Shock Index As A Predictor Of Hyperlactatemia For Early Detection Of Severe Sepsis In Patients Presenting To The Emergency Department Of A Low To Middle Income Country.

BACKGROUND: Early detection of sepsis in the emergency department is of prime importance and requires tools that are time and cost-effective. The Systemic Inflammatory Response Syndrome (SIRS) has been poorly associated with sepsis. Timothy et al in a retrospective analysis of Emergency Department (ED) visit stated estimate of SIRS at 17.8% accounting to an annual yield of 16.6 million adult visits with SIRS per year, among these only 26% accounted as an infectious aetiology of SIRS, trauma being 10% and other causes being rare. Shock index is found to be independently associated with 30-day mortality in a broad population of ED patients including sepsis. With limited health resources in a low to middle income country, focused utilization is important and so is the need for markers that are non-invasive, readily available, cost effective, and easy to interpret. Shock index can serve this purpose as a surrogate marker of disease severity in patients with severe sepsis and thus resulting in early detection of such patients. METHODS: This cross-sectional study was conducted from December 2014 to May 2015 at a tertiary care setup (Aga Khan University Hospital) in Karachi consisting of all septic patients received at the emergency department. Non-probability sampling technique was used. p-value <0.05 was taken as significant. RESULTS: Out of 180 study participants 94 (52.22%) were males while 86 (47.78%) were females. The mean age was 57.48±18.8 years. Cohen's κ was used to determine an agreement between the Shock index and Lactate levels. Shock index with cut off value of > 0.7 was used and moderate to the strong agreement between the two was found with kappa κ = 0.786 which was statistically significant (p=<0.001). Sensitivity was found to be 0.99, specificity 0.75, NPV 0.98, PPV 0.87. CONCLUSIONS: To conclude the shock index has some very favourable features, including availability, low cost, and direct relevance to sepsis in terms of its high validity. A high SI predicts elevated lactate levels in patients with sepsis.

Frequency of Vitamin D deficiency and its association with serum PTH levels in end stage renal disease patients.

OBJECTIVE: To assess the frequency of Vitamin D Deficiency and its association with serum Parathormone (PTH) levels in End stage renal disease patients in a tertiary setup. METHODS: This cross sectional study was conducted in the Department of Nephrology, Liaquat National Hospital from January to December 2016 and comprised patients with End stage renal disease on maintenance haemodialysis. Sample size of 113 at 8% prevalence was calculated inflated to 150. Participants were selected through purposive sampling technique. Numerical variables were expressed as mean ± SD (standard deviation) while categorical variables were expressed as frequency and percentages. To determine association between Vitamin D and serum Parathormone (PTH) levels chi-square test was applied. Association of serum alkaline phosphatase levels with both Vitamin D levels and PTH levels was analyzed using chi-square test. SPSS 20 was used for data analysis. P-value <0.05 was taken as significant. RESULTS: Of the 150 participants, 33 were drop outs, 63(53.8%) were males and 54(46.2%) were females. The overall mean age was 52.47±15.21 years. Of all, hypertension as a comorbidity was present in 64(54.7%), Diabetes mellitus was present in 8(6.8%) and cardiovascular disease in 7(6%). Among the biochemical markers, mean serum vitamin D levels were 18.6±13.6ng/ml, mean Serum PTH levels were 253.8±227.2pg/ml, mean serum alkaline phosphatase levels were 143.7±125.4µg/L, mean serum phosphorus levels were 4.81±3.46mg/dl and mean serum calcium levels were 21.41±114.4mg/dl. Among the study participants, 67(57.3%) were found to be Vitamin D deficient. Both low and normal vitamin D was associated with High PTH (P <0.001) Other significant associations noted were that of High Alkaline Phosphatase with High PTH levels and a normal Vitamin D level (P<0.001). CONCLUSIONS: Our study revealed more than half of our participants were Vitamin D deficient and an association was found between Normal Vitamin D levels and high serum PTH levels with associated high alkaline phosphatase levels.

Removal of copper from an electroplating industrial effluent using the native and modified spirogyra.

In the present study, biosorption behavior of a green filamentous alga, spirogyra in its native and modified states was investigated for copper removal from an electroplating industrial effluent. For this, the effluent containing 194 mg·L-1 Cu2+ in sulfate medium was contacted with both forms of spirogyra, under the parametric variations of effluent pH, adsorbent dosage, contact time, and sorption temperature. The study revealed spirogyra as a prominent candidate for removing contaminant metal cation; however, at the same condition, biosorption capacity of modified biomass in gel form was higher than the native spirogyra. At the optimized condition with 6 g sorbent dosage treated to 100 mL effluent for 30 min at pH 6.0 and temperature 20 °C, the maximum 82.8% and 96.4% copper could be adsorbed by the native and modified spirogyra, respectively. The batch sorption data using native biomass followed pseudo-first-order kinetic; exhibiting the multilayer sorption mechanism via surface diffusion could be defined by the Freundlich model. In contrast, the sulfuric acid treated modified spirogyra followed pseudo-second-order kinetics and intra particle diffusion as the rate-limiting step.

Value of Routine Preoperative Tests for Coagulation Before Elective Cranial Surgery. Results of an Institutional Audit and a Nationwide Survey of Neurosurgical Centers in Pakistan.

BACKGROUND: Routine preoperative blood testing has become a dogma. The general practice is to order preoperative workup as a knee-jerk response rather than individualize it for each patient. The fact that the bleeding brain tends to swell, which coupled with limited options for proximal control, packing, and overall hemostasis, leads to an overemphasis on the preoperative coagulation profile. MATERIAL AND METHODS: This is a retrospective review of the medical records of patients admitted at Aga Khan University Hospital from January 2010 to December 2015 for an elective craniotomy. The hospital registry was used to identify files for review. Data were collected on a predefined proforma. A nationwide survey was performed, and 30 neurosurgery centers were contacted across Pakistan to confirm the practice of preoperative workup. RESULTS: The survey revealed that all centers had a similar practice of preoperative workup. This included complete blood count, serum electrolytes, and coagulation profile, including prothrombin time, activated partial thromboplastin time (aPTT), and international normalized ratio (INR). A total of 1800 files were reviewed. Nine (0.5%) patients were found to have deranged clotting profile without any predictive history of clotting derangement; 56% were male and 44% were female. Median age was 32 years with an interquartile range of 27 years. Median aPTT was (40.8 with 20.8 IQR). Median INR was (1.59 with 0.48 IQR). Median blood loss was (400 with 50 IQR). No significant association between coagulation profile (aPTT, INR) and blood loss was found (P = 0.85, r = -0.07). CONCLUSIONS: We conclude that patients without a history of coagulopathy and normal physical examination do not require routine coagulation screening before elective craniotomy.

An Adult with Polyneuropathy and Hypogonadism due to Poems Syndrome.

POEMS (acronym for polyneuropathy, organomegaly, endocrinopathy, M protein myeloma and skin changes), is a rare disease which occurs in the setting of plasma cell dyscrasias. We describe a case of an adult lady who presented with gradual onset weakness of all four limbs and multisystem involvement characterized by pedal edema, ascites, hyperpigmentation and hypogonadism. Nerve conduction study showed severe sensorimotor polyneuropathy. Serum immunofixation showed lambda light chain restricted monoclonal gammopathy. Bone marrow biopsy consistent with plasma cell dyscrasia. Hormonal assay showed decreased FSH, LH and estradiol levels which led us to diagnosis of hypogonadotrophic hypogonadism. The patient responded well to combination therapy of thalidomide, melphalan and dexamethasone. Eight months after the therapy, she noted decreased paresthesias and increased strength. She had reduced edema and ascites.

Pilocytic astrocytoma: A rare presentation as intraventricular tumor.

BACKGROUND: Pilocytic astrocytoma (PA) is the most prevalent central nervous system (CNS) tumor in pediatric population and accounts for an approximate of 5-6% of all gliomas. This neoplasm can occur at all levels of the neuraxis, with majority (67%) arising in the cerebellum and optic pathway. PAs are World Health Organization Grade I tumors and are the most benign of all astrocytomas characterized by an excellent prognosis. Other differentials include subependymal giant cell astrocytoma (SEGA), ependymoma, meningioma, and low-grade gliomas such as pilocytic or diffuse astrocytoma; calcification is more commonly regarded as a feature of benign or slow-growing tumors. CASE DESCRIPTION: We present a case of a 17-year-old female presenting with an unusual cause of hydrocephalus, a rare case of a calcified pilocytic astrocytoma as an intraventricular tumor. CONCLUSION: PA rarely presents as an intraventricular tumor and should be included in the differential diagnosis of a large mass with massive intratumoral calcification.

Secretory paraspinal paraganglioma of thoracolumar spine: Case report and review of literature.

BACKGROUND: Pheochromocytomas are catecholamine secreting tumors of the adrenal medulla chromaffin cells, however, when present extra-adrenally they are called paragangliomas. Paragangliomas rarely produce catecholamine in excess, which is evident by clinical symptoms, urine, and blood biochemistry. Total resection of these tumors can lead to complete clinical and biochemical resolution. This case report presents the clinical features, radiological findings, and neurological outcome in a middle-aged female with a secretory paraganglioma. CASE DESCRIPTION: We present the case of a 34-year-old female who presented with a 2-year history of dizziness, flushing, headache, palpitations, and hypertension. Her blood workup showed raised urinary catecholamine levels. Magnetic resonance imaging (MRI) and iodine-123-meta-iodobenzylguanidine (MIBG) scans demonstrated a retroperitoneal mass located anterolateral to T11-T12 vertebral bodies reaching up to T12-L1 intervertebral disc. The patient was otherwise neurologically intact. She underwent resection of the tumor after alpha-adrenergic and beta-adrenergic blockade. En bloc resection was achieved without neurological complications. Postoperatively, the patient was initially hypotensive and subsequently became normotensive, and on follow-up, the patient had resolution of her symptoms and was stable. CONCLUSION: Secretory paraganglioma of the dorsal spine are rare and difficult to excise, needs preoperative preparation with pharmacological intervention, good operative technique, and postoperative care.

Post-dialysis effects in patients on haemodialysis.

OBJECTIVE: To assess the post-dialysis effects in normal and diabetic patients on haemodialysis. METHODS: This cross-sectional study was conducted from January to December 2013 at two hospitals in Karachi, and comprised patients receiving dialysis. Participants were selected through purposive sampling technique. SPSS 20 was used for data analysis. RESULTS: Of the 150 subjects, 148(98.8%) were diabetics. Overall, 93(62%) were men and 57(38%) women. Besides, 22(14.7%) participants were having dialysis as a complication of hypertension and 128(85.3%) as a complication of diabetes. Diabetes was a comorbid condition for 148(98.7%) patients, hypertension for 139(92.7%) and cardiac diseases for 40(26.7%). Of the total, 114(76%) subjects were having dialysis thrice a week, 31(20.7%) twice and 5(3.3%) once. Post-dialysis, dizziness was present every time in 25(16.6%) patients, nausea and vomiting in 14(10%), cramps in 22(14.7%), headache in 21(14%), anxiety and depression in 16(10.7%), hunger in 43(28.7%) and itching in 30(20%). CONCLUSIONS: Post-dialysis complications were common in normal and diabetic patients. Nutritional status was found to be poor among long-term dialysis-dependent diabetics.