Showing papers in "Journal of Pakistan Medical Association in 1999"

Pakistan National Diabetes Survey prevalence of glucose intolerance and associated factors in North West at Frontier Province (NWFP) of Pakistan.

Abstract: AIM To estimate the prevalence of non-insulin dependent diabetes mellitus (NIDDM) and impaired glucose tolerance (IGT) and their relationship with age and obesity in a population based survey in the rural areas of NWFP, Pakistan. SETTING Three villages, Pawakai, Reghi and Jhagra in NWFP were the target areas. METHODS Cluster sampling of 1035 adults aged 25 years and above (207 men, 828 women) was done. Oral glucose tolerance tests were performed and the diagnosis of diabetes and IGT was made according to WHO criteria. Height, weight and waist hip ratio of the study population were recorded. The Chi Square test was used to measure the association among the different variables. Basic demographic information from the subjects was collected by a physician using a standard questionnaire. RESULTS The overall prevalence of NIDDM and IGT in both sexes was 11.1% and 9.4%. The sex-specific prevalence of diabetes was 9.2% in men and 11.6% in women. Advanced age, positive family history of diabetes and obesity were associated with higher rates of diabetes. In both sexes high Waist Hip Ratio (WHR) was more closely associated with diabetes than was high Body Mass Index (BMI). CONCLUSION The prevalence of diabetes mellitus in rural areas of NWFP is high and almost similar to that of Sindh and Baluchistan.

Determinants of neonatal mortality.

Abstract: OBJECTIVES: To identify the common causes and contributory factors for high neonatal mortality in Pakistan and propose effective strategies to safeguard against it. METHODS: This retrospective study was carried out in Neonatal Unit (NNU) of Rawalpindi General Hospital (RGH) from January 1995 to December 1996. Relevant prenatal information obtained from referral forms, admission files or attendants was recorded on a proforma at the time of death of a newborn. This included obstetric and medical management of the mother, neonatal resuscitation and care, birth weight (wt) and gestational age. Cause of death was based on available clinical and laboratory data. RESULTS: During the study period, there were 3005 admissions and 268 deaths, resulting in 9% neonatal mortality. Eighty-eight percent of this mortality was due to early neonatal deaths. More than 50% of deaths were unavoidable due to their critical condition at admission and occurred within first 24 hours of hospitalization. Neonatal infections and birth asphyxia were two major causes of neonatal mortality (37% and 31% respectively), followed by idiopathic respiratory distress syndromes (IRDS), Meconium aspiration syndrome (MAS) and congenital malformations. Sixty-eight percent of mortality was contributed by low birth weight (LBW), 74% of them being preterm suggesting high mortality among LBW-preterm infants. Other less common contributory factors were maternal medical disease, complicated deliveries and multiple gestation. CONCLUSION: These causes and contributory factors of neonatal mortality reflect poor prenatal health services in this country. Hence there is a need for coordinated efforts to organise and regionalize MCH and prenatal health services with the help of a neonatal task force.

Immunization coverage in three districts of North West Frontier Province (NWFP).

Abstract: Aim: This community-based study was conducted to assess the progress of Expanded Programme on Immunization (EPI) in North West Frontier Province (NWFP) of Pakistan. Method: In this cross sectional survey, 120 randomly selected clusters in 03 districts of NWFP were included, 2673 children in the age group 12-35 months of 2583 randomly selected families were visited. Results: The results showed that 65% of children were fully immunized, but out of them only half could be verified by immunization, need of 2nd and 3rd dose and no faith in immunization were the major causes of failure of immunization programme. Moreover, mother too busy, absence of vaccinator and inconvenient place of immunization were the obstacles pointed out by the parents. Conclusion: This study suggests the areas where improvement can be made to achieve the real target of immunization coverage, It is concluded that despite of more than 20 years of efforts by EPI, the ultimate objectives have not been achieved OPMA 49:301,1999).

Foreign body aspiration in children--a persistent problem.

Abstract: OBJECTIVE: Cough and respiratory distress due to foreign body inhalation in children is a common problem in our society. This study was planned to identify the criteria for early diagnosis and management in suspected cases of foreign body inhalation. SETTING: The study was carried out on indoor patients of Paediatrics Department, Rawalpindi General Hospital (RGH) affiliated with Rawalpindi Medical College (RMC), from January, 1995 to December, 1996. Paediatrics Department has 50-bedded general paediatrics ward, 20-bedded neonatal unit (NNU) and 150-200 daily attendance of outpatient department (OPD). It offers primary to tertiary level care to its patients from whole of Rawalpindi Division. METHODS: This prospective study encompasses profile and immediate outcome of 20 suspected cases of foreign body inhalation. Selection of study subjects and subjection to bronchoscopy was based on symptomatology, clinical and radiological findings and response to treatment. The data with outcome was recorded on a proforma. RESULTS: In 18 cases foreign body was removed successfully by rigid bronchoscope with immediate relief of symptoms and normal chest roentgenograms. Most susceptable age for foreign body inhalation was 1-3 years (n = 14) and male children were at higher risk than females (13 vs 7). Valuable clinical features were sudden onset with respiratory distress, cough, choking, localized poor air entry, crepitations or rhonchi in descending order of frequency. Most common finding in chest roentgenogram was consolidation-collapse and/or emphysema in 50% cases. 30% cases (n = 6) with persistent respiratory tract infection inspite of adequate treatment of recurrent episodes of respiratory distress with wheeze turned out as foreign body inhalation and therefore, such cases need re-evaluation. Betelnut was the most common foreign body removed (n = 7) followed by peanut (n = 6). Most frequent site involved was right main bronchus (n = 7) followed by left main bronchus (n = 5). CONCLUSION: Public awareness through mass media needs attention to prevent foreign body inhalation. High index of clinical suspicion is mandatory for early diagnosis and management to prevent fatal outcome and long term morbidity. Language: en

Morphological pattern and frequency of thyroid tumors.

Abstract: OBJECTIVE The present study was done to evaluate the frequency of thyroid cancer and to find out the prevalence of histological types of thyroid tumor with respect to age and sex group. SETTING This study included consecutive cases of malignant tumors of thyroid gland, which were diagnosed in the Department of Pathology at the Aga Khan University Hospital, Karachi during the period of three years (1995-1997). METHODS These cases were evaluated on H & E stained sections from paraffin embedded 10% buffered formalin fixed tissue blocks. Special stains and immunohistochemical analysis were performed whenever required. RESULTS A total of 8541 malignant tumors were diagnosed in a period of 3 years which included 103 (1.2%) cases of thyroid cancer. Thyroid tumors were more prevalent in females with female to male ratio of 2.6:1. Papillary carcinoma (69%) was the most common histological type of thyroid tumors, followed by follicular carcinoma (11.6%), medullary carcinoma (9.7%), anaplastic carcinoma (5.9%), non-Hodgkin's lymphoma (2.9%) and unclassified tumors (0.9%) in order of frequency. CONCLUSION Thyroid cancer was more common in females. Papillary carcinoma was the most common histological type of thyroid tumors in females as well as in males. Papillary carcinoma was more prevalent in third, fourth and fifth decades of life while follicular and anaplastic carcinomas were more frequent after the fourth decade of life.

Effect of prepregnancy body mass index and gestational weight gain on birth weight.

Abstract: OBJECTIVE: Nutritional status of women has been considered an important prognostic indicator of birth outcome. The study aims to show the effect of various prepregnancy Body Mass Index (BMI) categories and corresponding gestational weight gain on newborn birth weight. METHODS: Two hundred women were included in the study. These women had regular antenatal visits and later delivered at The Aga Khan University Hospital (AKUH) between the period January 1, 1996 to December 31, 1997. RESULTS: For women with prepregnancy BMI 12.5 kg (P 26. CONCLUSION: Efforts should be made to attain adequate prepregnancy weight to reduce the likelihood of low birth weight babies. Hence, special attention should be paid to women with low prepregnancy BMI.

Clinical scoring system: a valuable tool for decision making in cases of acute appendicitis.

Abstract: Objective Decision making in cases of acute appendicitis poses a clinical challenge specially in developing countries where advanced radiological investigations do not appear cost effective and so clinical parameters remain the mainstay of diagnosis. The aim of our study was to devise a scoring system from our local database and test its accuracy in the preoperative diagnosis of acute appendicitis. Methods Clinical data from 401 patients having undergone appendectomy were collected to identify predictive factors that distinguished those with appendicitis from those who had a negative appendectomy. Ten such factors were identified and using Bayesian probability a weight was assigned to each and the results summated to get an overall score. A cut-off point was identified to separate patients for surgery and those for observation. The scoring system was then retrospectively applied to a second population of 99 patients in order to compare suggested actions (derived from the scoring system) to those actually taken by surgeons. The sensitivity, specificity and accuracy for the level of decision was then calculated. Results Of the 99 patients, the method suggested immediate surgery for 65 patients, 63 of whom had acute appendicitis (3.1% diagnostic error rate). Of the 33 patients in whom the score suggested active observation, 18 had appendicitis. The accuracy of our scoring system was 82%. The method had a sensitivity of 78%, specificity 89% and a positive predictive value of 97%. The negative appendectomy rate determined by our study was 7% and the perforation rate 13%. Conclusion Scoring system developed from a local database can work effectively in routine practice as an adjunct to surgical decision making in questionable cases of appendicitis.

Rural-urban differences in food and nutrient intake of Pakistani children.

Abstract: Background Global increase in urbanisation accompanied by increase in complexity of nutritional problems is a cause of concern for most nations. Objective The aim of this study was to assess the differences in frequency of food consumption and nutrient intake of urban and rural Pakistani children. Setting Forty rural, 59 middle income urban and 81 affluent urban children belonging to the province of Punjab. Children were recruited through schools in Lahore and Rayonpura, Kala-Shah-Kaku (Sheikhupura district). Method Three-day estimated diet records were kept by a total of 180, 10-12 year old school-children. The nutrient intake was calculated by the nutritional analysis package COMP-EAT and analysed on SPSS. The results of the three groups were compared. Results Consumption of chapati, eggs, yoghurt and some of the traditional vegetarian snacks was very similar in all the three groups. Consumption of lentils, cooked vegetables, paratha (fried Asian bread) and tea decreased and that of milk, meat curry, chicken curry, chocolates, cakes, ice-cream, fruit and raw vegetables increased with urbanization. As compared with the rural children, the urban children had a higher mean daily intake of calories, sugar, protein, total fats, cholesterol, calcium, sodium, potassium, niacin, vitamin B12, folic acid, antioxidant vitamins A, C and E and lower intake of total carbohydrates, fibre and starch. Conclusion It is concluded that although the macro-nutrient consumption pattern of rural children appears to be heart healthy lower consumption of protective micro-nutrients by them may put them at risk. In view of rapid urbanisation and its multidimensional impacts on the health of the populations living in the urban areas of the developing world, these dietary trends provide baseline information for health professionals.

Bone and renal stone disease in patients operated for primary hyperparathyroidism in Pakistan: is the pattern of disease different from the west?

Abstract: OBJECTIVE To document the clinical presentation of primary hyperparathyroidism (PHPT) in a developing country and note differences from the West. SETTING A tertiary care teaching hospital. METHOD The records of 37 patients operated for PHPT between January 1986 and December 1997 were reviewed. Symptoms, laboratory parameters and histopathology results were analyzed. RESULTS Surgery for PHPT accounted for 0.055% of 67,566 operative procedures performed in the Department of Surgery during the 12 year period. The mean age of our patients was 38.4 +/- 13.2 years (range 17 to 73 years). Ninety percent of patients were less than 60 years old and 51% less than 40 years. At presentation, the mean serum parathyroid hormone (sPTH) level was 618 +/- 741% above the upper limit of normal (range 0-2900% using a variety of assays). A solitary adenoma was present in 86.5%, hyperplasia in 5.4% and carcinoma in 5.4% of patients. There was one (2.7%) negative exploration. Thirty-five percent of patients had renal stone disease (StD), 32.4% had bone disease alone (BD) and 27% had both bone abnormality and stones (BStD). There were neither bone disease nor stones in 5.4% of patients. BD was associated with a statistically non-significantly (p = 0.08) higher alkaline phosphatase level (sALP) as compared to the StD and BStD groups. The mean urinary calcium (Ca) was higher in the BD group (482 +/- 340 mg/24 hours) as compared to StD group (265 +/- 89 mg/24 hours) (p = 0.013). The post-operative hospital stay was longer in the BD group (14.4 +/- 16 days) as compared to the StD group (6.7 +/- 3.7 days) (p = 0.001). CONCLUSION As compared to reports from the Western world, PHPT is less commonly diagnosed in our country and occurs at a younger age. In the absence of a screening programme, symptomatic disease and bone involvement occur more frequently. The high levels of PTH may indicate long-standing disease in our population, which may account for higher proportion of patients with symptoms. Unexpectedly, patients with bone disease had higher levels of urinary calcium than patients with stone disease.

Patients view of the anaesthetist in a developing country.

Abstract: Objective The objective of this study was to assess patients regarding their knowledge and perception of the anaesthetists' role in patient care in a developing country. Setting The audit was conducted at the Aga Khan University Hospital, Karachi. Methods Two hundred surgical and 102 medical out-patients were included in the audit prospectively who filled a detailed questionnaire. Results Fifty-six percent of the patients knew that anaesthetists were medically qualified but only 20% and 27% had an idea about their role in the intraoperative and immediate postoperative period. 14.6% were aware of the anaesthetists role outside the operating room. No difference was observed between the two groups of patients except that a higher percentage of surgical patients were interested in having more information regarding anaesthesia and wanted to choose their anaesthetist if the need arose. Gender difference was observed in answer to two questions only. A higher percentage of males know the role of anaesthetist in the recovery room whereas a greater number of females who had surgery before remembered their anaesthetist postoperatively. Conclusion The results of this audit show a poor perception of the anaesthetists role both inside and outside the operating room. Although public knowledge surveys have been carried out in developed countries there is a pressing need to repeat these in developing countries since the image as perceived by public may have a direct bearing on the recruitment of young doctors into an already shortage specialty in these less affluent countries.

The pattern of malignancies in Karachi (1995 to 1996).

Abstract: OBJECTIVE To determine the cancer pattern of the city of Karachi for the years 1995-1996. METHODS The Karachi Cancer Registry, established in 1995 by the Government of Sindh, in collaboration with the IARC is an active registry. The staff collect the data pertaining to cancer patients and record it on the registry forms. Hospitals in Karachi, district south as well as some of the hospitals in other districts of the city, where patients are likely to go for treatment or diagnosis are visited. People residing in the district for more than six months prior to the onset of the malignancy were considered "residents". All the cases diagnosed on or after 1st January 1995 till 31st December 1996 were considered for analysis. RESULTS In the years 1995-96, the most common cancer sites among males were cancers of the lung, oral cavity and lymph nodes. For females, breast cancer ranked first, followed by cancer of the oral cavity and ovary. The age standardized rate for all cancers was 96.3 per 100,000 in males and 96.9 per 100,000 in females. At this early stage of registration we assume that the registry has a missing rate of approximately 20-25%. CONCLUSION The pattern of malignancies in Karachi is similar to the western countries, with lung and breast being the commonest tumors amongst the males and females respectively. The Asian countries have stomach/lung/oral cavity/liver as the commonest tumors amongst the males and cervix/breast amongst the females. Pakistan being a Muslim country, the incidence of cervical cancer showed an expected low figure.

Drug resistance in Mycobacterium tuberculosis: a four years experience.

Abstract: OBJECTIVE To assess the prevalence of drug resistance amongst the clinical isolates of M. tuberculosis. SETTING Armed Forces Institute of Pathology, Rawalpindi. METHOD Four first line anti-tuberculosis drugs, isoniazid (INH), rifampicin (RIF), ethambutol (ETH) and streptomycin (STR) were tested on 300 isolates from clinical samples, by agar dilution method on Lowenstein Jensen medium. The sensitivities were interpreted by the resistance ratio method. RESULTS One hundred and fifty eight (52.66%) isolates were found resistant to one drug at least. Among the resistant isolates, 79 (26.33%) were resistant to INH, 72 (24.0%) to RIF, 84 (28.0%) to STR and 70 (23.33%) to ETH with or without resistance to other drugs. Multi-drug resistance (MDR) was found in 41 isolates (13.66%). CONCLUSION To overcome this problem there is a need to establish centres at a number of places all over the country with professionals trained to handle the emerging problem of MDR. Each centre must be equipped with adequate facilities for susceptibility testing so that the resistance pattern can be ascertained and treatment regimens tailored accordingly.

Demographic aspects of hepatitis C in northern Pakistan.

Abstract: OBJECTIVE To find out the prevalence of hepatitis C in various, age, sex and ethnic groups in Pakistan. SETTING Specimens obtained from military/civil hospitals and General Practitioners of Rawalpindi Islamabad, region and other areas of Northern Pakistan, in vicinity. SUBJECTS Serum of 1710 patients of hepatitis C, diagnosed at Armed Forces Institute of Pathology (AFIP), Rawalpindi between 1st July 1996 and Dec 31, 1997, tested for Anti HCV by 3rd generation Murex Elisa. Required information was collected on a proforma filled for each patient. RESULTS AND CONCLUSION The majority of the cases were between 30-60 years of age. There was male preponderance. The infection was more common in Urdu speaking fraction of the patients as compared with others.

Prevalence of macrovascular complications in diabetics of WAH, District Rawalpindi.

Abstract: OBJECTIVE To determine the prevalence of macrovascular complications in diabetic subjects with relation to age duration of diabetes and metabolic control. SETTING Primary care centres of WAH, District Rawalpindi cross sectional population based study. METHODS A total of 805 known diabetics (380 males and 425 females) were studied. Relevant history, detailed physician examination and ECG were done to assess the presence of ischaemic heart disease, stroke and diabetic foot complications. Their diabetic control was assessed by estimation of their plasma glucose and glycosylated haemoglobin. RESULTS The prevalence of macrovascular complications was as follows: Ischaemic heart disease 19.8% (female 4.7%, males 7.8%), cerebrovascular disease 6.2% (females 4.7%, males 22.1%) and diabetic foot complications 2.1%. The macrovascular complications increased with age, duration of diabetes and were more prevalent in uncontrolled diabetics having glycosylated haemoglobin > 8.6%. CONCLUSION Prevalence of macrovascular complication in our population is higher as compared to the West probably due to better management and diabetic care in those countries.

Bacteriological quality of drinking water in Punjab: evaluation of H2S strip test.

Abstract: OBJECTIVE To assess bacteriological quality of drinking water in Punjab and to evaluate usefulness of H2S strip test in comparison with multiple tube test METHOD Samples of water were tested using H2S strips and multiple tube test RESULTS Maximum bacterial contamination was observed in water from domestic pumps (9583%) Followed by tap water in rural areas of Punjab (9130%) and tap water in Lahore (4285%) Bacterial contamination was significantly higher (p < 0001) in rural areas as compared to urban areas Comparison of results of testing water samples by H2S strip test and multiple tube test revealed that H2S strip is 8724% sensitive and 100% specific for detection of bacterial contamination with a positive predictive value of 100% It was also observed that 100% water samples negative for total coliforms were also negative by H2S strip method Moreover, with increase in number of total coliforms in the water samples, positivity by H2S strip method also increased (samples with more than 10 total coliforms/100 ml were 100% positive by H2S strip method) Therefore, H2S strip test can be used as alternative to multiple tube test for detection of bacterial contamination of water supplies CONCLUSION It is concluded that bacterial contamination of water is a significant problem in Punjab It can be improved by regular monitoring of water supplies For this purpose use of H2S strip test is advocated at house hold level

Clinico-morphological pattern and frequency of bone cancer.

Abstract: OBJECTIVE The present study was done to find out the frequency of malignant tumors of bone and to categorize the prevalence of various histological types of osseous malignancies with respect to age, sex and site of origin. SETTING This study included consecutive cases of malignant bone tumors, which were diagnosed in the department of pathology at the Aga Khan University Hospital, Karachi during the period of three years (1995-1997). METHODS These tumors were initially evaluated on H & E stained section from paraffin embedded tissue blocks. Special stains and immunohistochemical analysis was performed whenever required. RESULTS A total of 169 malignant bone tumors were diagnosed during the study period. Metastatic tumors accounted for 28.4% of all malignant tumors of bone. Osteogenic sarcoma (27.2%) was the most frequent primary tumor of bone followed by Ewing's sarcoma (12.4%), Non-Hodgkin's lymphoma (10.6%), Chondrosarcoma (8.3%), Plasma Cell Myeloma (8.3%) and other rare entities (4.8%) in order of frequency. CONCLUSION The most common malignant neoplasm diagnosed in osseous biopsies was metastatic tumors. Osteogenic sarcoma was the most frequent primary bone tumor in this series. The bone tumors were relatively more prevalent in males. The frequency of malignant bone tumor was relatively high as compared to developed countries.

An introductory course on study skills forming a bridge between traditional and problem based learning (PBL).

Abstract: OBJECTIVE To introduce entrants in a medical university coming from traditional system of education to student-centered, problem based learning (PBL) and acquaint them with small group dynamics in order to make them life long learners. SETTING Ziauddin Medical University, Karachi, Pakistan. SUBJECTS First Year Students of Medical University. DESIGN The course was of ten hours, divided in six session. In the first session, there were exercises for interaction in small groups, followed by sessions on principles of learning, learning methodologies, PBL, assessment and lastly importance of feedback. RESULT Evaluation of the course revealed that 63% of the students agreed that the course achieved its objectives, 25% were not sure while 12% disagreed. Seventy one percent agreed that the course promoted student to student interaction, 24% were not sure while 5% disagreed. CONCLUSION The course made the process of transition from traditional system of learning to more innovative methods of learning, smoother for the students. The general feeling of the faculty members was that these students were able to perform better than the students who had not taken this course. It is too early to determine the success of this course. A follow-up study however is needed to evaluate the effectiveness of this course by determining the performance of students in small group session of Problem-Based Learning.

Clinico-morphological pattern of intracranial tumors in children.

Abstract: OBJECTIVE The objective of present study was to observe the histopathological pattern of intracranial tumors in children (< 15 yrs) and to correlate the site of lesion along with the histological diagnosis. SETTING The study included consecutive cases of intracranial tumors diagnosed in children (< 15 yrs.) in the section of histopathology at the Aga Khan University Hospital, Karachi during the period of three years. METHODS The initial histological evaluation of these lesions was performed on H and E stained section of paraffin embedded tissue. Special stains and immunohistochemical analysis was done whenever indicated. RESULTS During the study period, fifty-four cases of intracranial tumors were diagnosed in children. The age ranged from 1-1/2 years to 4 years with male to female ratio of 1.1:1. Astrocytoma comprised 39% of all intracranial tumors of childhood. Medulloblastoma (18.6%) ranked the second most prevalent brain tumor followed by empendymoma (13%), oligodendroglioma 7.5% while non-Hodgkin's lymphoma, primitive neuroblastoma 3.7% and ganglioglioma 3.7% while non-Hodgkin's lymphoma, primitive neuroectodermal tumors, mixed germ cell tumor, pineoblastoma, choroid plexus carcinoma and malignant meningioma constituted 1.8% each. CONCLUSION Astrocytoma was the most common pediatric brain tumor. Medulloblastoma was more common in males while pilocytic astrocytoma was more frequent in females. Posterior cranial fossa was the most common site (43.5%) of pediatric brain tumors. Low grade astrocytoma was more prevalent in posterior cranial fossa as compared to high grade astrocytoma which was more frequent in the supratentorial region.

Views about women's mental health: study in a squatter settlement of Karachi.

Abstract: OBJECTIVE Mental health of women is globally receiving particular attention. This study assessed community's view on certain aspects of women's mental health prior to introducing an intervention. SETTING The study was conducted in an urban squatter settlement located in District West of Karachi in 1997 where the Aga Khan University has set up a Primary Health Care program in partnership with the communities. METHODS Using convenient sampling, door to door household survey was conducted by medical students. RESULTS Two hundred and eighty one residents were interviewed. Respondents were asked to list contributory factors which lead to mental distress in women. Two hundred and ten (75%) were able to list certain factors. The factors listed were; low family income (40%), dispute amongst spouses (30%), verbal abuse by in-laws (25%) and too many children (5%). When asked what women in the community did while they were mentally distressed 35% respondents reported that women talked to their husbands and 18% said counselling from a health provider was sought. Main channels of social support desired were; revenue generation (67%), membership of a women's group (11%) and training of local community women in counselling skills (10%). CONCLUSION Signs of awareness about mental health issues are present even in marginalized communities of Pakistan. In order to improve the mental health of women interventions should primarily focus on raising family income.

Non-Hodgkin's lymphoma in Pakistan: a clinicopathological profile of 175 patients.

Abstract: Objective Non-Hodgkin's Lymphomas (NHL) are common in Southeast Asia, Middle East and Africa. The study was primarily undertaken to establish the demographic and clinicopathologic features of NHL in Pakistan. A secondary aim was to determine the applicability of the International Prognostic Index (IPI) developed by the international lymphoma task force in a developing country. Methods A retrospective and prospective analysis was performed on 175 patients over 14 years age who presented to the Department of Oncology between August 1994 and December 1996. All patients underwent initial staging according to Ann Arbor Staging System. Histopathologic classification was done according to the International Working Formulation. The IPI was applied to patients with aggressive lymphomas and age adjusted index to patients Results All 175 patients were evaluable. Median age of our patients was 45 years. Male to female ratio was 1.9:1. Seventeen (9.7%) patients were classified as low grade lymphomas while 158 (91.3%) had intermediate and high grade NHL. Large cell lymphoma was present in 30.9% patients. CHOP (cyclophosphamide 650 mg/m2 day 1, vincristine 1.4 mg/m2 day 1, doxorubicin--45 mg/m2 day 1 and prednisone 100 mg/m2 day 1-5) was the most common chemotherapy regimen used. Advanced stage (74.9%) > B symptoms (51%) and extranodal involvement (74.3%) were present. One hundred sixty-seven patients were evaluable for response of which 42.8% achieved CR. Median DFS was 19 months and median OS was 22 months. The IPI was applicable to 153 patients and age adjusted IPI to 124 of 153 patients. Conclusion Aggressive histology, extranodal diseases, B symptoms and advanced disease are common. International index and age adjusted international index predicted outcome accurately in various risk groups.

Perceived gynecological morbidity among young ever-married women living in squatter settlements of Karachi, Pakistan.

Abstract: BACKGROUND: Community-based information on obstetric and gynecological morbidity in developing countries is meager and nearly non-existent in Pakistan. OBJECTIVES: To estimate the prevalence of specific gynecological morbidities and investigate the predictors of pelvic inflammatory disease. METHODS: Users [404] and non-users [313] of modern contraceptives were identified from eight squatter settlements of Karachi, Pakistan and detailed information on basic demographics, contraceptive use, female mobility, decision-making and gynecological morbidities were elicited. RESULTS: The perceived prevalence of menstrual disorders were 45.3%, uterine prolapse 19.1%, pelvic inflammatory disease 12.8% and urinary tract infection 5.4%. The magnitude of gynecological morbidity was high with about 55% of women reporting at least one gynecological morbidity though fewer [20%] reported at least two gynecological morbidities. Significant predictors of pelvic inflammatory disease were intrauterine contraceptive device users (OR = 3.1; 95% CI 1.7-5.6), age < or = 20 years (OR = 2.3; 95% CI 1.1-4.8) and urban life style (OR = 2.1; 95% CI 1.0-4.6). CONCLUSION: There is an immense burden of reproductive ill-health and a significant association between ever users of intrauterine contraceptive device and pelvic inflammatory disease. We therefore suggest improvement in the quality of reproductive health services generally, but specifically for family planning services.

Aspiration pneumonia in pediatric age group: etiology, predisposing factors and clinical outcome.

Abstract: Introduction Aspiration pneumonia in children is an important disease in terms of the morbidity and mortality associated with it. The objective of this study is to characterize the cases of aspiration pneumonia on the basis of the predisposing factors, types of aspiration syndromes, materials aspirated and their clinical outcome. Methods A total of 107 patients diagnosed as having aspiration pneumonia, were included in this study. Cases were between 0-15 years of age, admitted to the Aga Khan University Hospital (AKUH) over five years. Results The most common form of aspiration syndrome seen was chemical pneumonitis (52.1%). The three most common factors predisposing to pulmonary aspiration were accidental ingestion (37.4%), altered consciousness (34.6%) and neurologic disorders (29%). Children who aspirated oropharyngeal flora were at higher odds to require mechanical ventilation than those aspirating inert fluids and particulate matter (OR = 6.4, 95% CI: 1.5-29.2, p = 0.003). Milk (31.8%), kerosene (21.5%) and oral secretions (19.6%) were the most common materials aspirated. Betel nuts were the most commonly aspirated foreign body. Patients aspirating oral secretions and milk were seen to have a relatively worse clinical outcome than those aspirating kerosene oil. Conclusion Aspiration pneumonia is a relatively uncommon clinical entity at AKUH in children. However, it does cause significant morbidity and mortality.

Adult non-Hodgkin's lymphoma.

Abstract: Adult Non-Hodgkin’s Lymphoma (NHL) is a diverse group of lymphoid malignancies, with an increasing annual trend world over. NHL has shGwn an increase by 39% in Caucasians and 46% in black population and is at least three times more frequent than Hodgkin’s disease, as shown by the SEER study.Intermediate grade lymphoma still constitutes the largest proportion of NHL. Increased incidenceof NHL is largely because of large share from NHL in older age groups. Increased incidence rates of NHL in younger age grouj are attributed to its association with AIDS in recent times and also to classify a large number of cases as NHL which previously used to be labeled as unspecified malignant lymphoma. NHL is more common in developing world and shows a wide geographic variation in its pathobiological characteristics. Extranodal lyinphoina is reportedly 26% of all lymphomas and has increased by 4%, with most frequent sites being stomach, skin, oral cavity, pharynx, small intestine and brain in that orde?. Some of the sub-types like diffuse large cell NHL, large cell immunoblastic NHL and small non-cleaved cell NHL are increasing. NHL can be aB cell or T cell type as cell of ongin. In a local population based study malignant lymphorna are 5.7-8.7% in males and 1.2-1.7% in females. The national cancer database organized by Pakistan Medical Research Council indicates that 6.3% of all male tumors and 1.9% of all females tumors are lymphoma. About 14.8% male lymphoma is NHIL, while 18.4% of female lymphoma are NHL. Inununogenetic sub-typing, flow cytornetty and gene re-arrangement studies and molecular biology tecimiques are increasingly being incorporated in lymphoma management and diagnosis and have changed over concepts tremendously. Hair dyes and herbicides are currently new entities in addition to genetic and envimmnental factors inetiology of NHL. Viruses (HTLV-1, HIVandEBV), congenital immunodeficiency, organ transplantation and autoimmune disorders are otherprecipitating factors. The treatment options are surgety, radiotherapy, chemotherapy (CHOP, M-BACOD, m-BACOD, ProMACE/cytaBOM, MACOP-B), with PBST/BMT9. The clinical presentation is vague with symptoms like decreased appetite, loss of weight, excessive night sweats, tiredness, itching, insomnia, discomfortorpain. Excision biopsy is preferred over FNAB where possible. Other tests are complete physical evaluation, CBC with ESR, biochemistry, XR, CT/MRI, bone marrow biopsy, Gallium scan of nodes, lymphangiogram, biopsy/exploration, endoscopy and biopsy. NHL usually shows centrifugal nodal involvement. Overall median survival is 8-9 years and increasing condition to early diagnosis combined withprompt and effective treatment. Currently REAL (Revised European American classification of lymphoid neoplasm) is widely used and accepted. The prognosis and overall survival in good in NHL, with early diagnosis and prompt treatment. The same can be achieved in our local lymphoma patients with improvement in diagnostic and therapeutic approach. There is an immense need for impfovement in histopathology training, incorporation of new diagnostic modalities and evaluation of cost effective treatment protocols for our population of patients. There is no reason not to achieve the same level of life expectancy and quality of life in our patients, if these above-mentioned considerations are given the due attention.

Fine needle aspiration cytology (FNAC) in the management of thyroid pathology--the Aga Khan University Hospital experience.

Abstract: OBJECTIVE To report the efficacy of FNAC in patients with thyroid disease. METHODS Between January 1990 and December 1994 the records of all patients treated surgically for thyroid disease at ENT Head and Neck Surgery of Aga Khan University were reviewed. All the patients had pre-operative FNAC as the first line of evaluation and the histopathologist examined post-operative thyroid specimen. RESULTS Forty-five patients (36 female and 9 male) had thyroid surgery. In 26 patients out of 45, FNAC was conclusive in diagnosing the nature of disease, while in 19 patients the FNAC was inconclusive because of the presence of follicular cell neoplasia. CONCLUSION Our results indicate that the FNAC is very accurate and a reliable test in the diagnosis of thyroid pathology, however, to distinguish follicular adenoma from follicular carcinoma final histology is required. FNAC is cost effective method of evaluating thyroid pathology pre-operatively and plays a vital role in planning the surgical management of thyroid nodule.

Sublingual human insulin for hyperglycaemia in type I diabetes.

Abstract: OBJECTIVE To investigate the hypoglycaemic effects of repeated sublingual doses of human insulin for the treatment of hyperglycaemia in type I diabetes. DESIGN Clinical trial. SETTING A Private clinic. METHOD Eight insulin dependent diabetic males with a mean age of 27 years (range 18-32 years) presenting with hyperglycaemia were given 1 U/Kg body weight of human soluble insulin in 5 equally divided doses at 15 min intervals, sublingually. Plasma glucose was estimated at 0, 15, 30, 45, 60, 90, 120 and 150 min. Urine examination for glucose was done at 45 min intervals. RESULTS The results showed that the mean plasma glucose before treatment was 19.93 + 2.1 mmol/L Hypoglycaemic effect was recorded at 15 min and reached a peak at 120 min when plasma glucose dropped to 10.9 + 1.2 mmol/L (p < 0.001). No side effect was reported and insulin was tolerated well. CONCLUSION We concluded that sublingual human insulin in repeated doses has a hypoglycaemic effect and could be used to control hyperglycaemia in type I diabetes.

Intrauterine growth restriction: a perspective for Pakistan.

Abstract: BACKGROUND Intrauterine growth restriction (IUGR) is the second leading contributor to the prevailing perinatal mortality and morbidity. It affects 23.8% of newborns around the world and 75% of these affected infants are born in Asia. In Pakistan the incidence of IUGR is around 25%, more than the WHO criteria for triggering a public health action. INTRODUCTION IUGR is implicated with profound long-term impacts in adult life; like coronary heart disease, NIDDM and abnormal cortisol levels. The effects of the short and long term sequelae are reviewed. ETIOLOGY IUGR is associated with a wide variety of etiological factors. But the factor unique in its importance to Pakistan is maternal malnutrition. The fetal gene expression is under the influence of nutrition. Growth projection curves showing the interaction between the genetic and environmental factors are discussed. SURVEILLANCE Identification of IUGR baby in a primary care setting and the options in diagnosis in secondary and tertiary care settings are overviewed. CONCLUSION The roots of this problem, with multi factorial causes are in the socioeconomic infrastructure. This calls for a synergistic approach of reducing this public health issue. Women empowerment can help us to get out of this intergenerational cycle of growth failure. Availability of resources aside, it is also a matter of political will to change things for the better.

Carotid Doppler ultrasonography in young stroke patients.

Abstract: BACKGROUND The present study focuses on the role of carotid doppler ultrasonography (CDUS) in the diagnosis and management of carotid stenosis in young stroke patients. METHODS The findings of carotid doppler in 45 ischemic stroke patients between 15-45 years of age were reviewed retrospectively. The variables of interest for this study included risk factors for atherosclerotic disease, primary abnormality detected on carotid doppler ultrasonography (ulceration vs. stenosis), degree of stenosis and the type of plaque (soft vs. calcified). RESULTS The prevalence of hypertension and diabetes was 50% and 35% respectively. The rate of carotid stenosis in the study population was found to be 31%. The degree of stenosis was mild in 35% and moderate in 21%. High-grade stenosis was found in 21% of patients. The plaque was soft in the majority of cases (43%). CONCLUSION The proportion of carotid stenosis in young stroke patients was relatively high compared with previous studies. This may be due to an increase in the risk factors for atherosclerotic disease in developing countries.

Syndrome X and family practitioners.

Abstract: Background: Increased incidence of hypertension, non-insulin dependent diabetes (NIDDM) and coronary heart disease often cluster in the same individuals and there have been speculations that a common mechanism may be responsible for all of these pathological conditions. This risk factor constellation, which is associated with an enhanced risk for cardiovascular disease, is sometimes referred to as the ‘Insulin Resistance Syndrome”, ‘Syndrome X”, or the “Metabolic Syndrome”. Aim: To find out the prevalence of Syndrome X in the population of patients coming to a preventive health check clinic at a tertiary care teaching hospital in a megacity of the developing world. Methods: A total of 270 patients, above the age of 40 years, who attended preventive health check clinics of 2 Family Physicians at the Aga Khan University from January 1996 to July 1997 were selected. Patients below 40 years were excluded from the study. Results: The prevalence of Syndrome X, defined as association of obesity, NIDDM, hypertension, raised LDL and raised triglycerides is 2.6% in patients above 40 years, who were screened in this study. Conclusion: The significant prevalence of Syndrome X is alarming and we need to strengthen our existing educational programs for prevention of obesity, increased physical activity and better control of hypertension. When drugs are selected for pharmacological treatment, priority should be given to those, which improve the insulin sensitivity index or are at least neutral in this respect (JPMA 49: 177, 1999).

H. pylori IgG antibodies in children.

Abstract: Objective The aim of the study was to see the exposure rate to H. Pylori (IgG) in apparently healthy children. Methods Serum samples of 100 apparently healthy children aged 6 months to 10 years were screened for IgG antibodies against H. pylori using Abbott's flexpack kit. Children were divided into two groups, group I included aged 6 months to less than 5 years and group II aged 5-10 years. Results Of 60 children in group I, 17 (28.3%) showed antibodies against H. Pylori indicating exposure. The exposure rate was 12.5% between 6 months to 11 months, 28.5% in 12 months to 23 months and 38% in 24-36 months. Exposure rate increased with lowering of socioeconomic status; being 13.3% in upper, 26.9% in middle and 42.1% in lower socioeconomic group. Of 40 children aged 5 years to 10 years, 16 (40%) showed H. Pylori antibodies. The exposure rate was 34.3% at years and increased to 62.5% in those aged 8-10 years. The H. pylori positivity was 33.3% in upper and middle socioeconomic group and 62.5% in lower socioeconomic group. Over all exposure rate to H. Pylori in children was 33%. Conclusions H. pylori exposure rate increased with the advancement of age and lowering of socioeconomic status. Early exposure might be related to the use of premasticated food by the mothers for feeding of children; dental plaque being the reservoir of infection in adults.