Amer Hayat Khan

Impact of Diabetes Mellitus on Treatment Outcomes of Tuberculosis Patients in Tertiary Care Setup

Background:Concurrent diabetes mellitus (DM) with tuberculosis (TB) has an increased risk of treatment failure. This study was aimed to evaluate treatment outcomes in patients with TB with and without DM. Methods:A retrospective cohort study was conducted at respiratory clinic of Hospital Pulau Pinang, Malaysia. All TB-registered patients from January 2006 to December 2007 were included in the study. A validated data collection form was used for collecting data. World Health Organizations criterion was used for categorizing treatment outcomes. Data were analyzed by using SPSS 16. Results:Of 1267 patients, 338 patients (26.7%) had concurrent TB-DM. In multivariate analysis, TB-DM was more likely to be present in Chinese (odds ratio [OR] = 1.401, P = 0.011), patients having age of 46 to 60 years (OR = 3.168, P < 0.001) and >60 years (OR = 2.524, P < 0.001) and patients with pulmonary TB (OR = 2.079, P < 0.001). Nine hundred and eighty-five (78.8%) patients were successfully treated. No statistically significant difference was observed between 2 groups: patients with TB-DM and patients with only TB. Successful treatment outcomes were observed in patients having age of 46 to 60 (OR = 1.567, P = 0.001), whereas male gender (OR = 0.721, P = 0.049) and patients with relapse TB (OR = 0.494, P = 0.002) were less likely to have successful treatment outcome. Conclusions:High prevalence of TB-DM in the study signifies the fact that patients with DM are at high risk of developing TB. Treatment outcomes in both groups were comparable. The gender-based and age-based disparity in TB treatment outcomes in this study indicates the importance of gender-specific and age-specific strategies of TB management.

Applicability of the World Health Organization recommended new shorter regimen in a multidrug-resistant tuberculosis high burden country.

In order to improve the adherence and treatment outcomes of multidrug-resistant (MDR) tuberculosis (TB) patients, the World Health Organization (WHO) has recently recommended a new, shorter and cheaper treatment regimen. The new regimen, comprised of 4–6 months of kanamycin, moxifloxacin, prothionamide, clofazimine, pyrazinamide, ethambutol and high dose isoniazid followed by 5 months of moxifloxacin, clofazimine, pyrazinamide and ethambutol [1], has produced excellent outcomes under operational research conditions is various settings [2–4]. However, the recommendation that it should be used only for MDR-TB patients who are neither previously treated with second-line anti-TB drugs, nor resistant to fluoroquinolones or injectable second-line anti-TB drugs [1], generates concerns about its applicability in MDR-TB high burden countries [5]. In the current cross-sectional study, culture-confirmed MDR-TB patients treated at two units for programmatic management of drug-resistant TB in Pakistan were evaluated for drug resistance pattern and eligibility to be treated with the new shorter regimen. High prevalence of ofloxacin resistance should not limit the applicability of the new shorter regimen in Pakistan http://ow.ly/HCAs306dUjU

Incidence, Characteristics and Risk Factors of Acute Kidney Injury among Dengue Patients: A Retrospective Analysis

Background Dengue induced acute kidney injury (AKI) imposes heavy burden of illness in terms of morbidity and mortality. A retrospective study was conducted to investigate incidence, characteristics, risk factors and clinical outcomes of AKI among dengue patients. Methodology A total 667 dengue patients (2008–2013) were retrospectively evaluated and were stratified into AKI and non-AKI groups by using AKIN criteria. Two groups were compared by using appropriate statistical methods. Results There were 95 patients (14.2%) who had AKI, with AKIN-I, AKIN-II and AKIN-III in 76.8%, 16.8% and 6.4% patients, respectively. Significant differences (P<0.05) in demographics and clinico-laboratory characteristics were observed between patients with and without AKI. Presence of dengue hemorrhagic fever [OR (95% CI): 8.0 (3.64–17.59), P<0.001], rhabdomyolysis [OR (95% CI): 7.9 (3.04–20.49)], multiple organ dysfunction [OR (95% CI): 34.6 (14.14–84.73), P<0.001], diabetes mellitus [OR (95% CI): 4.7 (1.12–19.86), P = 0.034], late hospitalization [OR (95% CI): 2.1 (1.12–19.86), P = 0.033] and use of nephrotoxic drugs [OR (95% CI): 2.9 (1.12–19.86), P = 0.006] were associated with AKI. Longer hospital stay (>3 days) was also observed among AKI patients (OR = 1.3, P = 0.044). Additionally, 48.4% AKI patients had renal insufficiencies at discharge that were signicantly associated with severe dengue, secondary infection and diabetes mellitus. Overall mortality was 1.2% and all fatal cases had AKI. Conclusions The incidence of AKI is high at 14.2% among dengue patients, and those with AKI portended significant morbidity, mortality, longer hospital stay and poor renal outcomes. Our findings suggest that AKI in dengue is likely to increase healthcare burden that underscores the need of clinicians’ alertness to this highly morbid and potentially fatal complication for optimal prevention and management.

Predictors of two months culture conversion in multidrug-resistant tuberculosis: findings from a retrospective cohort study.

Background Various studies have reported culture conversion at two months as a predictor of successful treatment outcome in multidrug-resistant tuberculosis (MDR-TB). Objectives The present study was conducted with the aim to evaluate the rate and predictors of culture conversion at two months in MDR-TB patients. Methods All confirmed pulmonary MDR-TB patients enrolled for treatment at Lady Reading Hospital Peshawar, Pakistan from 1 January to 31 December 2012 and met the inclusion criteria were reviewed retrospectively. Rate and predictors of culture conversion at two months were evaluated. Results Eighty seven (53.4%) out of 163 patients achieved culture conversion at two months. In a multivariate analysis lung cavitation at baseline chest X-ray (P = 0.006, OR = 0.349), resistance to ofloxacin (P = 0.041, OR = 0.193) and streptomycin (P = 0.017, OR = 0.295) had statistically significant (P<0.05) negative association with culture conversion at two months. Conclusion A reasonable proportion of patients achieved culture conversion at two months. Factors negatively associated with culture conversion at two months can be easily identified either before diagnosis or early in the course of MDR-TB treatment. This may help in better care of individual patients by identifying them early and treating them vigorously.

Defining acute kidney injury in dengue viral infection by conventional and novel classification systems (AKIN and RIFLE): a comparative analysis.

Background Several criteria have been used to stratify acute kidney injury (AKI) in dengue infection and have resulted in variations in its incidence as well as clinic-laboratory characteristics. The current study was aimed to compare three commonly used criteria of AKI among patients with dengue. Methods 667 patients with dengue were defined and staged according to the conventional definition (CD), the Acute Kidney Injury Network (AKIN) and the Risk, Injury, Failure, Loss of function, End stage renal disease (RIFLE) criteria. Appropriate statistical methods were used to compare these three criteria. Results The incidence of AKI during dengue infection was 14.2% by AKIN criteria, 12.6% by RIFLE criteria and 4.2% by CD. AKIN and RIFLE criteria were comparable while AKIN-I identified 11 more patients with AKI than RIFLE-R (76.8% vs 73.8%, p=0.023). CD was found to be less sensitive than AKIN and RIFLE due to stratification of only severe AKI cases with serum creatinine ≥176.8 µmol/L. Overall mortality was 1.2% and severe stages of AKI were associated with increased mortality (p<0.001). AKIN criteria identified seven risk factors, RIFLE identified six and CD identified three risk factors. Old age, severe dengue and the use of nephrotoxic drugs were found to be independent predictors identified by all criteria while hypertension was only identified by AKIN. Conclusions The incidence of AKI in dengue infection, the risk factors for its development and clinico-laboratory characteristics vary significantly according to the diagnostic criteria used. In our analysis, AKIN and RIFLE were comparable to each other and superior to CD with regard to early diagnosis and sensitivity.

Tuberculous lymphadenitis at Penang General Hospital, Malaysia.

Objective: To evaluate the incidence, treatment and clinical outcomes of tuberculous (TB) lymphadenitis at Penang General Hospital, Malaysia. Materials and Methods: Penang General Hospital is the referral center for all tuberculosis patients in the state of Penang. Patient records were reviewed to identify patients with confirmed diagnosis of TB lymphadenitis between January 2006 and December 2008. Data were analyzed using SPSS version 15. Results: Of 1,548 tuberculosis cases, 109 (7.0%) patients had TB lymphadenitis. The mean age was 36.4 ± 12.87 years and of the 109 patients with TB lymphadenitis, 35 (33.0%), 37 (34.0%) and 36 (33.0%) were observed for 2006, 2007 and 2008, respectively. Ethnically, 45 (41.3%) were Malay followed by 37 Chinese (33.9%). Among risk factors for TB lymphadenitis, HIV and diabetes mellitus were seen in 17 (15.6%) and 11 (10.0%) patients, respectively. Cough and fever were the most frequently reported symptoms. In a majority of cases (n = 90, 82.5%) positive results were obtained for fine-needle aspiration (FNA). Directly observed therapy was given to all patients. Sixty-two (56.9%) patients were successfully treated, and 5 (4.6%) patients died during the treatment. Conclusion: There was no increase in the incidence of TB lymphadenitis over the 3-year study period. The incidence was slightly higher in male than female gender and in Malay (ethnic group). Diabetes mellitus and HIV were the most commonly reported risk factors. FNA is the most reliable diagnostic test.

Evaluation of Health-Related Quality of Life among Tuberculosis Patients in Two Cities in Yemen

Background The health-related quality of life (HRQoL) of Tuberculosis (TB) patients is important because it directly influences the outcome of TB patients in several aspects. The current study aims to evaluate and to find the factors influencing the HRQoL of TB patients in two major TB-prevalent cities (Taiz and Alhodidah) in Yemen. Methods A prospective study was conducted, and all TB patients meeting the HRQoL criteria were asked to complete the HRQoL SF-36 survey. The records of TB patients were examined for disease confirmation, and a follow-up was consequently performed for patients during treatment between March 2013 and February 2014 in Taiz and Alhodidah Cities. HRQol scores were calculated by using QM scoring software version 4.5, in which the physical component score (PCS) and mental component score (MCS) were obtained. The scores obtained between 47–53 normal based score (NBS) were considered equivalent to the US normal score. Low scores indicate the poor health situation of TB patients Results A total of 243 TB patients enrolled in the study at the beginning of the treatment. A total of 235 and 197 TB patients completed the questionnaire at the end of the intensive phase (I.P.) and continuation phase (C.P.), respectively. The final dropout rate was 16.2%. The mean PCS and MCS scores at the beginning of treatment were low, thus showing the poor health situation of TB patients. The mean PCS scores at the beginning of treatment, end of I.P., and end of treatment were (36.1), (44.9), and (48), respectively. Moreover, the mean MCS score at the beginning of treatment, end of I.P., and end of treatment were (35.1), (42.2), and (44.3), respectively. The result shows that significant increases are observed at the end of I.P. for PCS and MCS because of the treatment and slight changes at the end of C.P. Despite this finding, the MCS score remains below the normal range (47), thus indicating a significant risk of depression among TB patients. Furthermore, general linear repeated measure ANOVA was performed for selected variables, to examine the changes of PCS and MCS over time. It was found that Alhodiah city, chewing khat habit, stigmatization, and duration of treatment more than six months were greatly associated with low mean MCS score of TB patient, indicating great risk of depression which may result in poor treatment outcome. Conclusion TB patients in Yemen were found to have poor QoL, with a significant likelihood of depression. Highly risk depression was found among TB patients in Alhodiah city, khat chewers, stigmatization and having a duration of treatment more than 6 months. Therefore, additional efforts should be made to improve their QoL because it may affect the final clinical outcome of patients.

First chikungunya outbreak in Pakistan: a trail of viral attacks

Despite explicit warning from the National Institute of Health, Pakistan experienced its first chikungunya outbreak in the metropolis of Karachi. We underscore the attention of health authorities and healthcare professionals towards contributing factors associated with this outbreak and the measures required to combat this viral disease.

Meta-synthesis Exploring Barriers to Health Seeking Behaviour among Malaysian Breast Cancer Patients

Barriers to health seeking constitute a challenging issue in the treatment of breast cancer. The current meta- synthesis aimed to explore common barriers to health seeking among Malaysian breast cancer patients. From the systematic search, nine studies were found meeting the inclusion criteria. Data extraction revealed that health behavior towards breast cancer among Malaysia women was influenced by knowledge, psychological, sociocultural and medical system factors. In terms of knowledge, most of the Malaysian patients were observed to have cursory information and the reliance on the information provided by media was limiting. Among psychological factors, stress and sense of denial were some of the common factors leading to delay in treatment seeking. Family members advice, cultural beliefs towards traditional care were some of the common sociocultural factors hindering immediate access to advanced medical diagnosis and care. Lastly, the delay in referral was one of the most common health system-related problems highlighted in most of the studies. In conclusion, there is an immediate need to improve the knowledge and understanding of Malaysian women towards breast cancer. Mass media should liaise with the cancer specialists to disseminate accurate and up-to-date information for the readers and audience, helping in modification of cultural beliefs that hinder timing health seeking. However, such intervention will not improve or rectify the health system related barriers to treatment seeking. Therefore, there is an immediate need for resource adjustment and training programs among health professional to improve their competency and professionalism required to develop an efficient health system.

Pregnant Women View Regarding Cesarean Section in Northwest Pakistan

Objective: Cesarean Section (CS) is a commonly performed procedure for women, with almost a third of women in many developed countries experiencing when they give birth. CS is still being perceived as an abnormal means of delivery by many antenatal women in remote areas of Pakistan. Aim of the study is to determine the perceptions of antenatal clients in the North West of Pakistan on CS. Materials and methods: A self-administered questionnaire based survey was designed. Subjects were enrolled from September 2009 to December 2009 in Women and Children Teaching Hospital Bannu, Pakistan. Pre-validated, self-developed questionnaire was used for study data. The data was fed to Statistical Package for Social Sciences (SPSS 16®) to analyze and presented in a simple frequency table. Results: Of 450 pregnant patients, 402 responded the questionnaire. Age of the respondents ranged between 16 and 44 (27.21 ± 4.04) years. Only 7 (1.7%) viewed CS as feasible and elected to undergo CS. Seventy one (17.6%) considered CS good in case of threat to their lives, whereas 195 (48.6%) didn’t accept CS in any circumstances. Only 35 (8.7%) women viewed CS uncomfortable in context of cultural barrier and a curse for women. Conclusion: Present study affirms previous suspicion that a significant proportion of antenatal clients are averse to CS and the negative cultural perception of the people to CS reinforced present aversion.