A rare case of suicidal ideation related to Adalimumab use.

INTRODUCTION: Patients undergoing treatment with an anti-tumor necrosis factor-alpha (TNF-α) agent can, as an adverse event, develop anti-TNF-α-induced lupus (ATIL). Neuropsychiatric symptoms such as depression and suicidal ideations are not commonly seen in patients who develop ATIL. We describe a case of a 56-year-old female who developed ATIL and suicidal ideations while on Adalimumab. CASE PRESENTATION: A 56-year-old female with rheumatoid arthritis (RA) and no known prior history of systemic lupus erythematosus or depression presented with suicidal ideations, joint pains and a malar rash after a recent change in her Adalimumab dose. She was treated for an acute ATIL episode based on her symptoms and serologies which were positive for anti-double-stranded deoxyribonucleic acid antibody. An inpatient psychiatric consultation determined that the patient's suicidal ideations may be an associated symptom of her current ATIL episode or possibly secondary to her chronic pain and debilitation from her RA. The patient's Adalimumab was discontinued and she was treated with a course of intravenous glucocorticoid. The patient's suicidal ideations resolved and her anti-double-stranded deoxyribonucleic acid antibody serologies became negative. She was subsequently started on Abatacept and has achieved remission of her RA with no further suicidal ideations. DISCUSSION: The development of ATIL in patients undergoing treatment with an anti-TNF-α agent is a rare occurrence. The aim of reporting our case is to increase understanding of ATIL by highlighting the occurrence of neuropsychiatric symptoms in a patient who developed ATIL.

RSV associated hospitalizations in children in Karachi, Pakistan: Implications for vaccine prevention strategies.

Major progress is being made in vaccines against Respiratory Syncytial Virus (RSV), with multiple vaccine candidates currently in the clinical phase of development. Making an investment case for public sector financing of RSV vaccine will require estimation of burden, cost-effectiveness, and impact. The aim of this study is to determine the proportion, age distribution and clinical spectrum of RSV associated hospitalizations in children in Karachi, Pakistan. A three years prospective study was conducted at the Aga Khan University Hospital in Karachi, a city of 20 million in south Pakistan, from August 2009 to June 2012. Children less than five years old admitted with acute respiratory infections (ARI) were enrolled. Throat swabs were collected and tested for RSV using real-time PCR. Multivariable log binomial regression analysis was performed to identify the associated factors of RSV infection. Out of 1150 children enrolled, RSV was detected among 223 (19%). Highest rate of RSV detection was in young infants less than 3 months of age (48/168, 29%), which accounted for 22% of all RSV detected. Most common diagnosis in RSV positive infants (<12 months of age) was bronchiolitis followed by pneumonia, while in older children between the ages of one and 5 years of age, pneumonia and asthma were the most common diagnosis. Although identified year-round, RSV was most prevalent from August to October with peak in September, coinciding with the rainy season. This study identified RSV to be independently associated with younger age (P = 0.036), rainy season (P < 0.001), post-tussive emesis (P = 0.008), intubation (P = 0.003), and discharge diagnosis of bronchiolitis (P = 0.004). Vaccines against RSV that target this age group are likely to yield remarkable benefit.

Comparison of antimicrobial activity of zinc chloride and bismuth subsalicylate against clinical isolates of Helicobacter pylori.

We determined the in vitro susceptibility of clinical isolates of Helicobacter pylori to ZnCl, compared its sensitivity to bismuth subsalicylate (BSS) and clarithromycin (CLR) that are used for the treatment of H. pylori infection and its activity at different gastric pH. One hundred sixteen clinical isolates of H. pylori strains were chosen. Agar gel dilution method was used to determine the susceptibility of H. pylori isolates to ZnCl 40 µg/ml, BSS 20 µg/ml, and CLR 2 µg/ml. Suspension of 10(9) bacteria/µl was streaked on the blood agar plate. The control consisted of H. pylori incubated without ZnCl, BSS, and CLR. One hundred ten H. pylori strains (95%) were susceptible to ZnCl 40 µg/ml compared to 114 (98%) to BSS 20 µg/ml (p=0.002) and 92 (79%) to CLR 2 µg/ml (p=0.602). H. pylori isolates from patients with nonulcer dyspepsia and from peptic ulcer were equally susceptible to ZnCl 40 µg/ml (90/96 vs. 26/26, p=0.208). H. pylori associated with chronic gastritis and chronic active gastritis were equally susceptible to ZnCl. H. pylori demonstrated susceptibility to ZnCl in vitro. H. pylori susceptibility to ZnCl 40 µg/ml was greater than BSS and comparable to CLR. ZnCl may be used in the treatment of H. pylori infection.

Comparison of the virulence markers of Helicobacter pylori and their associated diseases in patients from Pakistan and Afghanistan.

BACKGROUND/AIM: Helicobacter pylori is a Gram-negative bacteria, which is associated with development of gastroduodenal diseases. The prevalence of H. pylori and the virulence markers cytotoxin-associated gene A and E (cagA, cagE) and vacuolating-associated cytotoxin gene (vacA) alleles varies in different parts of the world. H. pylori virulence markers cagA, cagE, and vacA alleles in local and Afghan nationals with H. pylori-associated gastroduodenal diseases were studied. PATIENTS AND METHODS: Two hundred and ten patients with upper gastrointestinal symptoms and positive for H. pylori by the urease test and histology were included. One hundred and nineteen were local nationals and 91 were Afghans. The cagA, cagE, and vacA allelic status was determined by polymerase chain reaction. RESULTS: The nonulcer dyspepsia (NUD) was common in the Afghan patients (P = 0.025). In Afghan H. pylori strains, cagA was positive in 14 (82%) with gastric carcinoma (GC) compared with 29 (45%) with NUD (P = 0.006), whereas cagE was positive in 11 (65%) with GC and 4 (67%) with duodenal ulcer (DU) compared with 12 (18%) with NUD (P < 0.001 and 0.021, respectively). The vacA s1a/b1was positive in 10 (59%) of GC compared with 20 (31%) in NUD (P = 0.033). In Pakistani strains, cagE was positive in 12 (60%) with GC, 7 (58%) with GU, 12 (60%) with DU compared with 11 (16%) with NUD (P < 0.001, 0.004, and < 0.001, respectively). In Pakistani strains, cagA/s1a/m1 was 39 (33%) compared with Afghans in 17 (19%) (P = 0.022). Moderate to severe mucosal inflammation was present in 51 (43%) Pakistani patients compared with 26 (28%) (P = 0.033) in Afghans. It was also associated with grade 1 lymphoid aggregate development in Pakistani patients 67 (56%) compared with 36 (40%) (P = 0.016) in Afghans. CONCLUSION: Distribution of H. pylori virulence marker cagE with DU was similar in Afghan and Pakistan H. pylori strains. Chronic active inflammation was significantly associated with Pakistani H. pylori strains.

Frequency of poor quality of life and predictors of health related quality of life in cirrhosis at a tertiary care hospital Pakistan.

BACKGROUND: Cirrhosis produces variety of symptoms which eventually lead to a negative impact on Health Related Quality of Life (HRQOL). The general aim of this study was to evaluate the magnitude of poor HRQOL and to assess factors related with HRQOL in patients with CLD in Pakistan. FINDINGS: This was a cross sectional study conducted in gastroenterology outpatient clinics of Aga Khan University Hospital, Karachi on adult patients with cirrhosis. In this study chronic liver disease questionnaire (CLDQ) was used to assess HRQOL of these patients and CLDQ score was used as an outcome measure to determine factors related with HRQOL.273 participants were recruited in the study; 155 (57%) were males. Mean age of participants was 49 ± 11 years. The most common cause for cirrhosis was viral infection 247(91.5%). Mean Model for End Stage Liver Disease (MELD) score was 12.6 ± 6.8 and 2/3 of patients 209 (76.6%) had advanced cirrhosis in Child Turcot Pugh (CTP) B or C stage. Poor HRQOL was seen in 187(69%; 95% C.I.: 63%, 74%) of the participants. Mean CLDQ score was 4.36 ± 1.1. Amongst all of the domains, fatigue domain had lower CLDQ score. Hemoglobin (ß = 0.09 [SE = 0.04]), Albumin (ß = 0.32[SE = 0.09]), Diastolic Blood Pressure (DBP) (ß = 0.01[0.005) prior history of decompensation (ß = 0.98[SE = 0.39] were significant factors associated with HRQOL in patients with liver cirrhosis. CONCLUSION: Frequency of poor health related quality of life determined by CLDQ score is high in patients with liver cirrhosis. Hemoglobin, serum albumen, prior history of decompensation (like encephalopathy and upper gastro intestinal bleed), are associated with health related quality of life.

Prevalence of non Helicobacter pylori species in patients presenting with dyspepsia.

BACKGROUND: Helicobacter species associated with human infection include Helicobacter pylori, Helicobacter heilmannii and Helicobacter felis among others. In this study we determined the prevalence of H. pylori and non-Helicobacter pylori organisms H. felis and H. heilmannii and analyzed the association between coinfection with these organisms and gastric pathology in patients presenting with dyspepsia. Biopsy specimens were obtained from patients with dyspepsia on esophagogastroduodenoscopy (EGD) for rapid urease test, histology and PCR examination for Helicobacter genus specific 16S rDNA, H. pylori phosphoglucosamine mutase (glmM) and urease B (ureB) gene of H. heilmannii and H. felis. Sequencing of PCR products of H. heilmannii and H. felis was done. RESULTS: Two hundred-fifty patients with dyspepsia were enrolled in the study. The mean age was 39 ± 12 years with males 162(65%). Twenty-six percent (66 out of 250) were exposed to cats or dogs. PCR for Helicobacter genus specific 16S rDNA was positive in 167/250 (67%), H. pylori glmM in 142/250 (57%), H. heilmannii in 17/250 (6%) and H. felis in 10/250 (4%), respectively. All the H. heilmannii and H. felis PCR positive patients were also positive for H. pylori PCR amplification. The occurrence of coinfection of H. pylori and H. heilmannii was 17(6%) and with H. felis was 10(4%), respectively. Only one out of 66 exposed to pets were positive for H. heilmannii and two for H. felis. Histopathology was carried out in 160(64%) of 250 cases. Chronic active inflammation was observed in 53(56%) (p = 0.001) of the patients with H. pylori infection alone as compared to 3(37%) (p = 0.73) coinfected with H. heilmannii and H. pylori and 3(60%) coinfected with H. felis and H. pylori (p = 0.66). Intestinal metaplasia was observed in 3(3%)(p = 1.0) of the patients with H. pylori infection alone as compared to 2(25%) (p = 0.02) coinfected with H. heilmannii and H. pylori and 1(20%) coinfected with H. felis and H. pylori (p = 0.15). CONCLUSION: The prevalence of H. heilmannii and H. felis was low in our patients with dyspepsia. Exposure to pets did not increase the risk of H. heilmannii or H. felis infection. The coinfection of H. pylori with H. heilmannii was seen associated with intestinal metaplasia, however this need further confirmation.

Regular post dinner walk; can be a useful lifestyle modification for gastroesophageal reflux.

OBJECTIVES: To evaluate the correlation of gastroesophageal reflux disease (GERD) symptoms with routine post dinner physical activity and time interval before going to bed, in multiethnic South Asian population. METHODS: Prospective, cross sectional analytical, multicenter study was conducted from February 2009 to March 2010. Patient's relative sitting in outpatient clinics with no comorbids, nonsmoker and non alcoholic were included. They were asked to fill a validated GERD questionnaire and were also inquired about routine post dinner physical activity (lying, sitting, walking) and dinner-bed time interval. Odds Ratios (OR) and their 95% Confidence Intervals (CI) were estimated using Logistic Regression, with gastroesophageal reflux (GER) symptoms as an outcome. RESULTS: Subjects analyzed were 1875. Mean age was 35.37 +/- 12.69 years of which 689 (36.74%) had GERD symptoms. GERD symptoms were 42.08% in routine post dinner recumbency position. While 35.17% and 30.52% had the symptoms in post dinner sitting and walking before going to bed [OR for walking 0.66 (95% CI 0.5-0.88) when compared with lying posture]. GERD symptoms were 45.86% among those with dinner-bed time of one hour, progressively decreasing to 41.68%, 31.45% and 29.88% in the second, third and forth hour respectively. Odds ratio was significant only at 3rd [0.55 (0.41-0.74)] and > or = 4th hr [0.51 (0.37-0.71)] when compared with first hour. CONCLUSION: Regular post dinner walk and > 3 hour dinner-bed time interval were less associated with GERD symptoms.

Size or the number of portal tracts: which matters in a liver biopsy core in chronic hepatitis C?

Liver biopsy has an important role in staging of fibrosis (SoF) and grading of inflammation (GoI) in chronic hepatitis C (CHC) patients. The effect of size and number of portal tracts (NoP) on grading and staging of liver biopsy was evaluated. A total of 150 consecutive liver biopsy core (LBC) of patients with CHC were obtained. There were 98 (65.3%) males. Mean length of LBC was 1.45±0.48 cm. Mean number of portal tracts (NoP) was 11±4.6. Mean length of LBC was greater (1.60±0.45 cm) in stage 4 (n=41; 27.3%) and lesser (1.28+0.39) in stage 1 (n=23; 15%, p=0.04). The mean NoP were 8.5, 10.6 and 13.1 in GoI 1, 2 and 3 respectively (p<0.001). The mean NoP were 7.6, 11.1, 11.3 and 14.5 in SoF 1, 2, 3 and 4 respectively (p<0.0001). There was a good correlation between number of portal tracts and length of LBC (r2=0.56).