Cutaneous Leishmaniasis in Khyber Pakhtunkhwa Province of Pakistan: Clinical Diversity and Species-Level Diagnosis.

This study primarily aimed to identify the causative species of cutaneous leishmaniasis (CL) in the Khyber Pakhtunkhwa Province of Pakistan and to distinguish any species-specific variation in clinical manifestation of CL. Diagnostic performance of different techniques for identifying CL was assessed. Isolates of Leishmania spp. were detected by in vitro culture, polymerase chain reaction (PCR) on DNA extracted from dried filter papers and microscopic examination of direct lesion smears from patients visiting three major primary care hospitals in Peshawar. A total of 125 CL patients were evaluated. Many acquired the disease from Peshawar and the neighboring tribal area of Khyber Agency. Military personnel acquired CL while deployed in north and south Waziristan. Leishmania tropica was identified as the predominant infecting organism in this study (89.2%) followed by Leishmania major (6.8%) and, unexpectedly, Leishmania infantum (4.1%). These were the first reported cases of CL caused by L. infantum in Pakistan. PCR diagnosis targeting kinetoplast DNA was the most sensitive diagnostic method, identifying 86.5% of all samples found positive by any other method. Other methods were as follows: ribosomal DNA PCR (78.4%), internal transcribed spacer 2 region PCR (70.3%), culture (67.1%), and microscopy (60.5%). Clinical examination reported 14 atypical forms of CL. Atypical lesions were not significantly associated with the infecting Leishmania species, nor with "dry" or "wet" appearance of lesions. Findings from this study provide a platform for species typing of CL patients in Pakistan, utilizing a combination of in vitro culture and molecular diagnostics. Moreover, the clinical diversity described herein can benefit clinicians in devising differential diagnosis of the disease.

Role of Skill Laboratory Training in Medical Education - Students’ Perspective.

OBJECTIVE: To evaluate the perceptions of medical students regarding their training utilizing facilities provided in the skill laboratory of a public sector medical college. STUDY DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: Army Medical College, Rawalpindi, from October to December 2014. METHODOLOGY: Students of final year MBBS who had underwent skill laboratory training were recruited through convenience purposive sampling. Students not exposed to skill laboratory training were excluded. Data collection tool was a questionnaire having 23 questions with responses on Likert Scale as strongly disagree, disagree, agree and strongly agree coded as 1, 2, 3 and 4, respectively. Data was analysed on SPSS version 22. RESULTS: There were 78 (57%) male and 59 (43%) female students out of 137, with mean age of 22.59 ±0.74 years. The response rate was 68.5%. Cronbach's Alpha test was 0.84 showing high reliability. The mean of sum of all the 23 items was 63.85 ±8.71, whereas item means was 2.78 ±0.38, reflecting a high inclination of students towards skill laboratory training. Frequency of students responding in favour of skill laboratory training was significantly high (p < 0.05). CONCLUSION: Medical students perceived skill laboratory training as a favoured learning strategy as compared to practising on real patients for acquisition of various aspects of clinical skills, knowledge and attitude.

Perceptions of undergraduate medical students regarding case based learning and tutorial format.

OBJECTIVE: To evaluate the perception of medical students regarding tutorial and case-based learning formats. METHODS: The within stage mixed model research was conducted at the Army Medical College, National University of Sciences and Technology, Islamabad, Pakistan, from April 2012 to March 2013, and comprised medical students of 4th year. Data-collection tool was a self-developed questionnaire, and it was statistically analysed using SPSS 16. RESULTS: Of the 144 students, 86(60%) were males. The overall age range was 21.5-23.4 years. Case-based learning method had significantly higher scores compared to tutorial method for learning process (p<0.001), for behavioural influence of facilitators (p<0.001), for group dynamics (p<0.001), and for learning environment (p<0.001). For open-ended questions regarding like or dislike of the two methods, majority named some faculty members as their role models and appreciated their support in better and in-depth learning through case-based learning format. CONCLUSIONS: Case-based learning format was significantly more appreciated and favoured as a learning strategy by students.

Serum leptin values in the healthy obese and non-obese subjects of Rawalpindi.

OBJECTIVE: To determine serum leptin concentrations from a sample of Rawalpindi population in relation to body mass index, age and gender. METHODS: The observational, comparative study was conducted at the Armed Forces Institute of Pathology, Rawalpindi, and Benazir Bhutto Hospital, Rawalpindi from August 2008 to December 2008. Subjects were 100 including healthy obese, overweight and non-obese of both genders aged between 20-50 years. Sampling was done by non-probability convenience method. Body Mass Index was calculated by formula BMI = weight in kg/height in m2: non-obese subjects were defined as 18.5-23.0 kg/m2; overweight 23.1-27.4 kg/m2; and obese 27.5-40 kg/m2. Serum glucose was measured using Glucose oxidase-phenol amino phenazone (GOD-PAP) method and serum leptin by sandwich enzyme-linked immunosorbent assay method. RESULTS: Serum leptin concentrations were higher in obese subjects (mean 52.8 +/- 24.6 ng/mL; range 28.2-77.4 ng/mL; P < 0.001) than in non-obese subjects (mean 12.7 +/- 6.1 ng/mL, range 6.6-18.8ng/mL). Mean Body Mass Index in obese group was 31.7 +/- 3.1 kg/m2 (range 28.6-34.8 kg/m2) while it was 21.2 +/- 1.5 kg/m2 (range 19.7-22.7 kg/m2) in the nonobese group. Body Mass Index was strongly positively correlated with serum leptin concentration (r = 0.59, p < 0.001) in the obese group. The mean serum leptin concentration was much higher in the healthy obese and non-obese women (64.4 ng/mL and 8.7 ng/mL respectively) than in men of both categories (40.4 ng/mL and 5.5 ng/mL respectively). Age had no significant relation with serum leptin level (p = 0.416). CONCLUSIONS: In the study sample, serum leptin concentration was positively correlated with Body Mass Index in healthy obese and non-obese subjects of both genders. The levels were higher in women than in men. Age had no significant relation with serum leptin level in this age group.

Study of the role of novel RF-amide neuropeptides in affecting growth hormone secretion in a representative non-human primate (Macaca mulatta).

RF amide peptide family with distinctive terminal -Arg-Phe-NH(2) signature is evolutionarily conserved from invertebrates to mammals. These neuropeptides have been shown to affect diverse functions in invertebrates and vertebrates including influencing pituitary hormone secretion. More recently, two members of this family 26-amino acid and 43-amino acid RF amide peptide (26RFa and 43RFa, respectively) originally isolated from frog have been cloned in rats and humans. Actions of these peptides on hormone secretion have not been studied in primates. In the present study, effect of iv administration of three different doses of human 26RFa and 43RFa on GH secretion was studied in a representative higher primate, the rhesus monkey. As control against these two peptides, normal saline and a scrambled sequence of 26RFa was administered. A set of four intact adult male monkeys received the administration in a random order. Peripheral blood samples were obtained from the chairrestrained but fully conscious animals for a period of 30 min before and 240 min after the administration at 15-min intervals. For quantitative measurement of GH concentration, a human GH chemiluminescent immunometric assay was used. Peripheral administration of 38 and 76 nmol doses of 26RFa significantly (P < 0.05) stimulated GH AUC during a 0-120 min period after injection of 26RFa. In contrast to 26RFa, administration of 43RFa appeared to suppress GH levels during the later stages of the sampling i.e. from 120 to 240 min period. Mean AUC during the period was significantly (P < 0.05) reduced by 76 nmol dose of 43RFa, while 38 nmol dose of 43RFa also had similar effect but lacked full statistical significance (P = 0.058). To our knowledge present study reports for the first time-specific stimulatory effect of 26RFa on the GH secretion and a novel inhibitory and delayed effect of 43RFa on the GH secretion in higher primates. In conclusion, present findings extend evidence for endocrine actions of RF amides in primates and suggest differential effect of these peptides on GH secretion in primates.

Role of serum-ascites albumin gradient in differential diagnosis of ascites.

BACKGROUND: The classification of ascites as 'exudative' and 'transudative' based on ascitic fluid total protein (AFTP) has been challenged in many clinical conditions like cardiac ascites, patients on prolonged diuretic therapy and malignant ascites because it had poor diagnostic efficacy. These drawbacks have led to the development of another approach to classify ascites, which is based on Serum-Ascites Albumin Gradient (SAAG) to differentiate ascitic fluid into two categories: SAAG > or = 11 g/L in ascites due to portal hypertension and SAAG < 11 g/L in ascites unrelated to portal hypertension. Objective of this study was to compare the diagnostic efficacy of serum/ascites fluid albumin gradient and ascitic fluid total protein in patients having ascites. METHODS: This Cross-sectional comparative study was conducted in the Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology, Rawalpindi from 1st Jun 2007 to 30th May 2008. Ninety-three patients were included in the study by non probability convenience sampling. The patient grouped as: (Group I) 73 cases of liver cirrhosis, (Group II) 14 cases of hepatoma and 6 cases of tuberculous ascites. Ascitic fluid specimen and 3 ml blood were obtained for ascitic fluid estimation of ascitic fluid albumin, total proteins and serum albumin. Diagnostic efficacy of SAAG and AFTP was calculated by comparing the results with clinical, ultrasonographic, histopathological findings, ascitic fluid cell count/acid fast bacilli culture and other relevant investigations. RESULTS: Seventy-three cases had liver cirrhosis (group I), 14 cases had hepatoma and 6 cases had tubercular ascites (group II). Age ranged 25-80 years with mean age 56 years. Diagnostic accuracy, Sensitivity, Specificity, Positive predictive value (PPV) and Negative predictive value (NPV) of SAAG were 96%, 97%, 95%, 98.6%, and 90% respectively, whereas those of AFTP were 56%, 53%,70%, 86%, and 29% respectively. CONCLUSION: Differential diagnosis of ascites should be based on SAAG because diagnostic efficacy of SAAG was significantly higher than AFTP in work-up of ascites.

Serum inhibin B as a diagnostic marker of male infertility.

BACKGROUND: Infertility affects about 15% of all couples in the world. Approximately 40% of all infertility cases could be attributed entirely to male factors. Serum inhibin B has emerged as a sensitive marker of male fertility. Analysis of serum inhibin B reflects the relationship between inhibin B, Sertoli cell function and spermatogenesis. METHODS: This validation study was conducted to calculate the sensitivity, specificity, positive and negative predictive value of serum inhibin B in diagnosis of male infertility, using semen analysis as the gold standard. One hundred and sixty men were included in the study, they reported for semen analysis for evaluation of male infertility. Sperm count was done per standard procedure. Serum inhibin B level was determined by ELISA. RESULTS: Serum inhibin B level > or = 80 pg/ml was regarded as a normal response. The serum inhibin B test had 75% sensitivity, 93.1% specificity, 80.5% PPV and 90.7% NPV. CONCLUSION: Serum inhibin B has a positive correlation with sperm counts and could be used for evaluation of male infertility as a non-invasive predictor of spermatogenesis. The sensitivity, specificity and PPV are appropriate for clinical decision making and to avoid unnecessary testicular biopsies.

Frequency of conversion to overt hypothyroidism in patients with and without subclinical hypothyroidism.

BACKGROUND: Sub-clinical hypothyroidism (SCO) poses diagnostic and management difficulties for pathologists and clinicians. Cases of SCO are now diagnosed with increasing frequencies worldwide mainly because of availability of more sensitive methods for serum TSH, total T3 and free T4 assays. The rate of progression of SCO to overt hypothyroidism varies in different populations. Sub-clinical hypothyroidism has been suggested as a risk factor for hypothyroid complications. There is a need to identify and treat patients with SCO before they convert to overt hypothyroidism and develop complications. Objective was to compare the development of overt hypothyroidism in a cohort of patients of sub-clinical hypothyroidism and in subjects with normal thyroid function tests. METHODS: It was Cohort study conducted at Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology, Rawalpindi. Hundred patients of SCO and almost equal number of age and sex-matched subjects with normal Thyroid function test (TFT) were enrolled as healthy controls. Subclinical hypothyroid patients and controls were followed for a period of one year on six monthly bases. The patients were examined for signs and symptoms of hypothyroidism and serum TSH, total T3 and free T4 were estimated. The clinical history, physical examination and thyroid function tests were recorded on the pre-designed Performa. RESULTS: Fourteen (14%) out of 100 cases of the SCO patients developed overt hypothyroidism, SCO had 2.8 times more risk for conversion to overt hypothyroidism as compared to healthy controls. Moreover female gender and initial levels of serum TSH were the most important predictors for conversion of SCO to overt hypothyroidism. CONCLUSION: The frequency of conversion to overt hypothyroidism in SCO patients approaches 14% and was more commonly observed in female patients.

Association of leptin with type 2 diabetes in non-obese subjects.

BACKGROUND: South Asians have a high tendency to develop type 2 diabetes even at low BMI. We evaluated serum leptin levels in a group of non-obese type 2 diabetics. METHODS: An observational study conducted on 90 subjects, 55 with Type 2 diabetes mellitus, and 35 normal controls (non-diabetics). BMI, waist circumference, serum leptin, and serum glucose were measured. The correlation between these variables was studied by multiple regression analysis. RESULTS: Serum leptin levels were positively correlated with BMI in obese (r = 0.976) and non-obese diabetics (r = 0.956). Serum leptin was related with diabetes (r = -0.153, p = 0.001). Serum leptin was highly correlated with waist circumference in obese than non-obese diabetics, (r = 0.753). Mean serum leptin level was 21.4 etag/ml in non-obese diabetics and 34.9 etag/ml in diabetic group. It is even lower than the non-obese, non-diabetics (23.3 etag/ml). Multivariate linear regression analysis between leptin and age, weight, BMI, waist circumference in patients shows only a strong association with BMI in diabetics (p = 0.0001), while in non-diabetic it was not significant (p = 0.07). Serum leptin was high in diabetics taking oral hypoglycaemic (37.8 +/- 19.1 etag/ml), while it was low in diabetics taking insulin injections (29.3 +/- 24.2 etag/ml). CONCLUSION: Low leptin levels are associated with type 2 diabetes mellitus independent of changes in BMI.

Comparison of serum creatine kinase estimation with short tandem repeats based linkage analysis in carriers and affected children of Duchenne muscular dystrophy.

BACKGROUND: Duchenne Muscular Dystrophy (DMD) is an X-linked recessive lethal, genetic disorder characterised by progressive weakness of skeletal muscles which is untreatable and transmitted to males by carrier females. Advances in laboratory techniques now focus direct mutational analysis as the most reliable and indirect analysis based on Short Tandem Repeats (STR) based linkage analysis as feasible, inexpensive, and efficient method for carrier detection and prenatal diagnosis. The objective of this study was to compare the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic efficiency of Serum Creatine Kinase (SCK) with Short Tandem Repeats (STR) based linkage analysis in carriers and affected children of Duchenne Muscular Dystrophy. METHODS: The study was carried out from Dec 2006 to Dec 2007 in families having index clinical cases of DMD who were referred from different hospitals for evaluation/workup of DMD. SCK was done as a preliminary investigation in all index cases. The PCR assay with STR based linkage analysis with Intron 44, 45, 49 and 50 of DMD gene were performed in all families. Six families were informative with Intron 44 of DMD gene and one family was non-informative with all four intronic markers of DMD. SCK analyses were done in all the family members and compared with PCR analysis in informative families. SCK was not performed on Chorionic villous sample (CVS) done for prenatal diagnosis of DMD, and CVS and non-informative family members were excluded from the study. RESULTS: In carriers of DMD, the sensitivity and negative predictive value of SCK were 33.3%, and specificity and positive predictive were 100% with diagnostic efficiency of 50%. In affected cases of DMD the sensitivity and negative predictive value of SCK were 100%, and specificity and positive predictive were 91% and 88.8% respectively and diagnostic efficiency of 94.1%. CONCLUSION: The SCK is an excellent screening test for affected cases of DMD. For carrier identification we have to resort on PCR analysis so as to provide safer diagnostic tool for genetic counselling and prenatal diagnosis.

Evaluation of insulin-like growth factor-1 and insulinlike growth factor binding protein-3 in diagnosis of growth hormone deficiency in short-stature children.

BACKGROUND: Growth Hormone Deficiency (GHD) is conventionally diagnosed and confirmed by diminished peak Growth Hormone (GH) levels to provocative testing. Serum Insulin-like growth factor-1 (IGF-1) and insulin-like growth factor binding protein-3 (IGFBP-3) are under the influence of GH and reflect the spontaneous endogenous GH secretion. Owing to the absence of a circadian rhythm, it is possible to take individual measurements of IGF-1 and IGFBP-3 at any time of the day for evaluation of GH status instead of subjecting the individual to cumbersome provocative tests. Objectives of this study were to compare IGF-1 and IGFBP-3 assays with Exercise and L-Dopa stimulation tests in the diagnosis of growth hormone deficiency in short stature children using ITT as gold standard. METHODS: This validation study was conducted at Department of Chemical Pathology and Endocrinology, AFIP, Rawalpindi, from November 2005 to October 2006. Fifty-two short stature children were included in the study. Basal samples for GH levels and simultaneous IGF-1 and IGFBP-3 measurements were obtained and afterwards all children were subjected to sequential exercise and L-Dopa stimulation tests. Insulin Tolerance Test (ITT) was performed one week later with all the necessary precautionary measures. On the basis of ITT results, children were divided into two groups, i.e., 31 growth hormone deficient and 21 Normal Variant Short Stature (NVSS). RESULTS: The diagnostic value of exercise stimulation test remained highest with sensitivity 90.3%, specificity 76.0%, Positive Predictive Value (PPV) 84.84%, Negative Predictive Value (NPV) 84.2% and accuracy 84.6%. The conventional L-Dopa stimulation had sensitivity 96.7%, specificity 38.0%, PPV 69.7%, NPV 88.8 % and accuracy 73.0%. The serum IGF-1 and IGFBP-3 levels were positively correlated with post ITT peak GH levels (r = 0.527, r = 0.464 respectively, both p < 0.001). The diagnostic value of IGF-1 had sensitivity 83.87%, specificity 76.2%, PPV 83.87%, NPV 76.2% and accuracy 80.76%. The diagnostic value of IGFBP-3 had sensitivity 54.83%, specificity 90.47%, PPV 89.47%, NPV 57.57% and accuracy 69.23%. With combined use of IGF-1 and IGFBP-3 diagnostic value had sensitivity 69.35%, specificity 83.33% PPV 86%, NPV 64.81% and accuracy 75%. CONCLUSION: Growth Hormones provocative tests still remain the most useful investigations for the diagnosis of GHD. Measurements of IGF-1 and IGFBP-3 have shown comparable diagnostic performance with growth hormone stimulation tests and are valuable for patients' convenience and ease of performance and can be useful in the initial workup of short stature.

Familial dysbetalipoproteinemia: a potentially fatal disorder.

Familial dysbetalipoproteinemia is an inherited disorder in which both cholesterol and triglycerides are elevated in the plasma of the blood, which pre-disposes people to coronary artery disease and peripheral vascular disease. We report two young boys with multiple cutaneous xanthomas and grossly abnormal serum cholesterol and triglycerides. Two of the family members had died of cardiovascular accidents in young age and rest of the family members had deranged lipid profile. Patients were managed with lipid lowering drugs and fat restriction diet. All family members were counseled and advised regular exercise and follow-up.

Spectrum of lipid and lipoprotein indices in human subjects with insulin resistance syndrome.

BACKGROUND: Insulin resistance syndrome or metabolic syndrome is one of the major metabolic threats our recently urbanized society is going to face in near future. The management of this syndrome requires a very effective biochemical marker for screening. The objective of this cross sectional study were to compare various lipid and lipoprotein indices in human subjects with insulin resistance syndrome This study was carried out between April 2004 to January 2006 at the department of chemical pathology and endocrinology, Armed Forces Institute of Pathology, Rawalpindi. METHODS: A total of forty-seven subjects with metabolic syndrome were selected as per the criteria of National Cholesterol Education Program, Adult Treatment Panel III (NCEP, ATP III) from a target population diagnosed to have impaired glucose regulation at AFIP. Forty-seven age and sex-matched healthy controls were also included in the study. Insulin resistance was calculated by the method of HOMA-IR, using the formula of Mathew's et al. The various lipid and lipoproteins, their ratios and log-transformed versions were evaluated for differences between subjects with metabolic syndrome and controls. Finally the diagnostic performances of these candidate lipid markers were evaluated. RESULTS: Results between subjects with metabolic syndrome and controls were found to be significant for serum triglyceride (p < 0.05), HDL-C (p < 0.05), triglyceride/HDL-C (p < 0.01), Log triglyceride/HDL-C (p < 0.01), total cholesterol/HDL-C (p < 0.01), LDL-C/HDL-C (p < 0.01O). However there was weak correlation between these lipid based markers and HOMA-IR [(serum triglyceride: r = 0.225), (HDL-C: r = -0.235), (triglyceride/HDL-C: r = 0.333), (total cholesterol/HDL-C: r = 0.239)]. The AUCs for the diagnosis of metabolic syndrome remained highest for HOMA-IR [0.727 (95% CI: 0.642-0.812)], followed by triglyceride/HDL-C [0.669 (95%CI: 0.572-0.766)] and LDL-C/HDL-C [0.639 (95% CI: 0.537-0.742)]. CONCLUSION: The differences for lipids and lipoproteins between subjects with metabolic syndrome and controls remained significant. However, these markers have shown poor correlations with HOMA-IR along-with weaker diagnostic accuracy for the diagnosis of metabolic syndrome. Recommended cut-offs must be used, once these markers are employed in the diagnosis of metabolic syndrome.

Insulin resistance in human subjects having impaired glucose regulation.

OBJECTIVE: To determine insulin resistance in human subjects having impaired glucose regulation (IGR) by Homeostasis Model Assessment for Insulin Resistance (HOMA-IR). DESIGN: Comparative cross-sectional study. DURATION OF THE STUDY: This study was carried out between September 2004 to September 2005, at the Department of Chemical Pathology and Clinical Endocrinology, Armed Forces Institute of Pathology (AFIP), Rawalpindi. PATIENTS AND METHODS: A total of 100 subjects with impaired glucose regulation were selected for evaluation of metabolic syndrome as per the criteria of National Cholesterol Education Program, Adult Treatment Panel III (NCEP, ATP III), along with 47 healthy age and gender-matched controls. Physical examination to determine blood pressure and waist circumference was carried out and so was sampling for plasma glucose, serum triglycerides, HDL-cholesterol and insulin. Insulin resistance was calculated by the HOMA-IR. Finally, subjects with and without metabolic syndrome were compared with controls (n=47), using one-way ANOVA for studying insulin resistance between groups, with Tukey's post-hoc comparison. RESULTS: The frequency of finding metabolic syndrome in cases of IGR remained 47%. The insulin resistance demonstrated stepwise worsening from control population (mean=1.54, 95 % CI: 1.77-2.37) to subjects suffering from only IGR (mean=2.07, 95 % CI: 1.77-2.37) to metabolic syndrome (mean= 2.67, 95 %, CI: 2.34 - 3.00) [p<0.001]. CONCLUSION: Patients with impaired glucose regulation may have significant insulin resistance. It is, thus, recommended that a vigorous search be made to measure insulin resistance in all cases diagnosed to have impaired glucose regulation.

Microalbuminuria: association with ischaemic heart disease in non-diabetics.

BACKGROUND: In view of the high morbidity and mortality associated with ischemic heart disease (IHD), the estimation of individual cardiovascular risk over and above the assessment of classic risk factors, such as age, hypercholesterolemia and hypertension, is an important prerequisite for focusing preventive measures and therapeutic measures. Microalbuminuria (MA) as a marker of IHD in nondiabetics is currently under international debate. The present descriptive study undertaken at Combined Military Hospital, Lahore was aimed to determine the frequency of MA in nondiabetic IHD patients. METHODS: One hundred consecutive non diabetic patients with IHD (73 males, 27 females). Patients showing clinical albumiuria and with other causes of proteinuria were excluded. Urinary albumin in first morning sample was estimated by immunoturbidimetry method. Albumin to creatinine ratio (ACR) was calculated as mg/g. RESULTS: The frequency of MA (ACR >30 mg/g) was 37% in patients. Frequency was highest in older age bracket for both genders. The mean ACR was 131.8 +/- 66.2 mg/g. Significant difference was observed in mean MA level among different age groups. CONCLUSION: MA is common in nondiabetics patients with IHD. The mean level of MA was higher in older patients.

Microalbumiuria and associated risk factors in type II diabetics.

OBJECTIVE: To determine the frequency of microalbuminuria (MA) and its associated medical risk factors in type II diabetic patients. PLACE AND DURATION OF STUDY: This cross-sectional analytical study was conducted during Ist half of 2003 at Combined Military Hospital, Lahore. Non-probability purposive sampling was employed. MATERIALS AND METHODS: Study population included 150 type II diabetic patients (70 women, 80 men) attending outpatient department of the hospital. Patients having clinical albuminuria and with other causes of proteinuria were excluded. RESULTS: Women and men were of comparable ages. Women (26.4 kg/m2) had higher body mass index (BMI) than men (24.3 kg/m2). The frequency of MA was 46.7%, higher in males (50.6%) than females (41.5%). Fasting plasma glucose and HbA1c levels were significantly higher in patients with MA compared to those with normoalbuminuria (p <0.001). The microalbuminuric patients had significantly decreased HDL-c levels compared to normoalbuminuric subjects (p < 0.001). However, no relation of MA with age, gender, known duration of diabetes, BMI, history of smoking, hypertension and serum: total cholesterol, LDL - c, triglyceride, urea and creatinine was found. CONCLUSION: There is a strong association of poor glycaemic control and decreased HDL-c levels with the presence of microalbuminuria.

Differentiation of pulmonary embolism from high altitude pulmonary edema.

OBJECTIVE: To differentiate the high altitude pulmonary edema (HAPE) from pulmonary embolism (PE) by clinical probability model of PE, lactate dehydrogenase (LDH), aspartate transaminase (AST) and D-dimer assays at high altitude. DESIGN: A prospective study. PLACE AND DURATION OF STUDY: The study was carried out at CMH, Skardu, from October 2001 to December 2002. SUBJECTS AND METHODS: Consecutive 40 patients evacuated from height > 3000 meters with symptoms of PE or HAPE were included. Clinical pretest probabilities scores of PE, Minutex D-dimer assay (Biopool international) and cardiac enzymes estimation by IFCC approved methods, were used for diagnosis. Mann-Whitney U test was applied by using SPSS and level of significance was taken at (p<0.05). RESULTS: Out of 40 subjects, 31 HAPE and 9 patients of PE were initially diagnosed on the basis of clinical features, D-dimer assay and V-Q scanning. Out of 9 patients of PE; 3 had plasma D-dimer between 250-500 ng/ml and 6 > 500 ng/ml. Plasma D-dimer of 500 ng/ml was considered as cut-off value; 6 (66.7%) patients of PE could be diagnosed and 30 (96.7%) cases of HAPE excluded indicating very good negative predictive value. Serum LDH, AST and CK were raised above the reference ranges in 8 (89%), 7 (78 %) and 3 (33 %) patients of PE as compared to 11 (35%), 6 (19%) and 9 (29 %) of HAPE respectively. CONCLUSION: Clinical assessment in combination with D-dimer assay, LDH and AST can be used for timely differentiation of PE from HAPE at high altitude where diagnostic imaging procedures are not available.