Postpartum septic shock presenting as symmetrical peripheral gangrene: A rare entity.

Symmetric peripheral gangrene (SPG) is a rare clinical entity defined as ischemia of peripheral parts of the body without underlying vaso-occlusive disease. Its pathogenesis is unknown, but it is seen from previous reports that SPG is a sequel of underlying Disseminated Intravascular Coagulation (DIC). We report a case of a middle-aged woman who developed high-grade fever followed by painful black discoloration of the digits of four limbs, few days after spontaneous vaginal delivery at home. The patient developed septic shock. However, peripheral pulses were palpable and radiologic and laboratory investigations did not show any evidence of vessel occlusion. The patient had neutrophilic leukocytosis and a deranged clotting profile. Blood culture revealed growth of Staphylococcus Aureus and Pseudomonas Aeruginosa. The patient was diagnosed with SPG due to postpartum sepsis and DIC. She was managed with fluids, antibiotics, aspirin, and heparin but unfortunately, the patient underwent amputation of limbs due to irreversible ischemia. Therefore, prompt diagnosis and management of SPG are crucial to prevent mortality and morbidity.

Obesity & Diabetes: An experience at a public sector tertiary care hospital.

OBJECTIVE: To detect the frequency of Obesity in type 2 diabetic patients. METHODS: It was a Cross Sectional study carried out at Diabetes Clinic, Medical Unit III, Jinnah Postgraduate Medical Centre Karachi from 1(st) Jan 2012 to 30(th) June 2012. Three hundred and eighty seven (387) type II diabetic patients of either sex and any age were included in the study. Non-purposive convenience sampling technique was used to enroll patients in the study. History regarding diabetes, hypertension (HTN), Cerebrovascular Accidents (CVA), smoking and other tobacco exposure was taken. Physical examination was carried out and height, weight, body mass index (BMI), blood pressure, peripheral pulses and ankle-brachial index (ABI) was calculated. Categorical variables such as Gender, Age groups, BMI groups, HTN, smoking, hyperlipidemia and ABI were expressed as frequencies and proportions. Means with standard deviations were calculated for continuous variables such as age, duration of diabetes, BMI, duration of HTN and duration dyslipidemia. For categorical variables, differences between patients were tested using the chi-square test. P value of ≤ 0.05 was considered significant. RESULTS: Males were 128 in number (33%) and female were 259 in number (67%). Mean age was 52 yrs (+/- 9.67) and the mean duration of diabetes was 9.36 yrs (+/- 6.39). Hypertension was seen in 210 people (54%). 49(12.7%) were smokers and 39(10%) chewed tobacco. Normal BMI was seen in 62 patients (16%), 44 (11.4%) were overweight and 281(72.6%) was obese. Obesity was much more prevalent amongst the female gender that is 208(80%) versus male which was 73 (57%) and this was statistically significant (p-value 0.001). Hypertension was also more prevalent in obese patients and was statistically significant (p-value 0.04). Statistically significant lower mean BMI was found in smokers, tobacco chewers and/or had exposure to tobacco (0.001, 0.04, and 0.001 respectively). CONCLUSION: The study shows that there is a strong association of diabetes with obesity. Female gender had relatively higher BMI. Hypertension was more prevalent in obese diabetic subjects. Smoking and nicotine exposure was associated with significantly lower BMI.

Point prevalence probing of antimicrobial prescription patterns from a developing country.

BACKGROUND: Irrational use of antibiotics intensifies resistance and jeopardizes advances made in modern medicine. We aimed to conduct a baseline gap analysis survey on antibiotic prescription practices across Pakistan. RESEARCH DESIGN AND METHODS: This multi-centered cross-sectional survey was conducted at six public sector tertiary care hospitals from February 2021 to March 2021. Data related to various variables including hospital infrastructure, policies and practices, monitoring and feedback, and epidemiological, clinical, and antibiotic prescription for surveyed patients was collected using World Health Organization (WHO) Point Prevalence Survey (PPS) methodology. RESULTS: In a survey of 837 inpatients, 78.5% were prescribed antibiotics. Most commonly prescribed antimicrobial was ceftriaxone (21.7%), followed by metronidazole (17.3%), cefoperazone-sulbactam (8.4%), amoxicillin-clavulanate (6.3%), and piperacillin/tazobactam (5.9%). Surgical prophylaxis (36.7%) and community-acquired infections (24.7%) were the main reasons for antibiotic prescriptions. Single antibiotics were given to 46.7% of patients, 39.9% received a combination of two antibiotics, and 12.5% were prescribed three or more antibiotics. Among six hospitals surveyed, two had drug and therapeutic committees, three had infection prevention and control committees, and one had an antibiotic formulary. CONCLUSION: Findings demonstrate high consumption of broad-spectrum antimicrobials and emphasize the importance of expanding antimicrobial stewardship programs among hospitals. Mentoring clinical teams could help rationalize antimicrobial use.

Clinical features, diagnostic techniques and management of dual dengue and malaria infection.

OBJECTIVE: To find out clinical features, diagnostic techniques and management outcome of patients having dual dengue and malaria infection. STUDY DESIGN: A case series. PLACE AND DURATION OF STUDY: Medical Unit-III, Ward- 7, Jinnah Postgraduate Medical Centre, Karachi, from September 2007 to January 2008. METHODOLOGY: Patients presented with fever of less than or equal to 10 days duration, severe body aches, rash and bleeding manifestations were included. Patients with obvious features of other diseases like typhoid, hereditary bleeding diathesis and hematological malignancies and only malarial parasite positive with high grade intermittent fever without rash and myalgia were excluded from the study. Diagnosis of dengue and malaria was based on history, clinical features, laboratory parameters and malarial parasite test by thin and thick films. Serological evaluation was done by dengue IgM and IgG by ELISA test kit. Patients were divided into three groups. Group A was dengue IgM positive plus MP positive, group B was dengue IgM positive and MP negative and group C was dengue IgM negative and MP negative and were clinically suspected dengue and malaria. The clinical manifestations and laboratory parameters of dual dengue and malaria positive patients were compared with malaria and dengue negative patients. RESULTS: One hundred and fourteen patients were seen during the study period. Antibody titer (IgM) tested in all patients was found positive in 78 patients (69.64%). Among those 78 patients, 26 (23.21%) were concomitantly positive for malarial parasite (Group A). Plasmodium vivax was positive in 25 patients and falciparum in one patient. Fifty-two patients (46.42%) were dengue IgM positive and MP negative (Group B). Thirty four (30.35%) patients were MP and dengue IgM negative (Group C) but were strongly suspected for DHF and malaria on clinical and hematological basis. The hemoglobin of 34.61% of patients of group A, 5.76% of group B and 14.7% of group C were low, hematocrit level was also low in group A (92.3%), group B (15.38%) and group C (70.58%) patients. The platelet count was markedly low in 84.61% of patients of group A, 57.69% of group B and 94.11% of group C. Leukopenia was found in 34.61% of patients of group A, 78.84% in group B and 29.411% in group C. The liver function tests were deranged in all groups. CONCLUSION: The frequency of dual dengue and malaria infection was 23.21%. The serology of the dengue and malaria showed negative results in 30.35%. The diagnosis of dual infections could be made on the basis of history, clinical examination supported by hematological results. It is recommended that all the patients suspected for dual infections should be treated concomitantly for dengue and malaria in malaria endemic areas.

ECG changes in patients with primary hyperthyroidism.

INTRODUCTION: Thyroid hormones plays key role in regulating cardiovascular system. Its imbalance leads to various electrophysiological changes in cardiovascular system. This study was done to determine the frequency of electrocardiographic (ECG) changes in patients with primary hyperthyroidism. METHODS: It was a descriptive cross-sectional study conducted in the Department of Medicine, Medical Unit III, Ward-7, Jinnah Postgraduate Medical Centre, Karachi, from October 2013 to April 2014. A total of 103 patients newly diagnosed with primary hyperthyroidism were included in this study. Venous blood samples were collected for T3, T3, TSH analyzed by radioimmunoassay. ECG was performed. Outcome variables were the ECG changes i.e. sinus tachycardia and atrial fibrillation. RESULTS: The average age of the patients was 30.09±5.57 years (95%CI: 29 to 31.18). Out of 103 cases, 19 (18.45%) were male and 84 (81.55%) were female. Sinus tachycardia was observed in 60.19% (62/103) patients whereas atrial fibrillation was found in 11.65 (12/103) of cases. CONCLUSION: In this study frequency of electrocardiographic changes in term of sinus tachycardia was high. This report has emphasized the importance of thyrotoxicosis as a cause of cardiac morbidity and mortality in patients with thyrotoxicosis. These cardiac complications are readily reversible if timely optimal treatment is offered.

Peripheral artery disease in type II diabetes.

OBJECTIVE: To determine the frequency of peripheral arterial disease (PAD) in type 2 diabetic patients. STUDY DESIGN: Cross-sectional observational study. PLACE AND DURATION OF STUDY: Diabetes Clinic, Medical Unit III, Jinnah Postgraduate Medical Centre, Karachi, from January to June 2010. METHODOLOGY: Three hundred and eighty seven (387) type II diabetic patients of either gender and any age were included in the study. Patients with a previous history of trauma to the arterial vasculature, pregnancy and those who underwent arterial graft procedures were excluded. Non-purposive convenient sampling technique was used to enroll patients in the study. PAD was diagnosed when ankle-brachial index (ABI) was less than 0.9. A p-value of less than 0.05 was considered statistically significant. RESULTS: Out of 387 studied patients, 128 were males (33.1%) and 259 were females (66.9%). Mean age was 52.22 ± 9.671 (22 - 76) years in the entire cohort. Mean duration of diabetes was 9.38 ± 6.39 years. PAD was detected in 152 (39.28%) of the total study subjects. Thirty-one of 128 male patients (24.22%) had PAD disease while 121 out of 259 female patients (46.71%) had evidence of PAD (p = 0.001). Hypertension was a significantly associated factor (p = 0.002). CONCLUSION: A high frequency of PAD was observed in the diabetic population particularly with hypertension and more prevalent in females.