Effects of Half-Somersault and Brandt-Daroff exercise on dizziness, fear of fall and quality of life in patients with posterior canal benign paroxysmal positional vertigo: A randomised control trial.

The aim of this study was to compare the effects of Half-Somersault and Brandt-Daroff exercises on dizziness, fear of fall, and quality of life in patients with posterior canal benign paroxysmal positional vertigo (PC-BPPV). This study was conducted from July 2020 to November 2020. A total of 20 patients were enrolled in the study, through sealed envelope method, and assigned to two groups, A and B (10 in each). Vestibular activity and participation measure and Fall Efficacy Scale (FES) were used. The mean age of the patients was 36.70±11.58 years. There was a significant (p=0.05) difference between the Vestibular activities and participation measure (VAP) score at post intervention and Fall Efficacy Scale (FES) (p<0.05) between the groups. Within group analysis showed significant results (p=0.01). This study concluded that both manoeuvers are significantly effective in the treatment of PC-BPPV, but patients treated with Brandt-Daroff exercises reported more improvement in terms of quality of life and residual dizziness compared to the Half Somersault group. Clinical Trials.gov identifier (NCT number): NCT04469309.

Efficacy and Safety of N-Butyl 2 Cyanoacrylate Injection for Treatment of Gastric Varices: A five year experience from a tertiary care hospital in Karachi, Pakistan.

Objectives: To evaluate the efficacy and safety of N-Butyl 2 Cyanoacrylate injection for treatment of gastric varices. Methods: This was a retrospective observational cohort conducted at Medical Unit IV, Department of Gastroenterology, JPMC, Karachi from January 2014 to December 2018 (five years). All patients irrespective of age and gender that presented to the emergency department with complain of hematemesis or stigmata of UGIB were potential candidates. Once they were resuscitated and endoscopic evidence of gastric varices requiring intervention was found, the patients were inducted into the study. N-Butyl 2 Cyanoacrylate injection was performed until hemostasis and obliteration of gastric varices was achieved. Response to therapy was analyzed at three weeks with repeat endoscopy. Mortality was analyzed at six weeks. Major and minor complications recorded as well. Results: A total of 159 patients were inducted into the study. Isolated gastric varices Type-I was mostly encountered. A singular session was sufficient to achieve obliteration and hemostasis in over three quarter of the patients. Complications affected 11.30% of the patients. Six weeks mortality was exceptionally low at 1.20%. Conclusions: N-Butyl 2 Cyanoacrylate is safe and effective for treatment of gastric varices. There were few complications seen with this procedure in this study. It significantly reduces mortality at six weeks.

Combined effects of strength and balance training versus aerobic training on balance, neuropathy symptoms and quality of life in patients with diabetic peripheral neuropathy.

BACKGROUND: Diabetic peripheral neuropathy (DPN) occurs in >50% of diabetic patients and is a high risk-factor of balance problems and risk of falls. Impaired balance can lead to reduced function, which has a detrimental effect on patients' quality of life. Structured strength and balance training can result in sustained improvements in muscle strength, coordination, balance, functional status and quality of life. OBJECTIVE: To determine the combined effects of strength and balance training versus aerobic training on balance, severity of symptoms of DPN, and quality of life in patients with DPN. METHODS: This double blinded, two arm parallel design Randomized Clinical Trial. The study was conducted from March to December 2020 in the AIMS diabetic center Peshawar, Pakistan. Participants were selected through convenience sampling technique and randomly allocated into strength plus balance and aerobic training groups. Type 2 diabetic patients of both sexes, aged 40 to 80 years, with a Toronto neuropathy score ≥6 recruited, while patients with ulceration/infection of feet, medical/Surgical conditions, and non-ambulatory patients were excluded from this study. Intervention was applied 3 days a week for 8 weeks. The Toronto clinical neuropathy system was used to assess neuropathy severity, SF-36 to assess quality of life and the Berg balance scale was used for assessment of balance. Assessment was done at the baseline and after 8 weeks of intervention using SPSS. Version 22 was used for analysis. RESULTS: The mean age of the participants was 60.80 ± 9.73. Between group analysis, which showed were statistically insignificant for neuropathy severity, balance and all domains of quality of life (p-value >0.05) except SF-36 General Health Perception Score, with Mean ± SD of 62.50 ± 7.54 in group A versus Mean ± SD of in group B 60.00 ± 15.98 (p-value = 0.05). Within group analysis showed statistically significant results for neuropathy severity, balance and all domains of quality of life (p-value<0.05). CONCLUSION: This study concluded that there is a statistically significant effect of structured balance and strength training and aerobic training on severity of DPN, balance and quality of life. But there was no statistically significant difference in improvement between the two intervention groups.

Demographics, Biochemical Characteristics, and Phases of Chronic Hepatitis B Virus Infection: Retrospective Analysis From a Secondary Care Setup.

Introduction Hepatitis B virus (HBV) is the leading cause of cirrhosis in the developing world. Despite the development of effective vaccine(s) and direct-acting antivirals (DAAs) such as tenofovir and entecavir, the eradication of chronic HBV remains a distant dream in endemic regions. Factors such as treatment naivety, longer duration of disease, late diagnosis, family history of liver disorders and hepatocellular carcinoma, fatty liver disease, multiple comorbidities, alcoholism, use of tobacco products, noncompliance to drugs, and loss to follow-up all contribute to disease progression and development of complications. In order to promote a better understanding of the treatment initiation, duration, and eventual outcomes, the European Association for the Study of the Liver (EASL) updated its guidelines in 2017 and introduced a new staging system for chronic HBV. Since these guidelines are relatively recent, data regarding the new staging is virtually absent in local/regional settings. Moreover, it has been observed that patients presenting to secondary care setups at major urban centers have disease characteristics quite distinct from those of their rural counterparts or patients presenting to tertiary care setups, even in the same cities. Additionally, there is scarce published data with regard to this aspect. With this study, we hope to make progress on all of those fronts. Objective We aimed to evaluate the demographics, biochemical characteristics, and phases of chronic HBV at the secondary care level. Methods This was a retrospective observational cohort conducted at the Sindh Government Hospital, Liaquatabad from January to December 2020. Patients of either gender who were aged ≥12 years, and diagnosed as a case of chronic HBV were eligible to be enrolled in the study. Only treatment-naive patients were enrolled in the study. Demographics, biochemical characteristics, and phases of HBV (in light of the updated guidelines issued by EASL in 2017 with respect to HBV) were recorded and analyzed. Patient confidentiality was ensured at all times. Results A total of 102 patients were enrolled in the study. The mean age of our cohort was 34.31 ±12.42 years, and the male-to-female ratio was 3:2. All referrals were made from within the city district. Housewives and laborers made up the majority of our patients. The mean alanine transaminase (ALT) levels were 39.83 ±21.33 IU/L; otherwise, the biochemical profile of the patients was unremarkable. Phase III was the most frequently recorded stage of chronic HBV; 41 (40.19%) of the patients were diagnosed with it. However, nearly half of the patients had chronic active hepatitis (phases II and IV). Only a single case each of hepatitis Delta virus and decompensated liver disease (DCLD) was recorded. Conclusions All patients of chronic HBV presenting at the secondary care level were referred locally, were relatively older, and exhibited a higher frequency of chronic active hepatitis (phases II and IV). This corresponded to borderline elevations of ALT. But the remainder of the biochemical profile was largely unremarkable due to the very low prevalence of cirrhosis among these patients.

Organophosphate Poisoning: Demographics, Severity Scores and Outcomes From National Poisoning Control Centre, Karachi.

Introduction Organophosphate ingestion is the commonest cause of self-harm encountered at poison control centers in Pakistan. It usually affects a young populous. Organophosphates are found in various forms and formulations that are easily accessible to the general public. These compounds are extremely potent poisons causing rapid clinical deterioration with minimal ingestion or exposure. Signs and symptoms can range from mild or none to severe such as bradycardia, miosis, fasciculations, seizures and altered level of consciousness. Poisoning severity is measured using the Peradeniya Organophosphorus Poisoning (POP) scale. Mortality rates are relatively low for mild to moderate disease. Severe disease as calculated by the POP carries an exceptionally high mortality rate. The National Poisoning Control Centre (NPCC) at Jinnah Postgraduate Medical Centre, Karachi treats an extraordinary number of poisoning cases on a daily basis. Despite this data pertaining specifically to OP ingestion is nearly absent. There have been no studies analyzing the various aspects of organophosphate poisoning in the last 30 years to the best of our knowledge. Here, we look to rectify this. Aims To evaluate the demographics, severity scores and outcomes of organophosphate poisoning cases in the last year from the NPCC, Karachi. Methods This was a retrospective study. It was held from 1st January 2019 to 31st December 2019. All data was recorded from patients admitted to the NPCC with a proven diagnosis of organophosphate poisoning. Results Three thousand and three hundred patients were inducted into this study. Over 3/4th of the patients were teenagers or aged less than 30 years. Almost all referrals were made from within the city. Overall survival rate at 28 days was 89.45%. Most patients presented with mild to moderate disease as calculated by the POP; severe disease had a mortality rate of nearly 50%. Conclusion Organophosphates make up a significant portion of all cases of poisoning treated at the NPCC. The POP is an excellent tool to evaluate disease severity. Overall survival rates are good but mortality rate is high for severe disease even in young patients.

Frequency and Characteristics of Metabolic Syndrome in Patients With Ischemic Stroke Admitted to a Tertiary Care Hospital in Karachi.

Introduction Metabolic syndrome (MetS) is defined as a syndrome of truncal obesity, insulin resistance, hypertension, hypertriglyceridemia, and dyslipidemia. It is well known that MetS increases the risk of cardiovascular disease and adverse events. Each of its components is associated with an increased risk of cardiovascular disease, but data on the association with ischemic stroke are scarce. At the international level, a significant body of research has been conducted on this issue, but the situation is very different in Pakistan. Very little data are present on the subject matter. This study is an endeavor in this direction, generating data, that can be used in early identification and developing treatment services for patients with ischemic stroke having MetS. Aims To determine the frequency of MetS in ischemic stroke patients admitted to a tertiary care hospital in Karachi, Pakistan. Methods This six-month observational and cross-sectional study was conducted at Medical Unit I, Jinnah Postgraduate Medical Centre from July 1, 2019, to December 31, 2019. Patients with a diagnosis of acute ischemic stroke were enrolled. Detailed history, physical examination, and biochemical measurements were noted. The presence of MetS was defined in accordance with the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III)/American Heart Association (AHA) guidelines. Results A total of 224 patients fulfilling the inclusion criteria were inducted into this study. The mean age of presentation was 61.04 ± 14.72 years, and more than two-thirds of the patients were ≥60 years of age. A total of 150 (66.96%) patients with ischemic stroke also had MetS. The male-to-female ratio in this group was 2:1. The most common variables constituting the MetS were truncal obesity, hypertension, and dyslipidemia. The median MetS score was 3. Conclusions MetS is highly prevalent in patients presenting with ischemic stroke irrespective of age or gender. The three most deranged and common components of MetS in these patients are truncal obesity, hypertension, and dyslipidemia.

Acute Viral Hepatitis: Simultaneous Infection from Hepatitis A, B and E Viruses.

Acute viral hepatitis is a significant health problem in the developing world. Usually, the disease runs a benign course with complete resolution of signs and symptoms within days to weeks. It can be caused by any of the hepatitis viruses as well as other pathogens. Viral hepatitis can also be caused by co-infection from multiple hepatitis viruses, however, this is rare. Here, we report a unique case of acute hepatitis caused by simultaneous infection from Hepatitis A Virus (HAV), Hepatitis B Virus (HBV) and Hepatitis E Virus (HEV). This case is rare as all work-ups for probable causes of acute hepatitis were negative; and the review of the literature showed that such a case had not been previously reported.

A Case of Polyautoimmunity: Celiac Hepatitis, Grave's Disease and Autoimmune Hemolytic Anemia.

Celiac disease (CD) is an autoimmune disorder with high incidence of multi organ involvement; especially, gastrointestinal manifestations and an increased risk of malignancies. Here we report a case of CD with celiac hepatitis, autoimmune hemolytic anemia (AIHA) and Grave's disease (GD) with their complications. Polyautoimmunity requires comprehensive analysis. While CD and GD were previously diagnosed, AIHA and cirrhosis were diagnosed during admission upon extensive work-up. Similarly, other autoimmune etiologies, such as autoimmune hepatitis (AIH), and/or primary biliary cholangitis were ruled out. All three diseases were treated afresh with strict adherence to a gluten-free diet (GFD) and carbimazole along with addition of medications for cirrhosis complicated by ascites. This was a rare case where non-adherence to a GFD led to such severe adverse events. A case of celiac hepatitis presenting with such a wide array of signs and symptoms has rarely been reported in the literature and the management of this patient was unique and challenging.

Epidemiology, Clinical Characteristics, and Management Status of Hepatitis B: A Cross-sectional Study in a Tertiary Care Hospital at Karachi, Pakistan.

Background Hepatitis B virus (HBV) infection is a serious health problem in Pakistan. In view of the serious socioeconomic consequences, identifying patient characteristics and the current treatment for the disease will enhance HBV regulation and its medical management. Aims To describe the epidemiology, clinical characteristics, and current management status of patients infected by HBV. Methods We undertook an observational, cross-sectional, and epidemiological study at the Jinnah Postgraduate Medical Centre, Karachi, during the period from January 2014 to November 2017. Male and female patients of any age and with documentation for an HBV infection were eligible for inclusion in the study. An HBV infection was defined as a positive hepatitis B surface antigen test. Results A total of 500 patients were analyzed. The mean age at presentation was 29.86±13.68 years. The majority of the patients (25.6%) were ethnically Sindhi followed by Pathan (24.4%), indicating a high prevalence among the rural-based population of Pakistan. The mean duration of the disease was 3.51±4.46 years. The most common cause for the spread was positive family history (40.4%) followed by roadside barbers (30.0%). Most patients were Child-Pugh (CP) class A (84.6%) and the median Modified End-Stage Liver Disease (MELD) score was 7. Upper gastrointestinal bleeding was the most frequent hepatic complication (6.2%). Antiviral medications had been received by 18.6% of patients previously. Peg-interferon (6.0%) was the major antiviral medication prescribed to treatment-experienced patients. Conclusions This observational, real-life study has identified some gaps between clinical practice and guideline recommendations in Pakistan. To achieve better health outcomes, several improvements, such as disease monitoring and optimizing antiviral regimens, should be made to improve disease management.

Incidence of Vitamin D Deficiency in Different Seasons in the Adult Karachi Population Presenting in the Medical Outpatient Department with Generalized Body Ache.

Introduction The most important function of vitamin D is to maintain normal calcium homeostasis. Various factors play an important role but the most significant aspect of its normal physiological functioning is exposure to sunlight, therefore, it is also known as the sunshine vitamin. In adults, a prolonged deficiency of vitamin D (calcitriol) can lead to osteomalacia while a lower deficiency (insufficiency) is associated with various non-specific symptoms. Vitamin D deficiency has been observed in developed and developing countries, including the Middle East and the subcontinent. Vitamin D is mandatory for the maintenance of health due to the presence of its highly specific receptors, Vitamin D receptors, in all body tissues and its regulatory role in the encoding of more than 200 genes. The deficiency of Vitamin D, therefore, could affect any tissue or body system. Most interventions for this are done through outpatient departments (OPDs). The burden of vitamin D deficiency is affected by seasonal variation in our part of the world as well as internationally; data show a marked variation, however. Generalized body ache is a vague symptom. It is one of the most common complaints seen at the OPD and can be a manifestation of many a disease. But a correlation with low vitamin D levels has been observed previously. Whether this relation is affected by seasonal variation remains unascertained and data on the above-mentioned relationship for Pakistan are scarce. Objective We aim to evaluate the incidence of vitamin D deficiency in different seasons in the adult Karachi population presenting in medical OPDs with a generalized body ache. Materials and methods This study was conducted at Medical Ward 5, Jinnah Postgraduate Medical Center, Karachi, from January 2016 to December 2016. Data were collected from the OPD that was held twice-weekly (Mondays and Fridays). Only patients who exclusively complained of "generalized body ache" were inducted into the study. Patients with minor complaints, such as headache, backache, fatigue, and lethargy, were also seen only if there were no comorbidity at all. Meticulous lab and clinical workup were done to rule out potentially not-so-benign causes of the symptoms. Patients 18 years or older were inducted into the study. Once written consent was taken, Vitamin D levels were carried out via the COBAS (Roche Diagnostics, Mannheim, Germany) method. A vitamin D level of ≤30 ng/ml was considered deficient. Results were obtained within a week, and data were recorded and analyzed. Summer was defined as three months either side of the summer solstice (June 21) and winter was defined as three months either side of the winter solstice (December 21). Results A total of 577 patients were inducted into the study. The mean age of the patients was 39.33 ± 10.23 years. The patients were predominantly female (72.7%) and housewives. Of these, 298 (51.64%) had a vitamin D deficiency; in summer, the incidence was 44.23% and in winter, it was 60.37%. The mean level of vitamin D in deficient patients was 25.06±8.74 ng/dl. Conclusion Vitamin D levels are significantly decreased in patients complaining of generalized body ache even without any comorbidity. These affect predominantly the middle-aged female population. Seasonal variation occurs with most patients presenting during the winter months, along with lower means.

Treatment Outcomes for Patients Undergoing Hemodialysis with Chronic Hepatitis C on the Sofosbuvir and Daclatasvir Regimen.

Background Hepatitis C (HCV) infection is the most commonly acquired infection for patients on hemodialysis and is associated with significant morbidity and disease progression. Direct-acting antivirals (DAAs) have revolutionized the management of HCV. However, limited data exist regarding their efficacy in end-stage renal disease (ESRD), especially for patients on dialysis in South Asia. Aims To evaluate the treatment outcomes of patients undergoing hemodialysis with chronic hepatitis C (CHC) on the sofosbuvir (SOF) and daclatasvir (DAC) regimen. Materials and methods All patients who were 18 years or older, diagnosed cases of chronic kidney disease (stage V), and undergoing maintenance hemodialysis were inducted into this study. Active HCV infection was demonstrated by polymerase chain reaction (PCR) HCV ribonucleic acid (RNA) (qualitative). All patients were then treated with a double regimen of SOF (400 mg once daily) and DAC (60 mg once daily) taken per oral for 12 weeks. Response to treatment was assessed at four, 12, and 52 weeks. Results A total of 31 out of 80 patients were inducted into the study over two years. The prevalence of HCV in hemodialysis patients was 38.75%. Sustained virological response (SVR) was achieved by 27 (87.09%) patients at one year. Four (12.90%) patients had a relapse of HCV. There was no deterioration of hepatological status in any of the patients. Overall survival at one year was 93.54%. Conclusion HCV is highly prevalent in patients undergoing hemodialysis. Prompt treatment with SOF and DAC demonstrates a good response, with negligible side effects.

Epidemiological, Poisoning Characteristics and Treatment Outcomes of Patients Admitted to the National Poisoning Control Centre at Karachi, Pakistan: A Six Month Analysis.

INTRODUCTION:  Any substance if taken in enough quantity can be defined as a poison provided it causes physiological or anatomical harm. It can range from food products to therapeutic medications to toxins and chemicals. Animals, plants, and insects also produce toxins, which are poisonous. While any route of ingestion is dangerous, most poisons are either taken by mouth or inhaled. Rarely intravenous access as in the case of heroin/opoids overdose is seen as well. Poisoning whether deliberate or otherwise is a growing problem of the modern world. Young people are disproportionally affected by it. Mostly household products such as insecticides, bleach, acid, etc. are used. Harmful ingestion of prescription meds, recreational drugs, psychiatric medicines, and opoids has been on the rise in recent times. This is one of the major sources of poisoning these days. Data with respect to Sindh and Pakistan is scarce. As the largest referral center in the country, Jinnah Postgraduate Medical Centre sees its fair share of poisoning cases. Here we evaluate the trends and increasing burden of poisoning cases seen at this center. AIMS: To evaluate the epidemiological, poisoning characteristics and treatment outcomes of patients admitted to the National Poisoning Control Centre (NPCC) at Karachi, Pakistan. MATERIALS AND METHODS:  This is a retrospective study, held from July 1st to December 31st 2018. Data were recorded from all patients admitted to the NPCC after complete medico-legal work up. RESULTS:  A total of 2546 patients were inducted into the study. The mean age of presentation was 26.57 ± 11.82 years. Nearly 80% of patients were aged 40 years or younger. Both genders were equally affected and most cases were referred from within the city. Organophosphates (OPs) were the most frequent (46.11%) cause of poisoning seen. Overall mortality was 3.61%. CONCLUSION:  The burden of poisoning cases has risen sharply. Mostly young adults and teenagers are affected without gender bias. Mortality is high considering the young population involved.

Efficacy and Safety of Sofosbuvir and Ribavirin for Treating Chronic Hepatitis C, Genotype 3: Experience of a Tertiary Care Hospital at Karachi, Pakistan.

Background It is estimated that approximately 10 million individuals in Pakistan are infected with hepatitis C virus (HCV). Historically, it was very difficult not just to cure but even treat HCV as available options did not have desirable outcomes. However, the approval of directly acting antiviral (DAA) drugs has revolutionized treatment and management. These are specific proteases and polymerase inhibitors with profound capability for accomplishing elimination and overtime eradication of the virus. Objective The aim of this study was to evaluate the efficacy and safety of sofosbuvir (SOF) in combination with ribavirin (RIB) for the treatment of chronic hepatitis C virus with genotype 3. Materials and methods This prospective observational study was conducted at the gastroenterology section of Medical Unit IV, Jinnah Post-graduate Medical Center, Karachi and Medical Unit II, Dow University of Health Sciences, Ojha Campus, Karachi from January 2016 to December 2016. Patients aged 18 years or older of either gender having chronic active HCV infection as demonstrated by a positive Anti-HCV (ELISA) test and a qualitative polymerase chain reaction (PCR) analysis along with genotype analysis showing only type 3 were inducted into the study. Treatment was initiated with either 12-week or 24-week regimen of SOF 400 mg once daily along with weight-adjusted RIB orally. Successful treatment was indicated by the elimination of the virus, i.e., undetectable viral load/levels by PCR qualitative analysis. Rapid virological response (RVR), end of treatment response (ETR), and sustained virological response (SVR) were defined as the undetectable viral load at four, 12, and 24 weeks, respectively. Results A total of 300 patients were inducted into the study, predominantly female (57%). The mean age of presentation was 41.14 ± 11.48, and most (70.33%) were treatment naïve. The mean alanine transaminase (ALT), aspartate aminotransferase (AST), and gamma-glutamyl transferase (GGT) levels at presentation were 41.89 ± 46.23 IU/l, 68.57 ± 83.62 IU/l, and 54.52 ± 77.57 IU/l, respectively. ALT, AST, and GGT levels at 24 weeks were 33.84 ± 13.60 IU/l, 32.44 ± 16.16 IU/l, and 37.59 ± 22.41 IU/l, respectively, showing significant improvement. ETR was achieved in 99.1% (209) treatment-naïve patients and 98.9% (88) treatment-experienced patients. SVR rates were almost similar with 98% (208) achieving it in the treatment-naïve group and 96.6% (86) achieving it in the treatment-experienced group. Conclusion SOF in combination with RIB is safe and remarkably efficacious in the treatment of chronic HCV, genotype 3. Not only is this regimen associated with the elimination of viral replication but it also improved transaminase levels. Outcomes are rarely, if ever, affected by previous use of antiviral medications.