Adult Bochdalek Hernia with Organo-Axial Gastric Volvulus: Misdiagnosed as Hydropneumothorax.

Bochdalek hernia (BH) in an adult may manifest clinically with a myriad of abdominal or chest symptoms or a combination of them. Diagnosis of an adult BH is usually delayed in view of rarity of the lesion and its varied presentation. A 30-year-old adult gentleman presented to us with a left thoracostomy which was draining pus and ingested food particles. The tube thoracostomy had been performed in another hospital for an apparent left hydropneumothorax before he arrived in our hospital. Computed tomography of Chest and abdomen revealed a left diaphragmatic defect with herniation of stomach, spleen and omentum into the chest with organo-axial volvulus of the stomach. A thoracostomy tube was seen to be traversing through the stomach with its tip located close to the left pulmonary artery. The patient underwent left thoraco-abdominal exploration with dissection and reposition of the hernial contents in the abdominal cavity. The gastric perforations and the diaphragmatic defect were repaired. This case reiterates a well-known fact that an adult type BH must find a place in the differential diagnosis of a hydropneumothorax. Though the adult BH is a rare diagnosis, unawareness or reluctance to consider the possibility of adult BH may prolong the suffering of the patient as it happened in our patient who had iatrogenic perforation of the stomach due to tube thoracostomy.

Newspaper articles as a tool for cardiovascular prevention programs in a developing country.

The purpose of this study was to evaluate changes in knowledge and attitudes as intermediate measures of community impact of a health education campaign using newspaper articles. The intervention involved prominently placed, illustrated newspaper articles by Heartfile (heartfile.org) with nationwide urban outreach, posted regularly in the largest English newspaper in Pakistan using newspaper donated space for a period of 130 consecutive weeks. The post intervention evaluation involved a cross sectional telephone survey in a major city. In the total sample, 26.5% were readers of the newspaper and majority of them (72%) stated that they were regular readers. These 500 persons were eligible for the interview; of these, 93% remembered having seen the Heartfile articles. In this group, 87% of the respondents stated that the articles significantly supplemented their knowledge about diet, and in 5% they were the sole source of information. With respect to exercise, these articles supplemented the knowledge of 77% of the respondents and were the sole source of information for 9% whereas in the case of smoking, knowledge was supplemented in 85% and the articles were the sole source of information in 4% of the cases. Of those interviewed, 40% reported that they had made some dietary changes, 39% made some changes in their exercise habits and 8% reduced the amount of tobacco consumption as a result of reading these articles. In relation to newspaper articles, the per article production cost was US$ 169 and the articles were read regularly by an estimated 0.66 million and occasionally by 0.79 million individuals all over the country. Newspaper articles are a useful supplement to other health education activities as part of cardiovascular disease prevention programs. Lessons from the Heartfile experience in Pakistan could be useful for other similar initiatives in low resource settings.

Street children in Pakistan: a situational analysis of social conditions and nutritional status.

This paper examines the social conditions and nutritional status of street children in Pakistan. Nutritional status is evaluated by an assessment of height and weight relative to age. A heterogeneous sample of 108 street children in the twin cities of Rawalpindi and Islamabad was studied. One hundred and one of them were children "on the street" having regular family contact; seven were "of the street", without any family contact. Most street children came from large families which had recently moved to the city in search of economic opportunities. Their parents had low education levels and were either unemployed or employed in unskilled occupations. Poverty clearly was an important factor. The majority of the children moved to the street to augment family income. Most of the children were males (81%) and the average age at beginning life on the street was under 10 years. The majority was working 8-12 h daily with an average income of Rs. 40-60 per day (USD 1 = Rs. 60). Important issues were parental exploitation, police harassment, abuse, and the impact of other street peers in their lives. The distribution of height-for-age relative to the National Center for Health Statistics (NCHS) reference standard showed that 20% were stunted and 12% had wasting. Wasting was equal between sexes, while fewer girls than boys were stunted. The study concludes that the issue of street children in Rawalpindi and Islamabad is mainly one of "children on the street," while "children of the street" are an exceptional phenomenon. It was noted that, with some exceptions, street children in other world regions share similar risk factors and backgrounds. Findings from this study will facilitate both the identification of high-risk families, i.e. those whose children are likely to take to the street, and timely preventive and rehabilitative measures.

Waist-hip ratio and low HDL predict the risk of coronary artery disease in Pakistanis.

OBJECTIVE: To establish risk factor causal associations for coronary artery disease (CAD) in the native Pakistani population. METHODS: We conducted a hospital-based, case-control study of 200 cases with angiographically documented CAD and 200 age- and sex-matched controls without angiographic evidence of CAD. Patients on lipid lowering therapy were excluded. Lifestyle, anthropometric and biochemical risk factors were assessed in both groups. RESULTS: The presence of CAD was associated with current, past or passive smoking, a history of diabetes and high blood pressure, a positive family risk factors in this study; levels were below history of CAD, body fat percentage, waist-hip ratio (WHR), low apolipoprotein A1 or low HDL, lipoprotein (a), glucose, insulin, insulin resistance, C-reactive protein (CRP), total cholesterol to HDL ratio (TC/HDL) and creatinine on univariate conditional logistic regression analysis. In multiple regression analysis, significant independent associations were found with low HDL (OR 0.11; 95% CI 0.04-0.34; p < 0.001) positive family history (OR 1.79; 95% CI 1.09-2.93; p = 0.02), CRP (OR 1.45; 95% CI 1.19-1.75; p < 0.001) and WHR (OR 1.04; 95% CI 1.01-1.08; p = 0.01). Angiograms were also quantified for the extent and severity of CAD by the Gensini scoring system. Quantitative angiographic data showed associations with age (p = 0.01), the duration of diabetes (p = 0.04), WHR (p = 0.06), low HDL (p < 0.001), lipoprotein (a) (p = 0.001), creatinine (p < 0.001) and CRP (p = 0.007). Results indicate that total and LDL cholesterol were not significant currently accepted thresholds for treatment. CONCLUSIONS: The cardiovascular risk profile in this population is consistent with metabolic syndrome where low HDL and WHR can be used to predict the risk of CAD. Results suggest the need to redefine the currently practised approach to CAD management in this population to fit local needs.