Early renal damage assessed by the SLICC/ACR damage index is predictor of severe outcome in lupus patients in Pakistan

We investigated patients with systemic lupus erythematosus with the objective of assessing whether early damage accrued in systemic lupus erythematosus as measured by the SLICC/ ACR Damage Index predicts mortality in lupus patients that have been followed prospectively in a single center. Patients with systemic lupus erythematosus from Aga Khan University hospital presenting between 1992 and 2007 were included. This enabled all patients to be potentially followed for at least 10 years. Yearly SLICC/ACR Damage Index scores were determined for each patient. Early damage was defined as a score ≥1, and no damage as a score of 0 at the initial assessment. Kaplan—Meier and Log rank tests were used to compare the survival experience between those with and without damage, with all patients being assessed at 10 years. In this inception cohort 198 patients were identified and were followed for 10 years. Of these, 47 (23.7%) patients had a SLICC/ACR Damage Index score of 0 (no damage) while 151 patients (76.3%) had at least one SLICC/ACR Damage Index item scored (early damage). Mean renal damage score at 1, 5 and 10 years was 0.16, 0.34 and 0.67, respectively. Of lupus patients who exhibited renal damage at their first SLICC/ACR Damage Index assessment, 31% died within 10 years of their illness as compared with only 13% who had no early renal damage (p < 0.003). Mean renal damage score at 1 year after diagnosis was a significant predictor of death within 10 years of diagnosis (p < 0.002). Lupus (2010) 19, 1573—1578.

Health care risk factors among women and personal behaviours among men explain the high prevalence of hepatitis C virus infection in Karachi, Pakistan

To estimate the prevalence and identify factors associated with hepatitis C virus (HCV) infection among men and women in Karachi, Pakistan. We conducted a cross-sectional study of adult men and women in a peri-urban community of Karachi (Jam Kandah). Households were selected through systematic sampling from within all villages in the study area. All available adults within each household were interviewed about potential HCV risk factors. A blood specimen was collected to test for anti-HCV antibodies by enzyme immunoassay. We used generalized estimating equations while accounting for correlation of responses within villages to identify the factors associated with HCV infection. Of 1997 participants, 476 (23.8%) were anti-HCV positive. Overall, HCV infection was significantly associated with increasing age, ethnicity, and having received > or =2 blood transfusions, > or =3 hospitalizations, dental treatment and >5 injections among women. Among women, > or =2 blood transfusions [adjusted odds ratio (aOR) = 2.32], >5 injections during the past 6 months (aORs = 1.47), dental treatment (aOR = 1.31) and increasing age(aOR = 1.49), while among men, extramarital sexual intercourse (aOR = 2.77), at least once a week shave from barber (aOR = 5.04), > or =3 hospitalizations (aOR = 2.50) and increasing age (aOR = 1.28) were associated with HCV infection. A very high prevalence of HCV was found in the study population. Among women, unsafe health care practices, while among men extramarital sex, shaving from a barber and hospitalizations were associated with HCV infection. Efforts are needed to improve the safety of medical procedures to reduce the transmission of HCV in Pakistan [Corrections made in Summary after initial online publication.].

MDG 5: how close are we to success?

Only 6 years are left until 2015, the target date for achieving the Millennium Development Goals (MDG), yet improving maternal health (MDG 5) continues to lag behind. At the global level, maternal mortality still remains high in sub-Saharan Africa and Southeast Asian countries. Most deaths are preventable and occur due to unavailability of and/or poor quality of service. Skilled care at facilities ensures safety, cleanliness, the availability of supplies and equipment, and it makes management and supervision easier. With the mixture of professionals in a facility, life-saving emergency care can be provided quickly. Wherever childbirth takes place, it is essential that the person who helps has the core competencies for safe delivery, has the necessary equipment and supplies, and has the option to refer to a functioning facility offering emergency obstetric and newborn care. The continuing high incidence of maternal and perinatal mortality and morbidity is unacceptable precisely because it is solvable. We know how to make pregnancy and childbirth safe. The task is enormous but not insurmountable. Our efforts of investment need to be equal to the tasks and must be intensified if maternal and perinatal morbidity and mortality is to be reduced.

Subtypes of dissociative (conversion) disorder in two tertiary hospitals in Bangladesh

Dissociative (conversion) disorders are common among the patients attending in and out patients of Psychiatry Department of tertiary hospitals in Bangladesh. This study was done to see the subtypes of dissociative (conversion) disorder according to International Classification of Diseases, Tenth Revision (ICD-10). This is a descriptive, cross sectional study done on 100 consecutive patients from the Departments of Psychiatry, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka and Dhaka Medical College Hospital (DMCH). Study period was July 2005 to June 2006. Among the patients of dissociative (conversion) disorder, mixed dissociative (conversion) disorder was found highest 34%, followed by dissociative convulsion 33%, dissociative motor disorders 19%, dissociative anaesthesia and sensory loss 5%, dissociative amnesia 4%, dissociative fugue 3%. However, the researcher did not find any multiple personality disorder which is relatively common in North America. This finding reflected that there are differences in prevalence of sub types of dissociative disorders in Bangladesh and Western countries.

Sub arachnoid block for emergency cesarean section in a pituitary dwarf

Anaesthesia for parturient patients with dwarfism is an uncommon problem faced by anaesthesiologists. There is an ongoing debate regarding general versus regional anaesthesia in these cases. In many centers there is lack of facilities for epidural or continuous epidural anaesthesia. A primiparous dwarf woman of 27 years old having 124 cm height and 37 kg weight was admitted in Mymensingh Medical College Hospital for elective cesarean section due to cephalopelvic disproportion. She was diagnosed as a case of pituitary dwarf previously on antenatal checkup depending on both clinical and endocrine ground. After admission she suddenly developed respiratory distress with less foetal movement and presented in our department for emergency cesarean section. We have managed the case by sub-arachnoid block (SAB) using 7.5 mg (1.5 ml) of 0.5% heavy bupivacaine at a level of L3-L4 interspace having adequate level of block and analgesia. The case was managed successfully and uneventfully. In this presentation, the role of SAB and a management guideline has been highlighted.

Survival analysis and prognostic indicators of systemic lupus erythematosus in Pakistani patients

To aim of this study is to analyse the survival rate and prognostic indicators of systemic lupus erythematosus (SLE) in Pakistani population. A total of 198 patients with SLE diagnosed between 1992 and 2005 were reviewed retrospectively. Clinical features at presentation, subsequent evolving features, autoantibody profile, damage scores and mortality data were obtained. Prognostic factors for survival were studied by statistical analysis. Of 198 SLE patients studied, 174 were women and 24 were men. The women to men ratio was 7.2:1. Mean age at presentation was 31 years (range 14-76). Mean duration of symptoms before diagnosis was 2.8 years. Mean duration of follow-up was 34.21 months (+/-33.69). Mean disease duration was 15.6 years. At diagnosis, arthritis, malar rash, oral ulcers and alopecia were the commonest features. During the follow-up, the prevalence of nephritis, arthritis, neurological and hematological disease increased significantly. About 76% (n = 151) of the patients had organ damage at the time of data analysis, and renal disease was the commonest cause. Univariate analysis revealed that renal disease (P = 0.000), seizures (P = 0.048), pleural involvement (P = 0.019), alopecia (P = 0.000) and discoid lesions (P = 0.005) were predictors for damage. Multivariate model, however, revealed that only renal disease was independent risk factor for damage (P = 0.002). During the study period, 47 patients (24%) died (five due to disease-related complications and rest as a result of infections). The 3-, 5-, 10-, 15- and 20-year survival rates of our cohort were 99, 80, 77, 75 and 75%, respectively. Cox regression analysis revealed that renal involvement (P = 0.002) and infections (P = 0.004) were independent risk factors for mortality. The survival of our Pakistani SLE patients was significantly lower compared to that of the Caucasian series reported in last decade. Nephritis not only contributes to organ damage but also acts a major determinant for survival. Infection remains the commonest cause of death. Renal involvement and infections are independent risk factors for mortality. Judicious use of immunosuppressive agents is necessary to improve the short-term survival of lupus patients.

Central nervous system tuberculosis and adjuvant corticosteroid therapy

Tuberculous involvement of central nervous system is one of the important health issues causing high mortality and morbidity. Uncertainty and doubt dominate all aspects of CNS tuberculosis. Diagnosis is mainly based on clinical features, cerebrospinal fluid changes, and imaging characteristics. Few studies have shown that corticosteroids improve the clinical outcome, although the precise mechanism of action remains tentative. All the cases were selected on strong clinical suspicion of CNS tuberculosis. They were graded according to tuberculous meningitis (TM) severity grades. In this connection, we studied 13 patients in one medicine unit over 12 month's period to see the effect of corticosteroid as part of the outcome. Nine patients (69.23%) were in grade II, three (23.08%) patients were in grade III, and one (7.69%) was in grade I. Seven patients (53.85%) had tuberculous meningitis and six (46.15%) had tuberculoma (CT or MRI). Out of 13 cases 3 patients (23%) died in the hospital and 10 patients (77%) improved, of whom 2 patients (20%) recovered completely and 8 patients (80%) had residual neurological deficit. Our study suggests that the early detection of CNS tuberculosis is the most important prognostic factor. Timely started anti-Koch's treatment with adjuvant corticosteroid therapy has a direct bearing on patient outcome.

Addition of isovitalex in chocolate agar for the isolation of Haemophilus influenzae

BACKGROUND & OBJECTIVE

The reason for lack of data on burden of Haemophilus influenzae type b (Hib) in developing countries was mainly failure of detection of this fastidious organism in laboratories. Use of isovitalex (IVX) was suggested as an essential supplement for growing this organism. This study was carried out to investigate the impact of IVX supplementation to chocolate agar for detection of Hib.

METHODS

Chocolate agar with and without supplementation of IVX was prepared. Clinical samples as well as reference strains of Hib were simultaneously cultured on both the media.

RESULTS

H. influenzae isolates (N=194) were simultaneously grown on chocolate agar (CA) with and without isovitalex (IVX). Average colony size of H. influenzae on CA with IVX (CA-IVX) was larger only by 0.10 cm (range 0.05 to 0.16 cm) compared to CA alone. Addition of IVX to CA increased the cost of media by 2.1-fold.

INTERPRETATION & CONCLUSION

Isovitalex is not essential for the isolation and growth of H. influenzae almost halving the cost.