Safia Awan

Predictors of hospital stay and mortality in dengue virus infection-experience from Aga Khan University Hospital Pakistan

BackgroundDengue virus infection (DVI) is very common infection. There is scarcity of data on factor associated with increased hospital stay and mortality in dengue virus infection (DVI). This study was done to know about factors associated with increased hospital stay and mortality in patients admitted with DVI.ResultsOut of 532 patients, two third (72.6%) had stay ≤3 days while one third (27.4%) had stay greater than 3 days. The mean length of hospital stay was 3.46u2009±u20093.45 days. Factors associated with increased hospital stay (>3 days) included AKI (acute kidney injury) (Odd ratio 2.98; 95% CI 1.66-5.34), prolonged prothrombin time (Odd ratio 2.03; 95% CI 1.07-3.84), prolonged activated partial thromboplastin time (aPTT) (Odd ratio 1.80; CI 95% 1.15-2.83) and increased age ofu2009>u200941.10 years (Odd ratio 1.03; CI 95% 1.01-1.04).Mortality was 1.5%. High mortality was found in those with AKI (P <0.01), dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS) (P <0.001), respiratory failure (P0.01), prolong PT (P 0.001), prolong aPTT (P0.01) and increased hospital stay (P0.04).ConclusionIncreasing age, coagulopathy and acute kidney injury in patients with DVI is associated with increased hospital stay. Morality was more in patients with AKI, DHF and DSS, respiratory failure, coagulopathy and these patients had more prolonged hospitalization.

Medical mortality in Pakistan: experience at a tertiary care hospital

Aim: To acquire systematic data on the causes of hospital mortality in Pakistan, a developing country with scant mortality records. Study design: Retrospective review of death certificates and hospital charts of patients dying on general and specialty medical services at our hospital during one calendar year. Results: Of a total 10u2009590 admissions, 657 (6.2%) died in hospital. The deceased included 357 (54.4%) males and 299 (45.6%) females, with a collective median age of 63 years and mean length of stay 6.71 days (median 4 days, range 1–56 days). Primary cause of death was categorised as infectious (21.2%), pulmonary (17.2%), cancer related (15.7%), cardiovascular (12.6%), gastrointestinal and hepatic (10.8%), neurological (11.4%) and miscellaneous (11.1%). Within each category, the most common diagnoses were septicaemia (76.9% of infectious cases), pneumonia (55.7% of pulmonary cases), myocardial infarction (40.9% of cardiovascular), intracranial haemorrhage (37.3% of neurological), and cirrhosis (45.0% of gastrointestinal). There were multiple causes among malignant disorders with no single cause dominating. Patients with cardiovascular and pulmonary deaths tended to be older than the median age (pu200a=u200a0.001), while patients with gastrointestinal and cancer related deaths tended to be younger than the median age (pu200a=u200a0.001). Length of stay did not differ significantly among the various subgroups. About a quarter (26.4%) deaths occurred within 24 h of admission. Conclusions: Infections, including septicaemia and pneumonia, are the leading causes of hospital mortality in our setting, followed by malignancy and cardiovascular causes. The overall mortality rate is comparable to published mortality data from other hospital settings.

Range for normal body temperature in hemodialysis patients and its comparison with that of healthy individuals.

Background/Aims: Patients with chronic kidney disease undergoing hemodialysis have an altered homeostasis leading to altered body temperatures. We aimed to determine the range for normal body temperature in hemodialysis patients and compared it to healthy individuals. Also, we determined how much axillary temperatures differed from oral temperatures in both groups and whether axillary temperature is affected by the presence of an arteriovenous fistula (AVF) in hemodialysis patients. Methods: Oral and axillary (left & right) temperatures were recorded using an ordinary mercury-in-glass thermometer in 400 subjects (200 hemodialysis patients, 200 healthy individuals) at the Sindh Institute of Urology and Transplantation from mid-May to mid-June 2006. Comparisons were made between the temperatures of both groups. Results: Mean oral temperature in hemodialysis patients was higher than in healthy individuals [98.7°F (37°C) vs. 98.4°F (36.8°C); p < 0.001], as was the mean average axillary temperature [97.7°F (36.5°C) vs. 97.5°F (36.3°C); p = 0.02] and mean left axillary temperature [97.9°F (36.6°C) vs. 97.6°F (36.4°C); p < 0.001]. The fistula arm had higher axillary temperature in 77 (44%) hemodialysis patients. The difference between oral and axillary temperatures varied widely, making it impossible to obtain an accurate correction factor in both groups. Conclusion: Hemodialysis patients have higher normal body temperatures than healthy individuals. Axillary temperatures require cautious interpretation. In hemodialysis patients, the non-fistula arm should be preferred for recording axillary temperatures, as the presence of AVF may cause discrepancies in temperature measurements.

Prevalence of tobacco use among women: a cross sectional survey from a squatter settlement of Karachi, Pakistan

BackgroundWhile the prevalence of tobacco use has been slowly declining in the developed countries, rates have been steadily rising in the developing countries. This has led to a rapid rise in tobacco related lung diseases among women.ObjectiveDetermine the prevalence of tobacco use (both smoking and smokeless) among women in an urban squatter settlement (Orangi Town) in Karachi, Pakistan.MethodsA cross-sectional survey was conducted on 19,325 females aged between 15 and 80xa0years in Orangi Town, an urban squatter settlement in Karachi, Pakistan. Modified questionnaire, developed by World Health Organization WHO and Global Adult Tobacco survey (GATS), was used in Urdu. A total of 16,987 women agreed to participate.ResultsThe mean age was 37.3xa0±xa09.8xa0years amongst whom 15,255 (89.80xa0%) were married, 9143 (53.82xa0%) admitted that at least one person uses tobacco in some form in their homes. The prevalence of smokeless tobacco was 42.25xa0% (7178). The prevalence of smoking tobacco was low as compared to smokeless tobacco i.e. 18.0xa0% (3058). Among smokers, 85.47xa0% (1789) admitted that they had tried to quit smoking during last 12xa0months but failed.ConclusionTobacco use among women in an urban squatter settlement is very high and alarming. Preventive and control measures against tobacco use are required in these communities.

Multiple sclerosis in Pakistan: histocompatibility antigen composition and disability.

Dear Sir, An association between human leukocyte antigen (HLA) composition (especially DRB1 etc) and disability has been debated in the literature. A study of 380 multiple sclerosis (MS) patients showed that alleles *01 and *04 were independent predictors of increased disability,1 whereas an Iranian study of 183 MS patients did not show an association between DRB1*1501, DQA1*0102, DQB1*0602 and higher Expanded Disability Status Scale (EDSS) scores.2 Weinshenker and colleagues3 also did not find a correlation between DR15-DQ6 and DR13-DQ7 haplotypes and disease severity (as defined by EDSS and duration). Another study4 demonstrated an association between HLADRB1*1501, -DQB1*0301, -DQB1*0302, -DQB1*0602, and -DQB1*0603 alleles and more severe disease outcome on MRI. Disability related to MS was prevalent in our previous study of 142 patients;5 almost two-thirds of the patients in our previous series were severely disabled at 5.2 years after onset which is faster than the rate of progression seen in the West. Our present study was conducted to identify the prevalence of various HLA haplotypes among our MS patients as compared with a control population, and to evaluate a possible correlation between haplotypes and disease severity (EDSS). Patients (n = 100) with confirmed MS were prospectively enrolled from nine centers in Pakistan from January 2009 to September 2010; 40% were male, age range was 16–62 years (mean 32 years). Disease was classified as severe if patients had an EDSS score of 6 or more within 5 years of symptom onset. The control group for the distribution of HLA class II DRB1 and DQB1 alleles was composed of 1000 individuals, representing all major ethnic groups in Pakistan.6 HLA alleles were identified using a polymerase chain reaction and sequence specific primers (PCR-SSP) method as described by the manufacturer (One Lambda, Canoga Park, CA). HLA allele and haplotype frequencies were calculated using Pypop Win32-0.7.0 software. A total of 23% of patients developed severe disability (EDSS 6 or more) within 5 years of onset of symptoms. The most important factors associated with this rapid progression included a primary or secondary progressive course and spinal cord involvement. Almost 50% of patients in the severe disability group had a primary or secondary progressive course while 70% of patients in this group had spinal cord involvement. Higher disability scores showed a significant correlation with primary and secondary progressive MS (p = 0.001) and spinal cord involvement (p = 0.03). HLA typing and haplotype analysis of MS patients were compared with controls. There was no statistically significant difference between the two groups. There was a statistically significant association between high disability scores (EDSS 6 or more) and DQB1*0203 haplotype (p = 0.04). The clinical significance and possible mechanisms underlying this finding will have to be explored in future studies. The association between high disability scores and DRB1 alleles was non-significant. There was no significant correlation between haplotype and type of MS (relapsing– remitting versus primary or secondary progressive) and topography of MS (spinal cord versus optic and cranial involvement). Interestingly, the findings showed higher and more rapidly developing disability in Pakistani MS patients when compared to disability levels in Western MS patients. We wish to note that the recruiting centers are all tertiary care centers and the high disability may possibly be a selection bias.

Pattern of neurological diseases in adult outpatient neurology clinics in tertiary care hospital

ObjectivesThe burden of neurological diseases in developing countries is rising although little is known about the epidemiology and clinical pattern of neurological disorders. The objective of this study was to understand the burden of disease faced by neurologists a in tertiary care setting.ResultsA prospective observational study was conducted of all presentations to neurology clinics at Aga Khan University Hospital Karachi over a period of 2xa0years. A total of 16,371 out-patients with neurological diseases were seen during the study period. The mean age of the study participants were 46.2xa0±xa018.3xa0years and 8508 (52%) were male. Headache disorders were present in 3058 (18.6%) of patients followed by vascular diseases 2842 (17.4%), nerve and root lesions 2311 (14.1%) and epilepsies 2055 (12.5%). Parkinson’s disease was more prevalent in male participants 564 (70.8%) as compared to female 257 (62.1%) (pxa0=xa00.002). Migraines and vertigo disease were more diagnosed in females as compared to males. Epilepsies were seen more in younger age groups. Parkinson’s disease was seen in 50.9% of participants between the ages of 45 and 65xa0years, and the frequency increased with age.

Factors Affecting Inpatient Mortality in Elderly People with Acute Kidney Injury

Background Acute Kidney Injury (AKI) is common in elderly people (EP). There is paucity of data on predictor of mortality in EP with AKI. Objective This study was done to know more about factors associated with inpatient mortality in EP with AKI. Methods We retrospectively reviewed medical records of patients aged 65 years or above hospitalized with a diagnosis of AKI at Aga Khan University Hospital, Karachi, between January 2005 and December 2010. Binary logistic regression models were constructed to identify factors associated with mortality in EP with AKI. Results 431 patients had AKI, with 341 (79.1%) having stage I AKI, 56 (13%) having stage II AKI, and 34 (7.9%) having stage III AKI. Out of 431 patients, 142 (32.9%) died. Mortality increased with increasing severity of AKI. Mortality was 50% (17/34) in AKI stage III, 44.6% (25/56) in AKI stage II, and 29.3% (100/341) in AKI stage I. Factors associated with increased inpatients mortality were presence of stage III AKI (OR: 3.20, P = 0.04, 95% CI: 1.05–9.72), presence of oliguria (OR: 3.42, P = 0.006, 95% CI: 1.42–8.22), and need for vasopressors (OR: 6.90, P < 0.001, 95% CI: 2.42–19.65). Median bicarbonate 18 versus 17 between those who survived and those who died was associated with less mortality (OR: 0.94, P = 0.02, 95% CI: 0.89–0.99). History of hypertension (OR: 0.49, P = 0.03, 95% CI: 0.25–0.95) and high admission creatinine (OR: 0.68, P = 0.01, 95% CI: 0.50–0.91) were also associated with less mortality. Conclusion Mortality in EP increases with increasing severity of AKI. Presence of stage III AKI, oliguria, and hemodynamic instability needing vasopressor are associated with increased mortality. Increased median bicarbonate, presence of hypertension, and high admission creatinine were various factors associated with decreased inpatient mortality. Increasing age and need for dialysis did not increase mortality in elderly population.

Quality of Life in Individuals Surgically Treated for Congenital Hydrocephalus During Infancy: A Single-Institution Experience

BACKGROUNDnCongenital hydrocephalus (CH) is a frequently encountered birth anomaly that can hinder long-term neurologic maturity and social well-being of affected children. This study was undertaken to assess quality of life (QOL) 10-15 years after surgical treatment for primary CH during infancy at a tertiary care hospital in a developing country.nnnMETHODSnThis retrospective cohort study included individuals who presented to Aga Khan University Hospital, Karachi, Pakistan, between 1995 and 2005 at <1 year old and underwent surgery for primary CH. The Hydrocephalus Outcome Questionnaire was used to assess outcomes with respect to QOL.nnnRESULTSnOf 118 patients, 90 patients participated in the study. Mean age at first admission was 6.2 months. Mean length of follow-up was 5.4 years. Of these, 28 patients had died after surgery. Shunt infection (Pxa0= 0.012) and delayed milestones (Pxa0= 0.003) were found to be statistically significant factors affecting mortality in the patients who died. The mean overall health score was 0.67 ± 0.30. Age <6xa0months at the time of first surgery was a poor predictor of overall health on the Hydrocephalus Outcome Questionnaire (Pxa0= 0.039).nnnCONCLUSIONSnIn our analysis, we assessed the QOL associated with CH. We hope that these results will provide insight for future prospective work with the ultimate goal of improving long-term QOL in children with CH.

Association of hypercapnia on admission with increased length of hospital stay and severity in patients admitted with community-acquired pneumonia: a prospective observational study from Pakistan

Objective To determine whether the presence of hypercapnia on admission in adult patients admitted to a university-based hospital in Karachi, Pakistan with community-acquired pneumonia (CAP) correlates with an increased length of hospital stay and severity compared with no hypercapnia on admission. Study design A prospective observational study. Settings Tertiary care hospital in Karachi, Pakistan. Methods Patients who met the inclusion criteria were enrolled in the study. The severity of pneumonia was assessed by CURB-65 and PSI scores. An arterial blood gas analysis was obtained within 24u2009hours of admission. Based on arterial PaCO2 levels, patients were divided into three groups: hypocapnic (PaCO2 <35u2009mm Hg), hypercapnic (PaCO2 >45u2009mm Hg) and normocapnic (PaCO2 <35–45u2009mm Hg). Outcomes The primary outcome was the association of hypercapnia on admission with mean length of hospital stay. Secondary outcomes were the need for mechanical ventilation, ICU admission and in-hospital mortality. Results A total of 295 patients of mean age 60.20±17.0 years (157 (53.22%) men) were enrolled over a 1-year period. Hypocapnia was found in 181 (61.35%) and hypercapnia in 57 (19.32%) patients. Hypercapnic patients had a longer hospital stay (mean 9.27±7.57u2009days), increased requirement for non-invasive mechanical ventilation (NIMV) on admission (n=45 (78.94%)) and longer mean time to clinical stability (4.39±2.0u2009days) compared with the other groups. Overall mortality was 41 (13.89%), but there was no statistically significant difference in mortality (p=0.35) and ICU admission (p=0.37) between the three groups. On multivariable analysis, increased length of hospital stay was associated with NIMV use, ICU admission, hypercapnia and normocapnia. Conclusion Hypercapnia on admission is associated with severity of CAP, longer time to clinical stability, increased length of hospital stay and need for NIMV. It should be considered as an important criterion to label the severity of the illness and also a determinant of patients who will require a higher level of hospital care. However, further validation is required.

Validation study of the mini-mental state examination in the urdu language for a pakistani population

with CI secondary to FND and NDwere enrolled in an outpatient CIT program (n1⁄4219). The samplewas divided into 2 groups: patients that received NRD (n1⁄485) (G1), and patients that did not receive NRD (n1⁄4134) (G2). The groupswere paired by age, education,MiniMental StateExamination,Beck Inventory (BI), timeof progression, andnumber of sessions. Cognitive variables, behavioral variables, Activities of DailyLiving (ADL) andQuality of Life (QoL)were compared at treatment start and treatment end. Parametric statistics and analysis were performed at paired samples. Results: Drug-use rates were as follows: 37% antiplatelet aggregating agents, 32.9% antidepressant agents; 21% cholinesterase inhibitors (60.9% donezepil), 22.4% antiepileptic agents, 20.1% antipsychotic agents (60.5% quetiapine), and 17.4% memantine. Regarding NRD: 32.9% (n1⁄472/219) received benzodiazepines, 4.6%(n1⁄410/219) anticholinergic agents, and2.28%(n1⁄45/219) were administered barbiturates. At CIT end, G1 only evidenced improved QoL (mean change (MCh)1⁄44.78;p:0.01). G2 exhibited improved Subjective Memory (MCh1⁄45.74;p:0.03), basic ADL (MCh1⁄41.4;p:0.009) and instrumental ADL (MCh1⁄41.08;p:0.01), BI (MCh1⁄41.9;p:0.01), and Neuropsychiatric Inventory (MCh1⁄46.12; p:0.01).Conclusions: Asignificant number of patientswithCI received NRD. CIT led to significant improvement at some of the study variables, with a lower effect on patients who received drugs with prejudicial effects on cognition.