Wegener\u27s granulomatosis: a diagnostic challenge

Wegener\u27s Granulomatosis (WG) is a necrotizing granulomatous vasculitis that primarily involves small vessels in the body. Patient usually presents in the fourth to fifth decade. The clinical presentation is variable; however, majority of patients (90%) seek medical attention for nasal and sinus symptoms with or without lower respiratory symptoms of cough, dyspnoea and haemoptysis. The typical form of WG tends to involve the triad of upper and lower respiratory tract and the kidneys; while involvement of other organs like ocular, cutaneous, rheumatological, neural, gastrointestinal and lower genito-urinary tract is occasionally seen. A limited form with clinical findings isolated to the upper respiratory tract or lungs, occur in approximately one-fourth of cases. We present a case of Wegener\u27s Gmnulomatosis in an eighty five year old lady who presented with an acute pneumonia-like illness. She underwent an extensive work-up to reach a definitive diagnosis

Prevalence of behavioural and psychological problems in working children

OBJECTIVE: To determine the prevalence and screen the nature and types of behavioural and psychological problems among working children in Karachi. METHODS: A cross sectional study was conducted in three urban squatter settlements of Karachi from May to June 2006, targeting working children aged 11-16 years. Behavioural Problems of these children were estimated by using the self reported Urdu version of the Strengths and Difficulty Questionnaire. The results were cross-tabulated using SPSS 13.0 with the identified risk-factors. RESULTS: Out of a total of 225 respondents, 94.2% (n = 212) males and 5.8% (n = 13) females, the prevalence of Behavioural Problems among working children was found to be 9.8%. Peer problems were most prevalent (16.9%) seconded by Conduct problems (16.7%). Adverse family environment and work environment were closely associated with Behavioural Problems in these children. CONCLUSION: Our study reinforces the need for measures to improve the environment of the children and prevent the psychological and behavioural problems associated with working children. Gradual, long-term policies are required to decrease the need for working children, though sudden abolishment would cause more detrimental effects

Serum Ferritin Levels Lack Diagnostic Accuracy for Liver Fibrosis in Patients With Nonalcoholic Fatty Liver Disease

BACKGROUND & AIM: Series studies have associated increased serum levels of ferritin with liver fibrosis in patients with nonalcoholic fatty liver disease (NAFLD). We aimed to determine the accuracy with which measurements of serum ferritin determine the presence and severity of liver fibrosis, and whether combining noninvasive scoring systems with serum ferritin analysis increases the accuracy of diagnosis of advanced liver fibrosis. METHODS: We performed a retrospective analysis of data from 1014 patients with liver biopsy-confirmed NAFLD. Three cut-points of serum ferritin level, adjusted for sex, were established based on receiver operating characteristics curve analysis: 1.0 (the upper limit of normal [ULN]), 1.5-fold ULN, and 2.0-fold ULN. Three multiple logistic regression models were created to determine the association of these cutoff values with liver fibrosis, adjusting for age, sex, race, diabetes, body mass index, and level of alanine aminotransferase. RESULTS: A greater proportion of patients with increased serum levels of ferritin had definitive NASH and more-advanced fibrosis than patients without increased levels. In all models, serum level of ferritin was significantly associated with the presence and severity of liver fibrosis. However, for all 3 cutoff values, area under the receiver operating characteristic curve values were low (less than 0.60) for the presence of fibrosis or any stage of liver fibrosis; ferritin level identified patients with fibrosis with 16%–41% sensitivity and 70%–92% specificity. The accuracy with which noninvasive scoring systems identified patients with advanced fibrosis did not change with inclusion of serum ferritin values. CONCLUSIONS: Although serum levels of ferritin correlate with more-severe liver fibrosis, based on adjusted multiple logistic regression analysis, serum ferritin levels alone have a low level of diagnostic accuracy for the presence or severity of liver fibrosis in patients with NAFLD

Differences in Referral Access to Care Between Gastrointestinal Subspecialty Patients: Barriers and Opportunities

Purpose: Referral access to subspecialty care for patients with gastrointestinal (GI) diseases is not well defined, but has significant importance to patients. We hypothesized that patients experience barriers to care in two common gastroenterology subspecialties, Hepatology and Motility, in a university medical center. Methods: Two hundred thirteen clinic patients (mean age 46.5 years; 66.5% female; 85.6% Caucasians) completed a formatted questionnaire on access to care. Hepatology patients were older (49.7 years, p=0.008); motility patients predominantly female (76.8%, p<0.001). Gender distribution was even for hepatology (51.2% female). Both groups were overweight (mean body mass index 28.4). Results: Patients waited a mean 89.5 days to be seen by a subspecialist. There were differences by subspecialty (107.6 days for motility vs. 64.3 days for hepatology, p=0.022). A larger percentage of motility patients were told nothing was wrong with them (16.8%, p<0.01) and could not be helped (42.1%, p=0.000). Conclusions: Access to care for subspecialty gastroenterology patients in a university center appears to be impacted by a number of variables. While there are similarities, differences exist between these two subspecialties. Motility patients were more likely to have been told they have nothing wrong with them, suffer setbacks financially, and suffer mood problems. Their wait time for appointments was also greater than hepatology patients. Further investigations of referral access for gastroenterology patients may yield additional insights into disease-specific barriers to accessing subspecialty care