Six-minute walk test performance in healthy adult Pakistani volunteers.

OBJECTIVE: To determine the six-minute walking distance (6MWD) for healthy Pakistanis, identify factors affecting 6MWD, compare published equations with the local data and derive an equation. STUDY DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: Two medical institutes of Karachi, from January to May 2011. METHODOLOGY: Subjects between 15 and 65 years were prospectively enrolled after screening. A standardized 6MWT was administered. SpO2, HR, BP and dyspnoea scores were determined pre- and post-test. RESULTS: Two hundred and eleven (71%) men and 85 (29%) women participated. Mean 6MWD was 469.88 ± 101.24 m: men walked 502.35 ± 92.21 m and women walked 389.28 ± 74.29 m. On univariate analysis, gender, height, weight and age showed a significant relationship with the 6MWD. Gender and age were identified as independent factors in multiple regression analysis, and together explained 33% of the variance. The gender-specific prediction equations were: 6MWD (m) for men = 164.08 + (78.06*1) - (1.90*age in years) + (1.95*height in cms) 6MWD (m) for women = 164.08 - (1.90*age in years) + (1.95*height in cms). CONCLUSION: 6MWDs among the volunteer subjects were shorter than predicted by reference equations in literature. Height, gender and weight combined explained 33% of the variance. The moderate over-estimation of the 6MWD in Pakistani subject. The proposed equation gives predicted (mean) 6MWDs for adult Pakistani naïve to the test when employing standardized protocol.

Death certificate completion skills of hospital physicians in a developing country.

BACKGROUND: Death certificates (DC) can provide valuable health status data regarding disease incidence, prevalence and mortality in a community. It can guide local health policy and help in setting priorities. Incomplete and inaccurate DC data, on the other hand, can significantly impair the precision of a national health information database. In this study we evaluated the accuracy of death certificates at a tertiary care teaching hospital in a Karachi, Pakistan. METHODS: A retrospective study conducted at Aga Khan University Hospital, Karachi, Pakistan for a period of six months. Medical records and death certificates of all patients who died under adult medical service were studied. The demographic characteristics, administrative details, co-morbidities and cause of death from death certificates were collected using an approved standardized form. Accuracy of this information was validated using their medical records. Errors in the death certificates were classified into six categories, from 0 to 5 according to increasing severity; a grade 0 was assigned if no errors were identified, and 5, if an incorrect cause of death was attributed or placed in an improper sequence. RESULTS: 223 deaths occurred during the study period. 9 certificates were not accessible and 12 patients had incomplete medical records. 202 certificates were finally analyzed. Most frequent errors pertaining to patients' demographics (92%) and cause/s of death (87%) were identified. 156 (77%) certificates had 3 or more errors and 124 (62%) certificates had a combination of errors that significantly changed the death certificate interpretation. Only 1% certificates were error free. CONCLUSION: A very high rate of errors was identified in death certificates completed at our academic institution. There is a pressing need for appropriate intervention/s to resolve this important issue.

A randomized, double-blind, placebo-controlled trial of oral montelukast in acute asthma exacerbation.

BACKGROUND: Leukotriene receptor antagonists (LTRAs) are well established in the management of outpatient asthma. However, there is very little information as to their role in acute asthma exacerbations. We hypothesized that LTRAs may accelerate lung function recovery when given in an acute exacerbation. METHODS: A randomized, double blind, placebo-controlled trial was conducted at the Aga Khan University Hospital to assess the efficacy of oral montelukast on patients of 16 years of age and above who were hospitalized with acute asthma exacerbation. The patients were given either montelukast or placebo along with standard therapy throughout the hospital stay for acute asthma. Improvements in lung function and duration of hospital stay were monitored. RESULTS: 100 patients were randomized; their mean age was 52 years (SD +/- 18.50). The majority were females (79%) and non-smokers (89%). The mean hospital stay was 3.70 ± 1.93 days with 80% of patients discharged in 3 days. There was no significant difference in clinical symptoms, PEF over the course of hospital stay (p = 0.20 at day 2 and p = 0.47 at day 3) and discharge (p = 0.15), FEV1 at discharge (p = 0.29) or length of hospital stay (p = 0.90) between the two groups. No serious adverse effects were noted during the course of the study. CONCLUSION: Our study suggests that there is no benefit of addition of oral montelukast over conventional treatment in the management of acute asthma attack. TRIAL REGISTRATION NUMBER: 375-Med/ERC-04.

Atypical pathogens causing community-acquired pneumonia in adults.

OBJECTIVE: To determine the frequency of community-acquired respiratory pathogens with special focus on atypical organisms in patients presenting to a tertiary care facility with community-acquired pneumonia (CAP). METHODS: The descriptive study on adult patients was conducted from February 2007 to March 2008 at the Aga Khan University Hospital, Karachi. It comprised 124 consenting patients of age 16 and above who presentd with a diagnosis of community-acquired pneumonia. The diagnostic modalities used were based on significant changes in antibody titer or persisting high antibody titers in the case of Mycoplasma pneumoniae and Chalmydia pneumoniae infections, or bacterial antigen in urine, in the case of Legionella pneumophila serogroup 1 infection. Pyogenic bacteria were identified on the results of respiratory secretions or blood cultures. Continuous data and categorical variables were worked out using SPSS version 15. RESULTS: Among the 124 patients enrolled, an etiologic agent was identified in 44 (35.4%) patients. The most common organism was Mycoplasma pneumoniae (n = 21, 17%), followed by Chlamydia pneumoniae (n = 15, 12%), Streptococcus pneumoniae (n = 9, 7%), Haemophilus influenzae (n = 2, 1.6%), Klebsiella pneumoniae (n = 2, 1.6%) and Staphylococcus aureus (n = 1, 0.8%). Streptococcus pneumoniae was the most common organism isolated from blood cultures. No cases of Legionella pneumophila serogroup 1 were identified. CONCLUSIONS: Mycoplasma pneumoniae and Chalmydia pneumoniae are significant etiologic agents for community-acquired pneumonia occurring in Karachi. Local treatment guidelines for community-acquired pneumonia should include therapy directed specifically at these agents.

Pulmonary functions in patients with diabetes mellitus.

BACKGROUND: A reduction in lung capacity has been reported previously among diabetics. According to WHO estimates, Pakistan is currently eighth in the prevalence of diabetes mellitus (DM) and will become fourth by the year 2025 with over 15 million individuals. This study was designed to see the impairment of lung functions on spirometry in DM patients. OBJECTIVE: Our aim was to investigate the pulmonary functions tests of Pakistani patients with DM. MATERIALS AND METHODS: Between January to July 2004, 128 subjects who were never-smokers and had no acute or chronic pulmonary disease were recruited. Sixty-four of these subjects had DM and 64 were healthy matched controls. All underwent screening with detailed history, anthropometry, lipid profile, and spirometric measurements at the Aga Khan University Hospital, Karachi, Pakistan. RESULTS: The mean age of diabetics and matched control were 54.3±9 and 54.0±8 (P<0.87) years, respectively. Diabetes patients showed a significant reduction in the forced vital capacity (FVC) [mean difference (95% CI) - 0.36 (-0.64, -0.07) P<0.01], forced expiratory volume in one second (FEV(1)) [- 0.25(-0.50, -0.003) P<0.04], and slow vital capacity (SVC) [- 0.28(-0.54, -0.01) P<0.04], relative to nondiabetic controls. There was no significant difference noted in the forced expiratory ratio and maximum mid-expiratory flow between the groups. There was also a significant higher level of triglycerides noted among diabetics (P<0.001). CONCLUSION: Diabetic patients showed impaired lung function independent of smoking. This reduced lung function is likely to be a chronic complication of diabetes mellitus.

Assessing two spirometric criteria of pre-bronchodilator and post-bronchodilator FEV1/FVC ratio in detecting air flow obstruction.

OBJECTIVES: To assess the Pre-bronchodilator criteria and the Post-bronchodilator criteria of FEV1/FVC ratio in diagnosing Airflow obstruction. METHODS: An observational study was conducted from 1988 to 2006 at the Aga Khan University Hospital Patients referred to the pulmonary function test laboratory for spirometry with bronchodilator reversibility at the hospital during the above said period were enrolled. Forced spirometry was performed according to ATS guidelines. All patients who had pre-bronchodilator criteria of airflow obstruction were analyzed and compared with the post bronchodilator criteria. RESULTS: A total of 4222 individuals underwent spirometry out of which 4072 individuals were studied. Using the pre bronchodilator criteria, 1375 (34%) patients had airflow obstruction. Applying the post bronchodilator criteria on the same patients, 1098 (27%) had evidence of airway obstruction. Out of these 1375 patients who had airflow obstruction by using pre-bronchodilator criteria, 277 (20%) patients had no airflow obstruction by using the post bronchodilator criteria. Out of these 277 patients, 52% had significant airways reversibility as evidenced by >12% increase in their FEV1 pre and post bronchodilator. CONCLUSION: Pre bronchodilator criteria for detection of airflow obstruction overestimate the diagnosis of airflow obstruction and by using post bronchodilator criteria for airway obstruction on spirometry, decreases this over diagnosis of the condition

Osseous spinal sarcoidosis: an unusual but important entity to remember.

Sarcoidosis is a multi-system disorder of unknown aetiology characterised by non-caseating granulomatous inflammation with varying presentation and prognosis. Bone involvement is uncommon and vertebral involvement is rare. We report a case of vertebral osseous sarcoidosis which presented with pulmonary symptoms mimicking tuberculosis and later developed vertebral involvement despite administration of oral corticosteroids.