Abstract 

Chronic kidney disease (CKD) is an important epidemic and public health problem that is associated with a significant risk for vascular disease and early cardiovascular mortality as well as progression of kidney disease. Currently it is classified into five stages based on the glomerular filtration rate (GFR) as recommended by many professional guidelines. Radiolabelled methods for measuring GFR are accurate but not practical and canbe used only on a very limited scale while the traditional methods require timed urine collection with its drawback of inaccuracy, cumbersomeness and inconvenience for the patients. However, the development of formula-based calculation of estimated GFR (eGFR) has offered avery practical and easy approach for converting serum creatinine value into GFR result taking into consideration patient’s age, sex, ethnicity and weight (depending on equation type). The commonly used equations include Cockraft and Gault (1976), Modification of Diet in Renal Disease (MDRD) (1999) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) (2009). It is the implementation of these equations particularly the MDRD that has raised the medical awareness in the diagnosis and managementof CKD and its adoption by many guidelines in North America and Europe. The impact and pitfalls of each of these equations in the screening, diagnosis and management of patients with CKD are presented and discussed in this review.

Abstract 

Objective: To determine the knowledge, attitude and practices regarding the use of vitamin supplements among patients visiting Out-Patient clinics of a teaching hospital.

Methods: Four hundred patients were interviewed during the period of July to September 2008, at the Out-patient clinics, Aga Khan University hospital, Karachi. A pre-tested and structured questionnaire was used to collect information. It consisted of questions regarding demographics, awareness of vitamin supplements and its consumption, reasons for usage and its effects. The purpose of the study was explained and assurance of confidentiality was given. After obtaining written consent, eligible individuals were interviewed. Statistical Package for the Social Sciences version 19.0 was used to analyze the data.

Results: The results revealed that 98% of the respondents were aware of vitamin supplements. The most known vitamin was found to be Vitamin C (16.9%) with Vitamin K being the least well known(0.4%); while 51.8% of the respondents were unaware of the harmful effects of vitamin supplements. The results also showed that 84.8% of the study population had taken vitamin supplements, and 79% of the participants considered that vitamin supplementsto be helpful. Taking vitamin supplements as a compensation for the deficiencies in the body was the most frequently chosen answer (17.7%) as the reason for use of vitamin supplements. On the other hand, a majority of the population was unaware of the indications for use of vitamin supplements.

Conclusion: This study highlights a very significant yet ignored issue of vitamin supplementation in Pakistan. A need exists to inform the general population about the use of vitamin supplementation. The media and the medical community are required to play their role in this regard. Short/ refresher training courses are needed for doctors to update and disseminate adequate knowledge of vitamin supplementation to their patients.

Abstract 

Objectives: During infancy and early childhood, the spleencommonly enlarges in patients with sickle cell anemia (SCA), and it thereafter undergoes progressive atrophy due to repeated episodes of vaso-occlusion and infarction, leading to autosplenectomy in adult life. However, this may not always be the case as some studies have reported splenomegaly persisting into adult life. This study aims to determine and review the prevalence of autosplenectomy by abdominal ultrasonography in sickle cell anemic patients in Zaria, Nigeria.

Methods: An ex-post-facto cross study of 74 subjects was carried out between May to July in 2010. Hematological parameters were determined by an analyzer while B mode Ultrasonography was used to determine the craniocaudal length of the spleen, if visualized.

Results: The mean age of the sickle cell subjects was 23.2 ±5.3 years, while that of the controls was 22.7±12.4 years. Of the 74 sickle cell subjects, 55.4% were females; while of the 20 controls,50% were females. Forty one subjects (55.4%) had autosplenectomy and a significant difference existed in the mean splenic size compared with the control (p<0.0001). Only 3 (4.05%) subjects had splenomegaly, while 23 (31%) had a shrunken spleen.

Conclusion: Anatomical autosplenectomy is not an uncommon finding in SCA patients. This may be related to inadequate clinical care due to the lack of good health education, ignorance, poverty, and poor standard of care, as well as the lack of newer therapeutic agents.

Abstract 

Objective: To explore the diagnostic value and measurement of serum CA-125, the single measurement of progesterone (P),ß-HCG, and estradiol (E2) in the early diagnosis of ectopic pregnancy.

Methods: Serum levels of CA-125, progesterone, ß-HCG and estradiol were measured by Enzyme Linked Immuno Sorbent Assay (ELISA) techniques in 40 symptomatic women with ectopic pregnancy and 24 women with normal intrauterine pregnancy during gestational age of 4-10 weeks at Al-Kadhmiya Teaching Hospital, Baghdad, Iraq, between November 2010 and June 2011.

Results: The mean ±SEM serum levels of CA-125, progesterone, ß-HCG, and estradiol in patients with ectopic pregnancies (16.51±2.39U/ml; 2.54±0.47ng/ml; 72.75±12.27mIU/ml; 13.4±2.14pg/ml; respectively) were significantly lower than the levels in normal intrauterine pregnancies (74.25±18.5U/ml; 28.36±3.7ng/ml; 249.54±18.0mIU/ml; 112.7±23.6pg/ml; respectively). When using a CA-125 concentration of 20.5 U/ml as a cut-off value for the diagnosis of ectopic pregnancy, sensitivity was 75.7%, specificity 100%, the positive predictive value was100% and the negative predictive value 71.4%.

Conclusion: The measurement of CA-125 and progesterone levels is useful in discriminating ectopic from normal gestations.

Abstract 

Objectives: A clear knowledge of the location of the maxillo-facial foramina is essential for clinicians while performing endoscopic surgeries and regional nerve blocks. In the present study, a detailed analysis of the supraorbital foramen (SOF) and supraorbital notch (SON) of South Indian skulls is reported and the data are compared with those from other races and regions.

Methods: Anatomical variation of SOF/SON was studied in 83 adult human skulls bilaterally, using “travelling Vernier’smicroscope”. The skulls belonged to the cadavers of South Indian origin. The parameters used were distanced between the SON/SOF and the nasal midline; distance between the SON/SOF and the frontozygomatic suture (FZS); shape and height of the SOF; transverse diameter of the SON; the presence of accessoryforamina (ACF) and their number; as well as the location and distance from the main SON/SOF.

Results: SON was more frequently found than the SOF. Themean distance of SON/SOF to the nasal midline was 22.24 mmon the right side and 22.2 mm on the left side. The mean distanceof SON/SOF to the frontozygomatic suture was 29.34 mm on theright side and 28.7 mm on the left side. While the mean height ofSOF was 3.5 mm on the right side and 3.04 mm on the left side.Also, the mean transverse diameter of SON was 5.17 mm on theright side and 5.58 mm on the left side. The accessory supraorbitalforamina were observed in 66.25% of cases.

Conclusion: There is a difference in the position and dimensions of SOF /SON between different races and people of different regions. Anatomical knowledge of SON /SOF is important in facilitating local anesthetic, forehead lifting, blepharoplasty and other craniofacial surgical procedures.

Abstract 

Objectives: The histopathological diagnosis of Mycosis Fungoides (MF) is challenging in its early stages and can easily be confused with inflammatory dermatoses. This study aims to; (i) assessthe frequency and significance of different histopathological parameters in early MF, seen in Saudi patients, and (ii) to studythe utility of these parameters in differentiating between early MF and inflammatory dermatoses.

Methods: This is a five years study of 66 skin biopsies generated from 58 patients with clinically suspicious MF lesions or early patch stage MF. These cases were retrieved from the archives ofthe Department of Pathology, King Khalid University Hospital, Riyadh from the year 2002 to 2006. Histological criteria were assessed and graded semi-quantitatively on a four-point scale by adermatopathologist and two pathologists independently.

Results: The histological parameters suggesting the diagnosis in early stages MF include epidermotropism, dermal fibrosis, Pautrier’s micro abscesses, Basal alignment of neoplastic lymphocytes, hyperconvoluted dermal and epidermal lymphocytes and grandiosity sign (size of lymphocytes becoming larger as they migrate towards granular layer of epidermis). These parameters on univariate analysis achieved statistical significance (p<0.05) in differentiating MF from non-MF cases. In addition, hyperconvoluted dermal and epidermal lymphocytes proved to be highly reliable with high specificity and sensitivity.

Conclusion: The histopathological diagnosis of early MF lesions and their discrimination from inflammatory simulators can be achieved by carefully observing the hyperconvoluted dermal and epidermal lymphocytes along with the constellation of the other parameters.

Abstract 

Objectives: To assess the maternal and fetal complications of pregnancy in mothers with gestational diabetes mellitus (GDM) compared with non-diabetic patients who delivered in the hospital during the study period.

Methods: The outcome of pregnancy in 220 Saudi patients with GDM identified from the delivery register/hospital database and matched for age, parity and body mass index with 220 non-diabetic controls were studied retrospectively from their case files. Patients with multiple pregnancies and abnormal presentation of the fetus were excluded from the study.

Results: The GDM patients were treated with either diet alone or with additional insulin in some patients who required better control of their blood sugar levels. Patients with GDM had a significantly higher incidence of pre-eclampsia (p<0.0001); preterm delivery (p=0.0226); induction of labor (p<0.0001); cesarean section (p=0.0019); higher mean birth weight (p<0.0001) of babies; large for gestational age infants (p=0.0011); macrosomia (p=0.0186); and admission to the neonatal intensive care unit (p=0.0003), compared with the control group. However, the rates of Apgarscore <7 at 5 minutes, respiratory distress syndrome, neonatal hypoglycemia, hyperbilirubinemia and the need for phototherapy were similar in both groups of patients. Congenital anomalies and perinatal mortality rates were not significantly different in the two groups.

Conclusion: GDM is recognized to be associated with increased rates of adverse maternal and neonatal outcomes, which are supported by the findings of this study. Even the mild form of GDM seems to have significant consequences for women and their offspring and is recommended to be aggressively treated. Evidence suggests that early diagnosis and strict control of blood sugar levels throughout the pregnancy can significantly reduce maternal and fetal complications. A multicenter, randomized controlled trial, based on universally accepted criteria for GDM screening test, standardized diagnostic OGTT and management of all patients with GDM versus the standard obstetric management of the control is warranted.

Abstract 

Objectives: High-resolution computed tomography (HRCT) can detect the structural abnormalities in asthma. This study attempts to correlate these abnormalities with clinical and pulmonary function test (PFT) data.

Methods: Consecutive stable asthma patients attending Mubarak Al Kabeer Hospital, Kuwait, were subjected to HRCT during a six month period from July 2004 to December 2004, after initial evaluation and PFT.

Results: Of the 28 cases, sixteen (57.1%) had moderate, 6 (21.4%) had mild and 6 (21.4%) had severe persistent asthma. Thirteen (46.4%) patients had asthma for 1 to 5 years and 12 (42.9%) were having asthma for >10 years. Bronchial wall thickening (57.1%), bronchiectasis (28.6%), mucoid impaction (17.9%), mosaic attenuation (10.7%), air trapping (78.6%) and plate like atelectasis (21.4%) were noted. Bronchial wall thickening (p=0.044) and bronchiectasis (p=0.063) were most prevalent in males. Ten (35.7%) patients exhibited mild, 9 (32.1%) had moderate and 3 (10.7%) had severe air trapping. The difference in Hounsfield units between expiratory and inspiratory slices (air trapping) when correlated with percent-predicted FEV1 in right upper (r=0.25;p=0.30), left upper (r=0.20; p=0.41), right mid (r=0.15; p=0.53), left mid (r=-0.04; p=0.60), right lower (r=0.04; p=0.86) and left lower zones (r=-0.13; p=0.58) showed no relation. The same when correlated as above with the percent predicted FEF 25-75 did not show any significant association. The presence of air trapping was compared with sex (p=0.640), nationality (p=1.000), disease duration (p=1.000) and severity of symptoms (p=0.581).

Conclusion: Abnormal HRCT findings are common in asthma; however, air trapping when present was not related to the duration or severity of the illness or to the FEV1.

Abstract 

Objectives: Fine needle aspiration cytology (FNAC/FNA) is the primary investigation for thyroid nodules. Fine needle capillary cytology (FNCC/FNC) is an alternative technique not commonly used, though it is easy to perform. Both the techniques have their own advantages and disadvantages. This study aims to compare these two cytological techniques for better specimen and cytological diagnosis.

Methods: This prospective study was conducted on 50 patients attending the FR Muller Medical College Hospital from May 2006 to April 2008. The patients with thyroid nodules (diagnosed by palpation) were subjected to both the cytological techniques; FNA and FNC. The specimen and results were compared and then correlated with the final histopathological findings wherever surgical specimens were available (38 cases).

Results: The mean age of the patients was 39.16 with a female predominance. The majority of cases were diagnosed to have nodular goiters. The FNC technique yielded 88% diagnostic superiority and adequate specimens compared to 94% by FNA. Sensitivity was 50% for FNC and 100% for FNA while specificity was 100% for both techniques; accuracy score was 97.4% for FNC and 100% for FNA in predicting malignancy. While sensitivity was 75% for FNC and 100% for FNA; specificity was 100% for both techniques, and accuracy score was 97.4% for FNC and 100% for FNA in the prediction of neoplasia.

Conclusion: The results indicated that there was no significant difference between the two techniques; if done in tandem can give better and accurate cytological diagnosis. In highly cellular lesions, in which abundant material was obtained, FNC was more likely to be diagnostically superior, but FNA can diagnose most of the lesions. In less cellular lesions, FNA is more likely to be diagnostically superior to FNC.

Abstract 

Obstructive jaundice resulting from malignancy of gastrointestinal tract and hepatobiliary tract has been reported in various studies. Ovarian malignancy leading to obstructive jaundice due to portal lymphadenopathy is of rare occurrence. We report a case presented with obstructive jaundice and on further evaluation, found to have ovarian papillary cyst adenocarcinoma with secondaries at porta hepatis which was managed successfully by neoadjuvant chemotherapy followed by cytoreductive surgery.

Abstract 

Bronchogenic cysts originate from abnormal budding of the tracheal diverticula during the embryological period. Inaccuracy in the process of growing of the ventral foregut will give rise to bronchogenic cyst. Scapular bronchogenic cyst is an extremely rare form of this anomaly. A three years old boy suffered for 2 years with left sided suprascapular cystic lesion which was gradually increasing in size. The swelling was 4 × 3 cm in size and non tender. The cyst was evaluated by CT scan that showed complex cystic lesion over the left scapular spine. Total excision of the cyst was done and histopathology showed cutaneous bronchogenic cyst. The proposed mechanism for such cutaneous lesion is that the accessory buds from the tracheobronchial tree/primitive foregut migrated from the thorax in an aberrant manner to lie in periscapular positions. The definitive treatment of scapular lesions is total surgical excision. The final diagnosis is based on the histopathological findings in the majority of cases.

Abstract 

The 1.4Mb tandem-duplication in the PMP22 gene at 17p11.2 usually manifests as hereditary sensorimotor polyneuropathy with foot deformity, sensorineural hearing-loss, moderate developmental delay, and gait disturbance. Hypertelorism and marked phenotypic variability within a single family has not been reported. In a single family, the PMP22 tandem-duplication manifested as short stature, sensorimotor polyneuropathy, tremor, ataxia, sensorineural hearing-loss, and hypothyroidism in the 27 years-old index case, as mild facial dysmorphism, muscle cramps, tinnitus, intention tremor, bradydiadochokinesia, and sensorimotor polyneuropathy in the 31 year-old half-brother of the index-patient, and as sensorimotor polyneuropathy and foot deformityin the father of the two. The half-brother additionally presented with hypertelorism, not previously reported in PMP22tandem-duplication carriers. The presented cases show that the tandem-duplication 17p11.2 may present with marked intra-familialphenotype variability and that mild facial dysmorphism with stuck-out ears and hypertelorism may be a rare phenotypic feature of this mutation. The causal relation between facial dysmorphism and the PMP22 tandem-duplication, however, remains speculative.

Abstract 

A case of secondary postpartum hemorrhage was treated by uterine artery embolization with a view to preserve fertility as the patient was of low parity.

Abstract 

A 42-year-old male was hospitalized with unstable angina (UA) which had resulted in severe impairment of his daily activities. Coronary angiography revealed a 100% occlusion of the right coronary artery (RCA) and a 50% stenosis within the left anterior descending coronary artery. However, in view of the previously occluded RCA that was supplied by discernible collaterals, medical management was recommended and he was rehabilitated using a progressive exercise regimen to increase his anginal threshold and functional capacity. Following rehabilitation, the patient demonstrated increases in the rate-pressure product of his anginal threshold, as well as his symptom-limited walking distance. At discharge, he was able to negotiate 400 m without angina and was asymptomatic during his daily activities. He was started on a home-based exercise program and followed for 9 months during which time he was functionally independent and walked at least 1 km each day. These findings highlight the benefits of an exercise-based cardiac rehabilitation program among patients with previous UA in whom other treatment options have been exhausted.