Persistent organic pollutants distribution in plasma lipoprotein fractions

This study determines the associations among serum lipid profiles, risk of cardiovascular disease, and persistent organic pollutants. Using Gas chromatography technique, the intensity of toxic pollutant residues in serum samples of Hypertensive patients were measured. Based on statistical analysis, the effects of different covariates namely pesticides, age, systolic blood pressure, diastolic blood pressure, and lipid profile duration was checked using the logistic regression model. Statistical computation was performed on SPSS 22.0. The P-values of F-Statistic for each lipid profile class are greater than 0.01 (1%), therefore we cannot reject the null hypothesis for all cases. The estimated coefficients, their standard errors, Wald Statistic, and odds ratio of the binary logistic regression model for different lipid profile parameters indicate if pesticides increase then the logit value of different lipid profile parameters changes from -0.46 to -0.246 except LDL which increases by 0.135. The study reports a significantly increased threat of cardiovascular disease with increased concentrations of toxic pollutants.

A comparative density functional theory study of oxygen doping versus adsorption on graphene to tune its band gap

Graphene, having a perfect two-dimensional crystal structure, has many excellent features such as a high specific surface area, and extraordinary electrical, thermal and mechanical properties. However, its usage in electronic devices is possible only if band gap of desired value is induced in this gapless semi-metal. Therefore, first principle calculations have been carried out to investigate the role of oxygen (O) doping versus adsorption and, the impurity concentration and coverage to induce band gap in graphene employing PBE at GGA level. The band gap is induced owing to production of vacancies, dissociative adsorption of oxygen, subsituational doping and pre-dissociated oxygen adsorption. It is interesting to note that band gap is introduced by both the processes of doping and adsorption of O. The oxygen doping leads to induction of two energy gaps, smaller in value above and larger below the Fermi level; while adsorption irrespective of adsorption configuration produces single direct gap. Increase both in concentration and coverage leads to enhance band gap value maximum being 1.85 eV in case of hexagonal doping of 12.5% concentration with an exception in adsorption case. The results allow us to conclude that adsorption is as useful as doping to tune the band gap in graphene enabling its applications in designing high performance electronic devices.

Comparison and risk stratification of patients presenting with syncope in emergency department

Funding Acknowledgements

Type of funding sources: None.

Introduction :

Syncope is the sudden loss of consciousness, associated with an inability to maintain postural tone, with immediate and spontaneous recovery without requiring electrical or chemical cardioversion. It is a common condition associated with frequent hospitalization or visits to the emergency department. It has a prevalence of 40%, considering a lifetime of 70 years and an annual incidence of 6%. The prognosis after syncope ranges from relatively benign for vasovagal to poor for ventricular tachyarrhythmia, but invariably creates anxiety and potentially life-changing disruption demanding timely resolution Overall, morbidity and mortality in syncope patients are low, but 1-year mortality can reach significantly higher in certain subgroups.

Purpose :

To compare the mortality rates in men and women so that management of the disease and comorbidities can be done accordingly.

Methods :

Anyone who presented to the ED with transient loss of consciousness (TLOC) between 2015 and 2018 (n = 11,718) underwent evaluation for syncope. Initial evaluation included history, physical exam, orthostatic blood pressure, heart rate measurement and a 12-lead ECG with or without echocardiogram. All patients were followed up from their initial ED visit until either April 30, 2019, or death, whichever occurred first.

Results :

Among the patients who presented to the ED, 1,011 (8.62%) females and 1,391 (11.87%) males were admitted to inpatient facilities. The median age of females at the time of diagnosis was 49 years as compared to 54 years for males. Moreover, females had fewer comorbidities (67.9% with Charlson/Deyo comorbidity score of 0) as compared to males (61.8% with Charlson/Deyo comorbidity score of 0). At 30 days, among those admitted, females had a mortality rate of 2.2% vs. 5.1% for males, and among those discharged, females had a mortality rate of 0.1% vs. 0.6% for males (P < .001 for both). At 1 year, among those admitted, females had a mortality rate of 10.9% vs. 15.6% for males, and among those discharged, females had a mortality rate of 1.8% vs. 3.2% for males (P < .001 for both). All data were analyzed on SPSS version 20 and it was found that males had a 1.2 fold greater risk for death at 1 year compared to females.

Conclusion : By comparing the mortality rates of males and females presenting in the emergency department with syncope, we concluded that the mortality rate is higher in males. This finding will help us to manage the high-risk patients of syncope accordingly.

Identification, risk stratification and prognostication of stroke by detection of intra-carotid plaque hemorrhage

Funding Acknowledgements

Type of funding sources: None.

Introduction

Atherosclerotic stenosis of the internal carotid artery is present in 1% to 2% of the adult population and is the cause of  10% to 15% of ischemic strokes. Intra-plaque hemorrhage (IPH) in carotid stenosis increases the risk of cerebrovascular events. Magnetic resonance imaging can be used to detect pathologies like IPH and necrosis in carotid stenosis.

Purpose :

This study sought to compare the risk of stroke between patients with carotid artery disease with and without the presence of intraplaque hemorrhage (IPH) on magnetic resonance imaging.

Methods :

In this meta-analysis we gathered the data from 10 original cohort studies including 631 patients with symptomatic carotid stenosis and 157 patients with asymptomatic carotid stenosis. Primary outcome was the hazards of ipsilateral ischemic stroke which were compared between patients with and without IPH.

Results :

IPH was present in 57.1% of patients with symptomatic carotid stenosis and 24.7% of patients with asymptomatic carotid stenosis. During 1,334 observed person-years, 74 ipsilateral strokes occurred. Presence of IPH at baseline increased the risk of ipsilateral stroke both in symptomatic (hazard ratio [HR]: 11.7; 95% confidence interval [CI]: 4.7 to 22.8) and asymptomatic (HR: 6.8; 95% CI: 0.9 to 45.4) patients. Multivariate analysis identified IPH (HR: 11.7; 95% CI: 5.3 to 26.4) and severe degree of stenosis (HR: 3.8; 95% CI: 02 to 8.2) as independent predictors of ipsilateral stroke.

Conclusion : Our study concludes that IPH is common in patients with carotid artery stenosis and is a stronger predictor of stroke. Magnetic resonance imaging is the modality that can help in identification of patients with carotid disease who would benefit from revascularization.

Occurrence of adverse events in patient receiving community-based therapy for multidrug-resistant tuberculosis in Pakistan

Introduction

Pakistan ranks 4th among 22 multidrug resistant tuberculosis (MDR-TB) high burden countries. The increasing rate of MDR-TB in Pakistan underscores the importance of effective treatment programs of drug-resistant TB. Clinical management of MDR-TB requires prolonged multidrug regimens that often cause adverse events (AEs).

Materials and Methods

This retrospective case series study include all patients who were enrolled for MDR-TB treatment during January 2014 till April 2015 at Programmatic Management of Drug Resistant TB (PMDT) unit at tertiary care hospital, Lady Reading Hospital (LRH) Peshawar Pakistan. In this study we sought to ascertain the occurrence of treatment related adverse events and factors associated with these events. Here we also examined the frequency of and reasons for changing drug regimens. We further sought to determine whether the occurrence of adverse events negatively impacts the treatment outcome and management of adverse effects without requiring the discontinuation of MDR-TB therapy.

Result

At the time of analysis final outcomes of all 200 enrolled patients exist. Among these 52.5% were females and (81.5%) were aged ≤ 44 years. Among study cases 155 (77.2%) experienced at least one adverse event during treatment. The most commonly reported events were psychiatric issues (70%) whereas the less common was skin rashes (7.5%). A change in drug dose due to adverse events occurred in 16.5% cases, while 13.5% cases had at least one drug discontinued temporarily. Younger age and lung cavities at baseline were positive association with occurrence of adverse events. Association was also found between adverse events and treatment outcomes (OR 0.480, 0.236-0.978, p= 0.041).

Conclusions

Adverse events were prevalent among MDR-TB patients treated at PMDT-LRH Peshawar. All patients who were younger aged and cavitory lungs should be closely monitored for occurrence of adverse events.

Validity of Time to Sputum Culture Conversion to Predict Cure in Patients with Multidrug-Resistant Tuberculosis: A Retrospective Single-Center Study

To evaluate the predictive value of time to sputum culture conversion (SCC) in predicting cure and factors associated with time to SCC and cure in multidrug-resistant tuberculosis (MDR-TB) patients, a retrospective study was conducted at programmatic management unit of drug resistant tuberculosis (TB), Peshawar. A total of 428 pulmonary MDR-TB patients enrolled at the study site from January 1, 2012 to August 31, 2014 were followed until treatment outcome was recorded. Survival analysis using Cox proportional hazards model and multivariate binary logistic regression were, respectively, used to identify factors associated with time to SCC and cure. A P value < 0.05 was considered statistically significant. Overall, 90.9% patients achieved SCC, and 76.9% were cured. Previous use of second-line drugs (SLDs) (hazard ratio [HR] = 0.637; 95% confidence interval [CI] = 0.429-0.947), ofloxacin resistance (HR = 0.656; 95% CI = 0.522-0.825) and lung cavitation (HR = 0.744; 95% CI = 0.595-0.931) were significantly associated with time to SCC. In predicting cure, sensitivities of SCC at 2, 4, and 6 months were 64.1% (95% CI = 58.69-69.32), 93.0% (95% CI = 89.69-95.52), and 97.6% (95% CI = 95.27-98.94), respectively, whereas specificities were 67.7% (95% CI = 57.53-76.73), 51.5% (95% CI = 41.25-61.68), and 44.4% (95% CI = 34.45-54.78), respectively. Furthermore, patients' age of 41-60 (odds ratio [OR] = 0.202; 95% CI = 0.067-0.605) and > 60 years (OR = 0.051; 95% CI = 0.011-0.224), body weight > 40 kg (OR = 2.950; 95% CI = 1.462-5.952), previous SLD use (OR = 0.277; 95% CI = 0.097-0.789), lung cavitation (OR = 0.196; 95% CI = 0.103-0.371) and ofloxacin resistance (OR = 0.386; 95% CI = 0.198-0.749) were significantly associated with cure. Association of SCC with cure was substantially stronger at 6 months (OR = 32.10; 95% CI = 14.34-71.85) than at 4 months (OR = 14.13; 95% CI = 7.92-25.21). However in predicting treatment outcomes, the combined sensitivity and specificity of SCC at 4 months was comparable to SCC at 6 months. Patients with risk factors for delayed SCC were also at high risk of unsuccessful outcomes.

Rapid detection of Mycobacterium tuberculosis and rifampicin resistance in extrapulmonary tuberculosis and sputum smear-negative pulmonary suspects using Xpert MTB/RIF

BACKGROUND

Tuberculosis (TB) is a serious public health problem in developing countries such as Pakistan. Rapid diagnosis of TB and detection of drug resistance are very important for timely and appropriate management of multidrug-resistant TB (MDR-TB).

OBJECTIVE

The purpose of this study was to determine the diagnostic efficacy of the Xpert MTB/RIF assay for rapid diagnosis of TB and detection of rifampicin (RIF) resistance in extrapulmonary and smear-negative pulmonary TB suspects.

METHODS

A total of 98 bronchoalveolar lavage fluid (BALF) and 168 extrapulmonary specimens were processed by Xpert MTB/RIF. Culture results are considered as the gold standard for diagnosis of TB, and drug susceptibility testing for detection of RIF resistance. Diagnostic efficacy was measured in terms of sensitivity, specificity and positive and negative predictive values.

RESULTS

The Xpert MTB/RIF assay detected 40 (40.8 %) of 98 BALF of presumptive pulmonary TB and 60 (35.7 %) of 168 extrapulmonary specimens. Sensitivity and specificity of the Xpert MTB/RIF assay for detection of TB was 86 and 88.4 %, respectively. The positive predictive value was 71.5 % while negative predictive value was 95.1 %.

CONCLUSION

The Xpert MTB/RIF assay is a rapid and simple technique with high sensitivity and specificity for diagnosing TB and detecting drug resistance in extrapulmonary and smear-negative TB cases.

Characteristics and treatment outcomes of patients with multi-drug resistant tuberculosis at a tertiary care hospital in Peshawar, Pakistan

OBJECTIVES

To determine characteristics and treatment outcomes of multidrugs resistant tuberculosis (MDR-TB) patients and risk factors for poor outcomes in MDR-TB patients in a tertiary care hospital in Peshawar, Pakistan. 

METHODS

This retrospective study was conducted at the Programmatic Management of Drug Resistant TB Unit, Lady Reading Hospital Peshawar, Pakistan and included all MDR-TB patients registered between January 2012 and December 2012. A special proforma was used for data collection. Analysis was performed using SPSS version 16, after exporting data from the proforma. Differences in proportions were assessed using Pearson's Chi square test whereas for predictors of poor outcomes, multivariate logistic regression analysis with Wald Statistical criteria using backward elimination method was performed. 

RESULTS

The treatment success rate was 74.3%. In univariate analysis, poor outcomes were associated in patients with age ≥44 years (odds ratio [OR]=0.250; 95% confidence interval [CI]: 0.114-0.519, p=0.001), rural residence (OR=0.417; 95% CI: 0.18-0.937, p=0.03), lung cavitation (OR=0.22; 95% CI, 0.007-0.067, p=0.001), resistance to second line drugs (SLD) (OR=3.441; 95% CI: 1.579-7.497, p=0.001), and resistance to ofloxacin (OR=2.944; 95% CI: 1.361-6.365, p=0.005); whereas multivariate logistic regression analysis, poor outcomes were associated in patients with age ≥44 years (OR=0.249, 95% CI: 0.075-0.828, p=0.023), rural residence (OR=0.143, 95% CI: 0.052-0.774, p=0.032), and cavitatory lungs (OR=0.022, 95% CI: 0.007-0.072, p=0.000). 

CONCLUSION

The MDR-TB patient needs special attention for better treatment outcomes. The presence of older age, rural area residence, resistance to ofloxacin, SLD resistance, and cavitary disease are independent prognostic factors for poor outcome in patients with MDR-TB.

Screening outcomes of household contacts of multidrug-resistant tuberculosis patients in Peshawar, Pakistan

OBJECTIVE

To assess the profile of TB/multidrug-resistant TB (MDR-TB) among household contacts of MDR-TB patients.

METHODS

Close contacts of MDR-TB patients were traced in the cross-sectional study. Different clinical, radiological and bacteriological were performed to rule out the evidence of TB/MDR-TB.

RESULTS

Between January 2012 and December 2012, a total of 200 index MDR-TB patients were initiated on MDR-TB treatment, out of which home visit and contacts screening were conducted for 154 index cases. Of 610 contacts who could be studied, 41 (17.4%) were diagnosed with MDR-TB and 10 (4.2%) had TB. The most common symptoms observed were cough, chest pain and fever.

CONCLUSIONS

The high incidence of MDR-TB among close contacts emphasize the need for effective contact screening programme of index MDR-TB cases in order to cut the chain of transmission of this disease.

Management and treatment outcomes of MDR-TB: results from a setting with high rates of drug resistance

SETTINGS

Although Pakistan has a high burden of multidrug-resistant tuberculosis (MDR-TB), little is known about the management and treatment outcomes of MDR-TB patients in Pakistan.

OBJECTIVE

To evaluate management and predictors of unsuccessful treatment outcomes among MDR-TB patients.

METHODS

In this observational cohort study, 196 MDR-TB patients enrolled at the Programmatic Management Unit for drug-resistant TB of Lady Reading Hospital, Peshawar, Pakistan, between 1 January 2012 and 28 February 2013 were included. Patients were followed until an outcome was recorded or 31 January 2015.

RESULTS

Extensive concurrent resistance to ofloxacin (OFX) and pyrazinamide (54.6%) was observed. Among 181 patients for whom treatment outcome was available, 135 (74.6%) were cured, 1 (0.6%) completed treatment, 35 (19.3%) died, 8 (4.4%) failed treatment and 2 (1.1%) defaulted. In multivariate analysis, predictors of unsuccessful treatment outcome (death, failure and default) were age >40 years (OR 3.412, P = 0.009), baseline body weight <40 kg (OR 2.966, P = 0.020), concurrent comorbidity (OR 3.785, P = 0.023), resistance to OFX (OR 2.777, P = 0.023), lung cavitations at baseline chest X-ray (OR 5.253, P < 0.001) and regimen modification due to adverse events (OR 3.492, P = 0.037).

CONCLUSION

The treatment outcome results were encouraging. Patients with identifiable predictors of poor treatment outcome should receive enhanced clinical management. Early detection and management of mild adverse effects can help prevent regimen modification and may improve treatment outcomes.

Optic disc detection and boundary extraction in retinal images

With the development of digital image processing, analysis and modeling techniques, automatic retinal image analysis is emerging as an important screening tool for early detection of ophthalmologic disorders such as diabetic retinopathy and glaucoma. In this paper, a robust method for optic disc detection and extraction of the optic disc boundary is proposed to help in the development of computer-assisted diagnosis and treatment of such ophthalmic disease. The proposed method is based on morphological operations, smoothing filters, and the marker controlled watershed transform. Internal and external markers are used to first modify the gradient magnitude image and then the watershed transformation is applied on this modified gradient magnitude image for boundary extraction. This method has shown significant improvement over existing methods in terms of detection and boundary extraction of the optic disc. The proposed method has optic disc detection success rate of 100%, 100%, 100% and 98.9% for the DRIVE, Shifa, CHASE_DB1, and DIARETDB1 databases, respectively. The optic disc boundary detection achieved an average spatial overlap of 61.88%, 70.96%, 45.61%, and 54.69% for these databases, respectively, which are higher than currents methods.

Predictors of two months culture conversion in multidrug-resistant tuberculosis: findings from a retrospective cohort study

BACKGROUND

Various studies have reported culture conversion at two months as a predictor of successful treatment outcome in multidrug-resistant tuberculosis (MDR-TB).

OBJECTIVES

The present study was conducted with the aim to evaluate the rate and predictors of culture conversion at two months in MDR-TB patients.

METHODS

All confirmed pulmonary MDR-TB patients enrolled for treatment at Lady Reading Hospital Peshawar, Pakistan from 1 January to 31 December 2012 and met the inclusion criteria were reviewed retrospectively. Rate and predictors of culture conversion at two months were evaluated.

RESULTS

Eighty seven (53.4%) out of 163 patients achieved culture conversion at two months. In a multivariate analysis lung cavitation at baseline chest X-ray (P = 0.006, OR = 0.349), resistance to ofloxacin (P = 0.041, OR = 0.193) and streptomycin (P = 0.017, OR = 0.295) had statistically significant (P<0.05) negative association with culture conversion at two months.

CONCLUSION

A reasonable proportion of patients achieved culture conversion at two months. Factors negatively associated with culture conversion at two months can be easily identified either before diagnosis or early in the course of MDR-TB treatment. This may help in better care of individual patients by identifying them early and treating them vigorously.

Application of morphological bit planes in retinal blood vessel extraction

The appearance of the retinal blood vessels is an important diagnostic indicator of various clinical disorders of the eye and the body. Retinal blood vessels have been shown to provide evidence in terms of change in diameter, branching angles, or tortuosity, as a result of ophthalmic disease. This paper reports the development for an automated method for segmentation of blood vessels in retinal images. A unique combination of methods for retinal blood vessel skeleton detection and multidirectional morphological bit plane slicing is presented to extract the blood vessels from the color retinal images. The skeleton of main vessels is extracted by the application of directional differential operators and then evaluation of combination of derivative signs and average derivative values. Mathematical morphology has been materialized as a proficient technique for quantifying the retinal vasculature in ocular fundus images. A multidirectional top-hat operator with rotating structuring elements is used to emphasize the vessels in a particular direction, and information is extracted using bit plane slicing. An iterative region growing method is applied to integrate the main skeleton and the images resulting from bit plane slicing of vessel direction-dependent morphological filters. The approach is tested on two publicly available databases DRIVE and STARE. Average accuracy achieved by the proposed method is 0.9423 for both the databases with significant values of sensitivity and specificity also; the algorithm outperforms the second human observer in terms of precision of segmented vessel tree.

An approach to localize the retinal blood vessels using bit planes and centerline detection

The change in morphology, diameter, branching pattern or tortuosity of retinal blood vessels is an important indicator of various clinical disorders of the eye and the body. This paper reports an automated method for segmentation of blood vessels in retinal images. A unique combination of techniques for vessel centerlines detection and morphological bit plane slicing is presented to extract the blood vessel tree from the retinal images. The centerlines are extracted by using the first order derivative of a Gaussian filter in four orientations and then evaluation of derivative signs and average derivative values is performed. Mathematical morphology has emerged as a proficient technique for quantifying the blood vessels in the retina. The shape and orientation map of blood vessels is obtained by applying a multidirectional morphological top-hat operator with a linear structuring element followed by bit plane slicing of the vessel enhanced grayscale image. The centerlines are combined with these maps to obtain the segmented vessel tree. The methodology is tested on three publicly available databases DRIVE, STARE and MESSIDOR. The results demonstrate that the performance of the proposed algorithm is comparable with state of the art techniques in terms of accuracy, sensitivity and specificity.

Breast cancer after prophylactic mastectomy for Lobular Carcinoma-In-Situ (LCIS) - an unusual case

Bilateral risk reducing mastectomy results in the greatest breast cancer risk reduction but is an irreversible intervention. Total mastectomy can never remove all breast tissue and there is always a small risk of breast cancer. Regular follow up and surveillance is beneficial. We present the case of a 47-year-old woman who presented with axillary lymph node metastatic breast cancer after risk reducing mastectomy in which only Lobular Carcinoma-in-Situ (LCIS) was present on histopathology.

Ramadan Prospective Diabetes Study: the role of drug dosage and timing alteration, active glucose monitoring and patient education

AIMS

To observe the effects of active glucose monitoring, alteration of drug dosage and timing, dietary counselling and patient education in the occurrence of acute diabetic complications in fasting individuals with diabetes during the month of Ramadan.

METHODS

This prospective study was conducted at the outpatient department of the Baqai Institute of Diabetology and Endocrinology. Two educational sessions, one about drug dosage and timing alteration and glucose monitoring, and the other about dietary and lifestyle modifications, were given to the patients by a doctor and a dietician, respectively. Patients who had been recruited were advised to note their blood glucose readings on a chart for at least 15 fasting days, twice a day with at least one reading in the fasting state.

RESULTS

A total of 3946 readings were obtained in 110 subjects; 82 readings were in the hypoglycaemic range, and there were 22 episodes of symptomatic hypoglycaemia and 60 episodes of biochemical hypoglycaemia observed in 27 patients. Seven patients experienced symptomatic hypoglycaemia, whereas 20 patients had biochemical hypoglycaemia. Symptomatic hypoglycaemic episodes showed a downward trend from weeks 1 to 4. The highest frequencies of hypo- and hyperglycaemic episodes were observed pre-dawn. None of the patients developed diabetic ketoacidosis or hyperglycaemic hyperosmolar state.

CONCLUSION

We observed that, with active glucose monitoring, alteration of drug dosage and timing, dietary counselling and patient education, the majority of the patients did not have any serious acute complications of diabetes during Ramadan.

Risk factors for under-nutrition among children aged one to five years in Udupi taluk of Karnataka, India: A case control study

BACKGROUND

Despite her apparent economic success, India is plagued by a high burden of under-nutrition among children under five. This study was aimed at understanding some of the risk factors for under-nutrition in a region with favourable maternal and child health indicators.

METHOD

A case control study was carried out among children aged one to five years attending the paediatric outpatient department in six rural health care centres in Udupi taluk of Karnataka in Southern India. A total of 162 children were included in the study, of which 56 were cases. A semi-structured questionnaire was used to interview the caregivers of the children and the nutritional status was graded according to the Indian Academy of Paediatrics (IAP) grading of protein-energy malnutrition.

RESULTS

Under-nutrition was associated with illness in the last one month [OR- 4.78 (CI: 1.83 -12.45)], feeding diluted milk [OR-14.26 (CI: 4.65 - 43.68)] and having more than two children with a birth interval ≤2 years [OR- 4.93 (CI: 1.78 - 13.61)]. Lack of exclusive breast feeding, level of education of the caregiver and environmental factors like source of water did not have an association.

CONCLUSION

Childhood illness, short birth interval and consumption of diluted milk were some of the significant contributory factors noted among this population. Information, Education, Communication (IEC) campaigns alleviating food fads and promoting birth spacing is needed.

Isolated adenocarcinoma of the nipple

A 47-year-old female presented with a 1-year history of 'eczematous change' to the right nipple. Bilateral mammography and ultrasound were entirely normal. Free hand biopsy demonstrated invasive adenocarcinoma of the nipple. The patient underwent a right-sided central segmentectomy and sentinel node biopsy. Histology demonstrated that the nipple was almost completely replaced by an invasive ductal carcinoma with a maximum diameter of 13 mm. Invasion of the underlying breast tissue was to a depth of 3 mm. A single sentinel lymph node demonstrated metastatic carcinoma. Her oestrogen receptor status was positive while HER-2 status was negative. The patient subsequently underwent right-sided axillary node clearance to level three nodes. All 17 nodes in the specimen were found to be within normal limits. She is scheduled to undergo radiotherapy, chemotherapy and hormonal treatment.

An FTO variant is associated with Type 2 diabetes in South Asian populations after accounting for body mass index and waist circumference

AIMS

A common variant, rs9939609, in the FTO (fat mass and obesity) gene is associated with adiposity in Europeans, explaining its relationship with diabetes. However, data are inconsistent in South Asians. Our aim was to investigate the association of the FTO rs9939609 variant with obesity, obesity-related traits and Type 2 diabetes in South Asian individuals, and to use meta-analyses to attempt to clarify to what extent BMI influences the association of FTO variants with diabetes in South Asians.

METHODS

We analysed rs9939609 in two studies of Pakistani individuals: 1666 adults aged ≥40 years from the Karachi population-based Control of Blood Pressure and Risk Attenuation (COBRA) study and 2745 individuals of Punjabi ancestry who were part of a Type 2 diabetes case-control study (UK Asian Diabetes Study/Diabetes Genetics in Pakistan; UKADS/DGP). The main outcomes were BMI, waist circumference and diabetes. Regression analyses were performed to determine associations between FTO alleles and outcomes. Summary estimates were combined in a meta-analysis of 8091 South Asian individuals (3919 patients with Type 2 diabetes and 4172 control subjects), including those from two previous studies.

RESULTS

In the 4411 Pakistani individuals from this study, the age-, sex- and diabetes-adjusted association of FTO variant rs9939609 with BMI was 0.45 (95%CI 0.24-0.67) kg/m(2) per A-allele (P=3.0 × 10(-5) ) and with waist circumference was 0.88 (95% CI 0.36-1.41) cm per A-allele (P=0.001). The A-allele (30% frequency) was also significantly associated with Type 2 diabetes [per A-allele odds ratio (95%CI) 1.18 (1.07-1.30); P=0.0009]. A meta-analysis of four South Asian studies with 8091 subjects showed that the FTO A-allele predisposes to Type 2 diabetes [1.22 (95%CI 1.14-1.31); P=1.07 × 10(-8) ] even after adjusting for BMI [1.18 (95%CI 1.10-1.27); P=1.02 × 10(-5) ] or waist circumference [1.18 (95%CI 1.10-1.27); P=3.97 × 10(-5) ].

CONCLUSIONS

The strong association between FTO genotype and BMI and waist circumference in South Asians is similar to that observed in Europeans. In contrast, the strong association of FTO genotype with diabetes is only partly accounted for by BMI.

Replication of 13 genome-wide association (GWA)-validated risk variants for type 2 diabetes in Pakistani populations

AIMS/HYPOTHESIS

Recent genome-wide association (GWA) studies and subsequent replication studies have greatly increased the number of validated type 2 diabetes susceptibility variants, but most of these have been conducted in European populations. Despite the high prevalence of the disease in South Asians, studies investigating GWA-validated type 2 diabetes risk variants in this ethnic group are limited. We investigated 30 single nucleotide polymorphisms (SNPs), predominantly derived from recent GWA studies, to determine if and to what extent these variants affect type 2 diabetes risk in two Punjabi populations, originating predominantly from the District of Mirpur, Pakistan.

METHODS

Thirty SNPs were genotyped in 1,678 participants with type 2 diabetes and 1,584 normoglycaemic control participants from two populations; one resident in the UK and one indigenous to the District of Mirpur.

RESULTS

SNPs in or near PPARG, TCF7L2, FTO, CDKN2A/2B, HHEX/IDE, IGF2BP2, SLC30A8, KCNQ1, JAZF1, IRS1, KLF14, CHCHD9 and DUSP9 displayed significant (p < 0.05) associations with type 2 diabetes, with similar effect sizes to those seen in European populations. A constructed genetic risk score was associated with type 2 diabetes (p = 5.46 × 10(-12)), BMI (p = 2.25 × 10(-4)) and age at onset of diabetes (p = 0.002).

CONCLUSIONS/INTERPRETATION

We have demonstrated that 13 variants confer an increased risk of type 2 diabetes in our Pakistani populations; to our knowledge this is the first time that SNPs in or near KCNQ1, JAZF1, IRS1, KLF14, CHCHD9 and DUSP9 have been significantly associated with the disease in South Asians. Large-scale studies and meta-analyses of South Asian populations are needed to further confirm the effect of these variants in this ethnic group.

Efficacy of Dongsulin (rDNA human insulin) in a normal clinical practice setting

The aim of this study was to evaluate the effectiveness ofDongsulin (rDNA, insulin) in maintaining HbA1c level in a normal clinical practice setting and secondly to assess weight gain, episodes of hypoglycaemia, insulin dose change and its safety. Fifty two diabetic patients already on human insulin (rDNA) were enrolled to a 12 week of treatment. Patients with HbA1c level between 6-8% were switched to Dongsulin on same dosage. The compliance of the patient regarding dietary pattern, physical activity and insulin dosages were assessed. HbA1c was checked after 12 weeks. Patient known to have either of the noncompliance factors during the study period were grouped as group B (non compliant) while, patients who were compliant were grouped as group A (compliant). Thirty nine patients completed the study. No significant difference was found between the HbA1c of two visits in group A (p = 0.32) while, HbA1c in group B was significantly raised as compared to first visit (p = 0.000). In group B patients missed the doses, changes in their diets and decreased their physical activity significantly. The mean insulin dose and weight of the patient remained the same in both groups. No major episode of hypoglycemia was observed. This study has shown that patients who remained compliant during the study period, switched over to Dongsulin had no significant change in the glycaemic control as measured by HbA1c.

The personal cost of diabetic foot disease in the developing world--a study from Pakistan

AIMS

The aim of the present study was to estimate the direct cost of treatment of diabetic foot ulcer at a tertiary care hospital in Karachi, Pakistan in order to assess the extent of the economic burden which it imposes.

METHODS

Out of 383 patients seen at Foot clinic of Baqai Institute of Diabetology and Endocrinology (BIDE), records of 214 patients were analyzed while 169 patients left against medical advice (LAMA). The UT system was used to classify ulcer types. Information was retrieved on resource consumption (physician services, chiropody, investigations, medicines, hospital care and surgical procedures). Interventions were summed and multiplied by the unit price of each resource, using charges levied at BIDE in the year 2005, in order to calculate the total cost of treatment.

RESULTS

64% were male, with mean age 52.7 +/- 10.2 years. Mean duration of diabetes was 16.2 +/- 6.6 years. Majority (62.1%) were Grade 2 ulcer. The estimated direct cost of management increased from 2700 +/- 250 rupees (21 +/- 2 pounds) for a UT grade 1, stage B ulcer to 37,415 +/- 24,125 rupees (288 +/- 186 pounds) for UT grade 2, stage D and 49,058 +/- 30,144 rupees (378 +/- 232 pounds) for UT grade 3, stage D ulcers, respectively. The mean direct cost of major amputation (transtibial or transfemoral) was 46,182 +/- 30,742 ( 356 +/- 237 pounds) whilst the cost of a minor amputation was 50,494 +/- 30,488 rupees (389 +/- 235 pounds).

CONCLUSIONS

This retrospective study, despite having limitations, is important for a developing world country with limited data on health economics. Further larger scale prospective studies are needed to address this issue in more detail.

Glycaemic trend during Ramadan in fasting diabetic subjects: a study from Pakistan

The aim of this questionnaire based survey was to assess the glycaemic control care and management of our fasting diabetic subjects. This retrospective study was carried out at Baqai Institute of Diabetology and Endocrinology, its affiliated centers and Memon Diabetic Centre of Karachi. Data was collected by a questionnaire including socio-demographic data, duration of diabetes, life style, diet and treatment during and preceding Ramadan of year 2004. All Known diabetic Muslim subjects except children below 10 years were included. The subjects were asked if they had observed any of the hypoglycemic or hyperglycemic symptoms. The major severity of the symptoms was assessed depending upon the assistance needed. The plasma glucose level during these episodes was recorded where it was available. During the month of Ramadan 327 out of 453 subjects (72.5%) fasted. Mean age of subjects was 50.3 +/- 12.6 years. Average duration of diabetes was 9.3 +/- 7.3 years. Majority of the subjects (96.3%) fasted with type 2 diabetes while only 3.7% fasted with type I diabetes. Subjects fasted for an average of 25 days. Overall prevalence of hypoglycemia and hyperglycemia was 21.7 and 19.8%, respectively. Only 4.0% had major hypoglycemic episodes, while 8% had major hyperglycemic episodes. The present study suggests that all diabetic subjects who intend to fast should be counseled before Ramadan about change in medication timings and dose, dietary changes and pattern of physical activity and about role of self-monitoring of blood glucose especially during acute symptoms.

Primary drug resistance to antituberculous drugs in NWFP Pakistan

OBJECTIVE

To assess the prevalence of Primary drug resistance to Antituberculous drugs in NWFP METHOD: A cross-sectional prevalence study was undertaken to evaluate the prevalence of drug resistance among new TB patients, using a non-probability convenience sampling methodology. Sample size was calculated according to the population and WHO's estimated incidence of smear positive tuberculosis in the province/country. Sputum samples were obtained from 122 newly diagnosed patients of pulmonary tuberculosis from centres in Peshawar and Abbotabad in NWFP.

RESULTS

Sensitivities were performed by proportion method which showed the following resistance values in 118 eligible patients: 15 (12.7%) samples showed primary resistance to one or more drugs. 8 (6.4%) isolates were resistant to a single drug, 2 (1.6%) were resistant to 2 drugs, 4 (3.2%) to 3 drugs, 1 (0.8%) to 4 drugs while none to all 5 first line agents. Resistance to Streptomycin (10 microg/ml) was seen in 7 (5.9%), Isoniazid (1 microg/ml) in 10 (8.4%), Rifampicin (5 microg/ml) in 3 (2.5%), Ethambutol (10 microg/ml) in 2 (1.6%) and Pyrazinamide in 6 (5.0%) samples. Primary Multidrug resistance was 2.5%.

CONCLUSION

This study suggests that prevalence of MDR amongst untreated patients in NWFP is 2.5%, which is a cause of concern and should be addressed through effective TB control programmes with DOTS strategy.

Diabetes related knowledge, attitude and practices of family physicians in Pakistan

OBJECTIVE

To assess the Knowledge, Attitude and Practices (KAP) towards diabetes of Family Physicians (FPs) working in urban and rural areas of Pakistan.

METHODOLOGY

A cross-sectional survey was conducted on FPs through an interview by a trained person and filling up a questionnaire focused on diagnosis, treatment and complications of diabetes. The answers were scored by assigning marks and conversion to percentages. The computer package SPSS version 10 was used for statistical analysis.

RESULTS

A total of 767 FPs (756 males, 11 females, average age 42.18 years) with a mean clinical practice duration of 13.41 years, with 681 practicing in urban areas and 86 in rural areas, participated in the study. Each FP saw on an average 58 patients daily, spending a mean of 8.5 minutes with each case. More than 90% FPs treated diabetics and 107 (14%) of the doctors were diabetic themselves. Overall 62% answers were correct, with the FPs from Sindh having the highest score of 66% and the Federal Capital Area with the lowest 54%. The questions answered correctly by less than 50% of FPs pertained to diagnostic blood values of glucose, treatment of children with diabetes, pregnant diabetics, monitoring of diabetics and technique of insulin injection. The questions answered correctly by more than 50% of FPs were related to diagnosis of Impaired Glucose Tolerance (IGT), insulin in pregnancy, importance of education in diabetics and diabetes complications, screening and management.

CONCLUSION

This study has explored several aspects of diabetes related KAP of Family Physicians and identified the need for improvement in their practices for treating and educating diabetics. Awareness and education programmes are recommended to update the FPs on early detection and management of diabetes.

Prevalence of diabetes, impaired fasting glucose and associated risk factors in a rural area of Baluchistan province according to new ADA criteria

OBJECTIVE

To assess the prevalence of impaired fasting glucose (IFG) and diabetes in an adult rural population on the basis of fasting blood glucose (FBG) alone using American Diabetic Association (ADA) criteria and to assess the prevalence of and association between selected risk factors such as obesity, family history of diabetes and hypertension.

MATERIALS AND METHODS

Sixteen randomly selected villages from the Lasbella district of Baluchistan were included in this study. One month before the survey a team visited the areas; all the households located in the selected areas were approached and the family members aged 25 or above, who were available and willing to participate in the study, were recruited. On the day of survey anthroprometric and blood pressure measurements were taken; interviews were conducted to obtain demographic information and health history and fasting blood samples were collected. The blood samples were transported to the laboratory and analysed using "GOD-PAP" Enzymatic Colorimetric test method.

RESULTS

A total of 670 males and 1362 females were studied. Prevalence rate of diabetes using the ADA fasting criteria was 6.3% while the prevalence rate in males was 10.1% and in females was 4.3%. The prevalence rate of impaired fasting glucose was 4.2% in males and 2.3% in females. Overall prevalence of obesity between diabetics vs non-diabetics was 22% vs 16%, for hypertension 12.9% vs 6.5% and for positive family history of diabetes 1.6% vs 0.9% was higher among diabetics as compared to non diabetics; the difference of these parameters was statistically significant only among females (P < 0.01).

CONCLUSION

The results of this study suggest the need of continual use of OGTT for screening people at high risk of developing diabetes and perhaps also for diagnosing diabetes.

Diabetic foot ulcer--a prospective study

OBJECTIVE

To detect "Feet at Risk" early, its early diagnosis and treatment of foot ulceration to prevent amputation.

SETTING AND METHOD

One hundred patients with diabetic foot problems were seen at Baqai Institute of Diabetology and Endocrinology from 06-01-97 to 14-04-99. Each Patient was examined for peripheral pulses, sensations and reflexes, for dryness of skin, deformity, callus and nail disorders and were photographed on first visit.

RESULTS

There were 65% males and 35% females included in this study. Ninety nine patients were type II diabetics, 38% were either smokers or had other addictions (or were addicted to tobacco). Awareness about risk factors causing foot problems was lacking among all patients. Fifty percent patients were on oral hypoglycaemic agents, 48% were insulin treated, while 2% were on diet and exercise alone. Glycaemic control was poor in 70%, fair in 16% and was good in 14%, 31% were overweight and 5% patients were underweight. Duration of diabetes was greater than ten years in 58%, toes were affected in 44%, sole/metatarsal in 18%; rest included malleoli, heel etc. Eleven patients had ulcers on both feet. Neuropathic ulcer were 42%, neuro ischaemic 58%, Sixty nine percent patients were in the age group between 40-60 years. Cause unknown 29% blisters and boil 14%, trauma/cutting 17%, burns 8%, dry skin/callus 10%. Fundal changes were present in 37%; proteinuria in 37%, ischaemic heart disease in 20%, hypertension 18%, In 60% more than one antibiotic was used. Foot ulcers of fifty nine patients healed on conservative management, six patients had below knee amputation, fifteen had toe amputation; nine were still on treatment, eleven lost contact.

CONCLUSION

Lack of awareness, poor glycaemic control and duration of diabetes were the main factors causing diabetic foot problems. This study also confirmed that microvascular complications should be screened in patients with diabetic foot ulcers. Foot care education would be the most important way of dealing with this major problem.

Optimal selectin-mediated rolling of leukocytes during inflammation in vivo requires intercellular adhesion molecule-1 expression

Leukocyte interactions with vascular endothelium during inflammation occur through discrete steps involving selectin-mediated leukocyte rolling and subsequent firm adhesion mediated by members of the integrin and Ig families of adhesion molecules. To identify functional synergy between selectin and Ig family members, mice deficient in both L-selectin and intercellular adhesion molecule 1 (ICAM-1) were generated. Leukocyte rolling velocities in cremaster muscle venules were increased significantly in ICAM-1-deficient mice during both trauma- and tumor necrosis factor alpha-induced inflammation, but rolling leukocyte flux was not reduced. Elimination of ICAM-1 expression in L-selectin-deficient mice resulted in a sharp reduction in the flux of rolling leukocytes during tumor necrosis factor alpha-induced inflammation. The observed differences in leukocyte rolling behavior demonstrated that ICAM-1 expression was required for optimal P- and L-selectin-mediated rolling. Increased leukocyte rolling velocities presumably translated into decreased tissue emigration because circulating neutrophil, monocyte, and lymphocyte numbers were increased markedly in L-selectin/ICAM-1-deficient mice. Furthermore, neutrophil emigration during acute peritonitis was reduced by 80% in the double-deficient mice compared with either L-selectin or ICAM-1-deficient mice. Thus, members of the selectin and Ig families function synergistically to mediate optimal leukocyte rolling in vivo, which is essential for the generation of effective inflammatory responses.

Toxicity of dieldrin for dopaminergic neurons in mesencephalic cultures

Dieldrin can be retained for decades in lipid-rich tissue and has been measured in some postmortem PD brains. Dieldrin has been reported to deplete brain monoamines in several species and has been shown to inhibit mitochondrial respiration. To further investigate the possibility that it may be involved in the pathogenesis of parkinsonism, its toxicity for dopaminergic (DA) neurons was assessed in a mesencephalic cell culture model. Primary neuronal cultures of mesencephalic neurons were prepared from fetal rats or fetal mice, grown for 1 week and incubated with Dieldrin (0.01-100 microM) for 24 or 48 h. Toxicity for DA neurons was determined by measuring density of surviving tyrosine hydroxylase immunoreactive (TH-ir) cells. Toxicity for gamma-aminobutyric acid (GABA)-ergic neurons was determined by measuring survival of glutamate decarboxylase (GAD)-ir neurons. General, nonselective cytotoxicity was determined by counting cells visualized by phase contrast microscopy or by DAPI-stained cells with fluorescence microscopy. Dieldrin exposure for 24 h resulted in a dose-dependent decrease in survival of TH-IR cells (DA neurons) with a 50% decrease (EC50) produced by 12 microM in rat mesencephalic cultures. Dieldrin also produced a dose- and time-dependent decrease in mouse DA-ergic and GABA-ergic neurons in mouse mesencephalic cultures. GABA-ergic neurons were less sensitive to the toxin compared to DA-ergic neurons. Cellular uptake of 3H-DA was also affected by lower concentrations of Dieldrin (EC50 = 7.98 microM) than uptake of 3H-GABA (EC50 = 43 microM). Thus, Dieldrin appears to be a relatively selective DA-ergic neurotoxin in mesencephalic cultures. Dieldrin, which may be ubiquitous in the environment, is proposed as an agent which can initiate and promote dopaminergic neurodegeneration in susceptible individuals.

Transgenic murine dopaminergic neurons expressing human Cu/Zn superoxide dismutase exhibit increased density in culture, but no resistance to methylphenylpyridinium-induced degeneration

Primary dopaminergic neuronal cultures with increased superoxide dismutase (SOD) activity were established for studying the role of superoxide anion (O2-) in 1-methyl-4-phenylpyridinium (MPP+)-induced degeneration of dopamine (DA) neurons. Mean SOD activity in cultures prepared from transgenic (human) Cu/Zn SOD (hSOD1) mice was 2.46-2.60 times greater than in cultures prepared from nontransgenic control mice. After 1 and 2 weeks in culture, the mean density of DA neurons [number of tyrosine hydroxylase-immunoreactive (TH-ir) cells per visual field] was significantly higher in cultures prepared from transgenic mice compared with those prepared from nontransgenic control mice (4.55-5.63 TH-ir neurons per field in hSOD1 cultures vs. 2.66-2.8 TH-ir neurons per field in control cultures). However, uptake of [3H]DA relative to uptake of [3H]GABA was only slightly greater in hSOD1 cultures than in normal cultures (14.1 nmol of DA/100 nmol of GABA vs. 12.1 nmol of DA/100 nmol of GABA). Resistance to MPP+ toxicity was not significantly different from that in normal cultures when based on density of surviving TH-ir cell bodies (EC50 = 0.54 microM in hSOD1 and EC50 = 0.37 microM in normal cultures). A more sensitive measure of DA neuron integrity and function ([3H]DA uptake) also failed to demonstrate increased resistance of hSOD1 cultures to the toxin (EC50 = 73.7 nM in hSOD1 and EC50 = 86.2 nM in controls). These results do not support the hypothesis that neurotoxicity of the active metabolite of MPTP, MPP+, is mediated by generation of O2- in the cytoplasm. Nevertheless, mesencephalic cultures with increased hSOD1 activity appear to survive better than normal control cultures in the oxidatively stressful environment of cell culture incubators, and such mesencephalic cells may be useful for cell grafting studies in animal models of Parkinson's disease.

Refracting system for annular laser beam transformation

A refracting optical system is designed for the transformation of an annular laser beam to a uniform circular beam. The optical surfaces of the proposed system are easy to fabricate as they involve moderate values of radii of curvatrue. The change in the radii of curvature is found to be gradual throughout the surface.

Gaussian laser-beam-diameter measurement using sinusoidal and triangular rulings

Gaussian laser-beam-diameter measurements using triangular and sinusoidal rulings are analyzed. The effects of periodicity and contrast are considered. For the measurement of extremely small Gaussian beam diameter these rulings are found to be more reliable than Ronchi rulings.