Journal of Fatima Jinnah Medical University

Student�s perception regarding tutorials in pre-clinical undergraduate medical education

Faiza Irem — 2024-03-06

Background: Tutorials are one of oldest teaching methodologies and are effectively being used for teaching in medical education. The objective of this study is to identify student�s perspective regarding conventional tutorial teaching in undergraduate, pre-clinical medical curriculum and recognise appropriate changes needed to improve learning of higher order critical thinking and decision making skills among medical graduates in tutorials.

Subject and methods: This is a mixed method study conducted at Fatima Jinnah Medical University. Qualitative data was collected by structured interviews from twelve second year medical students. Interviews were transcribed and thematic analysis done for results. DREEM questionnaire was modified to design a questionnaire and was used to collected quantitative data from second year MBBS class, through an online survey.

Results: Twelve female medical students of 2^nd year MBBS of FJMU participated in structured interviews. Content analysis of transcribed interviews identified three main themes i. e self-directed learning, collaborative learning and problem-based learning. Majority of students made response that tutorials provide active class room participation (60%), learning motivation (55.7%) and learning stimulation (48%). They also opined learning is learner centered (53%) and objective oriented (70%), it builds competence (50%) and confidence (67%), add value to time (57%) and enhances interpersonal skills (44%) in stress free environment (70%). Students also valued handouts and learning materials provided in tutorials (59.6%). However, they felt teaching in tutorials is monotonous (69.36%), do not support memorization (44%) and lack problem solving skills learning (39%).

Conclusion: Overall, tutorial learning can be a powerful tool for enhancing student learning and development when implemented thoughtfully and strategically.

Comparison of Mean Duration of Third Stage of Labor with Oral Misoprostol versus Intramuscular Oxytocin

Rubina Shamsi — 2024-02-29

Background: This study delves into the comparison, recognizing the significance of effective management in preventing complications. Poor management of 3^rd stage can lead to retained placenta, excessive bleeding, and increased maternal morbidity. Addressing these concerns, the research aims to contribute valuable insights for enhancing obstetric care and reducing adverse outcomes associated with inadequate management during this critical phase of childbirth. The Study aims to Determine the mean duration of 3^rd stage of labor with oral misoprostol versus intramuscular oxytocin. A Prospective Comparative Study. This study was conducted at the Department of Gynecology and Obstetrics, Khair-Un -Nisa Hospital Lahore, Lahore over 12 months period from January 2022 to December 2022.

Material and Methods: A total of 100 pregnant women meeting inclusion criteria were included in the study and divided into two equal groups using lottery method. Patients in Group A received oral misoprostol 600�g (3tablets of 200�g) and patients in Group B received 10 units intramuscular oxytocin. Labor process was managed as per standard protocol. All the findings were noted in a predesigned proforma and analyzed using SPSS version 27.0.

Results: Mean age of the patients in this study was 25.92�4.55 years. In the study sample 40.0% women were primiparas whereas 60.0% were multiparas. Comparison of both the groups with regard to baseline characteristic produced insignificant difference between the groups (p-value>0.05). Mean duration of 3rd stage of labor was significantly high in group A than group B (4.98�0.82 vs. 3.72�0.80 min; p-value=0.000) and its stratification for age, parity and gestational age.

Conclusion: In conclusion, our study reveals a significantly prolonged mean duration of the third stage of labor in the oral misoprostol group compared to the intramuscular oxytocin group. This difference persists across age, parity, and gestational age subgroups, emphasizing the robustness of these findings and contributing insights into intervention efficacy.

Efficacy and safety of Narrowband UVB in Chronic Plaque Psoriasis in Skin type IV and V

Zahid Rafiq — 2024-02-26

Background: Narrowband (NB) UVB phototherapy is considered practically to be an effective and safe modality as compared to other systemic therapies and Broad band UVB phototherapy for management of psoriasis. The objective of the study was to determine the efficacy of narrowband UVB in chronic plaque psoriasis in skin type IV and V.

Patients & Methods: A Qausi experimental study was carried out in Dermatology Department, Sahiwal Teaching Hospital, for one-year duration from March 2022 to February 2023. Patients of both gender and age between 16 and 65 years were included. All the patients were exposed to thrice weekly sessions of narrowband UVB with starting dose of 280mj with 10 % increment weekly. Efficacy was assessed at baseline and then at 4th, 8th and 12th week by PASI (Psoriatic Area and Severity Index). All research data was noted on predesigned proforma and was analyzed by using SPSS version 26.

Results: Thirty-one patients were enrolled with male to female ratio of 23:8. The baseline mean PASI score was 16.62�6.03, and it significantly decreased to 2.77�1.70 after the 12-week follow-up, indicating the effectiveness of NUVB phototherapy in the treatment of chronic plaque psoriasis (P-value<0.05). Pruritus 22.6 %(n=7) was the common side effects noted followed by painful erythema 9.7 %(n=3).

Conclusion: Narrowband UVB has demonstrated to be effective and safe therapy in the treatment of psoriasis. This therapy typically results in fewer side effects.

Cesarean Section Rate in Tertiary Care Hospital of South Punjab using Robson Ten Group Classification System

Mehwish Najam — 2024-02-26

Background: The rise in cesarean section rates throughout the world is a major public health issue and a topic of controversy because to the potential maternal and perinatal dangers, financial challenges, and discrepancy in access. This research set out to determine the high prevalence of cesarean sections using the Robson Ten Group Classification System (TGCS).

Patients and Methods: The research was a cross-sectional prospective study. The TGCS was used to categorize all women who gave birth through lower segment cesarean section at Sheikh Zayed Hospital Rahim Yar Khan between January 2021 and July 2022. Rates of cesarean sections were determined both overall and by Robson group, as was each group's relative contribution to the cesarean section rate.

Results: There were 543 (18.4%) females of age <20 years, 1826 (61.8%) females had age 20-30 years and 581 (19.6%) were aged 30-37 years. Out of 2950 females, 39.6% females fall in RTGCS class 5, followed by 2b (11.2%), 2a (10.4%), class 1 (9.7%), class 9 (7.8%) and class 10 (7.1%) and so on.

Conclusion: Thus, RTGCS allows easy identi?cation of leading contributing patients groups. RTGCS can be effective criteria that can help to early predict the mode of delivery and prevent complications of cesarean section in several number of cases.

Investigation of rs80356932 of BRCA1 Gene and Other Physiological Factors with Benign Breast Disease

Unzila Yasin — 2024-02-26

Background: Benign Breast Diseases (BBD) are a diverse group of conditions characterized by abnormal breast morphology and lesions which may be caused by both genetic and environmental factors as well as infectious agents such as bacteria and viruses. Since it is generally accepted that these conditions do not usually pose a risk for breast cancer so a small amount of information is available about them. Present study undertook the investigation of the association of various factors with benign breast disease, including family history, history of abortions, tumors in other organs of the body, menopausal status, and rs80356932 variant of the BRCA1 gene.

Patients and Methods: This case control study included 91 patients of BBD and 100 normal individuals at Services Institute of Medical Sciences and Jinnah Hospital from July 2021 to July 2022. Demographical and clinical data was collected with the help of a pre designed form, and blood sample was also collected with informed consent. Tetra-ARMS-PCR was performed on DNA extracted from these samples to determine the genotype of rs80356932. Chi-square test of independence was used via SPSS version 22 for the measurement of association.

Results: The results reported that the family history, menopause status, history of abortions and tumor in any other organ of the body were found to be significantly associated with benign breast tumor/ disease (P-value <0.05). SNP rs80356932 was also found associated with presentation of benign breast diseases (P-value <0.05).

Conclusion: Family history, menopause status, history of abortions and BRCA1 variant rs80356932 are risk factors for BBD development. We recommend screening of all patients of benign breast disease for these factors to better understand and manage the condition, as well as to assess the possibility of development of breast cancer in these patients.

Comparison of Rockall Score and MELD Score for Predicting in Hospital Mortality Patients with Vericeal Bleeding

Jawad Naeem — 2024-02-26

Background: It has been shown in several studies that Rockall score and MELD score are significantly high in patients who died due to variceal bleeding, hence these scores can be reliably used to predict in-hospital mortality and preventive measures can be taken in earlier phase to prevent mortality. The Objective of this study is determine the in-hospital mortality in patients with variceal bleeding due to cirrhosis and to compare the mean Rockall score and MELD score in patients with or without in-hospital mortality after variceal bleeding.

Patients and Methods: The Observational study was conduct at Department of Gastroenterology, DQH Hospital, Gujranwala from June to December 2019. The Cirrhotic patients having age 16-70 years of either gender presenting with variceal bleeding that was diagnosed when there was blood in vomiting due to variceal hemorrhage detected on EGD were enrolled. Demographic details like name, age, gender, BMI, duration of variceal bleeding was obtained. At presentation, Rockall score and MELD score was calculated. The data was analyzed on SPSS version 21.0. Mean Rockall score and MELD score was compared in patients with or without in-hospital mortality by using independent samples t-test. P-value<0.05 was considered as significant.

Results: In this study 26% (62/241) patients had in hospital mortality. Among these patients mean Rockall and MELD score was significantly higher as compared to those patients who survived. [Rockall Score: Survivors: 1.82�0.96 & Non-Survivors: 2.46�0.50, p- value<0.001, MELD Score: Survivors: 14.22�3.87 & Non-Survivors: 26.50�5.06]

Conclusion: Thus Rockall and MELD score was significantly higher in patients with in hospital mortality. Hence these scores can be reliably used to predict in-hospital mortality and preventive measures can be taken in earlier phase to prevent mortality

Protective Effect of Aqueous Extract of Lawsonia Inermis (Henna) Leaves on Acetylsalicylic Acid Induced Gastric Mucosal Toxicity in Adult Albino Rats

Asma Fayyaz — 2024-02-26

Background: Non-steroidal anti-inflammatory drugs are the over-the-counter available medicine and is a major cause of the peptic ulcer disease. Large number of pharmaceuticals drugs are used to treat this but have many side effects. L.inermis is a plant derived drug and have gastroprotective effect.

Subject and Methods: 36 Healthy albino rats of either sex were purchased and kept in controlled environment. These are mainly divided into three groups named as Group A, Group B and Group C having 12 rats in each group. Leaves were dried in shade and kept in oven at 40�C for a week. The aqueous extract was prepared by mixing 25 gm of henna powder with 250 ml of distilled water for 12 hours then cooled and filtered by Buchner funnel and filter paper. The solvent will then be dried and concentrated using Rotary evaporator at 50�C. Extract was used in dose of 200mg/kg and aspirin was used in the dose of 100mg / kg drug solution is prepared. Six animals were sacrificed from each group on day 8^th and 15^th. Macroscopic ulcer was identified and ulcer index was calculated by using method described by Ganguly. Fibroblast, inflammatory cells, congested blood vessels were counted by micrometry. SPSS version 21 was used to statistically analyse the data

Results: Aspirin alone group have more ulcer, congested blood vessels, and increased number of fibroblasts compared to control and L.inermis group.

Conclusion: This confirms that L. inermis not only counteract the harmful effects caused by the aspirin on gastric mucosa but also helps in repairing and healing process at the site of injury brought by the aspirin. Histological studies of injured site, when compared with the control, shows a organized pattern of collagen, fibroblast and inflammatory cells.

Frequency of Obsessive Compulsive Disorder among Medical Students

Ammara Butt — 2024-02-26

Background: Obsessive-compulsive disorder (OCD) is a neuropsychiatric condition characterized by persistent and distressing obsessions and compulsions. These repetitive behaviors or thoughts often lead to significant distress and interference in daily life. Among the most common obsessional themes is an intense preoccupation with contamination and illness. The objective of the study is to determine frequency of obsessive compulsive disorder in medical students.

Material and Methods: After approval of the study proposal from Ethical review Board of college of physician and surgeon Pakistan a cross sectional study was conducted in the Department of Psychiatry, Allama Iqbal Medical College / Jinnah Hospital, Lahore. over a period of six months from 17-05-2022 to 17-11-2022. Detailed history was taken to assess for exclusion criteria. To assess for presence of obsessive compulsive disorder (OCD) all the medical students included in study was asked a series of questions using Yale-Brown Obsessive This was followed up by a one on one interview of these students with a consultant psychiatrist to make as well as re-affirm the diagnosis.

Results: We found that total of 140 students, 51.4 %( n=72) were in age group of 17-22 years and 48.6 %( n=68) were in age group of 23-28 years, mean age was 22.34�1.79 years and BOC scale was 5.40�8.78. There were 40.7 %( n=57) male and 59.3% (n=83) females. According to severity of symptoms, 77.9% (n=109) had subclinical, 2.9% (n=4) mild, 11.4% (n=16) moderate, 5.7% (n=8) severe and 2.1% (n=3) had extreme symptoms. Frequency of OCD was 22.1 % (n=31). There was significant association of age and gender with OCD (P-value<0.05)

Conclusion: The results clearly show the impact of being a medical student and the need to increase awareness of obsessive compulsive disorder (OCD) among health workers generally and medical students specifically.

The Surgical Management of Epilepsy - A Surgeon Perspective

Abdul Hameed — 2024-02-21

Epilepsy is stereotypical clinical manifestation of recurrent, paroxysmal, excessive, synchronous neuronal activity of cerebral cortex. It affects almost 50 million people world wide¹. The incidence of epilepsy is as high as 50- 60 per 100,000. A range of 4 to 10 per 100,000 person per year makes it one of the most prevalent neurological disorder. Its prevalence in Pakistan touches the upper boundary of world�s prevalence, being 9.99 per 1000 people. It is more prevalent in persons younger then 30 years and it is more prevalent in rural areas².

For a medical personal it may be a clinical scenario but for the affected person it is a big social stigma. Patients suffering from this disease are usually isolated, depressed and deprived of many social rights. Although considered to be disease of high IQ people, every successive fit cause a certain amount of cognitive damage to the affected patient and it can be potentially lethal for the patient and for society if these people have adopted certain professions.

For a county like Pakistan where economy is touching its nadir it is highly difficult for patients to comply with adequate antiepileptic drug (AED) therapy.

One should clearly differentiate between seizure and epilepsy. A seizure is defined as a �Transient occurrence of signs and symptoms due to abnormaly excessive and synchronous neuronal activity in the brain.� For practical purposes epilepsy can be defined as;

At least two un provoked (or reflex) seizures occurring > 24 hours apart.
One unprovoked (or reflex) seizure and probability of further seizures
Diagnosis of an epilepsy syndrome.

Monotherapy is ideal for treatment and control of epilepsy. With increase of number of AEDs the chances of epilepsy control decrease. Surgery is potentially curative for epilepsy or at least it is helpful for reduction of demand of AEDs in carefully selected patients.

International League Against Epilepsy (ILAE) gives its recommendations for selection of surgical candidates.

Spectrum of Haemoglobinopathies in Population of Lahore District

Arrosa Rahim — 2024-02-20

Background: Haemoglobinopathies describe a group of genetic disorders in which one or more globin chains are abnormally developed. Thalassemias are a common cause of hypochromic microcytic anemia, which arises from the reduced or absent synthesis of the globin chain of haemoglobin. Studies from various regions of Pakistan have indicated variable prevalence of the disease in Pakistani population with significant ethnic and geographical variations. This study was conducted to find the range of haemoglobinopathies among the population of Lahore District.

Patients and Methods: It was a descriptive cross-sectional study conducted at Haematology, Pathology Department, SIMS/Services Hospital, Lahore from 18-3-2021 to 18-9-2021. 364 Patients with both genders and age 1-65 years presenting with anaemia were enrolled in this study. A 5ml sample of intravenous blood was drawn and placed in an EDTA anticoagulant container. The data was analyzed using Statistical Package for Social Sciences (SPSS) version 22. Quantitative variables including age, haemoglobin was described as mean � Standard Deviation, while qualitative variables including gender, haemoglobinopathies and their spectrum were described using frequencies and percentages.

Results: In this study the mean age of the patients was 18.18�13.92 years, 169 (48.84%) patients were male and 177(51.16%) females. The frequency of haemoglobinopathies was found in 76 (21.97%) patients. The most common spectrum of haemoglobinopathies was beta thalassemia trait found in 52 (68.42%) patients followed by Beta thalassemia major 6 (7.89%) and HbD Punjab trait 4(5.26%).

Conclusion: This study concluded that the frequency of haemoglobinopathies was 21.97% and the most common spectrum of haemoglobinopathies was Beta thalassemia trait followed by Beta thalassemia major & HbD Punjab Trait in patients referred to Haematology, Pathology Department, Services Hospital Lahore for workup of anaemia.

Relationship between peer versus non-peer learning and academic performance of nursing students in Karachi, Pakistan

Rukhsana Muhammad Haroon — 2024-02-20

Background: Students learn through peer learning; it is one of the central learning approaches. Peer learning inspires students to teach and learn from each other. The objective of the study was to determine the relationship between peer versus non-peer group learning and the academic performance of nursing students (NS).

Methods: A correlational research design was conducted at two public sectors: Dow Institute of Nursing and Midwifery Karachi and College of Nursing Dr. Ruth K. M. Pfau Civil Hospital Karachi. Three hundred NS were included in the study through purposive sampling techniques and the study duration was four months (December 2022 to March 2023). The inclusion criteria were undergraduate NS who were acquainted with peer learning. Those NS who were not present at the time of data collection were excluded from the study. According to the study's objectives, a questionnaire was developed by reviewing previous studies. Data was entered and analyzed on SPSS version 26.

Results: Out of 300, n=156(52%) were from peer group and n=144(48%) were from non-peer-group and n=167(55.7%) had reported good performance (>3 GPA) and n=133(44.3%) reported average performance (?3 GPA) at academic. Both groups of NS showed significant differences in academic performance (P- value <0.05). The peer group of NS has found a positive correlation (r.1.000) and is highly significant (P- value <.005) with academic performance.

Conclusion: The current study concluded that most NS belonged to peer groups, and more than half of the NS attained good academic performance. Peer groups also showed a positive correlation and high significance with academic performance.

The Evaluation of Radiofrequency Ablation and Medial branch block in the pain Management of Lumber Spinal Pain. A two-year follow-up study

Shahzad Anwar — 2024-02-20

Background: Chronic back pain, which is increasingly common and has a considerable economic impact, is a significant disabling factor. For the past decade, radiofrequency ablation (RFA) is a method that is frequently used to treat many kinds of chronic pain. Therefore, the objective of the current investigation was to determine the long-term clinical outcomes of an RFA.

Patients and Methods: Randomized control trail was conducted from March 2019 to December 2021 at Iffat Anwar Medical Complex and department of pain medication Azra Naheed Medical Complex. After taking the written informed consent the patients meeting the inclusion criteria: low back pain for past 2 years, both gender, age > 30 years and failed to respond the previous treatments were enrolled in current study. After radiological assessment total 60 patients were randomized equally into two groups (Group A= Medial Branch Block, Group B= RFA) by using computer generated sequence. The primary outcome of the study was to determine the improvement in low back pain by using visual analog scale and physical impairment by using Oswestry low back disability index scale.

Results: A sample of 60 patients were selected. The mean age of the patients was 57.6+9.6 years. 35 (58.3%) of the patients were between 56 and 75 years of age. In the current study, 41 (60.0%) were females, including 21 (51.2%) in Control and 20(48.7%) in intervention group. At 12^th (week), one, 1.5, and 2 (years), 30%, 80%, 33.3%, and 90.0% of patients reported a reduction in pain with a significant difference (P-value < 0.05).

Conclusion: A significant number of people with lumbar spine pain benefit from effective and long-lasting therapy while using RFA of the lumbar medial branch. Lumbar zygapophysial joints have been subjected to radiofrequency denervation this results in long-term pain relief under normal clinical conditions.

Frequency and Antibiotic Sensitivity Pattern of Culture Positive Salmonella Typhi in Children Visiting to RHQ Hospital Gilgit

Muneera Ali — 2024-02-20

Background: Typhoid fever, caused by Salmonella enterica serovar typhi, is a common infection that affects multiple body systems. Salmonella is a constantly evolving and adaptable bacterium, so overuse of a particular treatment may eventually lead to the development of resistance. To determine the frequency and antibiotic sensitivity pattern of culture positive salmonella typhi in children visiting to RHQ hospital Gilgit.

Patient and Methods: An observational cross-sectional study was conducted at RHQ Hospital Gilgit from June to August 2022. Through non-probability, consecutive sampling, a total of 150 patients of either gender with ages ranging from 1 month to 12 years and enteric fever symptoms as well as positive blood culture results for Salmonella species were enrolled in this study. In the microbiology lab, the blood culture bottles were incubated for seven days at 37 �C while daily growth indicators were monitored. On the pre-designed proforma, the basic demographic history and Salmonella species' susceptibility patterns were noted. Data was entered and analyzed by SPSS 25.0.

Results: The average age of these patients was 6.63+3.35 years. Among the patients, the majority were male, accounting for 97 individuals (64.6%), while 53 individuals (35.4%) were female. Fever was most common symptoms among patients with highest frequency of 59, followed by body aches (35). Almost 98% of cases were resistant to ciprofloxacin, commonly used as a first-line drug against Salmonella Typhi in Pakistan. Resistance was also very high against ampicillin (92%). The Azithromycin and Imipenem were the only drugs with a sensitivity of more than 90%.

Conclusion: The existence of typhoid fever cases and the increasing resistance of Salmonella strains to ceftriaxone and Ampicillin are causes for serious concern. Meropenem and azithromycin, whether used individually or in combination, proved to be the most effective antibiotics for treatment.

Effect of Anticoagulation on The Hepatic Function of Non-Malignant Portal Vein Thrombosis

Muhammad Salman Afzal — 2024-02-20

Background: In various groups of PVT patients, portal vein thrombosis (PVT) occurs at a rate of 5-26%; the incidence increases with progressive liver disease. Portal vein thrombosis increases portal hypertension, increases the risk of variceal haemorrhage, and decreases hepatic perfusion, eventually leading to hepatic decompensation. Therefore this study is conducted toevaluate the effect of anticoagulation on the hepatic function of non-malignant portal vein thrombosis.

Patients and Methods: Total 200 patients were consecutively enrolled in this retrospective study among April 2021 to April 2022. Patients with malignant PVT and those who lacked enough clinical data at the time of PVT diagnosis and during the subsequent clinical course were excluded. Retrospective analysis was used in this study to assess how anticoagulation affected hepatic function. A predesigned proforma were used to collect data. All the data was entered and analyzed by SPSS version 25. All the quantitative variables were presented by Mean+ SD and qualitative with frequency and percentages. An independent sample t test was applied to find out the significant difference of hepatic function among groups. P-value< 0.05 was considered as significant.

Results: Total 200 patients were enrolled in current study among which 100 were treated with anticoagulation and 100 without anticoagulation. The mean age among groups were (T= 48.99+1.73 Vs. UT=49.50+1.63). Majority of the patients were male (115/200) and married (161/200). Majority of patients were Males, Married, normal weighted (123/200), moderate ascites (55/200), grade 3 hepatic encephalopathy (105/200) and child PUGH class A (97/200). There was insignificant mean difference of hepatic function among groups. The ALT, AST ALP, Albumin, Bilirubin shows insignificant difference (P-value>0.05).

Conclusion: Our research shows that anticoagulation reduces hepatic damage and enhances liver production in people with non-malignant PVT.

Surgical Outcomes of 23 Gauge Pars Plana Vitrectomy for Non Clearing Diabetic Vitreous Hemorrhage

Rifah Razzaq Wattoo — 2024-02-20

Background: Vitreous hemorrhage (VH) is one of the main causes of visual loss in patients with Diabetic Retinopathy. Initial management of VH is observation for 4-6 weeks. Non-clearing vitreous hemorrhage (NCVH) remains the most common indication for vitrectomy in such patients. The objective of the study was to investigate the surgical outcomes of 23-gauge vitrectomy with prior intravitreal bevacizumab for non-clearing diabetic vitreous hemorrhage.

Patients and Methods: This was a prospective interventional case series conducted at Ophthalmology Department, Allied Hospital, Faisalabad from 1^st January 2022 to 31^st December 2022 (1 year). After obtaining IRB approval and informed consent, 50 patients with non-clearing vitreous hemorrhage (VH) were included in this study. Patients with any type of retinal detachment and previous retinal surgery were excluded. After initial detailed pre-op assessment, all patients underwent 3-port pars plana vitrectomy with 23G instrumentation using Binocular Indirect Operating Mi�croscope (BIOM) system. Patients were followed up at one week, one month and three months to note visual acuity and any early or late post-operative complication. Data was analyzed by SPSS v. 25.0.

Results: Out of 50 patients, 35 (70%) were female and 15 (30%) were male. Age ranged from 32 to 78 years with mean age of 55.5 years. Only 4 (8%) patients were type I diabetics. Mod pre-operative best corrected visual acuity was 3/60 and it improved to mode BCVA of 6/36 on Snellen chart. Complete resolution of VH occurred in 42 (84%) patients while 6 (12%) patients had recurrent VH. Most common postoperative complication noted was raised intraocular pressure in 19 (38%) patients.

Conclusion: Our study suggested that 23-G vitrectomy is a safe option for patients with non-resolving diabetic vitreous hemorrhage. Mean BCVA improves after vitrectomy (depending on retinal status) and postoperative surgical complications also remain minimal.

Likelihood of Diabetes Mellitus Associated with Frozen Shoulder

Muhammad Zubair — 2024-02-20

Background: Frozen Shoulder (FS), is an extremely debilitating shoulder condition that causes serious functional impairment in activities of routine work. FS causes disability in 2-3 percent of the population. In Pakistan, fewer studies have been conducted in the past describing the association between diabetes with FS. Through this study, we would like to study links, create awareness among physicians, patients and treat the underlying disease to reduce morbidity. Our study objective is to find the prevalence of diabetes in patients with FS from Islamabad and Rawalpindi.

Subjects and Methods: Patients >18 years with shoulder pain or stiffness attending Shifa Medical and Pain Clinic were identified. Institutional review board and Ethical Committee approval and informed consent were obtained from the participants. A preformed questionnaire was used for the survey. The statistical analysis was carried out using the SPSS 23 version to evaluate the relationship between FS and age, sex, presence of diabetes, and control by HbA1c levels.

Results: Data of 700 patients, 206(29.4%) males 494(70.6%) females with MA�SD of 54�9. 287(41%) patients were found Diabetic with FS. 228(79.4%) diabetic patients were poorly controlled having HbA1c levels of more than 7%. The patient had high HbA1c levels showing a strong correlation of uncontrolled Diabetes with FS. 39(9.4%) patients with FS were incidentally diagnosed with diabetes.

Conclusion: Patients with frozen shoulder should be subjected to routine diabetes investigation and control should be monitored by blood glucose and HbA1c levels. Patients with diabetes should also be made aware of the role of glycemic control in the management of FS to prevent morbidity.

Challenges faced by a clinician to be a medical educator in Pakistan

Muhammad Asif Gul — 2024-02-20

Abstract:

Medical education is an emerging and essential discipline of medical science. It ensures quality education and training of medical students and doctors which will ultimately help in the best patient care. The clinicians who are involved in medical education face various problems and tension. There is need to explore these challenges and reasons behind these challenges. This study will explore the complex and multi-faceted challenges and reasons encountered by clinicians-educators.

Methodology:

A descriptive cross-sectional study was conducted at Post Graduate Medical Institute/ Lahore General hospital from April � June 2022. Total 50 participants were included in the current research who are medical educationist and Clinical educationist. respondents were of age group of 30 to 65 years including both male and female from all disciplines of medical colleges/universities. A self structured questionnaire was developed to collect data. Questionnaire have four domains (Time management, Economic burden. Social Life and rewards). Data was entered and analyzed by SPSS 25.0. All the qualitative variables were presented by frequency, percentages and graphs.

Results:

Total number of respondents 50. There were 35 males and 15 females. Majority (35) of the participants were 40-55yrs old. Experience as clinician medical educations varies among the participants from few months to 15 years. A significant portion of the participants (45) expressed challenges in managing time. Economic and financial obstacles were identified by 33 participants. Additionally, 31 participants indicated that they encounter social barriers, while 20 participants mentioned receiving rewards or privileges in their roles as medical educators. Those with up to 1 year of experience reported facing all the identified challenges, including difficulties with time management, economic constraints, social obstacles, and issues related to rewards.

Addiction a Complex Syndrome

Ammara Butt — 2024-02-20

Addiction is a complex and multifaceted issue that affects millions of people worldwide. It has the potential to ruin lives, destroy families, and damage communities. Addiction can be defined as a compulsive and uncontrollable urge to engage in a particular behaviour, despite the negative consequences that may result.¹ It can take many forms, from alcohol and drugs to gambling, sex, and even food. Addictive behaviours have a profound impact on individuals and society as a whole.

The origin of addiction is still a topic of debate among scholars and researchers, with some pointing to genetic predispositions and others highlighting environmental factors such as childhood trauma and stress. Whatever the cause, addiction is a chronic condition that requires support, understanding, and intervention to overcome.²

One of the most significant challenges of addiction is that it is often associated with negative stigmas, shame, and guilt. Many people who struggle with addiction do so in silence, afraid to seek help or admit they have a problem. This stigma can make it difficult for individuals to access the resources and support they need to overcome their addiction.³

Frequency of Celiac Disease in Children Presenting with Iron Deficiency Anaemia: A Single Centre Experience from Southern Punjab, Pakistan

Nadeem Iqbal Qaisrani — 2024-02-19

Background: Celiac disease (CD) is a chronic disease of immune-mediated damage to the small intestine resulting in variable symptoms of malabsorption. Iron deficiency anaemia (IDA) is one such frequent symptom. As these are high percentages for celiac disease in patients presenting with iron deficiency anaemia, the study's main aim was to determine the frequency of celiac disease in children presenting with IDA.

Material and Methods: It was a descriptive cross-sectional study conducted at Children's Hospital & the Institute of Child Health, Multan, for a duration of 6 months from 16th January 2020 to 15th July 2020. A total of 132 patients were enrolled; we included patients from Ages one year to 14 years of both genders, newly diagnosed patients with iron deficiency anaemia who are not taking treatment for this, we studied age, sex, duration of anaemia, the severity of anaemia, we investigated Hb, serum ferritin, anti-tissue transglutaminase antibodies level and endoscopic biopsy done.

Results: We enrolled 132 patients presenting with IDA. Among all 132 patients, CD was found in 23 (17.4%) Mean age of the patients was 7.61�4.21 years. The mean value of the duration of anaemia of the patients was 20.39�6.17 days. 60(45.45%) patients were male, and 72 (54.55%) were female.

Conclusion: The frequency of CD in children with iron deficiency is found to be 17.4%. Therefore, we recommend a Multicenter study at regional and national levels to assess the disease burden and early diagnosis for appropriate and timely management of this vulnerable population.

Effect of Different Water-Based and Gel-Based Conductive Media on the Efficacy of Electric Pulp Tester

Nosheen Sarwar — 2024-02-19

Background: The Electric Pulp Tester (EPT) is a valuable diagnostic tool used in dentistry to assess the vitality of dental pulp. However, the effectiveness of the EPT can be influenced by the type of conductive media used during the test. This study aimed to investigate the impact of different water-based and gel-based conductive media on the efficacy of EPT.

Subjects and Methods: An Analytical observational study conducted at the School of Dentistry PIMS Islamabad. The Study period was six months from May to October 2022. Three different water-based and gel-based conductive media was applied on the 100 healthy maxillary central incisors to check the efficacy of EPT with different substances. The recorded data were analyzed through SPSS 21.0 for Windows.

Results: The mean age of study participants was 22.5 � 1.2. The ultrasound gel has the least pulpal sensory threshold 4.11 � 1.26. Independent t-test was applied to find the correlation between gender and preference of materials. P value <0.05 was significant.

Conclusion: The choice of conductive media used during Electric Pulp Tester (EPT) procedures has a significant impact on the efficacy of the test. Ultrasound gel has better electric conductance, and females have a less pulpal sensory threshold.

Suicide Ideation and Patterns among Suicide Survivors Admitted in Teaching Tertiary Care Hospital Multan, South Punjab Pakistan

Hira Naveed — 2024-02-19

Background: Suicide, defined as a fatal self-injurious act with intent to die, is a significant public health concern worldwide. Loneliness, depression, and trauma are linked to suicidal ideation, and methods of suicide vary across regions. This study focuses on evaluating factors influencing suicidal ideation and behavior in a tertiary care hospital in Punjab, Pakistan.

Subject and Method: A quantitative survey was completed as part of a cross-sectional study among patients who had attempted suicide in order to determine the magnitude of suicidal ideation and behavior. A pre-tested questionnaire was employed, and a random sample of 62 people was used. The data was compiled, assembled, and jotted down using Google Forms. Data analysis and computation have been done via SPSS version 22.

Result: An examination of the data revealed and unacceptably high occurance of suicide.( prevalence) The majority felt life was not worth living, and many believed their families would be happier without them. Thoughts like "You�ll be sorry when I�m gone" were common, and 48 survivors had the thought "I won�t be in your way much longer" before attempting suicide. Another frightening factor was that most of the patients were in their early twenties.

Conclusion: The findings reveal high rates of suicidal thoughts among survivors of suicide attempts. Factors include hopelessness and a lack of understanding. So, there is a dire need for proper counselling and early recognition of problems. Comprehensive suicide prevention strategies and mental health support systems are crucial to addressing risk factors and providing effective intervention.

Comparison of Ultrasound and Computed Tomography Findings in Non-Alcoholic Fatty Liver Disease in Obese and Non-obese Patients

Nuzhat Mukhtar — 2024-02-19

Background: Non-alcoholic fatty liver disease (NAFLD) affects 15 to 40% of people in Western nations, 9 to 40% of people in Asian countries and 6-35% global incidence in Western industrialized countries.^1,2

Objective: To compare ultrasound and computed tomography findings in non-alcoholic fatty liver disease in obese and non-obese cases.

Methods: A cross sectional analytical study was conducted at DHQ Hospital Narowal. 270 patients of both genders with ages 13 and 95 years who had a fatty liver on ultrasound and are non-alcoholics were included in this study. Patients with any other liver abnormality and having history of alcohol intake were excluded. The variables of age, height, weight, gender and BMI were recorded. Patients were categorized in two groups obese and non-obese on basis of BMI. Grading of fatty liver on ultrasound and CT scan were noted down on a predesigned data collection sheet.

Results: Out of 270 patients of NAFLD, 55.9% were females and 44.10% were males while 74.44% subjects were obese 25.55% were non obese. The correlation between USG and CT findings was significant(r = 0.761 for non-obese and 0.868 for obese patients). Among obese cases of NAFLD grade I was the commonest, and lowest number of patients were of grade III. Among non-obese cases grade II was commonest.

Conclusion: There is a good correlation between the structural ultrasound criteria and CT criteria for diagnosis of nonalcoholic fatty liver disease. This disease is seen more commonly in obese individuals and is more common in females as compared to males.

Comparison of Effectiveness of Doxofylline VS Theophylline in Stable Chronic Obstructive Pulmonary Disease Patients

Syed Ali Raza — 2024-02-19

Background: Chronic obstructive pulmonary disease (COPD) is known as an obstructive pulmonary disease it causes particular small airway obstruction. Currently available medications for COPD are not able to reduce the progressive deterioration of lung function. The current study aims to determine the effectiveness of doxofylline and theophylline in improving the pulmonary functions in stable COPD patients.

Methods: A Randomized controlled trial was conducted on a total of 80(40 in each group). Stable COPD patients (FEV1/FVC < 0.70) patients visiting the outpatient department of Sir Ganga Ram Hospital for treatment and fulfilling inclusion criteria were enrolled to participate in the study. Both groups were given standard long-acting bronchodilator therapy such as salmeterol inhaler 25mcg twice daily. Group A was given theophylline, while group B was given doxofylline. Independent sample t-test was applied to compare the spirometry findings in both groups by using SPSS 25.0. A p-value of <0.05 was considered statistically significant.

Results: In current study it was reported that the 36 (45.0) of patients were 30-40 years old. The majority of patients were male 68(85.0%) and suffered from COPD. There was an increased improvement in spirometric parameters among both groups. The both groups have same effect on spirometric parameters in terms of FEV1, FVC, FEV1/FVC and FEC1% prediction. Both drugs increase the spirometry functionality. (p-value > 0.05). There was significant difference among side effect of both groups. Doxophylline was found to have fewer side effects compared to theophylline. (P value< 0.05)

Conclusion: It was concluded that the both drugs theophylline and doxofylline revealed consistent improvement in spirometric outcomes (FEV1, FVC, and the FEV1/FVC ratio) with the passage of time in COPD. The current study demonstrates that both drugs have a equal efficacy and safety profile than theophylline in patients with COPD.

Correlation in Academic Performance, Purpose in Life and Hopelessness among Final year Medical Students

Ammara Butt — 2023-06-15

Background: Student�s academic performance is the major concern for the educational sector because students are the future practitioners who will serve the society. The academic performance of students is a key feature in teaching. The present study aims to determine the relationship between academic performance, purpose in life and hopelessness among final year MBBS students, by taking hopelessness as predicting variable.

Methodology: A Correlational study was conduct at Fatima Jinnah Medical University, Lahore Pakistan. A total no. of 240 final year medical students were included by using convenient sampling technique and they were administered Purpose in Life (PIL) Scale and Beck�s Hopelessness Scale (BHS) along with demographic details. The academic performance of students was measured through 4^th year academic scores. Hopelessness was taken as independent variable (IV), while, academic performance and purpose in life served as dependent variables (DVs).

Results: The mean age of students was 22.5 years. Results found negative correlation between hopelessness and academic performance (p<0.01), as well as a negative correlation between hopelessness and purpose in life (p <0.01). Hopelessness negatively predicted academic performance (?= -.19, p<.01) and purpose in life (?= -.72, p<.001) among students. Total 25% students were in the normal range of hopelessness, 45.4% students scored in mild range, 23.8% students were in the moderate category, while 5.8% students were found in the severely hopeless category.

Conclusion: The study concluded that hopelessness does not only predict purpose in life negatively among students but also affect their academic performance. A wide range of students were found hopeless therefore, various interventions for the prediction of hopelessness in various academic institutes should be made by involving appropriate educational and administrative measures.

Chest Radiograph appearance of SARS-Cov-2 Infection: A Prospective Observational Study of Ambulatory Patients from a Field Hospital in a Middle-Income Country

Faryal Farooq — 2023-06-15

Background: The ongoing COVID-19 pandemic has had a profound impact on both individuals and society, resulting in widespread illness and death, as well as a global economic downturn. In order to examine chest X-rays (CXRs) of ambulatory patients diagnosed with COVID-19 in a field isolation center, our aim is to determine the proportion of patients with normal versus abnormal chest radiographs. Moreover, in cases where abnormal findings are present on the CXR, our goal is to document the distribution and patterns of these abnormalities.

Method: This prospective observational study was conducted on a cohort of 510 consecutive COVID-19 patients who tested positive for the virus and presented at the field isolation center between March 15^th and May 15^th, 2020. The study encompassed patients of all ages and both genders, with the exclusion criteria being patients requiring intensive care and those with unreadable CXRs due to technical limitations. The review of CXRs was performed by two certified radiologists, ensuring reliable and accurate assessments. Age, gender, and X-ray findings were noted.

Results: Among the total of 510 patients included in the study, 463 (90.8%) were male, while 47 (9.2%) were female. The age range of the study population spanned from 12 to 64 years, with the majority falling within the 23-33 year age group. During the review of CXRs, 433 (84.90%) were classified as normal, while 77 (15.10%) were deemed abnormal. The most frequently observed abnormal pattern was ground glass opacification, accounting for 54.5% of the cases, followed by the reticular pattern at 45.5%.

Conclusion: CXRs obtained from confirmed COVID-19 patients were normal in 85% of the patients. The most common abnormality seen in our study population was involvement of the lower lobes with patchy peripheral ground glass opacities or reticular shadowing, which was focal or multifocal in location.

Level of Adherence to the Gold Strategy Document for the Management of Patients with Acute Exacerbation of COPD in Sahiwal

Muhammad Waseem, Assistant Professor Pulmonology — 2023-06-15

Background: Chronic Obstructive Pulmonary Disease (COPD) and its exacerbation are a major cause of pulmonology OPD and emergency visits in Pakistan. The objective of this study was to measure the level of adherence to the GOLD (Global Initiative for Chronic Obstructive Lung Disease) strategy document in the management of patients with acute exacerbation of COPD, in Sahiwal Punjab Pakistan.

Methodology: This retrospective cross-sectional study comprised 480 patients with acute exacerbation of COPD. It was conducted in the Pulmonology Department DHQ Teaching Hospital, Sahiwal. The treatment given to these patients was compared to treatment guidelines mentioned in the GOLD strategy document for management of acute exacerbation of COPD.

Results: Out of total 480 patients, 408 (85%) were males. 312 (65%) patients belonged to age group 50-70 years. 100% Gold strategy treatment standards were not followed in any patient. Five out of ten management steps were followed in all cases. While remaining five steps were followed variably.

Conclusion: Overall adherence to the AECOPD management standards set by GOLD strategy document was not good. Improved physician�s awareness of guidelines and better adherence to treatment standards can improve patient care and outcome.

Psychological Behavior and Compliance of the General Population with Facemasks during the COVID-19 Pandemic: Implications for the Future

Samreen Misbah — 2023-06-15

Background: Globally people have succumbed to viral infections that posed a stupendous threat. Community wearing of facemask helped lowering the incidence of COVID-19. The objective was to determine the public opinion regarding prolonged mask-wearing practice, and to find out the behavioral differences as pertinent compensations for not wearing that may help combat pandemics because of emerging infections.

Methodology: This cross-sectional study carried out in the outpatient departments of Military Hospital (MH) Rawalpindi, Pakistan from January to June 2021 after ethical approval. Participants selected by non-probability convenience sampling technique of different residential, economic and educational backgrounds, above 16 years of age, from both genders to give their opinion on a validated questionnaire, �Multidimensional face mask perceptions scale� with eight domains.

Results: Among 175 participants, almost 81.7% participants were of the view that when they do not wear mask it is because facemasks get overheated and disrupt the breathing, 60.6% adopted compensation ways by avoiding people and 45.7% considered its wearing a hassle. Female participants felt more uncomfortable by disrupted breathing (p =0.029), male participants reflected about value of independence (p<0.001), and participants from rural area thought a difficult access to get facemasks (p =0.003).

Conclusion: The most likely reason for not wearing mask among participants was uncomfortable breathing. The other reasons includes adopting social distancing guidelines as a compensatory measure, finding facemask wearing practice a hassle, interference with freedom and access issues by rural population. Designing and implementing awareness sessions may halt such spread of pandemics because of emerging infections.

Persistently Elevated Parathyroid Hormone Level after Curative Parathyroidectomy in Patients with Primary Hyperparathyroidism

Tasnim Ahsan — 2023-06-15

Background: Persistent elevation of parathyroid hormone (PPTH) levels following curative parathyroidectomy is a dynamic & multifactorial process. This study was designed to study the frequency of persistent hyperparathyroidism in our patients and to identify the potential causal factors for persistent PTH elevation following parathyroidectomy.

Methodology: The study included prospectively collected data on post-operative patients of primary hyperparathyroidism who underwent parathyroidectomy from 2004-2018. Data was analyzed by SPSS version-21. For descriptive statistics, frequency and percentages were calculated, while mean �standard deviation were calculated for age, duration of disease, pre-operative and post-operative biochemical parameters, like serum PTH, calcium and vitamin D levels.

Results: A total of 11 (39.3%) patients, were diagnosed as persistent hyperparathyroidism, out of the 30 patients, who underwent parathyroidectomy. All patients were female with a mean age of 45.27+17.2 years and a mean duration of symptoms of 21.3 months. The mean post-operative PTH level, vitamin D and calcium were 154.04�78.64 pg/ml, 22.28�13.79 ng/ml 9.46�0.79 mg/dl, respectively. Fluctuation of PTH hormone in relation to erratic vitamin D intake was reported in 8 patients, and recurrent parathyroid adenoma was reported in three patients, which was subsequently re-operated.

Conclusion: Adequate vitamin D supplementation is essential in the pre and post-operative period to prevent persistent parathyroid stimulation and possible dysregulation. Surveillance for recurrence of hyperparathyroidism should be maintained long term.

The Recovery of Left Ventricular Function in Cases of Primary Angioplasty for Acute Myocardial Infarction

Muhammad Ramzan — 2023-06-15

Background: This study is to investigate the recovery in left ventricular ejection fraction in the first 3 months after acute myocardial infarction treated with primary angioplasty. Left ventricular function (LVF) is the main predictor of long term prognosis in cases of survival after acute myocardial infarction. Study aims to investigate successful improvement in left ventricular ejection fraction after primary angioplasty.

Methodology: A cross sectional study was conducted at Chaudhary Pervaiz Ellahi Institute of Cardiology, Multan from 1^stSeptember 2019 to 30^thSeptember 2020. Left ventricular ejection fraction was evaluated in 100 patients treated with primary angioplasty. Primary angioplasty is a very 1^st treatment to re-open the locked artery after acute myocardial infarction. Ejection fraction was measured with Echocardiography Simpson�s biplane method at 3^rd day and 3 months after angioplasty. Collected data was analyzed by using SPSS version 23. Chi square test was applied to see association among variables.

Results: One hundred patients were included this study. The mean age and BMI of the patients was 59.45�6.01 years and 24.76�8.02 kg/m², respectively. Male 70 (70%) and female 30 (30%) ratio was 7:3. LVEF at 3rd month was observed in ?40% in 223 (23.0%) patients and >40% in 77 (77%) patients. Male patients were greater in number that�s why LVEF is also observed in greater in male gender (p<0.001). Increase in age also have no impact on procedure success (p>0.050).

Conclusion: Results of this study reveal that primary angioplasty is successful treatment plan in patients with acute myocardial infarction. A significant recovery of left ventricular function during 3 months after primary angioplasty in acute Myocardial infarction (MI) patients was observed.

Health Consequences of Smokeless Tobacco Substance Abuse among High School Adolescents

Fahad Ali Mangiro — 2023-06-15

Background: People currently reside in a smokeless tobacco -oriented society, and the threat of illicit substances is visible in every part of the world, including Pakistan. Moreover, Substance abuse has become a big problem in our society now days, therefore current study conducted on health consequences and prevalence of smokeless tobacco substance abuse among high school adolescents at taluka Qasimabad, Hyderabad, Sindh, Pakistan.

Methodology: A cross sectional study conducted through predesigned survey form, in which 308 respondents were selected at random level from the full targeted sample of ninth and tenth grade pupils..

Results: the researcher revealed 22.9% of smokeless tobacco abuse among high school adolescents, in which male participants showed high prevalence as compare female. Furthermore, Areca nuts (57.1%), Safina sachet smokeless tobacco (19.2%), betel (14.6%), and Tara chewing smokeless tobacco (13.3%) had the highest percentage of smokeless tobacco used. In addition, data showed significant 0.05 association with smokeless tobacco abuse with health-related problem, i.e., throat pain, cough, mouth ulcer and headache, abdominal pain, loss of appetite and sleeping pattern disturb problem.

Conclusion: It is revealed that High school adolescents abused smokeless tobacco substances and suffered worst health consequences.

Communities of Practice: Redressal of Medical Education Leadership Challenges through a Workplace-Based Learning Approach

Syeda Amina Ahmad — 2023-06-15

Background: There is a realization that learning leadership skills is beyond classroom teaching and requires leaders to participate in communities of practice (CoP) that enables them to learn from the wisdom of seasoned leader because such leaders don�t ask budding leaders to follow their instructions, they rather set examples of best practices in medical education. However, dearth of published evidence both locally and internationally suggests that there is a need to investigate how have communicates of practice impacted leadership skills of physicians as medical education leaders.

Participants and Methods: A transcendental phenomenological study was conducted, involving seven physician leaders working as medical teachers from both basic and clinical sciences, heading the medical college and/or their departments as professors in a medical college on the basis of convenience sampling and their experiences as medical education leaders who had presumably experienced the phenomenon of �learning leadership skills�. The researcher conducted hour-long one-on-one interviews with participants at their workplace offices and one interview was conducted at the researcher�s home office. One of the participants was interviewed twice as additional gaps were identified from the initial analysis. Interviews conducted in the surgeon�s office were interrupted many a times by theatre assistants, but the continuity was resumed successfully. The qualitative data was analyzed manually by using the Stevick-Colaizzi-Keen method.

Results: One major theme namely �communities of practice impacting leadership skills� emerged from the transcripts whereas, two subthemes namely �gaining wisdom� and �uplifting emotional wellbeing� were identified as main aspects that had a major influence on leadership skills of physicians in the medical education milieu.

Conclusion: CoP has a positive impact on leadership skills. It enables leaders in medical education to learn wisdom to solve difficult leadership problems. Evidence supports that CoP also uplifts emotional wellbeing of leaders by preventing their burn out.

Prevalence of Indices of Stress with Degree of Insomnia and Academic Performance in Undergraduate Medical Students

Ghulam Mujtaba Nasir — 2023-06-15

Background: Studying medicine is quite challenging as medical students have to work hours and hours which leads to continuous psychological stress and as a result decrease in sleep duration and quality. This study aims to determine the prevalence as well as the relationship of academic stress and pattern of sleeping problems among medical students.

Subjects and Methods: In this cross-sectional study,128 non-obese medical students (18 -23 years old, BMI=18.5-24.9) are included and they are divided into 2 groups as non-stressed (K10?19) and stressed (K10>19) medical students. We have used Kessler Psychological Distress Scale(K10), Pittsburgh Sleep Quality Index Scale (PSQI) and percentage of Professional Examination Result to assess stress, sleep quality and academic performance, respectively.

Results: PSQI scores were less in the stressed[8.5(3?17)] as compared to non-stressed [6(1?17)] subjects (p=0.000) while academic score (percentage) in stressed [70.9(59?77)] was lesser than that of non-stressed[76.7(57?86)] subjects (p=0.000).Within the non-stressed subjects,K10 scores were positively correlated to PSQI scores (rho=0.294, p=0.018) and negatively correlated to academic score (rho= -0.319, p=0.010).Similarly in the stressed subjects there was a positive correlation between K10 and PSQI scores (rho=0.435, p=0.000) and a negative correlation between K10 and academic scores( rho= -0.251, p=0.045)

Conclusion: This study suggests that both sleep quality and academic performance reduces with increase in stress among non-obese medical students.

Keywords: stress, non-obese, medical students, sleep quality, academic performance.

Impact of Mentor-Mentee Relationship on Autonomy development of Mentees in Health Professional Education

Khadija Farrukh — 2023-03-31

Background: There is growing evidence in literature on how student autonomy promotes motivational and well-being in medical students. Now a day there is lots of stress on medical students, mentoring is a simple technique to support our students but how mentors are to be train to give effective support is another challenge. Our study aims to explore the awareness of mentors on impact of mentor-mentee relation on autonomy development of mentees in health professional education. Mentor-mentee relationship can supports or constrain autonomy development of mentees this study explored the phenomenon from mentor perspective.

Methodology: Qualitative case study design and interpretivist paradigm was used; study duration was six months in bahria university health sciences campus. Data was collected using unstructured interviews until data was saturated. Four individual interviews of mentors using video eliciations, in which mentors reflected on their recent mentoring interaction with mentees and two focus group discussion of 90-120 minutes duration. Eight mentors were included in each focus group discussion. Total of twenty mentors participated in study by fulfilling inclusion creteria. Open-ended non-directive questions were asked. Self- determination theory was used for guiding interviews. Pattern matching was used for data analysis, it seeks to condense the participant�s response to thematic units and synthesis of essential themes in order to describe them.

Results: Essential themes were identified after data analysis, �Conversation on behavior change�, �uncertainty on the extent to which they impact autonomy� and �social Factors�

Conclusion: Mentors were not certain on the extent to which they impact autonomy in mentees. Mentors training is required to develop skills of autonomy- supportiveness. Mentors should have clear guidelines regarding autonomy supportiveness well-being and professional growth. Autonomy supportiveness should continue parallel to professional identification development in undergraduate medical students.

Relationship between Sedentary Time and physical activity in patients with Non-Alcoholic Fatty Liver Disease

Mehreen Zaman — 2023-03-31

One of the most prevalent chronic liver diseases is nonalcoholic fatty liver disease (NAFLD). Public health is currently threatened by physical inactivity and the resulting health problems. The aim of this study was to investigate the relationship between sedentary behavior and physical activity level in NAFLD patients.

Methods: A cross-sectional study was carried at Allama Iqbal Medical College/Jinnah Hospital, Lahore. Purposive sampling was used to enroll 210 participants in the study. NAFLD patients aged between 18 and 80 years attending OPD were recruited after taking their informed consent. Data were entered into SPSS version 25.0 for analysis. Quantitative variables were reported as frequencies and percentages. Spearman rank correlation test was used to determine the relationship between sedentary time and physical activity level. Statistical significance was defined as a P value of 0.05 or less.

Results: Total 210 patients were enrolled in current study. Majority 147(70.0) of the patients were 20-50 years old, male 126(60.0%), married 186(88.6%). The most common sign and symptoms of non-alcoholic fatty liver disease were abdominal pain 169(80.5%), followed by change in weight 130(61.9%) and constipation 125(59.5%). Majority of the patients have low and moderate physical activities and have sedentary life style. Their sitting time is almost 6 to 10 hours a day. The current study results showed a negative strong correlation between sedentary time and physical activity of patients [r = -0.650**, P-value <0.05).

Conclusion: It was concluded from the current study that sedentary time and physical activity are negatively correlated in NAFLD. The results of current research indicate that reducing inactive time and enhancing physical activity levels are beneficial for reducing the risk of developing NAFLD.

COVID-19 Related Practices and Fears Among Patients with Chronic Diseases

Sarmad Zahoor — 2023-03-31

Background: Chronic diseases are considered as added risk of severity of COVID-19 infection. This study was planned to assess practices and fears of patients with chronic diseases during COVID-19 pandemic.

Participants and Methods: An online questionnaire was developed and shared with potential participants using the snowball technique. The questionnaire included questions about sociodemographic characteristics, practices and fears related to COVID-19. A total of 181 patients with chronic diseases filled the questionnaire.

Results: About 72.4% reported fear due to increased risk of severe COVID-19 infection. Male, married and those living with two or more chronic diseases were more panic as compared to others. About 56% were worried about emergency care for their existing condition.

Conclusion: The analysis showed good practices especially wearing a mask and avoiding crowded places among patients with chronic diseases. However, the presence of fear of the severe infection and emergency care might affect their mental health which needs attention and counseling.

Unleashing Potential: Fatima Jinnah Medical University's Global Acclaim and Inspiring Academic Journey

Bilquis Shabbir — 2023-03-31

Fatima Jinnah Medical University (FJMU), formerly known as Fatima Jinnah Medical College (FJMC), embarked on a transformative journey on July 1st, 2015 when it was awarded the esteemed status of a Medical University by the Government of Punjab from its status as a College for almost 7 decades. This transition from a medical college to a medical university marked a significant milestone in the institute's history. As FJMU continues to build upon its rich legacy, the transition to a medical university empowers the institution to expand its horizons and delve deeper into the realms of medical knowledge and practice. It provides a fertile ground for fostering innovation, nurturing talent, and producing well-rounded healthcare professionals.

Fatima Jinnah Medical University (FJMU) has, this year, achieved an extraordinary milestone, cementing its position among the top 800 to 1000 universities globally in the esteemed Times Higher Education Impact Ranking. Times Higher Education (THE) is a renowned global university-ranking organization.¹ While they do not specifically rank individual words, THE incorporates the Sustainable Development Goals (SDGs) into their ranking methodology. Their evaluations consider universities' contributions towards the SDGs, encouraging institutions to align their research, teaching, and societal impact with these global sustainability targets. This remarkable recognition not only places FJMU among the world's leading academic institutions but also establishes it as amongst the topmost medical university in Punjab, and the third-ranked medical university in Pakistan.²

Letter to Editor "Barret�s Esophagus Screening: An Inevitable Urge For Gastroenterologists"

Jibran Umar Ayub Khan — 2023-03-14

The presence of benign esophageal diseases including gastroesophageal reflux disease, barrets esophagus,hiatal hernia and achalasia have been arousing the curiosity of young clinicians , scientists and researchers for decades and years to follow.¹ Dyspepsia is one of the most common symptoms experienced by the patients and witnessed by the doctors during routine clinical consultations. This does accompany regurgitation of food, bad taste in mouth early morning, chest pain and sometimes alarm symptoms including hematemesis, malena, unintentional weight loss and dysphagia.That is the point where one has to rethink and diagnosis treatment strategies and review patients accordingly.²

Barrett�s oesophagus is defined as �an oesophagus in which any portion of the normal squamous lining has been replaced by metaplastic columnar epithelium. Barrets esophagus is a benign condition with a potential to transform to oesophageal carcinoma.³ There is a long history gastroesopheal reflux disease symptoms. In our country there is a trend of self medicating oneself before coming to any physician in the general practice who also treats the patients for years before referral to gastroenterologist who can think out of the box and do invasive investigations like endoscopy, CT chest and non invasive one like barium swallow. Most of the people ponder over when is right moment for screening the patients for Barrets esophagus and Esophageal Cancer Screening. A lot depends on the biopsy report and its findings in terms of having low grade, indefinite for dysplasia and high grade dysplasia.⁴

Low grade dysplasia in terms of surveillance carries less significance in which the guidelines suggest the time interval can be enhanced to 2-3 years in case of permanent regression with proton pump inhibitors given for 8 weeks The high grade dysplasia is an alarm finding for any gastroenterologist requirement more aggressive screening and management as there is a 30-40% risk of oesophageal carcinoma.⁵ This will need discussion by multidisciplinary teams including gastroenterologists, oncologists and pathologists as well.⁵

There is usage of proton pump inhibitors for years by the patients that is itself a risk factor for complications such as atrophic gastritis, pernicious anaemia, osteoporosis and even cancer.⁶ The resistance of symptoms to standard and even high doses of proton pump inhibitors is an indication for endoscopy as well. The role of PPI in asymptomatic patients is not substantiated by enough evidence in the literature However, in clinical practice, most patients are advised long term PPI based on the premise that chronic acid exposure may contribute towards Barrett�s Esophagus.⁶ So the bottom line is that there should be no hesitation in expediting the referral of such patients for urgent gastroenterology consultation who may do subsequent endoscopy after thorough examination of the patients.

American Gastroenterological Association has strong recommendations for screening for Barrett oesophagus in patients older than 50 years with symptomatic GERD and at least one additional risk factor for oesophageal adenocarcinoma.⁷ Almost similar guidelines have been formulated by other reputed societies as well including British Society Of Gastroenterology. There is a phobia of endoscopies in general public and they are reluctant to do them. But once the indication is clear then the patient should be counselled thorough as in case of oesophageal cancer for which a Barrets Oesophagus is a risk factor, early diagnosis is the key as surgery is curative. Indeed it is and should be irresistible urge for gastroenterologists to screen such patients.⁷

Frequency of the multi and extensively drug-resistant Salmonella Typhi in a health care facility

Tehreem Shabbir — 2023-03-14

Background: Antibiotic resistance is increasing against Salmonella Typhi (S. Typhi), causative agent of enteric fever, at a very high pace in Pakistan. The objective of this study was to evaluate the emergence of multi and extensively drug resistant Salmonella Typhi among suspected patients in a public health care facility in Lahore.

Patients and methods: 5cc blood samples from the patients with high grade fever (>38�C), vomiting and bradycardia (heart rate 84 bpm) were collected from laboratory of Arif Memorial Teaching Hospital, Lahore over six months (August 2020-January 2021), After informed consent, questionnaire were filled and total 97 samples were taken from suspected patients and screened for Salmonella Typhi by using Typhidot IgG/IgM by ELISA kit (one step typhoid fever) for S. Typhi. Gram staining, culture and biochemical testing was performed for confirmation. Antibiotic susceptibility testing was used to evaluate the emergence of antibiotic resistance. Statistical analysis was performed by using SPSS 20.0, software. Chi square test was used,

Results: Total 55 (56.7%) samples out of 97 (100%) were reported positive for Salmonella Typhi. Antimicrobial susceptibility testing results indicated that 6 samples were resistant to more than one antibiotic commonly called as multidrug resistant, 44 samples were extensively drug resistant and 5 samples were nonresistant/sensitive to selected antibiotics. Highest resistance was reported against Ampicillin (51 samples (92.7%) and Co-trimoxazole (50 samples (90%)). Resistance against Moxifloxacin and Tobramycin, Ciprofloxacin, Ceftriaxone Cefuroxime and Cefotoxime, Cefxime, Levofloxacin, Salbactum, Imepenum and Amikain was 47 (85.4%), 46 (83.6%), 45 (81.81%), 44 (80%), 37 (67.2%), 32 (58.18%), 14 (45%) and 9 (16.3%) respectively. Lowest resistance was reported against Meropenum 5 (9%) and Azithromycin 1 (1%).

Conclusion: It is concluded that the monitoring of MDR and XDR must be performed by all clinical microbiology/pathology laboratories to implement effective measures to reduce the emergence of antimicrobial resistance.

A study of morphological variations of fissures and lobes of formalin fixed cadaveric lungs

Farhana Jafri — 2023-03-14

Background: Variation of morphology of lung fissures and lobes affects the interpretation of results of radiological examination as well as line of action in cardiothoracic surgical procedures. A research was done to find out the incidence of variations of fissures and lobes in embalmed cadaveric lungs.

Materials and methods: This is a cross sectional study. All the formalin fixed lung specimens present in dissection halls and museums of the Anatomy Departments were observed for any abnormal fissures that are adding accessory lobes to lungs. Data was entered and analyzed by using SPSS 22.0. Descriptive analysis was applied by using frequencies and percentages for qualitative variables.

Results: Total 80 formalin-fixed specimens of lungs were examined and a total of 29 (36.25%) (%) were found to have incomplete fissures. It was observed that 14 (17.5 %) out of 80 lungs had incomplete oblique fissures, and out of these 6 (17.65%) were found in right lungs and 08 (19.05%) were present in left lungs, whereas 15 (39.47%) right lungs showed incomplete horizontal fissure. Among 80 lungs, 6 (7.5%) presented unusual accessory fissures and lobes, whereas 5 (14.7%) showed absent horizontal fissure reducing the number of lobes to two in right lung specimen.

Conclusion: There is a prevalent incidence of incomplete horizontal fissure that must be kept in mind when investigating and treating any lung pathology.

Delayed speech in children of working and non-working mothers in Lahore, Pakistan: Prevalence and associated factors

Robina Zaib — 2023-03-14

Background: Before going to school 2-3% of children have language problems and 3-6% have speech delays. This study was carried out to determine the prevalence of delayed speech in children of working and non-working mothers and to determine if speech and language development in children are affected by the working status of the mothers.

Subjects and methods: This cross-sectional study was conducted at Mayo Hospital, Services Hospital, Sheikh Zaid Hospital, Lahore College for Women University, and the University of Lahore, Pakistan. A total of 288 mothers were recruited. Among them, 144 were working women (aged 25-40, working hours 6-8 for at least 5 days a week), including all professionals, teachers, doctors, and job holders. The other group included 144 non-working women (aged 25-40 years) having both male and female children from 2 to 5 years of age (with normal developmental milestones mean age of 3.5 years). Data were analyzed using SPSS.

Results: The results showed that 44 (30.6%) children of working women and 40 (27.8%) children of non-working women had delayed speech. The overall prevalence of delayed speech in children was 29.1%. No significant relationship was found between the working status of mothers with speech delay. The socioeconomic parameter (Kuppuswami scale) of the study revealed that 29% of delayed speech children (late talkers) belonged to the upper class, while 65.5% belonged to the middle class. Of delayed speech children 41.7% lived in a nuclear family and 58.3% in a joint family system. A significant relationship between delayed speech was seen with gender, birth order, social class, and the schooling status of the child.

Conclusions: Delayed speech is significantly related to gender, birth order, and schooling status. The working status of mothers plays no significant role in the language and speech development of children in the current study.

Evaluation of right liver lobe size to serum albumin concentration ratio in predicting the presence of esophageal varices in cirrhotic patients taking endoscopy as gold standard

Hafiz Muhammad Sajid Jehangir — 2023-03-14

Background: Cirrhosis with its complication is a major health concern in Pakistan. Endoscopy is an invasive and expensive modality for screening for esophageal varices which is one of the most common complication of liver cirrhosis. Research is being conducted to explore non-invasive markers that can replace this invasive technique. We aimed to evaluate the predictive value of the ratio of the size of the right lobe of liver to serum albumin concentration in prediction of the presence of esophageal varices.

Methods: It was a cross-sectional study conducted at the Medicine Department, Ghurki Trust Teaching Hospital, Lahore from January 4 till July 31. The study included 297 patients of all the genders, aged 20-70 years, diagnosed cases of liver cirrhosis for at least 6 months and having suspected esophageal varices on right liver lobe size to serum albumin ratio >4.1. All the patients were subjected to upper GI endoscopy to confirm predicted varices. Data was analyzed using SPSS 23.0. PPV of the ratio was calculated. Post-stratification chi square was used to find association (p value <0.05 as significant).

Results: The patients had a mean age of 51.5 � 9.2 years with 180 (60.6%) male and 117 (39.4%) female patients. Diagnosis of esophageal varices was confirmed in 225 (75.8%) patients on endoscopy. There were 225 true positive and 72 false positive cases. Positive predictive value was 75.8%.

Conclusion: The positive predictive value of the ratio of the size of the right liver lobe to serum albumin was statistically significant in predicting the presence of esophageal varices on upper GI endoscopy. These findings were not dependent on the patient's age, BMI, gender, duration of disease or serum bilirubin level.

Cirrhosis, Esophageal Varices, Right Liver Lobe Diameter to Serum Albumin Ratio

Effect of physical activity level on orthodontic pain perception after separator placement in adult patients managed at a tertiary care teaching public sector hospital in Lahore

Zainab Fatima — 2023-03-14

Background: Different behavioral therapies are used to reduce pain severity in patients undergoing separator placement apart from pharmacological treatments. However, there is limited local data.This study aimed to determine the frequency of high and low levels of activity in adult patients who needed separator placement and compared the mean pain scores with respect to baseline physical activity level following the intervention.

Subjects and methods: It was a descriptive case series carried out at the Orthodontics Department, De�Montmorency College of Dentistry, Lahore, for a period of 3 months from 15.7. 2022 to 15.9.2022. Total 120 patients aged 18 to 40 years of both genders, who needed separator placement were included in the study. Patients were excluded if they had medical conditions or systemic diseases that was a contraindication for usage of fixed orthodontic appliances, had chronic pain or pain in the orofacial or dental region, had maxillary or mandibular fracture and who had previous history of mandibular or maxillary surgery. Baseline physical activity level was noted down as per clinical history. Patients then underwent separator placement.

Results: Mean age of the patients was 28.67�6.312 years. There were 62 (51.7%) males and 58 (48.3%) females. Baseline low physical activity was found in 77 (64.2%) patients while high activity was found in 43 (35.8%) patients. Mean pain scores in the low physical activity group were 3.9�2.056 and in the high physical activity group were 2.26�2.094 and the difference was statistically significant i.e. p=0.001 as assessed by independent t-test.

Conclusion: Frequency of low physical activity level was higher in patients and it was found to be associated with higher mean pain scores compared to patients who had high baseline level of physical activity.

Effect of caffeine consumption on sleep quality of undergraduate medical students of Multan

Ghulam Mujtaba Nasir — 2023-03-11

Background: Caffeine is extensively utilized as a stimulant of the central nervous system by more than 80% of the world�s population. About 94% of medical students are reported using caffeine which is likely to have a detrimental impact on sleep quality. The purpose of the study was to evaluate the relationship between caffeine consumption and sleep quality among non-obese. undergraduate medical students

Subjects and methods: An Observational cross-sectional comparative study was carried out at Nishtar Medical University, Multan during the months of November and December 2022.Total 83, both male and female, non-obese undergraduate medical students (18-23 years old, BMI=18.5-24.9) selected by simple random sampling were included in this study, and they were divided into 3 groups on the basis of low (58 � 29 mg/day), moderate (143�25 mg/day) or high (351�139 mg/day) caffeine consumption daily. Caffeine Consumption Questionnaire (CCQ) and Pittsburgh Sleep Quality Index Scale (PSQI) were used to assess the daily caffeine consumption (mg/day) and sleep quality, respectively. IBM SPSS-26 was used for data analysis. Mann-Whitney U test and Spearsman�s rho correlation were applied.

Results: PSQI scores were high [11(8?16)] in highly caffeinated participants, moderate [7(5?9)] in moderately caffeinated participants, and low [3(1?6)] in low caffeinated [3(1?6)] participants (p=0.000). Low-caffeinated subjects had lower PSQI scores compared to moderately and highly caffeinated subjects (p=0.000 and p=0.000, respectively). PSQI scores in moderately caffeinated were also less as compared to highly caffeinated (p=0.000). Within the low caffeinated, moderately caffeinated, and highly caffeinated subjects caffeine consumption was positively correlated to PSQI scores (r=0.529, p=0.004), (r=0.579, p=0.002), (r=0.592, p=0.001) respectively.

Conclusion: Increase in Caffeine consumption reduces sleep quality, implying that caffeine consumption and sleep quality are inversely related to each other.

Knowledge, attitude and issues in practicing kangaroo mother care at home after discharge from a kangaroo mother care ward of a tertiary care hospital in central Lahore

Humayun Iqbal Khan — 2023-03-11

Background: Kangaroo mother care (KMC) is well known intervention in preterm care. Mothers gets training from health professionals to provide skin to skin care, breast feeding which helps in infections prevention and early discharge. It is required to inquire the mothers experience during home environment to promote this technique after discharge from hospital. This study focused on gaining the knowledge, attitude of unsupervised mothers practicing KMC at home and determine the most common issues faced by them.

Subjects and methods: A cross-sectional study, conducted at KMC ward of the Department of Pediatrics, Unit-1, Services Institute of Medical Sciences (SIMS), Lahore from March 2020 to April 2021 after ethical approval. Hospitalized mothers of stable pre-term infants were taught KMC techniques by trained health care provider. After two weeks of discharge from hospital mothers were interviewed according to structured questionnaire by the trained doctor about their KMC knowledge, experience and issues faced at home.

Results: Out of 156 mothers 145 (92.9%) conducted KMC at home and 93 (59.6%) performed intermittent KMC during nighttime (p=0.001). 152 (97.4%) mothers felt good, 133 ( 85.3%) were comfortable and 122 (78.2% ) deemed the process safe for their babies. 82 (52.6%) felt ease with provided kits (p=0.032).120 (76,9%) husbands felt KMC was essential for their babies. 102 (65.4%) mothers were allowed by their husbands to do KMC at home (p=0.000) and 68 (43.6%) fathers sometimes performed KMC themselves (p=0.001). Family and friends were also supportive in 104 (66.7%) cases while 112 (71.8%) mothers felt the positive attitude of the community (p=0.000). 127 (81.4%) mothers were willing to recommend KMC to new mothers (p=0.019).

Conclusion: Most of the mothers performed intermittent KMC at home. They were assisted by husband and family members to carryout KMC at home. They are willing to recommend it to new mothers.

Comparison of dermatosis acne vulgaris in obese and non-obese patients

Malik Muhammad Qasim — 2023-03-11

Background: Obesity is a disorder characterized by increase fat deposition in human body. Acne vulgaris is a common skin disease, affecting approximately 9.4% of the world�s population, with considerable effect on the quality of life. According to a previously conducted study, the prevalence rate of acne in Pakistan was found to be 5%. Obesity is increasing rapidly in developed and developing world. Acne vulgaris is commonly associated with obesity. The objective of this study is to compare the acne vulgaris in obese and non-obese patients.

Patients and methods: It was a cross-sectional descriptive survey in which 300 obese and 300 non-obese patients were included respectively. Dermatosis, acne vulgaris was observed in the patients selected through inclusion criteria. This study was conducted in The University of Lahore Pakistan. Data was collected from outdoor Patients of skin Department of The University of Lahore Hospital during April 2020 to October 2020, by using questionnaire. Consent was taken before data collection. Data was analyzed through SPSS version 20.

Results: Mean age of obese group was 37.4�13.0 years and non obese group was 30.9�15.6 years. In obese group 161(53.7%) were females, while 139(46.3%) were males respectively. In non-obese patients 193(64.3%) were males and 107(35.7%) were females respectively. In obese group, 115 (38.3%) had acne vulgaris, while in non-obese group 41 (13.7%) were affected with acne (P value ? 0.05).

Conclusion: It is concluded that dermatosis acne vulgaris is significantly greater in obese patients as compared to non-obese patients. Obese persons should be given special consideration in terms of proper referral and management.

Role of neutrophils to lymphocytes ratio in identification of bacterial infection in adult population

Ayesha Kashmala Ghouri — 2023-03-11

Background: Bacterial infection are difficult to distinguish from viral infection. Neutrophils are the first cells mobilize to infectious site caused by bacteria and also apoptosis of lymphocytes in response to cell mediated immunity hence raised in neutrophils and decrease in lymphocyte count. The goal of this study is to determine the neutrophil to lymphocyte ratio in patient with positive blood culture for bacteria in patients admitted in hospital.

Patients and methods: This cross-sectional study was conducted at Department of Pathology, Hamdard University Karachi, Pakistan from 1st January to 31st June 2022. Total 123 adult patients with positive blood cultures admitted in ward or ICU were enrolled in the study. CBC Samples were collected from patients admitted in ward or ICU and blood culture were already sent due to clinical condition, the organism isolated in blood culture were recorded As blood culture is a gold standard investigation to detect bacterial infection .In this study we will record neutrophil to lymphocyte ratio in patients admitted with positive blood culture for bacteria. Age less than 15 years, pregnant female, OPD patients, negative blood cultures and patients on antibiotic therapy were excluded. Complete blood count (CBC) was performed in Beckman coulter model DxH 520 made by Germany. Age and ward of patient, organism isolated from blood culture, CRP.

Results: A total of 123 patients with positive blood culture were enrolled in the study. Out of 123 patients 61.8% (n=76) were male and 38.2% (n=47) were female. Mean NLR was 5.9� 13.1. Total 45.5% patients presented with high NLR. Mean CRP was 58.5� 68.7.

Conclusion: High NLR was seen in 45.5% which shows NLR is an important indicator of bacterial infection. More studies are needed to define true significance of NLR in all ages and negative blood cultures.

Immunohistochemical expression of HER2 and MUC1 in breast carcinoma and its correlation with histological grades

Sidra Ghazanfer — 2023-02-16

Background: Mucin 1 (MUC1) is overexpressed in almost 90% of CA breast cases and is usually associated with poor prognosis. On the other hand, HER2 is profoundly expressed in breast carcinoma and is also linked with increased disease recurrence, tumor invasion and poor prognosis. Thus, this study was designed to assess the expression of MUC1 and HER2 against the histological grades of breast carcinoma in our population.

Materials and methods: It was a cross sectional analytical study conducted at Post Graduate Medical Institute/General Surgery Departments of Lahore General Hospital (LGH), Lahore. Duration of study was 12 month from 27-3-2018 to 30-3-2019. Total 60 newly diagnosed cases of CA breast were included in the study. Immunohistochemistry technique was used and MUC1 and HER2 markers were applied to check the probable association between the two markers and the histological grades of cancer.

Results: A total of 60 cases were included in the study, out of which 96.7% (n=58) were invasive ductal carcinoma, while 3.3% (n=2) were Invasive lobular carcinoma. Among the total, 60% (n=36) were found positive for MUC1 (moderate/strong) and 40% (n=24) were found negative (negative/weak). Regarding HER2, 26.7% (n=16) were strong positive, 20% (n=12) were at the borderline/equivocal and 53.3% (n=32) were found negative for HER 2.

Conclusion: Statistically significant association was found between MUC1 and HER2 against the histological grades of breast cancer patients (p <0.05).

Short term outcome of treatment with percutaneous cross Kirschner wires in paediatric distal humeral metaphyseal diaphyseal junction fractures

Shahzad Anver Qureshi — 2023-02-16

Background: Soft tissue sarcomas (STS) are malignant tumours arising from mesenchymal tissue, comprising <1% of all the tumours of the human body and represent the second most common type of solid tumours in children and adolescents. Surgical resection is considered the mainstay of treatment, supported by multimodal therapies including chemotherapy and radiotherapy. Resource-limited countries, like Pakistan, face additional challenges due to inadequate resources. This study presents the experience of management of soft tissue sarcomas presenting to a tertiary care hospital in Central Lahore.

Patients and Methods: This was an observational study conducted in Surgical Unit I of Sir Ganga Ram Hospital Lahore from January 2017 till June 2022. American Joint Committee on Cancer (AJCC) staging system and F�d�ration Nationale des Centres de Lutte Contre le Cancer (FNCLCC) resection classification was applied. Surgical treatment including R0, R1 and R2 resections were carried out. SPSS 23 version was used for statistical analysis of collected data.

Results: A total of 36 patients; 24 male (66.7%) and 12 females (33.3%) were included. Anatomical site involvement was observed as 23 (63.8%) limb sarcomas and 13 (36.1%) trunk sarcomas. Out of 36 patients, 20 (55.6%) patients were staged as stage II, 11 (30.5%) patients as stage III and 5 (13.9%) as stage I. Total 17 (47.2%) patients underwent wide excision, 13 (36.1%) patients underwent limited excision, 4 (11.1%) patients underwent compartmental excision and 2 (5.6%) patients underwent palliative excision.

Keywords: Soft Tissue Sarcoma, Presentation, Resection, Histology, Outcome

Spectrum of soft tissue sarcomas: Experience of surgery at a tertiary care referral hospital in Central Lahore

Absar Nazir — 2023-02-16

Patients and methods: This was an observational study conducted in Surgical Unit I of Sir Ganga Ram Hospital Lahore from January 2017 till June 2022. American Joint Committee on Cancer (AJCC) staging system and F�d�ration Nationale des Centres de Lutte Contre le Cancer (FNCLCC) resection classification was applied. Surgical treatment including R0, R1 and R2 resections were carried out. SPSS 23 version was used for statistical analysis of collected data.

Conclusion: Thigh was the commonest site of involvement in extremity sarcomas. Retroperitoneal sarcomas were most frequent among trunk tumours. Leiomyosarcoma was the most common histopathological diagnosis followed by malignant peripheral nerve sheath tumours. Most of the patients presented with stage II disease. Resectional surgery, whether curative or palliative, was found to be the management modality of choice. Rhabdomyosarcoma most frequently recurred within 6 months of potentially curative surgery (R1), most likely due to compromised initial resection.

Does Covid-19 vaccination affect menstruation pattern?

Sadia Anwar, DR — 2023-02-16

Background: As Millions of people are receiving COVID-19 vaccine around the world, a number of side effects are being reported. Menstrual cycle disturbance is also a side effect reported by hundreds of women on social media. The objective of this study was to assess the association of menstrual abnormalities with COVID-19 vaccination.

Subjects and methods: This descriptive cross sectional study was conducted in Obstetrics and Gynecology OPD of Mufti Mehmood Hospital D.I. Khan from March 2021 to June 2021. The health care workers who received Sinopharm COVID-19 vaccine and consented were included. Data was collected about change in menstrual cycle pattern after COVID-19 vaccination.

Results: A total of 80 subjects were included in the study with mean age of 32.6 +7.89 years. There were 36 (45.0%) doctors, 33 nurses (41.25%), 6 (7.5%) paramedics and 5 (6.25%) medical students. According to their marital status, 51 (63.75%) were married and 29 (36.25%) were unmarried. Out of 80 subjects, 16 (20%) reported disturbance in menstrual cycle pattern, 13 (81.2%) after first dose and 3 (18.75%) after both first and second dose. Among these 9 (56.25%) reported heavy menstrual bleeding, 4 (25%) had prolonged bleeding days while 3 (18.75%) had irregular bleeding pattern.

Conclusion: Menstrual cycle disturbance is a reported side effect of COVID-19 vaccination. It is more commonly reported after first dose and heavy menstrual bleedings is the most common pattern followed by prolonged/irregular bleeding.

Demographic features and outcomes in critically ill mechanically ventilated COVID-19 patients with respiratory failure in a resource limited ICU setting � Report from a tertiary care center in Karachi

Mehak Hanif — 2023-02-16

Background: Studies done on severe COVID-19 have revealed a wide heterogeneity in intensive care clinical outcomes across various countries. We aimed to identify the demographic features and outcomes of mechanically ventilated COVID-19 patients with respiratory failure in Pakistan in resource limited settings.

Methods: This was a cross-sectional study conducted at the COVID-19 Intensive care unit (ICU) of Jinnah postgraduate medical center in Karachi, Pakistan. 86 patients who received mechanical ventilation in a period of five months from 1/2/2021 till 30/6/2021 were included in the study. Patient demographic characteristics, comorbidities, clinical manifestations of COVID-19 infection, laboratory values at the time of presentation (hemoglobin, Neutrophil lymphocyte ratio, platelets, glomerular filtration rate, C-reactive protein, D-dimers, Ferritin, liver function tests and electrolytes) and mode and duration of ventilation, final outcome (survivor vs. non-survivor) and cause of death in non-survivors were recorded.

Results: 86 patients, who required mechanical ventilation because of severe respiratory distress not alleviated by non-invasive methods of ventilation, were included in the study. 66.3% (n=57) were males and 33.7% (n=29) were females. Mean age was 59 (SD 12). The most common comorbidities were diabetes mellitus and hypertension 44.2% (n=38) each. Only 3 (3.4%) of mechanically ventilated patients were extubated and 1 patient was eventually discharged home on room air. The mortality rate was 98.8% and only one patient survived. The most common causes of death were respiratory failure (86%, n=74), renal failure (48.8%, n=42) and sepsis (18.6%, n=16).

Conclusion: Mortality in COVID-19 patients who require mechanical ventilation is very high in resource limited settings because of the lack of essential medications, specialized teams and established protocols of ICU management and is not related to the demographic characteristics and comorbidities of patients and severity of disease at presentation.

Keywords:

COVID-19, Intensive Care Unit, Mechanical Ventilation, Mortality

Comparison of effect of prophylactic administration of ondansetron and placebo on prevention of post induction hypotension in elderly patients undergoing surgery in general anesthesia

Lala Rukh Bangash — 2023-02-16

Background: Post-induction hypotension is a frequently encountered complication seen particularly in elderly population. Hypotension, by impairing vital organ perfusion, increases the morbidity and mortality of the patients. prophylactic use of ondansetron in preventing hypotension after induction of general anaesthesia in elderly patients , hence getting the benefit of preventing both hypotension and postoperative nausea and vomiting by the use of a single drug.

Subjects and method: This randomized controlled clinical trial was carried out in the operation theaters of general surgery, Mayo Hospital, Lahore, from 09-09-2017 to 09-09-2018. A total of 80 patients who were to undergo general anaesthesia for elective general surgical procedures were recruited for this study. After taking informed consent, the patients were randomly divided into two groups. Patients in group A received ondansetron and those in group B received placebo prior to the induction of anaesthesia. Efficacy was labeled in terms of absence of hypotension i.e. a drop in mean arterial pressure of no more than 25% of baseline at 1, 3, 5, 9 and 11 minutes after induction of anaesthesia. The data was recorded on a predesigned proforma. Statistical analysis was done using SPSS version 21.

Results: Both groups were comparable in terms of age, gender, ASA status, BMI and weight. Efficacy was seen in 19 (47.50%) cases managed by ondansetron vs. 10 (25%) in placebo group (p = 0.03). There was significant difference of efficacy in patients with age between 60 to 70 years where 63.63% patients in the Group A effectively maintained their blood pressure (p=0.02). Patients having age 70 years or above did not show statistically significant difference. History of hypertension made no impact on the efficacy of ondansetron for maintaining blood pressure after induction (p=0.53)

Keywords:

Ondansetron, Efficacy, Hypotension

Poliomyelitis in Pakistan: Evolving challenges and way forward

Taskeen Zahra — 2023-02-16

Poliomyelitis, an acute paralytic illness, affects children under the age of five. It is brought on by the Polio Virus (PV), a single-stranded RNA virus that comes in three serotypes (type 1, 2, and 3) which is transmitted by feco-oral route.^1,2Since 1988, there has been a 99.9% decrease in polio cases worldwide because of the World Health Organization's Global Polio Eradication initiative.¹ This initiative has played a vital role in eradication of the disease. Pakistan is one of the 2 nations where polio remains as an endemic disease even at the end of 2022, the other being Afghanistan.²

In 2021, Pakistan reported just 1 case of polio linked to the Wild Poliovirus type 1 (WPV1) against 14 cases from April 1 through July 31, 2022.² Eleven instances of polio have been reported in the Northwestern Waziristan in 2022, clearly illustrating the loopholes in national policies to completely eradicate the disease despite its goal to immunize 12.6 million children by 2022.² The goal of the Global Polio Eradication Initiative's (GPEI) current 5-year strategic plan is to interrupt WPV1 transmission by 2023.³

According to WHO and UNICEF estimates, in Pakistan approximately 83% of infants received three doses of the Oral Poliovirus Vaccine (OPV) and one dose of Inactivated Poliovirus Vaccine (IPV) in 2021. While none of the districts in Baluchistan, Khyber Pakhtunkhwa, and Sindh attained 80% vaccine coverage, 86% districts in Punjab province had >3 dose OPV coverage.⁴

Diagnostic accuracy of Non-ECG Gated Chest CT (NEGCT) for cardiac chambers� dimensions in comparison with echocardiography

Mahnoor Hafeez — 2023-02-16

Objective: To analyze the accuracy of Non-ECG Gated Chest CT (NEGCT) for cardiac chambers� dimensions, keeping Echocardiography as the gold standard.

Methods: After IRB approval, all patients that underwent concurrent contrast chest CT/CTPA and transthoracic 2D echocardiography exam at our institute within 1 month interval comprised the study population. Data was archived from HMIS PACS Database. The sizes of right ventricle (RV), left ventricle (LV) and left atrium (LA) was recorded in shot axis at axial CT sections and at echocardiography. RV and LV-transverse diameter was measured at basal third of the heart, from the inner to inner myocardium perpendicular to the inter-ventricular septum and LA-max. Anterior-posterior dimension was measured at the level of the aortic root.

Results: Total 213 subjects were studied, with average age of 52.1�15.8 years. The CT-Echocardiography measurement concordance rates were significantly high for LA, LV and RV measuring 93.8%, 96.7% and 69.01% respectively. Using CT threshold for LA, LV, RV enlargement > or equal to 45, 55, 35mm, the AUC via ROC curve analysis was estimated to be 0.912, 0.992, 0.650 respectively. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of NEGCT was found to be 66.67%, 95.10%, 37.5%, 98.5% and 93.90% for LA; 100%, 96.67%, 30.0%, 100%, 96.7% for LV and 33.33%, 74.86%, 17.86% 87.26% and 69.01% for RV respectively.

Conclusion: Overall, the accuracy of chamber dimensions at NEGCT was excellent with high CT-Echocardiography concordance, making it an alternative modality for examining chamber sizes, in the absence of cardiac MRI. Through it, a radiologist can also add more value to CT reporting.

Keywords:

Echocardiography, NEGCT, Dimensional Measurement

The hyperglycemic and dyslipidemic effects of L-arginine in streptozotocin-induced diabetic rats

Novera Sohail Bajwa — 2023-02-16

Background: Diabetes is a serious disease which is posing a great risk to the overall health care all around the globe. Major factor in its systemic adverse effects is the enhancement of lipolysis by prolonged hyperglycaemia ultimately leading to dyslipidemia. This dyslipidemia is a big risk feature for all cardiovascular diseases related to most of the diabetic patients. L arginine blessed with antioxidant properties can play a substantial role in the prevention, and management of diabetes and related complications. The study was aimed at finding the novel uses of L-Arginine in diabetes.

Subject and method: 15 adult Sprague Dawley rats , only female (to avoid pregnancy) weighing 250+ 50 g were used in this study which were divided equally (five rats each) into three groups randomly after ensuring that their lipid profiles and blood sugar were normal. After keeping one group as Normal Control Group (NC), the remaining two groups were made quasi-analogue Type II diabetic model through administration of Streptozotocin (35 mg/kg) in a single dose intra-peritoneal (IP). After lapse of 48 hours, all the rats of two groups had shown blood sugar levels over 300 mg/dl and therefore were taken as diabetic. One of the two diabetic groups was taken as �Positive Control� with DM rats (DM), while the other was taken as treatment group DM+L-ARG Group�.

Results: With regards to fasting blood sugar (BSF), total cholesterol (T-Chol), triglyceride (TG), low density lipoprotein (LDL) and high density lipoprotein (HDL), Group III (DM+L-ARG) showed significant improvement with the p-value of less than 0.001.

Conclusion: After conducting this experimental animal work, we are able to conclude that in Streptozotocin induced diabetic model, the novel use of antioxidant L-Arginine with good safety profile and minimal adverse effects also has significant anti-hyperglycemic and anti-lipidemic activity.

Determinants of child health in a rural Karakoram village

Spenta Kakalia — 2023-02-16

Background: Mountain communities have unique issues, being generally geographically remote, and politically and socially neglected. The objective was to evaluate the health and healthcare access of children in Tissar, a mountain village in Gilgit-Baltistan.

Subjects and methods: This was a cross-sectional study conducted in August 2021, in Tissar, Gilgit-Baltistan (GB), in Northern Pakistan. Interviews were conducted of adults over the age of 18 years, who had at least one child of age12 years and below, using a convenience sampling method. Descriptive summary statistics were computed using statistical software R version 4.1.2. Poisson regression was used to find potential risk factors associated with diarrhea and pneumonia.

Results: Semi-structured interviews were conducted on 400 participants. Although 363 (90.8%) people grew their own food; 203 (50.7%) still needed to purchase food with only 213 (53.2%) receiving up to three meals a day. Access to healthcare was perceived as inadequate, with only 42 (10.5%) satisfied with the healthcare their children were receiving. Up to 268 (67%) needed to borrow money or could not afford healthcare. Annual occurrence of diarrhea and pneumonia was reported in 100% households, most reporting repeated episodes in one year per child. On Poisson Regression, number of meals per day was negatively associated with diarrhea (rate ratio=0.646, 95%CI=0.591-0.706, p<0.001), adjusted for weaning. Number of meals per day was also negatively associated with pneumonia (rate ratio 0.529, 95%CI=0.487-0.574, p<0.001), adjusting for education and number of children in the family (>6 versus <6).

Conclusion: Health of Children needs to be addressed in mountain communities in Pakistan.

Effect of Torilis leptophylla on blood total leukocyte count and differential leukocyte count in asthmatic mice

Sheikh Maria Qammar — 2022-12-19

Background: Chronic inflammation, mucus hypersecretion and airway blockage are the characteristics of asthma. Current treatments of asthma are effective but cause adverse effects on their long term use. This research was designed to explore anti-inflammatory effect of Torilis leptophylla (T. leptophylla) on allergic inflammation of airways by estimation of blood total leukocyte count (TLC) and differential leukocyte count (DLC) to compare its effect with a standard drug in an animal model.

Materials and methods: This experimental study was carried out in Pharmacology Department, University of Health Sciences, Lahore. A total of 48 healthy, adult, male BALB/c mice were randomly divided into six groups. Group I (control), group II (diseased); groups III, IV and V were given 100, 200, 400 mg/kg T. leptophylla methanolic extract (TLM) respectively, and Group VI treated with standard drug monteleukast. Airway inflammation was induced in all groups with ovalbumin except control group. On day 28, cardiac puncture was done to collect the blood and TLC and DLC (lymphocytes, neutrophils, eosinophils and monocytes) were measured in blood. All the data was interpreted as mean � SD. SPSS 20 was used to carry out statistical analysis.

Results: T. leptophylla extract resulted in significant (p-value ? 0.05) decrease of TLC and DLC in blood. T. leptophylla cause 59-67% decrease in TLC, 67-80% decrease in lymphocytes, 69 - 72% decrease in neutrophils, and 45-51.7% decrease in eosinophils

Conclusion: In current study T. leptophylla successfully treated inflammation in asthmatic mice by reducing proportion of inflammatory cells.

Investigative analysis of extended-spectrum beta-lactamase (ESBL) producing Pseudomonas aeruginosa isolated from hospitals of Islamabad-Rawalpindi

Muhammad Bhader Sher — 2022-12-19

Background: Pseudomonas aeruginosa (P. aeruginosa) is a ubiquitous gram-negative rod shaped bacteria and a significant nosocomial opportunistic pathogen. Current study aimed at the investigation and determination of extended-spectrum beta-lactamase (ESBL) positive P. aeruginosa from clinical samples.

Materials and methods: A total of 150 catheter tubes, pus, blood, and sputum samples were collected from three different hospitals in the twin cities of Rawalpindi and Islamabad. The isolates were identified by using standard microbiology procedures. Antibiotic susceptibility of the isolates was done through the disc diffusion method as per the protocol given by CLSI guidelines. Phenotypic characterization of ESBL producers was performed by combination disc test (CDT), double disc synergy test (DDST) and through PCR.

Results: A total of 77/218 isolates were identified as P. aeruginosa. Among them 47 were resistant to different drugs, while 28 were identified as multidrug resistant. They were resistant to 9 different drugs including Cefotaxime (49%), Cefipime (41%), Cephradine (32%), Cefotetan (62%), Azetronam (50%), Cofaclor (42%), Ticarcillin (57%), Ciproflaxacin (45%), and Imipenem (36%). CDT and DDST showed that 7/29 isolates produce ESBL. One isolate was positive for VEB and 3 were positive for SHV ESBL genotype.

Conclusion: The phenomenon of ESBL production does not only remain in Klebsiella pneumonia and Escherichia coli but could also be found in P. aeruginosa. Moreover, SHV genotype is prevalent in local isolates of P. aeruginosa.

Paraphenylene diamine (Kala Pathar) poisoning in children of Bahawalpur and surrounding areas

Sumera Akram — 2022-12-19

Background: Paraphenylene diamine (commonly known as Kala Pathar in Pakistan) poisoning is a common presentation in adults as well as pediatric patients in Southern Punjab. The study was carried out to assess paraphenylene diamine poisoning in pediatric cases.

Patients and methods: The cross-sectional study was carried out at Bahawal Victoria Hospital Bahawalpur. All the pediatric cases (<15 years age) of paraphenylene diamine poisoning reported during April 2021 to April 2022. Data was entered and analyzed in SPSS.

Results: Total 84 children presented at pediatric department of the hospital. Out of these, 43 (51.2%) were males and 41 (48.8%) were females. Age range was between 02 months and 15 years, mean age being 9.4 + 4.49 years. Majority of cases (46.6%) ingested paraphenylene diamine accidentally, followed by suicidal intention (29.8%), homicidal intent (21.4%) and unknown motive in 2.4% cases. Of all, 49 (58.3%) died of poisoning and 35 (41.7%) survived. Of all the cases, 44 (52.4%) underwent emergency tracheostomy.

Conclusions: Paraphenylene diamine poisoning in children is an alarming trend. Although majority of the cases ingested it accidently but intake due to suicidal or homicidal reason were also high. Positive outcome was associated with higher age, carrying out early tracheostomy and mode of poisoning (homicidal cases had poorest outcome whereas accidental and suicidal pediatric cases had more chances of survival).

Financial burden on the parents of children infected with extensively drug resistant Salmonella infection

M. Hanif Memon — 2022-12-19

Background: Typhoid illness is a significant cause of morbidity in Pakistan. This study aimed to determine the financial burden on parents of children infected with extensively drug-resistant (XDR) salmonella infection.

Patients and methods: This observational study included 159 patients aged 6 months to 13 years admitted through OPD/ER of Karachi Adventist Hospital with the diagnosis of enteric fever and intravenous antibiotics started as per local antibiogram. To remove recall bias antibiotic cost before hospitalization was not included. All those patients who were culture positive for XDR salmonella, either continued or shifted to newer antibiotics as per susceptibility pattern were included. Depending upon the type and duration of antibiotic therapy cost was calculated in Pakistani rupee (1 USD = ~225 PKR).

Results: Total 60.4% of patients aged less than 7.5 years; 62.3% were male, 41.5% from urban areas, 15.1% had graduated mothers, 27% had graduated fathers, 5.7% uses boiled water, and 1.9% typhoid vaccination. In 54.1% of patients antibiotic cost reached >40k PKR. Patients with urban dwelling were 0.29 times less likely for higher cost, increase in duration of fever (>7 days) at admission increased the cost 5.73 times, XDR samples found 13.5 time more likely for higher cost, and TLC between 4000 � 11000/mm³ gave negative association with higher cost.

Conclusion: The burden of XDR salmonella infection is heavy and is related to urban residence, duration of fever at admission, and length of hospital stay.

Fungal osteomylitus in diabetic patients and COVID-19

Shaheen Anjum — 2022-12-19

Background: COVID-19 pandemic has become a big medical problem worldwide. In this era, COVID-19 patients� along with diabetes mellitus are at an increased risk of developing opportunistic infections. This study demonstrate association of COVID-19 infection in patients having uncontrolled diabetes with the fungal osteomyelitis.

Subjects and methods: This prospective cross-sectional study was done at a Nishter Institute of Dentistry, Multan. Patients diagnosed with fungal osteomyelitis of jaw bones presented during April to December 2021 were included in this study. Data was collected from the patients regarding history of the disease, clinical diagnosis, imaging findings by plain radiographs and CT scans, histopathology. Association of disease process with diabetes and COVID-19 was analyzed in SPSS.

Results: Between the period April 2021 to December 2021, 23 cases presented in Nishter Institute of Dentistry Multan with fungal osteomylitus were diagnosed clinically and fungal organism was identified by immunohistochemical studies by PAS and GMA stains. 22/23 (95.6%) patients were with uncontrolled diabetes mellitus and 18/23(78.2%) gave the history of Covid 19 infection 2 to 3 months before with moderate to severe symptoms.11/23 (47.8%) gave the history of treatment with systemic steroid. Age range was 38-72 years of age with mean age 53.26. 12/23(52.1%) were males and 11/23 (47.8%) were females. 17/23 (73.9%) patients presented with pain in jaws with exposed bone and 6/23(23%) complained of pain and loose teeth in arch. In 22/23 (95.6%) involved jaw was maxilla. In one patient associated medical condition was hepatitis C virus infection also with diabetes. 2 patients were cardiac and 3 were hypertensive along with diabetes. One patient was previously treated with radiotherapy of mandible due to alveolar cancer. Only one (0.04%) patient was non diabetic.

Conclusion: There is increased incidence of fungal osteomyelitis of jaws mostly maxilla in diabetic and COVID-19 infected patients.

The role of bone marrow biopsy in patients with pyrexia of unknown origin

Shehneela Jabeen — 2022-12-19

Background: Pyrexia of unknown origin (PUO) is a major complication which remains undiagnosed. Different diagnostic test were used to arrive at final investigation. Bone marrow biopsy (BMB) plays a vital role in diagnosis of PUO. The objective of current study was to determine the role of bone biopsy in diagnosing various types of causes of pyrexia of unknown origin.

Patients and methods: A prospective cross-sectional study was conducted from 1^st September 2018 to 28^th February 2019 at Department of Hematology, Combined Military Hospital Lahore, Pakistan. The data of 120 patients who were remained undiagnosed for at least 1 week were enrolled. Standard procedures were used to obtain the biopsy specimens and bone marrow aspiration was sent for microbiological examination. All the demographic information was kept on a structured self-designed proforma. Data was entered and analyzed using SPSS v.24.

Results: Out of 120 patients recruited in the study there were 67 (55.8%) were from age group 16 to 35 years, were males (65.8%) and 65.0% patients were suffering from fever for more than 3 days. The majority of the participants (30%) were diagnosed with infections, fever due to reactive changes (10.0%), acute leukemia (14.2%), lymphoma (11.7%), chronic leukemia (10.0%), aplastic anemia (4.2%), multiple myeloma (2.5%) and 11.7% patients were undiagnosed

Conclusion: In the diagnosis of pyrexia of unknown origin, morphological and histological investigation of bone marrow plays a vital role. However, if it is combined with other diagnostic modalities such as radiological, microbiological, and serological examinations, the efficiency of diagnosis can be improved.

Evaluation of amnion versus calcium alginate as split-thickness skin graft donor site dressing: A randomised controlled trial

Roeya -E-Rasul — 2022-12-19

Background: Split-thickness skin graft (STSG) covers patient�s primary wound, but, at the expense of a donor-wound which heals by secondary intention. This study evaluated the efficacy of amnion and calcium alginate dressings at STSG donor sites in terms of healing duration, patient comfort and incidence of infection.

Patients and methods: An open label randomised control trial was conducted during October 2018 to May 2019. Total 60 patients, aged 20-45 years, were randomly allocated to two equal groups. Amnion was applied to 30 donor sites in Group A and calcium alginate in 30 donor sites in Group B. Patients were phone-called on 1^st, 3^rd and 7^th post-operative days and donor site pain scored using numerical rating scale. Donor site was opened on 10^th postoperative day and signs of infection assessed. Lastly, the day on which donor site healed, revealing an epithelialized wound, was noted.

Results: Group A included 30 patients (11 females, 19 males) having mean age of 31.23 years and Group B included 30 patients (12 females, 11 males) having mean age of 31.30 years. Average pain scores on 1^st, 3^rd and 7^th post-operative days were 7.6, 6.6 and 4.4 in Group A and it was 8.2, 6.5 and 4.4 in Group B. Two cases of amnion, 4 of calcium alginate got infected. Average healing duration was 11 days in Group A; and it was 14 days in Group B (p-value = 0.000).

Conclusion: Amnion shows quicker healing and better pain control than calcium alginate.

Assessment of knowledge and behavior regarding cardiovascular diseases and their risk factors among medical students of a private medical college in Lahore

Muhammad Ashraf Choudhry — 2022-12-19

Background: Cardiovascular diseases (CVD) are a major cause of premature deaths globally. The gap between knowledge and behavior regarding modifiable risk factors related to these diseases has been noticed in medical students and is associated with a high number of morbidity and mortality. The aim of this study was to assess knowledge and behavior regarding cardiovascular diseases risk factors among newly enrolled MBBS students.

Subjects and methods: This cross-sectional study was conducted from May to September 2021. A total of 140 first-year MBBS students participated including 80 females and 60 males. Data were collected through a self-administered questionnaire having 17 questions and two sections, one for knowledge assessment and the other for the behavior of participants regarding CVD risk factors.

Results: Major risk factors for heart disease identified by students included obesity (99.3%), high cholesterol (98.6%), hypertension (97.9%), lack of physical activity (95.7%), smoking (82.1%), older age (89.3%), family history of heart disease (73.6%) and diabetes (78.6%). Pertaining to personal history, 10% were smokers, 32.1% regularly consumed soft drinks and 79.3% reported having any physical activities. Significant differences were found between male and female students regarding knowledge of CVD risk factors such as smoking (p-value = 0.003). Similarly, significant differences were observed between male and female students heart health behavior such as cholesterol checkup (31.7% vs. 16.2%, p-value = 0.032), use of soft drinks (48.3% vs 20%, p-value = 0.001) and physical activity (90% vs. 71.2%, p-value = 0.007).

Conclusion: First-year medical students have good knowledge of CVD risk factors but the behavior, regarding practice to avoid these risk factors, needs improvement. It was also observed by comparison that male students have more knowledge of heart disease risk factors as compared to female students.

Factors associated with low birthweight among newborns delivered at term in a tertiary care hospital in Lahore

Taskeen Zahra — 2022-12-19

Background: Low birth weight (LBW) is an important risk factor that contributes to mortality of 15-20% of newborn globally. This case-control study was conducted to determine factors associated with low birth weight among new-born delivered at term in obstetrical and gynecological wards of the hospital.

Patients and methods: Mothers of 150 low birth weight babies born at term were taken as cases and 150 normal weight babies born at same day, were taken as controls. Mothers were interviewed on using a semi-structured and pretested questionnaire. The data was analyzed on SPSS Version 22.0. A p-value <0.05 was considered statistically significant.

Results: Illiterate mothers had 2.332 odds of having low birth weight babies (0.03, 95% CI = 1.3317 to 4.152). Mothers from low socio-economic status had 3.54 odds of delivering LBW (p-value = 0.000, 95% CI = 2.184 to 5.94). The odds of having low birth weight babies was 4.004 times high in the mothers exposed to passive smoking (p-value = 0.000, 95% CI = 2.477 to 6.474). Hemoglobin value less than 10 gm/dl was found to be significantly associated with odd of having LBW 3.003 in anemic mothers versus non anemic mothers (p-value = 0.0027, 95% CI = 1.279 to 3.227). Mother with parity <3 had 0.0933 odds of having low birth weight babies. Mothers having adequate antenatal care had 0.394 odds of having low birth weight babies.

Conclusion: Illiteracy, low socio-economic status, employment, anemia, tobacco smoke exposure and inadequate antenatal care were significantly associated with LBW.

Androgen receptor (AR) expression in different Gleason scores of prostatic adenocarcinoma by immunohistochemistry

Ghazia Fatima — 2022-12-19

Background: Prostatic cancer is highly ominous in men and survives hormonal insufficiency. We studied Androgen Receptor (AR) expression in various Gleason scores (GS) of prostatic adenocarcinoma by using immunohistochemistry.

Materials and methods: This descriptive analytical study was carried out at King Edward Medical University/Mayo Hospital, Lahore in 2016. Slides were prepared from 60 paraffin blocks of prostatic adenocarcinoma and stained for evaluation of different parameters like Gleason score (GS), histopathological grades (well differentiated, intermediate or high grade) and AR immunohistochemistry score. Data entry and analysis was carried out using SPSS version 22. The relationship between different parameters was determined by Pearson chi-square test. A p-value of < 0.05 was considered statistically significant.

Results: Out of 60 cases, 15 (25%) had intermediate and 45 (75%) had high grade tumors. AR was positive in 59 (98.33%) cases. Among the positive cases, 5 (8.33%) had +1 score, 25 (41.67%) has +2 and 29 (48.33%) had +3 score. A significant association of AR expression with GS and histological grades was found.

Conclusion: AR positivity is significantly associated with Gleason Score and histological grading of prostate adenocarcinoma, hence it may prove a useful diagnostic and prognostic marker for carcinoma prostate.

Insulin deficient type 2 diabetics: Urgent need for enhanced research in Pakistan

Muhammad Naeem Afzal — 2022-12-14

Type 2 diabetes is classically associated with insulin resistance stemming from obesity along with relative pancreatic dysfunction to sustain this resistance.¹ In the recent past, Scandinavian researchers highlighted that a considerable proportion of type 2 diabetics are actually insulin deficient out of proportion to their insulin resistance.² These patients were younger, had low BMI, and more deranged glycemic control. Based on sophisticated tests measuring insulin secretion and resistance, high glycemia in this group was attributed more towards decreased insulin secretion instead of insulin resistance. This was described Cluster 2 or severe insulin deficiency diabetes (SIDD) in ANDIS data.² This data changed the perception about solitary attribute of insulin resistance in pathophysiology of type 2 diabetes, and the way we treat them on ameliorating insulin resistance predominantly.

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Laparoscopic management of hydatid cyst of liver

Shabbar Hussain Changazi — 2022-04-07

Background: Hydatic disease is caused by a parasite named Ecchinococcus granulosus. This disease is endemic in Pakistan. The disease mostly affects liver forming cysts. The treatment is mainly surgical which can be performed laparoscopically. This study was thus designed to assess the outcomes of the laparoscopic treatment of hydatid cyst of liver in terms of recovery of patient, complications and recurrence.
Subjects and methods: This case series was conducted from March 2015 to December 2020 in Surgical Department of Services Institute of Medical Sciences Lahore. Patients who were planned for laparoscopic surgery for hepatic hydatid cysts (CE2, CE3) were included in the study. Patients who have past history of hepatobiliary surgery, with multiple small cysts or those who has refused for laparoscopic surgery were excluded from study. Demographic data, presenting symptoms, clinicopatholigical findings, duration of surgery, hospital stay and complications were recorded on pre-designed Performa.
Results: Total of 42 patients were managed laparoscopically for hydatid liver cyst. The mean age of the patients was 39.42 + 12.04 years. There were 20 (47.62%) male and 22 (52.38%) female patients. Thirty patients (71.43%) were from rural areas. Twenty patients (47.62%) had history of close contacts with dogs or domestic animals. Patients mostly presented with symptoms of pain in right hypochondrium and abdominal mass. Majority of the patients had single hydatid cyst in the liver. Right lobe of the liver was more frequently involved than left lobe. Both lobes were involved in 2 (4.8%) patients. The mean duration of surgery was 76 minutes. No patient developed intra or postoperative anaphylactic shock. Biliary leakage was seen in 4 (9.5%), port site infection in 2 (4.8%) patients and conversion to laparotomy was done in 2 patients (4.8%). The mean hospital stay of patients was 3.41+ 2.82 days. There was no mortality of the patients or recurrence of cyst on 12 week follow up.
Conclusion: Laparoscopic surgery for hepatic hydatid cyst is safe and effectual treatment in carefully selected patients. It is a simple technique with lesser postoperative morbidity and potentially decreased risk of complications especially recurrence of disease.

The role of ocular coherence tomography angiography in the diagnosis of diabetic retinopathy and a comparison with the current gold standard fundus fluorescein angiography

Rayyan Zakir — 2022-04-07

Background: Diabetic retinopathy is a leading cause of preventable blindness in the world. Efficient and effective diagnosis and surveillance of diabetic retinopathy is of crucial importance to preserve the vision of patients. The FAZ (Foveal Avascular Zone) area is enlarged in patients of diabetic retinopathy. The purpose of this study was to evaluate the accuracy of OCT-A (Optical Coherence Tomography-Angiography) in delineating the FAZ area in cases of diabetic retinopathy and make a comparison with the findings of FFA (fundus fluorescein angiography) - the current gold standard.
Subjects and methods: This was a comparative analytical study carried out at a tertiary care hospital in Lahore, Pakistan. A series of 50 patients, 30 males and 20 females with a mean age of 40 years were selected from the hospital outpatient department with history of five years of diabetic retinopathy. They were classified according to the ETDRS classification system into NPDR and PDR groups. The patients were booked for OCT-A, the scans were then observed for findings with a specific focus on the area of the FAZ at the level of the superficial capillary plexus. The patients then underwent same day FFA the current gold standard modality for diabetic retinopathy, thereafter a comparison between the mean area of the FAZ in both the modalities was made & documented. Data was analyzed using SPSS version 25.0.
Results: The FAZ was easily distinguished by both FFA and OCT-A. The mean FAZ area was 0.62 mm²on FFA and 0.69 mm²on OCT-A. There was a statistically significant difference between the two means (p=0.002). Both the modalities had a Sensitivity of 100% at 0.44 and 0.48 cut-offs. OCT-A had a specificity of 91.9% and FFA had a Specificity of 89.2%.
Conclusions: OCT-A proved to be an effective and accurate modality in delineating the FAZ area and detecting macular ischemia in patients of diabetic retinopathy in comparison to the current Gold-Standard FFA.

Comparison of efficacy of electrocautery vs. cryotherapy in the treatment viral warts

Ahsan Anwar — 2022-04-07

Background: Warts are common cutaneous viral infections due to human papilloma virus (HPV) mostly affecting school age children and adults.¹Various therapeutic modalities are available including topical, physical, and systemic therapies. Physical therapies are considered to be effective in the management of viral warts. This study aims to compare the efficacy of electrocautery with cryotherapy in the treatment of viral warts.
Patients and methods: This randomized trial was conducted in Dermatology Department of GHAQ / DHQ Teaching Hospital/SLMC, Sahiwal from October 2020 to March 2021.A total of 50 patients with clinical diagnosis of warts either sex with age ranging from 5-60 years were enrolled in the study and were divided into two equal groups. Patients excluded were those with evidence of any superadded infection and number of warts >6, having documented hypersensitivity to lignocaine or taking any treatment for warts in last month. After obtaining an informed written consent group A was treated with electrocautery and group B with liquid nitrogen cryotherapy. The patients were treated until the complete clearance of warts or maximum of eight sessions on weekly basis. Demographic and clinical data as efficacy (cleared if not palpable or visible to naked eye) was recorded on predesigned proforma and was analyzed by using chi-square test through SPSS version 25.
Results: Out of total 50 patients, there were 27 (54%) male and 23 (46%) female patients, with an overall male to female ratio was 1:0.7. Most commonly observed clinical type of wart were plantar warts in 28 (56%) followed by palmar in 6 (12%). Electrocautery was found to be effective therapy in treatment of wart as indicated by complete clearance noticed in 19 (76%) patients as compared to cryotherapy in 11 (44%) participants.
Conclusion: Electrocautery is more effective as compared to cryotherapy in the treatment of warts especially plantar and deep-seated. However, promising effects of cryotherapy is seen in common and multiple warts as compared to electrocautery.

Correlation of inflammatory biomarkers with disease severity in hospitalised patients of COVID-19 at presentation

Hijab Batool — 2022-04-07

Background: The course of COVID-19 ranges from asymptomatic infection to life threatening critical illness. Inflammatory biomarkers have vital role in predicting outcome, disease severity and disease prognosis in COVID-19 cases. This study aims to observe the correlation of these biomarkers with disease severity in COVID-19.
Patients and methods: This cross-sectional study was conducted in Chughtai Institute of Pathology from February 2021 to May 2021. Blood was collected from 1300 hospitalized adult PCR confirmed COVID-19 patients categorized in mild to critical disease classes. Asymptomatic cases, patients having coagulopathies and those who received plasma infusion were excluded from the study. Blood was analyzed for serum Interleukin-6 (IL-6), Ferritin, C-reactive protein (CRP), procalcitonin and D Dimers. Data was analyzed using SPSS 23.0.
Results: From the study patients, 65.3% (n=849) were male and 34.7% (n=451) were female. Majority of the cases (43.5%, N=565) belonged to moderate group whereas only 0.6% (N=8) were in critical group. Study population had a mean age of 56 (+13.98) years. Serum IL-6 was taken as marker of disease severity, showed significant positive correlation with CRP (r =0.52), ferritin (r =0.33), D-dimers (r =0.32) but no correlation with procalcitonin (r =0.17) using spearmen correlation coefficient. All patients with critical disease had IL-6 levels above 1000pg/ml.
Conclusion: The inclusion of inflammatory biomarkers in routine panel of COVID-19 patients can allow risk stratification of COVID-19 patients in different disease severity groups as cases with critical disease had higher levels.

Short term outcome of primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction

Muhammad Kashif Zafar — 2022-04-07

Background: Percutaneous Coronary intervention (PCI) is a routinely performed procedure in coronary care units. The aim of our study was to investigate the frequency of major adverse cardiac events (MACEs) after percutaneous coronary angiography in acute ST-elevation myocardial infarction (STEMI) patients in our institution. The objective of the study is to determine the frequency of MACEs after Percutaneous Coronary Intervention (PCI) in patients with acute myocardial infarction.
Patients & Methods: This prospective observational study was carried out at Punjab Institute of Cardiology, Lahore from May 2017 to June 2017. A total 35 patients with STEMI who underwent Primary PCI were enrolled by consecutive sampling technique. An inclusion criterion was chest pain of 30 minutes to 12 hours duration with ECG showing ? 0.1mm ST-elevation in at least two contiguous leads. An exclusion criterion was thrombolysis within last 24 hours, malignancy, stroke and Left Main or equivalent disease on coronary Angiogram. Patients were followed after 2 weeks till 1 month for any MACES. (Including re-admission, need for repeat revascularization, stent thrombosis, recurrent acute MI, angina, stroke, and mortality). Frequency and percentages were calculated for MACEs by using SPSS 23.0.
Results: Out of 35 cases, 34 (97.1%) were male and 1 (2.9%) were female. Mean age was 47.11�10.59 years, 14 (40%) patients had hypertension, 10 (28.6%) were diabetics and 12(34.3%) were current smokers while 4 (11.4%) were ex-smokers, 10 (28.6%) had family history of CAD, and 3 (8.6%) had hyperlipidemia. Successful revascularization with TIMI-III flow was attained in 34(97.1%) cases. 33minutes was mean door to balloon time. At one month follow-up, out of 35 patients, angina was reported only in 1 (2.9%) patient. There was no readmission, repeat revascularization, stent thrombosis, myocardial infarction, stroke and death reported in study subjects.
Conclusion: Successful revascularization by Primary PCI was associated with very few early MACEs. For the treatment of coronary artery disease, PCI is an effective option. It has a few early MACEs and uses less contrast and has fewer distal complications than conventional angioplasty and invasive procedures.

Complications affecting outcome in COVID 19 patients admitted in high dependency unit Sir Ganga Ram Hospital, Lahore

Shazia Siddique — 2022-04-07

Background: Covid 19 is a highly contagious viral infection resulting in severe acute respiratory syndrome Coronavirus (SARS-CoV-2). The objective of this study was to determine the potential complications affecting the outcome of moderate to severe COVID 19 patients admitted in HDU of Sir Ganga Ram Hospital, Lahore.
Subjects and methods: It was a prospective cohort study. The study was conducted on 108 patients admitted in the COVID HDU of Sir Ganga Ram Hospital, Lahore with positive PCR for COVID-19 having moderate to severe disease. After written consent, all the demographic data and complications like ARDS, respiratory failure, cardiac injury and liver dysfunction, acute kidney injury and sepsis/DIC were obtained through specially designed proformas data was collected through specially designed proformas and data was analysed through SPSS version 22. During hospital stay, we observed the patients for the development of complications as mentioned above. All Patients were followed up till discharge and outcome were noted in terms of discharge or death.
Results: Out of 108 admitted patients in COVID HDU, 68 were discharged, 26 were died and14 got left against medical advice. The mean age was 53.6 + 15.94 years with 53.7% males (n=58), the most common complication during hospital stay was sepsis (31 affected with 16 deaths, 14 survived and p-value=0.000), acute kidney injury (27 affected, 13 died, 13 survived, p-value=0.002), ARDS (seen in 19 patients with 16 deaths, 3 survived and acute cardiac injury (17 affected, 9 died, 8 survived, p-value=0.005).
Conclusion: The complications like adult respiratory distress syndrome, respiratory failure, acute cardiac injury, acute kidney injury, and secondary infection had poor outcomes. This study could help clinicians to take early measures to prevent the development of complications in patients admitted in HDU.

Gender differences in the health status of the imprisoned population in Kot Lakhpat Jail in Pakistan

Iram Manzoor — 2022-04-07

Background: The prison population of any country is a high-risk population because of a lack of access to regular health care facilities. This research was planned to assess the gender differences in the health status of the imprisoned population of Lahore.
Patients and methods: An analytical cross-sectional study was conducted in Kot Lakhpat Jail in the province of Punjab, near Lahore, from January to August 2019. After getting permission from Inspector General, Police of Punjab, a sample of 320 inmates of Kot Lakhpat Jail was collected through a simple random sampling technique. Data was collected on a structured questionnaire based on history and examination. Data was entered in SPSS version 23, and the chi-square test was applied to assess the gender differences in health status, p-value ? 0.05 was taken as significant.
Results: General examination revealed that 143 (44.7%) had refractory errors, and 34 (10.6%) had mild deafness. Common infection in males were scabies (p = 0.002), Sore throat (p =0.015) and urinary tract infections (p=0.015). Hepatitis C was present in high frequency (9.1%). Assessment of sexually transmitted diseases showed discharge in 10.6%, vesicular herpetic eruptions in 8.8%, and ulcers in private parts in 3.8% of the sample. Males showed a significantly high frequency of hypertension (p =0.052) and arthritis (p=0.024). Evaluation of mental health status revealed significant high rates of depression in females (p =0.000) and a high frequency of insomnia (p=0.000). Social health problems revealed a high frequency of smoking in males (p=0.000) and feeling of stigmatization in females (p=0.000).
Conclusion: Male jail inmates showed high frequencies of scabies, sore throat and urinary tract infection, and hypertension. Females showed higher rates of depression, insomnia, and feeling of stigmatization.

Protective role of omega 3 on histological status of liver of albino rats affected by energy drinks

Imtiaz Aslam — 2022-04-07

Background: This study was planned to see the toxic effects of energy drinks on the liver. The study was done for a period of one month in the animal house of the postgraduate medical institute, Lahore, on albino rats. Omega 3 was selected as a protective agent against the toxicity of energy drinks on liver parenchyma. The purpose of this study was to evaluate the protective role of omega 3 on the histology of liver parenchyma damaged by an energy drink.
Subjects and methods: A total of 30 male adult albino rats were used in this experimental study. They were divided into three groups with 10 animals in each: Group 1 was treated with distilled water at the dose of 0.5ml/100g of body weight, Group 2 was given an energy drink at the dose of 1.5ml/100g of body weight and Group 3 at the dose of 0.04-0.05ml/100g of omega 3 and 1.5ml/100g of body weight of energy drink. All doses were given for 4 weeks, orally once daily.
Results: Hepatotoxicity was produced by the energy drink, as histological parameters deranged in experimental group 2, which was treated with the energy drink alone. While group 3, which was treated with omega 3 along with energy drink showed the protection of hepatic architecture to some extent by reducing inflammation and nuclear changes to prove the protective role of omega 3.
Conclusion: Energy drink when given at dose of dose was 1.5ml/100gram/body wt.1.8ml was average dose adjusted on average base for a period of one month causes hepatotoxicity in albino rats. Omega 3 was given as at dose of 0.04-0.05ml/100 gm of body weight/day for a period of one month. It is concluded that 0.04-0.05ml/100mg of b.w/day of Omega 3 offered partial protection to liver against damage by energy drinks.
Conclusion: It is concluded that 0.04-0.05ml/100mg of b.w/day of Omega 3 offered partial protection to the liver against damage by energy drinks.

Comparison of efficacy of single dose versus split dose prednisolone therapy in achieving remission in patients with nephrotic syndrome in children

Imran Qaisar — 2022-04-07

Background: Nephrotic syndrome is a medical problem clinically characterized by proteinuria, generalized body edema and hypercholesterolemia. We did this study to compare the effectiveness of single dose versus split dose prednisolone in achieving remission in patients with nephrotic syndrome in children.
Patients and methods: This open-ended randomized control trial was done in pediatric unit of tertiary care hospital from January to December 2019.We included one hundred Patients of nephrotic syndrome in the study who met the inclusion criteria. We divided total Patients into 2 groups (group A & B) 50 patients in each group. Group A was given single dose prednisolone, while group B was given split dose prednisolone therapy. Both groups were compared with respect of achievement of remission.
Results: Out of 50 patients of group A who were given single dose prednisolone 37 (74%) were male, while in group B who were given split dose prednisolone 22 (44%) were male (p-value=0.137). Mean age of patients of study group A and B was 4.5 �1.67 years and 4.9 �1.49 years respectively (p-value=0.1876). Mean serum creatinine level in study group A and B was 0.744�0.189 and 0.736�0.167 (p-value=0.823). Similarly mean serum albumin level in study group A and B was 2.34�0.358 and 2.39�0.33 (p-value=0.473). When both groups were compared with regard to response to treatment, in group A mean remission duration was 16.48 �3.69. In group B mean remission duration was 19.42 �3.11 days (p-value<0.05).
Conclusion: From our study we concluded that single dose prednisolone is more effective in achieving remission in steroid sensitive nephrotic syndrome as compared to split dose prednisolone.

Evolution of telehealth and its future in Pakistan

Iram Manzoor — 2022-04-07

Provision of health information, prevention, health care services, and monitoring of the patient by the health care provider through a technology-based virtual platform at the doorstep of the patient is termed as telehealth.¹ In 1959, the first telepsychiatry consultations were made between the Nebraska Psychiatric Institute in Omaha and the state mental hospitals.² Boom to this concept was observed with the emergence of internet access and digital devices. However, the worldwide development in telehealth has been steady and gradual in the last two decades, owing to the lack of sustainable health system models. The telehealth revolution was set in motion by the COVID-19 pandemic. The quarantine of patients required access to medical care, made possible by the virtual health care system, which eased the burden of disease on organizations and hospitals, as well as permitted health care providers with COVID-19 to stay at home and contribute to patients� care when possible.³ With the provision of telehealth services in a local tertiary health care facility in Virginia, a greater than 5000% rise in virtual health services was observed within a fortnight of the epidemic ⁴. This clearly depicts the twofold advantage of dealing with the epidemic while preserving the capacity of the healthcare system.
Telemedicine can be valuable to patients in inaccessible localities; this, in turn, reduces outpatient visits and benefit those with disabilities. It allows the health personals to witness evidence-based practices and deal with health data under the supervision of experts ⁵. Yet, the full incorporation of telehealth into best practice has evident risks and obstacles. Physical examinations, diagnostic procedures, rehabilitation, and certain mental health treatments cannot be replaced by virtual health services ⁶. Telehealth permits well-timed and adaptable care to patients anywhere they may be; though this is helpful for the patients yet, privacy, safety, and medical reimbursement are jeopardized. In a virtual meeting, it is difficult to ascertain the laws applicable in that context ⁷. The cost of telecommunication services, data management equipment and technical training for medical personnel in these services are major hurdles in the implementation of telehealth services in large areas. In Pakistan, equitability is another issue as many individuals and communities lack not only access to the internet but also the knowledge to operate electronic devices and, in many instances, the electronic gadget itself.
In Pakistan, the disproportionate delivery of healthcare personnel combined with the rapid increase in population has led to a persistent shortage of doctors. Health care service provision indicators show the availability of 0.8 doctors per 1000 residents.⁸ This shows poor access to health care providers. The position gets worse with areas distant from the large cities. There is a dire need to develop a system of telehealth in Pakistan in order to promote the international slogan of health coverage for all. This will also help Pakistan to comply with principles of equity and equality in health care coverage too. With the emerging need to develop telehealth services in Pakistan, initiatives are taken at governmental and non-governmental levels. The development of the whole telehealth department in KEMU is one of the great examples of this initiative. But, according to WHO, Pakistan has no laws and regulations in place for telehealth services.⁸ Need of the hour indicates that such laws and regulations should be made in lieu of the development of telehealth services too for effective implementation. India, Bangladesh, Kenya, and Uganda are examples of developing countries that have implemented telehealth services through various electronic applications for maternal and child care. Aga Khan University Hospital (AKUH) in Karachi has implemented Information technologies (IT) and mobile health (mHealth) services in a video?based educational intervention in post?stroke patients with great success. ^9,10 Another example of implementation of mHealth in rural areas is a mobile-based audiovisual application, employed by lady health workers to supervise the Feeding program for children under two years of age for their mothers, which is another successful intervention.¹¹ Regardless of technical advances, the major obstacle hindering the progress and feasibility of telehealth is a deficiency of physical contact with patients and the inability to perform clinical examinations.¹² Pakistan has recently opened a pathway for telehealth service provision. These services are introduced at a very primitive level and lack accessibility. Areas to be focused on a wider range of population due to lack of awareness. ¹³ Although COVID-19 has boosted the telehealth system in Pakistan, there is a lack of a patient-centered, preventive, collaborative, and cost-effective model of care. A well?informed policy catering to both public and private health care systems, in collaboration with stakeholders, is vital to revive the outdated and over-burdened health sector in Pakistan.³ Moreover, there is a dire need to establish training facilities for health care providers engaged in the provision of telehealth services.¹⁴ Such initiatives will enhance the progress of telehealth and promote the health care delivery system of Pakistan.

REFERENCES

Tuckson RV, Edmunds M, Hodgkins ML. Telehealth. New England Journal of Medicine. 2017 Oct 19;377(16):1585-92.
Mahdi SS, Amenta F. Eighty years of CIRM. A journey of commitment and dedication in providing maritime medical assistance. International Maritime Health. 2016;67(4):187-95.
Mahdi SS, Allana R, Battineni G, Khalid T, Agha D, Khawaja M, et al. The promise of telemedicine in Pakistan: A systematic review. Health Science Reports. 2022 Mar; 5(1):e438.
Barsom E, Feenstra T, Bemelman W, Bonjer J, Schijven M. Coping with COVID-19: Scaling up virtual care to standard practice. Nature Medicine. 2020; 26(5):632-634.
Keck C, Doarn C. Telehealth technology applications in speech-language pathology. Telemedicine and e-Health. 2014; 20(7):653-659.
Dorsey ER, Topol EJ. State of telehealth. New England Journal of Medicine. 2016 Jul 14;375(2):154-61.
Mirmoeini SM, Marashi Shooshtari SS, Battineni G, Amenta F, Tayebati SK. Policies and challenges on the distribution of specialists and subspecialists in rural areas of Iran. Medicina. 2019 Dec; 55(12):783.
Ahmed A, Ahmed M. The Telemedicine Landscape in Pakistan-Why are we falling behind. Journal of Pakistan Medical Association. 2018 Dec 1; 68(12):1820-2.
Iftikhar S, Saqib A, Sarwar MR, Sarfraz M, Arafat M, Shoaib QU. Capacity and willingness to use information technology for managing chronic diseases among patients: A cross-sectional study in Lahore, Pakistan. PloS One. 2019 Jan 10; 14(1):e0209654.
Kamal A, Khoja A, Usmani B, Magsi S, Malani A, Peera Z, et al. Effect of 5-minute movies shown via a mobile phone app on risk factors and mortality after stroke in a low-To middle-income country: Randomized controlled trial for the stroke caregiver dyad education intervention (MovIes4Stroke). JMIR mHealth and uHealth. 2020 Jan 28; 8(1):e12113.
Akber S, Mahmood H, Fatima R, Wali A, Alam A, Sheraz SY, et al. Effectiveness of a mobile health intervention on infant and young child feeding among children? 24 months of age in rural Islamabad over six months duration. F1000Research. 2019; 8.
Bradford N, Caffery L, Smith A. Telehealth services in rural and remote Australia: a systematic review of models of care and factors influencing success and sustainability. Rural Remote Health. 2016 Oct-Dec; 16 (4): 4268. RRH4268. 2016.
Ashfaq A, Memon SF, Zehra A, Barry S, Jawed H, Akhtar M, Kirmani W, Malik F, Khawaja AW, Barry H, Saiyid H. Knowledge and attitude regarding telemedicine among doctors in Karachi. Cureus. 2020 Feb 9; 12(2).
Ahmed W. Telehealth: Trend in Pakistan. Journal of the College of Physicians and Surgeons Pakistan. 2017 Oct 1;27(10):663-5.

Late sequelae of COVID-19 and its effect on the quality of life

Ayesha Irshad Hussain — 2022-04-04

Background: COVID pneumonitis presents with symptoms of fever, cough, fatigue, myalgia, inability to smell and shortness of breath. However, certain symptoms have been reported to be persistent in some people or novel post-recovery symptoms have developed. Due to the day today rise in the number of covid-19 cases in Pakistan, it is the need of the hour to determine the long-term consequences associated with this disease, to educate the general population and to establish the long-term management of the patients.
Patients and methods: This cross-sectional study was conducted using non-probability purposive sampling, in which a total of 75 patients who had recovered from Covid-19 infection in the past 2-10 months visiting tertiary care hospitals in Lahore for follow up were recruited and filled survey forms bearing different questions regarding their disease, post-recovery symptoms and quality of life. Data collected was then analyzed by SPSS-26.
Results: The most common symptoms were fatigue (66.7%), dry cough (46.7%), headache (44%) and joint pains (41.3%), followed by other general, neurological, pulmonary and psychological symptoms. The quality of life was analyzed in different domains exhibiting an average range of 60-68% which shows that covid-19 has significantly affected the quality of life of its victims.
Conclusion: Various post disease recovery symptoms have been seen in the covid-19 victims and their quality of life has been deteriorated in physical, psychological, environmental and social domains; therefore, we need a multi-disciplinary team comprising of physicians, nurses, psychologists, social and occupational health workers who should work in liaison to tackle with these issues.

Effect of video game addiction on the physical and mental wellbeing of adolescents of Karachi

Ferhana Shabih — 2022-04-04

Background: The current study aimed to determine the effect of video games among the Non-Video-Game Addicted (NVGA) and Video Game Addicted (VGA) in terms of mental health and physical activity among adolescents from Karachi.
Subjects and methods: A cross-sectional study was conducted at public sector schools and colleges of different socioeconomic status of Karachi, Pakistan, from Jan-March 2020. Total of 321 students, adolescents, aged from 15-19 years, from both genders and who used to play video games but were considered as non-video game adictors (using less than four hours per day on video games) and video game adictors (using more than 5 hours per day). Questionnaires were used to collect data based on DSM-5 to find gaming addiction in adolescents with 21 questions. "General Health Questionnaire (GHQ)," with 14 questions on mental health. "International Physical Activity Questionnaire," for physical activity status. Students were divided into two groups: non-video game addicted (NVGA) and video game addicted (VGA).
Results: Out of 321, 233 (72.6%) were VGA, and 88 (27.4%) were NVGA students. There were 184 (57.3%) males and 137 (42.7%) females. The mean addiction score was 2.221+0.49 and 3.34+0.35 in the VGA group and NVGA group, respectively. 19.0% of males and 8.4% of females were VGA. Variables used for video game addiction in the study were salience, tolerance to play the game, mood modification, relapse, withdrawal, conflict, and problems (such as sleep deprivation, etc.). The mean score for all these variables was higher in the VGA group (p<0.001). The mean score of MHQ responses was significantly higher in the VGA group, indicating the high intensity of distress.
Conclusion: It has been concluded from the study that a very high frequency of video game addiction in adolescents (VGA group) caused mental and physical health problems in the study population.

Serum adenosine deaminase activity: A novel test for early diagnosis of pulmonary tuberculosis - What about efficacy?

Muhammad Irfan — 2022-04-04

Background: Pulmonary tuberculosis is a tremendous public health problem, increasing significantly, especially in developing countries. Getting a TB-free globe appears to be not more than a dream. Mycobacterial culturing is the gold standard for precise diagnosis but requires six-week time, in the meantime, patients remain a source of inadvertent disease dissemination in the community. The unavailability of sputum also poses a challenge several times. As adenosine deaminase level measurement is easy, rapid and independent of a sputum sample, this study was conducted to determine the diagnostic efficacy of adenosine deaminase activity for pulmonary tuberculosis.
Patients and methods: This prospective study was conducted at Pulmonology-OPD, Gulab Devi Chest Hospital, Lahore, from 01-01-2019 to 30-06-2019. A total of 300 sputum smear-positive patients with clinical and radiological evidence consistent with diagnosis of pulmonary tuberculosis and 30 normal participants without any clinical, radiological or haematological evidence of tuberculosis were included. While, smear-negative patients and those having any evidence of hepatic disease, hematopoietic malignancy, infectious mononucleosis, typhoid or pregnancy were excluded. The serum ADA level of each participant was determined. All patients were subjected to AFB culture. Diagnostic accuracy was determined by considering sputum culture as a gold standard.
Results: At cut-off value of >15 IU/L, a sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of 98.30%, 100.00%, 100.00%, 85.71%, 98.46% respectively were defined.
Conclusion: Serum ADA level, having excellent sensitivity and specificity, can diagnose pulmonary tuberculosis even if sputum sample is not available.

Pattern of dermatophytes among skin, hair, and nail specimens in a tertiary care hospital of Lahore

Majid Rauf Ahmad — 2022-04-04

Background: Dermatophytes are considered to be the most common cause fungal of infections globally. The geographical distribution of these fungi varies from region to region. The aim of this study was to isolate and determine the frequency and variety of various dermatophytes from clinically suspected cases of dermatophytoses.
Patients and methods: This was a descriptive study carried out at the Department of Microbiology, Post graduate Medical Institute, Lahore over a period of nine months from July 2013 till March 2014. Nonprobability convenient sampling was used. One hundred clinically suspected cases of dermatophytosis were selected for this study. Specimen of skin, hair and nail were taken from patients and were evaluated by both microscopic examination and culture. Dermatophytes were identified based on the colony morphology as well as microscopic arrangement of macroconidia and microconidia. Data was collected and entered in Statistical Package for the Social Sciences (SPSS) version 20.0.
Results: Out of a total of 100 patients, 48 were male and 52 were female. The majority of cases were from the age group of 31-40 (25%) followed by less than 10 years (18%). Out of hundred patients, 59 (59%) were positive on direct microscopy with KOH wet mount. Fungal culture was positive in 56 (56%) cases. Out of these 56 positive cultures, twenty-three were identified as dermatophyte species. Trichophyton rubrum was the commonest isolate. Other dermatophyte species isolated were Trichophyton mentagrophytes, Trichophyton verrocosum, Microsporum canis, Trichophyton tonsurans, and Microsporum audonii.
Conclusion: Studying the pattern of dermatophyte species is necessary as it helps in the early diagnosis and treatment of dermatomycoses. This study identified Trichophyton rubrum as the commonest etiological agent of dermatophytoses.

Effectiveness of trans-scleral cyclophotocoagulation for refractory paediatric glaucoma

Fiza Azhar — 2022-04-04

Background: The aim of this study was to find out the effectiveness of trans-scleral cyclophotocoagulation in lowering intraocular pressure in the paediatric population.
Patients and methods: This quasi-experimental study was conducted between July 2020 and January 2021 in Department of Ophthalmology, The Children�s Hospital, Lahore. Total 45 eyes of 42 children of age 1-14 years, both genders, with glaucoma were enrolled in this study. Diode cyclophotocoagulation unit and probe of make Quantel Medical was used for cycloablation under general anesthesia. Postoperative intraocular pressure was noted by using handheld Perkins applanation tonometer Mk2 after every 3 weeks for 12 weeks. If an IOP of ?21mmHg was achieved, then efficacy or success was labeled. Patients with an IOP of >21mmHg after 12 weeks were selected for repeat cycloablation treatment. Failure was labeled to an IOP of >21mmHg even after a repeat session. Data analysis was done using SPSS 24.
Results: In this study, 45 eyes were included with a mean age of 4.49 � 3.12 years. There were 21 (46.7%) males and 24 (53.3%) females. At the time of presentation, the most common diagnosis was primary congenital glaucoma [28 (62.2%)], followed by aphakic glaucoma [10 (22%)], Anterior segment dysgenesis [2 (4.4%)], Pseudophakic glaucoma [2 (4.4%)], Sturge weber syndrome [2 (4.4%)] and Post-traumatic [1 (2.2%)]. The mean IOP at baseline was 26.67�3.66 mmHg, which was reduced to 19.60�6.33 mmHg with mean change in IOP of 7.07�4.56 mmHg (p<0.05). The mean anti-glaucoma drugs used at baseline was 2.91�0.42, which was reduced to 0.93�1.2 with mean change in use of anti-glaucoma drugs of 1.98�1.06 (p<0.05). Success was achieved in 34 (75.56%) eyes, while 11 (24.44%) needed second session. After repeat session 2 (4.4%) eyes went into treatment failure.
Conclusion: Diode cyclophotocoagulation is a useful therapy for the management of glaucoma in children.

Outcome of pars plana vitrectomy with pre-operative intra vitreal bevacizumab in diabetic patients with vitreous haemorrhage

Alina Mustafa — 2022-04-04

Background: Intravitreal bevacizumab causes regression of retinal neo vessels in proliferative diabetic retinopathy as it is anti-vascular endothelial growth factor (anti VEGF). So this study was done to observe the effect of pre-operative intravitreal bevacizumab on intra operative outcome when administered in patients with vitreous hemorrhage undergoing pars-plana vitrectomy (PPV).
Patients and methods: This quasi-experimental trial was carried out in the Department of Ophthalmology Services Hospital Lahore from June 2020 to December 2020. Fifty seven diabetic patients with vitreous hemorrhage were selected who were eligible for PPV. Patients with recurrent hemorrhage were not included. Demographics were recorded and all patients were given intravitreal bevacizumab (1.25 mg/0.05 ml) one week prior to vitrectomy and intra-operative bleeding was noted. Intra-operative bleeding was graded as No, Mild and Severe bleeding.
Results: The mean age of patients undergoing PPV was 55.36 � 4.62 years. There were 35 (61%) males and 22 (39%) females. The mean duration of diabetes was 10.35�1.92 years. Out of 57 eyes, 36 (63.15%) had no bleeding, 11 (19.29%) had mild and 10 (17.54%) had severe intra-operative bleeding.
Conclusion: Intravitreal bevacizumab prior to PPV is quite effective in reducing the risk of intra-operative bleeding in patients with vitreous hemorrhage.

Prospective analysis of factors affecting the surgical outcomes of pediatric depressed skull fractures

Hassaan Zahid — 2022-04-04

Background: Around 42% of the pediatric patients present with skull fractures and the prognosis depends on several factors including type and location of fracture along with severity of associated brain trauma. The objective of this study was to find the factors affecting the outcome in childhood depressed skull fractures.
Patients and methods: This prospective observational study included 68 patients with depressed fractures presenting in the neurosurgery emergency department of Children Hospital Lahore. After detailed history and routine investigations, patients underwent the standard surgical procedure and were closely observed during the hospital stay. All were followed up for one month after being discharged from the hospital.
Results: The mean age of the children was 7.72�3.80 years. The male-to-female ratio was 1.42:1. Most of the patients had a history of fall (N=39, 57.4%). Twenty-nine (42.6%) had simple and 39 (57.4%) had complex fractures. Mostly presented with injuries at parietal (25%) and frontal (20.6%) region. Forty-seven (69.1%) were having GCS in between 13-15 (mild), 12 (17.6%) in between 9-12 (moderate) and 09 (13.2%) of the children were having GCS ?8 (severe) at the time of presentation. Regarding outcome, good recovery was noticed in 49 (72.1%) children, moderate disability in 8 (11.8%), severe disability in 4 (5.9%), the vegetative state in 3 (4.4%), and death in 4 (5.9%) of the patients. A strong association was found between the GCS category and outcome of the surgery (p<0.001). No significant association was found between outcome and mode of injury (p=0.45), site (p=0.553), and type of fracture (p=0.66).
Conclusion: Children with depressed fractures and a history of trauma normally present with minor brain injury and have a good post-surgical outcome.

Impact of duration of occupational exposure on physical and mental health of construction workers in Lahore, Pakistan

Irum Qureshi — 2022-04-04

Background: Construction industry is one of the most hazardous and accident prone occupation causing around 270 million accidents and 2 million deaths annually. In Pakistan reporting of incidence of occupational injuries and accidents is low. The present study aimed to determine the physical and mental health profile of construction workers in Lahore, Pakistan.

Subjects and methods: An analytical cross-sectional study was conducted among construction workers in Lahore from January 2020 to September 2020. The study included 181 participants by using non-probability convenience sampling technique. Data was collected by using a self-structured, pre-tested questionnaire. Data was analyzed using SPSS version 23. Chi-square test was applied and p-value <0.05 was taken as significant to find out association with duration of occupational exposure.

Results: Maximum number of the participants 55 (30.4%).was between age group 26-35 years and 97 (53.6%) were illiterate. Among 181 participants, 112 (61.87%) were found to be hypertensive, 98 (54.1%) were drug abusers. The total duration of hours spent on work per day was reported more than 10 hours in 50 (27.6%) of the participants. A significant association was observed between duration of occupational exposure and presence of chronic illnesses (p value=0.028) and mental health issues (p=0.041). A significant association (p-value= 0.026) was also found with duration of exposure with drug abuse. Bad effect of health on job performance was reported by 97 (53.6%) of the workers and 71(39.2%) of the workers reported restricted movements after injury during occupational exposure.

Conclusion: In this study, a relatively higher prevalence of chronic diseases, injuries and stress has been reported by construction workers, negatively affecting their occupation. Significant associations are seen with duration of exposure and its impact on physical and mental health.

Treatment response in prostatic neoplastic lesions using CyberKnife (stereotactic body radiation therapy)

Nimrah Sultana — 2022-04-04

Objective: To evaluate the treatment response of CyberKnife stereotactic radiotherapy in patients with prostatic neoplastic lesions.
Patients and methods: This prospective observational study was conducted at Radiology and Cyberknife Robotic Radiosurgery Department of Jinnah Post Graduate Medical Centre (JPMC), Karachi from 22nd June 2019 to 21st June 2020. Males with biopsy-proven prostatic adenocarcinoma with age 55 years or more having Gleason's score of 6 to 8, clinical stage of T1 to T2C, and prostate-specific antigen (PSA) of ?30 ng/ml were consecutively enrolled. Detailed information regarding PSA concentration, Gleason score, T stage, risk group and ADT (Androgen Deprivation Therapy) usage were noted which were given to high risk patients only for 9 months. Drop in the PSA (biochemical marker) was assessed at baseline, at 3 months and 6 months follow-up.
Results: The median age of the patients was 65 years. The overall median PSA level was 2.7 (0.86-7.3) ng/ml. Majority 49 (90.7%) patients presented with T2 N0 M0 TNM status while only 5 (9.3%) patients presented with T1 N0 M0 TNM status. There were 5 (9.3%) patients with high risk, 26 (48.1%) with intermediate risk, and 23 (42.6%) with low risk. ADT was received by 5 (9.3%) patients. The median PSA at baseline was 10.1 (6.9-18.1) ng/ml which significantly drops to 1.6 (0.8-3.6) ng/ml at 3rd months, and 0.4 (0.2-1.2) at 6th months (p-value <0.01).
Conclusion: The findings showed an adequate treatment response of CyberKnife stereotactic radiotherapy of patients with prostatic neoplastic lesions.

Quantitative MRI T2 relaxometry of knee joint in early detection of osteoarthritis

. Aneeta — 2022-04-04

Background: Magnetic resonance imaging (MRI) T2 is an advance modality for the early diagnosis of osteoarthritis. This study was performed to determine the MRI T2 relaxometry value of knee joint in early detection of osteoarthritis among suspected cases.
Patients and methods: This observational study was conducted at Department of Radiology, Jinnah Postgraduate Medical Centre (JPMC), Karachi, Pakistan from 20^th September 2020 to 28^th February 2021. All patients aged 20-60 years of either gender suspected of knee osteoarthritis were consecutively enrolled. Osteoarthritis was confirmed based on Kellgren & Lawrence (KL) radiographic grading of 2-5. MRI T2 relaxometry was performed in all patients.
Results: Of 102 patients, there were 67 (65.7%) males and 35 (34.3%) females. Mean age was 43.72 �14.01 years. KL grading showed that KL grade 0 observed in 29 (28.4%), grade I in 13 (12.7%), grade II in 25 (24.5%), grade III in 30 (29.4%), and grade IV in 5 (4.9%) patients. The frequency of osteoarthritis was found in 60 (58.8%) patients. Mean MRI T2 value was found to be 94.12 �16.32. Mean MRI T2 value was found significantly higher in patients with KL grade IV (109.89 �5.38) followed by KL grade III (107.35 �3.24), KL grade II (97.72 �14.65), KL grade I (89.54 �13.69), and KL grade 0 (76.65 �10.56). (p-value<0.001) The findings of ROC curve showed that AUC was found to be 0.911 (0.85-0.97) (p-value<0.001).
Conclusion: MRI T2 relaxometry is highly recommended for the prediction of osteoarthritis in suspected cases.

Chikungunya virus: An emerging public health challenge for Pakistan

Faiz Ahmed Raza — 2022-03-20

Chikungunya is a viral illness caused by the Chikungunya virus (CHIKV), an enveloped single-stranded linear RNA alphavirus belonging to the family Togaviridae. The CHIKV is transmitted by the same Aedes mosquito (Ae. aegypti and Ae. albopictus) responsible for transmitting the dengue and Zika viruses to humans.¹These viruses can co-circulate in an area and concurrent infections are possible in the same person.¹

CHIKV infections are mostly symptomatic (~80%), and the symptoms are similar to dengue virus infection, with fever and polyarthralgia being the commonest. The Chikungunya fever can be divided into three stages: acute (1-21 days), post-acute (22 to 90 days), and chronic stages (>90 days).² However, post-acute and chronic stages are not observed in all patients.³ The acute stage starts after a very brief incubation period (average 3 days, range 1-12 days) with typical symptoms including high-grade fever (>38.5^oC), arthralgia, arthritis with edema and pain, myalgia, headache, a maculopapular rash with cutaneous pruritus (soles and palms), facial edema, and lymphadenopathy. The infection is associated with mild thrombocytopenia, increased levels of liver enzymes, increased C-reactive protein (~50�60 mg/L), and lymphopenia (<1000 cells/mm³) being the main findings. Anorexia and asthenia are commonly observed after the subsiding of fever.³^{, 4} However, the disease may present atypically (like severe pain even after intake of pain relievers, thrombosis, bleeding, dehydration, decompensation of chronic disease, organ failure) in 0.5% of vulnerable patients (elderly, young children, patients with chronic diseases, pregnant females, etc.).³

Rare complications of Chikungunya fever may include myocarditis, retinitis, uveitis, hemorrhages, Guillain-Barr� syndrome, nephritis, hepatitis, bullous skin lesions, meningoencephalitis and cranial nerve palsies.⁵ One-time infections with CHIKV usually provide lifelong immunity against re-infection.^3-5

Differential diagnosis of Chikungunya fever from dengue fever is challenging due to similar clinical features. But usually CHIKV infection result in high fever, severe joint pain, rash, arthritis, and lymphopenia in contrast to dengue infection which results in neutropenia, thrombocytopenia, hemorrhage, shock and death.⁵ Laboratory confirmation of the CHIKV infection is carried out through viral cultures or viral nucleic acid detection in human serum/plasma by reverse-transcriptase polymerase chain reaction (RT- PCR) from day 1 to 5 of onset of symptoms. Serum IgM antibodies can be detected after five days of fever (and even earlier) and remain detectable for many months post-infection. A four-fold rise in the titer of CHIKV IgG antibodies in paired sera can be carried out to diagnose current infection.³

There is no definite treatment available at the moment to treat Chikungunya fever. Symptomatic treatment is provided to patients to prevent fever, relieve pain, avoid dehydration and organs damage. Among analgesics, acetaminophen is recommended; however, nonsteroidal anti-inflammatory drugs and salicylates are not recommended within two weeks of the disease onset due to the risk of bleeding and Reye's syndrome.³ Currently, no vaccine is approved to prevent CHIKV infections, but many potential vaccine preparations are being evaluated. More promising results have been shown by live attenuated, single-dose vaccine prepared by Valneva/Karolinska Institute in Phase-III clinical trials. The vaccine was effective in 98.5% of participants, and only mild or moderate adverse events were recorded.⁶ It could be assumed that a safe and effective vaccine will soon be available against CHIKV infections.

A seroepidemiological study conducted in Pakistan in the 1980s detected CHIKV antibodies in humans and rodents.⁷ Although in this study, CHIKV antibodies were detected in only one participant, the first report indicated co-circulation of CHIKV and other arboviruses locally. However, no outbreaks were recorded during the last three decades until 2016, when cases of a "mysterious" disease started to emerge in Karachi, which was later identified as CHIKV infections.⁸ The disease rapidly spread to other provinces and was also detected in the federal capital Islamabad by mid-2017.⁹ Another seroepidemiological study detected the co-circulation of CHIKV and DENV in Lahore, Rawalpindi, and Peshawar.¹⁰ More recently, in November 2021, several local newspapers reported prevalence of another "mysterious disease" affecting a large number of people along with the ongoing dengue epidemic in Lahore and Karachi.^11-13 The mystery disease had dengue-like symptoms but tested negative for it. Many medical practitioners suspected it as Chikungunya fever; however, the exact diagnosis was not made due to lack of expertise, unavailability of diagnostic facilities, and lack of interest and cooperation by the medical fraternity with the researchers interested in deciphering the mystery.

The co-circulation of multiple arboviruses in Pakistan is a worrisome situation as it will inflict a burden on the already fragile health system. There is an urgent need to develop diagnostic facilities and strengthen vector control and surveillance activities to prevent any future epidemics. To control CHIKV infection, developing an efficacious and affordable vaccine and treatment guidelines are need of time.

REFERENCES

Le Coupanec A, Tchankouo-Nguetcheu S, Roux P, Khun H, Huerre M, Morales-Vargas R, et al. Co-infection of mosquitoes with chikungunya and dengue viruses reveals modulation of the replication of both viruses in midguts and salivary glands of Aedes aegypti Int J Mol Sci. 2017;18(8):1708.
Simon F, Javelle E, Oliver M, Leparc-Goffart I, Marimoutou C. Chikungunya virus infection. Curr Infect Dis Rep. 2011;13(3):218-28.
Chikungunya virus: advances in biology, pathogenesis, and treatment. Okeoma CM, editor. Switzerland: Springer International Publishing; 2016.
Thiberville S-D, Moyen N, Dupuis-Maguiraga L, Nougairede A, Gould EA, Roques P, et al. Chikungunya fever: epidemiology, clinical syndrome, pathogenesis and therapy. Antiviral Res. 2013;99(3):345-70.
Chikungunya virus USA: U.S. Department of Health & Human Services; 2022 [cited 2022 Feb 18]. Available from: https://www.cdc.gov/chikungunya/symptoms/index.html.
Begley A. Chikungunya vaccine effective in 98.5 percent of participants 2021 [cited 2022]. Available from: https://www.europeanpharmaceuticalreview.com/news/159755/chikungunya-vaccine-effective-in-98-5-percent-of-participants/.
Darwish MA, Hoogstraal H, Roberts TJ, Ahmed IP, Omar F. A sero-epidemiological survey for certain arboviruses (Togaviridae) in Pakistan. Trans R Soc Trop Med Hyg. 1983;77(4):442-5.
Mysterious disease affects 30,000 people in Karachi. Dunya News. Retrieved 22 August, 2019. Accessed from: http://dunyanews.tv/en/Pakistan/366034-Mysterious-disease-affects-30000-people-in-Karach
Harb H, Mansour D, Abouahmed Y. Intravaginal isosorbide mononitrate in addition to misoprostol versus misoprostol only for induction of labor: a randomized controlled trial. QJM. 2020;113(Supplement_1):hcaa056. 13.
Raza FA, Javed H, Khan MM, Ullah O, Fatima A, Zaheer M, et al. Dengue and Chikungunya virus co-infection in major metropolitan cities of provinces of Punjab and Khyber Pakhtunkhwa: A multi-center study. PLoS Neg Trop Dis. 2021;15(9):e0009802.
Bhatti MW. Mysterious virus spreading in Karachi causing dengue-like symptoms: experts. The News International. 2021 November 12, 2021
Asghar RJ. A mysterious disease in Karachi? The Express Tribune. 2021 20 November 2021.
Ilyas F. Suspected new variant of dengue under analysis in Karachi Dawn. 2021 November 19, 2021

Culture and sensitivity patterns of bacteriological agents in children admitted to a tertiary care hospital

Samia Naz — 2021-12-07

Background: Culture from various infected body fluids is one of the commonly used investigations to establish the etiology of infections and helps clinicians to select appropriate antimicrobial therapy. This study is aimed to determine the culture and sensitivity patterns of bacteriological agents grown in children admitted to a tertiary care center.

Patients and methods: This descriptive cross-sectional study was conducted at the Department of Pediatric Medicine, The Children�s Hospital and the Institute of Child Health, Lahore from April 2019 to December 2019. All admitted children of age � 15 years who fulfilled the criteria of systemic inflammatory response syndrome and sepsis were enrolled in the study. Blood and other body fluids were cultured in appropriate medium as indicated. Profile of microorganisms grown and their sensitivity patterns were noted and recorded on a predesigned data sheet. Statistical analysis was performed by SPSS v.22.

Results: A total of 500 patients were enrolled in the study. Eighty-three of them (16.6%) had growth of different microorganisms on culture and were further analyzed. Total 58 of these 83 (69.87%) were <5 years of age, Male to female ratio was 1.2:1. Blood culture was positive in 36 patients (43.37%). Cultures from throat swabs, sputum and tracheal secretions showed growth of organisms in 15 (18.10%), while cerebrospinal fluid culture was positive in 14 (16.87%) and urine culture in 11 (13.25%). Microorganism isolated were: Klebsiella spp. (15.66%), Salmonella spp. (14.45%), Escherichia coli (13.25%), Staphylococcus aureus (12.04%), Acinetobacter (12.04%), Streptococcus pyogenes (10.84%), Pseudomonas aeruginosa (10.84%), Enterobacter spp. (7.23%) and Stenotrophomonas maltophilia (3.61%). Klebsiella spp. and E. coli showed resistant to various antibiotics including penicillin, co-amoxiclav, cephalosporin, fluoroquinolones and nalidixic acid. Salmonella spp. was mostly sensitive to meropenem and azithromycin. Staphylococcus aureus was sensitive to cephalosporin, amikacin, vancomycin and linezolid.

Conclusion: Commonest micro-organism isolated were Klebsiella spp., Salmonella spp., Escherichia coli, Staphylococcus aureus and Streptococcus pyogenes. Resistance to commonly used antibiotics was observed in most cultures, which is a whistle blower against inappropriate use of these drugs.

Diagnostic accuracy of toluidine blue in early detection of oral squamous cell carcinoma

Muhammad Salman Chishty — 2021-12-07

Background: Indian sub-continent (India, Pakistan, and Bangladesh) is one of the high-risk populations for oral cancer cases. Intraoral screening is critical to diagnosis and treating oral cancer at an early stage for a better prognosis. Among the diagnostic adjuncts, toluidine blue staining is considered a simplistic, cost-effective, and highly sensitive method. The objective of the current study was to find out the diagnostic accuracy of toluidine blue in the early detection of oral squamous cell carcinoma.

Patients and methods: This prospective observational study was undertaken at the Department of Oral and Maxillofacial Surgery, Institute of Dentistry, CMH Lahore Medical College from15-09-2019 to 15-03-2020 after getting approval from IRB. Based on inclusion criteria, a sample size of 100 was calculated and enrolled in the study. Non-probability convenient sampling technique was utilized. Oral staining of 100 patients was done with 1% toluidine blue on an OPD basis, and incisional biopsies were then performed. Staining pattern and histopathology reports of patients were evaluated to assess the diagnostic accuracy

Results: The study results revealed the sensitivity of Toluidine Blue as 89.87%, and specificity of toluidine blue was found as 76.19%. Positive and negative predictive values of Toluidine Blue remained 93.42% and 66.67%, respectively.

Conclusion: Toluidine blue has good diagnostic accuracy for early detection of oral squamous cell carcinoma (SCC).