Correlation of Transient Elastography with Liver Iron Concentration and Serum Ferritin Levels in Patients with Transfusion-Dependent Thalassemia Major from Oman.

Aims: In a longitudinal study, we aimed to assess the correlation between ultrasound transient elastography (TE), serum ferritin (SF), liver iron content (LIC) by magnetic resonance imaging (MRI) T2* along with the fibrosis-4 (FIB-4) score as a screening tool to detect significant liver fibrosis among chronically transfusion-dependent beta-thalassemia (TDT) patients. Methods: The study was conducted at a tertiary health center treating TDT patients. Transient elastography was performed within 3 months of Liver MRI T2* examinations at the radiology department over a median of one-year duration. T-test for independent data or Mann-Whitney U test was used to analyze group differences. Spearman correlation with linear regression analysis was used to evaluate the correlation between TE liver stiffness measurements, Liver MRI T2* values, and SF levels. Results: In this study on 91 patients, the median age (IQR) of the subjects was 33 (9) years, and the median (IQR) body mass index was 23.8 (6.1) kg/m2. Median (IQR) TE by fibroscan, MRI T2*(3T), Liver iron concentration (LIC) by MRI Liver T2*, and SF levels were 6.38 (2.6) kPa, 32.4 (18) milliseconds, 7(9) g/dry wt., and 1881 (2969) ng/mL, respectively. TE measurements correlated with LIC g/dry wt. (rS =0.39, p=0.0001) and with SF level (rS =0.43, P=0.001) but not with MRI T2* values (rS =-0.24; P=0.98). Conclusion: In TDT patients, liver stiffness measured as TE decreased significantly with improved iron overload measured as LIC by MRI and SF levels. However, there was no correlation of TE with the fibrosis-4 (FIB-4) score.

Composition and structure of plant communities in the Moist Temperate Forest Ecosystem of the Hindukush Mountains, Pakistan.

Here, we investigated the relationship between Plant communities and the environment from the moist temperate vegetation of Lakoo mountainous forest District Swat. We sampled data from 162 sampling units (Quadrates) using 1x1m2 for herbs 5x5m2 and shrubs, while 10 x10m2 for trees, systematically considering six elevation gradients between the altitudinal from 1970m to 3095m. We performed statistical analysis like Canonical correspondence analysis (CCA) and TWINSPAN (two-way indicator species analysis) for ecological assessment and clustering of plant communities. To check upon the correlation of species (CR) with topographic and edaphic variables we used statistical software PC-ORD version 7. We recognized 264 species plants belonging to thirty families. We recorded key sampling measurements of density, frequency, and cover for all these species which are vital for community description. The results showed Shannon-Winner,s, and Simpson diversity values as 19.18 and 3.17 respectively. The importance value indexes (IVI) were used to identify the leading and rare species of plant in each community or cluster group. In total we recognized eleven different communities as: Berberis- Abies- Bergeni, Picea - Indigofera- Poa,Abies- Parrotiopsis- Poa, Quercus- Viburnum- Poa, Picea- Salix- Primula, Abies- Viburnum- Poa, Viburnum- Taxus- Poa, Pinus- Viburnum- Lithospermum, Abies-Berberis- carex, Pinus- Viburnum- Poa and Parrotiopsis- Picea- Poa through hierarchical cluster analysis (TWINSPAN). CCA analysis revealed that of all studied edaphic and topographic variables altitude, silt, calcium carbonate, and organic matter were the strongest factors determining plant community diversity and composition in each microclimate of the eleven communities. Visually the vegetation of the forest was dominated by small-sized trees followed by shrubs, and regenerates indicating the stage of secondary regeneration. We found severe human interference in disturbing the existing biodiversity, which requires immediate conservation to ensure sustainable management and utilization of natural resources of the Lalkoo moist temperate forest.

Community health workers' knowledge and practice in relation to pre-eclampsia in Ogun State, Nigeria: an essential bridge to maternal survival.

BACKGROUND: Pre-eclampsia is a leading cause of maternal and fetal morbidity and mortality worldwide. Early detection and treatment have been instrumental in reducing case fatality in high-income countries. To achieve this in a low-income country, like Nigeria, community health workers who man primary health centres must have adequate knowledge and skills to identify and provide emergency care for women with pre-eclampsia. This study aimed to determine community health workers' knowledge and practice in the identification and treatment of pre-eclampsia, as they are essential providers of maternal care services in Nigeria. METHODS: This study was part of a multi-country evaluation of community treatment of pre-eclampsia. Qualitative data were obtained from four Local Government Areas of Ogun State, in south western Nigeria by focus group discussions (N = 15) and in-depth interviews (N = 19). Participants included a variety of community-based health care providers - traditional birth attendants, community health extension workers, nurses and midwives, chief nursing officers, medical officers - and health administrators. Data were transcribed and validated with field notes and analysed with NVivo 10.0. RESULTS: Community-based health care providers proved to be aware that pre-eclampsia was due to the development of hypertension and proteinuria in pregnant women. They had a good understanding of the features of the condition and were capable of identifying women at risk, initiating care, and referring women with this condition. However, some were not comfortable managing the condition because of the limitation in their 'Standing Order'; these guidelines do not explicitly authorize community health extension workers to treat pre-eclampsia in the community. CONCLUSION: Community-based health care providers were capable of identifying and initiating appropriate care for women with pre-eclampsia. These competencies combined with training and equipment availability could improve maternal health in the rural areas. There is a need for regular training and retraining to enable successful task-sharing with these cadres. TRIAL REGISTRATION: NCT01911494 .

Collagen types I and II distribution: a relevant indicator for the functional properties of articular cartilage in immobilised and remobilised rabbit knee joints.

The objective of the present work was to study changes in collagen type I and type II distribution in the articular cartilage of immobilised and remobilised rabbit knee joints. Twenty-four adult male rabbits were divided into three groups. One of the groups was a control group with free movement. The right knee joints of animals of the other two groups were immobilised for 4 weeks, followed by a period of 10 weeks of remobilisation for animals of group 3. Collagen type I and type II in the articular cartilage of tibial medial condyle of the right knee joint were estimated immunohistochemically in all groups. A degenerative process was evident after 4 weeks of immobilisation of rabbit knee joint leading to a partial shift in the density of collagen composition from type II to type I. After a period of 10 weeks of remobilisation, regenerative processes, evidenced by a restoration of collagen type II to normal, proceeded on top of degenerative processes, evidenced by the significantly higher content of collagen type I compared with normal. The present study pointed to the importance of assessment of collagen distribution as a relevant indicator for the functional properties of articular cartilage in immobilised and remobilised joints.

Response of first-line antibiotic therapy in patients with febrile neutropenia during treatment of hematological disorders.

Patients with hematological disorders develop febrile neutropenia (FN); most of these events remain undetermined in origin. We performed a prospective study to determine the microbiological characteristics of infections and their response to the first-line antibiotic therapy in FN. The study was conducted at National Institute of Blood Disease and Bone Marrow Transplant. Two-hundred episodes of FN were assessed for the bacterial growth, antimicrobial susceptibility pattern and response to the first-line treatment of FN. All patients were given Ceftazidime and Amikacin Bosch Pharmaceutical (Pvt. Ltd), as first-line antibiotic in FN. Out of 200 episodes we had 108 clinically and microbiologically documented infections. The isolated frequencies for gram negative and gram positive organisms were n = 52 and 49 (48 and 45 %) respectively. Among gram negative micro-organisms, Escherichia coli (E. coli) was isolated in 15 (28.8 %), Klebsiella pneumonae in 4 (7.6 %) and Pseudomonas aeruginosa in 10 (19.2 %) were in highest frequencies. Methicillin sensitive staphylococci emerged as the frequently isolated gram-positive bacteria. Eight-one episodes (45.3 %) responded to the first-line treatment and death reported in 20 cases (10 %). Our study showed almost equal trend of gram positive and gram negative bacteria isolated from patients suffering from neutropenic fever. Empirical use of Ceftazidime and Amikacin as first-line antibiotics was able to cover the infection only in 45.3 % of episodes suffering from FN.

Targeted case finding for hepatitis B using dry blood spot testing in the British-Chinese and South Asian populations of the North-East of England.

Chronic infection with the hepatitis B virus (HBV) is a frequent cause of cirrhosis and liver cancer. Targeted HBV screening is recommended by the Centre for Disease Control (CDC) and Prevention for subjects born in countries with >2% HBV prevalence. However, there are no UK guidelines. Here, we applied the (CDC) recommendations to the British-Chinese and British-South Asian community of North-East (NE) England. British-Chinese and South Asian subjects were invited to attend for HBV education and screening sessions held in community centres. Hepatitis B surface antigen (HBsAg) and hepatitis B core total antibody (HBcAb) were tested with dry blood spot tests. South Asians were also tested for hepatitis C antibody (HCVAb). A total of 1126 subjects (606 Chinese and 520 South Asian) were screened. Sixty-two (5.5%) were HBsAg positive. Ten of these reported a previous diagnosis of HBV. The prevalence of HBsAg positivity was 4.6% when previously diagnosed individuals were excluded. The HBsAg prevalence was significantly higher in the Chinese subjects compared with South Asians (8.7% VS. 1.7% P < 0.001). In Chinese subjects, HBsAg positivity was highest in subjects born in Vietnam (17.4%), followed by China (11%), Hong Kong (7.8%) and the UK (6.7%). Subjects from Pakistan had the highest HBsAg and HCV Ab prevalence in the South Asians (3.1% and 1.8%, respectively). Ten percentage of HBsAg positive patients who had follow-up assessment had active disease requiring antiviral treatment. Undiagnosed HBV infection was above the 2% threshold for screening suggested by the CDC in the British-Chinese and Pakistani community of NE England, which provides evidence for a UK HBV-targeted screening programme.

Clinical skills assessment: comparison of student and examiner assessment in an objective structured clinical examination.

BACKGROUND: Learning of basic clinical skills is introduced in Years 1 and 2 of the MBBS Program; the Aga Khan University, Pakistan, through a structured Clinical Skills Teaching program. Acquisition of competence in performing these skills is assessed through use of the Objective Structured Clinical Examination (OSCE). Self-assessment is defined broadly as the involvement of learners in judging whether or not learner-identified standards have been met. OBJECTIVE: Compared Year 2 students' self-assessment of clinical skills with examiners' assessment of performance in an OSCE using a standard rating scale. METHODS: A self-assessment questionnaire was completed by all Year 2 students immediately after the OSCE. Students assessed their performance at three stations, using a performance rating scale. Examiners observed and evaluated the students during history-taking and physical examination using the same rating scale. RESULTS: There were significant positive correlations between examiners' assessments of performance and students' self-assessed ratings in taking consent, obtaining demographic information, history of presenting problems and summarization. Significant differences were observed in pre-procedural skills, comment on prostate, liver palpation percussion and spleen percussion. CONCLUSIONS: Findings highlight the strengths and weaknesses in clinical competence at the end of Year 2 and provide a direction to improve the gaps in the Clinical Skills Teaching program.

Maternal risk factors associated with low birth weight in Karachi: a case-control study.

To evaluate maternal risk factors associated with low birth weight (LBW) among women aged 15-35 years, we carried out a hospital-based, case-control study on 262 cases (mothers of neonates weighing < or = 2.5 kg) and 262 controls (mothers of neonates weighing > 2.5 kg). Odds of delivering a low-birth-weight baby decreased with increase in maternal haemoglobin [odds ratio (OR): 0.701; 95% confidence interval (CI): 0.62-0.79]. Odds were greater among mothers not using iron supplements during pregnancy (OR: 2.88; 95% CI: 1.83-4.54). Mothers of LBW babies had lower haemoglobin levels before delivery.

Increased body fat percentage and physical inactivity are independent predictors of gestational diabetes mellitus in South Asian women.

OBJECTIVE: This study aims to identify lifestyle predictors of gestational diabetes mellitus (GDM) in South Asian women. Pre-gravid body mass index, body composition, rate of weight gain during pregnancy, physical activity (PA) and dietary intake were studied. DESIGN: Prospective cohort study (n=611) of South Asian women at Aga Khan University Hospital antenatal clinic in Karachi, Pakistan. Weight, height and body fat % were measured and data on PA, diet and socio-economic covariates were collected at baseline. A glucose screen was performed at 29.8+/-2.6 weeks. RESULTS: Using logistic regression analysis for the full cohort, the risk of GDM increased with older maternal age (odds ratio (OR) 1.13, confidence interval (CI) 1.06-1.21), increased body fat % (OR 1.07, CI 1.03-1.13) and the risk was inversely associated with PA (100 kcal) (OR 0.79-0.99, CI 0.89). Using a nested case (n=49) control (n=98) design to study dietary intake, the risk of GDM decreased with increasing protein (% energy) in the diet (OR 0.75, CI 0.60-0.95). CONCLUSIONS: Body fat %, physical inactivity and, possibly, diet quality are important modifiable risk factors for GDM. 2006.

Knowledge and awareness of pregnant women about ultrasounsd scanning and prenatal diagnosis.

OBJECTIVE: Antenatal screening and ultrasound scan has become an integral part of the antenatal care in the present time. The aim of this study is to accurately describe the background knowledge and awareness of pregnant women about ultrasound scan and prenatal diagnosis. METHODS: It is a clinic based cross sectional study. Four hundred women, attending the antenatal clinics, were asked to fill in a pre tested structured questionnaire. Different variables of interest were collected. Statistical Program for the social sciences (SPSS) was used for the data management. RESULTS: Over 93.5% of the women were aware that ultrasound examination is an important investigation. They believed that it should be performed at least twice during pregnancy but were not sure about the timing of the test. Most of them felt that it was to check the growth of the baby and 97% of women considered ultrasound to be safe. However, only 26% of women had any knowledge about Down's syndrome or its screening. CONCLUSION: Pregnant women in our set-up are aware of importance of ultrasound examination during pregnancy. However, there is a need to improve public awareness of problems like Down's syndrome.

Risk factors and behaviours for coronary artery disease (CAD) among ambulatory Pakistanis.

OBJECTIVE: To determine the frequency and distribution of various risk factors and behaviours for coronary artery disease (CAD) among ambulatory Pakistanis. METHODS: It is a cross-sectional descriptive study carried out at the Aga Khan University Hospital, a teaching hospital in Karachi. All the subjects were adults (18-60 years) presenting at the general checkup clinic with no history or evidence of CAD by convenient sampling method. Demographic variables included risk factors and behaviors including diabetes, hypertension, dyslipidemia, family history of heart disease, obesity, smoking and sedentary lifestyle. RESULTS: Among 370 ambulatory Pakistanis, the proportions of major risk factors for CAD were: sedentary life style 72%, family history 42%, dyslipidemia 31%, obesity 24%, hypertension 19% and diabetes mellitus 15%. Diabetes, hypertension and dyslipidemia were poorly controlled in the study population. Proportions of the three major risk factors (smoking, hypertension and dyslipidemia) occurring singly, doubly and all three together in the study population were found to be 39%, 11% and 1%, respectively. Data were also analyzed for risk factors by comparing those with and without family history of CAD to eliminate any bias. The results were not statistically significant except for the sedentary life style (P=0.016). CONCLUSION: There is a high prevalence of CAD risk factors in this study population. Modifiable risk factors like diabetes, hypertension and high cholesterol need better control. Preventive screening programs and healthy lifestyle behaviours need to be emphasized upon in the community.

Antimicrobial activity of varying concentrations of sodium hypochlorite on the endodontic microorganisms Actinomyces israelii, A. naeslundii, Candida albicans and Enterococcus faecalis.

AIM: To determine the resistance of microorganisms associated with refractory endodontic infections to sodium hypochlorite used as a root canal irrigant. METHODOLOGY: Two strains each of Actinomyces naeslundii, Candida albicans and Enterococcus faecalis were tested as late logarithmic phase inocula, against sodium hypochlorite adjusted to 0.5, 1.0, 2.5 and 5.25% w/v. Contact times used were 0, 10, 20, 30, 60 and 120 s. In the case of E. faecalis, additional experiments used contact times of 1.0, 2.0, 5.0, 10.0 and 30.0 min. Anti-microbial action was halted by sodium thiosulphate addition. Survivors were measured primarily using viable counts on drop plates. Additionally, pour plates were used to count low colony-forming units (cfu) and dilutions to 10(-6) were used to count high cfu. RESULTS: All concentrations of NaOCl lowered cfu below the limit of detection after 10 s in the case of A. naeslundii and C. albicans. However, E. faecalis proved to be more resistant to NaOCl. Using 0.5% NaOCl for 30 min reduced cfu to zero for both strains tested. This compares with 10 min for 1.0%, 5 min for 2.5% and 2 min for 5.25% (P < 0.001). Regression analysis for the dependent variable log(e)(count + 1) with log(e)(time + 1) and concentration as explanatory variables gave rise to a significant interaction between time and concentration (P < 0.001). CONCLUSION: The published association of E. faecalis with refractory endodontic infection may result, at least partially, from high resistance of this species to NaOCl. This does not appear to be the case with A. naeslundii or C. albicans.

Prevalence and factors associated with anxiety and depression among family practitioners in Karachi, Pakistan.

OBJECTIVE: We aimed to assess anxiety and depression and to identify the factors associated with these conditions among family practitioners in Karachi, Pakistan. METHODS: A self-reported postal survey was conducted among 540 family practitioners in Karachi during the months of July - August 2003. Aga Khan University Anxiety and Depression Scale (AKUADS) was used to assess anxiety and depression. Additional questions were also inquired to get information about socio-demographic, professional and lifestyle characters. RESULTS: Using AKUADS, 155 (39%) family practitioners had anxiety and depression. Mutlivariate analysis disclosed five factors to be significantly associated with anxiety and depression; these were female sex (AOR = 6.4, 95% CI 3.2-12.6); age group of < 35 years (AOR = 23.3, 95% CI 9.0-60.3); lack of regular exercise (AOR = 4.9, 95% CI 2.4-10.2) and working for more than 48 hours per week (AOR = 12.7, 95% CI 6.2-26.2). CONCLUSION: This study reveals that prevalence of anxiety and depression among family practitioners in Karachi is high and higher than general population in Karachi. Further research and intervention studies are required to identify preventive measures in this regard and also to assess the impact of these interventions.

Maternal anaemia and its impact on perinatal outcome in a tertiary care hospital in Pakistan.

Maternal anaemia is a common problem in pregnancy, particularly in developing countries. We investigated the relationship between maternal anaemia and perinatal outcome in a cohort of 629 pregnant women from October 2001 to 2002. Of these, 313 were anaemic (haemoglobin < 11 g/L). Perinatal outcomes included preterm delivery, low birth weight, intrauterine growth retardation, perinatal death, low Apgar scores and intrauterine fetal death. Univariate and multivariate analyses were performed. The risk of preterm delivery and low birth weight among the anaemic women was 4 and 1.9 times more respectively than the non-anaemic women. The neonates of anaemic women also had 1.8 times increased risk having low Apgar scores at 1 minute and there was a 3.7 greater risk of intrauterine fetal death among the anaemic women than the non-anaemic women.

Knowledge about hepatitis B and C among patients attending family medicine clinics in Karachi.

Knowledge about hepatitis B and C was assessed in a cross-sectional study of 300 adults aged 18 or older attending family medicine clinics at The Aga Khan University Hospital, Karachi. Most knew that hepatitis B and C are viral diseases that primarily affect the liver, but knowledge about risk factors for disease transmission was poor. Approximately 70% knew that hepatitis B is vaccine preventable; 60% had the misconception that hepatitis C is also vaccine preventable. The majority incorrectly believed that people with hepatitis B or C should follow the diet 'parhaiz'. Generally women knew more than men about the diseases. This study suggests that health education about these infections should be provided to the public. Family physicians can play an important role in educating people about the prevention of these diseases.

Delayed presentation of esophageal perforation simulating paraesophageal hernia.

Generally, benign lesions, which make up the majority of mediastinal tumors and cysts, are asymptomatic; however, they may produce clinical findings. We report on a patient with presumed silent esophageal perforation whose clinical and radiologic assessment was suggestive of massive paraesophageal hiatus hernia. However, surgery revealed a paraesophageal cyst and histology was reported as acute organizing pleurisy. A reasonable, tentative, preoperative diagnosis for each mediastinal lesion can be frequently made by considering its location in the mediastinum, the age of the patient, the presence or absence of local or constitutional symptoms and signs, and the association of a specific systemic disease state. However, the precise nature of a lesion in the mediastinum, as elsewhere, cannot be determined without histologic examination of the tissue. To our knowledge, this unusual clinical case is not been reported in the literature.

Foreign body in tracheal bronchus simulating bronchogenic cancer.

A foreign body in the bronchial tree may mimic many pathological conditions. We present a case of a 62-year-old patient with a foreign body in the tracheal bronchus simulating bronchogenic cancer. After the removal of the foreign body, there has been a gradual regression of the foreign body induced inflammatory changes. To the best of our knowledge, a similar case has not been reported in the English medical literature.