Measurement of Radioactivity in the Granites of Pakistan: A Review

All human beings are exposed to primordial radiation. The main source of primordial radiation has been naturally radioactive building materials. In Pakistan, among building materials, granites are most commonly used. This paper reviews the previous studies conducted for the estimation of natural radioactivity of granites from Rustam-Koga, Shewa-Shahbazgarhi, Bunair, Mansehra, and Nagarparkar. The techniques used for these studies include gamma spectrometry and field surveys. To assess the radiation hazards associated with granites of Pakistan, primordial radionuclides and corresponding radiation hazards have been estimated. Most of these granites are found to be safe except Rustam-Koga granite, which presents high excess lifetime cancer risk.

Control of the stereochemistry of C14 hydroxyl during the total synthesis of withanolide E and physachenolide C

The stereochemical outcome of the epoxidation of Δ_14–15 cholestanes with mCPBA is controlled by the steric bulk of a C17 substituent. When the C17 is in the β configuration, the epoxide is formed in the α face, whereas if the C17 is trigonal (flat) or the substituent is in the α configuration, the epoxide is formed in the β face. The presence of a hydroxyl substituent at C20 does not influence the stereochemical outcome of the epoxidation.

The epoxide configuration in oxidation of C14–C15 alkenes is determined by the configuration of the C17 substituent.

Granulomatous Interstitial Nephritis: A Rare Cause of Acute Kidney Injury

Acute granulomatous interstitial nephritis (GIN) is a rare cause of acute kidney injury (AKI) but treatable. It is present in 0.5 to 0.9% of native renal biopsies. Treatment with moderate dosage of steroids is associated with good prognosis. We herein review a case of a 48-year lady having AKI following drug-induced damage [non-steroidal anti-inflammatory drugs (NSAIDs) and antibiotics]. Her renal functions did not improve after one month of drug withdrawal, so renal biopsy was done that showed acute GIN. She was treated with intravenous then oral steroids that completely resolved AKI.

Socio-economic factors affecting quality of life of Hemodialysis patients and its effects on mortality

Objective

Many factors affect quality of life (QOL) of dialysis patients. This study was conducted to determine the effect of socio-economic factors effecting QOL of hemodialysis patients.

Methods

This descriptive multi-centric, follow up study was conducted at Department of Nephrology, Mayo Hospital, Lahore, from February 2015 to August 2017. All patients who were on regular maintenance hemodialysis (MHD) for more than three months and able to read and understand Urdu version of Kidney Disease Quality Of Life (KDQOL) tool were included in the study. Patients were included from hemodialysis units of Mayo Hospital (MH), Shalamar Hospital (SH), and Shaikh Zayed hospital (SZH), Lahore. Patients with less than three-month duration on dialysis, with cognitive impairment, dementia, active psychosis, non-Urdu readers/speakers were excluded. Demographic data and lab data was collected on predesigned pro forma. Patients were divided into different groups on the basis of education, monthly income, source of funding for treatment and employment. Patients were followed up for two years to determine the effect of QOL on mortality.

Results

One hundred and thirty-five patients were included in the study. Socio-economic factors like education, employment, income, funding was compared with KDQOL sub scales and were found statistically significant (p-value (<0.05). We found that patients with higher income had better work status (p=0.039) but social (0.04) and sexual function (p=0.029) were relatively better in patients with low income. Employed patients had better work status (p=0.01), ability to do social function (p=0.027) but they had more pain (0.049), symptoms/problems of disease (p=0.05) and effect of kidney disease (p=0.015). Those patients whose dialysis were funded by their family could socially interact (p=0.012) better and deal more efficiently with effect of kidney disease (p=0.007). Higher education was associated with better emotional well being (p=0.045), patient satisfaction (p=0.046) and staff encouragement (p=0.045) then patient with lower level of education. QOL had no effect on mortality.

Conclusion

The socio-economic factors consisting of education, employment, income and funding are important parameters affecting QOL of kidney patients. QOL does not affect mortality of the dialysis patients.

Factors Affecting Dermatological Manifestations in Patients with End Stage Renal Disease

OBJECTIVE

To determine skin changes in patients of End Stage Renal Disease (ESRD) on maintenance hemodialysis (MHD) and factors affecting these changes.

STUDY DESIGN

Cross-sectional observational study.

PLACE AND DURATION OF STUDY

Nephrology Department, Mayo Hospital, Lahore in collaboration with Dermatology Department, King Edward Medical University, Lahore, from October 2015 to January 2016.

METHODOLOGY

Two hundred patients who were undergoing MHD for more than three months were included in the study. Patients' demographic data, laboratory reports and dialysis records were noted in a predesigned questionnaire. Skin examination was carried out by consultant dermatologist after patient's permission.

RESULTS

Among 200 patients included in study, 105 were malesand rest of them were females. Major causes of ESRD were Diabetes Mellitus (n=83, 41.5%, followed by Hypertension (n=80, 40%), Nephrolithiasis (n=15, 7.5%) and Chronic glomerulonephritis (n=5, 2.5%). At least one cutaneous finding was present in every patient. Common skin findings observed were pigmentation (86%), xerosis (83%), pallor (79%), pruritus (69%), acquired ichthyosis (50.5%), and bacterial skin infections (18.5%). Among them, nail manifestations were half-and-half nails (52%), onychomycosis (30.5%), onycholysis (20.5%), subungual hyperkeratosis (23.5%), and Mee's lines (7.5). Among hair changes were sparse scalp hair (38.5%), brittle and lustreless hair (28%). The factors contributing to skin changes were patient's age, cause of ESRD, anti HCV positivity, high urea and creatinine levels, duration and frequency of hemodialysis, hemoglobin levels, calcium phosphate product and socioeconomic status. Some skin manifestations were interrelated with each other like xerosis with pruritus (p<0.001), pruritus with bacterial infection (p<0.022), acquired Ichthyosis (p=0.008) and hair changes (p=0.035).

CONCLUSION

ESRD patients on hemodialysis develop various skin changes during the course of disease process, which contribute to increased morbidity. Different factors affecting skin changes were the cause of ESRD, adequacy and duration of dialysis, employment, financial status, anti HCV positivity, and metabolic factors.

The adverse effects of interferon-free regimens in 149 816 chronic hepatitis C treated Egyptian patients

BACKGROUND

Interferon-free regimens are associated with high sustained virological response; however, associated adverse effects have yet to be fully reported.

AIM

To evaluate the adverse effects associated with the different direct-acting antiviral drug (DAA) regimens in Egyptian patients.

METHODS

This multicenter retrospective study included all adverse effects during and after treatment with DAA regimens of 149 816 chronic hepatitis C treated Egyptian patients. Patients received sofosbuvir (SOF)/ribavirin (RBV) (n = 21 835), SOF/simeprevir (n = 24 215) SOF/daclatasvir (DCV) (n = 58 477), SOF/DCV/RBV (n = 45 188) and paritaprevir/ombitasvir/ritonavir/RBV (n = 101). The duration of treatment varied between 12 and 24 weeks. All changes in the treatment regimens, discontinuation, mortality, and serious side effects were reported.

RESULTS

Adverse effects developed in 2475 (1.7%) (mean age [54 ± 9], male gender [53%]) patients. Serious side effects developed in 68% of these patients, and SOF/RBV was the most common causing regimen (73%, P < 0.001). Anaemia and hyperbilirubinemia were the most common side effects (731/149816, 0.5% and 463/149816, 0.3%, respectively) and SOF/RBV (588/21835, 3% and 353/21835, 1.6%, respectively) showed the highest incidence in the treated patients. Hepatocellular carcinoma and mortality were reported in 0.02% and 0.06% of all treated patients, respectively. Patients with liver cirrhosis showed higher incidence of serious side effects (Log rank P = 0.045) and mortality (Log rank P = 0.025) than patients without liver cirrhosis. Male gender (P = 0.012), lower haemoglobin (P < 0.001), platelets (P < 0.001) and albumin (P = 0.001), higher bilirubin (P = 0.002) and cirrhosis (P < 0.001) were factors associated with serious side effects development.

CONCLUSION

Adverse effects associated with DAAs are few, anaemia being the most common. SOF/RBV regimen showed the highest rate of side effects while SOF/DCV showed the least.

Outcome of Chronic Kidney Disease Patients on the Basis of Referral to Nephrologist: A One-Year Follow-up Study

OBJECTIVE

To determine the outcome of chronic kidney disease (CKD) patients presenting for dialysis on the basis of referral to nephrologist.

STUDY DESIGN

Observational study.

PLACE AND DURATION OF STUDY

Nephrology Department of King Edward Medical University/Mayo Hospital, Lahore, from January 2014 to January 2016.

METHODOLOGY

All patients who were presented in nephrology outpatients department and with the indication of dialysis were included in study. Patients who refused dialysis, and with acute kidney failure were excluded from the study. Proforma was designed for demographics, vital signs, volume status, and laboratory data (hemoglobin, urea, creatinine, albumin, bicarbonate etc.) of all the patients. On the basis of referral, patients were divided into two groups, i.e. early referral and late referral. Early referrals were those patients who were referred to a nephrologist more than three months before dialysis initiation. Late referrals were those patients who were referred to a nephrologist less than three months before dialysis initiation. Patients were followed up at one, three, six, and 12 months for outcome, i.e. still on dialysis or died.

RESULTS

One hundred and seventy-six patients were enrolled in the study, and 141 were followed up to one year. Seventy- two (51.1%) patients were male, 69 (48.9%) were female and most (n=69, 48.9%) were in the middle age group. Major causes of end-stage renal disease (ESRD) were hypertension 70 (49.6%) and diabetes mellitus 66 (46.8%). Seventy-six (53.9%) patients were in fluid overload and acidotic (n=123, 87.2%). Twenty-seven (19.1%) patients were referred early and 114 (80.9%) were referred late. Overall mortality was 78 (55.3%) at one year. Factors affecting mortality were financial status and metabolic acidosis, but not referral. Temporary access for hemodialysis has 1.38 times more risk for mortality than the patients with permanent access.

CONCLUSION

There is no difference on the outcome of dialysis patients on the basis referral to nephrologist. Factors affecting overall mortality in both groups were financial status, metabolic acidosis, and temporary access for dialysis. Most of the patients were referred late to the nephrologists.

Role of water chemistry and stabilizers on the Vero-cells-based infectivity of Newcastle disease virus live vaccine

Newcastle disease virus (NDV) live vaccines are supplied in lyophilized form and usually administered through conventional routes (drinking water, spray, or eye drop) following reconstitution in a diluent. Virus inactivation due to physico-chemical properties of the diluent at the time of administration may lead to vaccine failure. The present study aimed to evaluate the survival of NDV live vaccine strain immersed in 5 pH-amended water samples (pH 5.00, pH 6.00, pH 7.00, pH 8.00, and pH 9.00) by sequential determination of virus infectivity on Vero cells for 3 hours. Minimum reduction in virus infectivity was recorded in the water with neutral or slightly alkaline pH, while the virus was relatively less stable at extreme pH conditions. Maximum reduction of infectivity was observed in the water with pH 9.00 in which the virus was completely inactivated within 3 hours. Addition of stabilizers (Cevamune^® or skimmed milk) slightly altered the pH and total dissolved solids (TDS) values of the virus-charged water samples. In the stabilizer-added water samples, minimum reduction in infectivity was observed in the water with neutral pH, followed by the ones with a pH of 8.00, 6.00, 5.00, and 9.00. In all types of water samples, T-90 values (time required for 90% reduction in virus infectivity) were highest (485 minutes) at neutral pH (pH 7.00) and lowest (102 to 134 min) at an extreme alkaline condition (pH 9.00). Results of the present study indicate that water with a pH range of 7.00 to 8.00 is suitable for administration of NDV live vaccines. However, the addition of Cevamune^® or skimmed milk may have beneficial effects on preserving the infectivity of the virus, even at extreme pH conditions.

Identification for the First Time of Cyclo(d-Pro-l-Leu) Produced by Bacillus amyloliquefaciens Y1 as a Nematocide for Control of Meloidogyne incognita

The aim of the current study was to describe the role and mechanism of Bacillus amyloliquefaciens Y1 against the root-knot nematode, Meloidogyne incognita, under in vitro and in vivo conditions. Initially, the exposure of the bacterial culture supernatant and crude extract of Y1 to M. incognita significantly inhibited the hatching of eggs and caused the mortality of second-stage juveniles (J2), with these inhibitory effects depending on the length of incubation time and concentration of the treatment. The dipeptide cyclo(d-Pro-l-Leu) was identified in B. amyloliquefaciens culture for the first time using chromatographic techniques and nuclear magnetic resonance (NMR ¹H, 13C, H-H COSY, HSQC, and HMBC) and recognized to have nematocidal activity. Various concentrations of cyclo(d-Pro-l-Leu) were investigated for their effect on the hatching of eggs and J2 mortality. Moreover, the in vivo nematocidal activity of the Y1 strain was investigated by conducting pot experiments in which tomato plants were inoculated with M. incognita. Each and every pot was amended 50 mL of fertilizer media (F), or Y1 culture, or nematicide (N) (only once), or fertilizer media with N (FN) at 1, 2, 3, 4 and 5 weeks after transplantation. The results of the pot experiments demonstrated the antagonistic effect of B. amyloliquefaciens Y1 against M. incognita as it significantly decreases the count of eggs and galls per root of the tomato plant as well as the population of J2 in the soil. Besides, the investigation into the growth parameters, such as the length of shoot, shoot fresh and dry weights of the tomato plants, showed that they were significantly higher in the Y1 strain Y1-treated plants compared to F-, FN- and N-treated plants. Therefore, the biocontrol repertoire of this bacterium opens a new insight into the applications in crop pest control.

First report on molecular characterization of Leishmania species from cutaneous leishmaniasis patients in southern Khyber Pakhtunkhwa province of Pakistan

OBJECTIVE

To report presence of Leishmania major in Khyber Pakhtunkhwa of Pakistan, where cutaneous leishmaniasis (CL) is endemic and was thought to be caused by Leishmania tropica only.

METHODS

Biopsy samples from 432 CL suspected patients were collected from 3 southern districts of Khyber Pakhtunkhwa during years 2011-2016. Microscopy on Giemsa stained slides were done followed by amplification of the ribosomal internal transcribed spacer 1 gene.

RESULTS

Leishmania amastigotes were detected by microscopy in 308 of 432 samples (71.3%) while 374 out of 432 samples (86.6%) were positive by ribosomal internal transcribed spacer 1 PCR. Subsequent restriction fragment length polymorphism confirmed L. tropica in 351 and L. major in 6 biopsy samples.

CONCLUSIONS

This study is the first molecular characterization of Leishmania species in southern Khyber Pakhtunkhwa. It confirmed the previous assumptions that anthroponotic CL is the major CL form present in Khyber Pakhtunkhwa province. Furthermore, this is the first report of L. major from a classical anthroponotic CL endemic focus identified in rural areas of Kohat district in southern Khyber Pakhtunkhwa.

Soluble Serum Transferrin Receptor (STFR) Levels in Hemodialysis Patients

<p><strong>Objectives:  </strong>Anemia is a frequent disorder in patients with end stage renal disease. Erythropoietin is advised in these patients; however, this therapy is not effective in patients who are iron deficient. So, diagnosis of iron deficiency which is traditionally based on ferritin and other iron parameters becomes difficult in these patients, as chronic kidney disease is a chronic inflammatory condition which affects these markers and masks the iron deficiency. In present study, we assessed the reliability of another indicator of body iron supply; serum transferrin receptor, in hemodialysis patients. It is not affected in case of inflammation unlike other markers of iron status.</p><p><strong>Patients and Methods:</strong><strong>  </strong>Eighty Patients with end</p><p>stage renal disease, 20 to 60 years of age and both sexes were included. All cases were examined for complete blood count, serum iron, serum ferritin, serum total iron binding capacity, transferrin saturation and serum soluble transferrin receptor. Data was analysed by using independent sample <em>t</em> test and Pearson’ correlation. A <em>p </em>value of ≤ 0.05 was considered as significant.<strong></strong></p><p><strong>Results:  </strong>The results of our research showed that mean values of serum soluble transferrin receptor and serum ferritin were 3.28 ± 0.83 µg/ml and 286.31 ± 165 ng/ml respectively which were significantly higher than the upper normal limit (<em>p </em>&lt; 0.001). Levels of sTfR were statistically different (<em>p </em>= 0.002) between iron replete group (SF &gt; 100 ng/ml) and iron deplete group (SF &lt; 100 ng/ml). Additionally, there was negative and significant correlation between sTfR and Hemoglobin.</p><p><strong>Conclusions:  </strong>Levels of serum soluble transferrin receptor can be used as a reliable marker of iron defi-ciency in hemodialysis patients.</p>

Translation, Validation and Reliability of the Kidney Diseases Quality of Life-Short Form (KDQOL-SF Form) Tool in Urdu

OBJECTIVE

To translate, validate and assess the reliability of kidney disease quality of life - short form (KDQOL-SF-36) in Urdu, national language of Pakistan.

STUDY DESIGN

Amulticentric descriptive cross-sectional study.

PLACE AND DURATION OF STUDY

Department of Nephrology, Mayo Hospital, Lahore, from February to July 2015.

METHODOLOGY

Patients of end-stage renal disease (ESRD) on maintenance hemodialysis (MHD) for more than three months, were included in the study. Patients of ESRD not on dialysis, and those with acute renal failure were excluded. The English version of KDQOL-SF-36 was translated in Urdu and then translated back in English; further validation was done by a senior professor of Punjab University, Lahore.

RESULTS

One hundred and thirty patients were included in the study. Fifty patients were from Mayo Hospital, 35 from Shalamar Hospital and 50 from Shaikh Zayed Hospital, Lahore. The internal consistency reliability coefficient for overall scale was 0.84. Twelve sub-scales (symptoms, effect of kidney disease, burden of kidney disease, cognitive function, quality of social interaction, sexual function, social support, physical functioning, role physical, pain, emotional well-being and role emotional) had more than 0.70 internal consistency reliability coefficient. Overall mean score of the domains i.e kidney disease component score (KDCS), physical component score (PCS), and mental component score (MCS) was 60.62 ±17.61, 43.12 ±19.54, and 49.27 ±14.52, respectively. Asignificant positive relationship was observed between KDCS and MCS domains, KDCS and PCS domains, PCS, and MCS domains.

CONCLUSION

The Urdu version of KDQOL-SF-36 is a reliable and valid version to measure QOLin kidney disease patients on dialysis in Pakistan.

Alkanna tinctoria leaves extracts: a prospective remedy against multidrug resistant human pathogenic bacteria

Background

Plants are rich source of chemical compounds that are used to accomplish biological activity. Indigenously crude extracts of plants are widely used as herbal medicine for the treatment of infections by people of different ethnic groups. The present investigation was carried out to evaluate the biological potential of Alkanna tinctoria leaves extract from district Charsadda, Pakistan against multidrug resistant human pathogenic bacteria including Acinetobacter baumannii, Escherichia coli, Pseudomonas aeruginosa and Staphylococcus aureus.

Methods

Anti-multi-drug resistant bacterial activity of aqueous, chloroform, ethanol and hexane extracts of Alkanna tinctoria leaves were evaluated by well diffusion method. Minimum inhibitory concentrations (MICs) and minimum bactericidal concentrations (MBCs) of different extracts were determined. Moreover qualitative phytochemicals screening of the studied extracts was performed.

Results

All four selected bacteria including A. baumannii, E. coli, P. aeruginosa and S. aureus were categorized as multi-drug resistant (MDR) as they were found to be resistant to 13, 10, 19 and 22 antibiotics belonging to different groups respectively. All the four extract showed potential activity against S. aureus as compare to positive control antibiotic (Imipenem). Similarly among the four extracts of Alkanna tinctoria leaves, aqueous extract showed best activity against A. baumannii (10 ± 03 mm), P. aeruginosa (12 ± 0.5 mm), and S. aureus (14 ± 0.5 mm) as compare to Imipenem. The MICs and MBCs results also showed quantitative concentration of plant extracts to inhibit or kill MDR bacteria. When phytochemicals analysis was performed it was observed that aqueous and ethanol extracts showed phytochemicals with large number as well as volume, especially Alkaloides, Flavonoides and Charbohydrates.

Conclusion

The undertaken study demonstrated that all the four extracts of Alkanna tinctoria leaves exhibited considerable antibacterial activity against MDR isolates. Finding from the current study will be helpful for further elucidation of lead molecules from Alkanna tinctoria leaves for future therapeutic use against MDR pathogens.

Restless legs syndrome in end stage renal disease patients on haemodialysis

Objective: This study was cross sectional survey conducted to find the prevalence of Restless legs syndrome (RLS) in end stage renal disease (ESRD) patients on haemodialysis (HD).

Methods: Data were obtained from 250 patients on chronic maintenance HD. To assess the prevalence of RLS, Clinical diagnostic criteria for RLS was used which is established by the International RLS Study Group.

Results: Total 250 patients were included in this study. 153 (61.2%) patients were male and 97 (38.8%) were females. Mean age of the patients was 45.27 years. Mean duration of HD was 26.10 months. Total162 (64.8%) patients were found to be suffering from RLS. Out of 153 males, 87(56%) were suffering from RLS and among 97 females, 75(77.3%) were suffering from RLS. In our study, gender was statistically significantly associated with RLS (p-value 0.001). In age groups 159(63.6%) patients were below 51 years; among them 102(64.1%) were suffering from RLS; whereas 91(36.4%) patients were equal or above 51 years of age and among this group 60(65.9%) patients were suffering from RLS. There was no statistically significant association between RLS and age groups (p-value 0.776).

Conclusions: RLS is common in patients undergoing regular HD. It is more commonly seen in females.

Isolation and characterization of an antimicrobial lipopeptide produced by Paenibacillus ehimensis MA2012

In this study, a novel lipopeptide antibiotic was isolated from the culture supernatant of Paenibacillus ehimensis strain MA2012. After analyses by mass spectrometry (MS), nuclear magnetic resonance (NMR), and high resolution mass spectrometry (HR-MS/MS) the compound was identified to be polypeptin C consisting of 3-hydroxy-4-methyl-hexanoic acid moiety and nine amino acids as peptide body. It has the same molecular mass (1115 Da) with that of polypeptin A and B but the amino acid positions differ. A relatively low concentration (125 ppm) of polypeptin C lowered the surface tension of water from 72.2 to 36.4 mN/m. It showed antimicrobial activity against several plant pathogenic bacteria and fungi. When the polypeptin C was applied to the ripe pepper fruits previously inoculated with conidia of Colletotrichum gloeosporioides, the hyphal growth on the fruit was significantly suppressed. Moreover, the hyphal morphology of C. gloeosporioides was greatly affected by the purified compound. All these data suggest the great potential of P. ehimensis MA2012 to control plant fungal and bacterial diseases.

Demographic factors affecting quality of life of hemodialysis patients - Lahore, Pakistan

Objective: The objective of the study was to determine the demographic factors affecting Quality Of Life (QOL) of hemodialysis (HD) patients.

Methods: This observational study was conducted at Shalamar Hospital, Lahore. Patients of End Stage Renal Disease (ESRD) and on maintenance HD for more than three months were included during the period March to June 2012. Patient of ESRD not on dialysis and Acute Renal Failure were excluded. One hundred and twenty five patients who fulfilled the criteria were included. Demographic data containing age, sex, residence, socio economic status, education, mode of traveling for dialysis, total time consumed in dialysis were collected by the investigators. QOL index was measured using 26 items, WHO QOL BREF.

Results: There were 89(71.2%) male and 36(28.8%) female patients. Environmental domain score was highest (p=0.000) than all other domains in HD Patients. In overall analysis age, marital status and total time consumed in getting HD effect QOL significantly (p=<0.05). In domain wise analysis, male has better QOL in social relationship domain than female. Age has negative relationship with physical health and psychological health domain. QOL of unmarried and literate patients is significantly better (p=<0.05) in physical health domain. Employed patients have better QOL in physical, psychological and social relationship domain (p=<0.05) than unemployed patients. Patients of residence of rural areas have better QOL in physical and environment domain. Financial status of HD patients affect QOL in social domain. Distance covered to reach hospital effect QOL in psychological domain (p=<0.05). Patients traveling in private transport have better QOL in environmental domain (p=<0.05). Total time consumed in getting HD effect social relation in QOL (p=<0.05). According to linear regression model, marital status is positive predictor and unemployment is negative predictor of QOL in physical health domain. Age is negative predictor of QOL in psychological domain, monthly income is positive predictor of QOL in domain. Unemployment is positive predictor of QOL in social relation domain. Monthly income and place of residence is positive predictor of QOL in environment domain.

Conclusion: Gender, age, marital status, unemployment, residence of rural area, economical status, distance covered to reach hospital, mode of transport, total time consumed in getting HD, effect QOL in HD patient. Education level is a positive factor for improving QOL of HD patients.

Comparison of awareness about nephrology and kidney diseases amongst doctors in institutes with and without nephrology departments

Objective: To compare the awareness about nephrology and kidney diseases in medical officers and postgraduate trainee doctors working in institutes with and without nephrology departments.

Methods: This cross sectional study was conducted at Nephrology Department, Shalamar Hospital Lahore from 1^st Jan to 31^st Mar 2013. Doctors working on medical floor with more than one year experience after house job were included in the study. Each doctor was given questionnaire comprising of 28 questions.

Results: Two hundred and eleven doctors fulfilling the criteria were included in the study. Most of the doctors were male 150(71.1%). Knowledge had strong correlation with practice (p= 0.001). Knowledge regarding nephrology and chronic kidney disease (CKD) was found significantly different among doctors of different hospitals [(F=36.09, p=0.000). Practice regarding nephrology and chronic kidney disease (CKD) was found significantly different (F= 7.222, p=0.000)] among doctors of different hospitals of Lahore. Doctors working in the Shaikh Zayed Hospital (SZH), Lahore were having maximum score in the components of the knowledge and practice than other hospitals.

Conclusion: Awareness of the Medical Officers and postgraduate doctors is poor regarding nephrology and kidney diseases. Doctors working in institutes with established nephrology services have better knowledge than other units. Working experience of doctors improve the practice significantly.

Association of Attention Deficit Hyperactivity Disorder with Heroin Addiction

Objectives: To study the association of attention-deficit hyperactivity disorder (ADHD) with heroin addiction. Study design: A cross-sectional, hospital based study. Place and duration of study: The study was carried out at Lady Reading Hospital and Khyber Teaching Hospital, Peshawar, Pakistan from 4th April 2012 to 13th September 2012. Subjects and Methods: A sample of 137 adult heroin addicts were analyzed that whether they were ADHD and that childhood problem continues to manifest symptoms in adults. For retrospective assessment of childhood ADHD, the Wender Utah Rating Scale (WURS) as well as the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) symptom checklist for ADHD was used. The Conners’ Adult ADHD Rating Scales (CAARS) was used to assess the persisting symptoms of ADHD in adults. Inclusion criteria: Patient diagnosed with heroin addiction according to ICD-9 and DSM-IV. Exclusion criteria: Patient has co-morbid with any other mental illnesses. Results: The difference between the mean score of WURS and CAARS of ADHD patients were significantly greater than the normal patients. Heroin addicts showed 41.6% (WURS) and 38.6% (DSM-IV diagnostic criteria) that indicated evidence of retrospective ADHD affliction in childhood. 22.6% were IV users. CAARS was presented in 37.9% heroin addicts who exhibited a substantiation of ADHD persistent in adulthood. The difference between the mean score of WURS and CAARS of ADHD patients were significantly greater (P = 0.003), than the normal patients. Conclusions: These results revealed that addiction is associated with co-morbidity with ADHD, expressed in the form of heroin addiction. DOI: http://dx.doi.org/10.3329/bjms.v13i2.18294 Bangladesh Journal of Medical Science Vol.13(2) 2014 p.128-134

Study of natural radioactivity in Mansehra granite, Pakistan: environmental concerns

A part of Mansehra Granite was selected for the assessment of radiological hazards. The average activity concentrations of (226)Ra, (232)Th and (40)K were found to be 27.32, 50.07 and 953.10 Bq kg(-1), respectively. These values are in the median range when compared with the granites around the world. Radiological hazard indices and annual effective doses were estimated. All of these indices were found to be within the criterion limits except outdoor external dose (82.38 nGy h(-1)) and indoor external dose (156.04 nGy h(-1)), which are higher than the world's average background levels of 51 and 55 nGy h(-1), respectively. These values correspond to an average annual effective dose of 0.867 mSv y(-1), which is less than the criterion limit of 1 mSv y(-1) (ICRP-103). Some localities in the Mansehra city have annual effective dose higher than the limit of 1 mSv y(-1). Overall, the Mansehra Granite does not pose any significant radiological health hazard in the outdoor or indoor.

Purification and properties of a Meloidogyne-antagonistic chitinase from Lysobacter capsici YS1215

The root-knot nematodes, Meloidogyne spp., cause serious diseases in various plants and their chemical control may lead to environmental problems. Therefore, alternative control measures against the phytopathogenic nematodes are being sought. One of the potential targets against Meloidogyne spp. may be the chitinolysis and degradation of nematode eggs. Therefore, in the present study, a chitinolytic and nematicidal strain of Lysobacter capsici YS1215 was isolated from an agricultural field in Korea. The aim of this study was to purify chitinase secreted by L. capsici YS1215 and investigate its nematicidal role against Meloidogyne incognita. The chitinase secreted by L. capsici YS1215 was purified by protein precipitation with 80% ammonium sulphate, anion-exchange chromatography with DEAE-cellulose and gel-filtration chromatography with Sephadex G-100. By chitinase-active staining of the purified enzyme, a single band was obtained with an estimated molecular mass of 43.6 kDa. The optimal pH and optimal temperature for the highest chitinase activity were 6.0 and 40°C, respectively. The purified chitinase degraded the chitin layer of the eggshells and significantly reduced hatch of second-stage juveniles. The activity of chitinase secreted by L. capsici YS1215 was not affected by CoCl2, MnCl2, MgCl2, CuSO4, CaCl2 or EDTA. The purified enzyme could also hydrolyse swollen chitin, glycol chitin, glycol chitosan and chitin powder. Thus, the role of chitinase secreted by L. capsici YS1215 against Meloidogyne spp. may be useful for further development of a biocontrol agent.

Role of Bacillus licheniformis in phytoremediation of nickel contaminated soil cultivated with rice

Heavy metal contamination in soil is an important environmental problem and it has negative effect on agriculture. Bacteria play a major role in phytoremediation of heavy metals contaminated soil. In this study, the effect of Bacillus licheniformis NCCP-59, a halophilic bacterium isolated from salt mines near Karak, Pakistan, were determined on a three week old greenhouse grown seedling and germinating seeds of two rice varieties (Basmati-385 (B-385) and KSK-282) in soil contaminated with different concentrations (0, 100, 250, 500, and 1000 ppm) of Nickel. Nickel significantly reduced the germination rate and germination percentage mainly at 500 and 1000 ppm. Significant decrease in ion contents (Na, K, and Ca) was observed while Ni ion concentration in the plant tissues increases as the concentration of Ni applied increases. The photosynthetic pigments (chlorophyll a (chl a), chlorophyll b (chl b), and carotenoids) were also decreased by the application of different concentrations of Ni. Total protein and organic nitrogen were found to be reduced at higher concentrations of Nickel. Inoculation of Bacillus licheniformis NCCP-59 improved seed germination and biochemical attribute of the plant under Ni stress. It is clear from the results that the Bacillus Licheniformis NCCP-59 strain has the ability to protect the plants from the toxic effects of nickel and can be used for the phytoremediation of Ni contaminated soil.

Genetic diversity of Newcastle disease virus in Pakistan: a countrywide perspective

Background

Newcastle disease (ND) is one of the most deadly diseases of poultry around the globe. The disease is endemic in Pakistan and recurrent outbreaks are being reported regularly in wild captive, rural and commercial poultry flocks. Though, efforts have been made to characterize the causative agent in some of parts of the country, the genetic nature of strains circulating throughout Pakistan is currently lacking.

Material and methods

To ascertain the genetics of NDV, 452 blood samples were collected from 113 flocks, originating from all the provinces of Pakistan, showing high mortality (30–80%). The samples represented domesticated poultry (broiler, layer and rural) as well as wild captive birds (pigeons, turkeys, pheasants and peacock). Samples were screened with real-time PCR for both matrix and fusion genes (1792 bp), positive samples were subjected to amplification of full fusion gene and subsequent sequencing and phylogenetic analysis.

Results

The deduced amino acid sequence of the fusion protein cleavage site indicated the presence of motif (¹¹²RK/RQRR↓F¹¹⁷) typical for velogenic strains of NDV. Phylogenetic analysis of hypervariable region of the fusion gene indicated that all the isolates belong to lineage 5 of NDV except isolates collected from Khyber Pakhtunkhwa (KPK) province. A higher resolution of the phylogenetic analysis of lineage 5 showed the distribution of Pakistani NDV strains to 5b. However, the isolates from KPK belonged to lineage 4c; the first report of such lineage from this province.

Conclusions

Taken together, data indicated the prevalence of multiple lineages of NDV in different poultry population including wild captive birds. Such understanding is crucial to underpin the nature of circulating strains of NDV, their potential for interspecies transmission and disease diagnosis and control strategies.

Genetic analysis of peste des petits ruminants virus from Pakistan

Background

Peste des petits ruminants (PPR) is an endemic and highly contagious disease in small ruminants of Pakistan. Despite the fact that an effective vaccine is available, outbreaks are regularly occurring in the country. Thus so far, the diagnosis has primarily been made based on clinical outcome or serology. This study was carried out to characterize PPRV from an emerging wave of outbreaks from Punjab, Pakistan.

Results

A total of 32 blood samples from five different flocks were tested with real-time PCR for the presence of PPRV genome. The samples detected positive in real-time PCR (n = 17) were subjected to conventional PCR for the amplification of the nucleoprotein (N) gene. Phylogenetic analysis of the sequenced N genes (n = 8) indicated the grouping of all the sequences in lineage IV along with PPRV strains from Asian and Middle East. However, interestingly sequences were divided into two groups. One group of viruses (n = 7) clustered with previously characterized Pakistani isolates whereas one strain of PPRV was distinct and clustered with Saudi Arabian and Iranian strains of PPRV.

Conclusions

Results demonstrated in this study expanded the information on the genetic nature of different PPRV population circulating in small ruminants. Such information is essential to understand genetic nature of PPRV strains throughout the country. Proper understanding of these viruses will help to devise control strategies in PPRV endemic countries such as Pakistan.

Antagonistic potential of Paenibacillus elgii HOA73 against the root-knot nematode, Meloidogyne incognita

This study was conducted to evaluate the nematicidal potential of Paenibacillus elgii strain HOA73 against the root-knot nematode, Meloidogyne incognita, under both in vitro and in vivo conditions. The novel strain HOA73 (GenBank accession number JQ12069) produced hydrolytic enzymes including gelatinase and chitinase. Exposure of M. incognita to various concentrations (10-30%) of the bacterial culture filtrate (BCF) or 0.05-0.4 mg ml−1 of the crude enzymes produced by P. elgii HOA73 significantly reduced hatch of the second-stage juvenile (J2) and caused substantial mortality under in vitro conditions. The hatch inhibition and J2 mortality rate was enhanced with the increase in the concentration of BCF and the crude enzymes. Similarly, the antagonistic effects also increased significantly over the time for which the treatments were given. Moreover, the crude enzymes partially destroyed cuticle layers of eggs and juveniles at 0.4 mg ml−1 concentration. Furthermore, the pot experiment indicated that addition of HOA73 culture into potted soil significantly reduced the root galling, number of egg masses and nematode population by 62.1%, 69.8% and 53.0%, respectively, as compared to the control at 7 weeks after M. incognita infestation. HOA73 inoculation also promoted tomato plant fresh shoot weight by 17.9% as compared to control. Hence, the present results demonstrated the ability of P. elgii HOA73 as a potential biocontrol candidate against the root-knot nematode as well as a plant growth promoter for tomato.

Molecular detection of Toxoplasma gondii in water sources of district Nowshehra, Khyber Pakhtunkhwa, Pakistan

Toxoplasmosis is spread through contamination of water sources and results in morbidity globally. In the current study 300 water samples were processed by polymerase chain reaction (PCR) for detection of Toxoplasma gondii. The overall prevalence in different water sources was 6.6% (17/300). Among different water sources the highest prevalence was recorded in drain water at 7% (7/100), followed by tube well water at 7.5% (3/40) and open well water at 5% (5/100) ,and the lowest was recorded in tap water at 3.33% (2/60). The highest prevalence was recorded in summer. Evidence indicates that cleaning and filtration need to be adopted to avoid the health hazards of waterborne zoonotic parasites.

Biocontrol potential of Lysobacter antibioticus HS124 against the root-knot nematode, Meloidogyne incognita, causing disease in tomato

Lysobacter antibioticus HS124 is an antagonistic bacterial strain that was previously isolated from the rhizosphere soil of pepper and showed an enhanced ability to produce lytic enzymes as well as an antibiotic that was identified as 4-hydroxyphenylacetic acid (4-HPAA). In the present study, nematicidal activity of the strain and 4-HPAA against the root-knot nematode, Meloidogyne incognita, causing disease in tomato was investigated in both in vitro and in vivo conditions. For this purpose, adding different concentrations of culture filtrate, crude extract collected from extraction with ethyl acetate and 4-HPAA, in 24-well plates containing ca 500 eggs or 300 second-stage juveniles (J2), significantly decreased the rate of nematode hatch and caused higher mortality of J2 compared with the control treatments. Nematicidal activity of the bacterial strain was further confirmed by conducting pot experiments in which tomato plants were inoculated with M. incognita and the HS124 culture (BC). The control pots were treated with commercial nematicide (CN, 5% Ethoprophos), tap water (TW) or the non-inoculated bacterial culture medium (BCM). In these pot experiments, results demonstrated a strong antagonistic potential of L. antibioticus HS124 against M. incognita where the disease was significantly reduced in the pots treated with BC as compared to TW or BCM. Furthermore, the shoot fresh weight was also increased significantly, which may be attributed to the disease control ability of the strain. Hence, L. antibioticus HS124 may be further developed as a potential biocontrol of root knot nematode in the field.

Analyzing various non-surgical treatment modalities for laryngopharyngeal reflux

Objective:To compare the outcomes of various medical treatment modalities for laryngopharyngeal reflux.Study design: Prospective study design.Methods: 150 patients were divided into three groups (A, B, C) based on the mode of intervention used for the control of LPR. Each study group enrolled 50 patients using random tables.• Group A: These patients were put on a twice daily dosage of esomeprazole(20 mg b.d.) and domeperidone(10 mg b.d. ) for four months• Group B: These patients were put on b.d. dosage of esomeprazole(20 mg) and domeperidone(10 mg): and also received counseling for dietary and lifestyle changes. The duration of treatment was for four months.• Group C: These patients received, in addition to above, 10 mg of amitriptyline (tricyclic antidepressant) b.i.d , again for four months.Results: The success achieved in controlling LPR was defined as greater than 50 % improvement in baseline symptoms. The success achieved in Group A was 46 %, in Group B was 54 % and in Group C was 40 %. The relative change in RSI over any given period of time was significantly higher than the relative change in RFS. The relative change in RSI over first month was 30.99%, which is significantly higher than the relative change of RFS (6.39%) over the same period. The mean RSI scores during four months of treatment fell from 20.67 to 8.9 (p < 0.01) in Group A, from 23.3 to 8.6 (p < 0.01) and from 21.3 to 10.8 (p < 0.05) in Group C. The mean RFS during four months fell from 15 to 6.5 (p < 0.05) in Group A, from 16 to 6.4 (p < 0.05) and from 15 to 6.4 (p < 0.05) in Group C.Conclusions:• All the three interventions had a statistically significant impact on the signs and symptoms of LPR.• However, higher success rates were achieved in Group B where patients were put on a b.i.d dosage esomeprazole and domeperidone nad counseled for lifestyle and dietary changes. Paradoxically, success rates achieved in Group C was lower than other groups, possibly because of the anticholinergic effects of amitriptyline causing dry mouth and dry throat.• The symptomatic improvement was seen much earlier than the improvement in laryngoscopic findings. This was evidenced by the fact that relative change in RSI was much higher than the relative change of RFS over a given period of time.• If diagnosed with enough surety and certainty, patients of LPR do not need any antidepressant medications as these medications may not have any role in the treatment of same and may, however, worsen the condition owing to their anticholinergic side effects.  DOI: http://dx.doi.org/10.3329/bjo.v18i1.10413  Bangladesh J Otorhinolaryngol 2012; 18(1): 42-47

Dialysis-related factors affecting quality of life in patients on hemodialysis

INTRODUCTION. Treatment modalities for end-stage renal disease affect quality of life (QOL) of the patients. This study was conducted to assess the QOL of patients on hemodialysis and compare it with caregivers of these patients. Cause of ESRD and dialysis-related factors affecting QOL were also examined. MATERIALS AND METHODS. This cross-sectional study was conducted on patient on maintenance hemodialysis for more than 3 months at 3 dialysis centers of Lahore. Fifty healthy individuals were included as controls from among the patients' caregivers. The QOL index was measured using the World Health Organization QOL questionnaire, with higher scores corresponding to better QOL of patients. RESULTS. Eighty-nine patients (71.2%) were men, 99 (79.2%) were married, 75 (60.0%) were older than 45 years, and 77 (61.6%) were on dialysis for more than 8 months. Patients on hemodialysis had a poorer QOL as compared to their caregivers in all domains except for domain 4 (environment). There was no difference in the QOL between the three dialysis centers of the study, except for domain 3 (social relationship) of the patients at Mayo Hospital (a public hospital), which was significantly better. Nondiabetic patients had a better QOL in domain 1 (physical health) as compared to diabetic patients. Duration of dialysis had a reverse correlation with the overall QOL. CONCLUSIONS. We found that QOL of hemodialysis patients was poor as compared to caregivers of the patients, especially that of diabetics. Also, duration of dialysis had a reverse correlation with QOL.

Beta-2 microglobulin levels in hemodialysis patients

The objective of the study was to determine the level of beta2-microglobulin (beta2-m) in hemodialysis (HD) patients and the factors affecting it. This cross sectional, hospital based study was conducted between September and December 2008 at the Hemodialysis unit of Shalamar Hospital, Lahore. All patients with end-stage renal disease (ESRD) who were on maintenance HD for more than three months were included in the study. Patients with acute renal failure and on dialysis for less than three months were excluded. Demographic data were collected and details of dialysis (type of dialyzers, dialysate bath, membrane used) were recorded. Blood samples of the patients were drawn for hematological (hemoglobin, hematocrit), biochemical (urea, creatinine, uric acid, albumin) and beta2-m level measurement. The total number of patients studied was 50. The major causes of ESRD included diabetes mellitus and hypertension seen in 37 (74%) and 10 patients (20%), respectively. The beta2-m levels were significantly elevated in the study patients; 92.6 +/- 17.1 mg/L with a range of 54 to 130 mg/L as compared to 2.0 +/- 1.29 mg/L in the control group. The patients' age had a statistically significant relationship with the beta2-m level. The major reason for increased beta2-m level was use of low-flux dialyzers. Synthetic polysulphone membrane, bicarbonate, ultra pure dialysate and duration on HD were not asso-ciated with high beta2-m levels. Also, we found an inverse relationship between beta2-m levels and serum albumin of the study patients. Our study suggests that the beta2-m levels are significantly high in dialysis patients. Use of low-flux dialyzer seems to be the major reason for the high beta2-m levels. Age and albumin have statistically significant relationship with beta2-m levels.

Anemia and hypoalbuminemia at initiation of hemodialysis as risk factor for survival of dialysis patients

OBJECTIVE

To determine the survival of patients undergoing chronic maintenance hemodialysis by determining the relative risk (RR) of anemia and hypoalbuminemia at initiation of dialysis on survival.

STUDY DESIGN

Cohort study.

PLACE AND DURATION OF STUDY

Hemodialysis Unit of Shalamar Hospital, Lahore, from June 2003 to October 2006.

METHODOLOGY

This study was conducted on all patients of end stage renal disease who presented in Accident/Emergency Department of the hospital for the first time or received calls from other departments in getting dialysis. Patients with acute renal failure and those lost to follow-up were excluded from the study. At presentation, a history and examination was done and recorded. At the same time a blood sample was sent for routine hematological parameters (hemoglobin, total leucocyte count (TLC), biochemical (urea, creatinine, serum potassium and albumin) and viral markers (anti-HCV and HbsAg). Patients were followed up for outcomes. The outcomes of the study were continued dialysis, death and renal transplant. Kaplan-Meier and log Rank tests were used for determining survival. Relative risk was assessed on medical 9.2.

RESULTS

One hundred and eighty five patients were studied including 99 (52.8%) males and 86 (47.2%) females. Major causes of renal failure were Diabetes mellitus in 125 (67.6%), chronic glomerulonephrotis in 31 (16.8%) and hypertension in 18 (9.7%). Most of the patients - 105 (60%) were euvolemic. Sixty percent of patients had very high urea (> 200 mg/dl) and creatinine (> 8.0 mg/dl). The mortality of haemodialysis patients was seventy four percent per 100 patients per year, 62.24% being in the initial 6 months. One hundred and sixty four patients (91.1%) were anemic (hemoglobin < 11 gm/dl) and 124 (67%) were hypoalbuminemic (serum albumin < 4 gm/dl) on first presentation. Patients with group 1 have hemoglobin less than 11 gm/dl (7.83 + or - 1.51), group 2 had hemoglobin of equal to more than 11 gm/dl (11.56 + or - 0.64) which was statistically significant (t = - 9.54, p= 0.000). The survival freedom in group 2 (Hb > 11 gm/dl) was higher than group 1 (Hb < 11 gm/dl) which is statistical significant (p = 0.023). On the basis of serum albumin (S.Alb), patients were divided into two groups i.e S.Alb less than 4 (3.15 + or - 0.38 gm/dl) was group 1, and more than or equal to 4 (4.23 + or - 0.28 gm/dl) was group 2, which were statistically significant (t = - 11.58, p < 0.001). The overall survival time was significantly shorter in group 1 patients than group 2 (p = 0.037). RR for low albumin was 1.27 and for low hemoglobin, it was 1.30.

CONCLUSION

Mortality of haemodialysis patients was seventy four percent per 100 patients per year. Amongst these 62.24% were in the initial 6 months. The mean survival time was 296 days. Patients with very low hemoglobin and albumin are at more risk for early deaths than patients with normal hemoglobin and albumin on first presentation for dialysis.

Effect of anemia and hyperhomocysteinemia on mortality of patients on hemodialysis

INTRODUCTION

Anemia and hyperhomocysteinemia are risk factor of mortality of patients on dialysis. This study was conducted to assess the relationship of hemoglobin and homocysteine levels and mortality of patients on hemodialysis.

MATERIALS AND METHODS

Fifty patients on hemodialysis and 20 healthy individuals were enrolled in the study. Blood samples were drawn for measurement of hematological parameters, serum iron, serum ferritin, transferrin saturation, and homocysteine levels. The patients were followed up for 1 year to determine the mortality rate and evaluate its association with anemia and hyperhomocysteinemia.

RESULTS

The majority the patients (54%) were not on erythropoietin therapy. Forty-three patients (86%) were anemic (hemoglobin < 11 g/dL). Serum ferritin was high (> 500 ng/mL) in 33 patients (66%). Mortality was 28% in 1 year (33% in anemic patients versus no death among patients with a hemoglobin level greater than 11 g/dL). The relative risk of mortality was increased by 1.58 with every 1 g/dL decrease in hemoglobin level. All of the patients had a high homocysteine level, and a significant difference was observed between the homocysteine levels of the patients on hemodialysis and the control group (P < .001). Hyperhomocysteinemia did not affect mortality. In multivariate Cox regression analysis, only hemoglobin level was associated with mortality.

CONCLUSIONS

Almost all of our patients on hemodialysis were anemic and this condition was a risk factor of mortality. Iron stores, however, were adequate in more than half of the patients. The reason of anemia could be untreated erythropoietin deficiency. Hyperhomocysteinemia was present in the majority of the patients, but it did not independently affect mortality.

Erectile dysfunction in haemodialysis patients

BACKGROUND AND OBJECTIVE

There is a very high prevalence of Erectile Dysfunction (ED) in dialysis patients. There is no as such available data on ED and factors affecting it in our patients.

METHODS

Analytical, cross-sectional, hospital based study conducted from January to March 2008, Haemodialysis unit of Shalimar and Mayo Hospital, Lahore. All male patients of end stage renal disease (ESRD) on maintenance haemodialysis therapy, whose spouses are alive and able to perform intercourse, were included in the study. Patient with cognitive and communication deficits were excluded from study. International index of erectile function-5 (IIEF-5), adopted in Urdu was used for the determination of prevalence of erectile function. Categorization of erectile dysfunction was done as mild, moderate and severe. Demographic data were collected and certain laboratory parameters (haemoglobin, haematocrit, urea, HBsAg and Anti HCV) were sent.

RESULTS

Total numbers of patient were fifty. Major cause of ESRD was diabetes mellitus 28 (56%). Most of the patients 33 (66%) have passed 10tH grade or they were under 10TH grade. Prevalence of ED was 86% with mean IIEF-5 score of 10.36 +/- 7.13. Majority of patients 33 (64.7%) were suffering from severe degree of ED. Factors responsible for ED are diabetes mellitus, age more than 50 year, high pre dialysis urea and Anti HCV positive patients. In this study, smoking, duration of dialysis and monthly spending is not related with ED.

CONCLUSION

Majority of the patients suffering from ESRD, on maintenance haemodialysis are having ED. None of the patients suffering from ED were taking any treatment for it. Haemodialysis does not improve sexual dysfunction. Major factors responsible for ED are diabetes mellitus, age more than 50 years, high pre dialysis urea and Anti HCV positive patients.

Multiple myeloma in younger age

A Multiple Myeloma (MM) is rare in younger age group. We report MM in a 30-year-old female, who presented with multiple lytic areas upon skeletal survey, but with negative Bence Jones protein. Bone marrow biopsy confirmed it to be a case of multiple myeloma. Patient was put on chemotherapy and radiography to which she responded and now is ambulatory.

Referral pattern fof hemodialysis patients to nephrologists

OBJECTIVE

To determine the referral pattern of dialysis patients to nephrologists and the effects of late referral on clinical, hematological and biochemical parameters in patients presenting for the first-time to dialysis center.

STUDY DESIGN

Cross-sectional study.

PLACE AND DURATION

Hemodialysis Unit of Shalamar Hospital, Lahore, from June 2003 to October 2006.

PATIENTS AND METHODS

This study was conducted on all patients of end stage renal diseases presenting for the first-time for undergoing hemodialysis at our center. Patients with acute renal failure were excluded from the study. At presentation, a history was taken from all the patients regarding seeking of nephrology services and referral pattern. Early and late referral was defined as the time of first referral or admission to a nephrologists greater or less than six months respectively before initiation of hemodialysis. All the patients were examined and their blood sample was drawn at the same time for routine hematological, biochemical parameters (urea, creatinine, serum potassium, calcium, phosphate and albumin) and viral markers (Anti HCV and HbsAg).

RESULTS

In this study, 248 patients were enrolled, amongst them, 131 (52.8%) were male and 117 (47.2%) were female. Major causes of renal failure were diabetes mellitus, chronic glomerulonephritis and hypertension. Most of the patients were euvolemic and hypertensive. Sixty percent of patients were having very high urea ( > 200 mg/dl) and creatinine ( > 8.0 mg/dl). Most of the patients, 226 (91.1%), were anemic (Hemoglobin < 11gm/dl) and 224(90%) were hypoalbuminemic (serum albumin<4gm/dl) on first presentation. Majority of patients were hyperkalemic, 139 (56.0%), hypocalcemic, 168 (67.7%) and serum phosphate level was high in only 117 (47%) patients.

CONCLUSION

All the patients presented in emergency room to nephrologists at very late stage (100% late referral), when disease was very much advanced. All of them did not have permanent vascular access for hemodialysis on first presentation to dialysis center. Reasons for late referral were non-availability of nephrologists and nephrology services, non-renal doctors biased, unawareness and training of medical professionals for these patients, patients' own denial for dialysis, fear and wrong perception about dialysis procedure, socioeconomic factors and use of non-evidenced based treatment modalities.

Role of hysterosalpingoscintigraphy in the workup of infertility

OBJECTIVE

To assess the role of hysterosalpingoscintigraphy (HSSG) in the evaluation of fallopian tube patency and function and compare the results with hysterosalpingography (HSG) and laparoscopy (LS).

DESIGN

Cross-sectional study.

PLACE AND DURATION OF STUDY

The study was conducted at Multan Institute of Nuclear Medicine and Radiotherapy (MINAR), Multan from August 2004 to February 2005.

PATIENTS AND METHODS

HSSG was performed after instillation of 4mCi (148 MBq) 99mTechnetium-macroaggregated albumin (99mTc-MAA) in posterior vaginal fornix in 65 patients. Serial static images were acquired in supine position at 1 hour, 2 hours, 3 hours and, if needed, at 24 hours. The results were compared to the findings on LS and HSG.

RESULTS

Out of 65 patients, 37 (56.9%) patients had bilateral blocked tubes, 17 (26.1%) patients had bilateral patent tubes, 6 (9.2%) patients had blocked left tube and 5 (7.1%) patients had blocked right tube. The calculated sensitivity, specificity, positive predicted value (PPV), negative predicted value (NPV) and accuracy for HSSG were 90%, 83%, 90% and 90% respectively. The agreement between HSSG and LS was found in 32 out of 35 patients and agreement between HSG and HSSG was found in 24 out of 30 patients.

CONCLUSION

This simple procedure can delineate tubal physiology; in selected cases it can replace HSG and in others augment the information gathered by HSG. HSSG should be part of the infertility workup algorithm.

Evaluation of nutritional status of patients on haemodialysis

OBJECTIVE

To evaluate the nutritional status of patients on haemodialysis for chronic renal failure.

DESIGN

Single center cross-sectional hospital based study.

PLACE AND DURATION OF STUDY

This study was carried out at haemodialysis unit of Shaikh Zayed Hospital, Lahore from March to May 2000.

PATIENTS AND METHODS

Fifty-one patients on regular haemodialysis were included in the study. Nutritional status was checked by laboratory data (hemoglobin, hematocrit, blood urea nitrogen, serum albumin, total protein, and lipid profile), anthropometric measurements (height, dry weight, body mass index (BMI), mid arm circumference (MAC), triceps skin fold thickness (TSF) and mid arm muscle circumference (MAMC)) and symptoms.

RESULTS

The total number of patients was 51. Twenty-four patients were male and 27 female. Mean age was 43 years. Majority of the patients, 27 (53%), was between 21 to 50 years of age. Major cause of end-stage renal disease was chronic glomerulonephritis in 19 (35%) patients followed by diabetic nephropathy 14 (27%) and hypertensive nephropathy in 11 (21%). Hemoglobin and hematocrit was normal only in 7 patients and rest of the 44 patients were anemic. Serum albumin was 3.64+/-0.59 gm/dl (Mean +/- SD), total protein 7+/-0.86 gm/dl, serum calcium 9.5+/-0.7 mg/dl, serum phosphorus 4.8+/-0.5 mg/dl, serum cholesterol 170+/-43.56 mg/dl,LDL 96.94+/-40.76 mg/dl, HDL 45.7+/-19.61 gm/dl, serum triglyceride 176.8+/-99 gm/dl. Adequacy of dialysis, urea reduction ratio (URR) was adequate only in 16(31%) and rest of the patients 35(69%) were getting inadequate amount of dialysis. On anthropometric measurements, majority of the patients was malnourished and in moderate to severe category of malnutrition. Symptoms of uremia (nausea, vomiting, body aches, pain and pulmonary oedema) were more in patients who were getting inadequate dialysis i.e. urea reduction ratio more than 70% (p-value<0.05).

CONCLUSION

Majority of patients was anaemic, undernourished and factors responsible for the same were economical, late referral to nephrologist, inappropriate dietary restrictions and inadequate dialysis.

Percutaneous renal biopsy by automated biopsy gun

OBJECTIVE

To study the safety and efficacy of automated biopsy gun in obtaining the renal tissue by percutaneous renal biopsy.

DESIGN

Single centered prospective hospital based study.

PLACE AND DURATION OF STUDY

Department of Medicine, Unit II, Lahore General Hospital, Lahore for more than one year from January 2000 to February 2001.

SUBJECTS AND METHODS

Forty patients of either gender having clinical features of renal disease with overt proteinuria were included in the study. An informed consent was taken from patients. Patients were lied prone, local anaesthesia was given at lower pole of left kidney. Renal biopsy was performed under ultrasound guidance, using 18G spring loaded automated biopsy gun.

RESULTS

Majority of patients, 28(70%), was male. The mean age was 26.9 years with range of 5-70 years. In 37 (97.5%) patients successful biopsy was done while there was its failure in 3 (7.5%) patients. The average core length of renal tissue obtained was Mean+/-SD (1.02+/-0.34) cm with a mean number of glomeruli per core Mean+/-SD (7.76+/-2.36) and histopathological diagnosis was made in all cases. Total number of attempts were 1-3. In 70% patients single attempt was done. No major complication related to the procedure was seen.

CONCLUSION

Renal biopsy with automated biopsy gun is relatively safe and effective in establishing the diagnosis of renal diseases. Although renal biopsy can be done on outpatient basis, it is better to observe the patients for 24 hours post-operatively for any complication

Interaction of tissue plasminogen activator inhibitor with cell surface guanidinobenzoatase and urokinase plasminogen activator

This study employs fluorescent inhibitor molecules to detect both cell surface proteases and their receptor sites on colonic carcinoma cells. Present studies are concerned with the interactions of the tumour associated proteases, guanidinobenzoatase (GB) and plasminogen activators (PAs) with PAs inhibitor type 1 (PAI-1). The active enzymes on the cell surfaces in frozen sections of human colonic carcinoma tissue were located by staining with two active site directed fluorescent inhibitors, 9-aminoacridine (9-AA) and Rhodamine labelled PAI-1 (Rh-PAI-1), followed by fluorescence microscopy. Fibrin treated sections, which now lack GB but have receptor proteins for GB, fail to bind 9-AA and Rh-PAI-1. When these fibrin-treated sections were incubated with purified colonic carcinoma GB and u-PA, both enzymes were bound to the tumour cells in these sections and subsequent challenging with fluorescent probes for GB resulted in bright fluorescence under appropriate microscopic conditions. On the other hand when fibrin treated sections were incubated with t-PA, followed by challenging with Rh-PAI-1, no red fluorescence was observed. It is suggested that the GB and u-PA have similar specific binding sites which can recognise and bind to the receptors on tumour cells in fibrin-treated sections, but t-PA has no such binding site and fails to recognise the cell surface receptors for GB. These GB-receptors may have a possible role in the regulation of GB and u-PA activity during tumour cell invasion and metastasis.

Location of tumour cells in colon tissue by Texas red labelled pentosan polysulphate, an inhibitor of a cell surface protease

Pentosan polysulphate (PPS), a highly negatively charged polysaccharide, is a significant inhibitor of an isoenzymic form of a cell surface protease referred to as guanidinobenzoatase GB, associated with colonic carcinoma tissues in frozen sections and free GB in solution, in a concentration-dependent manner. However PPS failed to recognise and bind to the isoenzymic form of GB associated with normal colon epithelial cell surfaces. Texas red labelled PPS (TR-PPS) binds to the tumour cell surfaces of colonic carcinoma and colonic polyps and these cells fluoresce red, whilst the normal colon cell surfaces failed to bind the TR-PPS, and hence lacked red fluorescence. Polysulphonated suramin also selectively recognised and inhibited the colonic carcinoma GB isoenzyme. The kinetic data indicated that this inhibition was not caused by a mere polyanionic effect, since highly sulphated heparin failed to show a significant inhibition of colonic carcinoma GB, however trypan blue did show 50% inhibition. Kinetic studies have also shown that PPS is a non-competitive, reversible inhibitor of colonic carcinoma GB, with an apparent Km 6.8 x 10(-7) M. Gel analysis has shown that PPS binds to another site, distinct from the active centre, and after binding PPS changed the conformation of GB. These studies suggest that TR-PPS is a potent inhibitor of colonic carcinoma GB, and can be used as a novel fluorescent probe for the location of tumour cells in frozen sections of human colon tissues. PSS could also have potential as a vehicle for the transport of cytotoxic compounds to carcinoma cells of the colon.

Dansyl fluoride, a fluorescent inhibitor for the location of tumour cells in human tissues

Dansyl fluoride (Dan-F), an active site directed fluorescent inhibitor of guanidinobenzoatase (GB), has been used for the location of tumour cells in frozen sections of human squamous cell carcinoma and colonic carcinoma tissues. The tumour cell surfaces having active GB bind Dan-F and fluoresce blue. The surrounding normal epithelial lung cell surfaces fail to bind Dan-F and hence lack fluorescence, whilst the normal colon cell surfaces have another isoenzymic form of GB, bind Dan-F and fluoresce blue. Kinetic studies have shown that Dan-F is an irreversible inhibitor of GB, and Dan-GB complexes are not dissociated with SDS and high salt concentration. However hydroxylamine (1 M) can dissociate Dan-GB complexes in the presence of 0.1% SDS, both on membrane-bound and in free solution. These studies suggest that Dan-F is a potent inhibitor of GB, and in very low concentration (3 x 10(-8) M) can be used as a novel fluorescent probe for the location of tumour cells in histological sections of human tissues.

Selectivity of the plasminogen activator inhibitor (PAI-1) for the iso enzyme of guanidinobenzoatase on the surface of colonic carcinoma cells

The interaction of plasminogen activator-inhibitor (PAI-1) with a cell surface protease, guanidinobenzoatase (GB), has been studied in free solution and on the surface of colonic epithelial cells. It has been demonstrated that PAI-1 recognises and inhibits the iso enzymic form of GB associated with colonic carcinoma cells but fails to bind to the iso enzymic form of GB associated with normal donor colonic epithelial cells. This interaction is mediated by a lysyl binding site on the GB: complex formation prevents GB binding to fibrin fibrils which also involves lysyl binding sites.

Differential competitive inhibition of a cell surface protease on normal epithelial cells and carcinoma cells of the colon

The cell surfaces of normal colonic epithelial cells and colonic carcinoma cells both possess a protease referred to as guanidinobenzoatase (GB). Previous studies have shown that these cells possess two distinct isoenzymic forms of GB which could be distinguished by their selective recognition of cytoplasmic protein inhibitors of GB. In the present study we have used competitive inhibitors of GB to demonstrate the differential inhibition of the GB on normal colonic epithelial cells whilst the GB on colonic carcinoma cell surfaces remains active. The enzymic status of GB on these cells has been determined by challenging the treated cells in frozen sections with a second fluorescent inhibitor, followed by fluorescence microscopic analysis.