The Hirsch index - a play on numbers or a true appraisal of academic output?

Citation metrics have rapidly gained importance in today's landscape and are being increasingly utilized as a yardstick in making several important decisions regarding academic funding and appointments. The impact factor has traditionally been the metric most often employed in this regard. However, the emergence of the Hirsch index has provided an alternative to the impact factor. The h-index, despite its flaws, continues to gain acceptance and popularity in the medical community. Several medical journals have evaluated and endorsed the use of the h-index. However, it must be interpreted with all of its limitations in mind

Institutional review boards - a mixed blessing

Institutional Review Boards (IRBs) are an important checkpoint for all types of research in medicine. Although these bodies originated primarily in the developed world, they have special contemporary consideration in the context of developing countries due to the large number of clinical trials being conducted in these regions with the financial support of large pharmaceutical companies. IRBs are vital to ensure that all scientific investigation is conducted in a manner that is transparent, scientifically feasible and ethically sound. However, they have also been variably criticized for introducing unnecessary and often protracted bureaucracy and red tape into the system. There is a need to reorganize and better delineate the exact functions of the IRBs in view of the dynamic changes in the realm of research so that they can function in a more efficient, judicious and effective fashion

Hughes-Stovin Syndrome

Hughes-Stovin Syndrome (HSS) is a very rare clinical disorder characterized by thrombophlebitis and multiple pulmonary and/or bronchial aneurysms. Less than 40 published cases of HSS have been described in English medical literature so far. The exact etiology and pathogenesis of HSS is unknown; possible causes include infections and angiodysplasia. HSS has also been considered as a variant of Behcet's disease (BD). Patients with HSS usually present with cough, dyspnea, fever, chest pain and haemoptysis. The management of HSS can either be medical or surgical. Medical management includes the use of steroids and cytotoxic agents. Cyclophosphamide, in particular, is a favored therapeutic agent in this regard. Antibiotics have no proven role in HSS while anticoagulants and thombolytic agents are generally contraindicated due to an increased risk of fatal hemorrhage. However, their use may be considered with great care under special circumstances, for instance, intracardiac thrombi or massive pulmonary embolism. For cases of massive hemoptysis due to large pulmonary aneurysms or those with lesions confined to one segment or one lung, lobectomy or pneumectomy can be carried out. However, surgical risks merit serious consideration and must be discussed with the patient. Transcatheter arterial embolization has emerged as a less invasive alternative to surgery in selected cases of HSS. Overall, patients with HSS have a poor prognosis and aneurysmal rupture is the leading cause of death. However, early diagnosis and timely intervention is crucial in improving the prognosis. There is a need to clearly elucidate the genetic, etiologic and pathologic basis for HSS in the future. Although most of the evidence put forward to refute the role of an infectious agent in the etiology and pathogenesis of HSS is based on negative blood and other body fluid cultures, more robust objective assessment is needed through the use of electron microscopy or 16 sRNA studies. The development of better therapeutic agents is also needed to address and prevent the serious consequences arising from pulmonary arterial aneurysms seen in BD and HSS. Also, the issue of anticoagulation in these patients is challenging and requires further deliberation

Primary IgA and IgG subclass deficiency in a 17-year-old Pakistani girl: a case report

Primary immunodeficiency disorders pose a diagnostic dilemma for physicians in the developing countries such as Pakistan because of lack of adequate diagnostic facilities. We present here the case of a 17-year-old girl who had a history of recurrent respiratory tract infections since childhood and had been treated with anti-tuberculous medications thrice; for a total of 24 months. She had also received multiple courses of antibiotics. Her initial presentation to our hospital was with acute bronchopneumonia. Her past medical history of recurrent infections also alerted the treating physician to the possibility of bronchiectasis secondary to a variety of underlying potential pathologies such as post-infection, immunodeficiency syndromes or ciliary dyskinesia disorders. Cystic fibrosis was also an important consideration. Direct enquiry revealed that there was no history of consanguineous marriage in her parents. Her sweat chloride test was within normal range (<40 mmol/L). Blood analysis was performed which showed IgA, IgG2 and IgG4 deficiency. She has been following up at our hospital for the past few years. In that course of time, she has had multiple episodes of pneumonia, gastroenteritis and maxillary sinusitis. She was successfully treated with intravenous immunoglobulins on four occasions when she presented with systemic crisis secondary to severe systemic infection. She also developed biopsy proven intermediate grade non-Hodgkin’s lymphoma five years after the diagnosis of immunoglobulin deficiency was first made. This appeared to be a complication of her immunodeficient state. She has been receiving chemotherapy for the lymphoma. Physicians should be cognizant of the morbidity that primary immunodeficiency syndromes such as immunoglobulin deficiency can have in the form of multiple infections and increased risk of malignancies as seen in our patient

Resistant thyrotoxicosis in a patient with graves disease: a case report

Background: Conventional management of thyrotoxicosis includes antithyroid drugs, radioactive iodine, and surgery while adjunctive treatment includes beta-blockers, corticosteroids, inorganic iodide and iopanoic acid. Very rarely, patients may be resistant to these modalities and require additional management. Case Presentation: A 50-year-old lady presented with weight loss and palpitations diagnosed as atrial fibrillation. Her past history was significant for right thyroid lobectomy for thyrotoxicosis. Thyroid functions tests at this presentation showed free T4 of 6.63 ng/dl (normal range: 0.93-1.7) and TSH of \u3c0.005 μIU/mL (normal range: 0.4-4.0). She was given aspirin, propranolol, heparin and carbimazole; however free T4 failed to normalize. Switching to propylthiouracil (PTU) did not prove successful. She was then given high doses of prednisolone (1 mg/kg/day) and lithium (400 mg twice daily) which prepared the patient for radioactive iodine treatment by reducing free T4 levels (2.82 ng/dl). Two doses of radioactive iodine were then administered 6 months apart. Subsequently she became hypothyroid and was started on thyroid replacement therapy. Conclusion: This case highlights management options in patients with resistant thyrotoxicosis. Radioactive iodine and surgery are definitive modes of treatment in such complex cases while steroids and lithium play an important role in preparing patients for more definitive treatment

Incomplete, atypical kawasaki disease or evolving systemic juvenile idiopathic arthritis: a case report

Kawasaki disease is an acute febrile condition seen in children. However, it is also well recognized that some patients do not fulfill the classic diagnostic criteria for the diagnosis of kawasaki disease. The incomplete form of kawasaki disease is termed as ‘Incomplete KD’ or ‘Atypical KD’. We present a case of a 6 year old child with a history of prolonged fever, periorbital, oral and lip changes, changes in the extremities and an erythamatous, maculopapular rash. Based on the physical exam and her echocardiogram that showed right coronary artery dilatation, Intravenous immune globulin was administered in this patient. This patient was refractory to two doses of intravenous immune globulin and therefore was started on methylprednisolone, to which she responded dramatically. The diagnostic dilemma primarily arose when this child presented with joint pain a day after her discharge from the hospital and a positive laboratory workup. So, was this a case of incomplete Kawasaki refractory to intravenous immuno globulin therapy or systemic juvenile idiopathic arthritis? We suggest that physicians should be cognizant of the fact that they must individualize every patient’s management to the best of their knowledge and judgment, rather than merely going by the guidelines

Geriatric patients\u27 expectations of their physicians: findings from a tertiary care hospital in Pakistan

Background: Geriatric health is a neglected and under-explored area internationally and in Pakistan. We aimed to ascertain the expectations of the geriatric Patients from their physicians and the factors associated with Patient satisfaction in this particular age bracket. Methods: A cross-sectional survey was carried out at a tertiary care teaching hospital in Karachi, Pakistan. Data collection was carried out via face-to-face interviews based on structured, pretested questionnaires. All consenting individuals aged 65 years or above were recruited into the study. Convenience sampling was used to draw the sample. The data was analyzed using SPSS version 16. Geriatric Patient\u27s expectations from physicians were elicited using a set of 11 questions that were graded on a scale of 1-3 where 1 = not important, 2 = important, 3 = very important. Results: Three hundred and eighty geriatric Patients were interviewed. The response rate of this study was 89.8%. The mean age of the respondents was 73.4 +/- 6.8 years. Two hundred and forty eight respondents (65.3%) were female. Diabetes mellitus (53.7%), hypertension (59.5%), arthritis (40.5%) and renal disease (32.1%) were common ailments among geriatric Patients. More than 50% of the Patients were visiting their physicians once every two to three months. Discussing treatment options and letting Patients make the final decision (79.2%), prescribing minimum possible medications (84.5%), physician\u27s holistic knowledge about the spectrum of care issues for geriatric Patients (79.2%), being given a realistic but optimistic picture of future health by physicians (85.5%) were ranked as very important expectations by Patients from their physicians. Cumulative household income (p = 0.005), most important health complaint (p = 0.01) and frequency of experiencing health complaint (p \u3c 0.001) emerged as independent predictors of the satisfaction of geriatric Patients from care provided by physicians. Conclusion: We have documented the expectations of the geriatric Patients from their physicians in a developing country. Physicians belonging to all disciplines should keep these expectations in mind during clinical encounters with geriatric Patients