Blood product transfusion practices in pediatric critically ill patients at a tertiary care hospital, Pakistan

Objective

To determine the frequency of inappropriate blood product transfusions in pediatric critically ill patients.

Methods

We collected data for this descriptive study from January to December 2020 at the Pediatric Intensive Care Unit (PICU) of Dr. RKMP Civil Hospital, Karachi. We included all patients one month to 12 years of age, admitted to pediatric intensive care unit and received any blood product transfusion. We reviewed their medical records and noted the demographic and clinical variables, type of blood product transfused with its indication and determined whether transfusion was appropriate or not, as per the standard guidelines and consensus recommendations.

Results

Number of patients who were transfused was n=39, out of which females were 51.3%. Mean age of the patients was 49.0 months ±50.9 months. Total number of transfusions done were n=135, with most common blood product transfused being Fresh Frozen plasma (FFP) in 44.4%. A total of n=117 (86.66%) transfusion were appropriate as per the standard guidelines, while 18 (13.33%) were inappropriate (P-value <0.5). The most common indication of FFP transfusion was INR >2.0 in 51.6%, for Packed red cell transfusion was hemoglobin between 5 and 7 gm/dl in 35.5% and for Platelets was <20,000 with risk of bleeding in 36.6%.

Conclusion

This study highlights the occurrence of inappropriate transfusions in critically ill pediatric patients. We need to reinforce the knowledge of our health care workers and display the guidelines in intensive care units.

830 A Case of Colo-Colonic Intussusception Secondary to A Large Lipoma in An Adult

Colonic lipomas are benign tumours, most commonly in the right colon or caecum, usually detected incidentally at colonoscopy and are often asymptomatic not requiring treatment. Lipomas leading to intussusception have previously been described in case reports, but it remains a rare occurrence, no specific incidence data has been documented. We present the case of a patient with a 7cm colonic lipoma that developed an intussusception.

This patient suffered non-specific pulling pain along the right and upper abdomen for many years. A distal ascending colonic lipoma was identified, on repeated imaging and colonoscopy and biopsied. It was concluded that the abdominal pain was due to gallstones, diverticulitis and adhesions from previous pelvic surgery. In early December 2020, the patient was reviewed and listed for elective cholecystectomy. Later the same month, the patient was admitted with severe abdominal pain, watery and bloody diarrhoea. CT scan showed the colonic lipoma had acted as the lead point for an intussusception, with the lipoma and surrounding colon having intussuscepted into the transverse colon. Patient had an open right hemicolectomy and anastomosis for colo-colic intussusception secondary to the lipoma. Subsequently, the patient developed anastomotic breakdown requiring relook laparotomy with resection of ileo-colic anastomosis and end ileostomy formation.

Adults presenting with intussusception is rare and associated with nonspecific signs and symptoms. Variability in clinical presentation highlights the need for a low index of suspicion in people with known colonic masses. In addition, early surgical intervention should be considered in masses &gt;4cm as previously suggested in the literature.

Sclerosing angiomatoid nodular transformation of spleen in a 8-year old girl

Sclerosing angiomatoid nodular transformation of spleen is a rare, benign vascular lesion with an uncertain pathogenesis. It has been described as a separate entity through specific histopathological characters. It is usually asymptomatic, occurring commonly in adult females. Only a few cases of paediatric cases have been reported which have been commonly symptomatic. This disease has excellent prognosis after splenectomy, which is the only treatment. We report the case of an eight-year-old girl who presented with distended abdomen and history of bleeding from the nose following a road traffic accident. Examination revealed stunted height, decreased weight, tachypnoea, tachycardia, anaemia and a firm, massive spleen. Lab investigations further revealed microcytic anaemia, thrombocytopenia, deranged platelet profile and low vitamin B12 and folate levels. Computed tomography confirmed enlarged spleen. Therefore, a diagnostic biopsy was planned which confirmed sclerosing angiomatoid nodular transformation of spleen. Splenectomy was successfully performed soon after and the child is now healthy with no remissions of previous symptoms.

Pierson Syndrome Associated with Hypothyroidism and Septic Shock

Pierson syndrome is caused by mutations in the laminin β2 gene causing absent β2 laminin, which is a normal component of the basement membranes of the mature glomerulus, structures in the anterior eye and neuromuscular junctions. The mutations manifest as congenital nephrotic syndrome and microcoria which are characteristic ocular features of this disease. These mutations may also result in neurological abnormalities such as hypotonia and psychomotor retardation. We report a two-month old boy who presented to the Pediatrics Department of Dr. Ruth K. M. Pfau Civil Hospital, Karachi, Pakistan, in 2015, with the typical features of microcoria and congenital nephrotic syndrome. The hypocalcaemia, hypoproteinaemia and probable immunocompromised state consequent to nephrotic syndrome resulted in seizures, hypothyroidism and urosepsis. Despite being treated aggressively with high dose antibiotics, ionotropic support, angiotensin-converting enzyme inhibitors, thyroxine replacement and nutritional support, the infant died due to significant multiorgan disease including renal failure and septic shock.

Seizures and Basal Ganglia Calcification Caused by Hypoparathyroidism

Seizures, not a typical feature of hypoparathyroidism, may present along with myalgia and tetany in patients of hypoparathyroidism. Thorough history and examination, derangement of biochemical parameters such as hypocalcemia, hyperphosphatemia, and inappropriately low levels of parathyroid hormone, along with basal ganglia calcification as seen on imaging, lead to the diagnosis of hypoparathyroidism in a 10-year-old child who presented to us. Treatment with calcium and active vitamin D significantly improved his condition. In this report, we discuss the presentation and treatment of hypoparathyroidism. Early detection and follow-up at clinically appropriate intervals is important to avoid complications.

A prospective study of tea drinking temperature and risk of esophageal squamous cell carcinoma

Previous studies have reported an association between hot tea drinking and risk of esophageal cancer, but no study has examined this association using prospectively and objectively measured tea drinking temperature. We examined the association of tea drinking temperature, measured both objectively and subjectively at study baseline, with future risk of esophageal squamous cell carcinoma (ESCC) in a prospective study. We measured tea drinking temperature using validated methods and collected data on several other tea drinking habits and potential confounders of interest at baseline in the Golestan Cohort Study, a population-based prospective study of 50,045 individuals aged 40-75 years, established in 2004-2008 in northeastern Iran. Study participants were followed-up for a median duration of 10.1 years (505,865 person-years). During 2004-2017, 317 new cases of ESCC were identified. The objectively measured tea temperature (HR 1.41, 95% CI 1.10-1.81; for ≥60°C vs. <60°C), reported preference for very hot tea drinking (HR 2.41, 95% CI 1.27-4.56; for "very hot" vs. "cold/lukewarm"), and reported shorter time from pouring tea to drinking (HR 1.51, 95% CI 1.01-2.26; for <2 vs. ≥6 min) were all associated with ESCC risk. In analysis of the combined effects of measured temperature and amount, compared to those who drank less than 700 ml of tea/day at <60°C, drinking 700 mL/day or more at a higher-temperature (≥60°C) was consistently associated with an about 90% increase in ESCC risk. Our results substantially strengthen the existing evidence supporting an association between hot beverage drinking and ESCC.

Congenital Cytomegalovirus Infection and Tetralogy of Fallot: An Unusual Association in a Three-month-old Baby

Congenital cytomegalovirus (cCMV) infection is the leading cause of infant morbidity and mortality worldwide. Despite being associated with significant neurological sequelae in infected infants, it remains an under-recognized public health entity. Symptomatic newborns most frequently display hepatosplenomegaly, petechiae, jaundice, microcephaly, intrauterine growth restriction, chorioretinitis, purpura, and seizures. Progressive sensorineural hearing loss is the most prominent adverse outcome of both symptomatic and asymptomatic CMV infections in infants. We report the case of a three-month-old baby who presented with complaints of progressive jaundice for three months and a two days history of fever associated with one episode of fits. The baby was diagnosed with congenital CMV infection on the basis of positive CMV IgM and IgG and positive maternal serum CMV IgG. Finding a murmur on physical examination prompted echocardiography which revealed Tetralogy of Fallot (TOF). The child was managed with a 6-week course of ganciclovir after which his symptoms improved and he was referred to cardiology for the evaluation of his heart defect. Follow-ups at the clinic have shown normal growth and development. This is the first reported association of cCMV infection with TOF. This case highlights the need to consider the possibility of the presence of heart defects in all infants with cCMV infection in addition to neurodevelopmental abnormalities. Clinicians should maintain a high degree of suspicion for cCMV infection in all neonates to ensure timely intervention and to prevent long-term neurological sequelae.

The First Case of Rowell Syndrome with Lupus Nephritis and Lobar Pneumonia in a Male Child Reported in Pakistan

Rowell syndrome (RS) is a rare entity that presents with lupus erythematosus (LE), erythema multiforme (EM) like lesions and characteristic immunological findings including positive rheumatoid factor (RF), speckled antinuclear antibody (ANA) and positive anti-Ro or anti-La antibodies in the serum. Only a few cases have been reported in the literature, mostly in middle-aged women. Our case is about an 11-year-old male child who had a history of pustular rashes over the whole body with scattered targetoid lesions for the past few months and later developed respiratory distress and swelling of the body. He was extensively investigated and confirmed on specific positive immunochemistry markers as RS along with lobar pneumonia (LP) and lupus nephritis. The co-existence of lobar pneumonia in our patient was a unique feature that has not been previously reported.

Maculopapular Cutaneous Mastocytosis in a Six-month-old Boy Who Presented with Respiratory Distress

Mastocytosis is a diverse group of rare disorders characterized by mast cell proliferation and its aberrant accumulation within various organs including respiratory, gastrointestinal, genitourinary mucosa and most commonly the skin. The spectrum of presentations ranges from torpid disease (cutaneous mastocytosis) having normal life span with transient sign and symptoms to highly vigorous disease (systemic mastocytosis) and life-threatening malignant conditions. Prevalence of the disease in general population is unknown. It occurs in all races and there is no sex predilection. Peak incidence is during infancy and early childhood with second peak occurring in middle age. We report a case of maculopapular cutaneous mastocytosis (MCM) in a six-month-old male child who presented with respiratory distress. According to our literature search it is one of the least frequent cases reported in our country, Pakistan.

Eugenia jambolana extract reduces the systemic exposure of Sitagliptin and improves conditions associated with diabetes: A pharmacokinetic and a pharmacodynamic herb-drug interaction study

Eugenia jambolana (EJ) is an Indian traditional herb widely used for the treatment of diabetes mellitus. This herb is globally marketed as single or multi herb formulations. Many diabetes patients consume EJ extract oral hypoglycemic drugs together. This calls for a need to assess risks versus benefit of this co-administration.

In present investigation, pharmacodynamic and pharmacokinetic interactions of aqueous extract of EJ seeds at the dose of 400 mg/kg are studied with 10 mg/kg of oral hypoglycaemic drug sitagliptin (SITA) by co-administrating them for 28 days in streptozotocin (STZ) induced diabetic rats. The pharmacokinetic parameters of SITA were determined using HPLC-ESI-MS/MS and it was found that the combination treatment reduces the systemic exposure of SITA by showing 38.70% reduction in concentration maximum (Cmax) and 22.40% reduction in area under curve (AUC). Despite low levels of SITA, the combination demonstrated a significant reduction in blood glucose level when compared with individual drug and individual extract administered groups during pharmacodynamic study. In addition, the liver function, the kidney function and the lipid parameters were found to be significantly improved and beneficial effects were found with respect to food intake and water intake and urine output in case of combination treatment groups when compared with individual treatment groups. Histopathological examination of pancreatic tissue suggests its significant recovery of having normal acinus with better cell protection in combination treatment. In conclusion, the combination treatment demonstrated reduced systemic exposure of SITA without compromising on its antihyperglycemic activity and improvement in conditions associated with diabetes.

Non-pseudomonal Ecthyma Gangrenosum and Idiopathic Myelofibrosis in a Two-Year-Old Girl

Ecthyma gangrenosum is a skin lesion consequent to bacteremia, mostly due to Pseudomonas aeruginosa, although it may develop secondary to other organisms as well. The disease is often witnessed in patients with leukemia; however, a few cases of ecthyma gangrenosum in adults were reported to be associated with myelofibrosis. We report a case of ecthyma gangrenosum due to Escherichia coli (E. coli) in a two-year-old girl with idiopathic myelofibrosis.

A survey of ward round practice

Aims and Method

A postal questionnaire was sent to consultant psychiatrists in the West Midlands to establish their current ward round practice. This questionnaire addressed ward round etiquette, practical issues and educational function. Consultants received only one mailing.

Results

A total of 96 (out of 139) consultants replied (69% response rate). The majority of consultants saw patients on the ward round (97%) and all consultants introduced both themselves and team members to the patient; 72% explained the purpose of the ward round. A median of seven professionals attended the ward round with psychology (6.5%) and pharmacy services (0%) being underrepresented. When consultants added comments, the recurrent themes were that ward rounds were an effective use of professional time but were often daunting for patients.

Clinical Implications

Our results indicate some uniformity in the conduct of ward rounds. The lack of representation at ward rounds for certain professional groups may adversely affect the range of opinions and therapies for patients. Changes could be made to incorporate the views of users, which would make ward rounds more productive for users and professionals.

Do We Need To Give Measles Vaccine To Children Earlier Than The Currently Recommended Age?

BACKGROUND

Measles is a leading cause of death among children. No specific drug has yet been discovered to treat measles but an available vaccine can effectively prevent the infection. In Pakistan children are vaccinated against measles by two doses given at age of nine months onward. The last few years have witnessed an increasing number of measles cases at age lower than nine months.

METHODS

Secondary data analysis of the records of Expanded Program on Immunization from all districts of Sindh was performed from January-April 2016. Data included all patients of any age or gender, fulfilling the World Health Organization case definition of measles, along with positive IgM antibodies for measles in their blood. Data was analysed using windows SPSS version 21.0.

RESULTS

Analysis of 658 confirmed measles cases showed an age range of 3 months to 336 months with a mean of 32.82. Most patients (41.4%) belonged to age group 10-24months. Some noteworthy18% of cases were ≤9 months old including 1.8% patients who were ≤6 months age. An unexpected 76 (11.6%) were >60 months of age. 50.6% of the cases were male while 49.4% were female. Most of the patients (73.9%) belonged to urban areas.

CONCLUSIONS

We conclude that a sizeable number of children are infected by measles before reaching the age of first recommended inoculation against measles. It is affecting people at both extremes of life ranging from as young as three months up to 28 years of age.

Midpoint Results of National Surveillance of Childhood Tuberculosis

BACKGROUND: There is little detailed epidemiologic and clinical data about tuberculosis (TB) disease in children in Canada.

OBJECTIVES: To characterize the epidemiologic, clinical, and treatment data for all cases of TB in children under age 15 in Canada through the Canadian Pediatric Surveillance Program’s (CPSP) Childhood Tuberculosis Study. The initial results of the 3 year study presented here includes cases from September 2013 to October 2015.

DESIGN/METHODS: TB cases were identified through a monthly form sent by the CPSP to approximately 2500 active pediatricians, pediatric subspecialists, and select non-pediatricians who manage childhood TB. For cases meeting inclusion criteria, a detailed questionnaire was sent to collect clinical, epidemiological, and treatment data, followed by 6-month follow-up surveys until 6 months after treatment completion.

RESULTS: Of 164 unique incident cases reported, 84 met inclusion criteria and returned a detailed questionnaire. Selected demographic data is shown here:

Mesenchymal stem cell (MSC) viability on PVA and PCL polymer coated hydroxyapatite scaffolds derived from cuttlefish

In the present study, cuttlefish bones are used to prepare highly porous hydroxyapatite (HA) scaffolds via hydrothermal treatment at 200 °C.

HEMATOLOGICAL CHANGES IN COMPLETE BLOOD PICTURE IN PAEDRIATRIC PATIENTS OF MALARIA CAUSED BY PLASMODIUM VIVAX AND FALCIPARUM

BACKGROUND

Malaria is a major health problem and one of the major killers in paediatric population particularly in the developing world. High mortality is usually compounded by various haematological complications if left untreated. Their identification as risk factors for progression to severe disease may make the basis for optimal management of malaria. This study was conducted to determine various changes in the complete blood picture caused by malaria and to compare the severity of these changes among the prevalent species of plasmodia.

METHODS

It was cross sectional study conducted in paediatric ward of Civil Hospital, Dow University of Health Sciences, Karachi over a period of six months. Children aged >2 months to 15 years, of either sex, with fever above 101 degrees F in the preceding 72 hours with positive malaria parasite on peripheral blood smear were included in the study. Children already on anti-malarial. treatment and long standing antibiotics, having co-morbidities like immune-compromised states, haemolytic disease or with any other haematological disorder were excluded from the study. Blood was tested for anaemia, leukopenia, leukocytosis, and thrombocytopenia. Data analysis was done via SPSS-15.0.

RESULTS

Out of 374 children half were under 5 years of age with mean age of 66.7 +/- 46.8 months, 50.8% were female with male to female ratio of 1:1.03. Overall 364 (97.3%) children had anaemia with mean haemoglobin level of 11.7 +/- 6 g/dl. Overall mean WBC count was 10443 +/- 154 per cubic millimetre. Leukopenia was found in 39% cases. Mean platelets count of enrolled children was 69451 +/- 648 cubic millimetre and 51.3% cases had mild thrombocytopenia. Anaemia (p=0.012), leukopenia (p=0.001) and thrombocytopenia (p=0.004) were significantly more common in falciparum as compared to vivax malaria.

CONCLUSION

We concluded that malaria frequently causes severe anaemia, leukopenia and thrombocytopenia in children. P. falciparum is the species more responsible for these changes.

Association between fetal overgrowth and metabolic parameters in cord blood of newborns of women with GDM

AIM

There is evidence that arthrosclerosis may originate at birth, so assessment of serum lipid levels in cord blood might be important. The aim of this study was to investigate the association between fetal overgrowth and metabolic parameters in cord blood of newborns of women with gestational diabetes mellitus (GDM) and to compare these parameters with those in newborns of non-diabetic.

METHODS

The study group included 112 women (singleton pregnancy, and GDM diagnosed following WHO criteria), and as controlled subjects, 159 matched healthy pregnant women and their newborn babies were selected. A sample of cord blood was obtained at delivery. The cord blood's insulin, glucose, and lipids (total cholesterol, high-density cholesterol, low- density cholesterol, and triglyceride) were determined. The relationships between these metabolic parameters and large for gestational age (LGA) were also assessed.

RESULTS

There were no significant differences between total cholesterol (TC), HDL cholesterol (HDL -C), triglyceride (TG) and glucose levels between two groups but the LDL-C level, LDL/HDL ratio and insulin level were significantly higher in newborns of mother with GDM. LGA newborns of diabetic mothers, show the HDL-C level were significantly lower and LDL-C level were significantly higher than AGA (Appropriate for Gestational Age).

CONCLUSION

These results show that GDM altered neonatal plasma lipids metabolism and so newborns of diabetic mothers may be predisposed early in life to LDL hypercholesterolemia and thus may be at a greater risk of developing coronary heart disease later in life.

Increased nuchal translucency and pregnancy outcome

BACKGROUND

To study the outcome of cases with nuchal translucency (NT) ≥ 95th centile in the first trimester of pregnancy.

METHODS

This cross sectional study was performed at Iranian Fetal Medicine Foundation (FMF) between January 2009 and December 2011. Totally, 186 cases with NT≥ 95th centile who attended for the first trimester screening were studied. All cases with increased NT including those with normal karyotype were followed up with anomaly scan at 18-22 weeks and fetal echocardiography at 22-24 weeks. Pregnancy outcome was extracted from delivery records and pediatrics notes and telephone interviews.

RESULTS

Of screened cases, 186 fetuses had an NT≥95th centile, of them 19.8% were abnormal karyotype, including 29 cases of trisomy 21, three of trisomy 18, two of trisomy 13, three of Turner syndrome. 77.8% did not show any abnormalities on follow-up examinations. 4.6% of cases were found to have malformation antenatally and 4% cases postnatally. 11.4% women elected termination of pregnancy without further follow up. There were 4.6% fetal loss and 1.3% hydrops fetalis.

CONCLUSION

In this unselected population, the study showed one out of four fetuses with enlarged NT had an adverse pregnancy outcome (miscarriage, fetal loss, and fetal abnormalities), however the chance of having a normal child after exclusion of chromosomal abnormalities and adverse pregnancy outcome was 95%.

Coincidence of trisomy 18 and robertsonian (13; 14)

This case report presents a coincidence of trisomy 18 and balanced Robertsonian translocation (13;14). Aneuploidy was suspected based on anomalies detected in ultrasound scan and confirmed with karyotype. In a 31 years-old healthy woman with a history of one miscarriage, second trimester ultrasound scan reported IUGR (<3rd percentile) with normal amniotic fluid, bilateral choroid plexus cysts, suspicious agenesis of corpus callosum and clenched hands. Amniocentesis was performed and karyotype was 46xx,der(13;14) (q10;q10),+18. Maternal karyotype was 45xx,der(13;14)(q10;q10). Pregnancy was continued due to legal limitation for termination after 20 weeks gestation. Delivery was done at 36 weeks gestation. A female newborn was borned and a physical feature was hypotonia, small mouth, prominent occiput, low-set and posteriorly rotated ears, clenched hands with overlapping fingers and rocker bottom feet. Ultrasound scan and echocardiography detected agenesis of corpus callosum and VSD, ASD, PDA and cardiomegaly. These features are typical of trisomy 18. Balanced Robertsonian translocation usually has no phenotypic expression. Genetic counseling and prenatal diagnosis for future pregnancy was recommended.

First-trimester screening for chromosomal abnormalities by integrated application of nuchal translucency, nasal bone, tricuspid regurgitation and ductus venosus flow combined with maternal serum free β-hCG and PAPP-A: a 5-year prospective study

OBJECTIVE

To investigate the performance of first-trimester screening for chromosomal abnormalities by integrated application of nuchal translucency thickness (NT), nasal bone (NB), tricuspid regurgitation (TR) and ductus venosus (DV) flow combined with maternal serum free β-human chorionic gonadotropin (fβ-hCG) and pregnancy-associated plasma protein-A (PAPP-A) at a one-stop clinic for assessment of risk (OSCAR).

METHODS

In total, 13,706 fetuses in 13,437 pregnancies were screened for chromosomal abnormalities during a period of 5 years. Maternal serum biochemical markers and maternal age were evaluated in combination with NT, NT + NB, NT + NB + TR, and NT + NB + TR + DV flow data in 8581, 242, 236 and 4647 fetuses, respectively.

RESULTS

In total, 51 chromosomal abnormalities were identified in the study population, including 33 cases of trisomy 21, eight of trisomy 18, six of sex chromosome abnormality, one of triploidy and three of other unbalanced abnormalities. The detection rate and false-positive rate (FPR) for trisomy 21 were 93.8% and 4.84%, respectively, using biochemical markers and NT, and 100% and 3.4%, respectively, using biochemical markers, NT, NB, TR and DV flow.

CONCLUSION

While risk assessment using combined biochemical markers and NT measurement has an acceptable screening performance, it can be improved by the integrated evaluation of secondary ultrasound markers of NB, TR and DV flow. This enhanced approach would decrease the FPR from 4.8 % to 3.4 %, leading to a lower number of unnecessary invasive diagnostic tests and subsequent complications, while maintaining the maximum level of detection rate. Pre- and post-test genetic counseling is of paramount importance in either approach.

Multiple autoimmune syndrome: Hashimoto's thyroiditis, coeliac disease and systemic lupus erythematosus (SLE)

Various autoimmune diseases have association with each other but it is very rare to see multiple autoimmune diseases in one patient. Presence of more than two autoimmune diseases in one patient is known as multiple autoimmune syndrome (MAS). We report the case of an 11 years old girl who presented with history of swelling in front of the neck along with constipation, anorexia, weight gain and increasing pallor over a period of six months. Additionally she had an episodic history of joint pains and abdominal pain with no specific relation to diet, time, other gastrointestinal or genitourinary symptom. Hypothyroid goiter (Autoimmune thyroiditis, Hashimoto's thyroidits) was diagnosed by raised thyroid stimulating hormone (TSH), low T4 and presence of thyroid specific antibodies in blood. Patient was discharged on tablet Levothyroxine to which she responded well with reduction in size of the swelling and relief of the symptoms except for the joint pains and abdominal pain. To evaluate the persistent symptoms she was investigated further for other autoimmune diseases and was diagnosed to be having systemic lupus erythematosus (SLE) and Coeliac disease also. The final diagnosis was multiple autoimmune syndrome (Hashimoto's thyroiditis, Coeliac disease and SLE).

Primary closure versus T-tube drainage after open choledochotomy

BACKGROUND

Choledochotomy followed by T-tube has long been a standard surgical treatment for choledocholithiasis. It is still a preferred choice in many hospitals where minimal invasive procedures are not feasible. The use of T-tube is not without complications. To avoid the complications associated with T-tube, we have performed primary closure of the common bile duct (CBD) after exploration. This pilot study assesses the safety of primary closure of CBD, which would help form a basis for implementation on a wider scale.

OBJECTIVE

To compare the clinical results of primary closure with T-tube drainage after open choledochotomy and assess the safety of primary closure for future application on a greater mass.

PATIENTS AND METHODS

This comparative study was conducted at surgical unit IV Liaquat University of Medical and Health Sciences, Jamshoro, from January 2007 to December 2007. Thirty-five patients were included in the study of which 16 patients underwent primary closure.

RESULTS

Thirty-five patients were included in the study. The mean age of patients who had primary closure done (n = 16) was 46.0 +/-16.8 and there were two (12.5%) males and 14 (87.5%) females. After primary closure of the CBD, bile leakage was noted in one patient (6.3%), which subsided without any biliary peritonitis as compared to the T-tube group in which two patients (10.5%) had bile leakage. Postoperative jaundice was seen in one patient (5.3%) who had a T-tube because of a blockage of CBD. Not a single patient had a retained stone in both groups as well as no recurrence of CBD stones. The postoperative hospital stay after primary closure was 5.56 +/-1.1 days as compared to after T-tube drainage which was 13.6 +/-2.3 days. The total cost of treatment in patients who underwent primary closure was USD194.5 +/-41.5 but after T-tube drainage it was USD548.6 +/-88.5. The median follow up duration for both groups was 6 months.

CONCLUSION

Primary CBD closure is a safe and cost effective alternative to routine T-tube drainage after open choledochotomy.

Intestinal amoebiasis in children and its effect on nutritional status

OBJECTIVE

To determine the frequency and clinical presentation of amoebic diarrhea in children and its effect on the nutritional status of the affected children.

STUDY DESIGN

Descriptive.

PLACE AND DURATION OF STUDY

Department of Diarrhea Treatment Unit (DTU), Dow Medical College and Civil Hospital, Karachi, from November 1998 to April 2001.

METHODOLOGY

Paediatric patients between the ages of > 1 month to 15 years were included, who visited the DTU of the department with diarrhea. Stool samples of all these patients were checked under microscope for the vegetative forms of Entamoeba Histolytica (E.H.). Patients who were positive for E.H. were evaluated for the symtomatology including the type of diarrhea {acute watery diarrhea (AWD) or dysentery}, abdominal pain, tenesmus and nausea/vomiting. Examination carried out was assessed for state of hydration, fever and anaemia and nutritional status of those less than 5 years of age. The patients were divided into three age groups to assess the association of the age with severity and type of clinical presentation. Chi- square test was applied to calculate the p-values. P-values of 0.05 or less were considered statistically significant.

RESULTS

The stool samples of 3870 patients with diarrhea were examined under microscope. Three hundred and twenty eight (8.47%) of these samples were positive for E.H. The difference between the number of patients presenting with acute watery diarrhea n=157, 47.86% and with dysentery n=171, 52.13% was found to be statistically non-significant (p=0.364). Two hundred and seventy seven (84.45%) patients had tenesmus, while abdominal pain was present in 287 (87.5%). Fever and malnutrition were present in 169 (51.52%) patients each. Malnutrition was significantly most frequent in 1-5 years of age groups (n=98, 57.98%, p=0.026). The nutritional evaluation of the 272 under-5 children with amoebic diarrhea showed a significantly normal status in 123 (45.55%, p-value < 0.001). All the signs and symptoms followed a similar trend with 1-5 years age group being the most affected group. However, the frequency of blood in stools increased in direct proportion to the increasing age.

CONCLUSION

Although dysentery was the more common presenting complaint, almost half of the patients presented with watery diarrhea. Most of the patients with dysentery were under the age of 5 years. Fever was present in a high number of patients. The age group most affected by amoebiasis and malnutrition was 1-5 years.

Role of clinical and ultrasound findings in the diagnosis of retained products of conception

OBJECTIVE

To assess the role of clinical and ultrasound findings as predictors of retained products of conception (RPOC) in women with a suspicion of incomplete miscarriage.

METHODS

This was a retrospective study of 91 patients admitted for suspected RPOC after spontaneous first-trimester miscarriage who were evacuated surgically, and for whom histopathological reports were available. All the women underwent transvaginal sonography after their miscarriage. The decision to evacuate the uterus was based on vaginal bleeding, lower abdominal pain and/or sonographic findings of hyperechoic material or endometrial thickness more than 8 mm. Maternal age, gestational age, clinical signs and symptoms and sonographic findings were recorded. Clinical and sonographic findings were compared with the histopathological reports and the sensitivity and specificity of vaginal bleeding, abdominal pain and sonographic appearance of the endometrium for detecting the products of conception were assessed.

RESULTS

Histopathological analysis confirmed the presence of chorionic villi in 55 women (60%) and decidua in 36 (40%). Vaginal bleeding was more frequent in women with RPOC (P < 0.001), whilst lower abdominal pain was a more frequent symptom in those with decidua (P = 0.019). The ultrasound finding of hyperechoic material had a sensitivity of 78%, specificity of 100% and positive and negative predictive values of 100% and 75%, respectively, in predicting RPOC. Vaginal bleeding as a predictor of RPOC had a sensitivity of 93%, specificity of 50%, and positive and negative predictive values of 74% and 82%, respectively. The combination of hyperechoic material and/or vaginal bleeding increased the sensitivity to 98% and negative predictive value to 95%. There was no significant difference in endometrial thickness between the two groups.

CONCLUSION

The ultrasound finding of hyperechoic material is the best predictor for diagnosing RPOC. In the absence of hyperechoic material and vaginal bleeding, RPOC are extremely unlikely.

Intrapartum maternal glucose infusion and fetal acid-base status

OBJECTIVE

To compare the effects of an intrapartum infusion of a lactated Ringer solution or a glucose-boosted saline solution on the acid-base status of umbilical arterial blood.

METHOD

In a prospective clinical trial 178 women in labor were randomized to receive intravenously either a lactated Ringer solution or a saline solution boosted with 5% glucose. Umbilical arterial blood was then assessed for acid-base status.

RESULTS

There were significant differences between the lactated Ringer group and the glucose group in umbilical artery pH values (7.25+/-0.07 vs. 7.28+/-0.06; P=0.008), pCO2 values (44.8+/-5.6 mm Hg vs. 41.6+/-4.1 mm Hg; P=0.001), and base excess (-7.3+/-2.1 mEq/L vs. -6.6+/-1.8 mEq/L; P=0.02).

CONCLUSION

Intrapartum intravenous fluid containing a 5% glucose solution reduces umbilical cord acidemia and hypercarbia.

Topical nasal steroids for intermittent and persistent allergic rhinitis in children

BACKGROUND

Allergic rhinitis is a very common chronic illness affecting 10% to 40% of children worldwide. There has been a significant increase in prevalence among children over the last two decades and this increase has been accompanied by a parallel increase in comorbid illnesses such as asthma.

OBJECTIVES

To evaluate the therapeutic effectiveness and adverse event profiles of topical nasal steroids for intermittent and persistent allergic rhinitis in children.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2005), MEDLINE (1950 onwards) and EMBASE (1974 onwards) on 5(th) September 2005. CINAHL, mRCT(a meta-database of controlled trials), NRR (the National Research Register), LILACS, MedCarib, KOREAMED, IndMed, Samed, Panteleimon, Zetoc, ISI Proceedings, the GlaxoSmithKline Clinical Trials Database and the websites of AstraZeneca, Schering Plough and Aventis were also searched.

SELECTION CRITERIA

Randomised controlled trials comparing topical nasal steroid preparations against each other or placebo, prescribed for allergic rhinitis in children.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data from the included trials. The limited and variable quality of reported data precluded any pooling of results and only a descriptive summary is presented.

MAIN RESULTS

Three trials involving a total of 79 participants were included. All three trials, which compared topical nasal steroids against placebo for perennial rhinitis, provided some, albeit limited data, relevant to our primary outcomes; but in two of the trials the data analysis was flawed and in the third trial it was incomprehensible. None of the trials provided data relevant to our secondary outcomes. There were no adverse events reported from any of the interventions.

AUTHORS' CONCLUSIONS

The three included trials provided some weak and unreliable evidence for the effectiveness of Beconase(R) and flunisolide used topically intranasally for the treatment of intermittent and persistent allergic rhinitis in children. The reduction of severity in symptoms as assessed by the trialists could not be confirmed with the data provided and decisions on the use of these medications should, until such time as more robust evidence is available, be guided by the physician's clinical experience and patients' individual circumstances and preferences.

Hereditary methemoglobinemia

Methemoglobinemia is a rare congenital disorder of blood associated with central cyanosis. We report a case of 12 years old male child who had asymptomatic central cyanosis since birth in the absence of any cyanotic cardiorespiratory disease. He shared this cyanosis with seven other family members spanning over three generations. He was diagnosed as a case of methemoglobinemia on the basis of history and investigations, put on methylene blue and later ascorbic acid, to which he showed a very good response.

Gastroprotective effect of cardamom, Elettaria cardamomum Maton. fruits in rats

Cardamom, the fruits of Elettaria cardamomum Maton. (Zingiberaceae) commonly known as "Heel khurd" is used in Unani system of medicine to treat gastrointestinal disorders. A crude methanolic extract (TM), essential oil (EO), petroleum ether soluble (PS) and insoluble (PI) fractions of methanolic extract, were studied in rats at doses of 100-500, 12.5-50, 12.5-150 and 450 mg/kg, respectively for their ability to inhibit the gastric lesions induced by aspirin, ethanol and pylorous ligature. In addition their effects on wall mucus and gastric acid output were recorded. All fractions (TM, EO, PS, PI) significantly inhibited gastric lesions induced by ethanol and aspirin but not those induced by pylorus ligation. TM proved to be active reducing lesions by about 70% in the EtOH-induced ulcer model at 500 mg/kg. The PS fraction reduced the lesions by 50% at 50 and 100mg/kg (no dose response was observed) with similar effect than the PI fraction at 450 mg/kg. In the aspirin-induced gastric ulcer, the best gastroprotective effect was found in the PS fraction, which inhibited lesions by nearly 100% at 12.5mg/kg. In our experimental conditions, the PS extract at doses >or=12.5mg/kg proved to be more active than ranitidine at 50mg/kg.

The burden of diabetes and impaired glucose tolerance in India using the WHO 1999 criteria: prevalence of diabetes in India study (PODIS)

This random multistage cross-sectional population survey was undertaken to determine the prevalence of diabetes mellitus (DM) and impaired glucose tolerance (IGT) in subjects aged 25 years and above in India. The study was carried out in 77 centers (40 urban and 37 rural). 18363 (9008 males and 9355 females) subjects were studied. 10617 (5379 males and 5238 females) were from urban areas and 7746 (3629 males and 4117 females) from rural areas. Blood samples were taken after a fast of 10-12 h and 2 h after 75 g of oral glucose. Subjects were categorized as having IGT or DM using the World Health Organisation (WHO) (1999) criteria. The standardized prevalence rate for DM in the total Indian, urban and rural populations was 4.3, 5.9 and 2.7%, respectively. The corresponding IGT rates in the three populations was 5.2, 6.3 and 3.7%, respectively. The urban prevalence of DM and IGT was significantly greater than in the rural population (P < 0.001 in both instances). The prevalence of DM was significantly, more than that of IGT (P < 0.001) within both the rural and urban populations. Type 2 diabetes is a major health problem is India.

A rare case of chondrosarcoma of the clavicle

Although all types of tumour and tumour-like conditions have been described to occur in the clavicle, they only contribute to less then 0.5% of all skeletal tumours. The incidence of primary chondrosarcoma of the clavicle is extremely rare. To our knowledge it has not been reported in Malaysia. We would like to highlight the possibility of chondrosarcoma as a differential diagnosis for a clavicular lesion.

Comparing the ADA 1997 and the WHO 1999 criteria: Prevalence of Diabetes in India Study

This random multistage cross-sectional population survey was undertaken to determine the prevalence of type 2 diabetes mellitus (DM) in subjects aged 25 years and above in India. The study was carried out in 77 centres (42 urban and 35 rural) to reflect the size and heterogeneity of the Indian population. 18,363 (9008 male and 9355 female) subjects were studied. 10,617 (5379 males and 5238 females) were from urban areas and 7746 (3629 males and 4117 females) from rural areas. Blood samples were taken after a fast of 10-12 and 2 h after 75 g of oral glucose. Subjects were categorized as having impaired fasting glycemia (IFG) or DM using the 1997 ADA or having impaired glucose tolerance (IGT) or DM using the 1999 WHO criteria. The age- and gender-standardized prevalence rate for DM using the ADA criteria was 3.6% whilst that using the WHO criteria was 4.3% (P < 0.001). The respective standardized prevalence of DM, using the two criteria was, 4.7 and 5.6%, respectively (P < 0.001) in the urban Indian population and 2.0 and 2.7% (P < 0.02) in the rural Indian population. Using the WHO criteria, 581 subjects were newly diagnosed whilst the ADA criteria newly diagnosed 437 subjects. The respective numbers for the urban population were 425 and 323, and for the rural population were 146 and 114, respectively. The ADA criteria could diagnose 75.2, 76.0 and 73.0% of the subjects who had DM as per the WHO criteria. Of 739 Indian subjects who had IFG, 106 (14.3%) were diagnosed as having DM by the WHO criteria whilst 505 (68.3%) had values compatible with a diagnosis of IGT. Of the 536 urban subjects with IFG, 74 (13.8%) had DM and 350 (65.3%) had IGT using the WHO criteria. Of the 302 rural subjects with IFG, 32 (15.8%) had DM and 155 (76.3%) had IGT using the WHO criteria. 505 (49.9%) of 1012 Indian subjects with IGT as per the WHO criteria had IFG. 350 (47.7%) of 733 urban subjects and 155 (55.5%) of 279 rural subjects with IGT had values compatible with IFG as per the ADA criteria. Type 2 diabetes is a major health problem is India. The use of the ADA criteria would underestimate the prevalence of DM by not diagnosing subjects showing a poor response to a glucose challenge. This along with the discrepancies between subjects showing IGF or IGT could be a challenge to any prevention program.

The burden of diabetes and impaired fasting glucose in India using the ADA 1997 criteria: prevalence of diabetes in India study (PODIS)

This random multistage cross sectional population survey was undertaken to determine the prevalence of diabetes mellitus (DM) and impaired fasting glycemia/glucose (IFG) in subjects aged 25 years and above in India. The study was carried out in 108 centers (49 urban and 59 rural) to reflect the size and heterogeneity of the Indian population. 41,270 (20,534 males and 20,736 females) subjects were studied. 21,516 (10,865 males and 10,651 females) were from urban areas and 19,754 (9669 males and 10,085 females) from rural areas. Blood samples were taken after a fast of 10-12h and the subjects were categorized as having IFG or DM using the 1997 American Diabetes Association criteria. The age and gender standardized prevalence rate for DM and IFG in the total Indian population was 3.3 and 3.6% respectively (P < 0.001). The standardized prevalence of DM and IFG in urban areas was significantly higher than that for the rural population (urban DM prevalence 4.6% versus rural DM prevalence 1.9%, P < 0.001; urban IFG prevalence 4.8% versus rural IFG prevalence 2.5%, P < 0.001). There was no statistically significant difference in the prevalence between DM (4.6%) and IFG (4.8%) in the urban population. The rural prevalence of IFG (2.5%) was significantly (P <0.001) more than the rural prevalence of DM (1.9%). Type 2 diabetes is a major health problem is India.

Renal and post-renal causes of acute renal failure in children

OBJECTIVE

To identify the causes of acute renal failure (ARF) in pediatric population along with the identification of the age and gender most affected by the failure.

DESIGN

Descriptive study.

PLACE AND DURATION OF STUDY

This study was carried out at the Pediatric Medical Ward of National Institute of Child Health (NICH), Karachi over a period of two years from 1996 to 1998.

SUBJECTS AND METHODS

The study included children under the age of 12 years who presented with signs and symptoms suggestive of ARF (oliguria/anuria, vomiting, acidotic breathing etc.) along with raised blood urea nitrogen (BUN) serum creatinine and metabolic acidosis as shown by arterial blood gases (ABGs). Patients were divided into two groups on the basis of age; group A consisting of 0-2 years and group B from >2 years. Patients presenting with transient pre-renal azotaemia were excluded from the study. After providing initial emergency cover, detailed history, physical examination and investigations were carried out according to a proforma specially designed to ascertain the cause of ARF. Patients were managed for ARF as per standard recommendations and investigations completed or repeated as and when required.

RESULTS

A total of 119 patients with ARF were admitted in the ward over a period of two years constituting 1.36% of the total admissions and 16.39% of the admissions due to renal pathology. Mean age of presentation was 4.5 years with 56.7% of the patients under the age of 5 years. Male predominance was noted in all ages with an overall male to female ratio of 2.3:1. Most common cause leading to ARF in younger age group was found to be hemolytic uremic syndrome [25(54.34%)] followed by septicemia [7(15.21%)]. In older patients renal calculus disease was the most common [22(30.13%)] underlying pathology followed by pre-existing, undiagnosed chronic renal failure [16(21.91%)]. More than 90% of cases were related, directly or indirectly, to infections.

CONCLUSION

ARF is fairly common in children especially under the age of 5 years showing a male predominance. More than 90% of the cases can be prevented by improving primary health care and by early and prompt treatment of infections.

High and low dose oxytocin in augmentation of labor

OBJECTIVE

To compare the efficacy and safety of high dose oxytocin in the augmentation of labor.

METHOD

Two hundred pregnant women requiring augmentation of labor were randomly assigned to receive oxytocin by either a low dose protocol (1.5 microm/min initially, increased by 1.5 microm/min every 30 min) or a high dose protocol (4.5 microm/min initially, increased by 4.5 microm/min every 30 min).

RESULTS

High dose of oxytocin was associated with a significant shortening of labor 4 (1.10-10) vs. 6 (1-10) h, p<0.0001 without a significant difference in cesarean delivery rate, neonatal and maternal outcome.

CONCLUSION

The use of high dose oxytocin is associated with significantly shorter labor without any adverse fetal and maternal effects.

Leber's congenital amaurosis with anterior keratoconus in Pakistani families is caused by the Trp278X mutation in the AIPL1 gene on 17p

BACKGROUND

Leber's congenital amaurosis (LCA) represents the earliest and severest form of retinal dystrophy leading to congenital blindness. A total of 20% of children attending blind schools have this disease. LCA has a multigenic basis and is proving central to our understanding of the development of the retina. We describe the clinical and molecular genetic features of four inbred pedigrees from neighbouring remote villages in northern Pakistan, in which some of the affected members have concurrent keratoconus.

METHODS

History-taking and physical and eye examinations were performed in the field. Venipuncture, DNA extraction, studies of linkage to known LCA genes, automated sequencing and polymorphism analyses for haplotype assessments were done.

RESULTS

We examined 12 affected and 15 unaffected family members. By history, there were an additional nine blind people in the four pedigrees. In each pedigree a consanguineous marriage was evident. We found a homozygous nonsense mutation in the AIPL1 gene, which replaces a tryptophan with a stop codon (Trp278X). The phenotype is severe and variable, despite the common molecular genetic etiology in each family. Affected patients had hand motion to no light perception vision and fundus findings ranging from maculopathy to diffuse pigmentary retinopathy. Three affected members had definite keratoconus, and two were suspects based on mild cone formation in the cornea of at least one eye.

INTERPRETATION

We have identified four Pakistani families with a severe form of LCA that is associated with severe keratoconus in some affected members. The molecular etiology in all four families is a homozygous nonsense mutation, Trp278X, in the photoreceptor-pineal gene AIPL1. To our knowledge, this is one of the first phenotype-genotype correlations of AIPL1-associated LCA.

Hemodialysis Utilization in a Single in-Center Dialysis Unit, in the Kingdom of Saudi Arabia

This study was performed to find out the trends in the demand for regular maintenance hemodialysis (HD) and to assess the utilization with reference to selected variables. In a retrospective cohort study, data from a single in-center HD unit of a secondary care hospital located in the south-western part of the Kingdom of Saudi Arabia, were analyzed. Cases of end-stage renal failure (ESRF) registered for regular maintenance HD from the commencement of the HD services in this center (1987 to 2000) formed the subjects of this study. Utilization of the in-center HD was assessed by annual growth rate, death rate, renal transplantation rate and utilization rate. Simple descriptive statistics were used for data analysis. During the study period, 393 cases were registered for regular maintenance HD. There were 183 males (46.6%) and 210 females (53.4%). The mean and median ages of the patients at the initiation of HD were 40.7 and 35 years respectively. Saudis constituted 75.1%(295) over the years studied. The mean annual growth rate, death rate, renal transplantation rate and utilization rate were 7.44, 9.3, 4.33 and 139.57% respectively. Demand for maintenance HD was more from young individuals, which is similar to the national figures. Annual growth rate of those requiring HD was far higher than population growth of this region during the period of study caused primarily by an increased number of new entries coupled with low death and transplantation rates. We conclude that HD utilization studies help to unearth the problems, understand the needs, communicate with the authorities (with facts and figures), find out solutions, and create a network between providers and consumers.

The story of Lot and the Qur'ăn's perception of the mortality of same-sex sexuality

Discussion of the morality of same-sex sexuality in Islam is beginning to come to the forefront. It is a controversial topic that evokes differing views in Islam and, as such, needs to be addressed and understood. This study narrows the scope of the investigation to the use of moral terminology in the Lot story and elsewhere in the Qur'ăn. The method of semantic analysis that shall be applied is similar to the one espoused by Toshihiko Izutsu. In order to acquire a better understanding of how same-sex practices are qualified morally in the Qur'ăn, same-sex activities shall also be looked at in comparison to other opposite-sex and non-sexual practices. It is my contention that, in the Qur'ăn, same-sex practices are viewed no differently from certain opposite-sex and non-sexual activities. In quoting from the Qur'ăn, I will give my own translation of the Arabic terms that shall be analyzed. In general, however, I adopt Qur'ănic passages from Arthur J. Arberry, The Koran Interpreted, and where necessary, modify Qur'ănic passages with my own translations. I will also use Arberry's verse numbering, following that of Flügel.

Pruritus among End-Stage Renal Failure Patients on Hemodialysis

Pruritus is commonly encountered in individuals with end-stage renal failure (ESRF) on dialysis. This study was performed in order to find out the prevalence and pattern of pruritus in patients on regular maintenance hemodialysis (HD) as well as to analyze its relationship to age, sex of the patient, site of itching and timing of hemodialysis. One hundred patients with ESRF (age ranging from 13 to 80 years) free from systemic, skin or psychiatric disorders and other secondary causes attributable to pruritus, undergoing maintenance HD (duration on HD 7-141 months; mean 49.9 and median 43 months) at Samtah General Hospital, Samtah, Gizan, Kingdom of Saudi Arabia were evaluated for pruritus on two occasions at one week interval by each author independently. The data were analyzed by simple descriptive statistics viz mean, median and chi-square test. Pruritus was observed in 27 of 40 males (67.5%) and 40 of 60 females (66.7%) with an overall prevalence of 67%. It was mild in 34 (50.8%), moderate in 22 (32.8%) and severe in 11 (16.4%). Sub-group analysis with reference to age and sex revealed that pruritus was significantly more in women aged 45 years and above, when compared with men of similar age-group (p < 0.05) or women below 45 years (p < 0.02). Pruritus was predominant in spinal dermatomes. Discomfort of pruritus was more during HD in three (two men and one woman) and HD gave relief for the day in 10 other individuals (four men and six women). Our study suggests that pruritus is observed in all age-groups and of both sexes of ESRF patients on HD although the intensity and site of itching and relationship to HD sessions varied with individuals.

Nail changes in end-stage renal failure patients on hemodialysis

To evaluate the fingernail changes in patients with end-stage renal failure (ESRF) on regular hemodialysis (HD), we reviewed 69 patients (male 25, female 44; age 40 +/- 14.8 years) who have been on HD at Samtah General Hospital, Gizan, Kingdom of Saudi Arabia for a mean of 4.3 +/- 3.06 years. They were free from congenital, systemic or primary skin disorders contributing to nail changes. The patients were also free from ornamental dyes like henna, traumatic injuries or infections in the fingernails. They were also clinically free from features suggestive of the carpal tunnel syndrome or vascular steal syndrome secondary to arteriovenous fistula (AVF) created for vascular access. Their nails were examined under bright day light by the authors independently. The findings consistent among all three observers were taken for analysis. Hemoglobin and serum albumin levels were also estimated. We compared these changes according to age, sex, and duration on chronic hemodialysis, AVF, and the levels of serum albumin and hemoglobin. One or more nail changes were observed in 44/69 (64%) patients. The commonest abnormality was the so-called "Half-and-half nail changes", which was observed in the finger nails of 18/69 (26%) of the study patients (males to female ratio was 2:1). Typically, the half-and-half nails are nails where the distal portion of the nail bed is red, pink or brown, occupies 20-60% of the total nail length and is always sharply demarcated with the proximal portion. The latter has a dull whitish ground glass appearance and when pressure is applied, the distal discoloration does not fade completely. Non-specific nail changes were observed 26/69 (38%) patients. The hemoglobin and serum albumin levels were not significantly different of those with 'half-and-half' nail, non-specific nail changes or no nail changes. We conclude that various fingernail changes are observed in ESRF patients on HD. These nail changes are independent of the age of the patient, duration on HD, AVF or hemoglobin or albumin levels. However, a gender dependent trend was noticed and the half-and-half nail seems to be characteristic of uremia.