforma. Data was analysed using SPSS 23. RESULTS: Of the total 212 patients, 36(16.9%) had some complication. There were significantly more complications in people aged 40 years or above compared to those <40 years (p<0.05). Of the total surgeries, 126(59.43%) were in the abdomino-pelvic region. CONCLUSIONS: Peri-operative complications were found to be significantly related with age of the patient and the type of surgery.

Auto-Brewery Syndrome: A Clinical Dilemma.

Auto-brewery syndrome (ABS), also known as gut fermentation syndrome, is a very rare disorder. It is characterized by the endogenous production of alcohol. It typically presents with the signs of alcohol intoxication, such as staggering gait, slurred speech, gastrointestinal distress, and state of confusion. Due to the nonspecific symptoms, it is necessary to rule out other etiologies before reaching a diagnosis of ABS. The confirmatory test for this syndrome is the raised levels of blood or breath ethanol after a glucose challenge test. The management includes the use of antifungal drugs and avoidance of a carbohydrate-rich diet. In this review, we summarize the etiology, clinical presentation, diagnostic tests, management, and medicolegal aspects of ABS.

Dupilumab for Atopic Dermatitis: The Silver Bullet We Have Been Searching for?

Atopic dermatitis is a chronic inflammatory condition of the skin affecting a large number of people worldwide. Historically, this condition has been managed by topical corticosteroids and general skincare measures. The inadequacy of these management strategies has always driven efforts to find better drugs. Dupilumab has been recently approved for the management of atopic dermatitis. It is a human monoclonal antibody that inhibits the binding of key interleukins involved in the pathogenesis of atopic dermatitis, thus blocking the signaling mechanisms and disrupting the disease progression. Dupilumab reduces the severity and associated symptoms of atopic dermatitis. It improves the life quality of patients and reduces the anxiety associated with the disease. Combination therapy of dupilumab and topical corticosteroids is more effective than dupilumab monotherapy. The treatment-related adverse events include headache, injection site reaction, conjunctivitis, nasopharyngitis, and herpes viral infections. Moreover, the simultaneous use of live vaccines with dupilumab is contraindicated. It is also beneficial in the management of asthma, chronic rhinosinusitis, and eosinophilic esophagitis. In this review, we have discussed the clinical efficacy and safety profile of dupilumab in the management of atopic dermatitis.

Assessment of Knowledge, Attitude, and Practices Regarding Self-medication for Acne Among Medical Students.

Introduction Acne is one of the most common skin conditions worldwide. Self-medication for acne is a fairly common practice among medical students. The objective of our study was to identify the prevalence of self-medication and to assess its knowledge, attitude, and practices among medical students. Materials and methods This descriptive cross-sectional study was conducted at Rawalpindi Medical University, Rawalpindi, Pakistan, from January 2019 to June 2019. Data were collected by using the convenient sampling technique. Students were asked to fill a semi-structured questionnaire. Students of all the medical years studying in our university were included in the study. Data were entered and analyzed using the Statistical Package for Social Sciences (SPSS) version 23.0 (IBM Corp., Armonk, US). Results Out of 349 students, 244 (69.9%) suffered from acne and self-medication was practiced by 123 (50.4%) acne sufferers. The practice of self-medication was significantly higher in students having acne lesions on the face (52.2%). The most common source of information was reported to be acquaintances (55.8%). Most of the students had knowledge of the dosage of drugs (46.3%) and precautions for their use (41.5%). Sixty-three percent of the students were of the opinion that self-medication is part of self-care. Most of the students read the expiration date on the drug label (88.6%). Conclusion Acne is a highly prevalent condition among medical students and the practice of self-medication among acne sufferers is high. The practice of self-medication and visits to dermatologists were both significantly more common in the students with lesions on the face. The knowledge of students regarding self-medication of acne was not adequate.

Hepatopulmonary Syndrome in a Thirteen Year Old Boy: A Case Report.

Hepatopulmonary syndrome (HPS) is a late complication associated with liver cirrhosis. Recent studies have suggested that it can also occur in non-cirrhotic portal hypertension. The criteria that need to be met for making the diagnosis of HPS include chronic liver disease, impaired gaseous exchange leading to hypoxemia and intrapulmonary vascular dilation. The pathophysiology of this disease includes mediators like nitric oxide (NO), and endothelial growth factors which play an important role in intrapulmonary dilation of vessels. This, in turn, leads to ventilation-perfusion mismatch which is the main etiology of pulmonary symptoms associated with this syndrome. The classical symptoms include dyspnea, orthodeoxia and platypnea. Contrast echocardiography has emerged to be a very sensitive test for its diagnosis. The timing of appearance of microbubbles help to differentiate between intracardiac and intrapulmonary shunting, with the latter being the hallmark of HPS. The only curative treatment available is liver transplantation. Here we present a case of a 13-year-old patient who presented in Nishtar hospital in Multan, Pakistan. He initially presented with signs of liver cirrhosis but no definite cause could be found. The patient didn't come for a follow-up after that. Now he presented with signs of HPS and acute decompensated liver disease. HPS was confirmed on contrast echocardiography. This is a rare presentation of HPS in this age group.

Hereditary Hemorrhagic Telangiectasia: A Rare Cause of Anemia.

Hereditary hemorrhagic telangiectasias (HHT), also known as Osler-Weber-Rendu syndrome, is an uncommon genetic disorder. It is inherited as an autosomal dominant disorder with varying penetrance and expression. The diagnosis of HHT requires the presence of at least three out of four clinical criteria. These so-called Curaçao criteria include epistaxis, telangiectasias, visceral involvement, and a family history of HHT in a first-degree relative. Visceral involvement can involve the gastrointestinal (GI) tract, resulting in the development of GI telangiectasias. One of the complications is anemia due to the chronic blood loss from these vascular malformations. Here, we present a case of a 26-year-old male who was diagnosed with HHT. He initially had episodes of epistaxis but now presented to us with features of anemia. According to the patient, he didn't have epistaxis for the past many months and on his esophagogastroduodenoscopy (EGD) and colonoscopy, there was evidence of multiple small telangiectasias seen in his stomach, duodenum, and colon. He was managed with blood transfusion and was discharged on oral iron supplementation. This is a rare cause of anemia and should be evaluated if other features of HHT are present.

Irreversible Electroporation For Liver Tumors: A Review Of Literature.

The prevalence of liver tumors is increasing worldwide. These can be broadly classified into primary and secondary types, depending upon the origin of the tumor. Multiple modalities are available for the management of these tumors. Ablative techniques are becoming the cornerstone of management especially for the tumors which are unresectable. Thermal ablative techniques include radiofrequency ablation (RFA), microwave ablation (MWA), and cryotherapy. Recently, a non-thermal technique known as irreversible electroporation (IRE) is gaining importance owing to its better clinical outcome and a good safety profile. IRE works by high voltage and intensity electrical discharge which makes pores in the membrane of the cells. Its clinical outcome is reported in different studies in terms of progression-free survival (PFS), frequency of complete ablation, and local recurrence of the tumor. Favorable results were seen especially for the small size tumors and very early hepatocellular carcinoma (HCC). It was also found to be useful for the management of tumors which are close to vital structures of the liver. The adverse effects of IRE are also comparable to other ablative techniques like RFA and MWA. The common complications associated with this procedure include liver abscess, bleeding, renal failure, pleural effusion, fever, and partial portal vein thrombosis. In view of this literature review, IRE is found to be a good alternative for the management of liver tumor in patients who cannot undergo surgery, thermal ablative procedures or tumor lying close to vital structures. The safety profile of this procedure is also encouraging. Further studies and clinical trials need to be done to explore this technique.

Association of Obesity Indicators with Hypertension in Type 2 Diabetes Mellitus Patients.

OBJECTIVES: To study the association of waist circumference (WC), waist to hip ratio (WHR) and body mass index (BMI) with hypertension in type 2 diabetes mellitus (DM) patients in a tertiary care hospital. METHODS: The anthropometric measures of patients were recorded in the Diabetic Outdoor of Nishtar Hospital Multan from 2013 to 2018 after taking approval from the Institutional Ethical Review Committee. All patients were evaluated in detail after obtaining informed consent. Data was entered and analyzed in SPSS version 20 (IBM Corp., Armonk, NY, USA). RESULTS: Data of 4556 type 2 DM patients, 2549 (55.9%) females, and 2007 (44.1%) males, was analyzed. Mean age of the study population was 47.72 years. Mean age of females was 47.32 years, while of males was 48.23 years. A total of 3393 (74.5%) of the patients had hypertension, 1912 females and 1481 males. The mean systolic blood pressure (SBP) was 130.84 mmHg, while the mean diastolic blood pressure (DBP) was 82.65 mmHg. Mean WC was 102.85 cm. Mean hip circumference was 100.33 cm. Mean weight was 66.93 kg. Mean height was 1.59 m. Mean WHR was 1.02. Mean BMI was 26.37 kg/m2. Obesity (BMI >27 kg/m2) was found in 1,891 (41.5%) of patients. Central obesity was found in 80.7% and 94.7% of type 2 DM patients according to the WC and WHR cutoff, respectively. Hypertension was significantly associated with all the obesity indicators (p<0.001). Type 2 DM patients with a high WHR were more likely to be hypertensive as compared to those with normal WHR (75% versus 65%, odds ratio (OR) 1.6, p<0.001). A higher than normal WC was also significantly associated with hypertension (79% versus 56%, OR 2.9, p<0.001). Similarly, obese type 2 DM patients with a BMI >27 kg/m2 were more likely to be hypertensive as compared to those with a normal range (18.5 to 22.9 kg/m2) BMI (83.1% versus 64.4%, OR 2.7, p<0.001). CONCLUSION: Diabetes is more prevalent in females and middle-aged people. Hypertension and obesity are two very common comorbidities of diabetes. Hypertension is strongly associated with all the parameters (WC, WHR, and BMI) of obesity.

Bacteriological Profile and Antibiogram of Cultures Isolated from Tracheal Secretions.

Background Respiratory infections are associated with high morbidity and mortality, especially in critically ill patients. The excessive use of broad-spectrum antibiotics has led to the development of drug resistance, thus resulting in the emergence of pathogens which are difficult to treat. The aim of this study was to identify common pathogens in tracheal secretions and to study the patterns of their sensitivity and resistance to various antibiotics. Materials and methods This descriptive cross-sectional study was conducted in the Department of Pathology and Microbiology, Holy Family Hospital, Rawalpindi, Pakistan, from August 2017 to December 2017, using the convenient sampling technique. Tracheal secretions from patients in the intensive care unit (ICU), tested in the Pathology and Microbiology Department of Holy Family Hospital, were included in the study. The culture was done on blood and MacConkey agar and the sensitivity pattern was performed on Muller Hinton agar. Data were analyzed using SPSS v.23.0. Results Out of the bacteria isolated from positive growth cultures, Acinetobacter (45; 53.6%) was the most common isolate followed by Klebsiella (11; 13.1%). Acinetobacter was most sensitive to tigecycline (94.7%), and gram-negative bacteria such as Acinetobacter, Klebsiella, and Pseudomonas showed resistance to higher generation cephalosporins. Conclusion Acinetobacter was the most common gram-negative bacilli isolated. Tigecycline was found to be effective against Acinetobacter.

Epidemiology, Bacteriological Profile, and Antibiotic Sensitivity Pattern of Burn Wounds in the Burn Unit of a Tertiary Care Hospital.

INTRODUCTION:  Burn wounds are commonly infected by organisms which delay wound healing. Therefore, it is necessary to evaluate the flora obtained from wounds of burn patients in order to determine the most effective treatment. The aim of this study was to determine the frequencies of various bacteria isolated from burn wounds and to determine their antimicrobial susceptibility.  Materials and methods: This descriptive cross-sectional study was conducted from January 2018 to November 2018 which included consecutive samples of burn wounds from patients admitted to the burn ward of a tertiary care hospital. Bacteria and their antimicrobial susceptibility were determined by swab cultures and sensitivity tests by standard aseptic techniques. Data were analysed via the Statistical Package for Social Sciences (SPSS), v23.0 (IBM SPSS Statistics, Armonk, NY). Chi-square tests were applied between qualitative variables, while the Kruskal-Wallis test was applied to compare the means of asymmetrical data. Bacterial isolates and their susceptibility pattern were represented as frequencies and pie charts. RESULTS:  A total of 178 samples were obtained from 109 patients from burn wounds. One hundred and twenty-two wounds (68.5%) showed growth and 56 (31.4%) showed no growth after 24 hours of incubation. Positive cultures were significantly more frequent in wounds of greater than one-week duration (p < 0.002). Out of 158 bacterial isolates, the most common isolate was Pseudomonas aeruginosa - 41 specimens (24.91%), followed by Staphylococcus aureus - 38 specimens (24.05%), Acinetobacter - 27 (17.09%), Klebsiella - 24 (15.19%), Escherichia coli - 13 (8.23%), Proteus - 7 (4.43%), other coliforms - 6 (3.8%), Enterococcus - 1 (0.63%), and Enterobacter - 1 (0.63%). Drug resistance to penicillin G, ampicillin, Augmentin, ceftazidime, cefotaxime, ceftriaxone, meropenem, and piperacillin+tazobactam was exceptionally high. CONCLUSION:  The most common bacterial isolates are Pseudomonas aeruginosa and Staphylococcus aureus. Piperacillin+tazobactam against Pseudomonas aeruginosa and vancomycin and linezolid against Staphylococcus aureus are highly effective and can be used as empirical therapies.