Medical Students' Perceptions at Dow University of Health Sciences using Dundee Ready Education Environment Measure Inventory.

Objectives: To assess medical students' perceptions regarding learning, teachers, academics, atmosphere at campus and social self-perceptions at Dow University of Health Sciences using Dundee Ready Education Environment Measure (DREEM) Inventory. Method: This cross-sectional observational study was conducted from March 1st, 2022 to September 30th, 2022. All medical students at Dow University of Health Sciences were offered to participate. All students were given the choice to respond to DREEM questionnaire via online Form or printed copy anonymously. The DREEM Inventory measures five domains of students' perceptions of a given institution. Comparison of responses between different years and institution was carried out by χ2 test. Means scores were compared by Student's t-test and ANOVA, p-value of ≤.05 was taken as significant. Results: Total of 1054 out of 1750 (60.23%) students submitted fully completed forms and were included, out of these 632 (60.0%) belonged to Dow Medical College & 422 (40.0%) belonged to Dow International Medical College. The mean ±SD of total score of DREEM by DMC students was 100.07 ±31.46 and that of DIMC was 100.52 ±32.73. According to DREEM Global scoring both colleges scores fell into category of "many problems". Analysis according to domains showed that maximum score was given to 2nd domain of their "perception regarding teachers" and minimum score was allocated to 5th domain regarding "social self-perceptions". Conclusion: Overall Students perceived environment at DUHS as "many problems" category. This needs to be investigated for betterment of Educational Environment (EE) at campus.

Yield & accuracy of Gastric Lavage in non-expectorating adults with Suspected Pulmonary Tuberculosis.

Objective: To determine the yield of Gastric lavage (GL) in non-expectorating adults with suspected Pulmonary Tuberculosis (PTB) and accuracy of GL-AFB smear with GL-GeneXpert (GXP) by taking AFB culture as gold standard. Methods: Cross-sectional study on suspected PTB patients was done at Ojha Institute of Chest Diseases during period 16th July 2020 till 15th January 2021. Adult patients of either gender suspected to have PTB and not expectorating were included. GL was performed and sent for AFB smear, GXP and AFB culture. Odds ratio, sensitivity and specificity were calculated. Results: After informed written consent, 206 patients, mean age was 38.17 ±17.30 years were inducted, including 89 (43.2%) males and 117 (56.8%) females. Gene Xpert, AFB smear & AFB culture were positive in 83(40%), 50 (24%) & 72 (35%) respectively in GL samples. Odds of PTB were 3.95 times higher among patients with ≤1 month of duration of symptoms (aOR 3.95, 95% CI 1.82-8.57, p-value 0.001), 6.24 times higher among patients with weight loss (aOR 6.24, 95% CI 3.03-12.84, p-value <0.001), and 4.22 times higher among patients with cavitation (aOR 4.22, 95% CI 1.99-8.93, p-value <0.001). GL-AFB smear showed sensitivity 63.89%, specificity 97.01%, positive predicted value 92%, negative predicted value 83.3%, and overall diagnostic accuracy 85.4%. Whereas GL-GXP showed sensitivity 94.4%, specificity 88.81%, positive predicted value 81.93%, negative predicted value 96.75%, and overall diagnostic accuracy 90.78%. Conclusion: Yield of GL significant to detect PTB in suspected cases who are not expectorating. GL-GXP diagnostic accuracy and sensitivity is higher than GL-AFB smear.

Muscle weakness assessment in non-hypoxemic COPD out-patients at tertiary care hospitals.

OBJECTIVE: To determine frequency of Muscle Weakness in Non-Hypoxemic COPD out-patients and Comparison with age matched non-COPD Controls. METHODS: This cross-sectional study was conducted at OPD of Ojha Institute of Chest Diseases and Medicine, Dow University of Health Sciences, Karachi, Pakistan, during the period 8th September 2019 till 30th May 2020. Patients of both genders aged 25-70 years who were satisfying GOLD criteria for COPD and having SpO2 ≥ 94% were included. An age matched control group was added as control. Hand Grip Strength (HGS) and Chair to Stand time (CST) were recorded. RESULTS: Two hundred fifty-six patients were inducted with aged and BMI matched group of non-COPD Control patients in ratio of 1:2 (n = 128). Comparison of HGS between Control and COPD Groups showed significant weakness in COPD group. Significant weakness in lower limbs in COPD Group with longer timings to complete the task. Mean FEV1 had significant low values in COPD Group. Age correlated negatively with HGS & positively with CST. BMI correlated positively with FEV1 and CST but negatively with HGS. HGS correlated positively with FEV1 and no correlation was found with CST. No correlation was found of CST with FEV1. CONCLUSION: Muscle weakness in COPD patients was shown by simple validated bedside tools. The older COPD patients had less HGS and were slower in doing CST whereas those COPD ones who had higher FEV1 had more HGS.

Role of Montelukast in Asthma and Allergic rhinitis patients.

OBJECTIVES: Our objective was to evaluate the effect of Montelukast on the symptoms of asthma and allergic rhinitis (AR), assess its effect on the individual quality of life (QoL), and estimate the proportion of participants having adverse effects. METHODS: This prospective, open-label study conducted at Dow University of Health Sciences, Ankle Saria Hospital and Sindh Government Hospital Liaquatabad, Karachi, from August 2018 to September 2019, included patients aged >18 years with a clinical diagnosis of Asthma, AR, or both. Patients were given a 10 mg Montelukast tablet each day and then called for follow-up in the fourth week, where the questions related to the improvement in the symptoms of asthma or AR were asked. Patients were also asked about the improvement in QoL and any adverse effects. RESULTS: A total of 694 patients were registered of which 138(19.8%) had AR, 294(42.4%) had asthma, while 273(39.3%) had both. Mean age was 41.1±14.63 years and 352 (50.7%) were male and 342(49.3%) were females. On a follow-up visit, there was a sufficient improvement in 351 asthmatics (63.9%), and 288 patients with AR (70.1%) overall, strong or marked improvement in the day (n=342,62.3%) and night time (n=331,60.3%) asthma symptoms. Overall improvements in QoL were very good or good in 419 patients. Montelukast was well-tolerated here with adverse effects (like abdominal discomfort, fever, fatigue, headache, rash, and upper respiratory tract symptoms) seen in 125 patients (18.01%). CONCLUSION: Montelukast was very effective in improving the symptoms and QoL of the individuals suffering from asthma and/or AR.

Frequency of Blood Eosinophilia in newly diagnosed Chronic Obstructive Pulmonary Disease patients.

OBJECTIVE: To determine Blood Eosinophilia frequency in newly diagnosed Chronic Obstructive Pulmonary Disease patients. METHODS: An observational cross-sectional research on newly diagnosed COPD patients with age ≥ 40 years was performed at Ojha Institute of Chest Diseases, Dow University of Health Sciences Karachi. COPD patients diagnosed in outpatient clinic or admitted in Chest Unit during six-month period from September 2018 to May 2019 were selected. Each patient underwent spirometry, and blood was tested for eosinophilia (≥ 2% eosinophils in blood), after obtaining informed consent and clinical history. RESULTS: One hundred and fifty COPD patients were diagnosed and evaluated for Blood Eosinophilia, out of which 86 (57.3%) and 64 (42.7%) patients were Males and Females respectively with mean age of 63.72 ± 10.24 years. Current Smokers were 48 (32.0%), Ex-Smokers 15 (10.0%), and Biomass Exposure was present in 76 (50.7%) of patients. Spirometric severity of COPD was Mild in 11 (7.3%), Moderate in 68 (45.3%), Severe in 59 (39.3%), and Very Severe in 12 (8.0%) patients. Blood Eosinophilia was present in 59 (39.3%) patients of COPD among which majority 43 (72.9%) were having Moderate 24 (40.7%) and Severe 19 (32.2%) COPD respectively. CONCLUSION: Frequency of Blood Eosinophilia in newly diagnosed COPD patients was high, among which most of the COPD patients were moderate to severe.

Role of Bronchial Washing Gene Xpert in Sputum-Scarce Cases of Suspected Pulmonary Tuberculosis.

OBJECTIVE: To determine the frequency of mycobacterium tuberculosis detection, in bronchial washing in sputum-scarce cases of suspected pulmonary tuberculosis. METHODS: A descriptive cross-sectional study was conducted at the Ojha Institute of Chest Diseases, Dow University of Health Sciences, Karachi, during July 2016 to December 2017. Sputum-scarce patients with suspicion of pulmonary tuberculosis were selected and underwent for bronchoscopy, detailed examination of bronchial tree was performed, and bronchial washing collected for testing of mycobacterium tuberculosis with Gene Xpert. RESULTS: A total of 120 patients were included. In this study 55 (45.8%) patients were female and 65 (54.2%) were male with mean±SD of age was 39.9 ±14.7 years. Bronchial washing Gene Xpert for mycobacterium tuberculosis was detected in 83 (69.2%) sputum-scarce cases of suspected pulmonary tuberculosis patients. CONCLUSION: Bronchial washing Gene Xpert has an excellent diagnostic yield for detection of mycobacterium tuberculosis in sputum-scarce cases of suspected pulmonary tuberculosis.

Risk factors for mortality among inpatients with smear positive pulmonary tuberculosis.

OBJECTIVE: To evaluate risk factors having significant effect on mortality of smear positive Pulmonary Tuberculosis (PTB) inpatients. METHODS: A descriptive cross-sectional study was conducted at Ojha Institute of Chest Diseases, Dow University Hospital Ojha Campus, Karachi. One hundred and seventy (170) inpatients of smear positive PTB confirmed by Acid Fast Bacilli (AFB) smear, aged between 13-80 years were enrolled by using consecutive sampling technique while patients with drug resistant Tuberculosis (TB) and extra pulmonary TB were excluded from the study. Selected patients were interviewed for collecting demographic data and risk factor data by using a standard questionnaire. RESULTS: Out of 170 PTB inpatients, mortality was observed in 23 (13.5%) patients among which male patients were 12 (52.2%), and female were 11 (47.8%). Mortality was significantly associated with increasing age (p=0.003), socioeconomic status (p=0.019), anemia (p=0.03), Chronic Liver Disease (CLD) (p=0.005), Diabetes Mellitus (DM) (p=0.001), Human Immunodeficiency Virus (HIV) (p=0.007), Hypertension (HTN) (p=0.006), recurrent TB (p=0.001), and smoking (p=0.001). CONCLUSION: Increasing age, poverty, smoking history, and presence of comorbidities like DM, CLD, HIV, hypertension, and anemia are associated with higher mortality in smear positive PTB cases.

Non-specific impairment of Lung Function on Spirometery in Patients with Chronic Hepatitis-C.

OBJECTIVES: To document frequency of non-specific impairment of lung functions (NILF) in patients of HCV and to compare according to gender, genotype, liver fibrosis score and smoking status. METHODS: Patients of chronic hepatitis C were included after informed consent. Demographic data was recorded, and they underwent baseline investigations, fibroscan, abdominal ultrasound and PFT. Patients were segregated on basis of gender, fibroscan stages and smoking status. NILF was labelled if any two of three criteria are fulfilled (a) FVC < 80% of Predicted, (b) FEV1 < 80% Predicted, (c) FEV1/FVC ≥ 70. RESULTS: Two hundred thirty four patients were of chronic HCV who fulfilled the selection criteria were inducted in study. These included 49.6% males and 50.4% females. There were 15.0% smokers, 16.2% were ex-smokers while 68.8% were never smokers. NILF was present in 130 (55.6%) out of which 61.5% were female and 38.5% were male (p <0.001), its presence in smokers was 56.2% and in never smokers was 55.3% (p=0.507). Presence of NILF increased with Fibroscan stages from F1 to F4 (p <0.001). CONCLUSIONS: NILF pattern on spirometry with normal chest radiograph is common among HCV patients. It was found more common in females and frequency increased progressively with fibro scan stages.

Yield of closed pleural biopsy and cytology in exudative pleural effusion.

OBJECTIVE: To determine diagnostic yield of Closed Pleural Biopsy (CPB) and Cytology in Exudative Pleural Effusion (PE). METHODS: This prospective comparative study was conducted at Chest Unit-II & Medical Unit-IV of Dow University of Health Sciences, Karachi Pakistan from January 2011 till December 2014. RESULTS: Ninety-four patients with exudative PE were finally included. The mean age (SD) was 44.0 (13.8) years. Overall Specific Diagnosis was reached in 76/94 patients; 46 Tuberculosis PE (TPE) & 30 Malignant PE (MPE). CPB diagnosed all TPE patients alone and 28/30 of MPE. Cytology diagnosed only 10/30 patients of MPE with 8 patients having both CPB & Cytology positive for malignancy whereas in the remaining two cases only Cytology positive. The sensitivity of CPB in detecting TPE and MPE was 93.9% and 82.4% respectively whereas specificity for both was 100%. The diagnostic yield of cytology in detecting MPE is only (33.3%). The diagnostic yield of CPB for TPE and MPE is 100% and 93.3% respectively. The overall specific diagnostic yield of CPB is 78.7%. CONCLUSION: CPB is better than pleural fluid cytology alone with the later adding little to diagnostic yield when both combined in distinguishing TPE from MPE, the two main differential of exudative PE in a TB-Endemic country.

Frequency of minimal hepatic encepalopathy in illeterate patients with compensated cirrhosis.

OBJECTIVE: To determine frequency of Minimal Hepatic Encephalopathy in illiterate patients with compensated cirrhosis. METHODS: Illiterate patients with compensated cirrhosis with F4 Score on Shear-wave Elastography were selected for study after informed consent. Sample size was estimated at 106. Selected patients were subjected to two tests for detection of MHE, Number Connection Test A and Block Design Test. Patients taking ≥ 30 seconds were labelled as Positive for MHE. RESULT: Out of 110 selected patients 10.9% were alcoholics and in 8.2% of patients no hepatic virus infection was detected. HCV was positive in 48.2% patients while HBV was positive in 13.6% of patients. MHE was detected in 72 (65.5%) of patients. Major differences were found in MHE Stage II & III by two tests. Over all BDT detected more cases and gave higher Staging in Stage II & III as compared to NCT-A test. CONCLUSION: Minimal Hepatic Encephalopathy (MHE) could be detected in illiterate patients using NCT-A and BDT Tests.

Comparison of British Thoracic Society and American Thoracic Society reintroduction guidelines for anti-tuberculous therapy induced liver injury.

OBJECTIVE: To compare the efficacy of British Thoracic Society and American Thoracic Society guidelines for reintroduction of anti-tuberculous therapy after drug-induced liver injury, and to assess the ease of administration of each guideline on a scale of 1-10. METHODS: The randomised prospective interventional study was conducted at the Department of Medicine and Pulmonology, Dow University of Health Sciences, Karachi, from December 2011 to November 2013. Patients with anti-tuberculous therapy drug-induced liver injury were selected. Hepatotoxic anti-tuberculous therapy was stopped and modified anti-tuberculous therapy was started. Patients were followed weekly till clinical and biochemical parameters got stabilised. After stabilisation, the patients were randomised to one of the two groups to receive re-introduction of anti-tuberculous therapy under the guidelines of British Thoracic Society (Group I) or those of American Thoracic Society (Group II). Means of the groups were analysed by Student's t test and proportions were compared by chi-square test. Multivariate analysis was done for age, body mass index and serum albumin for recurrence of drug-induced liver injury after the re-introduction. P value < 0.05 was taken as significant. RESULTS: Of the total 325 patients, 163 (50.15%) were in Group I, while 162 (49.84%) were in Group II. The frequency of recurrence of drug-induced liver injury in Group I was 16 (9.8%) and in Group II it was 18 (11.1%).There was no statistically significant difference between the two groups (p < 0.7). Age was positively related with drug-induced liver injury, while body mass index and serum albumin were negatively associated. CONCLUSION: There was no significant difference between the two major guidelines though the American Thoracic Society guideline was easier to follow.

Association between insulin resistance and BMI with FEV1 in non-hypoxemic COPD out-patients.

OBJECTIVES: This study was conducted to determine the impact of insulin resistance using Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) score and BMI in non-hypoxemic out-patients with COPD on FEV1 using linear and polynomial regressions and to determine their correlation. METHODS: COPD patients of both genders were included after informed consent. Fasting blood sugar and serum insulin were done to calculate HOMA-IR, which were segregated into two groups of ≥ 3 and < 3 labeled insulin resistance present and absent, these were compared with BMI. Patients were segregated into GOLD Grade 1-4 per GOLD Guidelines and compared with HOMA-IR and BMI. Curve and linear regressions, multivariate and univariate analysis of HOMA-IR with BMI, FVC, and FEV1 were done. RESULTS: A total of 273 subjects were inducted after informed consent. There was a linear correlation between HOMA-IR and BMI (r2 0.498, P < 0.001) and nonlinear correlation between HOMA-IR and FEV1 (r2 0. 617, P < 0.001) which showed little evidence of association above FEV1 > 60 predicted, but a clear negative association below that. Significant increase in HOMA-IR was seen from GOLD-2 to 3 and from GOLD-3 to 4 classes. The impact of HOMA-IR on FEV1 was 49.9% (P < 0.001) on FVC was 43.7%. CONCLUSIONS: The results indicate that there is a high prevalence of IR in non-hypoxemic COPD. A nonlinear association is present between FEV1 and HOMA-IR which is most evident with FEV1 <60% predicted.

Sustained virological response based on rapid virological response in genotype-3 chronic hepatitis C treated with standard interferon in the Pakistani population.

AIM: To document the sustained virological response (SVR) in rapid virological responders (RVR) of genotype-3 chronic hepatitis C with standard interferon (SdIF). METHODS: Hepatitis C genotype-3 patients during the period July 2006 and June 2007 were included. Complete blood counts, prothrombin time, ALT, albumin, qualitative HCV RNA were done. SdIF and ribavirin were given for 4 wk and qualitative HCV RNA was repeated. Those testing negative were allocated to group-A while the rest were allocated to group-B. Treatment was continued a total of 16 and 24 wk for group A and B respectively. HCV RNA was repeated after 24 wk of treatment. End virological and sustained virological responses were compared by c2 test. ROC of pretreatment age, ALT and albumin were plotted for failure to achieve SVR. RESULTS: Of 74 patients treated, RCV RNA after 16 wk of therapy became undetectable in 34 (45.9%) and was detectable in 40 (54.1%) and were allocated to groups A and B respectively. SVR was achieved in 58.8% and 27.8% in groups A and B respectively. SVR rates were significantly higher in patients who had RVR as compared to those who did not (P = 0.0; gamma = 2). Both groups combined ETR and SVR were 70% and 33% respectively. ROC plots of pretreatment age, ALT and albumin for SVR showed only ALT to have a significantly large area under the curve. CONCLUSION: SVR rates were higher in patients who had RVR with SdIF and high pre treatment ALT values correlated to probability of having RVR.

Appraisal of the knowledge of Internet users of Pakistan regarding hepatitis using on-line survey.

BACKGROUND: Hepatitis B and hepatitis C are global health care problems causing morbidity and mortality. Much of it could be prevented by better education of the masses regarding its spread. The study was conducted to assess the knowledge base of internet users of Pakistan to help in formulating education strategies. METHODS: A survey questionnaire consisting of 20 close ended questions was designed and hosted on a website. The responses submitted at the website were auto-emailed to the author. RESULTS: A total of 1024 complete responses were included. The survey shows increased level of awareness according to the educational status. The knowledge status of lowest education level was also adequate possibly due to access to internet to these respondents. CONCLUSION: Internet users in Pakistan have adequate core knowledge regarding hepatitis.

Frequency of rectal varices in patients with cirrhosis.

OBJECTIVE: To document the frequency of rectal varices in patients with cirrhosis of liver and compare it with that of oesophageal varices in liver and to compare the frequency of rectal varices with non-cirrhotic controls. DESIGN: A cross-sectional analytical survey. PLACE AND DURATION OF STUDY: The study was conducted in the medical wards of Civil Hospital, Karachi from August 2000 to July 2001. PATIENTS AND METHODS: All patients of confirmed cirrhosis of liver, presenting during the study period, were selected for initial workup. On the basis of upper gastrointestinal (GI) endoscopy, patients were segregated into those with oesophageal varices (Group-A) and those without them (Group-B). A matched control group (Group-C) was added, which consisted of patients of irritable bowel syndrome (IBS) who underwent sigmoidoscopic/colonoscopic examination during the study period. Fiberoptic sigmoidoscopy was done in all selected patients. Statistical analysis for continuous variables was done by student's 't' test while non-continuous variables were analyzed by Mann-Whitney-U test. RESULTS: A total of 104 patients (males 61; females 43) were included. Hepatic encephalopathy grade was significantly lower in Group-B (p < 0.0001). Grade-I varices were seen in 13 patients, Grade-II in 38 and Grade-III in 33 patients of Group-A. Rectal varices were present in 59.9% of patients in Group-A as compared to Group-B in which no one had them (p <0.0001). CONCLUSION: Rectal varices are common in patients of portal hypertention.