The Utility of the Platelet-Albumin-Bilirubin Score as a Non-invasive Predictor of Esophageal Varices and Variceal Hemorrhage in Patients With Liver Cirrhosis Compared to Child-Turcotte-Pugh and Model of End-Stage Liver Disease-Sodium Scores.

Introduction Research on non-invasive tools for detecting gastro-esophageal varices is underway. We investigated the Platelet-Albumin-Bilirubin (PALBI) score in comparison with the Child-Turcotte-Pugh (CTP) and MELD-Na (MELD-Na) scores in patients with liver cirrhosis. Methods Three hundred and twenty-three patients with liver cirrhosis were studied. The PALBI, CTP and MELD-Na scores were calculated and analyzed for gastroesophageal varices and their characteristics using SPSS version 26 (IBM Corp., Armonk, NY, USA). Results Two hundred and sixty-four patients had esophageal varices and 102 presented with variceal hemorrhage. Mean PALBI, CTP and MELD-Na scores were significantly higher for patients with varices versus without varices (p < 0.05). Unlike the mean MELD-Na score, the mean PALBI and CTP scores were significantly higher in patients with large high-risk varices as compared to patients with small low-risk varices (p < 0.05). The mean CTP scores were significantly higher in patients with variceal hemorrhage than those without hemorrhage (p < 0.05), while the difference between mean PALBI and MELD-Na was insignificant, in this regard. The PALBI score had better sensitivity than the CTP and MELD-Na scores in indicating the presence of varices but was similar to the CTP score in predicting high-risk varices. Conclusion The PALBI score proves to have good utility and efficiency in predicting varices in comparison to CTP and MELD-Na scores. It can determine high-risk stigmata of variceal hemorrhage with similar performance as the CTP Score.

Clinical Accuracy Of Dermatologists And Nondermatologists In The Diagnosis Of Dermatological Diseases.

OBJECTIVE: To compare the clinical diagnostic accuracy of dermatologists and non- dermatologists in the diagnosis of dermatological diseases. Method: The descriptive, cross-sectional study was conducted at the Dermatopathology department of a tertiary healthcare hospital in the Punjab province of Pakistan from January 1 to December 31, 2019, and comprised biopsy specimens of patients with diseases of the skin and subcutaneous tissue. The clinical diagnoses of general surgeons, otolaryngologists, dental/maxillofacial surgeons, plastic surgeons and gynaecologists were noted and compared with those of dermatologists in the light of histopathological findings. Data was analysed using SPSS 16. RESULTS: Of the 386 specimens submitted, 113(29.3%) were sent by dermatologists and 273(70.7%) by non-dermatologists. Clinical diagnostic accuracy of dermatologists 92(81.4%) compared to non-dermatologists 137(50.2%) (p<0.005). The dermatologists diagnosed significantly more cases belonging to inflammatory and miscellaneous cutaneous diseases category accurately than non-dermatologists (p<0.005). Similarly, the dermatologists diagnosed significantly more cases of neoplastic disorders accurately than the non-dermatologists (p= 0.018). There was no significant difference in the clinical diagnostic accuracy of dermatologists and non-dermatologists in cases of cystic lesions (p>0.05). In the neoplastic category, no significant difference was found in the clinical accuracy of dermatologists and plastic surgeons (p=0.347). CONCLUSIONS: The specialised skills of dermatologists could not be matched by any other group of physicians.

A case-control study to assess the association of Alopecia areata with thyroid dysfunction and thyroid Autoimmunity.

BACKGROUND: Several previous studies have suggested a positive association between Alopecia Areata and thyroid disorders. However, there is a paucity of such studies in our country. Our study aimed to know the frequency of thyroid dysfunction and thyroid autoimmunity in patients reporting to Dermatology Outdoors with Alopecia Areata (AA) and to compare it with normal controls. METHODS: This was a Case-Control study conducted at the Dermatology outpatient of a tertiary care hospital in Pakistan. 102 patients with AA and 102 age and sex-matched controls were enrolled. The age of onset of the disease, the involved sites and the presence of other associated diseases were noted. Venous blood samples were taken from patients and controls for Thyroid function tests and Anti- Thyroid peroxidase antibodies (Anti-TPO Ab). The data was analyzed using Statistical Package for Social Sciences (SPSS) version 23. RESULTS: The mean age of onset of the disease was 30.37±12.53. 91.2% of patients had the classic patch type of AA. The most commonly involved site was Scalp. Associated diseases were found in eight (7.8%) patients. Thyroid dysfunction was found in two patients and none of the Controls. Both the patients had Subclinical thyroid disease. The p-value was 0.157, which was not statistically significant. Thyroid autoimmunity (raised Anti-TPO Ab titre) was detected in five (4.90%) patients and none of the Controls. The p-value was 0.024, which was statistically significant. CONCLUSIONS: AA is significantly associated with Thyroid autoimmunity but there is no significant association between AA and clinical or subclinical thyroid disease.

Frequency and Antibiotic Susceptibility Pattern of Community-associated Methicillin-resistant Staphylococcus Aureus (CA-MRSA) in Uncomplicated Skin and Soft Tissue Infections.

OBJECTIVE: To determine the frequency and antibiotic susceptibility pattern of CA-MRSA in patients with uncomplicated skin and soft tissue infections reporting to the dermatology outpatient of a tertiary health care hospital. STUDY DESIGN: A descriptive study. PLACE AND DURATION OF STUDY: Dermatology outpatient of a tertiary care hospital in Punjab province of Pakistan, from September 2020 to August 2021. METHODOLOGY: Patients of all age groups and both genders reporting during the study period with community-associated uncomplicated bacterial skin and soft tissue infections were enrolled in the study. Samples were collected from skin lesions and cultured on blood agar and MacConkey agar plates. Antimicrobial susceptibility testing using the modified Kirby Baur disc diffusion technique was performed. RESULTS: A total of 157 patients were included in the study. Impetigo was most common infection (n=80, 51%), followed by Furunculosis (n=47, 29.9%). The frequency of MRSA isolates was 54.1% (n=85). MRSA was significantly more frequently isolated from patients with furunculous, carbuncle and cutaneous abscesses as compared to impetigo. All MRSA isolates were sensitive to linezolid, teicoplanin, and vancomycin. 97.6%, 84.7%, and 72.9% of MRSA isolates were sensitive to rifampicin, minocycline, and fusidic acid respectively. 89.4% of MRSA were sensitive to amikacin and clindamycin. 63.5% were sensitive to doxycycline and 58.8% were sensitive to co-trimoxazole. Only 20% of MRSA were sensitive to ciprofloxacin. CONCLUSION: The antibiotics active against CA-MRSA including rifampicin, minocycline, amikacin, and clindamycin may be used empirically in patients with furunculosis, cutaneous abscess, and carbuncles. Linezolid, teicoplanin, and vancomycin should be reserved for severe infections. KEY WORDS: Uncomplicated skin and soft tissue infections, Community-associated Methicillin-resistant staphylococcus aureus (CA-MRSA), Antibiotic susceptibility pattern.

In vitro α-glycosidase and urease enzyme inhibition profile of some selected medicinal plants of Pakistan.

The current study aims at exploring enzyme inhibition of four species of medicinal herbs, namely Senna bicapsularis, Thevetia peruviana, Nerium oleander and Vinca major. Plant selection was done on the basis of their therapeutic uses by local practitioners. The crude methanolic extracts of these plants were tested for their α-glycosidase and urease enzyme inhibition potential. The observed urease inhibitory potential for the crude extract of S. bicapsularis, T. peruviana and N. oleander were 8.3 ± 0.33 µg, 6.98 ± 0.98 µg and 9.56 ± 1.43 µg, respectively while the V. major did not show any inhibition. In addition, the IC50 value for Thiourea was 22.3 ± 1.14 µg. The crude extracts of S. bicapsularis, T. peruviana, N. oleander, V. major were shown to inhibit α-glycosidase activity with an IC50 value of 630.3 ± 0.03 µg, 700.7 ± 2.43 µg, 430.4 ± 3.97 µg, and the standard (acarbose) 880 ± 1.03  µM, respectively. Based on the TLC profile, the extract of S. bicapsularis was subjected to column chromatography and the major component named rhein (1) was identified. Compound 1 exhibited excellent urease and α-glycosidase inhibitory activity with an IC50 value of 7.4 ± 0.32 and 622.3 ± 1.03 µM, respectively.

Diagnostic accuracy of cerebrospinal fluid adenosine deaminase in detecting Tuberculous Meningitis.

OBJECTIVE: To determine diagnostic accuracy of Cerebro Spinal Fluid (CSF) Adenosine De-Aminase (ADA) in detecting Tuberculous Meningitis (TBM) keeping CSF Polymerase Chain Reaction (PCR) for Mycobacterium Deoxy Ribonucleic Acid (DNA) as gold standard. METHODS: This cross sectional validation study was conducted at Department of General Medicine of PNS Shifa Naval Hospital Karachi, Pakistan from Oct 2015 to Mar 2017 for a total duration of one and a half year. One hundred and thirty six patients were included. The diagnosis of TBM was based clinically on symptoms like fever, headache, altered mental state and signs of meningeal irritation with CSF findings of increased proteins, low glucose and lymphocytic pleocytosis. Lumbar puncture was done and approximately 4ml of CSF sample was withdrawn for analysis. Diagnosis of TBM was confirmed by doing CSF PCR test for mycobacterium tuberculosis DNA. RESULTS: Total 136 patients were enrolled in this study. Mean age in our study was 47.09±12.80 years, whereas frequency and percentages of male and female patients was 102 (75%) and 34 (25%) respectively. The diagnostic accuracy, sensitivity, specificity, positive predictive value and negative predictive value of CSF ADA level in detecting TBM was 71.32%, 84.21%, 95.45%, 98.97% and 53.85% respectively. CONCLUSION: The study concludes that diagnostic accuracy of CSF ADA in detecting TBM is high which is proposed as an investigation to differentiate it from other causes of meningitis in places where PCR test is not available.

Classification of normal and arrhythmic ECG using wavelet transform based template-matching technique.

OBJECTIVE: To propose a wavelet-based template matching technique to extract features for automatic classification of electrocardiogram signals of normal and arrhythmic individuals. METHODS: The study was conducted from December 2014 to December 2015 at the Department of Electrical Engineering, Institute of Space Technology, Islamabad, Pakistan. Electrocardiogram signals analysed in this study were taken from the freely available database www.physionet.org. The data for normal subjects was taken from the Massachusetts Institute of Technology-Beth Israel Hospital's normal sinus rhythm database and data for diseased subjects was taken from the arrhythmia database. RESULTS: Of the 30 subjects, there were 15(50%) normal and 15(50%) diseased subjects. The group-averaged phase difference indices of arrhythmic subjects were significantly larger than that of normal individuals (p<0.05) within the frequency range of 0.9-1.1 Hz. Moreover, the scatter plot between the phase difference index and magnitude of wavelet cross-spectrum for frequency range of 0.9-1.1 Hz demonstrated a satisfactory delineation between normal and arrhythmic individuals. CONCLUSIONS: Wavelet decomposition-based template matching technique achieved satisfactory delineation of normal and arrhythmic electrocardiogram dynamics.

Vitiligo in Children: A Distinct Subset.

OBJECTIVE: To determine clinical profile of vitiligo in children. STUDY DESIGN: A descriptive study. PLACE AND DURATION OF STUDY: Combined Military Hospital, Abbottabad, from January 2010 to June 2013. METHODOLOGY: All new patients below the age of 15 years, clinically diagnosed to have vitiligo, were included in the study. A detailed history was obtained, thorough physical examination was performed, and findings were recorded on a specially designed proforma for each patient separately. Computer programme SPSS-14 was used to manage and analyze the data. RESULTS: Out of 157 children, 68 (43.3%) were males and 89 (56.7%) were females. Mean age at onset was 6.55 ±3.43 years. The disease started before 10 years of age in 123 (78.3%) children. Average duration of the disease was 1.48 ±1.87 years. Average duration of the disease was 1.73 ±2.09 years in male children and 1.29 ±1.67 years in female children. Generalized vitiligo was the commonest type (n = 83, 52.9%). The disease started most commonly from head and neck (n = 75, 47.8%). A family history of vitiligo was found in forty-nine (31.2%) children, Koebner phenomenon in 39 (24.8%) children and associated autoimmune or endocrine diseases in 8 (5.1%) patients. CONCLUSION: Majority of the children developed the disease before 10 years of age. Generalized vitiligo was the commonest type. Childhood vitiligo was more common in female children.

Clinical pattern of vitiligo.

All new cases of vitiligo reporting to Dermatology Outpatient of Combined Military Hospital, Panu Aqil, were included in the study. Of the 230 patients, 124 were male (53.9%) and 106 were female (46.1%). Males were more commonly affected. The disease affected all age groups. Mean age at presentation was 27.02 + 18.34 years and age at presentation ranged from 5.5 months to 82 years. The mean age at onset was 22.03 + 16.97 years with majority 30.4% (n=70), developing vitiligo in first decade of life. Generalized vitiligo was the most common type (n=132, 57.4%) followed by focal (n=53, 23%) and acro-facial vitiligo (n=16, 7%). Head and neck was the most common initial site of onset (n=100, 43.48%). Koebner phenomenon was observed in 72 patietns (31.3%), family history was present in 64 patients (27.8%) and 16 patients (7%) had associated diseases.

Harlequin ichthyosis in two siblings.

Harlequin ichthyosis is a rare and extremely severe form of congenital ichthyosis. The affected neonates usually do not survive beyond first few days after birth, but several long-term survivals have been noted. The inheritance is thought to be autosomal recessive. It has recently been shown that the vast majority of affected individuals are homozygous for mutations in the ABCA12 gene, which cause a deficiency of the epidermal lipid transporter and result in hyperkeratosis and abnormal barrier function. Prenatal diagnosis is possible. We report a case of a newborn with Harlequin ichthyosis, a product of consanguineous marriage, with a history of similar disease leading to early neonatal death previously in a sibling.

Constitutional and behavioral risk factors for chilblains: a case-control study from Pakistan.

OBJECTIVES: To study constitutional and behavioral risk factors for chilblains in patients at Abbottabad and Sialkot, Pakistan. METHODS: One hundred patients and matched controls completed a single-page, close-ended questionnaire which included demographic data and questions related to possible constitutional and behavioral risk factors for chilblains. Computer program SPSS-10 was used to manage and analyze the data. Risk factors were identified statistically by determining odds ratios and 95% confidence intervals using multivariate analysis. RESULTS: There were an equal number of male and female respondents in each group. Age of the patients and controls ranged from 2 to 80 years with a mean of 24.51 +/- 16.02. Twenty-six patients and 3 controls had a positive family history for chilblains (odds ratio = 9.33); 42 patients and 14 controls reported a history of constipation (odds ratio = 2.69); 32 patients and 8 controls had a history of either numbness or tingling of fingers or toes (odds ratio = 2.93); 55 patients and 45 controls led sedentary lifestyles (odds ratio = 1.27); 85 patients and 58 controls consumed a low number of cups of tea daily (odds ratio = 3.20); 65 patients and 29 controls frequently washed their hands and/or feet (odds ratio = 4.93); and 56 patients and 33 controls had occasional sun exposure during winter months (odds ratio = 2.08). CONCLUSION: Significant risk factors for the development of chilblains for people at Abbottabad and Sialkot included a history of chilblains in first-degree relatives, numbness and tingling sensations of fingers or toes, frequent hand or feet washing, and lower tea consumption during winter months.

Treatment of toxic epidermal necrolysis (TEN) with low dose intravenous immunoglobulin in child.

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN, Lyell's disease) are severe, episodic, acute mucocutaneous reaction that may be caused by various factors particularly drugs. Treatment is primarily supportive care and there are no specific therapy regimens. Intravenous immunoglobulin (IVIG) has recently been shown to be a useful and safe therapy in paediatric patients with SJS/TEN, though no such case has so far been reported from Pakistan. The authors report the experience with low dose IVIG (0.1 g/kg/day for four consecutive days for treating a 3 years old boy with toxic epidermal necrolysis with favourable outcome without early complications.