Cerebrospinal fluid procalcitonin as a biomarker of bacterial meningitis in neonates

OBJECTIVE

The objective of the study was to study the performance of cerebrospinal fluid (CSF) procalcitonin as a marker for bacterial meningitis in neonates, and to determine its optimal 'cutoff' in CSF that can be called significant for the diagnosis.

STUDY DESIGN

Neonates qualifying for lumbar puncture were prospectively studied. Procalcitonin and established CSF parameters were recorded.

RESULTS

At a cut-off value of 0.33 ng ml^-1, CSF procalcitonin had a sensitivity of 0.92, specificity of 0.87, with positive and negative likelihood ratios of 7.13 and 0.092, respectively. The area under the curve for different CSF parameters was: 0.926 (0.887 to 0.964) (P<0.001) for procalcitonin, 0.965 (0.956 to 0.974) for total leukocyte count, 0.961 (0.94 to 0.983) for neutrophil count, 0.874 (0.825 to 0.923) for protein, 0.946 (0.914 to 0.978) for sugar and 0.92 (0.955 to 0.992) for CSF:serum sugar ratio. The lumbar puncture was traumatic in 36 (21.4%) patients; out of these 15 (41.7%) had bacterial meningitis and 21 (58.3%) had no meningitis. In traumatic lumbar tap group, the median (IQR) CSF procalcitonin in patients with and without meningitis was 1.41 (0.32-3.42) ng/ml and 0.21(0.20-0.31) ng/ml respectively (p<0.05).

CONCLUSIONS

Procalcitonin measurement has diagnostic efficiency similar to the established CSF markers. Routine assessment of procalcitonin in clean non-contaminated CSF may not yield additional information, but it may have clinical utility in situations where diagnosis of meningitis is in dilemma, as in the case of blood contamination of CSF in traumatic lumbar punctures.

Profil Kecukupan Asupan Makanan pada Rawat Inap

Latar belakang. Kekurangan Jumlah asupan makanan pasien rawat inap sering kali ditemukan.Tujuan. Mengetahui profil kecukupan asupan makanan pada pasien anak rawat inap. Metode. Penelitian cross sectionaldilakukan November 2011- Januari 2012 pada pasien anak rawat inap di RSUP Dr. Mohammad Hoesin, Palembang. Sampel dipilih secara consecutivedengan kriteria usia >1-10 tahun, dirawat >24 jam, tidak menderita sakit kritis, bukan gizi buruk, tidak terdapat kontraindikasi makan per oral, tidak terdapat masa atau asites diberikan asupan nutrisi berdasarkan buku rekomendasi IDAI tentang asuhan nutrisi pediatrik. Data asupan makan dihitung setelah perawatan 3 hari rawat dan data dianalisis dengan uji Fisher. Asupan dinyatakan tidak cukup apabila asupan rata-rata energi dan protein 3 hari pertama <80% kebutuhan.Hasil. Didapatkan 105 pasien yang diteliti, terbanyak usia 6-10 (59%) tahun, jenis kelamin perempuan (52%), status gizi baik (52%). Umur 1–5 tahun, asupan energi tidak cukup 27,9%; asupan protein tidak cukup 34,9%. Umur 6–10 tahun, asupan energi tidak cukup 50%; asupan protein tidak cukup 37,1%. Anak laki-laki, asupan energi tidak cukup 36%; asupan protein tidak cukup 15 30%. Anak perempuan, asupan energi tidak cukup 45,5%; asupan protein tidak cukup 41,8%. Gizi baik, asupan energi tidak cukup 38,2%; asupan protein tidak cukup 36,4%. Gizi kurang, asupan energi tidak cukup 44%; asupan protein tidak cukup 36%.Kesimpulan. Ketidakcukupan energi dan protein lebih banyak dialami oleh perempuan dan kelompok umur 6–10 tahun.

Pharmacological agents for reducing the haemodynamic response to tracheal intubation in paediatric patients: a systematic review

The primary aim of this review was to assess the effect of pharmacological agents administered to attenuate the haemodynamic response to tracheal intubation in paediatric patients up to 16 years of age undergoing elective surgery. Secondary aims were to identify adverse effects related to these agents, and the agents' roles in decreasing arrhythmias. A systematic search was conducted for articles listed in PubMed, CINAHL or the Cochrane database between January 1980 and June 2014. We included randomised controlled trials where the stated aim of the study included observing the effects of pharmacological agents on the haemodynamic response to tracheal intubation. The outcome measures were changes in mean, systolic and diastolic blood pressure and heart rate, adverse effects of drugs and arrhythmias. Sixteen publications with a total of 1408 children (ages two to 15 years) were identified. These studies varied in methodology and quality. Opioids were the commonest agents used and appeared to obtund the response in a dose-related manner. Fentanyl 2 µg/kg, remifentanil 1 µg/kg, sufentanil 0.1 and 0.2 µg/kg and alfentanil 25 µg/kg blunted the haemodynamic response. Remifentanil 3 µg/kg and sufentanil 0.3 µg/kg were the most effective in obliterating the response but led to hypotension in unstimulated patients. Opioid-related side-effects and arrhythmias were observed in few patients. We recommend that when required, the safe and effective doses identified in this review be used to obtund the haemodynamic response to intubation in paediatric patients, with close observation for the uncommon but recognised side-effects.

Management of Post Traumatic Posterior Urethral Stricture; Internal Urethrotomy verses Perennial Urethroplasty

Objective: To compare the efficacy and cost effectiveness of cold knife optical internal urethrotomy with perineal urethroplasty (excision and end to end anastomosis) in the management of post traumatic short posterior urethral stricture. Design: an observational prospective study. Place and duration of study: the study was performed in the department of urology and kidney transplantation Services hospital/post graduate medical institute Lahore, from September 1997 to December 1999. Patients and methods: Forty male patients of post traumatic posterior urethral stricture revealed by their urethrogram were included in the study. Patients were divided in two groups randomly (group A & group B). After complete evaluation, patients of group A were managed by internal uretherotomy, while those of group B by perineal urethroplasty. Follow up was done at 1,3,6,9 & 12 months. Results: age range of the patients was 20 to 59 years with the mean age of 35.5 years. Road traffic accident was the main cause (82.5%). After facing the traumatic urethral injury, there was history of attempted Foley catheterization (47.5%), bouginage (15%) and intervention by rail road technique in 10% of the patients. All patients were with supra pubic catheter because of failure to void. The length of stricture varied from 0.5 to 2.0 cm (mean 1.4 cm). Clinical response at the end of the study in group A & B was "good" in 58.82% & 66.66%, "satisfactory" in 23.52% & 22.22% and "poor" in 17.64% &11.11% respectively. The mean cost of operation, hospital stay and loss of working hours were less in group A as compared to that of group B. Conclusion: The results of perineal urethroplasty are comparatively better than optical urethrotomy. The other differences of the two procedures lie in operative time cost of the operation and mean hospital stay. It is concluded that optical urethrotomy is an acceptable alternative to urethroplasty in patients with short post traumatic posterior urethral stricture.

Comparison of Snodgross and para-meatal based flap technique for hypospadiasis

Objective: To compare the two surgical procedures Snod gross & parameatal based flap technique for mid & distal penile hypospadias including cosmosis. Study design: Randomized Clinical interventional trail. Place of study: This study was conducted in the Urology Department of Assir Central University Hospital ABHA, KSA and Department of Urology & Renal transplantation, Jinnah Hospital, Lahore from June 2002 to Dec 2004. Material & Methods: Thirty-two patients were selected for this randomized clinical intervention study with mid shaft & distal hypospadias fulfilling the inclusion criteria. Snod Gross and parameatal based flap technique was assigned randomly to patients comprising of two groups of sixteen each. Watertight closure was made with 6/0 vicryl. Tourniquet or 1:10000 epinephrine were used. Follow up at 2 weeks, three months; 6 months post catheter or stent removal and the patient were assessed on criteria of cosmosis, time for surgery and complications associated with the procedure. Results: Th irty-two patients who underwent procedure of Snodgross & parameatal-based flap in the management of mid shaft & distal penile Hypospadias. Age ranged from 2-12 years. The mean age was 5.23+4 years. The presentation of patients was dystocia of external meatus with misdirected stream in sixteen (50%) patients, spraying of urine in six (25%) and narrow stream in 4(13%) patients. Eighteen patients were having distal penile and fourteen were having mid shaft hypospadias. Following Snod grass technique all patients had good cosmetic results without any complication. Following parameatal based flap, one patients (6.3%) develop wound dehiscence, three patients (18.8%) develop urethral fistula, two patients (12.5%) showed metal retrieval and twenty patients showed good cosmosis. In our study, comparison between Snodgross & parameatal-based flap, the success rate was 100% and 62.4% respectively. Conclusions: Success with Snod gross procedure is better with no complications and good cosmosis. Complications rate was 37.6 % in-patient with para-meatal technique.

Serum vitamin D and vitamin D receptor gene FokI polymorphisms in children with tuberculosis

Background Vitamin D deficiency and vitamin D receptor (VDR) gene polymorphisms are strongly associated with tuberculosis (TB) susceptibility in countries with four seasons. As a country with sufficient sunlight for vitamin D production in skin, the incidence of TB in Indonesia remains high. Objective To assess for possible associations between the incidence of tuberculosis and serum vitamin D level, as well as VDR FokI polymorphisms in children. Methods A case-control study was conducted at the Department of Child Health, Dr. Mohammad Hoesin Hospital, Palembang from November 2011 to April 2012. Subjects were children with TB (the case) and children without TB who had been exposed to TB in the home (the control). Serum vitamin D [1,25(OH)2D3 or calcitriol] level was measured by immunodiagnostic system (IDS) 1,25-dihydroxy vitamin D enzyme immunoassay (EIA) kit. The VDR FokI polymorphisms were identified by polymerase chain reaction (PCR) and restriction-fragment length polymorphism (RFLP) analysis. Results Sixty subjects was divided equally into the case and control groups. The mean serum calcitriol level in the case group was significantly lower than that of the control group [105.5 (SD 66.9) pmol/L vs. 162.9 (SD 52.9) pmol/L, respectively; (P=0.001)]. We found 9 subjects with calcitriol deficiency, 8 in the TB group and 1 in the healthy contact group (OR 10.5; 95%CI 1.2 to 90.7) The VDR FokI polymorphism was seen in 28 subjects in the case group and 22 in the control group (OR 5.0; 95%CI 0.9 to 26.4). Conclusion Vitamin D (calcitriol) deficiency and lower serum levels are associated with higher risk of TB in children. The VDR gene FokI polymorphism also contributes to susceptibility for TB.

Micropropagation and Attempts to Develop RAPD Molecular Markers for Salt Tolerant Cultivars of Pearl Millet

Differences were observed among four salt tolerant cultivars of pearl millet to in vitro culture media. Among the four cultivars, Cv IP 6098 is the most salt sensitive had maximum number of multiple shoots (15)/ seed, and the more salt tolerant cvs IP 6106 and IP 22269 developed 3-6 shoots/seed while cv IP 19612 the seeds remained single shooted in MS+3.0mg/L media up to 7 months. The multiple shoots 20% of cv IP 6098, flowered in 5 months with the reduction in hormone concentration (MS+1.0 mg/L BAP) whereas, the other three cultivars did not flower under the tested conditions. The present study was carried to detect genetic differences among the four cultivars of pearl millet at molecular level through RAPD PCR markers. RAPD analysis was carried with 12 primers, each 10-mer, only 7 primers were amplified showed polymorphism for the four cultivars. Primer OPM 16 revealed a single unique band of approx. 485bp in the genotype IP 22269 and three polymorphic bands in the genotype IP 6106. The results were repeatable, and further studies in this direction may enable to link the single band in the genotype IP 22269 to a morphological trait or physiological condition like salt tolerance.

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.

Cervical spinal injuries in moderate to severe head injuries

BACKGROUND

Traumatic Brain Injury (TBI) is the leading cause of death in all age group. The incidence of CSI increases with the severity of TBI so prompt care of cervical spine is necessary in all patients with moderate to severe head injury. The objective of this study was to determine the frequency of cervical injury in patients with moderate to severe head injury and different types of trauma.

METHODS

This descriptive cross sectional study was conducted in department of Neurosurgery Ayub Medical College, Abbottabad from October 2011 to October 2012. A total of 369 patients were included in this study by consecutive (non probability) sampling. All patients were subjected to X-rays and CT-Scan of the skull for evaluation of head injury. X-rays and CT scan with MRI of cervical spine were done for evaluation of cervical spinal injury.

RESULTS

A total of 369 patients were included in our study, out of which 276 (74.8%) were males and 93 (25.2%) were females. Age of the patients ranged from 3-90) years with mean of 31.93 +/- 21.35. Among these patients most common cause of injury was fall 196 (53.1%), whereas the RTA was 159 (43.1%) and assault was 14 (3.8%). Out of the 369 patients 42 (11.3%) were found to have cervical spinal injuries.

CONCLUSION

The frequency of cervical injury associated with moderate to severe head injury remains the same in all over the world with minor difference in percentages; that we have observed in our study. Furthermore, we have observed that cervical injury is directly proportional to the severity of head injury. All the head injured patients should be suspected of having cervical spinal injury unless proved otherwise.

Lack of germ line changes in KISS1 and KAI1 genes in sporadic head and neck cancer patients of Pakistani origin

BACKGROUND

Head and neck cancer is included among the top five most commonly prevailing cancers worldwide. Abnormalities of either genetic or epigenetic factors are found responsible for the development and progression of head and neck cancer. Metastasis is the leading cause of death in patients with head and neck cancer. Down regulation of metastasis suppressor genes (MSGs) expression have been frequently observed in advanced tumours.

METHODOLOGY

The present study was designed to screen two of the most frequently down-regulated MSGs (KISS1 and KAI1) for mutations in 120 diagnosed head and neck cancer affected Pakistani patients. The questionnaire was filled for basic information about age, gender, smoking habits and area of cancer affected and other relevant details. Primers for both genes were designed using "Primer 3" software in such a way that both intron exon boundaries were included in this region. DNA isolation and estimation was done by using organic method and agarose gel electrophoresis. Single Strand conformational polymorphism technique was used after amplification of the respective genes. Mobility patterns were analyzed using BioDoc Analyzer.

RESULTS

Data of patients were analyzed on the basis of age, sex and type of cancer as variables. The mean age of patients and controls was 44 years. There were 53% females and 47% males in this group of study, 63% nonsmokers and 37% smokers and larynx cancer was found to be most frequent type of cancer with a percentage of 64. Lack of germ line mutation was observed in the entire coding region in both coding regions as well as splice sites of the respective genes.

CONCLUSION

Germ line mutations in KISS1 and KAI1 are thus considered to be a less frequent event in head and neck cancer patients. However, two polymorphisms in intronic region of exon 3 and exon 9 of KAI1 gene were observed in 1% of patients. In non coding region downstream of exon 3 (KAI1), there was a C 29166 T substitution and in intronic region upstream exon 9 of KAI1 gene, a C 52840 A substitution was observed. Both patients were females with ages 47 and 50 years respectively. A detailed analysis of regulatory mechanism is required to explore the genetic basis of down regulation of these MSGs for a better understanding of head and neck cancer progression.

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.

Choroidal metastasis from renal cell carcinoma presenting with cataract

We report a case of rare involvement of the eye with choroidal metastasis from renal cell carcinoma presenting 08 years after the primary tumor was removed. The patient initially presented with cataract most probably induced by the tumor. After cataract extraction, tumor was detected when it induced vitreous involvement and retinal detachment. Enucleation was performed and an extraocular mass was also excised. Histopathology confirmed the diagnosis of metastasis from renal cell carcinoma in the ocular tumor, extraocular mass and the vitreous.

Campomelic dysplasia: case report and review

Initial ultrasound of a fetus in the third trimester demonstrated shortened and bent fetal extremities with a narrow and misshapen thorax. These findings were suggestive of a fetus affected with a possible lethal skeletal dysplasia. Decisions regarding antepartum, intrapartum and neonatal care were made in this context. A newborn with campomelic dysplasia was delivered and suffered a rapid downhill course.

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.