Publications by authors named "Om Parkash"

63 Publications

Infiltrative gallbladder tuberculosis versus locally infiltrating tumour of the gallbladder: a diagnostic dilemma unmasked by histopathology.

BMJ Case Rep 2021 Jun 23;14(6). Epub 2021 Jun 23.

Department of Medicine, Aga Khan University, Karachi, Pakistan

Gallbladder tuberculosis (TB) as an isolated infection and is an extremely rare entity even in parts of the world with endemicity. Though it has myriad ways of presentation, it can be cured successfully. We present a case of a 53-year-old man who presented with epigastric fullness and bloating with on and off low-grade fever for 2 months and significant weight loss. He underwent a CT scan, which showed a soft tissue gallbladder mass causing mural thickening of the antrum and lesser curvature. This was followed by a CT-guided core biopsy and gastric antrum biopsy via gastroscopy. Histopathology revealed chronic granulomatous inflammation in both samples. Various clinical presentations of gallbladder TB have been reported in literature, but to the best of our knowledge, the present case has a unique presentation and has never been reported before.
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http://dx.doi.org/10.1136/bcr-2020-241178DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8231025PMC
June 2021

SARS-CoV-2 Myocarditis Due to Severe Obesity.

Cureus 2021 May 17;13(5):e15074. Epub 2021 May 17.

Internal Medicine, Chicago Medical School Internal Medicine Residency Program at Northwestern Medicine McHenry Hospital, McHenry, USA.

Myocarditis is defined as a myocardial injury concomitant with myocardial dysfunction. Several causes are associated with it, including infectious versus inflammatory and inherited cardiomyopathies. It can be acute, subacute, or chronic, and it can present as focal versus diffuse myocardial dysfunction. Viruses diseases, including the Coxsackie B3 virus, have been a well-established cause of viral myocarditis. It is a significant cause of mortality typically among young individuals due to lymphocytic or granulomatous inflammation of the myocardium. At present, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been a detrimental cause of myocarditis with significant mortality and morbidity. Literature has revealed that most of the individuals affected by SARS-CoV-2 have significant other comorbidities, including cardiovascular, renal, or endocrine system-related comorbidities. It is noticed worldwide that patients with hypertension, diabetes mellitus, chronic obstructive pulmonary disease, and obesity are at a higher risk of developing severe infection. Obesity itself is related to chronic low-grade inflammation, and SARS-CoV-2 infection creates an environment of an inflammatory storm by excessive activation of cytokines, thus creating a vicious cycle of injury and organ damage. We present the case of a 33-year-old Hispanic morbidly obese male without other comorbidities diagnosed with SARS-CoV-2 pneumonia, complicated by severe systolic heart failure due to SARS-CoV-2 myocarditis.
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http://dx.doi.org/10.7759/cureus.15074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8211705PMC
May 2021

Gastric volvulus in adults in a tertiary care hospital Karachi, Pakistan: A case series.

J Pak Med Assoc 2021 Apr;71(4):1277-1281

Aga Khan University, Karachi, Pakistan.

Gastric volvulus is a rare surgical emergency which is rare in children and occasionally presents in adults. It results due to pathological malrotation of the stomach along its longitudinal or short axis. The condition, if not treated promptly, can result in increased morbidity and carries a high risk of death. Very few cases have been reported in literature regards this important clinical condition. Early decompression and repair of anatomical defects are the corner stone of its management. There is a dire need to develop guidelines and algorithms for management and treatment of this rare condition to improve patient outcome, prevent recurrence and facilitate early diagnosis by practicing physicians and surgeons. We report three such cases which presented to our setup in emergency along with a brief description of how they were successfully managed.
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http://dx.doi.org/10.47391/JPMA.386DOI Listing
April 2021

Acute Pancreatitis: A Possible Side Effect of COVID-19 Vaccine.

Cureus 2021 Apr 28;13(4):e14741. Epub 2021 Apr 28.

Internal Medicine, Rosalind Franklin University of Medicine and Science, Northwestern Medicine McHenry Hospital, McHenry, USA.

For the first time, the mRNA technology was utilized to produce a vaccine against COVID-19 after the unprecedented pandemic equally affected every part of the world. Pfizer-BioNTech (BNT162b2) mRNA vaccine against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was granted emergency use authorization (EUA) by Food and Drug Administration (FDA) in December 2020. EUA has been widely discussed in the medical literature and the general public. The safety of the BNT162b2 vaccine has been investigated in short-term trials with data available for three months. We present a case of a 96-year-old female with a past surgical history of cholecystectomy who presented with acute onset severe abdominal pain a few days after getting the first dose of Pfizer-BioNTech COVID-19 vaccine. She was diagnosed with acute pancreatitis with a lipase level of 4036 U/L. Extensive history and investigations were unable to find any etiology. The patient was conservatively managed and discharged home without any complications. There has been some data available in medical literature showing an association between acute pancreatitis and COVID-19 infection. Trial data of Pfizer COVID-19 also shows one case of acute pancreatitis in the treatment group. There have also been individual cases of unexplained acute pancreatitis shared by medical professionals on online forums. Our main goal to write this case is to make medical literature aware of possible emerging side effects of the COVID-19 vaccine, one of such side effects being self-resolving uncomplicated acute pancreatitis.
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http://dx.doi.org/10.7759/cureus.14741DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8163516PMC
April 2021

"Chopper Shield" Technique to Protect Corneal Endothelium During Phacoemulsification Surgery for Rock Hard Cataracts.

Clin Ophthalmol 2021 24;15:2161-2165. Epub 2021 May 24.

Eye Department, Vision Eye Institute, Melbourne, Victoria, Australia.

Purpose: To describe an innovative technique of using a chopper as a shield for preventing mechanical corneal endothelial trauma that can occur during the phacoemulsification of brunescent cataracts.

Methods: This prospective study included patients with hard cataracts (grade nuclear opalescence 4 and above on LOCS III) who underwent phacoemulsification surgery. The chopper shield technique was performed in 48 eyes of 44 patients. The technique entailed placing the chopper horizontally as a shield anterior to the emulsifying nuclear fragment between the phaco tip and corneal endothelium to prevent nucleus fragments from coming into contact with the corneal endothelium. Outcome measures included cumulative dissipated energy (CDE), corneal edema (day one), CCT (assessed at one day, one week, and one month), and endothelial cell density assessed at three months.

Results: Of the 48 eyes included in the study, 23 were males and 25 were females (mean age: 70.02±5.98years). Preoperatively, mean central corneal thickness (CCT) was 529.62±21.70 microns, and endothelial cell counts were 2258.76±182.22 cells per mm. Postoperatively on day one, CCT increased to 563.93±24.53 microns, a 6.47% increase from preoperative central corneal thickness. CCT became 534.83±22.64 microns on postoperative day seven, a 0.98% increase from preoperative CCT. Endothelial cell loss was 6.77% at three months from the day of surgery.

Conclusion: The chopper shield technique offers continuous protection to the corneal endothelium by minimizing endothelial cell loss during phacoemulsification of dense nuclear cataracts.
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http://dx.doi.org/10.2147/OPTH.S308750DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8163620PMC
May 2021

Demonstrating competence in Endoscopic Retrograde Cholangiopancratico graphy (ERCP): Recently credentialed operator's performance for deep biliary cannulation over 1 year period from a tertiary care hospital in Pakistan.

J Pak Med Assoc 2021 Mar;71(3):929-932

Department of Medicine. The Aga Khan University Hospital, Karachi.

Objective: To measure the success rate of endoscopic retrograde cholangiopancreaticography biliary cannulation of a recently credentialed endoscopist at a tertiary hospital.

Methods: The clinical audit was conducted at the Aga Khan University Hospital. Karachi, and comprised data of all patients who underwent endoscopic retrograde cholangiopancreaticography under the care of a single operator during 2016. Data was retrospectively extracted from patient charts by an assistant blinded to the study. Data extracted included demographics, admission type, details and indication for the procedure, diagnosis, cannulation outcome, duct clearance, complications, follow-up surgical intervention, radiological imaging and mortality post-endoscopy. Data was analysed using SPSS 19.

Results: Of 143 procedures performed, 102(71.3%) were included. The mean age was 52±17 years and 54(52.9%) of them were females. Most common indication was choledocholithiasis in 70(68.6%). The average procedure time was 41.5±5.5 minutes. Cannulation success rate was 96(94.1%). Complications included post-procedure pancreatitis in 5(4.9%), minimal bleeding in 8(7.8%) and oesophageal perforation in 1(0.98%). There was no procedure-related mortality.

Conclusions: The success rate was high and complications were low with zero mortality.
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http://dx.doi.org/10.47391/JPMA.1219DOI Listing
March 2021

Creating Hospital Spaces for Coronavirus Disease 2019 in Pakistan.

Asia Pac J Public Health 2021 Mar-Apr;33(2-3):324-325. Epub 2021 Jan 9.

Aga Khan University, Karachi, Pakistan.

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http://dx.doi.org/10.1177/1010539520986250DOI Listing
January 2021

Development and Evaluation of an Electrochemical Biosensor for Detection of Dengue-Specific IgM Antibody in Serum Samples.

Diagnostics (Basel) 2020 Dec 26;11(1). Epub 2020 Dec 26.

Department of Medical Microbiology and Parasitology, School of Medical Science, Universiti Sains Malaysia, Kubang Kerian 16150, Malaysia.

Dengue is an arbovirus disease transmitted mainly by mosquitoes. As dengue shares similar clinical symptoms with other infectious diseases, prompt and accurate diagnosis is pivotal to clinicians' decisions on appropriate management. Conventional diagnostic tests to detect the dengue-specific IgM antibody are limited in their performance and ease of use. To address these issues, we developed and evaluated a biosensor based on screen-printed carbon electrodes (SPCEs) for the detection of dengue-specific immunoglobulin M (IgM) antibodies. Various optimisations were performed in order to increase the sensitivity and specificity of the biosensor. For optimal and proper orientation of the paratope sites of goat anti-human IgM capture antibodies (GAHICA), various antibody techniques, including passive, covalent, protein A, protein G and streptavidin/biotin systems, were tested on the SPCEs. The assay reagents for the biosensor were also optimised prior to its evaluation. Analytical sensitivity evaluation was carried out using pooled sera, while analytical specificity evaluation was conducted on a panel of six non-dengue serum samples. Subsequently, diagnostic sensitivity and specificity evaluation were performed using 144 reference samples. Electrochemical current signals generated from HO catalysed by HRP-labelled anti-dengue detection antibodies were measured using the chronoamperometric technique. With a limit of detection (LOD) of 10 serum dilution, the analytical sensitivity of the developed biosensor was 10 times higher than commercial ELISA. The analytical specificity of this dengue IgM biosensor was 100%. Similarly, the biosensor's diagnostic performance was 100% for sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). These findings suggest that the developed biosensor has a great potential to be used to diagnose dengue after seroconversion.
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http://dx.doi.org/10.3390/diagnostics11010033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7824051PMC
December 2020

Clinical Spectrum in a Cohort of Patients With High Fecal Calprotectin Levels.

Cureus 2020 Nov 3;12(11):e11314. Epub 2020 Nov 3.

Section of Chemical Pathology, Department of Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi, PAK.

Introduction: Distinguishing between inflammatory bowel disease (IBD) and functional gastrointestinal disorders is a diagnostic challenge. The need for non-invasive biomarker as a diagnostic tool in the assessment of gastrointestinal symptoms is required. The objectives of current study were to determine the spectrum of clinical features in patients tested for fecal calprotectin presenting with high levels and to compare calprotectin levels among already diagnosed patients known to have IBD as per biopsy findings and documented on patients' file with newly presenting patients who were being investigated and did not have a diagnosis.

Methods: This retrospective cross-sectional study was conducted in the Department of Pathology and Laboratory Medicine and Department of Medicine, Aga Khan University, Karachi, Pakistan from January 2017 to December 2019. Subjects tested for fecal calprotectin who had elevated fecal calprotectin levels (n = 150) were included in the current study. Each patient deposited a random stool sample in an airtight container for calprotectin analysis. Biochemical analysis of calprotectin was performed by enzyme-linked immunosorbent assay using epitope calprotectin test kit (Epitope Diagnostics, Italy) on ETI-Max 3000 immunoassay analyzer (DiaSorin, Italy). A structured history form was used for data collection.  Results: One hundred and fifty patients were available for inclusion in the final analysis. Majority of the patients (n = 117, 78%) were adults (>18 years of age), and 52.7% (n = 79) were females. Median fecal calprotectin (IQR) was 317.3 μg/g (549.10 - 239.2 μg/g) in children (n = 33) and 305 μg/g (609.9 - 201.6 μg/g) in adults; the difference was statistically non-significant (p value > 0.05). On categorization according to disease, fecal calprotectin levels were significantly elevated (p value = 0.033) in IBD patients compared to normal subjects, 644 μg/g (644 - 587.8 μg/g) vs 308.5 μg/g (505.4 - 233.8 μg/g), respectively. Diarrhea (n = 13, 38.4%), abdominal cramps (n = 12, 36.4%), and weight loss (n = 11, 33.3%) were the most common complaints noted in children with high fecal calprotectin levels, whereas in adults, abdominal cramps (n = 60, 51.3%), diarrhea (n = 59, 50.4%), and weight loss (n = 46, 39.3%) were the common complaints. The median fecal calprotectin levels in children already known to have IBD (n = 3) were higher than the levels noted in children with no diagnosis (n = 30); p value > 0.05. Similarly, median fecal calprotectin levels in adults with IBD (n = 28) were higher than the levels noted in patients with no specific diagnosis (n = 91), 400.7 μg/g (656.6 - 244.3 μg/g) vs 302.7 μg/g (564.6 - 206 μg/g); p value > 0.05.

Conclusion: Current study affirms that the fecal calprotectin test can be used in identifying IBD patients in all age groups.
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http://dx.doi.org/10.7759/cureus.11314DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7714742PMC
November 2020

Adenoma detection rate as a quality indicator for colonoscopy: a descriptive cross-sectional study from a tertiary care hospital in Pakistan.

Endosc Int Open 2020 Nov 22;8(11):E1707-E1712. Epub 2020 Oct 22.

Section of Gastroenterology, Department of Medicine, Aga Khan University, Karachi, Pakistan.

Adenoma detection rate (ADR) is validated for measuring quality of colonoscopy, however there is lack of colorectal cancer (CRC) screening program in South Asia. The purpose of this study is to analyze and review the polyp detection rate (PDR) and ADR and provide insight into the factors that influence them in Pakistan. This retrospective, cross-sectional study was performed at the Aga Khan University Hospital, Karachi, Pakistan, on patients ≥ 18 years, who underwent colonoscopy between January 1, 2017 and June 30, 2018. Of 1985 patients, 59 % were male and 41 % female, with mean age of 47.8 ± 16.2 years. The most common indication for colonoscopy was bleeding-per-rectum (28.0 %) and overall PDR and ADR were 17.9 % and 9.9 %, respectively. There was no significant difference between genders for either PDR (  = 0.378) or ADR (  = 0.574). Significantly higher PDR and ADR were found for patients ≥ 50 years (  < 0.001), as well as for suboptimal bowel preparation [PDR (25.7 %;  = 0.007) and ADR (18.6 %;  = 0.014)]. Interestingly, endoscopists with < 500 colonoscopy-procedural-experience reported a higher PDR (21.6 %;  = 0.020) and ADR (14.4 %; P = 0.049), corresponding to a significantly higher PDR (20.6 %;  = 0.005) and ADR (11.7 %;  = 0.02) for endoscopists in practice for ≤ 10 years. We have noticed low PDR and ADR, which require further investigation and research. In addition, we believe there should be a different baseline ADR and PDR as a quality indicator for colonoscopy in our region, where no internationally recommended colonoscopic screening programs have been implemented.
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http://dx.doi.org/10.1055/a-1244-1646DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7581484PMC
November 2020

Nuclear scaffold: Three-dimensional indigenous capsular bag support combined with IOL scaffold and capsular tension ring to prevent posterior capsule rupture in zonulopathy.

J Cataract Refract Surg 2019 12;45(12):1696-1700

Dr. Om Parkash Eye Institute, Amritsar, India.

We describe a technique for performing phacoemulsification in eyes with zonular fiber dehiscence of less than 90 degrees using hard nuclear fragments as a scaffold. In conjunction with a capsular tension ring (CTR), hard nuclear fragments and the intraocular lens (IOL) are used as scaffolds during different steps of nuclear emulsification to prevent posterior capsule rupture and aggravation of zonulopathy. Devices such as capsular hooks, CTRs, and IOLs are used to support the capsular bag associated with zonulopathy. The mass of hard nuclear fragments provides support toward the anteroposterior and the horizontal planes, thereby providing 3-dimensional capsular bag support.
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http://dx.doi.org/10.1016/j.jcrs.2019.08.046DOI Listing
December 2019

Structure of Apatite Nanoparticles Derived from Marine Animal (Crab) Shells: An Environment-Friendly and Cost-Effective Novel Approach to Recycle Seafood Waste.

ACS Omega 2019 Jul 26;4(7):12753-12758. Epub 2019 Jul 26.

Department of Ceramic Engineering, Indian Institute of Technology (Banaras Hindu University), Varanasi 221005, Uttar Pradesh, India.

In the present investigation, crab shells as seafood wastes were successfully recycled into an extremely useful biomaterial by the thermal treatment method. Thermogravimetric-differential thermal analysis studies concluded that the calcination temperature must be beyond ∼570 °C to get a fine and crystalline apatite powder from the crab shells. Thus, the calcination temperature is taken to be 700 °C. Powder X-ray diffraction analysis of the calcined crab shells revealed hydroxyapatite (HAp)/carbonated HAp (CHAp) with an average crystallite size of 24.4 nm. Scanning electron microscopy revealed the surface morphology of the crab shells-derived apatite powder as needle-like nanorods of HAp of diameter ≈ 100-300 nm and nanospheres of CHAp of diameter ≈ 100-500. Energy-dispersive X-ray spectroscopy showed the presence of calcium, phosphorous, magnesium, and oxygen as major elements in the apatite constituents. Fourier transform infrared as well as Raman spectroscopies confirmed the formation of apatite powder. X-ray photoelectron spectroscopy results indicated the electronic environment and oxidation states of the constituent elements, Ca, C, and P. On the basis of the results obtained from various characterization techniques, the overall study emphasized an environment-friendly and cost-effective approach for recycling of the bio-pollutant and synthesis of ultra-fine, ultra-crystalline apatite-based excellent biomaterial derived from crab shells as seafood wastes with its application as a futuristic biomaterial in bone/teeth implants.
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http://dx.doi.org/10.1021/acsomega.9b00134DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6681996PMC
July 2019

Rosai-Dorfman's disease, an uncommon cause of common clinical presentation.

J Pak Med Assoc 2019 Aug;69(8):1213-1215

Department of Gastroenterology and Hepatology, Aga Khan University Hospital, Karachi.

Sinus histiocytosis with massive lymphadenopathy also known as Rosai-Dorfman disease is a rare benign disease that typically manifests as lymphadenopathy with or without systemic manifestations whose etiology remains poorly understood. Most common clinical presentation is painless bilateral cervical lymphadenopathy. However, it also can present in various extranodal sites and can easily be missed because of its rarity if not considered in the differential diagnosis. It commonly occurs in children and young adults with a slightly male predominance. Clinically patients may be mistaken for lymphoma and other infectious disorders like tuberculosis especially in developing countries like in Pakistan where tuberculosis is more prevalent. Here we report a case of a 38-years-old gentleman with bilateral cervical lymphadenopathy and worsening ascites. His symptoms initially mimicking tuberculosis and lymphoma, was finally diagnosed as having Rosai-Dorfman's Disease on intra abdominal lymph node biopsy.
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August 2019

A rapid technique for en masse soft cataract phacoemulsification.

Clin Ophthalmol 2019 26;13:755-762. Epub 2019 Apr 26.

Department of Ophthalmology, Vydehi Institute of Medical Sciences and Research, Bangalore, Karnataka, India.

To describe a new, en masse, stepwise technique for purely soft cataracts. RAPID, a soft cataract phacoemulsification technique, is an acronym-based procedure where R is rotation of nucleus, A is alignment of phacoemulsification tip sideways, P is placement of tip adjacent to the nuclear rim, I is impaling of tip into nuclear rim and D is devouring wherein nucleus is aspirated/emulsified. RAPID technique was performed in 54 eyes of 54 patients (31 males and 23 females; mean age 46.35±3.95 years). The soft nucleus was emulsified, after performing hydrodissection, in a stepwise manner in the safe zone away from posterior capsule and corneal endothelium. Centurion/Infiniti Phacoemulsification system (Alcon Laboratories, Inc.) was used with vacuum parameters at 475 mm Hg and an aspiration flow rate of 0-45 mL/min in linear mode. The primary outcome measures were cumulative dissipated energy (CDE), ultrasound time (UST), amount of fluid used, surgical complications and mean endothelial cell loss. Phacoemulsification with IOL implantation was performed successfully in all patients without any intraoperative complications. CDE was 1.03±0.61. Total UST for nuclear emulsification was 3.84±3.27 seconds and fluid used was 10±2.35 milliliters. Postoperative follow-up examinations were done on 1, 4, 14, 30 and 90 days. Mean percentage of endothelial cell loss was 7.05±2.65% (mean endothelial cell counts were 2383.75±105.21 cells/mm preoperatively and 2215.78±114.9 cells/mm 3 months postoperatively). RAPID is an en masse non-fragmentation technique for purely soft cataracts. This technique requires neither any specialized instrumentations nor the use of high vacuum with complimenting surge preventing software. Simple stepwise multi-planer approach of RAPID technique allows easy and fast emulsification of soft cataracts with simultaneous safeguarding of posterior capsule and corneal endothelium.
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http://dx.doi.org/10.2147/OPTH.S197359DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6497114PMC
April 2019

The role of T regulatory cell-associated markers in monitoring tuberculosis treatment completion and failure.

Immunol Res 2018 10;66(5):620-631

Department of Immunology, National JALMA Institute for Leprosy and Other Mycobacterial Diseases, Agra, India.

Monitoring tuberculosis (TB) treatment success is crucial for clinical decision-making. The only available tool in this regard is sputum microscopy, but it has demerits. Moreover, in case of smear negatives and extrapulmonary TB, an efficient tool is still sought for. Therefore, we evaluated T regulatory cell (Treg)-associated markers (CD25, CD39, and FoxP3) and cellular subsets in monitoring treatment success in treatment-completed groups. Expression profile of various markers and subsets were compared real time among treatment-naive pulmonary TB patients (TN-PTB), followed-up treatment-completed (TC-fu) cohort, and a not followed-up (TC-nfu) cohort. Peripheral blood mononuclear cells from various groups were incubated overnight and were stained with antibodies for specific markers and studied by flow cytometry. In both the treatment-completed groups, a decline in frequencies of CD25 marker and CD4CD25, CD4CD25FoxP3, CD4CD25CD39 Treg was observed with clearance of infection, indicating their potential in monitoring treatment success. However, in the case of treatment failure patient (Tfp), a drastic increase in frequency of CD4CD25FoxP3 Treg subset was found, indicating its usefulness in predicting treatment failure. Although the investigation unveils markers useful in predicting treatment success or failure, the findings from this study needs to be validated in a larger cohort.
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http://dx.doi.org/10.1007/s12026-018-9022-7DOI Listing
October 2018

Assessment of malnutrition in patients with liver cirrhosis using protein calorie malnutrition (PCM) score verses bio-electrical impedance analysis (BIA).

BMC Res Notes 2018 Aug 2;11(1):545. Epub 2018 Aug 2.

Department of Medicine and Community Health Sciences, Aga Khan University Karachi, Karachi, Pakistan.

Objective: Malnutrition is a common problem in patients with liver cirrhosis and tools for nutritional assessment are under debate. We conducted this study to assess prevalence of malnutrition in cirrhotic patients using PCM score and BIA. Additionally we compared BIA to PCM score for detecting malnutrition in this patient population.

Results: This was a cross sectional study conducted in two tertiary care hospitals of Karachi Pakistan on adults with liver cirrhosis. Malnutrition was assessed by PCM score using anthropometric measurements and biological specimens and (ii) Body cell mass was assessed using BIA. Malnutrition as estimated by the PCM score was present in 122 (73%) of patients in which most patients had mild malnutrition (n = 72 (45%)), followed by 34 (21%) with moderate malnutrition and 3 (1.9%) with severe malnutrition. Malnutrition according to BIA estimated through body cell mass could detect it in 98 (61%) of patients. There was optimal correlation of PCM score with body call mass (Pearson correlation coefficient = 0.3 (p value 0.001)). We conclude that majority of the patients with liver cirrhosis had malnutrition as determined by PCM score. BIA underscored the malnutrition in this patient population.
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http://dx.doi.org/10.1186/s13104-018-3640-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6071307PMC
August 2018

Efficacy of T Regulatory Cells, Th17 Cells and the Associated Markers in Monitoring Tuberculosis Treatment Response.

Front Immunol 2018 5;9:157. Epub 2018 Feb 5.

Department of Immunology, National JALMA Institute for Leprosy and Other Mycobacterial Diseases, Agra, India.

Treatment monitoring is an essential aspect for tuberculosis (TB) disease management. Sputum smear microscopy is the only available tool for monitoring, but it suffers from demerits. Therefore, we sought to evaluate markers and cellular subsets of T regulatory (Treg) cells and T helper (Th) 17 cells in pulmonary TB patients (PTB) for TB treatment monitoring. Peripheral blood mononuclear cells (PBMCs) were stimulated (with purified protein derivative (PPD)) overnight which was followed by a polychromatic flow cytometry approach to study Treg and Th17 markers and cellular subsets in PTB ( = 12) undergoing antituberculous treatment (ATT). The baseline levels of these markers and cellular subsets were evaluated in normal healthy subjects (NHS). We observed a significant decrease in the expression of CD25 (<0.01) marker and percentage of T-cell subsets like CD4CD25 (<0.001) and CD4CD25CD39 (<0.05) at the end of intensive phase (IP) as well as in the continuation phase (CP) of ATT. A decrease in CD25 marker expression and percentage of CD4CD25 T cell subset showed a positive correlation to sputum conversion both in high and low sputum positive PTB. In eight PTB with cavitary lesions, only CD4CD25FoxP3 Treg subset manifested a significant decrease at the end of CP. Thus, results of this study show that CD25 marker and CD4CD25 T cells can serve as better markers for monitoring TB treatment efficacy. The Treg subset CD4CD25FoxP3 may be useful for prediction of favorable response in PTB with extensive lung lesions. However, these findings have to be evaluated in a larger patient cohort.
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http://dx.doi.org/10.3389/fimmu.2018.00157DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5810270PMC
April 2019

Modified 30 G needle trypan blue staining technique under air for a uniform and consistent anterior capsule staining.

Clin Ophthalmol 2017 14;11:1651-1656. Epub 2017 Sep 14.

Dr Om Parkash Eye Institute, Amritsar, India.

Purpose: To describe a trypan blue dye staining technique under air, a modification of the previously described 30 G needle under-air technique.

Design: This is a prospective, randomized study of 1,000 eyes of 952 patients undergoing phacoemulsification in a private practice setting from January 2015 to August 2016. Three variants as a modification of the previously known 30 G needle technique are described. In our technique, after injecting one drop of the dye under air, the needle is kept in the anterior chamber (AC) for 15 seconds. In the second variation, along with the additional hold time, 0.05 mL air is injected prior to dye injection to deepen the AC in eyes with shallow ACs or in cases with increased posterior pressure. The third variation is the selective painting approach in which more than one drop is injected for a homogenous staining.

Main Outcome Measures: The main outcome measures were safety and reproducibility of the technique along with homogeneity and uniformity of the anterior capsule staining.

Results: AC remained stable during the hold time of 15 seconds with no egress of air. No iatrogenic trauma occurred in any of the cases. All cases had a homogeneously stained anterior capsule. The staining intensity was excellent in 80.8% of the eyes and good in 19.2% of the eyes.

Conclusion: This is a safe, simple, and cost-effective technique which achieves consistent, uniform, and reproducible staining. It overcomes the shortcomings of the known 30 G needle technique.
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http://dx.doi.org/10.2147/OPTH.S147510DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5608478PMC
September 2017

De novo descending aorta thrombus in a patient with metastatic colorectal cancer: A case report.

J Pak Med Assoc 2017 Oct;67(10):1606-1608

Aga Khan University Hospital, Karachi, Pakistan.

Thromboembolic events in patients with cancer are frequently reported in literature and usually involve the venous circulation. De novo thrombus formation in the arterial system without any underlying atherosclerosis, dissection or aneurysm is extremely rare. We report the case of a patient with metastatic colorectal carcinoma who developed a thrombus in the descending aorta without any intervention or risk factors. The patient presented with non-specific gastrointestinal symptoms. A CT scan revealed an aortic thrombus obstructing 70% of the lumen. She opted for no treatment of her thrombus and was later complicated by extensive lower limb emboli. Patients with aortic thrombosis usually present with subtle symptoms which may be underestimated by both the patient and the physician. A high index of suspicion is required for early recognition and prevention of complications.
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October 2017

Flap motility as a sign of posterior capsule rupture in peripherally extended anterior capsular tears.

Clin Ophthalmol 2017 8;11:1445-1451. Epub 2017 Aug 8.

Department of Ophthalmology, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, India.

Purpose: To describe various types of anterior capsular tears and an early diagnostic, flap motility, as a sign of posterior capsular rupture following posterior extension of radial tears.

Design: This was a prospective study carried out in 4,331 eyes that underwent phacoemulsification in a private practice setting from April 2015 to February 2016. Twenty six consecutive cases of anterior capsular tears were included. Morphological features of anterior capsular tears and resultant complications were evaluated. Parameters studied were surgical step during which the tear occurred, shape of tear, its extension in relation to the equator, and flap nature and motility in tear extending up to equator.

Main Outcome Measures: The main outcome measures were motility and nature of flaps in anterior capsular radial tears and the relation to posterior capsule rupture.

Results: Based on shape, extent, and angulation, anterior capsular tears were categorized into 5 types: Type I, pre-equatorial radial tear (26.92%); Type II, post-equatorial radial tear (3.85%); Type III, Argentinean flag sign pre-equatorial tear (57.69%); Type IV, Argentinean flag sign post-equatorial tear (7.69%), and Type V, mini punch (3.85%). Flaps were either seen to be everted and fluttering or inverted and non-fluttering. In all cases with everted fluttering flaps no posterior capsular rupture (PCR) was observed, while in cases with inverted non-fluttering flaps a PCR was observed (<0.05).

Conclusion: Everted and fluttering flaps of the anterior capsular tears indicate pre-equatorial tear, while inverted and non-fluttering flaps indicate posterior capsule rupture following tear extension beyond the equator.
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http://dx.doi.org/10.2147/OPTH.S136532DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5558569PMC
August 2017

A large choledochocystolithiasis mimicking Mirizzi syndrome.

BMJ Case Rep 2017 Jun 24;2017. Epub 2017 Jun 24.

Department of Medicine, Aga Khan University, Karachi, Pakistan.

An 18-year-old man presented with spontaneous severe epigastric pain, progressing and radiating to back since 3 days. It was associated with epigastric tenderness, bilious vomiting and jaundice. He had been intermittently experiencing these symptoms for the last 1 year. No known comorbid. Ultrasound showed a poorly visualised heterogeneous focus at porta hepatis; considering poor visualisation, this might represent an enlarged calcified lymph node or cystic duct calculus causing extrinsic compression or a large sludge ball within the common bile duct (CBD), leading to dilatation of common hepatic duct and intrahepatic biliary system. Subsequent magnetic resonance cholangiopancreatography revealed a focal saccular dilatation of middle part of CBD, a type I-B choledochal cyst, large heterogeneous focus seen within it representing choledochocystolithiasis. Later, CT was performed for further characterisation of surrounding anatomy and pathology, which confused the appearance of choledochocystolithiasis for Mirizzi syndrome. Later, surgery and histopathology confirmed type I-B choledochocystolithiasis and chronic cholecystitis.
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http://dx.doi.org/10.1136/bcr-2017-219582DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5534906PMC
June 2017

Clinical Characteristics and Outcome of Budd-Chiari Syndrome at a Tertiary Care Hospital in Pakistan.

J Coll Physicians Surg Pak 2017 May;27(5):301-304

Department of Medicine, The Aga Khan University, Karachi.

Objective: To determine the clinical characteristics of Budd-Chiari syndrome (BCS), its causes and outcome at a tertiary care hospital.

Study Design: An observational study.

Place And Duration Of Study: The Aga Khan University Hospital,Karachi, from 2004 to 2014.

Methodology: Aretrospective analysis of data was conducted. Apredesigned questionnaire was filled from medical records of patients with BCS. Clinical features, etiology, management and outcome was noted from 2004 to 2014. Descriptive statistics were determined.

Results: Forty-five patients' charts were reviewed; 26 (57.8%) were male patients. The median (IQR) age at diagnosis was 26.0 (20.5 to 34.5) years. Primary BCS was seen in 27 (60.0%) patients. The most frequent clinical features included ascites (82.2%), abdominal pain (55.6%), and hepatomegaly (31.1%). Acombined hepatic vein/inferior vena cava block was found in 25 (55.6%) patients. Out of the 28 tested patients protein C and protein S deficiencies were detected in 22 (78.6%) and 17 (60.7%) patients, respectively. Antithrombin III deficiency was detected in 14 (58.3%) of those tested patients. Anticoagulants were used in 24 (53.3%) patients. TIPS was done in 11 (24.4%) patients. Mortality was 6.7% (n=3).

Conclusion: Congenital thrombophilia was a major causal factor. Age, clinical features, biochemistry and management are important factors in survival.
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http://dx.doi.org/2617DOI Listing
May 2017

Electrophysiological changes in patients with liver cirrhosis in a tertiary care hospital in Karachi, Pakistan.

J Ayub Med Coll Abbottabad 2016 Oct-Dec;28(4):676-679

Department of Medicine, Section of Gastroenterology, Aga Khan University Hospital, Karachi, Pakistan.

Background: Electrophysiological changes in cirrhosis are well known but least investigated especially in our country hence we wanted to see electrophysiological changes especially QT interval in cirrhotic patients.

Methods: A cross-sectional study was conducted at Aga Khan University Hospital Karachi (AKUH) in which medical records (duration 2008-2010) of cirrhotic patients were reviewed.

Results: Three hundred and eighty cirrhotic patients' charts were studied, 227 (59.7 %) were male and mean age of this cohort was 52.8±12.6 years. The most common cause for CLD was Hepatitis C (CHC) in 260 (68.4%), NBNC in 56(14.7%) and HBV in 51 (13.4%). Only 225 had complete ECG workup, the mean corrected QT interval was 0.44±0.067sec. Among the electrophysiological abnormalities, 79 (35%) had a prolonged corrected QT interval, 7 (3.1%) had a prolonged PR interval (>0.22s) and prolonged QRS duration was seen in 23 (10.4%) patients. QT prolongation was seen in 1 of the 5 patients with Child Class A (20%), 22 of the 73 patients with Child Class B (30.1%), and 25 of the 61 patients with Child Class C (41%). However, this difference however was not statistically significant. (p-value=.331).

Conclusions: We conclude that QT prolongation is more frequent in patients with liver cirrhosis especially when the disease is more advanced like in Child C hence these patients are more prone to sudden cardiac death. Moreover, this study shows that the risk associated with QT prolongation is present through all classes of liver cirrhosis. We recommend that routine cardiac screening with ECG of all cirrhotic patients be performed.
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November 2017

Elevated risk of subsequent malignancies in patients with appendiceal cancer: A population-based analysis.

Indian J Gastroenterol 2016 Sep 6;35(5):354-360. Epub 2016 Sep 6.

Division of Thoracic Surgery, Department of Surgery, Icahn School of Medicine, Mount Sinai Health System, New York, NY, USA.

Background: Appendiceal cancer is extremely rare with excellent survival after curative resection. There is a concern for the development of additional cancers in survivors of appendiceal cancer. However, existing data is limited to small anecdotal reports on appendiceal carcinoid only. We aim to investigate the risk of subsequent malignancies in patients with appendiceal carcinoma and correlate the risk according to patient and clinical characteristics.

Methods: We identified 3788 patients with appendiceal cancer from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database between 1992 and 2011. Standardized incidence ratios (SIRs) for the risk of additional cancers were calculated and quantified based on tumor site, gender, race, latency, primary tumor stage, and histology.

Results: Three hundred and fifty-nine subsequent malignancies were identified in 313 patients (mean age 60 years, male to female ratio 1.3:1). The overall risk for a subsequent malignancy was elevated by 20 % compared with the general population. Most common sites with significantly increased risk for subsequent cancers included the small intestine (n=13) and the colon/rectum (n=48). Malignant carcinoid and adenocarcinoma were the dominant histological subtypes at these sites, respectively. Significant elevated risk was observed within the first 5 years of follow up in white males with either localized or regional disease. Adenocarcinomas and goblet cell carcinoid tumors of the appendix were associated with increased risk; whereas, the risk was significantly reduced in patients with malignant carcinoid tumors.

Conclusion: There is an increased risk of subsequent cancers in patients with appendiceal carcinoma.
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http://dx.doi.org/10.1007/s12664-016-0687-3DOI Listing
September 2016

Next big threat for Pakistan Hepatocellular Carcinoma (HCC).

J Pak Med Assoc 2016 06;66(6):735-9

Department of Medicine, The Aga Khan University & Hospital, Karachi.

In our country, world hepatitis day (28th May 2013) was observed as a liver cancer day to draw global attention on the global health menace caused by Hepatocellular carcinoma (HCC). This is the right time to write a review article to apprise the nation of this growing burden of HCC caused most commonly by viruses in our country. Pakistan is also recognized as one of the countries of the world where hepatitis C virus (HCV) is endemic. Recent large national surveys suggest an overall HCV prevalence of 4.8% and that of HBV as 2.5%. There are however communities where the sero-prevalence of HCV can be as high as 23%. No wonder that chronic liver disease is the fifth most common reason for morbidity and mortality in the country and Pakistan has been perhaps accurately called a "cirrhotic state". Hence majority of such patients are at risk of developing HCC.
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June 2016

Observations on traditional usage of ethnomedicinal plants in humans and animals of Kangra and Chamba districts of Himachal Pradesh in North-Western Himalaya, India.

J Ethnopharmacol 2016 Sep 15;191:280-300. Epub 2016 Jun 15.

Institute of Himalayan Bioresource Technology, Palampur 176062, Himachal Pradesh, India.

Ethnobotanical Relevance: Medicinal plants are frequently used by Gaddi and Gujjar tribes of Kangra and Chamba districts of Himachal Pradesh, India to cure various ailments in humans and livestock. Therefore, extensive field work was conducted to document the traditional use of ethnomedicinal plants by these tribes.

Materials And Methods: Direct interviews of 208 informants were conducted. The data generated through interviews was analysed using quantitative tools such as use-value (UV), factor informant consensus (Fic) and fidelity level (Fl).

Results: A total of 73 plant species in 67 genera and 40 families were observed to be medicinal and used to cure 22 ailment categories. The highest number of ethnomedicinal plants was recorded from the family Asteraceae followed by Lamiaceae, Apiaceae, Acanthaceae, Caesalpiniaceae, Polygonaceae, Ranunculaceae, Rosaceae and Rutaceae. Leaves were the most frequently used plant part used to treat various ailments followed by whole plant and roots or rhizomes. Ajuga parviflora, Berberis lycium, Viola canescens, Vitex negundo and Zanthoxylum armatum were the most important medicinal plants used for treating human diseases, whereas Achyranthes bidentata, Aloe sp., Cassia fistula, Podophyllum hexandrum and Pogostemon benghalensis were the most important medicinal plants used for treating animal diseases as per use value. The important ailment categories classified on the basis of factor informant consensus were gastrointestinal and respiratory disorders.

Conclusion: The present study revealed that people of the study area are extensively using the ethnomedicinal plants to cure various ailments. Plants with high use value and fidelity level should be subjected to pharmacological investigation for scientific validation.
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http://dx.doi.org/10.1016/j.jep.2016.06.033DOI Listing
September 2016

Proton pump inhibitors and other disease-based factors in the recurrence of adverse cardiovascular events following percutaneous coronary angiography: A long-term cohort.

Indian J Gastroenterol 2016 Mar 8;35(2):117-22. Epub 2016 Apr 8.

Department of Medicine, Aga Khan University Hospital, Stadium Road, Karachi, Sindh, Pakistan.

Background: Dual aspirin-clopidogrel antiplatelet therapy (DAPT) has been shown to decrease the risk of adverse cardiac events after percutaneous coronary intervention (PCI). Proton pump inhibitors (PPIs) are used in these patients to decrease the risk of gastrointestinal bleeding and several studies have reported potential interaction and conflicting clinical outcomes with their use. We aim to assess the effect of different PPIs and other factors on the recurrence of cardiovascular (CV) events in patients following PCI.

Methods: We performed a retrospective cohort on patients who underwent PCI in the last 5 years and were discharged with or without PPIs. Strict inclusion criteria were adopted, outcome measures were defined, and patient follow up up to 2 years was collected.

Results: Out of 740 patients, 453 (61.2 %) had received PPIs and 287 (38.8 %) were discharged without PPIs. Ninety-five (12.8 %) patients were readmitted due to adverse CV events. Statistically, there was no significant difference in the recurrence of CV events with the use of different PPIs (p = 0.384) and PPI use had an overall protective effect (p = 0.009, HR 0.58 (CI 0.39-0.88). Patients with history of diabetes mellitus (p = 0.048) had an increased risk of adverse CV events.

Conclusion: We conclude that pharmacokinetic interaction between PPIs and antiplatelet therapy is not associated with adverse CV events. A comprehensive, multicenter, open-label trial including all PPI subclasses and patient and disease-based factors is warranted for a fair evaluation.
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http://dx.doi.org/10.1007/s12664-016-0645-0DOI Listing
March 2016

Primary Hepatic Carcinoid Tumor with Poor Outcome.

J Coll Physicians Surg Pak 2016 Mar;26(3):227-9

Department of Medicine, The Aga Khan University Hospital, Karachi.

Primary Hepatic Carcinoid Tumor (PHCT) represents an extremely rare clinical entity with only a few cases reported to date. These tumors are rarely associated with metastasis and surgical resection is usually curative. Herein, we report two cases of PHCT associated with poor outcomes due to late diagnosis. Both cases presented late with non-specific symptoms. One patient presented after a 2-week history of symptoms and the second case had a longstanding two years symptomatic interval during which he remained undiagnosed and not properly worked up. Both these cases were diagnosed with hepatic carcinoid tumor, which originates from neuroendocrine cells. Case 1 opted for palliative care and expired in one month’s time. Surgical resection was advised to the second case, but he left against medical advice.
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http://dx.doi.org/03.2016/JCPSP.227229DOI Listing
March 2016

Diagnosis of Dengue Infection Using Conventional and Biosensor Based Techniques.

Viruses 2015 Oct 19;7(10):5410-27. Epub 2015 Oct 19.

Department of Medical Microbiology and Parasitology, School of Medical Science, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia.

Dengue is an arthropod-borne viral disease caused by four antigenically different serotypes of dengue virus. This disease is considered as a major public health concern around the world. Currently, there is no licensed vaccine or antiviral drug available for the prevention and treatment of dengue disease. Moreover, clinical features of dengue are indistinguishable from other infectious diseases such as malaria, chikungunya, rickettsia and leptospira. Therefore, prompt and accurate laboratory diagnostic test is urgently required for disease confirmation and patient triage. The traditional diagnostic techniques for the dengue virus are viral detection in cell culture, serological testing, and RNA amplification using reverse transcriptase PCR. This paper discusses the conventional laboratory methods used for the diagnosis of dengue during the acute and convalescent phase and highlights the advantages and limitations of these routine laboratory tests. Subsequently, the biosensor based assays developed using various transducers for the detection of dengue are also reviewed.
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http://dx.doi.org/10.3390/v7102877DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4632385PMC
October 2015

Hereditary Hemochromatosis.

J Coll Physicians Surg Pak 2015 Sep;25(9):644-7

Department of Medicine, The Aga Khan University Hospital, Karachi.

Objective: To describe the clinical and laboratory features of hereditary hemochromatosis associated liver disease in a tertiary care hospital.

Study Design: Observational study.

Place And Duration Of Study: The Aga Khan University Hospital, Karachi, from January 2002 to October 2012.

Methodology: Charts of patients with Hereditary Hemochromatosis (HHC) were reviewed. Data collected and analyzed consisting of clinical presentations, liver function tests, serum ferritin, transferrin saturation, hepatic imaging and histology in patients with HHC.

Results: A total of 22 patients were identified as having hemochromatosis. All subjects were men with a mean age of 53 ±9.2 years at the time of diagnosis. The most common presentation was skin pigmentation seen in 17 (77%), followed by loss of libido/ impotence in 11 (50%) and then arthralgias in 10 (45%) and weakness in 6 (27%). Eleven (50%) subjects had diabetes mellitus and one subject had concomitant cardiac involvement. Patients with diabetes were diagnosed earlier as compared to those without it. Eighteen (81%) subjects had cirrhosis at the time of diagnosis. Serum iron was 164 ±53 ug/dl, ferritin 3391 ±1960 ug/L, TIBC 202 ±61 ug/dl and transferrin saturation 76.8 ±14%. Liver biopsy was done in 10 (45%) and using Pearls' stain histopathological features were consistent with hemochromatosis and none had carcinoma. Only 3 (14%) patients had regular phlebotomy.

Conclusion: Hemochromatosis is not a rare disease in Pakistan and should be looked in those subjects whose liver function tests are deranged.
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http://dx.doi.org/09.2015/JCPSP.644647DOI Listing
September 2015
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