Efficacy of Pemafibrate Versus Fenofibrate Administration on Serum Lipid Levels in Patients with Dyslipidemia: Network Meta-Analysis and Systematic Review

BACKGROUND

Pemafibrate is a novel fibrate class drug that is a highly potent and selective agonist of peroxisome proliferator-activated receptor α (PPARα). We performed the first ever network meta-analysis containing the largest ever group of patients to test the efficacy of pemafibrate in improving lipid levels compared with fenofibrate and placebo in patients with dyslipidemia.

METHODS

Potentially relevant clinical trials were identified in Medline, PubMed, Embase, clinicaltrials.gov, and Cochrane Controlled Trials registry. Nine randomized controlled trials met the inclusion criteria out of 40 potentially available articles. The primary effect outcome was a change in the levels of triglycerides (TG), high-density lipoproteins (HDL), or low-density lipoproteins (LDL) before and after the treatment.

RESULTS

A total of 12,359 subjects were included. The mean patient age was 54.73 (years), the mean ratio for female patients was 18.75%, and the mean examination period was 14.22 weeks. The dose for pemafibrate included in our study was 0.1, 0.2, or 0.4 mg twice daily, whereas the dose for fenofibrate was 100 mg/day. Data showed a significant reduction in TG and a mild increase in HDL levels across the pemafibrate group at different doses and fenofibrate 100 mg group (with greatest effect observed with pemafibrate 0.1 mg twice daily). A mild increase in LDL was also observed in all groups, but the increase in LDL in the 0.1 mg twice daily dose group was statistically insignificant.

CONCLUSION

Pemafibrate 0.1 mg twice daily dose led to highest reduction in TG levels and the highest increase in HDL levels compared with other doses of pemafibrate, fenofibrate, and placebo.

A CABG Complication - LIMA Graft to Cardiac Venous System Anastomosis Rescued by Percutaneous Coronary Intervention

Inadvertent graft anastomosis to the great anterior cardiac vein is a known but rare complication of coronary artery bypass graft surgery (CABG). This is usually managed with percutaneous embolization of the inadvertently anastomosed graft with stenting of underlying atherosclerotic coronary artery disease (CAD) or by surgical correction. We present a similar case of the inadvertent left internal mammary artery (LIMA) graft anastomosis to the cardiac venous system, managed with the less complicated percutaneous coronary intervention of the underlying coronary artery disease due to anginal symptoms without the need for surgical correction or embolization of the graft.

A Comparative Investigation Applying Testicular Fine Needle Aspiration Cytology and Open Testicular Biopsy Histology for the Diagnosis of Azoospermia and Severe Oligospermia

Open testicular biopsy histology and fine needle aspiration cytology (FNAC) are the most popular tests used to diagnose male infertility. This study aimed to assess the cytological characteristics of 186 infertile males aged 24-63 with testicular FNAC. Furthermore, the existing relationship between males with severe oligospermia (sperm count: 5 million/ml) and azoospermia was investigated via both cytological and histological diagnosis methods. With a 1.5-inch and 25-gauge needle, the testis was aspirated from three locations (the upper, middle, and lower poles). Papanicolaou stain or Giemsa stain was used to make smears on albumenized slides, which were then dried in the air and stained. A biopsy of the testicles was performed there, preserved in Bouins solution, processed as usual, and stained with hematoxylin and eosin stain. According to our findings, 66.7% of patients had secondary maturation arrest, whereas 18.3% and 15.1% of them had hypospermatogenesis and Sertoli cell only (SCO). Results of the comparison showed that both procedures were very similar. According to biopsy histological examinations, only 3 (1.6%) of the 28 normal FNAC instances had hypospermatogenesis with lymphocyte infiltration. The majority of SCO patients were over 50 years old. These findings revealed that FNAC is more effective than testicular histology for the assessment of male infertility.

Management of Right Atrial Thrombus During MitraClip Implantation: A Case Report and Review of Literature

Transcatheter mitral valve repair (TMVR) is a relatively novel approach for treatment of symptomatic severe mitral regurgitation. Intra procedural thrombus formation is a rare but potential complication. Herein, we describe a case of large right atrial thrombus formation after transseptal puncture, that was successfully managed using aspiration thrombectomy.

Impact of systemic lupus erythematosus on in-hospital outcomes of peripheral artery disease—insight from the National Inpatient Sample database

Chronic inflammatory disorders like systemic lupus erythematosus (SLE) and rheumatoid arthritis are associated with worse outcomes in ischemic heart disease. However, there is a paucity of data regarding outcomes in patients with peripheral arterial disease (PAD) with concomitant SLE. The purpose of this study was to compare clinical features and in-hospital outcomes of PAD in patients with and without SLE from the general population using the Healthcare Cost and Utilization Project National Inpatient Sample database. We performed a cross-sectional analysis on 520,665 patients diagnosed with PAD from quarter 4 of 2015 to 2017. The primary endpoint was risk-adjusted in-hospital mortality. Of the total patient population, 3080 patients (0.6%) had SLE compared with 517,585 controls (99.4%). The observed in-hospital mortality was higher in patients with SLE (6.3% vs. 4.6%, P < 0.001). To the best of our knowledge, this is the largest population-based study investigating the impact of SLE in patients with PAD. Our analysis showed higher in-hospital mortality in SLE patients than in those without SLE. Early diagnosis and aggressive management of SLE and its complications in these patients have the potential to improve overall outcomes.

Risk factors and outcomes associated with Left Ventricular Thrombus in patients with Peripartum Cardiomyopathy: An insight from National Inpatient Sample Database

Background

: We sought to assess the prevalence and impact of left ventricular thrombus (LVT) in patients with peripartum cardiomyopathy (PPCM).

Methods

: We performed a retrospective cohort study of all admissions with PPCM as the primary diagnosis from the Nationwide Inpatient Sample database over a 11-year period. Univariate analysis of all risk factors and outcomes and multivariable logistic regression analysis of certain variables were performed and represented as odds ratio (OR) with 95% confidence interval (CI). A p value of < 0.05 was considered statistically significant. Statistical analysis was performed using epiDisplay in ‘R’ studio.

Results

: In the time frame spanning 2005 -2014, 43,986 admissions with PPCM were found which included 43,534 without LVT and 452 patients with LVT. Black race was associated with a higher incidence of LV thrombus, (p value <0.001). Comorbidities more prevalent in the LVT group were smoking, drug abuse, pregnancy induced hypertension, diabetes with complications, valvular heart disease, connective tissue disorders, coagulopathy, anemia and depression. Adverse outcomes such as congestive heart failure, arrhythmias and stroke were higher in LVT group. Conversely, Caucasian race, obesity, preeclampsia (p <0.005) were higher in those without LVT. Mean length of stay (9 vs 5 days, p <0.001), in hospital mortality (3.32% vs 1.41%, p = 0.001) and mean hospitalization charges ($85,390 vs $48,033) were higher in those with LVT. However, on multivariate logistic regression, although stroke was higher in the LVT group (adjusted OR 5.51, 95% CI, 2.2, 13.81, 5.05, p 0.002), in-hospital mortality was not significantly different between the two groups (adjusted OR 1.17, 95% CI,0.32, 4.23, p = 0.817).

Conclusion

: Our study showed that PPCM patients with LV thrombus had worse outcomes with respect to stroke, length of stay and in hospital mortality. Higher prevalence in patients with black race, complicated diabetes, peripheral vascular disease, valvular disease, coagulopathy, smoking, drug abuse, depression and psychoses calls for special attention to such high-risk groups for aggressive risk factor modification.

The dynamics of genome size and GC contents evolution in genus Nicotiana

Hybridization and Polyploidization are most common of the phenomenon observed in plants, especially in the genus Nicotiana leading to the duplication of genome. Although genomic changes associated with these events has been studied at various levels but the genome size and GC content variation is less understood because of absence of sufficient genomic data. In this study the flow cytometry technique was used to uncover the genome size and GC contents of 46 Nicotiana species and we compared the genomic changes associated with the hybridization events along evolutionary time scale. The genome size among Nicotiana species varied between 3.28 pg and 11.88 pg whereas GC contents varied between 37.22% and 51.25%. The tetraploid species in genus Nicotiana including section Polydiclae, Repandae, Nicotiana, Rustica and Sauveolentes revealed both up and downsizing in their genome sizes when compared to the sum of genomes of their ancestral species. The genome sizes of three homoploid hybrids were found near their ancestral species. Loss of large genome sequence was observed in the evolutionary more aged species (>10 Myr) as compared to the recently evolved one's (<0.2 Myr). The GC contents were found homogenous with a mean difference of 2.46% among the Nicotiana species. It is concluded that genome size change appeared in either direction whereas the GC contents were found more homogenous in genus Nicotiana.

Cardiovascular Events in Patients with Thyroid Storm

CONTEXT

Thyroid storm can present as a multitude of symptoms, the most significant being cardiovascular (CV). It is associated with various manifestations such as cardiac arrhythmia, heart failure, and ischemia. However, the frequencies of events and characteristics associated with patients that experience these events are not known.

METHODS

Study cohort was derived from the National Inpatient Sample database from January 2012 to September 2015. Total hospitalizations of thyroid storm were identified using appropriate ICD-9 diagnostic codes. The analysis was performed using SAS.

OBJECTIVE

To better understand the frequency and characteristics CV occurrences associated with thyroid storm, through a retrospective analysis of thyroid storm hospital admissions.

DESIGN

The study cohort was derived from the National Inpatient Sample database from January 2012 to September 2015.

SETTING

Total hospitalizations of thyroid storm were identified using International Classification of Diseases (ICD)-9 diagnostic codes. The analysis was performed using Statistical Analysis System (SAS).

RESULTS

A total of 6380 adult hospitalizations were included in the final analysis, which includes 3895 hospitalizations with CV events (CEs). Most frequently associated CEs were arrhythmia (N = 3770) followed by acute heart failure (N = 555) and ischemic events (N = 150). Inpatient mortality was significantly higher in patients with CEs compared with those without CEs (3.5% vs 0.2%, P < 0.005). The median length of stay was also higher in patients with CEs compared with those without CEs (4 days vs 3 days, P < 0.0005). Atrial fibrillation was the most common arrhythmia type, followed by nonspecified tachycardia.

CONCLUSIONS

In patients who were hospitalized due to thyroid storm and associated CEs significantly increased in-hospital mortality, length of stay, and cost. Patients with obesity, alcohol abuse, chronic liver disease, and COPD were more likely to have CEs. Patients with CV complications were at higher risk for mortality. In-hospital mortality increased with ischemic events and acute heart failure. Further evaluation is needed to further classify the type of arrhythmias and associated mortality.

O6: EARLY ANASTOMOTIC BILIARY COMPLICATIONS AFTER LIVER TRANSPLANTATION

Introduction

Biliary leaks and anastomotic strictures are common early biliary complications (EBC) following liver transplantation. However, their impact on outcomes remains controversial and poorly described.

Method

The NHS registry on adult liver transplantation between 2006 and 2017 was retrospectively reviewed (n=8304). Multiple imputations were performed to account for missing data. Adjusted regression models were used to assess predictors of EBC, and their impact on outcomes. 35 potential variables were included, and backwards stepwise selection enabled unbiased selection of variables for inclusion in final models.

Result

EBC occurred in 9.6% of patients. Adjusted cox regression revealed that EBCs have a significant and independent impact on graft survival (Leak HR=1.325; P=0.021, Stricture HR=1.514; P=0.002, Leak plus stricture HR=1.533; P=0.034) and patient survival (Leak HR=1.218; P=0.131, Stricture HR=1.578; P&lt;0.001, Leak plus stricture HR=1.507; P=0.044). Patients with EBC had longer median hospital stay (23 versus 15 days; P&lt;0.001) and increased chance for readmission within the first year (56% versus 32%; P&lt;0.001). On adjusted logistic regression the following were identified as independent risk factors for development of EBC: donation following circulatory death (OR=1.280; P=0.009), accessory hepatic artery (OR=1.324; P=0.005), vascular anastomosis time in minutes (OR=1.005; P=0.032) and ethnicity ‘other’ (OR=1.838; P=0.011).

Conclusion

EBCs prolong hospital stay, increase readmission rates and are independent risk factors for diminished graft survival and increased mortality in liver transplantation. We have identified factors that increase the likelihood of EBC occurrence; further research into interventions to prevent EBCs in these at-risk groups is vital to improve liver transplantation outcomes.

Take-home message

Using a large registry database we have shown that early anastomotic biliary complications are independent risk factors for decreased graft survival and increased mortality after liver transplantation. Research into interventions to prevent biliary complications in high risk groups are essential to improve liver transplant outcomes.

Risk factors and impact of early anastomotic biliary complications after liver transplantation: UK registry analysis

Background

Biliary leaks and anastomotic strictures are common early anastomotic biliary complications (EABCs) following liver transplantation. However, there are no large multicentre studies investigating their clinical impact or risk factors. This study aimed to define the incidence, risk factors and impact of EABC.

Methods

The NHS registry on adult liver transplantation between 2006 and 2017 was reviewed retrospectively. Adjusted regression models were used to assess predictors of EABC, and their impact on outcomes.

Results

Analyses included 8304 liver transplant recipients. Patients with EABC (9·6 per cent) had prolonged hospitalization (23 versus 15 days; P < 0·001) and increased chance for readmission within the first year (56 versus 32 per cent; P < 0·001). Patients with EABC had decreased estimated 5-year graft survival of 75·1 versus 84·5 per cent in those without EABC, and decreased 5-year patient survival of 76·9 versus 83·3 per cent; both P < 0.001. Adjusted Cox regression revealed that EABCs have a significant and independent impact on graft survival (leak hazard ratio (HR) 1·344, P = 0·015; stricture HR 1·513, P = 0·002; leak plus stricture HR 1·526, P = 0·036) and patient survival (leak HR 1·215, P = 0·136, stricture HR 1·526, P = 0·001; leak plus stricture HR 1·509; P = 0·043). On adjusted logistic regression, risk factors for EABC included donation after circulatory death grafts, graft aberrant arterial anatomy, biliary anastomosis type, vascular anastomosis time and recipient model of end-stage liver disease.

Conclusion

EABCs prolong hospital stay, increase readmission rates and are independent risk factors for graft loss and increased mortality. This study has identified factors that increase the likelihood of EABC occurrence; research into interventions to prevent EABCs in these at-risk groups is vital to improve liver transplantation outcomes.

Comparing Transcatheter Aortic Valve Replacement (AVR) With Surgical AVR in Lower Risk Patients: A Comprehensive Meta-Analysis and Systematic Review

Background

Transcutaneous aortic valve replacement (TAVR) is a novel percutaneous procedure for severe aortic stenosis and has been recently approved by Food and Drug Administration in lower risk patients. We performed the first ever meta-analysis and literature review of clinical trials comparing both 30-day and 1-year outcomes in lower risk patients undergoing TAVR vs. surgical aortic valve replacement (SAVR, having Society of Thoracic Surgeons score < 4% or equivalent).

Methods

Using predefined selection criteria as above, 68 articles were identified. Seven eligible articles were selected after extensive review. Primary effect outcomes were 30-day and 1-year all-cause mortality using risk ratio (RR) with significant P value of < 0.05.

Results

A total of 4,859 subjects were included. Risk of 30-day all-cause mortality was 40.1% less in TAVR group, RR 0.59 (95% confidence interval (CI): 0.38 - 0.92, P = 0.02) with no significant heterogeneity. Six studies except Schymik et al also reported 1-year risk. This was, however, not statistically significant with a 21% decrease in the TAVR group, RR 0.79 (95% CI: 0.57 - 1.09, P = 0.15). Six studies reported 30-day risk of secondary outcomes. The risk of 30-day stroke was 36% less in TAVR group, although this was not statistically significant, RR 0.64 (95% CI: 0.38 - 1.9, P = 0.10). The risk of acute kidney injury (AKI) stage 2 and above was 56% less in post-TAVR patients, RR 0.43 (95% CI: 0.35 - 0.54, P < 0.001) with no heterogeneity. For vascular complications, RR was high in TAVR group 4.62 (95% CI: 1.42-15.18, P = 0.01). Significant heterogeneity was demonstrated though (I² = 81). The risks for permanent pacemaker (PPM) were also higher in the TAVR group, RR 3.30 (95% CI: 2.04 - 5.33, P < 0.001) and significant heterogeneity was observed. After removing Thyregod et al and Partner 3 trial from the analysis, heterogeneity was removed, but the RR was still high 3.21 (95% CI: 2.54 - 4.068, P < 0.001). Post-operative incidence of endocarditis among TAVR patients was low but not statistically significant. The 30-day risk for infective endocarditis was RR 0.67 (95% CI: 0.13 - 3.48, P = 0.63). The 1-year risk was similarly low but not significant, RR 0.73 (95% CI: 0.28 - 1.92, P = 0.53).

Conclusions

Among low risk patients, TAVR was found to be superior in short-term all-cause mortality and 1-year stroke, a result that was statistically significant for TAVR and close to significance for stroke. TAVR patients were also less likely to have post-operative bleeding and AKI stage 2 and beyond. Post-operative incidence of endocarditis among TAVR patients was low but not statistically significant. However, the rates of PPM and vascular complications are higher in TAVR patients. The results of TAVR in low risk population are thus extremely encouraging. However, the issue of long-term valve durability in this group needs further studies. Also, caution needs to be exercised while extending the indications to extremely young patients due to lack of enough studies.

Abstract 394: Effect Of Introduction Of Non Invasive Risk Stratification On Cardiac Catheterization Referrals In A Community Hospital

Background: Appropriate use criteria recommend against unwarranted cardiac catheterization (caths) in low risk patients. Reporting of risk stratification on non-invasive cardiac stress test reports was implemented at our institution to reduce low risk cardiac cath referrals.

Methods: We performed a retrospective study to compare the effect of introduction of risk stratification in cardiac stress test reports. The percentages of low risk patients by nuclear stress, who underwent cardiac cath, before and after application of risk stratification were compared. Chi-square and Mann-Whitney-Wilcoxon tests were used for analysis.

Results: There were significantly fewer low risk referrals after risk stratification, 43.2% of patients of low-risk patients were referred for catheterization before, compared to 28.3% of low-risk patients after risk stratification (p value 0.01). There was reduction in the percentage of normal cardiac caths in the low risk category after introduction of risk stratification (61.5% vs 33.3%, p value 0.05).

Conclusion: Risk stratification led to a decrease in the percentage of low-risk patients referred for cath following a stress test.

Meta-Analysis of Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Patients With Low Surgical Risk

Transcatheter aortic valve implantation (TAVI) is the current standard of care for patients with severe aortic stenosis who are at high risk for surgery. However, several recent studies have demonstrated the comparable safety and efficacy of TAVI in low-risk patients as well. We sought to pool the existing data to further assert its comparability. MEDLINE, Cochrane, and Embase databases were evaluated for relevant articles published from January 2005 to June 2019. Studies comparing outcomes of TAVI versus surgical aortic valve replacement in patients who are at low risk for surgery were included. Twelve studies (5 randomized controlled trials and 7 observational studies) totaling 27,956 patients were included. Follow-up ranged from 3 months to 5 years. Short-term all-cause mortality, short-term, and 1-year cardiac mortality were significantly lower in the TAVI group. One-year all-cause mortality, short-term, and 1-year stroke and myocardial infarction were similar in both groups. Rate of acute kidney injury and new-onset atrial fibrillation were lower in the TAVI group, whereas permanent pacemaker implantation and major vascular complications were higher in the TAVI group. Subgroup analysis of randomized controlled trials showed significantly lower 1-year all-cause mortality in the TAVI group. In conclusion, in severe aortic stenosis patients at low surgical risk, TAVI when compared with surgical aortic valve replacement, demonstrated a lower rate of short-term all-cause mortality, short-term, and 1-year cardiac mortality and similar in terms of 1-year all-cause mortality. TAVI is emerging as a safe and efficacious alternative for low surgical risk patients.

Candesartan, rather than losartan, improves motor dysfunction in thioacetamide-induced chronic liver failure in rats

Minimal hepatic encephalopathy is more common than the acute syndrome. Losartan, the first angiotensin-II receptor blocker (ARB), and candesartan, another widely-used ARB, have protected against developing fibrogenesis, but there is no clear data about their curative antifibrotic effects. The current study was designed to examine their effects in an already-established model of hepatic fibrosis and also their effects on the associated motor dysfunction. Low-grade chronic liver failure (CLF) was induced in 3-month old Sprague-Dawley male rats using thioacetamide (TAA, 50 mg·kg-1·day-1) intraperitoneally for 2 weeks. The TAA-CLF rats were randomly divided into five groups (n=8) treated orally for 14 days (mg·kg-1·day-1) as follows: TAA (distilled water), losartan (5 and 10 mg/kg), and candesartan (0.1 and 0.3 mg/kg). Rats were tested for rotarod and open-field tests. Serum and hepatic biochemical markers, and hepatic histopathological changes were evaluated by H&E and Masson's staining. The TAA-CLF rats showed significant increases of hepatic malondialdehyde, hepatic expression of tumor necrosis factor-α (TNF-α), and serum ammonia, alanine aminotransferase, γ-glutamyl transferase, TNF-α, and malondialdehyde levels as well as significant decreases of hepatic and serum glutathione levels. All treatments significantly reversed these changes. The histopathological changes were moderate in losartan-5 and candesartan-0.1 groups and mild in losartan-10 and candesartan-0.3 groups. Only candesartan significantly improved TAA-induced motor dysfunction. In conclusion, therapeutic antifibrotic effects of losartan and candesartan in thioacetamide-induced hepatic fibrosis in rats are possibly through angiotensin-II receptor blocking, antioxidant, and anti-inflammatory activities. Improved motor dysfunction by candesartan could be attributed to better brain penetration and slower "off-rate" from angiotensin-II receptors. Clinical trials are recommended.

Subclinical cardiovascular disease in patients with chronic obstructive pulmonary disease: a systematic review

BACKGROUND

Cardiovascular disease (CVD) accounts for a significant portion of deaths in patients with COPD; however, evidence for early detection strategies for CVD in this population remain limited. Our paper aims to summarize existing data regarding subclinical CVD in patients with COPD with a view to identifying screening strategies in these patients.

METHODS

A systematic review of published literature was conducted for studies examining the relationship of COPD and markers of subclinical disease such as coronary artery calcification (CAC), carotid intima media thickness (cIMT), endothelial dysfunction, arterial stiffness as measured by pulse wave velocity (PWV) and augmentation indices (AIx). Both MEDLINE and EMBASE databases were searched till October 2015.

RESULTS

A total of 22 studies were included in the review. Compared with control subjects, patients with COPD had significantly higher cIMT (SMD 0.53, 95% CI 0.16-0.90), PWV (SMD 0.91, 95% CI 0.67-1.16) and AIx (SMD 0.86, 95% CI 0.52-1.19). Additionally, an overall higher prevalence of subclinical CVD as assessed by CAC, ABI and FMD was noted in our review.

CONCLUSION

Although our findings need further evaluation in prospective studies, our review presents significant evidence in support of increased subclinical CVD burden in COPD patients independent of smoking status. Further large-scale case-control studies are required to highlight the significance of subclinical CVD screening in COPD patients.

Transient Complete Heart Block Secondary to Bed Bug Insecticide: A Case of Pyrethroid Cardiac Toxicity

Pyrethroids are the major components of various commercially used insect repellants. These are less toxic to humans due to their slow absorption and rapid metabolism. However, cases of suicidal and accidental poisoning with household insecticides are not uncommon. We report a case of a 59-year-old female who presented with syncope after an accidental exposure to bed bug repellant spray at home. She was found to be in complete heart block and was treated conservatively. There was complete resolution of symptoms and atrioventricular conduction abnormality on day 2 of hospitalization. She was discharged in a stable condition with an uneventful follow-up course. Cardiac involvement in pyrethroid toxicity is rare. We describe various clinical manifestations and the pathophysiology of toxicity caused by pyrethroid-containing insecticides.

Exchange bias in two-step artificially grown one-dimensional hybrid Co-BiFeO3 core-shell nanostructures

One-dimensional core-shell nanostructures consisting of a ferromagnetic cobalt core and a multiferroic BiFeO3 (BFO) shell were fabricated by an artificial two-step methodology. The coupling between the ferromagnetic core and multiferroic shell manifests a significant exchange bias effect which gives a clear demonstration of the anti-ferromagnetic functionality of the BFO shell material. Exchange biases of 30 Oe and 60 Oe are observed at 300 K and at 5 K, respectively. Superparamagnetic contributions at lower temperatures play an important role in contributing to overall magnetic behavior. Dominant shape anisotropy causes parallel alignment of the easy magnetization axis along the axis of core-shell nanowires. A coherent mode of the magnetization reversal mechanism is observed by the angular dependence of coercivity (H c). This versatile two-step methodology can be employed to fabricate and investigate many other hybrid nanostructures leading to a vast scope of investigation for researchers.

Efficacy of Retigabine on Acute Limbic Seizures in Adult Rats

Background and Purpose:

The efficacy of retigabine (RGB), a positive allosteric modulator of K+ channels indicated for adjunct treatment of partial seizures, was studied in two adult models of kainic acid (KA)-induced status epilepticus to determine it’s toleratbility.

Methods:

Retigabine was administered systemiclly at high (5 mg/kg) and low (1–2 mg/kg) doses either 30 min prior to or 2 hr after KA-induced status epilepticus. High (1 µg/µL) and low (0.25 µg/µL) concentrations of RGB were also delivered by intrahippocampal microinjection in the presence of KA.

Results:

Dose-dependent effects of RGB were observed with both models. Lower doses increased seizure behavior latency and reduced the number of single spikes and synchronized burst events in the electroencephalogram (EEG). Higher doses worsened seizure behavior, produced severe ataxia, and increased spiking activity. Animals treated with RGB that were resistant to seizures did not exhibit significant injury or loss in GluR1 expression; however if stage 5–6 seizures were reached, typical hippocampal injury and depletion of GluR1 subunit protein in vulernable pyramidal fields occurred.

Conclusions:

RGB was neuroprotective only if seizures were significantly attenuated. GluR1 was simultaneously suppressed in the resistant granule cell layer in presence of RGB which may weaken excitatory transmission. Biphasic effects observed herein suggest that the human dosage must be carefully scrutinized to produce the optimal clinical response.

Enhanced exchange bias and improved ferromagnetic properties in Permalloy-BiFe0.95Co0.05O3 core-shell nanostructures

Hybrid core-shell nanostructures consisting of permalloy (Ni80Fe20) and multiferroic(BiFeO3, BFO/BiFe0.95Co0.05O3, BFC) materials were synthesized by a two-step method, based on wet chemical impregnation and subsequent electrodeposition within porous alumina membranes. Structural and magnetic characterizations have been done to investigate doping effect on magnetic properties and exchange bias. The magnetometry analysis revealed significant enhancements of the exchange bias and coercivity in NiFe-BFC core-shell nanostructures as compared with NiFe-BFO core-shell nanostructures. The enhancements can be attributed to the effective reduction of ferromagnet domain sizes between adjacent layers of core-shell structure. It indicates that it is possible to improve properties of multiferroic composites by site-engineering method. Our approach opens a pathway to obtain optimized nanostructured multiferroic composites exhibiting tunable magnetic properties.

Metformin in prostate cancer: two for the price of one

BACKGROUND

Androgen deprivation therapy (ADT) for prostate cancer treatment induces a metabolic syndrome, which may contribute to non-cancer-related morbidity and mortality. Metformin may abrogate these effects. Additionally, metformin has potential antineoplastic activity in various malignancies including prostate cancer.

MATERIALS AND METHODS

A literature review using PubMed with the keywords: AMPK, androgen deprivation therapy, insulin resistance, metabolic syndrome, metformin and prostate cancer was undertaken.

RESULTS

This overview will look at the current evidence linking ADT and metabolic syndrome while discussing ongoing clinical trials under way assessing the effectiveness of metformin in abrogating these effects. The potential antineoplastic activity of metformin, mediated by multiple proposed mechanisms based on evidence from preclinical and clinical studies, will also be elucidated in this review.

CONCLUSIONS

Overall available data support the potential dual benefit of metformin on ADT-induced metabolic syndrome and in its antineoplastic activity in prostate cancer, justifying the need for ongoing clinical trials to confirm these effects as the evidence currently available for standard practice is lacking.

Clinical presentation and outcome of autosomal dominant polycystic kidney disease in Pakistan: a single center experience

OBJECTIVE

To delineate clinical presentation and outcome of Autosomal Dominant Polycystic Kidney Disease (ADPKD) in terms of need for renal replacement therapy of kidney transplantation in Pakistani patients.

METHODS

Patients with ADPKD were identified using strict clinical criteria. Medical charts were evaluated retrospectively for initial presenting complaints, co-morbids, family history of ADPKD, any palpable mass on abdominal examination, cardiac examination for any abnormal finding and use of any anti-hypertensive drugs. Laboratory parameters were assessed. Chi square and Logistic regression analyses at 95% CI were used for statistical significance. A p value of less 0.05 was considered statistically significant.

RESULTS

A total of 56 patients fulfilled our criteria of ADPKD. There were 40 (71.4%) males and 16 (28.6%) females in our study. The mean age at the time of diagnosis of ADPKD was 47.0 +/- 14.5 years. Mean follow up period for all patients was 7.6 +/- 4.2 years. Most common form of presentation was hypertension in 38 (67.9%) patients. Kidneys were palpable in 33 (58.9%), liver in 16 (28.6%) and spleen in 6 patients (10.7%). Microscopic haematuria was observed in 38 (67.8%) patients while gross haematuria was present in 10 (17.9%) patients. The murmur of mitral valve prolapse was found in 10 patients on clinical examination which was later confirmed on transthoracic echocardiography (TEE). On MRI/MRA 2 (3.6%) patients each had berry aneurysm and AV malformations. Three patients (5.4%) received renal transplant and 19 (33.9%) patients were dialysis dependent at the end of study. A total 11 (20%) were lost to follow up. Two patients (3.5%) died during six years follow up. Male sex and uncontrolled hypertension were most important predictors of poor prognosis (p < 0.03 and < 0.048 respectively).

CONCLUSION

Pre-symptomatic patients with ADPKD should be monitored with blood pressure measurements and assessment of their renal function. The advantages of such monitoring include the ability to prevent or control infection and hypertension, to identify potential kidney donors from among the family, to offer advice on marriage and childbearing, and to provide prenatal diagnosis.

Outcome of triple procedure in older children with developmental dysplasia of hip (DDH)

OBJECTIVE

To evaluate the radiographic and functional results of the triple procedure (open reduction, femoral shortening and Salter's Osteotomy) in the treatment of Developmental Dysplasia of the Hip (DDH) disease in older children.

METHODS

This case-series comprising 23 patients (29 hips) underwent the triple procedure of open reduction, femoral shortening and Salter osteotomy, at Aga Khan University Hospital between June 1995 and June 2005. Patients were classified pre-operatively according to the Tonnis class. Postoperative functional evaluation was performed using Modified MacKay's scoring system and radiographic assessment using Severin's scoring method.

RESULTS

The mean age of patients at presentation was 6.84 years and the average follow-up was 19.6 months. The MacKay score was 'Good' to 'Excellent' in 25 hips; we had a failure in 1 hip joint. The Severin's class was I in 15 (51.7%) hips at the time of final evaluation as compared to none at the time of presentation. Patients younger than 5.6 years of age had a better radiological and clinical outcome as compared to older patients (p-value < 0.05).

CONCLUSIONS

The triple procedure of open reduction, femoral shortening and Salter osteotomy gives best results in younger children. Early diagnosis and intervention is therefore imperative in the successful treatment of patients suffering from DDH.

Who should pay for home monitoring of heart failure?

Despite the recent advancement in medical therapy for heart failure, morbidity associated with heart failure continues to be excessive, with rising hospitalization rates and costs. Disease management models have been instituted successfully for several chronic disease states, and observational trials have shown different models to be beneficial. A multidisciplinary approach to management of heart failure improves outcomes. Multiple recent trials involving various models of integrated and comprehensive disease management have demonstrated promising results, such as reduction in mortality and hospitalizations. Future models for disease monitoring may include implantable devices that directly monitor hemodynamics combined with multidisciplinary care.

Pre-operative renal function and selective renal vein renin levels as markers of favourable outcome in renovascular hypertension

OBJECTIVE

To evaluate factors that affect outcome following revascularization in patients with renovascular hypertension.

METHODS

This study was conducted at the Aga Khan University Hospital. It included all the patients diagnosed to have Renovascular hypertension confirmed by renal angiography between July 1996 to September 2000. Using ANOVA (Analysis of variance) and paired-sample t-test, several preoperative factors were evaluated for their ability to predict postoperative improvement of blood pressure and renal function. For descriptive purpose patients were divided into cured, improved and failure groups.

RESULTS

Of the total 15 patients, 9 were males and 6 were females. Before the surgical procedure, 13 patients were on 3 or more antihypertensive drugs. Eleven patients received vein grafts, three patients had PTFE (polytetraflouroethyline) grafts while one patient underwent angioplasty and stenting. The patients had a median follow-up period of nine months with a range of 2 to 84 months. Five were completely cured, as they became normotensive without antihypertensive therapy after operation, whereas four showed marked improvement in BP control postoperatively, requiring two antihypertensive drugs. Six patients showed no improvement requiring 3 or more drugs. Extended cure or improvement of renovascular hypertension was achieved in nine patients. Normal preoperative serum creatinine level, high preoperative unstimulated peripheral renin levels and renal vein renin ratio of at least 1.75:1 were the most significant predictive factors for favorable outcome.

CONCLUSION

This study confirms the long term effectiveness and safety of renovascular reconstruction in the relief of severe hypertension. The results further suggest that normal preoperative renal function, high renal vein renin ratio and high preoperative unstimulated peripheral renin levels are associated with the most favourable postoperative outcome (p <0.01). Preoperative severity and duration of hypertension and degree of disparity in kidney sizes do not affect the overall results in terms of postoperative improvement in renal function and blood pressure control (p=0.734).

Do clinical manifestations of Systemic Lupus Erythematosus in Pakistan correlate with rest of Asia?

OBJECTIVE

Systemic Lupus Erythematosus (SLE) is known to be different among people with different racial, geographical and socio-economic back grounds. Asia has diverse ethnic groups broadly, Orientals in the East and Southeast Asia, Indians in South Asia and Arabs in the Middle East. These regions differ significantly from the Caucasians with reference to SLE. The purpose of this study was, therefore, to delineate the clinical pattern and disease course in Pakistani patients with SLE and compare it with Asian data.

METHODS

Patients with SLE fulfilling the clinical and laboratory criteria of the American Rheumatism Association admitted at the Aga Khan University Hospital between 1986 and 2001 were studied by means of a retrospective review of their records. The results were compared with various studies in different regions of Asia.

RESULTS

Demographically, it was seen that SLE is a disease predominantly of females in their third decade, which is generally consistent with Asian data. There was less cutaneous manifestations, arthritis, serositis, haematological and renal involvement compared to various regions in Asia. The neurological manifestations of SLE, however, place Pakistani patients in the middle of a spectrum between South Asians and other Asian races.

CONCLUSION

This study has shown that the clinical characteristics of SLE patients in our country may be different to those of other Asian races. Although our population is similar to South Asians, but clinical manifestations of our SLE patients are considerably different, suggesting some unknown etiology. Further studies are required to confirm the above results and to find statistically sounder associations.

Bilateral breast enlargement due to Trichophyton rubrum

Gynecomastia is the most common cause of breast enlargement in males. Trichophyton rubrum is a common dermatophyte, is responsible for a variety of infections, and may rarely manifest as a dermatophytic pseudomycetoma. We report the case of a 52-year-old man who presented with progressive bilateral breast enlargement. This is the first reported case of bilateral breast pseudomycetoma due to T. rubrum. Long-term antifungal therapy with itraconazole was successful.

Mutagenic effect of acridine orange on the expression of penicillin G acylase and beta-lactamase in Escherichia coli

AIMS

The present work aimed to improve the production of penicillin G acylase (PGA) and reduce the beta-lactamase activity through acridine orange (AO) induced mutation in Escherichia coli.

METHODS AND RESULTS

Three wild E. coli strains BDCS-N-FMu10, BDCS-N-S21 and BDCS-N-W50, producing both the enzymes PGA and beta-lactamase were treated by AO. Minimum inhibitory concentration of AO was 10 microg ml(-1) and it was noted that bacterial growth was gradually suppressed by increasing the concentration of AO from 10 to 100 microg ml(-1). The highest concentration that gave permissible growth rate was 50 microg ml(-1). The isolated survivals were screened on the bases of PGA and beta-lactamase activities. Among the retained mutants, the occurrence of beta-lactamase deficient ones (91%) was significantly higher than penicillin acylase deficient ones (27%).

CONCLUSIONS

In seven of the mutants, PGA activity was enhanced with considerable decrease in beta-lactamase activity. One of the mutant strains (BDCS-N-M36) exhibited very negligible expression of beta-lactamase activity and twofold increase in PGA activity [12.7 mg 6-amino-penicillanic acid (6-APA) h(-1) mg(-1) wet cells] compared with that in the wild-type strain (6.3 mg 6-APA h(-1) mg(-1) wet cells).

SIGNIFICANCE AND IMPACT OF THE STUDY

The treatment of E. coli cells with AO resulted in mutants with enhanced production of PGA and inactivation of beta-lactamase. These mutants could be used for industrial production of PGA.

Healing during physician-patient consultation

OBJECTIVE

To determine the patient perceptions regarding healing during a physician-patient consultation.

DESIGN

A questionnaire-based survey.

PLACE AND DURATION OF STUDY

Family Practice Center of the Aga Khan University Hospital, Karachi, Pakistan, in June 2004.

PATIENTS AND METHODS

A questionnaire was designed that included the demographic profile of patients comprising age, gender, education and occupation as well as questions in line with the study objective. It was administered to 111 patients, visiting outpatient department of the hospital. Participants were explained the study objective, a written consent was taken and full confidentiality was assured.

RESULTS

The mean age of the study population was 27.86 years. Majority of the subjects were males with 68% having graduate or more education. A physician-patient consultation has healing properties for patients and physicians, according to 99 (89%) and 67 (65%) respondents respectively, with 65 (58%) having had experienced healing during the consultation process. The competence of a physician, individual attention given by a physician and a cool and calm attitude of a physician, were reported to increase healing in a physician-patient consultation according to 34 (30%), 32 (29%) and 13 (11%) respondents respectively. The unhelpful physician behavior, incorrect diagnosis and physician's rude and arrogant attitude were reported to decrease healing according to 42 (37%), 15 (14%) and 14 (13%) respondents respectively.

CONCLUSION

The study shows that a majority of the patients believe a physician-patient consultation has healing properties on its own, based on healing potential in the consultation process itself. Physicians must try to find ways to improve their ability to act as healers during consultation with patients.

Human granulocytic anaplasmosis affecting the myocardium

A case of 65-year-old male is reported who presented with myalgias, headache, and fever. He subsequently developed myocarditis and was diagnosed to have anaplasmosis on peripheral blood smear. He was treated with doxycycline for 30 days. A coronary angiogram done after recovery showed normal epicardial arteries. The case illustrates the importance of a careful examination of the peripheral smear, with a high index of clinical suspicion, which led to prompt treatment and complete recovery of the patient.

Patient expectations from an emergency medical service

BACKGROUND

Patient expectation survey at the Emergency Medical Services can improve patient satisfaction. A need was established to conduct such a survey in order to recommend its use as a quality improvement tool.

METHODS

The study was conducted on patients visiting the Emergency Medical Services, Aga Khan University, Karachi. A questionnaire was used to collect information on the demographic profile, and expectations of patients. The ethical requirements for conducting the study were met.

RESULTS

A hundred patients were surveyed. The majority was relatively young, married men and women, well educated and better socio-economically placed. The majority of the patients expected a waiting time and a consultation time of less than 30 minutes and 20 minutes, respectively. The majority of respondents expected and agreed to be examined by a trainee but there were reluctant to be examined by the students. There was an expectation that the consultant will examine patients and not advice the attending team over the phone. The majority of the patients expected intravenous fluid therapy. There was a desire to have patient attendant present during the consultation process. The majority of the patients expected to pay less than three thousand rupees for the visit. An expectation exists for investigations and hospitalization. Involvement of patients in decisions concerning their treatment and written feedback on their visit was expected.

CONCLUSIONS

We have documented the need and value of patient expectation survey at the Emergency Medical Services department. The use of such a tool is recommended in order to improve the satisfaction levels of patients visiting such facilities.

Rapid immunochromatography-based detection of mixed-species malaria infection in Pakistan

We report the identification of mixed Plasmodium infections in four recent patients with malaria clinically refractory to empiric chloroquine therapy using the rapid antigen detection kit, NOW ICT Malaria Pf/Pv. A rapid in vitro immunodiagnostic test, the NOW ICT Malaria Pf/Pv test kit was used for the detection of circulating Plasmodium falciparum (Pf) and Plasmodium vivax (Pv) antigens in whole blood. Peripheral blood microscopy confirmed mixed-species infection in all the cases. Thick and thin peripheral blood films were made and stained with Giemsa stain and examined by both hospital laboratory staff and an experienced parasitologist who was blinded to the results of the rapid malarial antigen tests. Four recent patients (all male; mean age, 24 years) with mixed malarial infection were identified. All the subjects were males working for an oil company in a coastal area of Pakistan, and all had been diagnosed presumptively with malaria based on clinical grounds (without microbiologic confirmation), and were treated empirically with chloroquine without clinical response. Semiquantitative malaria counts via microscopy were as follows: P. vivax, scanty (2 patients) and moderate (2 patients); for P. falciparum--scanty (1 patient), moderate (2 patients), and heavy (1 patient). The present case series, although limited by the small number of patients with proven mixed P. falciparum-P. vivax infection, highlights the usefulness of the rapid antigen test in a highly malarious region of Pakistan where chloroquine resistance is prevalent. Although there was full concordance between the results of blood smear microscopy and rapid antigen testing, these techniques are potentially most useful when there is a discrepancy with microscopy findings. Accurate and rapid diagnosis of parasites, particularly in cases of mixed P. falciparum and P. vivax infection, is of immense importance for individual patient management and in reducing the burden of disease, especially in regions of chloroquine resistance.

Clinico-laboratory findings in male lupus patients from a tertiary care hospital, Pakistan

This study was conducted to delineate the clinical pattern of a cohort of Pakistani male patients with systemic lupus erythematosus (SLE). Clinical and laboratory data were collected of 24 male patients who were diagnosed with SLE and admitted to a tertiary care hospital between 1986 and 2001. Imaging and invasive studies (including aspirations and biopsies) were also recorded. Fourteen patients (58%) had renal involvement, with WHO class 4 and 5 comprising 89% of the cases. Eight patients (33%) had neurological involvement. Out of these 8 patients, 3 presented with psychosis (12.5%) and 4 (17%) with seizures. Twenty three patients (96%) had hematological involvement, 6 (25%) had serosal and 10 (41%) had articular involvement. Cutaneous lesions were noted in 10 (41%) patients. A majority of the patients were noncompliant and were lost to follow-up; therefore, ultimate outcome could not be clearly delineated. A high index of suspicion for SLE in males may permit early diagnosis and dictate the need for more aggressive therapy.

Systemic lupus erythematosus presenting as hemolytic uremic syndrome: a case report

Associating systemic lupus erythematosus (SLE), with an initial presentation of hemolytic uremic syndrome (HUS) is rare. We report a case of 21-year old Afghani female admitted to our hospital with an initial complaint of high grade fever and diffuse maculopapular rash and swelling of lower limbs. Diagnosis of atypical HUS was established according to the clinical triad of HUS without a veriotoxin-producing organism in her stool and the pathological finding compatible to thrombotic microangiopathy. In addition, her symptoms fulfilled the 1982 revised criteria for the classification of SLE. After pulse methylprednisolone, cyclophosphamide and plasmapheresis therapies, her laboratory findings and general condition improved. Unfortunately she was lost to follow up as she decided to return back to Afghanistan.

Deglutition-induced atrial fibrillation

We present the case of 38-year-old woman who experienced palpitations on swallowing, which were later found to be atrial fibrillation. Her symptoms improved on treatment with disopyramide and verapamil. Within 9 months, she was weaned from both medications without recurrence of symptoms.

Radiocontrast nephropathy: is it dose related or not?

OBJECTIVE

To assess the safety of high dose non-ionic contrast media during a single radiological procedure in patients with pre-existing renal impairment.

METHODS

One hundred eighteen patients, with serum Creatinine greater than 1.3 mg/dl who were undergoing coronary angiography or percutaneous transluminal coronary angiography (PTCA) were included in the study. All patients received the nonionic dye ULTRAVIST (lopromide). Serum creatinine were measured before, 48 hours and 1 week after the administration of contrast agent. An acute contrast induced reduction in renal function was defined as an increase in Serum Creatinine concentration of >=0.5 mg/dl, 48 hours after the administration of contrast agent. All patients with end stage renal disease or patients undergoing coronary bypass surgery within a week after coronary angiography or had any concomitant factors that could cause acute renal failure e.g., sepsis, hypotention, etc., were excluded. Patients receiving a dose of upto 100 ml of contrast agent (low dose group) were separated from those who received greater than 100 ml of contrast agent (high dose group). Patients in both groups had similar characteristics in terms of sex, age, weight and underlying disease. Student's t-test was used for statistical analysis.

RESULTS

The mean age of our patients was 62.3+/-8.83 (range 40-84 years). There were 93 (78.8%) males and 25 (21.2%) females. The mean pre-contrast creatinine in the low contrast group was 1.97+/-0.92 and high dose group was 2.16+/-1.90 (p=0.48). The post-contrast Creatinine at 48 hours was 2.11+/-1.11 and 2.06+/-1.39 in the groups receiving low and high dose contrast agents respectively (p=0.830), while at 7 days post-contrast it was 2.17+/-1.28 and 1.95+/-1.43 respectively in the two groups (p=0.391). The contrast-induced reduction in renal function (rise in serum Cr >=0.5 mg/dl above base line) occurred in 14% (n=8) of patients in low dose and in 11% (n=7) in high dose contrast group (p=0.830, insignificant).

CONCLUSION

The results of our study confirm that high dose non-ionic contrast is not associated with increased risk of contrast-mediated nephrotoxicity in patients with pre-existing renal insufficiency undergoing cardiac angiography (p=0.830, insignificant).

Assessment of tracheal intubating conditions in children using remifentanil and propofol without muscle relaxant

BACKGROUND

Tracheal intubation in children can be achieved by deep inhalational anaesthesia or an intravenous anaesthetic and a muscle relaxant, suxamethonium being widely used despite several side-effects. Studies have shown that oral intubation can be facilitated safely and effectively in children after induction of anaesthesia with propofol and alfentanil without a muscle relaxant. Remifentanil is a new, ultra-short acting, selective mu-receptor agonist that is 20-30 times more potent than alfentanil. This clinical study was designed to assess whether combination of propofol and remifentanil could be used without a muscle relaxant to facilitate tracheal intubation in children.

METHODS

Forty children (5-10 years) admitted for adenotonsillectomy were randomly allocated to one of two groups to receive remifentanil 2 microg.kg(-1) (Gp I) or remifentanil 3 microg.kg(-1) (Gp II) before the induction of anaesthesia with i.v. propofol 3 mg.kg(-1). No neuromuscular blocking agent was administered. Intubating conditions were assessed using a four-point scoring system based on ease of laryngoscopy, jaw relaxation, position of vocal cords, degree of coughing and limb movement. Mean arterial pressure (MAP) and heart rate (HR) measured noninvasively before induction of anaesthesia to 5 min after intubation (seven time points).

RESULTS

Tracheal intubation was successful in all patients without requiring neuromuscular blocking agent. Intubating conditions were clinically acceptable in 10 of 20 patients (50%) in Gp I compared with 18 of 20 patients (90%) in Gp II (P < 0.05). MAP and HR decreased in both groups after induction of anaesthesia (P < 0.01). Both HR and MAP were significantly lower in Gp II compared with Gp I after tracheal intubation (P < 0.01). No patient in the present study developed bradycardia or hypotension.

CONCLUSIONS

We conclude that remifentanil (3 microg.kg(-1)), administered before propofol (3 mg.kg(-1)) provides acceptable tracheal intubating conditions in children, and completely inhibited the increase in HR and MAP associated with intubation.

Is routine histological evaluation of pediatric hernial sac necessary?

Advocates of routine histological examination of hernial sac recommend it for surgical quality assurance, to report injuries to the vas deferens, and to detect occult malignant and benign diseases such as tuberculosis. However, the value of this routine examination is debated in this era of cost containment in health care. We conducted a retrospective study of our practice and reviewed the relevant literature to find any justification to continue this practice. Only 2.2% of hernial sacs submitted for histopathology showed unusual findings, and none of these findings were clinically important. In conclusion, the findings of our study and our review of the current literature do not support the routine histological examination of hernial sac in the pediatric age group.

Maximum tolerable dose of cyclophosphamide and azathioprine in Pakistani patients with primary renal disease

OBJECTIVE

The immunosuppressive regimens, at present, mainly rely on western guidelines that were derived from studies conducted in western populations. No such study exists for South Asian population, which is home to almost two billion people different in both genetics and environment from west. Locally derived thresholds for side effects markedly different from western figures may warrant re-adjustment of current local immunosuppressive regimens that are at present based largely on western guidelines. In order to define optimum dose for Cyclophosphamide (CYC) and Azathioprine (AZA) based immunosuppressive therapy, we conducted this study to find out maximum tolerable doses of azathioprine (AZA) and cyclophosphamide (CYC) beyond which neutropenia and thrombocytepenia are most likely to occur in patients with primary renal pathology.

METHOD

Patients with systemic vasculitis and idiopathic glomerulonephritis who were on CYC and AZA were identified through review of medical records at a tertiary care hospital in Pakistan (The Aga Khan University Hospital, Karachi). Patients were categorized under three principal diagnosis i.e. systemic lupus erythematosus (SLE), primary (idiopathic) glomerulonephritis (GN) and Wegener's granulomatosis (WG). The Receiver Operating Curve (ROC) was used to calculate the maximum tolerable dose for both CYC and AZA.

RESULTS

We identified 94 patients aged 6-82 years (median 44.5 years) with primary renal disease (Wegener's granulomatosis n=13, Systemic lupus erythematosis n=62 and idiopathic glomerulonephritis n=19) who received CYC or AZA. Of these 94 patients, 36.2% (n=34) received CYC and 63.8% (n=60) received AZA. The mean dose of CYC was 1.54 +/- 0.50 mg/kg of body weight (range: 0.77-2.93). The mean dose of AZA was 1.64 +/- 0.59 mg/kg of body weight (range: 0.47-2.97). The maximum tolerable doses calculated for CYC and AZA were 1.25 mg/kg and 1.30 mg/kg of body weight respectively. The maximum tolerable dose for CYC and AZA among males could not be calculated, because of insufficient number of patients who developed neutropenia and thrombocytopenia. The maximum tolerable doses for CYC and AZA among females were 1.34 mg/kg and 1.03 mg/kg of body weight respectively. Also we found out that AZA was relatively more likely to cause neutropenia and thrombocytopenia (p=0.07).

CONCLUSION

We thereby recommend that CYC should be initiated at a dose no more than 1 mg/kg of body weight and AZA at an initial dose of 0.75-1.0 mg/kg of body weight. The dose may be adjusted later on the basis of clinical response and laboratory reports.

Spectrum of complications and mortality of bacterial meningitis: an experience from a developing country

OBJECTIVE

The aim of this study was to obtain data on predisposing factors, causative organisms and their associated mortality and complications related to acute bacterial meningitis.

METHODS

The chart review of all patients in whom acute bacterial meningitis was diagnosed at The Aga Khan University Hospital from January 1995 through December 2001.

RESULTS

One hundred ninety-four patients were included in study. There were 146 males and 48 females. The mean age of our study population was 41 +/- 12.3 years. One hundred and ninety (97.9%) patients had community-acquired meningitis; only 4 (2.0%) patients developed meningitis nosocomially. The two most common predisposing factors were diabetes mellitus (13.9%) and otitis media (7.7%) among all 194 patients. A significant proportion of patients with complications had diabetes mellitus (24.6%, p < 0.001). CSF and blood cultures were positive in 53 (27.3%) and 42 (21.6%) patients respectively; there was no statistical difference found. The most common organisms isolated were Streptococcus pneumoniae in 35 (36.8%) patients followed by Neisseria meningitides in 30 (31.5%) patients. Approximately 68% of positive cultures yielded S. pneumoniae and N. meningitides (p < 0.0001). The overall mortality rate was 22.1%. The mortality rate for Streptococcus pneumoniae was 17.1%. The highest mortality was observed in patients with Pseudomonal meningitis where all four patients expired followed by mortality rate of 85.7% in Escherichia coli afflicted patients (p < 0.001). Complications occurred in 73 (37.6%) patients with persistent complications in 31 (42.4%) patients. Complications resolved in 34 (46.5%) patients. The most common complications were seizures (12.8%) and cranial nerve palsies (11.3%). Seizures were more likely to occur in older patients (p < 0.05) whereas hydrocephalus was more common in younger patients (p < 0.05).

CONCLUSION

Bacterial Meningitis remains a serious disease associated with substantial morbidity and mortality. Most cases are community acquired with S. Pneumoniae being the most common pathogen. Old age, diabetes mellitus, a positive culture, seizures as a complication and late stage in the disease are the important predictors of a poor outcome.

Tuberculosis: do we know enough? A study of patients and their families in an out-patient hospital setting in Karachi, Pakistan

SETTING

In Pakistan approximately 5.7 million people suffer from tuberculosis, with 260 000 new cases occurring every year. This study was conducted in an outpatient hospital setting in Karachi.

OBJECTIVE

To explore the level of awareness about tuberculosis amongst patients and their families, and recommend strategies for increasing understanding of the disease.

DESIGN

Descriptive cross-sectional survey based on a structured questionnaire using convenience sampling.

RESULTS

Of the 203 patients interviewed, 131 were males. Nearly 82% knew that tuberculosis is contagious and 78% were aware that lungs are commonly affected. Almost half knew that it spreads by droplets and causes cough and that treatment is long and costly. With regard to commonly affected age and sex, however, respectively only 43% and 23% had the correct knowledge. Less than one third could identify appropriate risk factors and ways to cure and limit spread. Almost half considered tuberculosis to be a social stigma. Media emerged as the main source of information. Respondents with more than 12 years of formal education were more likely to have better knowledge.

CONCLUSIONS

Further population-based studies are recommended. Misconceptions about tuberculosis need to be removed through focused health education messages. The importance of complete and appropriate treatment needs to be emphasised.

Renovascular hypertension: factors affecting the outcome following surgical revascularisation

This study was conducted at the Aga Khan University Hospital, Karachi, Pakistan to evaluate factors that affect outcome following revascularisation in patients with renovascular hypertension. We included all the patients diagnosed to have renovascular hypertension, confirmed by renal angiography, between July 1997 and September 2000. Of the total 15 patients, nine were males and six were females. Eleven patients received venous grafts, three received polytetraflouroethyline (PTFE) grafts while one patient underwent angioplasty and stenting. All were followed-up for a period of nine months (median) with the range from 2 to 84 months. A total of 33.3% of the study patients were completely cured, as they became normotensive without anti-hypertensive therapy after operation, while 27% showed marked improvement in blood pressure control post-operatively. Thus, extended cure or improvement of renovascular hypertension was achieved in 60% of patients. Normal pre-operative serum creatinine level, high pre-operative unstimulated peripheral renin levels and renal vein renin ratio of at least 1.75:1 were the most significant predictive factors for favorable outcome (p < 0.012). The pre-operative severity and duration of hypertension as well as degree of disparity in kidney sizes did not predict the post-operative improvement in renal function and blood pressure control.

Bidirectional cavopulmonary shunt for cyanotic heart disease: surgical experience from a developing country

OBJECTIVE

The importance of bidirectional cavopulmonary anastomosis for palliation of complex cyanotic congenital heart disease is widely recognized. This study was conducted to highlight our surgical experience with this procedure in a developing country.

METHODS

A retrospective study was conducted using medical records at the Aga Khan University Hospital, Karachi, Pakistan. Clinical findings at presentation, anatomical defects seen on transthoracic echocardiography, pre-operative McGoon index, cardiopulmonary bypass time, use of cardioplegia, post-procedure oxygen saturations and complications were evaluated.

RESULTS

A total of 8 patients underwent bidirectional cavopulmonary anastomosis. There were 6 males (75%) and 2 females (25%). Ages and weights at operation averaged 5.7 +/- 3.7 years (range 2-14 years) and 18.6 +/- 10.4 kg (range 8.5-35.5 kg) respectively. The most common symptoms were the presence of cyanosis in all (100%) patients followed by recurrent respiratory tract infections in 3 (37.5%) patients. Transthoracic echocardiography revealed 6 (75%) patients with atrial septal defects, 5 (62.5%) with tricuspid atresia, 3 (37.5%) with ventricular septal defects, 3 (37.5%) with malposition of great vessels, 2 (25%) with pulmonary stenosis and 2 (25%) with double inlet left ventricles. The mean pre-procedure McGoon index was 2.1 +/- 0.5 (range 1.37-2.80). All patients received cardioplegia. Cardiopulmonary bypass was used in all patients for a mean time of 154.1 +/- 83.6 minutes (range 60-298 minutes). All patients were ventilated for a mean period of 1.5 +/- 0.7 days (range 1-3 days). The ICU stay was 3.0 +/- 0.6 days (range 2-5 days) with a total hospital stay of 9.8 +/- 3.8 days (range 7-18 days). The mean post-procedure oxygen saturation was 82.6 +/- 3.5% (range 76-86%). The most common post-operative complication was supraventricular arrhythmia in 2 (25.0%) patients. There were no intra-operative or early (within 7 days of procedure) deaths. One patient developed pulmonary artery hypertension and died 23 months later due to cardiac arrest.

CONCLUSION

Patients tolerated the procedure well. After a mean follow-up of 10 months, 6 patients were assessed to be in New York Heart Association (NYHA) functional class I and one patient in NYHA class II. Clinical and post-procedural data gathered from our experience confirms the safety of bidirectional cavopulmonary anastomosis.

Renal cortical necrosis: a case series of nine patients & review of literature

BACKGROUND

The purpose of this study is to review cases of renal cortical necrosis (RCN) which we came across during a period of five years, confirmed on needle biopsy specimens, with literature available so far.

METHODS

All renal biopsy records between January 1996 to December 2001 at the Aga Khan University Hospital, Karachi, Pakistan were reviewed to identify patients with histologically proven renal cortical necrosis. Seven patients were also referred by the department of Nephrology, Lady Reading Hospital, Peshawar, Pakistan. Patients' medical records were reviewed for demographic, clinical, and follow up data.

RESULTS

There were total of nine patients identified with renal cortical necrosis. The mean age was 26.21 +/- 13.01 year. Five cases (55.5%) were caused by obstetric complications. The most common histology type of RCN was patchy cortical necrosis in seven patients (77.8%). Three patients were alive at last follow up; remaining patients were lost to follow up.

CONCLUSION

Obstetric complications remain the leading cause of renal cortical necrosis in our setting. The recognition of this entity and value of renal biopsy in cases of acute renal failure needs to be emphasized as this helps in establishing diagnosis, to assess prognosis and to aid in selection of a rational approach to therapy.

Seasonal variation in bacterial pathogens isolated from stool samples in Karachi, Pakistan

OBJECTIVE

To determine the seasonal variation of the commonly isolated bacterial pathogens in stool samples.

MATERIAL AND METHODS

A retrospective descriptive study was undertaken of all the stool samples submitted from within Karachi to the Aga Khan University Hospital Laboratory over a period of five years (January 1997- December 2001) in order to determine the commonly isolated bacterial pathogens and to predict their seasonal variation.

RESULTS

A total of 16379 stool samples were included in this review. Bacterial isolates were found in 6670 stool samples (culture detection rate=40.7%). The mean age at the time of culture of each sub-group was < or = 1 year group (6.58 +/- 3.1 months), 1-5 years (2.13 +/- 0.94 years), 5-14 years (8.3 +/- 2.6 yrs) and adults (43.2 +/- 18.5 years). Male: Female ratio was 1.2:1. Vibrio cholera 01 Ogawa (32.8%), Campylobacter jejuni (17.3%), Enteropathogenic Escherichia coli (9.9%), Salmonella paratyphi b (6.6%) and Shigella flexneri (6.2%) were the most common organisms isolated. These organisms show a distinct seasonal variation with summer predilection.

CONCLUSION

In contrast to the previous studies from South Asia, which have identified E. coil, followed by Vibrio cholerae as the most common enteric isolates, we found Vibrio cholera 01 Ogawa followed by Campylobacter jejuni as the most common enteric pathogens isolated in an urban setting. It is important to consider seasonal variation when empirically treating diarrheal diseases in our region.