Showing papers in "Journal of Pakistan Medical Association in 2005"

Hydrocephalus in children.

Abstract: The word "hydrocephalus" is derived from two Greek words: hydro meaning water; and cephalus meaning head; also known as "water on the brain". Historically it is believed to result from imbalance between CSF production and absorption, with net accumulation of fluid in the cranial cavity; characterized by increase in size of the cerebral ventricles. It is classified as: Communicating hydrocephalus, in which flow is not obstructed, but CSF is inadequately reabsorbed in the subarachnoid space and the Non-communicating hydrocephalus or the Obstructive type, in which flow of CSF from the ventricles to subarachnoid space is obstructed. This type may also be sub-classified into Congenital and Acquired. The overall incidence of hydrocephalus is not known. Approximately 55% of all hydrocephalus are congenital. The etiology depends upon the age of the child. The clinical features are increase in the size of head, with wide anterior fontanelle, prominent scalp veins, sun-setting eyes, optic nerve atrophy, nystagmus and increased muscle tone in children upto 2 years. Children more than 2 years may present with these as hydrocephalus progresses; or if the fontanelles are closed, head size may be normal. These may present with optic atrophy or papilloedema, abnormal hypothalamic functions (short stature or gigantism, obesity, delayed puberty, primary amenorrhea or menstrual irregularity and diabetes inspidus) and spastic lower limbs. Performance IQ is worse than verbal IQ and learning problems are common. The diagnostic procedures include measurement of head circumference, Plain X ray of head, Ventriculography, Pneumoencephalography, Ultrasonography, Computed Tomography and Magnetic Resonance Imaging. The management may be non-surgical and surgical.

Premenstrual syndrome: frequency and severity in young college girls.

Abstract: Objectives: To find out the frequency of premenstrual syndrome (PMS) in young college girls and to describe the severity of emotional, physical and behavioural symptoms. Methods: An observational study was conducted at the Khyber Medical College, Peshawar by convenient sampling on 384 young girls. Data was collected over two cycles by filling a 29 items shortened premenstrual assessment form based on Moos Menstrual Distress Questionnaire after taking consent from medical students. Results were given according to both criteria i.e. ICD-10 and DSM-IV. Results: The frequency of premenstrual syndrome was 53% according to ICD-10 criteria, among which 42% was mild, 18.2% moderate and 31.7% severe. A total of 64 girls (18.2%) met the DSM-IV criteria for severe PMS or Premenstrual Dysphoric disorder (PMDD). The order of frequency of symptoms occurring in PMS was general body discomfort, anxiety, backache, fatigue and depression. Most frequently reported symptoms in PMDD group were anger, anxiety, stress, depression, fatigue and general body discomfort. Conclusion: Premenstrual syndrome is a common problem in young girls. Doctors should adopt comprehensive measures to reduce its incidence and improve the quality of life in the affected (JPMA 55;546:2005).

Frequency and sensitivity pattern of Extended Spectrum beta Lactamase producing isolates in a tertiary care hospital laboratory of Pakistan.

Abstract: OBJECTIVE: To determine frequency, distribution and sensitivity pattern of Extended-Spectrum beta Lactamase (EBSL) producing organism at a tertiary care hospital in Pakistan. METHODS: All members of enterobacteriacae isolated between April and August 2002 were studied. Isolates were speciated according to standard biochemical tests. Susceptibility testing was performed by Kirby-Bauer method. ESBL was detected using double disc method using cefotaxime versus cefotaxime plus clavulanate according to NCCLS. Statistical analysis was performed by SPSS version 10. Test of significance were calculated using chi-square test. RESULTS: During the study period, 1137/2840 (40%) of the isolates tested were found to be ESBL producing. ESBL positivity was detected in 50% Enterobacter sp., 41% E. coli and 36% K. pneumoniae. ESBL production was noted in 52% of nosocomial isolates tested (415/799). ESBL was more frequent in patients at the extremes of ages (under 5 years and more than 60 years). Cross-resistance to non-beta lactam antibiotics (flouoroquinolones, aminoglycosides and co-trimoxazole) was also more frequent in ESBL producing organisms (p<0.05). CONCLUSION: A high frequency of ESBL positivity amongst our isolates is documented which is alarming in low-income settings where expensive second line agents are unavailable. Our data supports urgent need for regular screening and surveillance for these organisms.

Menstrual irregularities with excessive blood loss: a clinico-pathological correlation.

Abstract: Objective: To evaluate various histo-pathological features in endometrial curettings of patients complaining of menstrual irregularities with excessive blood loss and correlating them with clinical presentations. Methods:A total of 260 endometrial curettings were obtained by Dilatation and Curettage done at the Department of Gynecology and Obstetrics, Railway Hospital, Rawalpindi. All the preserved specimens were processed under standard conditions at the Pathology Department, Islamic International Medical College (IIMC). The sections were studied after staining with Haematoxylin and Eosin stain. Results: The patients presented with menorrhagia in 51.9%, metrorrhagia in 35.4%, polymenorrhoea in 9.2% and polymenorrhagia in 3.5% cases. History of hormonal intake was observed in 0.66% patients. Menstrual disorders were most common in 41-50 years age group accounting for 48% cases. Pathology was diagnosed in 40% of endometrial biopsies. The endometrial lesions included endometrial hyperplasia (24.7%), chronic nonspecific endometritis (13%), endometrial polyp (1.2%), pill pattern endometrium (2.3%) atrophic endometrium (0.8%) menopausal pattern endometrium, squamous metaplasia, squamous cell carcinoma and chorioncarcinoma (0.4% each). Conclusion: The dilatation and curettage was found to be an appropriate approach with a good diagnostic yield. Fortunately frequency of endometrial malignancy appeared to be very low. Endometrial hyperplasia was the leading causes of excessive menstrual bleeding (JPMA 55:486;2005).

Hospital waste management in the teaching hospitals of Karachi.

Abstract: Objective To evaluate the current practices of segregation approaches, storage arrangements, collection and disposal systems in the teaching hospitals of Karachi. Methods A cross-sectional survey was conducted in eight teaching hospitals of Karachi, using convenient sampling technique. The instrument of research was a self administered questionnaire, with four sections, relating to the general information of the institution, administrative information, information regarding Health Waste Management personnel and a check-list of Hospital Waste Management activities. Results Out of eight hospitals visited 2 (25%) were segregating sharps, pathological waste, chemical, infectious, pharmaceutical and pressurized containers at source. For handling potentially dangerous waste, two (25%) hospitals provided essential protective gears to its waste handlers. Only one (12.5%) hospital arranged training sessions for its waste handling staff regularly. Five (62.5%) hospitals had storage areas but mostly it was not protected from access of scavengers. Five (62.5%) hospitals disposed off their hazardous waste by burning in incinerators, two (25%) disposed off by municipal landfills and one (12.5%) was burning waste in open air without any specific treatment. No record of waste was generally maintained. Only two (25%) hospitals had well documented guidelines for waste management and a proper waste management team. Conclusion There should be proper training and management regarding awareness and practices of waste disposal. Research must be undertaken to seal existing gaps in the knowledge about hospital waste management. The hospital waste management guidelines enacted on 7th June 2004 should be followed and regulated by law enforcement agencies rigorously.

Knowledge of students regarding hepatitis and HIV/AIDS of a private medical university in Karachi.

Abstract: Objective: To determine and assess the level of awareness among students of a private medical college regarding HIV/AIDS, Hepatitis B and C. Methods: A survey was conducted to assess the awareness of medical students on HIV/AIDS, hepatitis B and C. They were asked to fulfill a pre-tested structured questionnaire. The variables accessed were their knowledge of disease regarding etiology, mode of transmission, and prevention. Results: A total of 267 students participated, with 117 (43.8%) students from pre-clinical years and 150 (56.2%) from the clinical years. The male female ratio was 1:2, mean age of respondents was 21 + 1.5 years. Majority of the students (98%) agreed that an infected person is a major source of transmitting these infections. Almost all (95%) students knew that blood transfusion was an important source of transmitting these infections. Wearing gloves (87%) and safe disposal of sharps waste (98%) were known by the students to be the ways to protect against these infections. A significant difference was noted on comparing the knowledge between preclinical and clinical students regarding medical / surgical procedures causing these infections (p<0.001) and also regarding the ways to protect against these diseases (p=0.001). Conclusion: There is a lack of awareness among the medical students entering into the profession. It is the need of the hour to emphasize on practicing universal precautions. In addition, some preventive measures should be taken by the management of the universities and medical students to avoid the occurrence of these problems (JPMA 55:285;2005).

Knowledge, attitude and practice of parturients regarding Epidural Analgesia for labour in a university hospital in Karachi.

Abstract: The objective was to assess the knowledge sources of knowledge attitude (fears and misconceptions) regarding Epidural Analgesia (EA) and practices of parturients delivery at Aga Khan University hospital (AKUH). A hospital based cross sectional study was conducted at the obstetric unit of AKUH from November to December 2003. A questionnaire was filled through verbal interviews conducted on 448 parturients fulfilling the inclusion criteria. Seventy six percent of the females were aware of epidural analgesia as a labor pain relieving method. However only 19% availed EA. About 40% had heard about EA from their obstetricians and 64% from friends or relatives. Twenty even percent believed that EA has detrimental effects on the baby while 9% stated that EA can prolong the duration of labour. Majority of the pregnant females delivering at Aga Khan University Hospital were aware of epidural analgesia for labour. However only a small proportion are availing this service due to fears and misconceptions. (authors)

Comparative study of knowledge, attitude and practices among antenatal care facilities utilizing and non-utilizing women.

Abstract: Objective: To compare the knowledge, attitude and practices among antenatal care facilities utilizing and non-utilizing women, aged 15-49 years. Methods: A Cross-sectional survey was conducted between October 2003 and April 2004, including 200 married women in the age range 15-49 years. Knowledge, attitude and practices of women utilizing and not utilizing antenatal care facilities during their previous pregnancy were compared by calculating odds ratios and 95% confidence intervals. P values were obtained by doing chi-square test. Results: Pallor was significantly lower among women utilizing antenatal care (57%) as compared to those who were not (77.6%). (O.R 0.38 95% CI(0.18-0.81) p value 0.02). Tetanus toxoid coverage was higher among women utilizing antenatal care (92%) compared to those who were not (59.2%) (O.R 10.8 95% CI(4.5-26.2). Knowledge about danger signals in pregnancy and realization of the importance of eating a healthy diet during pregnancy was significantly higher among women utilizing antenatal care. Conclusion: Lesser prevalence of Anaemia and better tetanus toxoid coverage was seen among women attending antenatal care facilities.Identification of danger signals in pregnancy and recognition of nutritional demands of pregnancy are better understood by women utilizing antenatal care facilities.

Prevalence of microalbuminuria in type 2 diabetic patients in Karachi : Pakistan a multi-center study

Abstract: Objective: To determine the frequency of microalbuminuria and its associations in type-2 diabetic subjects attending diabetes centers/clinics across Karachi, Pakistan. Methods: Two thousand one hundred subjects with type-2 diabetes were screened for microalbuminuria using Micral test strip II. A single screening test was performed in 25 diabetes centers/units in different districts of Karachi from January 2003 to December 2003. Results: The overall prevalence of microalbuminuria was 34%. Mean age of subjects was 53.1 years + 11.9 years, mean BMI was 25.8 ± 4.1 and mean duration of diabetes was 8.8 ± 5.21 years. Fifty seven percent were males and 43% females. Sixty two percent of the subjects had a systolic blood pressure >130 mmHg. Forty five percent had a family history of diabetes and 5% had a family history of hypertension. Univariate analyses demonstrated significant associations between microalbuminuria and age, duration of diabetes, male gender, smoking status, microvascular and macrovascular complications, hypertension, high triglycerides, high serum LDL, low serum HDL, and high fasting & random blood sugars. When adjusted for the effects of other variables in the model, age, diastolic blood pressure, serum LDL and retinopathy were found to be significantly associated with microalbuminuria. Conclusion: The prevalence of microalbuminuria in type 2 diabetic subjects in this cross-sectional multicentre study across Karachi was 34% and this was significantly related to age, diastolic blood pressure, serum LDL and retinopathy (JPMA 55:382;2005).

Association of literacy of mothers with malnutrition among children under three years of age in rural area of district Malir, Karachi.

Abstract: Objective: To determine the association of literacy of mothers with malnutrition among children under three years of age in rural area of district Malir, Karachi. Methods: A cross-sectional study was conducted on four hundred children under three years of age, residing in the rural area of district Malir, Karachi. The selection of the children was irrespective of gender, ethnicity and religion. Results: Three hundred nineteen mothers (79.75%) were illiterate and 81 (20.25%) were literate. In the latter group, three mothers could read or write only, 38 had primary, 10 middle, 15 matric, 12 intermediate and 3 mothers had education upto graduate level. Maximum malnutrition regarding stunting (40.75%) was seen in children who's mothers were illiterate and maximum underweight (57.89%) was seen in children who's mothers had education up to primary level and maximum wasting (33.33%) was seen in children who's mothers (only 3 mothers out of 400) were graduates. There was a significant difference regarding underweight between the children who's mothers were illiterate or had education up to primary level in comparison to the children who's mothers had education to more than primary level (P<0.016), but in significant difference regarding stunting and wasting was found. Overall a total of 217 (54.25%) children were underweight, 156 (39%) were stunted and 86 (21.5%), had wasting. Conclusion: Mother's literacy status has a definite association with the malnutrition of the children <3 years of

Frequency of isolation of shigella serogroups/serotypes and their antimicrobial susceptibility pattern in children from slum areas in Karachi.

Abstract: Objectives To assess the frequency of serogroups and serotypes, as well as the antimicrobial susceptibility pattern of Shigella species isolated from known cases of diarrhoea and dysentery from Karachi, Pakistan. Methods A cross-sectional study was conducted between January 2002 and March 2003 at Aga Khan University on stool samples received from children with diarrhoea and dysentery from four low socio-economic areas (Sultanabad, Rehri Goth, Hijrat and Sherpao colony) of Karachi. Stool samples yielding growth of Shigella species, were further identified for serotypes by slide agglutination. Antibiotics susceptibility was performed by Kirby Bauer disk diffusion method. Results Out of 4688 stool samples received, 193 (4.1%) were positive for Shigella species. Shigella flexneri was the predominant serogroup (58%) followed by Shigella sonnei (16%), Shigella boydii (15%) and Shigella dysentriae being the least common (11%). A number of serotypes were isolated in each serogroup, 8 serotypes in S. flexneri, 8 serotypes in S. dysenteriae, 9 serotypes in S. boydii, and Phase 1 & 2 were found in S. sonnei. 17% isolates remained non-serotypeable. All isolates were susceptible to Ofloxacin and Ceftriaxone, high rate of resistance was observed in Cotrimoxazole (87.75%) and Ampicillin (55.5%). Emerging resistance against Nalidixic acid (39%) was observed. Conclusion Shigella still accounts for a significant proportion of bacillary dysentery in many tropical and subtropical countries. Serotype identification can help in devising strategies such as development of effective vaccine for controlling this problem. Increasing antibiotic resistance against commonly prescribed drugs signify that treatment options have become difficult in cases of severe dysentery.

Frequency of irregular red cell alloantibodies in patients with thalassemia major: a bicenter study.

Abstract: Objective: To provide frequency and distribution pattern of various types of irregular red cell alloantibodies in patients with thalassemia major. Methods: This is a descriptive study conducted at two centers from Januaryto December 2001. Purposive sampling was done and all patients diagnosed to have thalassemia major were included in the study. Antibody identification was carried out on serum employing commercial two-cell panel using standardized blood bank methods. If patients were found to have an irregular red cell alloantibody then the antibody identification was performed using 16 panel cells. Results: A total of ninety-seven patients were included in the study. Fifty-three patients were males and 44 females. Mean age was 10.6 years. Irregular red cell alloantibodies were found in 9 (9.2%). Mean age of patients who developed red cell alloantibody was 11.9 years. Three (33.3%) patients developed anti-K while two (22.2%) had non-specific antibody. One patient each developed anti-D (11.1%) and anti-E (11.1%). Two had anti-D (11.1%) and anti-C while the other one (11.1%) developed anti-E and anti-K. Conclusion: We concluded that there is relatively high rate of alloimmunization in our set of patients when compared to data from our region. We also suggest that red cell alloimmunization should not be overlooked in patients receiving regular blood transfusions (JPMA 55;563:2005).

Rotavirus infection in infants and young children in Makkah, Saudi Arabia.

Abstract: Objective: To determine the prevalence of rotavirus in infants and young children in Makkah, Saudi Arabia. Methods: A population-based prevalence study was done in randomly selected infants and young children suffering from acute diarrhoea. Faecal specimens were collected from 479 patients. A latex agglutination test was used for rotavirus detection. All positive and 10 negative samples for rotavirus by latex agglutination were also tested by enzyme-linked immunosorbent assay (ELISA). Results: Rotavirus was detected in 48 (10%) patients using latex agglutination test. ELISA detected 46/48 positive samples. Ten samples that tested negative with latex test were also negative with ELISA. Infection with rotavirus was more frequent among infants and children < 2 years old, with a maximum incidence among children 0-12 months. Rotavirus infection was 3.1% in Saudi nationals, compared to 6.9% in other nationalities. Conclusion: In this study the prevalence rate of 10% was low compared to other studies done in different regions of Saudi Arabia. This low rate could be due to the geographical location of Makkah with very hot and dry summer, and mild winter and almost no rain throughout the year.

Pattern of tobacco consumption among adult women of low socioeconomic community Karachi, Pakistan.

Abstract: OBJECTIVE To assess pattern and to determine risk factors associated with tobacco consumption in various forms among adult women above 18 years of age in a low socioeconomic community of Manora Island, Karachi. METHODS A cross-sectional survey was conducted and 200 adult women above 18 years of age were selected using systematic sampling with random start from a community of 5000 people in Manora Island, Karachi. There were 400 households in the community. Every 2nd household was visited and a woman above 18 years was selected. A semi-structured pre-tested questionnaire was administered to respondents by investigators. Data on tobacco consumption and other variables such as age, sex, marital status, education, employment and stress and anxiety related symptoms were obtained. RESULTS A total of 104 (52%) reported tobacco consumption. Use of huqqa (hubble bubble) was more prevalent (79%). Women above 30 years of age, being married and living in a joint family were more likely to consume tobacco. Illiterate women as compared to women with more than five years of schooling were more likely to consume tobacco (OR = 3.16,95% CI = 1.13-7.72). Women having household income more than 5000 rupees were more likely to consume tobacco (OR = 2.63,95% CI = 1.36-5.09) and face more financial difficulties at home (OR = 4.72, 95% CI = 2.45-9.81). Women consuming tobacco reported anxiety related symptoms more as compared to women who did not consume tobacco. CONCLUSION Our study concluded that in this particular study setting, huqqa is the commonest form of tobacco consumption among women of low socioeconomic class. They start huqqa usually in childhood and after marriage by peer pressure especially in joint families. Women consuming tobacco report more psychosomatic symptoms and financial difficulties at home.

Evaluation and outcome of pregnancy complicated by heart disease.

Abstract: Heart diseases are the most important non obstetrical causes of maternal deaths during pregnancy accounting for almost 10% of maternal deaths. They complicate 1-3% of all pregnancies with congenital defects in 70-80% of the cases. In developing countries like Pakistan rheumatic heart disease (RHD) still accounts for the majority of cases and mitral stenosis is the most frequently observed valvular lesion. The risk of congenital heart disease (CHD) in the offspring is 2-4% if either parent is affected. Valvular heart disease is often recognized for the first time during pregnancy when the pregnancy associated cardiovascular changes increase the demand on the heart and exacerbate the symptoms and signs of valvular lesion. The presenting symptoms are shortness of breath palpitation syncope fatigability and haemoptysis. Examination may reveal cyanosis clubbing raised JVP cardiomegaly murmurs arrhythmias and basal crepts. The functional capacity of the heart is assessed by investigations as electrocardiography (ECG) echocardiography oxygen saturation and complete blood examination. Close liaison between obstetrician and cardiologist is required throughout pregnancy. If possible pregnancy should not be allowed in patients with uncorrected severe valvular lesion or those requiring anticoagulation. This is due to increased maternal and foetal morbidity and mortality. Medical therapy and balloon valvuloplasty have greatly improved the outcome and now term gestation is possible. Foetal outcome depends on the degree of maternal well being. Foetal mortality is not exceptionally high in patients with New York Heart Association (NYHA) class I and II however if there is associated pulmonary hypertension there is a risk of abortions intrauterine growth retardation preterm delivery and early neonatal death. In this study we evaluated 50 pregnant patients having various cardiac problems and described their outcome. (excerpt)

Bed wetting in school children of Karachi.

Abstract: Objectives: To estimate the frequency of primary nocturnal enuresis (PNE) in Pakistani children and to examine the factors associated with it. Methods: A randomly selected cross-sectional study was conducted in five elementary schools, one in each of five districts of Karachi. The parents of 5000 children age between 3-13 years were asked to complete a questionnaire which included items about the frequency of daytime wetting and nocturnal enuresis, family history, urinary tract infection, parents and child's own concern about this problem and acquisition of treatments. Results: Over all corrected response rate to the questionnaire was 69% (3395). Enuresis was present in 9.1% (308). There were 166 (53.9%) boys and 142 (46%) girls with a median age of 7 years. Only 54% (166) children sought help for their problem of which 26% consulted doctors, 16% visited homeopaths while 11% used hakeems and home remedies. Of the bed wetters, 30% were wet every night, 30% for more than three nights a week and 40% for less than three nights every week. Parents of 68.5% (211) children reported concern for the problem while 69.8% (215) children were also anxious about their enuresis. Among the concerned children group, 22% parents were not concerned about their child's problem. Family history of enuresis was present in 25.6% (79) children. Conclusion: The frequency of enuresis among the school going children in Karachi is 9.1% and is similar to that reported in European countries and other Asian countries including Korea and Taiwan. Enuresis causes concern to both parents and children, but only a small percentage of parents seek medical help for this problem.

Evaluation of serum transferrin receptor concentration in diagnosing and differentiating iron deficiency anaemia from anaemia of chronic disorders.

Abstract: Objective To diagnose and differentiate iron deficiency anaemia (IDA) from anaemia of chronic disorders (ACD) using serum concentration of soluble transferrin receptors (sTfR). Methods One hundred and seventy six adult anaemic patients were diagnosed on bone marrow examination as IDA and ACD in the Department of Haematology, Armed Forces Institute of Pathology, Rawalpindi from November 2001 to May 2003. They were further evaluated with sTfR, serum iron, total iron binding capacity (TIBC) and serum ferritin. These biochemical investigations were compared with results of bone marrow iron status, which served as gold standard. Absence of stainable iron in the bone marrow was diagnostic of iron deficiency, whereas abundance of iron along with decreased siderocytes and sideroblasts was considered diagnostic of ACD. Data was collected on a proforma and analysed using software SPSS (version 11.0) and t-test was used to test the statistical significance. Specificity, sensitivity positive and negative predictive value of the sTfR test was calculated. Results Out of 176 patients studied, 90 (51.1%) were diagnosed as ACD whereas 86 (48.8%) as IDA. The mean +/- SD sTfR levels in IDA patients was 9.68 +/- 2.48 mg/I, whereas mean +/- SD sTfR levels in ACD patients was 2.96 +/- 1.28 mg/I, thus clearly separating the two categories of anaemic patients. Both the sensitivity and specificity of sTfR in IDA was found to be 100%, whereas in ACD, these were 66.6% and 100% respectively. The positive and negative predictive value, in case of IDA was 100%, whereas in ACD it was 100% and 74.1% respectively. The results of serum iron, TIBC and serum ferritin correlated well in IDA, with a fall in serum iron, raised TIBC and decreased serum ferritin, except in few cases in which concomitant inflammatory conditions resulted in falsely high serum ferritin level. Serum iron and TIBC were not useful in cases of ACD. However, the serum ferritin cutoff level of 90 ng/ml was evaluated which virtually excludes IDA, and found this highly effective in cases of IDA alongwith chronic inflammatory conditions. Conclusion The results show that in case of simple IDA, sTfR concentration is significantly raised and it has a very high test efficiency in this condition. However in case of ACD the positive predictive value is high (100%) but the negative predictive value is compromised (74.1%). It is therefore a reliable laboratory index of IDA and in distinguishing IDA from ACD).

Knowledge regarding management of tuberculosis among general practitioners in northern areas of Pakistan.

Abstract: Tuberculosis (TB) was declared as a global emergency by WHO in 1993. Pakistan accounts for 44% of total TB burden in East Mediterranean Region and ranks 6th among the highest burden countries. While 210000 new TB cases occur each year only one in four cases is ever diagnosed in the country. North West Frontier Province (NWFP) and the Northern area (NA) are situated in the northern part of Pakistan both regions with high TB prevalence. The prevalence of pulmonary TB in a village from Northern Area was reported to be 557/ 100000 for smear positive and 1949/100000 for smear negative cases. Similarly a study conducted on prisoners in NWFP showed that 48% of the male prisoners had latent tuberculosis. Major problems encountered in Pakistan are late and improper diagnosis prescription of inadequate treatment regimens poor supervision of the therapy leading to irregular intake of drugs and poor follow-up. This in turn leads to failure relapse and emergence of multidrug resistance tuberculosis (MDR-TB) which is increasing at an alarming rate in Pakistan. (excerpt)

Spectrum of common childhood skin diseases: a single centre experience.

Abstract: Objective: To assess the pattern of childhood skin diseases and to analyze the attitude towards consultation and self-treatment. Methods: Children with complaints of skin diseases visiting outpatient department of Jinnah Postgraduate Medical Centre and National Institute of Child Health were enrolled in this study during the period of May 2002 to July 2003. A detail performa was filled in, for all the patients. 250 cases were finally analyzed in 15 months duration. The diseases were sub-classified on etiological basis e.g. infectious (bacterial, fungal, viral, parasitic) immune mediated, congenital, allergic and miscellaneous. The children's sex, race, age, duration, history of previous treatment and family and past history for skin or systemic diseases were noted. Results: Of all the patients visiting the outpatient department (OPD), 31% were children with skin diseases. Infectious skin diseases were the commonest (60%). Among the infections, fungal were maximum (20.6%), followed by bacterial diseases (12%). Eczemas constituted 21% of skin diseases and 6.4% children had congenital skin conditions. Previous treatment history was present in 43.6% patients. Antibiotics (topical and/or systemic) were taken by 28.4% of patients; whereas history of steroids (topical and/or systemic) was present in 15.2% of patients. Most children (550) had a normal weight and 13.6% were severely malnourished. Conclusion: Skin diseases are fairly common in children especially infectious skin diseases. Eczematous and allergic skin diseases are also frequently encountered in children. Self medication is a common practice. Topical steroids were the most commonly used medications.

Effect of environmental lead pollution on blood lead levels in traffic police constables in Islamabad, Pakistan.

Abstract: OBJECTIVE To determine the blood lead levels and trace elements (copper and manganese) in traffic police constables in Islamabad in order to assess the effects of environmental pollution on the levels of metals in body fluids. METHODS Blood samples were collected from 47 male traffic police constables, 21 to 45 years of age, posted in different areas of Islamabad and controlling traffic from 3 months to 18 years, 8 hours/day, 6 days/week. Adolescent males (13-19 years), residing in comparatively clean and very low traffic areas were included as controls. Blood lead, copper, and manganese concentrations were estimated by atomic absorption spectrophotometry. RESULTS The mean blood lead level among constables (27.27 microg/dl) was significantly (p<0.0001) high as compared to controls (3.22 microg/dl). Twenty one percent constables had elevated blood lead levels (over 25 microg/dl) and 13% had levels above the safety limit (40 microg/dl). No correlation was found between blood lead levels and length of service. No significant difference was found in the mean values for copper between traffic constables (93.49 microg/dl) and controls (71.15 microg/dl). The mean blood manganese levels in traffic constables (21.94 microg/dl) were significantly (p<0.0001) higher than in controls (1.70 microg/dl). The mean blood lead levels were significantly high in traffic constables of Karachi (47.7 microg/dl) as compared to Islamabad (27.2 microg/dl), which shows direct relation of rise in blood lead levels with vehicle exhaust. CONCLUSION Environmental lead pollution is associated with an increased blood lead concentration in those who are regularly exposed to vehicle exhaust in high traffic areas. The degree of lead pollution arising from vehicle exhaust differs in Karachi and Islamabad. Exposure to air containing dust particles rich in manganese may affect blood manganese levels.

Anaesthetic reasons for cancellation of elective surgical inpatients on the day of surgery in a teaching hospital.

Abstract: Objective A prospect audit was conducted to find out the anaesthetic reasons for cancellation of surgical in patients on the day of surgery, and to plan for future suggestive corrective actions to reduce unnecessary cancellations. Methods The audit was conducted at Aga Khan University Hospital for one year from 1st January to 31st December 2003. Data was collected monthly on a pre-designed form and the files of cases that were cancelled were reviewed by two consultants and labeled as justifiable or not justifiable cancellation. Results Eight thousand, five hundred and twenty six patients were scheduled for surgery during the study period, 359 (4%) were cancelled on the day of surgery after their names appeared on the operating room schedule. Only 28 (8%) of all cancellation were anaesthetic cancellations, 15 of which fell in nonjustifiable category. Conclusion Although anaesthetic cancellations were only 0.3% of total elective admissions, this number can be improved further in the interest of the patients by implementing and following the recommendations that have been proposed following this audit.

Proportion of gastroesophageal reflux symptoms in patients with chronic obstructive pulmonary disease.

Abstract: Objective: To determine the proportion of gastroesophageal reflux symptoms in patients with chronic obstructive pulmonary disease and its association with the severity and worsening of the symptoms of chronic obstructive pulmonary disease (COPD). Methods: A prospective, questionnaire based, case control, analytical study was conducted in the Department of Pulmonology, Jinnah Postgraduate Medical Centre, Karachi during June 2002 to January 2005. Gastroesophageal reflux symptoms were compared between 100 chronic obstructive pulmonary disease patients who fulfilled the inclusion criteria and 150 control subjects. Both groups were interviewed according to modified version of Mayo clinic GER questionnaire. Chronic obstructive pulmonary disease patients were divided into two groups according to pulmonary function tests (PFTs) results into FEV1 50%. Results: Chronic obstructive pulmonary disease patients had more frequent gastroesophageal symptoms than controls (25% vs. 9.33% respectively; p=0.001), heartburn/acid regurgitation (70% vs. 43.33% and 56% vs. 30.66% respectively; p-value=0.001), dysphagia (15% vs. 4%; p-value=0.002) and chronic cough (89% vs. 29.33%; p-value=0.001). Twenty six COPD patients reported respiratory symptoms associated with reflux, whereas control subjects denied such association. Of the 11 patients with frequent gastroesophageal symptoms, 10 patients increased their inhaler use (p=0.001). Frequent gastroesophageal symptoms had shown a significant association with decreased FEV1 (25 % vs. 0% p-value 0.001). In contrast Pulmonary function test results were similar among chronic obstructive pulmonary disease patients with and without gastroesophageal symptoms (48.13′20.81 vs. 50.94′23.33). Anti-reflux medication proton pump inhibitor and H2-blockers were utilized more by COPD patients as compared to control subjects. Conclusion: A higher proportion of frequent gastroesophageal symptoms were noted by COPD patients than control subjects and higher proportion of gastroesophageal symptoms was present in severe COPD patients.

Phloroglucinol for acceleration of labour: double blind, randomized controlled trial.

Abstract: Objectives: To determine the effects of Phloroglucinol in acceleration of labour and its adverse effects on mother and foetus. Methods: A double blind randomized, placebo controlled trial was conducted on 100 patients in active phase of uncomplicated labour selected by convenient sampling. Patients were given Phloroglucinol or Placebo (distilled water) intravenously. Progress of labour was plotted on Partogram. Any adverse effects of the drug on mother and fetus were noted. Student's t-test was applied for statistical analysis. Results: In patients receiving Phloroglucinol there was a mean 34% reduction in duration of 1st stage of labour and a mean 23% reduction in 2nd stage as compared to Placebo group respectively. Blood loss >500ml was observed in 2% patients. Otherwise there were no adverse effects on mother or foetus. Conclusion: Phloroglucinol shortens the duration of labour, is non toxic to both mother and fetus and does not cause primary post partum haemorrhage.

Herpes simplex encephalitis: analysis of 68 cases from a tertiary care hospital in Karachi, Pakistan.

Abstract: Objective: To evaluate clinical presentation, radiological and cerebrospinal fluid findings and outcome of patients with Herpes simplex encephalitis (HSE). Methods: The charts of all the patients (n=88), who were admittedto The Aga Khan University, Karachi with diagnosis of HSE, from 1990-2002, were retrospectively reviewed. Sixty eight patients were included in the study. The variables were identified (including demographic data, signs and symptoms at presentation and laboratory investigations such as CSF analysis including, PCR, serum IgM antibodies, EEG and neuroimaging). The patients were included in the study if they had any three of the five criteria positive in addition to clinical features suggestive of herpes encephalitis. Results: Sixty eight patients, that fulfilled the criteria, were included in the study. Clinical findings included fever, seizures, altered mental status, aphasia and hemiparesis. CSF, analysed in all the patients, was abnormal in 65 patients (96%) and EEG was abnormal in 82% patients. All patients underwent CT or MRI of the brain, 66% patients had abnormal scans. Temporal lobe involvement was seen in 34 patients (50%) and 11 patients had purely extra temporal lesions. All patients were treated with standard Acyclovir. Seven patients died. At the time of discharge, 17 patients showed normal neurological examination, 29 were ambulatory with assistance and 15 were bedridden. Conclusion: Our study suggests that large number of patients with HSE have extra temporal involvement on CT or MRI. Majority of patients had complete or good recovery after completion of therapy (JPMA 55: 146;2005).

Prognostic indicators in patients with primary intraventricular haemorrhage.

Abstract: Objectives: Primary intraventricular haemorrhage (PIVH) is a rare clinical entity. We sought to evaluate risk factors, clinical and radiological features, and outcome of patients with PIVH. Materials and Methods: Cases ofPIVH were identified from cohort of patients with non traumatic intracerebral haemorrhage (ICH) by reviewing the radiological data. Their charts were reviewed and demographic, clinical, radiological and laboratory data was recorded and analyzed. Chi square and t test were used to determine predictors of poor outcome. Results: Fifteen of 677 (2%) patients with ICH had PIVH. Nine (60%) were men. Median age was 56 years. Predisposing factors included hypertension in twelve (80%), coagulopathy in five (33%) and vascular malformations in two (13%) patients. Eleven (73%) patients developed hydrocephalus. Two patients died. Univariate analysis identified diabetes mellitus, blood in all ventricles and coagulopathy as predictors of death during initial hospital stay and hydrocephalus as predictor of poor outcome (death and disability combined) (p<0.05). Conclusion: Hypertension is most common associated risk factor for primary intraventricular haemorrhage followed by coagulopathy. Hydrocephalus Is a common complication, associated with poor outcome. Diabetes mellitus, coagulopathy and panventricular blood predict early mortality (JPMA 55:315;2005).

Cutaneous tuberculosis: a three year prospective study.

Abstract: Objective: To study the pattern of clinical presentation of cutaneous tuberculosis. Methods: All patients with clinical suspicion of cutaneous tuberculosis, visiting outpatient department of Dermatology Unit, Jinnah Postgraduate Medical Centre, Karachi were included in this study.Total number of the patients enrolled were 74.The lesions were then classified into four clinical types viz: lupus vulgaris, scrofuloderma, tuberculids and tuberculosis verricosa cutis. Results: A total of 0.1% patients visiting out patient department had cutaneous tuberculosis. Scrofuloderma was the commonest form seen in 48 (64.9%) patients, followed by lupus vulgaris in 16 (21.5%), tuberculosis verrucosa cutis in 6 (8.1%) and tuberculids 4(5.6 %).The presence of regional lymphadenopathy had correlation with the disseminated disease. Conclusion: There is an increasing trend of cutaneous Tuberculosis over the years. Scrofuloderma was the most common clinical presentation, followed by lupus vulgaris, tuberculosis verrucsa cutis and tuberculids. Tuberculous gumma was not seen in any patient.recheche.

Role of isoniazid prophylaxis for prevention of tuberculosis in haemopoietic stem cell transplant recipients.

Abstract: Objective: To evaluate the role of isoniazid prophylaxis in prevention of tuberculosis among allogeneic stem cell transplant recipients. Methods: This study was conducted at Armed Forces Bone Marrow Transplant Center Rawalpindi, Pakistan from July 2001 to October 2003. Patients suffering from various haematological disorders undergoing allogeneic stem cell transplantation were included in the study. The demographic information, primary diagnoses and relevant investigations were recorded. Patients had negative tuberculin skin tests and chest X-Ray at pre-transplant assessment. First 25 patients (group I) did not receive isoniazid prophylaxis while the next 25 (group II) were given isoniazid in a dose of 5-10 mg/kg (maximum 300 mg/day). Isoniazid prophylaxis was started on day-1 and continued for 6 months post transplant. The patients developing tuberculosis were treated with rifampicin, ethambutol, isoniazid, and pyrazinamide during first 3 months followed by 2 drugs for a total duration of 12 months. Minimum follow up in group I and II was 783 and 403 days respectively. Results: There was significant difference (p<0.001) in frequency of tuberculosis between two groups. In group I, four patients developed Tuberculosis (frequency 16%) whereas none of the patients in group II had the disease. Out of these four cases 3 had extrapulmonary disease. One patient died two weeks after the start of anti tuberculosis treatment while others successfully completed the treatment. Conclusion: Tuberculosis in stem cell transplant recipients is an important opportunistic infection especially in areas of high disease prevalence like Pakistan. Isoniazid prophylaxis for 6 months is effective in preventing tuberculosis among this class of patients (JPMA 55:378;2005).

Surgical management of genitourinary fistula.

Abstract: Objective: To determine the commonest cause of genitourinary fistulae and evaluate the experience of the surgical management. The study was carried out at the Urology Department, Jinnah Postgraduate Medical Centre (JPMC),Karachi. Methods: Twenty two patients were operated including 14 of Vesicovaginal Fistula (WF), and 8 of Ureterovaginal Fistula (UVF). In one patient of WF fistula was extending up to proximal urethra. Out of 14 WF cases, 9 patients underwent transvaginal repairs, 1 extraperitoneal transvesical repair and 1 transperitoneal repair. Three urinary diversions including 1 Mitrofanoff and 2 ileal conduits were also made. Ureteroneocystostomy was done in cases of UVF with adjuvant procedures in 3 cases including Psoas Hitch in 1 and Boari's flap in 2 patients. Results: The mean age was 35 (range 21-50) years. WF due to obstetric causes was seen in 71.4% patients while 28.6% developed WF secondary to gynaecological procedures. Majority of (91%) WF were repaired successfully in the first attempt in patients subjected to the procedure (78.6% cases of WF). There was only one recurrence in transvaginal repair, which was successfully treated with extraperitoneal transvesical approach in second attempt, thus augmenting the success rate to 100%. However 3 (21.4%) cases of VVF required urinary diversion as there was complete loss of sphincter mechanism in one case, in which fistula was extending up to the urethra, and in two cases of complex VVF with complete loss of posterior bladder wall surrounded by extensive scarring. All cases of UVF were successfully treated with ureteroneocystostomy alone or with adjuvant procedure in 37.5% cases. Conclusion: Uncomplicated VVF can be successful repaired transvaginally by refreshing the fistulous edges without excising it. Transabdominal route should be reserved for complicated VVF. Ureteroneocystostomy with antireflux mechanism with or without adjuvant procedure is the treatment of choice for UVF resulting from complete transaction or ligation of ureter.

Use of recombinant factor VIIa for massive postpartum haemhorrage: case series and review of literature.

Abstract: Recombinant activated factor VII is indicated mainly for the treatment of patients with haemophilia inhibitors. It has also been found successful in the treatment of platelet disorder Glanzmanns thrombasthenia. Recently its use in trauma patients and in patients with intracereberal haemorrhage has become well established. We present three cases of massive post partum haemorrhage treated with rFVIIa following caesarean section. The response of these three patients is discussed along with review of literature. (authors)

Reasons for the problems faced by patients in government hospitals: results of a survey in a government hospital in Karachi, Pakistan.

Abstract: Objective To assess the reasons for the problems faced by patients in the government hospitals to make an emphasis on higher authorities for identification of problems and implementation of effective measures. Methods A questionnaire-based doctor's survey was conducted at Jinnah Postgraduate Medical Centre (JPMC). The survey included 10 doctors each from 5 wards of JPMC. Informed consent was taken from study participants and ethical considerations were fulfilled. All the doctors were asked questions related to the problems created by hospital management, due to the irresponsibility and concerns of the doctors and also due to the patients themselves. The responses were evaluated separately. Results A total of 50 doctors participated, out of which, 19 were males and 31 females. Out of all the reasons listed, 84% doctors favored the reason of inadequate salary to doctors & paramedical staff by government while other two reasons favored by 80% doctors were lack of facilities and security for doctors and illiteracy and poverty of patients. Conclusion This hospital based study showed that the causes were related mainly to hospital management, doctors' attitude and responsibility and also to patients' illiteracy and poverty. This calls for adequate measures by higher authorities to rectify the situation.