Showing papers in "Jcpsp-journal of The College of Physicians and Surgeons Pakistan in 2004"

General seroprevalence of hepatitis C and hepatitis B virus infections in population.

Abstract: Objective To determine the prevalence of hepatitis C virus (HCV) and hepatitis B virus (HBV) infection by detection of anti-HCV and hepatitis B surface antigen (HbsAg) in general population of Pakistan. Design Observational. Place and duration of study Community clinic of Shifa International Hospital, Islamabad, from January 1998 to June 2004. Materials and methods Sera of healthy adult individuals who presented for medical evaluation as a pre-employment criteria in the Gulf region were examined for presence of hepatitis B surface antigen and anti-HCV antibody. Alanine aminotransferase levels were also determined. Results A total of 47,538 individuals were examined. Out of these, 2528 (5.31%) were positive for anti-HCV and 1221 (2.56%) individuals had positive HBsAg. Hepatitis B surface antigen and anti-HCV both were found in 92 (0.19%) individuals. Mean age of subjects, positive for HCV antibody was 44 years and 40.5 years for HBV. Ninety-four percent individuals were males and 6% were females. Alanine aminotransferase (ALT) was normal in 56 % of subjects with positive HCV and 84% of individuals with HBV. Conclusion This study which evaluated predominantly a healthy male population, showed a high seroprevalence of anti-HCV and average seroprevalence of hepatitis B virus infection. A large majority of these patients was young and had normal ALT.

Frequency of chronic complications of type II diabetes.

Abstract: OBJECTIVE: To assess the frequency of chronic complications of type II diabetes in subjects attending a tertiary care unit in Karachi, Pakistan. DESIGN: A cross-sectional analytical study. PLACE AND DURATION OF STUDY: First visit of all type II diabetic subjects attending the outpatient department of Baqai Institute of Diabetology and Endocrinology from September 1996 to December 2001. SUBJECTS AND METHODS: Computerized clinical records of 2199 type II diabetic subjects were analyzed for this study. The clinical and laboratory variables were statistically evaluated with significance at p. RESULTS: Means of glycosylated hemoglobin HbA1c, fasting and random plasma glucose levels, systolic blood pressure, triglycerides and high density lipoproteins (HDL) were higher than the risk indicator value for both genders (p <0.005). Mean body mass index and total blood cholesterol was higher for females only. Hyperglycemia was present in 88%, high HbA1c in 81%, low HDL in 81%, obesity in 66% and hypertriglyceridemia in 54%, neuropathy in 36%, proteinuria in 28% and hypertension in 50% of the subjects. Frequency of obesity, low HDL and hypertension was higher among females (p < 0.001 in each case). Retinopathy (p<0.05), nephropathy (p<0.005), neuropathy (p<0.005) and foot ulcers (p<0.001) were higher among males. Frequency of obesity was significantly higher among those with shorter duration and in younger group while frequency of other complications was higher among those with longer duration and in the older groups. CONCLUSION: Higher rates of complications were observed compared to previous studies. Certain variables showed significant association with gender and age as described above.

Red cell immunization in beta thalassaemia major.

Abstract: OBJECTIVE To find out the frequency, pattern and factors influencing red cell immunization secondary to multiple blood transfusions in patients of beta-thalassaemia major. DESIGN A cross-sectional study. PLACE AND DURATION OF STUDY Armed Forces Institute of Transfusion, Rawalpindi, in November 2002. PATIENTS AND METHODS One hundred and sixty-one patients suffering from beta-thalassaemia major and on regular blood transfusions were included in the study. Their blood samples were tested for blood grouping, direct antiglobulin test and antibody screening/identification using reagents of DiaMed-ID Gel microtyping system. RESULTS The total rate of red cell immunization was found to be 6.84%. Red cell alloantibodies were detected in 4.97% patients, and belonged mainly to Rh system, with one example each of anti-K, anti-Jsb and anti-Jka. Direct antiglobulin test was positive in 3 patients (1.87%) with increased hemolysis. Two had warm panreactive IgG antibodies suggesting red cell autoimmunization. Red cells of the 3rd patient showed sensitization with c-3d, with presence of an autoreactive cold agglutinin in the serum having a titre of 1:4. The red cell alloantibody formation was not influenced by age at first transfusion, number of blood transfusions and ethnicity. CONCLUSION The rate of red cell alloimmunization in beta-thalassaemia major is relatively low in our setup and may be related to red cell homogeneity between the donor and recipient population. Routine pre-transfusion matching of blood, other than ABO and Rh "D" antigens is not recommended because of low rate of red cell alloimmunization, and high costs associated with such testing. Hyperhaemolysis, due to acquired red cell autoantibodies was found to be an important complication. Patients who develop this complication should be tested for presence of underlying alloantibodies and considered for immunosuppressive treatment.

Screening for hepatocellular carcinoma.

Abstract: Liver cancer remains one of the most common causes of cancer death globally, and its cure rate has not improved for the past 20 years. Hepatocellular carcinoma develops in patients with cirrhosis of any etiology. Patients with cirrhosis are thus usually included in screening program aiming to achieve early detection and effective treatment for HCC. Only those patients diagnosed with HCC who would benefit with the available treatment, should undergo the screening procedure. This is based on ultrasonography and alpha-fetoprotein every 3-6 months based on the prevalence and economic status of the community being tested.

Microbiology and drug sensitivity patterns of chronic suppurative otitis media.

Abstract: Objective To identify the commonest microorganisms associated with chronic discharging ears and their antimicrobial sensitivities. Design Descriptive study. Place and duration of study This study was carried out from August 2003 to February 2004 at the Department of Otorhinolaryngology and Head and Neck Surgery, Fauji Foundation Hospital, Rawalpindi. Materials and methods A total of 124 patients with unilateral or bilateral active chronic suppurative otitis media attending the outpatient clinic were included in the study. All patients were evaluated through detailed history and clinical examination. Pus samples were collected from the discharging ear(s) and sent to the hospital laboratory where culture and sensitivity studies were done for aerobes, anaerobes and fungi and antibiotic sensitivity patterns. Results Overall microbiology of 142 samples was studied. Among them, 108 (76%) were pure cultures and 34 (23.9%) were mixed. There were 186 isolates including 182 (97.8%) aerobes, nil anaerobes and only 4 (2.1%) fungi. Pseudomonas aeruginosa 94(50.5%) was the most common isolate, followed by Staphylococcus aureus 44 (23.6%). Drug sensitivities pattern of Pseudomonas aeruginosa showed that ciprofloxacin was active against majority 95.8% of isolates followed by amikacin 83.3%, gentamicin and tobarmycin 60% and cefotaxime 41.6%. Staphylococcus aureus isolates were resistant to penicillin, ampicillin and amoxicillin in 77.2% whereas majority was sensitive to coamoxiclav 81.8% and cephradine 86.3%. Conclusion Commonest organisms isolated from chronic discharging ears were Pseudomonas aeruginosa and Staphylococcus aureus. Majority of isolates of Pseudomonas aeruginosa were sensitive to ciprofloxacin. Majority of strains of Staphylococcus aureus were resistant to penicillin. Cephradine and coamoxiclav were effective against most of the isolates of Staphylococcus aureus.

Staphylococcus aureus and MRSA nasal carriage in general population.

Abstract: OBJECTIVE Assessment of Staphylococcus aureus (S. aureus) and MRSA nasal carriage in our general population. DESIGN Cross-sectional analytical study. PLACE AND DURATION OF STUDY A private Pathology Laboratory in Lahore city from January 2002 to December 2003. MATERIALS AND METHODS Nasal swabs were obtained from the apparently healthy persons accompanying the patients attending the laboratory. These swabs were inoculated on blood and mannitol salt agar plates and incubated at 37 degrees C. The isolate(s) were identified as S. aureus on the basis of colony morphology, Gram staining, catalase and coagulase tests. Sensitivity to Oxacillin was determined using standard Kirby Bauer technique. RESULTS Nasal swabs from 1660 subjects from the community were studied. Out of these samples, a total of 246 (14.82%) samples were positive for growth of S. aureus (nasal carriers of S. aureus). Out of 246 S. aureus isolates, 48 (19.51%) isolates were methicillin resistant S. aureus (MRSA). Nasal carriage was higher in males (15.47%) as compared to females (13.26%), in urban areas (16.99%) as compared to rural areas (11.32%) and in the year 2002 (16.02%) as compared to year 2003 (13.08%). However, the difference was significant only for the urban vs. rural comparison (p<0.05). MRSA isolates were also significantly higher among S. aureus isolates from the nasal cavities of urban subjects (22.98%) as compared to rural ones (11.11%). Maximum nasal carriage was present in the age group upto 9 years (20.23%) with decrease in the age groups 10-19, 20-29 and 30-39 years followed by small rise in the older subjects. CONCLUSION The nasal S. aureus carriage as well as methicillin resistance among these isolates are more common in urban community.

Common genotypes of hepatitis B virus.

Abstract: Objective To find out the frequency of common genotypes of hepatitis-B virus (HBV). Design An analytical study. Place and duration of study The present study was carried out at Division of Infectious Diseases and Molecular Diagnostics, Centre for Applied Molecular Biology, Ministry of Science and Technology, Lahore, Pakistan from May 2002 to February 2004. Subjects and methods HBV genotypes were determined in 112 HBV DNA positive sera by a simple and precise molecular genotyping system based on PCR using type-specific primers for the determination of genotypes of HBV A through H. Results Four genotypes (A, B, C and D) out of total eight reported genotypes so far were identified. Genotypes A, B and C were predominant. HBV genotype C was the most predominant in this collection, appearing in 46 samples (41.07%). However, the genotypes of a total of 5 (4.46%) samples could not be determined with the present genotyping system. Mixed genotypes were seen in 8 (7.14%) HBV isolates. Five of these were infected with genotypes A/D whereas two were with genotypes C/D. One patient was infected with 4 genotypes (A/B/C/D). Genotype A (68%) was predominant in Sindh; genotype C was most predominant in North West Frontier Province (N.W.F.P.) (68.96) whereas genotypes C and B were dominant in Punjab (39.65% and 25.86% respectively). Conclusion All the four common genotypes of HBV found worldwide (A, B, C and D) were isolated. Genotype C is the predominant. Genotypes B and C are predominant in Punjab and N.W.F.P whereas genotype A is predominant in Sindh.

Management of foreign bodies in the esophagus.

Abstract: Objective To evaluate management of foreign bodies in the upper gastrointestinal tract. Design Cross-sectional analytical study. Place and duration of study Ear, Nose, Throat Department of Mayo Hospital, Lahore, from February 1999 to December 1999. Patients and methods A total of 103 patients with history of foreign body ingestion were included in this study. X-ray neck and rigid oesophagoscopy was carried out in all patients for diagnosis and removal of foreign bodies. A structured questionnaire was designed to record all information. Results Dysphagia (92%) and tenderness in neck (60%) were the most common clinical features. Majority (89%) patients had come to the hospital within 24 hours. X-ray of the neck (lateral view) was the most useful investigation with presence of air in the esophagus being a significant finding. Post-cricoid region was the site of impaction of foreign bodies in 84% of the subjects. The procedure of esophagoscopy was successful in 90 patients (97%) and failed in 3 patients (3%). Coins were the most common foreign bodies (60%), followed by meat related foreign bodies (22.5%) and dentures in 5% cases. Complications occurred in 18% patients and were more common in adults (37.1%) compared to children (8.8%). The most serious complication was pneumomediastinum. Maximum complications occurred with dentures (80%) and bone chips (42%). Conclusion Foreign body in the esophagus is a serious condition and early removal by rigid esophagoscopy is recommended which is a safe and effective procedure.

Emerging drug--resistance and guidelines for treatment of malaria.

Abstract: The increasing prevalence of multi-resistant Plasmodium falciparum malaria worldwide is a serious public health threat to the global control of malaria, especially in poor countries like Pakistan. In many countries choloroquine-resistance is a huge problem, accounting for more than 90% of malaria cases. In Pakistan, resistance to choloroquin is on the rise and reported in up to 16- 62% of Plasmodium falciparum. four to 25% of Plasmodium falciparum also reported to be resistant to sulfadoxine-pyrimethamine and several cases of delayed parasite clearance have been observed in patients with Plasmodium falciparum malaria treated with quinine. In this article we have introduced the concept of artemisinin- based combination therapy (ACT) and emphasize the use of empiric combination therapy for all patients with Plasmodium falciparum malaria to prevent development of drug resistance and to obtain additive and synergistic killing of parasite.

Alcohol and road traffic injuries in South Asia: challenges for prevention

Abstract: Among the one million people killed on the roads during 2000, nearly 75% died in developing countries of the world, about half of them in Asia. A selective examination of RTIs in the region indicate that they constitute the second or third leading cause of death in the 5-44 years age group. The increase in direct and indirect health risk associated with alcohol usage has been well-documented in recent years. Alcohol is a major risk factor for RTIs as it impairs judgment and increases the possibility of involvement in other high risk behaviours (e.g., speeding, violating traffic rules, etc.). Precise information on the involvement of alcohol in RTIs and deaths is clearly not available from South Asian countries. With the recognition that road safety needs to focus on reducing drinking and driving, many high-income countries have formulated and implemented a number of coordinated, integrated and sustainable programmes based on scientific research. Considering the gravity of the situation, ongoing efforts to reduce the problem and lessons learnt from high-income countries, it is important to change strategies and mechanisms to reduce drink driving in South Asia.

Road traffic injuries in Sri Lanka: a call to action.

Abstract: Road traffic injuries and associated deaths have reached epidemic proportions in Sri Lanka, resulting in 2,000 deaths and 14,000 injuries each year. Accurate information on the patterns and trends in fatal and non-fatal outcomes are essential to identify emerging issues relating to vulnerable road user groups. This information is also needed to raise community awareness, prioritize public action, mobilize and allocate resources for intervention, and monitor the impact of road safety programmes. Another important gap relating to road traffic injury in Sri Lanka is the scant data regarding the determinants and consequences of road traffic injuries. It is essential to engage with local communities to understand their concerns and attitudes as well as develop partnerships that can mobilize support and action to address this problem. At the national level, a lead government agency, for example the Ministry of Health, should be identified and empowered to guide and coordinate inter-sectoral road traffic injury prevention efforts. The response must include a systematic approach to assessing the problem and addressing research gaps. The initiatives developed must provide the necessary evidence to develop context-relevant actions that can prevent road crashes and minimize the consequences of road traffic injuries.

Transvaginal versus transabdominal sonography in the evaluation of pelvic pathology.

Abstract: Objective To find the accuracy of sonographic information provided by transvaginal sonography (TVS) in pelvic pathology as compared to transabdominal sonography (TAS). Design A comparative study. Place and duration of study The study was carried out in Military Hospital (MH) and Combined Military Hospital (CMH) Rawalpindi from January 2002 to June 2002. Materials and methods Hundred patients were included in the study from a total of 212 referred for pelvic sonography. Two radiologists independently performed transabdominal and transvaginal sonography of these patients. An independent observer compared the findings. TVS was graded as superior, equal or inferior to TAS depending on the score assigned by them. Results TVS was considered superior in 63%, equal in 27% and inferior in 10% of the cases as compared to transabdominal sonography. It was graded inferior to TAS in cases with large pelvic masses and superior in majority of cases of ovarian follicle monitoring, polycystic ovaries, endometrial carcinoma and suspected ectopic pregnancy. Cases in which both techniques were considered equal included patients with no abnormal finding, some pelvic masses and advanced pelvic inflammatory disease. Conclusion Transvagival sonography is superior to transabdominal sonography in most cases of pelvic pathology. However, TAS should still be the initial sonographic technique for routine evaluation of the female pelvis followed by TVS if indicated. In cases of ovarian follicle monitoring, suspected polycystic ovaries, endometrial pathology and suspected ectopic pregnancy, TVS may be used as the initial sonographic technique and can even replace TAS.

The vermiform appendix: not a useless organ.

Abstract: The appendix has often been seen more as a nuisance rather than an important part of the human anatomy. Early misconceptions have led to the indiscriminate removal of the appendix from the body. Long thought to be an evolutionary remnant of little significance to normal physiology, the appendix has more recently been identified as an important component of mammalian mucosal immune function, particularly B-lymphocyte-mediated immune responses and extrathymically derived T-lymphocytes. This structure helps in the proper movement and removal of waste matter in the digestive system, contains lymphatic vessels that regulate pathogens, and lastly, might even produce early defences that prevent deadly diseases. The appendix is one of the guardians of the internal environment of the body from the hostile external environment.

Brain abscess--diagnosis and management.

Abstract: Objective To evaluate the clinical presentation, diagnosis, sources of infection, surgical management outcome and microorganisms involved in the brain abscess in our locality. Design Descriptive study. Place and duration of study The department of Neurosurgery, Chandka Medical College Hospital, Larkana from July 1998 to June 2003. Subjects and methods All patients who were confirmed cases of brain abscess were entered into the study. Data collected on proforma, contained categories of age, gender, clinical presentation, diagnostic laboratory findings, computed tomography scan reports, associated anomalies, surgical management, culture reports antibiotic therapy, microbiologic features and treatment out come. Results Out of 82 patients, 58 were males and 24 females. Mean age was 18 years (range 05 months to 55 years). Headache with papilloedema was the commonest presentation (82%). Neurological deficit was present in 46%. A source of infection was present in 89%. Otogenic source was the commonest (63%). CT scan was diagnostic in all (100%) cases. Solitary abscess was found in 79% of the cases while in 21% of the cases multiple abscess were found. Temporal lobe was the commonest site involved (55%). Cultures were found positive for microorganism in 82% of the cases. Bacteriodes (38%) and Streptococci (25%) were the commonest isolates. Burr hole aspiration was done in only 38% of the cases while excision of the capsule along with aspiration was carried out in 62% of the cases. Over all morality was 22% in this series; causes of death were septicemia, ventriculitis and pneumonia. Conclusion Diagnosis with CT scan, appropriate antibiotic therapy and complete removal of abscess along with excision of capsule could reduce the mortality and neurological deficits from brain abscess.

An audit of head trauma care and mortality.

Abstract: OBJECTIVE To analyze the factors contributing to deaths from head trauma by using standardized assessment parameters and to provide a peer-review of head injury deaths with focus on identifying deficiencies and analyzing contributory factors. DESIGN Descriptive study. PLACE AND DURATION OF STUDY The study was carried out at the Emergency, Aga Khan University Hospital during January 1998 to December 1999. SUBJECTS AND METHOD One hundred and three patients above the age of 15 years presenting alive to the Aga Khan University Hospital (AKUH) emergency with head injury were included in this study. Identified deaths data was reviewed by the Hospital Trauma Peer Review Committee and consensus arrived at for categorization of deaths. The potential deficiencies in care were identified and final recommendations made. The data was computed on CDC Trauma Registry (V 3.0) and SPSS (V 8.0). RESULTS Mean age was 31.9 years (n=103) with predominant male population (4:1). Severe head injury (GCS<8) accounted for 21.3 % (n=22) of all cases with a total number of deaths being 12.6 % (n=13). Deaths were categorized preventable in 3 cases with non-preventable and potentially preventable in 4 and 6 cases respectively. Road traffic accidents were the predominant mechanism (n=8) in all deaths (n=13). The time interval in relation to mortality was biphasic, most deaths occurring either within 24 hours or between 3-7 days of injury. Inappropriate pre-hospital treatment, pre-hospital delays and inappropriate mode of transportation without inter-hospital communication were the process-related defects in pre-hospital care with major determinant of deaths outside AKUH (n=5). Prolonged emergency stay, delayed intensive care availability were the process-related deficiencies whereas inappropriate initial resuscitation, inappropriate initial head injury management were provider-related deficiencies in in-hospital care. CONCLUSION Transfer of inappropriately managed patients, lapses in inter-hospital communications, delayed transfers were identified as the major pre-hospital factors whereas lack of ICU beds, portable ventilators in emergency room, delays in CT scan facilities were the deficiencies in the hospital services. Opportunities for improvement in head trauma care are needed to focus on initial resuscitation and appropriate surgical management.

Role of somatostatin analogues in the management of enterocutaneous fistulae.

Abstract: Objective To observe beneficial effects of somatostatin analogues in terms of time taken by the enterocutaneous fistula to close, total hospital stay, cost of treatment and mortality. Design A comparative study. Place and duration of study The study was carried out from 01-10-1999 to 30-09-2002 in Surgical Units of Bahawal Victoria Hospital, Bahawalpur. Patients and methods In this study 33 patients were distributed randomly in two groups. Both groups were almost similar in terms of age, sex, anatomical location and cause of enterocutaneous fistulae. In group-A, 17 patients were treated by conventional methods (nil per orum, total parenteral nutrition, antibiotics, skin and wound care and control of sepsis). While in group-B, 16 patients were treated by long acting somatostatin analogue (Sandostatin 300 microgram subcutaneously /day in three divided doses) in addition to the conventional treatment. Results Of the 33 patients studied, 52% enterocutaneous fistulae were arising from ileum, 18% from jejunum, 12% from colon, 9% from biliary tree/pancreas, 6% from duodenum, and 3% from appendix. Low output fistulae (less than 200 ml/24 hour) were 24.24% in group A and 18.18% in group-B. Moderate output fistulae were 15.15% and 21.21% respectively. High output fistulae (>500 ml/ 24 hours) were 12.12% and 9.10% respectively. Etiologically, 85% were post-operative, 9% traumatic, 3% tuberculous and 3% due to inflammatory bowel disease. Fifty-two percent patients having fistula were malnourished, and 60% were anemic. In group-B with somatostatin the fistula closure time and hospital stay were marginally decreased, which was statistically insignificant. The cost of treatment was statistically significant in same group. In all the 33 patients studied, fistula closed except in 5 who expired. Mortality was not affected by the use of somatostatin. Conclusion Somatostatin and its analogues can be used to decrease fistula output, thus making enterocutaneous fistulae easy to manage in terms of fluid and electrolytes and protein imbalances. Somatostatin and its analogues have shown some beneficial effects with regard to fistula closure rate and hospital stay, but the effects are statistically insignificant. There was significant increase in the cost of treatment. Thus the role of somatostatin is not established in the closure of enterocutaneous fistula.

Evidence of Helicobacter pylori infection in dental plaque and gastric mucosa.

Abstract: Objective To determine the presence of Helicobacter pylori (H. pylori ) in dental plaque of individuals suffering from H. pylori associated gastric disease. Design descriptive. Place and duration of study The study was conducted at the Department of Medicine in collaboration with Departments of Dentistry and Pathology at PNS Shifa, Karachi during a period extending from July 1998 to June 1999. Patients and methods Patients presenting with symptoms/signs of chronic gastritis were included in the study. Specimens of dental plaque and gastric biopsy were collected from all the patients. The dental plaque specimen was processed for helicourease test and the gastric biopsy specimens were processed both for the helicourease test and histopathology. Results Out of all patients studied (n=52), 32 (61.53%) were positive for helicourease test with gastric biopsy while 48 (92.30%) were positive with dental plaque. The histopathology of gastric biopsy showed H. pylori associated chronic active gastritis in 42 (80.76%) patients. Eight (15.38%) patients showed chronic active gastritis which was not associated with H. pylori while in 2 (3.84%) patients the gastric biopsy specimen was unremarkable. Conclusion Majority of the patients have possible H. pylori colonization in dental plaque while about two-thirds have H. pylori associated chronic active gastritis. Oral cavity may be the first place for colonization and then the infection involves the gastric mucosa.

Gender based response to fluoxetine hydrochloride medication in endogenous depression.

Abstract: OBJECTIVE To determine the gender based response to fluoxetine HCl medication in relation to tryptophan metabolism in depressed patients. DESIGN A comparative, analytical study. PLACE AND DURATION OF STUDY Clinical Biochemistry and Psychopharmacology Research Unit, Department of Biochemistry, University of Karachi during the year 2002 to 2003. SUBJECTS AND METHODS Sixteen adults depressed patients who were not having any other major comorbidity were selected from the outpatients department of local psychiatric clinic for the study. They were subjected to a semi-structured interview for associated clinical characteristics and diagnosis of depression according to ICD-10 criteria. A control group of normal health male and female individuals was identified for comparison with the depressed group. All the depressed patients were treated with fluoxetine hydrochloride (Prozac 20 mg/day) for four weeks. Healthy individual's data was compared with the depressed group and evaluated for gender based response to fluoxetine HCl medication. RESULTS Significant decreases were found in total tryptophan concentrations (33 %, p<0.01,56%, p<0.01) in depressed male and female patients respectively, in contrast, serum cortisol levels were increased by 68% and 98% in male and female depressed patients respectively as compared to healthy controls. Significant increases (23%, p<0.05) in albumin levels were found in females only. Four weeks treatment of male and female depressed group by Fluoxetine HCL (Prozac) 20 mg/kg/day, increased serum total tryptophan concentrations significantly by 32% (p<0.05) in males and by 83% (p<0.01) in females. Serum-free tryptophan concentrations were increased by 22% (p<0.05) in males only. In contrast serum cortisol concentrations were decreased by 31% (p<0.01) and 45.35% (p<0.01) in males and females respectively. CONCLUSION Increases in tryptophan and decreases in cortisol concentrations were greater in females which may contribute to better response of the drug in females.

Acute puerperal uterine inversion.

Abstract: Objective To determine the frequency, causes, clinical presentations, management and maternal mortality associated with acute puerperal inversion of the uterus. Design Cross-sectional analytical study. Place and duration of study The Department of Obstetrics and Gynaecology, Jinnah Postgraduate Medical Centre (JPMC), Karachi, over eight years period from 1st January 1995 to 31st December 2002. Materials and methods All the patients who developed acute puerperal inversion of the uterus either in or outside the JPMC were included in the study. Patients of chronic uterine inversion were not included in the present study. Abdominal and vaginal examination was done to confirm and classify inversion into first, second or third degrees. Results 57036 deliveries and 36 acute uterine inversions occurred during the study period, so the frequency of uterine inversion was 1 in 1584 deliveries. Mismanagement of third stage of labour was responsible for uterine inversion in 75% of patients. Majority of the patients presented with shock, either hypovolemic (69%) or neurogenic (13%) in origin. Manual replacement of the uterus under general anaesthesia with 2% halothane was successfully done in 35 patients (97.5%). Abdominal hysterectomy was done in only one patient. There were three maternal deaths due to inversion. Conclusion Proper education and training regarding placental delivery, diagnosis and management of uterine inversion must be imparted to the maternity care providers especially to traditional birth attendants and family physicians to prevent this potentially life-threatening condition.

Frequency and risk factor of abdominal wound dehiscence.

Abstract: OBJECTIVE To find out the frequency of abdominal wound dehiscence (AWD) in a tertiary care hospital and the assessment of associated risk factors. DESIGN a cross sectional analytical study. PLACE AND DURATION OF STUDY This study was carried out at Nishter Hospital Multan between May 1998 to May 2000. SUBJECTS AND METHODS This study was carried out on 406 patients who underwent laparotomy for intra peritoneal procedure and complied with inclusion criteria. Demographic features were recorded and any complications documented. RESULTS Out of a total of 406 patients, 32 showed wound dehiscence giving an over all frequency of 7.8%. The male to female ratio was 2.8:1. The frequency was greater in males than in females. Majority patients suffered from an underlying malignancy. Malignant intestinal obstruction was the leading cause of wound dehiscence. Forty three patients had hypo-albuminemia(serum albumin <35 gm/l) and 09 of them had AWD. Emergency surgery showed a higher frequency of AWD(12.5%), as compared to elective surgery (18/143 and 14/263 respectively ). Wound infection was a major contributor to AWD as out of 406, 76 patients developed infection and then 21 manifested AWD. older age was also associated with greater frequency. The overall mortality of AWD in this study was 28.1%. CONCLUSION AWD still continues to be major post operative complication, with a high morbidity and mortality. The significant risk factors in this study were age more than 55 years, male gender, underlying malignancy, wound infection, jaundice, use of steroids, emergency surgery, uraemia and technique of closure.

Splenic artery aneurysm rupture in pregnancy.

Abstract: Rupture of a splenic artery aneurysm, commonly associated with pregnancy is a rare and catastrophic event. We report here a case of a patient in her second pregnancy who presented with a short history of left hypochondriac and epigastric pain, followed by collapse at 32 weeks gestation. Sudden fetal distress lead to emergency caesarean delivery when splenic artery aneurysm rupture was diagnosed. With timely involvement of multidisciplinary personnel both mother and baby survived and had an uneventful recovery.

Symptoms of depression and anxiety in post-myocardial infarction patients.

Abstract: OBJECTIVE To assess the frequency of symptoms of depression and/or anxiety following acute myocardial infarction (AMI) and to analyse their association with demographic variables. DESIGN A cross-sectional analytical, non-interventional hospital based study. PLACE AND DURATION OF STUDY The study was carried out at Punjab Institute of Cardiology (PIC), Lahore, from January 2000 to January 2001. PATIENTS AND METHODS A total number of 100 inpatients suffering from AMI were studied. After a careful selection of the subjects the Urdu version of Hospital Anxiety and Depression Scale (HADS) was administered to each patient during the period of 5-7 days following AMI to assess symptoms of depression and anxiety. A semi-structured clinical interview was also conducted which included demographic information, psychiatric history and other variables. Results were analyzed by using Statistical Package for Social Sciences (SPSS version 8.0). RESULTS Out of 100 subjects, 80 (80%) were males and 20 (20%) were females. Their ages ranged from 30-60 years (mean age, 50.92+/-8.53). Overall, symptoms of anxiety and/or depression were found in 50 (50%) patients. More specifically, symptoms of depression were found in 14%, anxiety symptoms in 18% and mixed symptoms (anxiety and depression) in 18% of the patients. Results revealed that patients above 45 years of age (i.e. 46-60 years) were more likely to experience symptoms of depression and/ or anxiety following AMI. A significant association was also found between female sex (p <0.02), lower socioeconomic status (p <0.05) and symptoms of depression and/ or anxiety in these patients. However, no significant association was found in relation to educational status, marital status and origin (urban/rural). CONCLUSION The high proportion of patients with AMI found to be suffering from symptoms of depression and/ or anxiety one week after AMI highlights the essential need to assess these symptoms in all such patients during the post-MI period as they merit appropriate treatment along with the other complications of AMI.

Perinatal mortality rate in relation to gender.

Abstract: OBJECTIVE To calculate the gross and gender adjusted perinatal mortality rate (PMR) and determine the association between gender and susceptibility towards perinatal death. DESIGN A cross-sectional hospital-based study conducted at Gynae Unit-I of Bolan Medical Complex Hospital, Quetta from 1st January to 31st December, 2002. PATIENTS AND METHODS The study included the total births and perinatal deaths over one year period. The cause of death was ascertained through specifically-designed questionnaires and external autopsy. PMR was defined as the number of fetal deaths from 28 weeks of gestations to early neonatal deaths within 7 days after birth. Birth weight of >1000 grams or 35 cms crown-heel length was considered in lieu of unknown gestational age. Multiple pregnancies and stillbirths occurring at home were excluded. Extended Wiggles Worth classification was used to study the etiology of perinatal death separately. RESULTS The PMR was calculated to be 113 per 1000 births. Stillbirth rate was 103 per 1000 total births; out of these, 56.5% were intrapartum and 43.3% antepartum. Male stillbirths were 89.24% in intrapartum and 62.5% in antepartum (df=1,X2=16, p < 0.001). Out of 16 early neonatal deaths, 11 were male infants. Aberdeen classification revealed obstetric causes of PMR as antepartum haemorrhage (34 cases;76% males), malpresentations (28 cases; 57% males), and congenital anomalies (26 cases; 80% males), after adjusting for maternal age and parity. CONCLUSION This study shows fetal gender as statistically significant risk factor and it will pave the way for future community-based studies to confirm such an association, after adjusting for other co-variables.

Pyrazinamide induced hyperuricemia in patients taking anti-tuberculous therapy.

Abstract: Objective To record the effect of pyrazinamide on uric acid in patients of tuberculosis. Design Descriptive and observational study. Place and duration of study Chandka Medical College Hospital, Larkana from February 2000 to January 2003. Patients and methods All patients receiving anti-tuberculosis drugs with pyrazinamide were included. Serum uric acid levels were monitored at weeks 0, 2, 8 and 12 of therapy. Serum creatinine was done at weeks 0, 8 and 12. Results Results were reported on 216 patients. Mean uric acid and creatinine levels at the start of therapy, i.e., week '0' were 5.07 -/+ 0.57 mg/dl and 0.87 -/+ 0.11 mg/dl respectively. The results show significant increase in uric acid levels from week '0' to week '2', at the end of week '8', the levels remained elevated and there was no statistical significant difference from that at week '2'. The uric acid levels reduced at week '12' after pyrazinamide was stopped and the difference was significant. Despite that renal function steadily improved with the treatment of tuberculosis to the extent that comparable pre-treatment values were obtained at the end of treatment. Conclusion Anti-tuberculous therapy with pyrazinamide affects the uric acid levels early. This change is reversible after the withdrawal of the agent.

Comparative efficacy of psoralen - UVA photochemotherapy versus narrow band UVB phototherapy in the treatment of psoriasis.

Abstract: OBJECTIVE To compare the clinical improvement in psoriasis with psoralen - UVA photochemotherapy versus narrow band UVB phototherapy alone. DESIGN An interventional quasi- experimental study. PLACE AND DURATION OF STUDY Dermatology Department, Nishtar Hospital, Multan, from May 2002 to June 2003. PATIENTS AND METHODS Forty patients with chronic plaque type psoriasis were included in the study. These were divided into two equal groups each having 20 patients. PUVA or UVB therapy was given thrice weekly. Clinical improvement in lesions was observed by decrease in the severity of erythema, scaling and plaque elevation. RESULTS Clearance of psoriasis was achieved in significantly greater proportion of patients treated with PUVA (85%) than with UVB phototherapy (60%) (p=0.03814). Significantly fewer number of exposures were required for clearance with PUVA (median number of treatments=17) as compared to UVB (median number of treatments=25.5) (p=0.0002). Median cumulative dose for PUVA was 69.1 J/cm2 and for UVB was 34.15 J/cm2, respectively (p<0.0001). CONCLUSION When given thrice weekly, PUVA was more effective treatment for psoriasis than narrow band UVB phototherapy.

Emergency care in South Asia: challenges and opportunities.

Abstract: One of the striking deficiencies in the current health delivery structure is lack of focus on emergency care in primary health systems, which are ill-equipped to offer appropriate care in emergency situations resulting in a high burden of preventable deaths and disability. Emergency medical systems (EMS) encompass a much wider spectrum from recognition of the emergency, access to the system, provision of pre-hospital care, through definitive hospital care. The burden of death and disability resulting from lack of appropriate emergency care is very high in low- and middle-income countries. In South Asia, health services in general, and emergency care in particular, have failed to attract priority, investments and efforts for a variety of reasons. It has to be emphasized that integrating EMS with other health system components improves health care for the entire community, including children, the elderly, and other vulnerable groups with special needs. Out-of-facility care is an integral component of the health care system in South Asia. EMS focuses on out-of-facility care and also supports efforts to implement cost-effective community health care. There is a possibility of integration of other health services and programmes with an innovative, cost-effective EMS in the region.

Pre-operative evaluation of ovarian mass: risk of malignancy index.

Abstract: Objective To evaluate the risk of malignancy index (RMI) for pre-operative diagnosis of ovarian mass. Design Observational study. Place and duration of study Department of Chemical Pathology and Endocrinology at Armed Forces Institute of Pathology (AFIP), Rawalpindi from January 2001 to January 2002. Subjects and methods The study consisted of 100 female patients consecutively admitted for surgical exploration of ovarian mass. Pre-operatively ultrasonic evaluation of ovarian mass, menopausal status and serum cancer-associated antigen 125 (CA 125) levels were carried out. Postoperatively histopathology of the resected ovarian mass was done to confirm the diagnosis. To increase the sensitivity and specificity of CA 125 for early detection of ovarian cancer, a combination of serum CA 125 with ultrasonography and menopausal status, designated as risk of malignancy index (RMI) for each patient, was calculated. Results The sensitivity and specificity of CA 125 alone for the diagnosis of ovarian cancer, at cutoff level of 35 U/ml, were 83% and 82% respectively. Using RMI, at cutoff level of 125, the sensitivity was 87%, and specificity was 88%. Receiver operating characteristic (ROC) curves reveal that RMI was a better discriminant than CA 125 alone for differentiating between benign lesions and malignant ovarian tumors. Conclusion The risk of malignancy index (RMI) is a better diagnostic marker as compared to CA 125 alone because of its high specificity and sensitivity in differentiating ovarian cancer from ovarian benign lesions. It is a simple scoring system and, therefore, its application is recommended to evaluate ovarian masses in clinical practice.

Sensitivity and spectrum of bacterial isolates in infectious otitis externa.

Abstract: OBJECTIVE To determine the spectrum and antibiotic sensitivity pattern of organisms from aural swabs taken from cases of infectious otitis externa. DESIGN Descriptive study. PLACE AND DURATION OF STUDY Department of ENT, Combined Military Hospital, Peshawar, from May 2002 to April 2003. SUBJECTS AND METHODS One hundred and twenty-four patients, diagnosed clinically as infectious otitis externa without concomitant suppurative otitis media, perforated tympanic membrane or otomycosis, were selected for the study. Samples of pus from external auditory canal were taken on sterile cotton swabs and were cultured on blood agar and MacConkey Agar for 24 to 48 hours. Sensitivity was tested and interpreted by Kirby-Bauer disc diffusion method of grading zones of inhibition. RESULTS One hundred and twenty four subjects were cultured. Sixteen samples showed no growth. One hundred and eight specimens yielded growth of bacteria. No specimen revealed multiple organisms. Staphylococcus aureus was found in 38%, and Pseudomonas aeruginosa was found in other 38%. Others included Proteus, Enterococci, Klebsiella, and E. coli. Majority of organisms were resistant to co-trimoxazole, amoxicillin and erythromycin, while 100% were sensitive to imipenem. Sensitivity to enoxacin was 96%, Ninety-two percent were sensitive to ciprofloxacin and ofloxacin. CONCLUSION Pseudomonas aeruginosa and Staphylococcus aureus were the most common bacterial isolates. Both were sensitive to fluoroquinolones. The latter can be used empirically for treatment of acute infectious otitis externa.