Showing papers in "Jcpsp-journal of The College of Physicians and Surgeons Pakistan in 2012"

Adverse effects of low dose methotrexate in rheumatoid arthritis patients.

Abstract: Objective To determine the frequency of adverse effects attributed to Methotrexate (MTX) toxicity and serum minimum toxic concentration with low dose MTX in Rheumatoid Arthritis (RA) patients. Study design Cross-sectional observational study. Place and duration of study Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology, Rawalpindi, from March 2010 to March 2011. Methodology One hundred and forty adult patients of RA receiving low dose MTX (10 mg/week) for at least 3 months, ere included by consecutive sampling. Blood samples were collected 2 hours after the oral dose of MTX. Serum alanine transaminase and creatinine were analyzed on Hitachi and blood counts on Sysmex analyzer. Serum MTX concentration was measured on TDX analyzer. Results Out of one hundred and forty patients; 68 males (49%) and 72 females (51%), 38 developed MTX toxicity (27%), comprising of hepatotoxicity in 12 (8.6%), nephrotoxicity in 3 (2.1%), anaemia in 8 (5.7%), leucopenia in 2 (1.4%), thrombocytopenia in 3 (2.1%), pancytopenia in 2 (1.4%), gastrointestinal adverse effects in 5 (3.6%) and mucocutaneous problems in 3 (2.1%). Receiver operating characteristic curve revealed serum minimum toxic concentration of MTX at cutoff value of 0.71 μmol/l with a sensitivity of 71% and specificity of 76%. Conclusion Adverse effects of low dose MTX were found in 27% of RA patients, mainly comprising of hepatotoxicity and haematological problems. MTX toxicity can be detected by therapeutic drug monitoring of serum concentration of 0.71 μmol/l with sensitivity of 71% and specificity of 76% in the patients on low dose MTX maintenance therapy.

Awareness among parents of β-thalassemia major patients, regarding prenatal diagnosis and premarital screening.

Abstract: Objective To assess the knowledge among parents of thalassemia major patients about prenatal diagnosis, premarital screening for carrier detection and impact of consanguineous marriage on disease transmission. Study design Descriptive study. Place and duration of study The Thalassemia Centre, Sir Ganga Ram Hospital, Lahore, from July to September 2009. Methodology One hundred and fifteen parents of β-thalassemia major patients were enrolled in this study. A questionnaire was developed and parents were interviewed to assess their knowledge about preventive measures against thalassemia major. Parents of patients with all other types of blood disorder were excluded from the study. Results There were 74 male (64.3%) and 41 female (35.7) patients with mean age of 9.5 ± 5.1 years. Eighty-eight patients (76.5%) were accompanied by mothers and the rest by their fathers. Seventy-four parents (32.1%) were illiterate; among the literates only 7 were highly educated (3%). Ninety-four couples (81.7%) had consanguineous marriage. Fiftytwo parents (44.6%) knew that thalassemia is an inherited disorder. Thirty-eight (33%) had heard about the test for detecting thalassemia carrier. Premarital screening and prenatal diagnosis was known to 97 (84.3%) and 88 (76.5%) parents respectively. Ninety-nine parents (86.1%) knew about the termination of pregnancy on positive prenatal test but only 69 considered it acceptable religiously (60%). Major source of information to the parents were doctors. Conclusion Parental knowledge about thalassemia and its preventive measures was inadequate; this requires intervention in the form of public health education programs concentrating on high risk/targeted population.

Association of gestational weight gain and pre-pregnancy body mass index with adverse pregnancy outcome.

Abstract: Objective: To determine the association between gestation weight gain (GWG) and adverse pregnancy outcome in a Pakistani population. Study Design: Analytical study. Place and Duration of Study: The Aga Khan University, Karachi, from February 2003 to 2007. Methodology: This study used secondary data of 4,735 women from a large cohort study on fetal growth. Pre-pregnancy BMI was categorized according to the recommendations from the institute of medicine (IOM, 2009) and gestation weight gain (GWG) was noted. Chi-square test was used to find the association of GWG and pre-pregnancy BMI with low birth weight (LBW), preterm delivery , large for gestational age (LGA), and caesarean section. Logistic regression analysis was performed to control for confounders like age, parity, working status and ethnicity. Results: The prevalence of LBW decreased with increasing BMI. GWG of the population was noted as 8.5 kg. LBW was observed to have an inverse relationship with GWG. W omen below the age of 19 were twice more likely to have LBW than above 35 years of age. Weight gain above the recommended range were twice more likely to have large for dates. Overweight women were 1.5 times more likely to deliver preterm whereas obese women were 1.4 times more likely to undergo caesarean section than women with normal BMI. Conclusion: The optimal weight gain was estimated to be 8.5 kg to prevent low birth weight in our population. Obese women are more likely to have LGA, caesarean sections and pre-term deliveries.

Medical Students' Perspective About Role-Plays As A Teaching Strategy in Community Medicine

Abstract: Objective: To assess the students' perspective about role-plays conducted as a teaching methodology in community medicine. Study Design: A quasi-experimental study. Results: Sixty-three students were selected as participants of this study in which 46 belonged to the fourth year MBBS class (73%) and 17 were third year MBBS students (27%). There were 13 male (20.6%) and 50 female (79.4%) students. Role-plays were identified as most effective method of teaching (n = 25, 37.9%) followed by lectures (n = 17, 25.8%, p = 0.054). Fifty-two students (78.5%) admitted that role-plays improved their knowledge of the subject, 55 (84.6%) said that it will help them in their clinical performance. Fifty-nine participants (89.4%) found role-plays interesting and 49 (74.2%) wanted to incorporate role-plays as a part of curriculum. Fifty-six of the participants (88.9%) agreed that role-plays improved their communication skills. Twenty-one participants (31.8%) believed that it helped them in making acquaintance with the local situation. Forty-six students (76.7%) identified role-plays as a feasible way of andragogy (p = 0.005) and 48 (76.2%) said that it provoked critical thinking about the subject (p = 0.038). Fifty-four students (85.7%) admitted that their attention span was better in role-plays as compared to lectures (p = 0.047). Conclusion: Role-plays were well accepted by the students as an effective teaching methodology and can be incorporated as a part of teaching strategies in Community Medicine.

Comparison of different craniofacial patterns with pharyngeal widths

Abstract: Objective: To compare different craniofacial patterns with pharyngeal widths. Study Design: Cross-sectional analytical study. Place and Duration of Study: Orthodontic Clinic at the Aga Khan University Hospital, Karachi, from June 2002 to June 2010. Methodology: Data were collected using pre-treatment records including orthodontic files and pre-treatment lateral cephalographs of 360 orthodontic patients. The inclusion criteria were subjects of Pakistani origin, aged between 14-20 years and having no pharyngeal pathology or complaints of nasal obstruction at the initial visit. The sample comprised a total of 360 subjects divided into 2 groups: skeletal Class I (n=180) and skeletal Class II (n=180) subdivided according to the vertical pattern into normodivergent, hyperdivergent and hypodivergent facial patterns. Upper and lower pharyngeal airways were measured using McNamara's airway analysis. The intergroup comparison of upper and lower airways was performed with oneway ANOVA and the Tukey test as the second step. Results: There were 172 males and 188 females with average ages of 15.3±1.3 and 15.4±0.8 years respectively. Hyperdivergent facial pattern subjects belonging either to skeletal Class I or Class II malocclusion showed a statistically significant narrow upper pharyngeal airway width as compared to normodivergent and hypodivergent facial patterns. However, no statistically significant difference was found in lower pharyngeal airway widths in sagittal and various vertical facial patterns. Conclusion: Sagittal malocclusion type does not influence upper pharyngeal width. However, hyperdivergent subjects have statistically significant narrower upper pharyngeal width when compared to other two vertical patterns.

Seropositivity of hepatitis C, hepatitis B and HIV in chronically transfused β-thalassaemia major patients.

Abstract: The purpose of this study was to determine the frequency and trend of transfusion transmitted infections (TTI) in chronically transfused β-thalassaemia major (TM) patients with reference to the duration of transfusions. A cross-sectional study was done on 160 β-TM patients and 5517 healthy blood donors to find out the prevalence of HCV, HBV and HIV infections. Out of 160 patients, 21 cases (13.1%) were anti-HCV positive, 2 (1.25%) were HBsAg positive. HIV antibodies were not detected in any sample. However, 109 (1.9%) and 104 (1.8%) of 5517 blood donors were positive for HCV and HBV respectively. No donor showed HIV antibodies. Anti-HCV was positive in 9/111(8.4%) thalassaemics ( 10 years of age] showing significant difference (p = 0.005) among the two groups. For the past 10 - 12 years the screening of blood has reduced the magnitude of the disease significantly as shown by the trend in two age groups. Further improvements need to be done to implement uniform screening throughout the country.

Bacterial spectrum and their sensitivity pattern in patients of chronic suppurative otitis media.

Abstract: The study was conducted from March 2008 to February 2010 in Microbiology Department, Citi Lab, Rawalpindi, to determine the causative microorganisms and their antibiotic sensitivity pattern in patients with chronic suppurative otitis media. One hundred and eighty-three samples received at Citi Lab were included in the study. Pus samples were cultured aerobically. Antibiotic sensitivity testing was done with standard antibiotic discs using modified Kirby-Bauer disk diffusion method. Out of 183 patients, microbiological culture was yielded from 154 specimens (84%). There were 148 bacterial isolates (96%) and 06 fungi (4%). Pseudomonas aeruginosa (n=59, 38%) was the most common isolate followed by Staphylococcus aureus (n=34, 22%). Susceptibility pattern of Pseudomonas aeruginosa showed that 100% isolates were sensitive to Piperacillin/Tazobactam, whereas 98% isolates were sensitive to Imipenem and 76% to Ciprofloxacin. Continuous surveillance of susceptibility pattern is suggestive for effective therapy of chronic suppurative otitis media.

Serum alkaline phosphatase screening for vitamin D deficiency states.

Abstract: Objective: To determine whether serum vitamin D levels are correlated with serum levels of alkaline phosphatase or not. Study Design: Cross-sectional, observational study. Place and Duration of Study: Multi-centre study, conducted at Liaquat National Hospital and Medical College, National Medical Centre and Medicare Hospital, Karachi, from January to October 2009. Methodology: Patients attending the Orthopaedic OPDs with complaints of pain in different body regions and serum vitamin D 3 levels of ″ 30 ng/ml were included in the study. Patients with vitamin D deficiency were further categorized into mild deficiency or insufficiency (vit. D 3 = 20-29 ng/ml), moderate deficiency (vit. D 3 = 5 - 19 ng/ml) and severe deficiency forms (vit. D 3 < 5 ng/ml). Pearson correlation was applied to test the correlation of serum alkaline phosphatase levels with serum vitamin D 3 levels. P-value < 0.05 was considered to be significant. Results: Out of 110 samples, 26 had mild (23%), 61 had moderate (55%) and 21 had severe (19.1%) vitamin D deficiencies. All of the patients in the three groups had alkaline phosphatase with in normal limits and the total mean value of the enzyme was 135.97 ± 68.14I U/L. The inter group comparison showed highest values of alkaline phosphatase in the moderate vitamin D deficiency group. The correlation coefficient of alkaline phosphatase and serum vitamin D 3 levels was r =0.05 (p =0.593). Conclusion: Serum vitamin D3 levels may not be correlated with increased serum alkaline phosphatase levels. Therefore, alkaline phosphatase may not be used as a screening test to rule out vitamin D deficiency.

Severity of depression in hepatitis B and hepatitis C patients

Abstract: Objective: To assess and compare the severity of depression in chronic hepatitis B (CHB), chronic hepatitis C (CHC) and healthy subjects Study Design: Comparative study

Gender inequalities and poor health outcomes in Pakistan: a need of priority for the national health research agenda.

Abstract: 273 The United Nations Millennium Development Goals report 2011 has prioritized the goal for promoting gender equality and women empowerment but targets are far from its reach, especially in South Asia.1 Pakistan is challenged with gender inequalities, and despite efforts there is a wide gap between males and females in terms of employment opportunities, paid work, access to health services and health outcomes in Pakistan.2 The gender inequality has deep roots in Pakistani society. Culturally, women are at a disadvantage from birth and are subject to discrimination during their entire lifecourse in Pakistan, while men are perceived economic and social utility.2,3 This gender preference can be assessed by unbalanced gender ratio (91 women for every 100 men) in Pakistan, when compared with industrialized countries.2 Male infants enjoy more family resources and care in terms of better nutrition and healthcare access than females of the same age. Female children are, therefore, susceptible to face more neglect and live in poor health compared to male children.2 This neglect of girls continues in their childhood and adolescence, with only 25% of women able to complete their primary education as compared to 49% of men in Pakistan.2 Female literacy is only twothirds that for men in urban Punjab,2 and is beyond doubt much worst in rural areas of Pakistan. These early life experiences may simply reinforce the intergenerational continuity of female vulnerability in the

Efficacy of intra-alveolar chlorhexidine gel in reducing frequency of alveolar osteitis in mandibular third molar surgery.

Abstract: Objective: To determine the efficacy of intra-alveolar administration of chlorhexidine (CHX) gel in reducing the frequency of alveolar osteitis (AO) after impacted mandibular third molar surgery. Study Design: A randomized control trial study. Place and Duration of Study: Department of Oral and Maxillofacial Surgery, Armed Forces Institute of Dentistry, Rawalpindi, Pakistan, from January to December 2007. Methodology: One hundred patients including 65 males and 35 females with the age range 18-40 years were divided in two equal groups (50 each in the CHX and the control groups). Surgical removal of impacted mandibular third molar was carried out and after surgery CHX gel was placed into the alveolus of CHX group. Patients were followed at the first, second and third postoperative days. A proforma indicating presence or absence of pain, blood clot disintegration, halitosis and AO was filled for each patient. Frequencies and percentages were calculated for qualitative data. Chi-square test was applied to compare both subgroups. Results: Eighteen patients (18%) were diagnosed with AO (11 males and 7 females). Out of these 18 cases, 14 (28%) were found in control group (9 males and 5 females), while 4 cases (8%) in the CHX group (2 males and 2 females). This was statistically significant p=0.017. Conclusion: Single application of CHX gel was effective in reducing frequency of AO following mandibular third molar surgery.

Comparison of laparoscopy and laparotomy in the surgical management of ectopic pregnancy.

Abstract: OBJECTIVE To compare the operative findings, operative procedure and complications, postoperative complications and hospital stay in patients with ectopic pregnancy managed by laparoscopy and conventional laparotomy. STUDY DESIGN A cross-sectional, observational study. PLACE AND DURATION OF STUDY Department of Obstetrics and Gynaecology, Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal, from October 2009 to October 2010. METHODOLOGY All patients with ectopic pregnancy confirmed during surgery, were included in the study. Patients with preoperative diagnosis of ectopic pregnancy but confirmed not to be so during surgery were excluded. Data regarding the studied variables were collected by interviewing patients postoperatively, reviewing the charts and operative notes and by following-up the patients till discharge. RESULTS There were a total of 32 cases of ectopic pregnancy which was 4.4% of total deliveries during the study period. Twelve patients (37.5%) were managed by laparoscopy and 20 patients (62.5%) by laparotomy. All the patients who underwent laparoscopy and 40% patients who underwent laparotomy were haemodynamically stable pre-operatively. Laparoscopy was mostly performed for tubal abortion (40%) and unruptured ectopic pregnancy (25%) whereas laparotomy mostly for ruptured ectopic pregnancy (70%). Salpingectomy was the commonest procedure in both routes of surgery. One patient in the laparoscopy group and 4 patients (20%) in laparotomy group had complications with two of the latter requiring admission in intensive care unit. CONCLUSION Laparoscopy is feasible and safer than laparotomy in the surgical management of ectopic pregnancy.

Human papilloma virus and oral lesions in gutka eating subjects in Karachi.

Abstract: Objective: To determine the frequency of HPV in eaters of Gutka (betel, areca, lime and tobacco concoction), presenting with oral lesions. Study Design: A descriptive study. Place and Duration of Study: Ziauddin University Research Laboratory, from February to July 2010. Methodology: Subjects munching Gutka fulfilled the inclusion criteria. Samples were collected in the form of 20 - 40 ml oral rinse from 262 subjects who were habitual eaters of Gutka after an informed consent. Gentle brushings from the lesion were taken from subjects with the help of a brush at the other end of dental floss and the oral rinse was stored at 4°C until DNA extraction. DNA was extracted and PCR was performed using HPV consensus primers Gp5+/Gp6+. Oral cavity was examined for the presence of ulcer, trismus, sub-mucosal fibrosis, leukoplakia and/or warts. Results: Out of 262 subjects, 42 were females and 220 males with an average age of 27± 10 years. HPV was positive in 47 subjects (17.9%). HPV frequency was 2.7% greater in chewers with more than 10 years of habit compared to less than 10 years. Examination of oral cavity showed 78% presenting with more than one complaint including oral ulcers (25%), rough mucosa (62%), sub-mucosal fibrosis (24%), leukoplakia (20%) and erythroplakia (10.6%). Highest frequency of HPV was observed in erythroplakia (25%). Association between presence of symptoms and HPV shows an ODDS RATIO: ad/bc= 4982/430=11.6 Conclusion: Oral lesions caused by constant exposure to Gutka are associated with high frequency of HPV infection, which may be a risk factor for squamous cell carcinoma of the oral cavity. People should be educated about the consequences of Gutka abuse.

Frequency of newly diagnosed diabetes mellitus in acute ischaemic stroke patients.

Abstract: Objective: To determine the frequency of newly diagnosed diabetes mellitus in acute ischaemic stroke patients. Study Design: Observational study. Place and Duration of Study: Jinnah Postgraduate Medical Centre, Karachi, from June 2007 - June 2008. Methodology: This study included adult patients (age > 30 years, both genders) with the diagnosis of acute ischaemic stroke. Patients who were known to have diabetes mellitus prior to stroke, had a non-lacunar stroke or were admitted to intensive care units for any reason were excluded. Detailed history and examination, fasting blood sugar, fasting lipid profile, a non-enhanced CT scan brain and electrocardiogram were done on every patient. Data were entered on a preformed proforma. The results were analyzed on SPSS version 10. Chi-square test was applied. P-value <0.05 was considered to be statistically significant. Results: A total of 250 patients were enrolled. The male: female ratio was 1: 0.9. Mean age was observed as 60.9±10.1 years. In total, 50 new cases of diabetes mellitus were identified (20%). Average fasting blood sugar in diabetic subjects was 148±10 mg/dl. The most common risk factors in the newly diagnosed diabetic subjects were hypertension 26 (52%), smoking 18 (36%) and hyperlipidemia 14 (28%). Atrial fibrillation and myocardial infarction were seen in 12 subjects (24%) and 9 subjects (18%) respectively. Conclusion: Twenty percent patients with acute ischaemic stroke had un-diagnosed diabetes. Therefore, it is advisable to screen acute stroke patients for diabetes to reduce their long-term morbidity and mortality.

Migration of health workers: a challenge for health care system.

Abstract: The migration of health workers has resulted in a growing apprehension universally because of its impact on health system of the developing countries. Although the choice to migrate is basically a personal one, however, the overall social and economic circumstances have important impact on the decision to migrate. The "push and pull" factors for migration are disparity in working conditions, pay, lack of promotion opportunities, poor living conditions, desire to gain experience, professional development, family background and family wealth. A strategic approach by the government and other agencies is mandatory for regulating the flow of health workers between countries. A range of policies and interventions are needed to deal with the broader health system issue and problems of health workers that influence their recruitment, retention, deployment and progress.

PubMed-based quantitative analysis of biomedical publications in the SAARC countries: 1985-2009.

Abstract: Objective: To conduct a geographical analysis of biomedical publications from the South Asian Association for Regional Cooperation (SAARC) countries over the past 25 years (1985-2009) using the PubMed database. Study Design: A qualitative study. Place and Duration of Study: Web-based search during September 2010. Methodology: A data extraction program, developed by one of the authors (SFS), was used to extract the raw publication counts from the downloaded PubMed data. A search of PubMed was performed for all journals indexed by selecting the advanced search option and entering the country name in the 'affiliation' field. The publications were normalized by total population, adult illiteracy rate, gross domestic product (GDP), secondary school enrollment ratio and Internet usage rate. Results: The number of PubMed-listed papers published by the SAARC countries over the last 25 years totalled 141,783, which is 1.1% of the total papers indexed by PubMed in the same period. India alone produced 90.5% of total publications generated by SAARC countries. The average number of papers published per year from 1985 to 2009 was 5671 and number of publication increased approximately 242-fold. Normalizing by the population (per million) and GDP (per billion), India (133, 27.6%) and Nepal (323, 37.3%) had the highest publications respectively. Conclusion: There was a marked imbalance among the SAARC countries in terms of biomedical research and publication. Because of huge population and the high disease burden, biomedical research and publication output should receive special attention to formulate health policies, re-orient medical education curricula, and alleviate diseases and poverty.

Peripheral artery disease in type II diabetes.

Abstract: Objective: To determine the frequency of peripheral arterial disease (PAD) in type 2 diabetic patients. Study Design: Cross-sectional observational study. Place and Duration of Study: Diabetes Clinic, Medical Unit III, Jinnah Postgraduate Medical Centre, Karachi, from January to June 2010. Methodology: Three hundred and eighty seven (387) type II diabetic patients of either gender and any age were included in the study . Patients with a previous history of trauma to the arterial vasculature, pregnancy and those who underwent arterial graft procedures were excluded. Non-purposive convenient sampling technique was used to enroll patients in the study. PAD was diagnosed when ankle-brachial index (ABI) was less than 0.9. A p-value of less than 0.05 was considered statistically significant. Results: Out of 387 studied patients, 128 were males (33.1%) and 259 were females (66.9%). Mean age was 52.22 ± 9.671 (22 ‐ 76) years in the entire cohort. Mean duration of diabetes was 9.38 ± 6.39 years. PAD was detected in 152 (39.28%) of the total study subjects. Thirty-one of 128 male patients (24.22%) had PAD disease while 121 out of 259 female patients (46.71%) had evidence of PAD (p = 0.001). Hypertension was a significantly associated factor (p = 0.002). Conclusion: A high frequency of PAD was observed in the diabetic population particularly with hypertension and more prevalent in females.

Ventilator-associated pneumonia in children.

Abstract: Objective To determine the frequency of Ventilator-Associated Pneumonia (VAP) and to identify the associated factors, causative organisms and outcome of VAP in children admitted to ICU. Study design Cross-sectional, observational study. Place and duration of study Medical ICU (MICU) of the Children's Hospital and Institute of Child Health, Lahore, from August 2008 to March 2009. Methodology All children admitted to MICU and requiring ventilation during the study period were included and monitored for any features suggestive of VAP. Partial septic screen was done in all suspected cases. VAP was labelled when any patient on the ventilator for more than 48 hours had at least 2 of the following features of nosocomial infection - fever > 101°F, TLC 15000 per mm3, neutrophils > 85%, CRP > 48 mg/L or new findings on chest examination suggestive of pneumonia; and radiological evidence of new or progressive and persistent infiltrates. Percentages were compared using chi-square test with the significance at p-value less than 0.05. Results Of the 93 children requiring mechanical ventilation during the study period, 16 developed VAP (17%). Almost half (46%) were younger than 1 year with male to female ratio of 1.2:1. Children developing VAP required ventilation for 13.5 (+ 10.1) days compared to 7.7 (+ 5.5) days in those who did not develop VAP. The common organisms isolated were Pseudomonas, Klebsiella and E. coli. Factors associated with increased frequency of VAP included age less than 1 year, unplanned emergency intubation and use of continuous intravenous sedation. Features that strongly suggested underlying VAP included purulent tracheal secretions compared to increased secretions alone, CRP > 48 mg/L, positive radiological findings and positive tracheal aspirate culture. Overall mortality was 23% among the ventilated cohort. Thirty two percent of them had VAP compared to only 13% among those who survived to discharge (p = 0.03). Conclusion The frequency of VAP was 17% in this series. Factors significantly associated with VAP were age less than 1 year, unplanned intubation and continuous sedation. The important predictors of VAP included purulent tracheal secretions, high CRP and persistent new radiological findings.

Serum Cholesterol: Could it be a Sixth Parameter of Child-Pugh Scoring System in Cirrhotics Due to Viral Hepatitis?

Abstract: Objective: To determine the association of serum cholesterol levels with Child-Pugh class in patients with decompensated chronic liver disease due to viral hepatitis. Study Design: Cross-sectional analytical study.

Fibrinoid necrosis and hyalinization observed in normal, diabetic and hypertensive placentae.

Abstract: Objective: To determine the fibrinoid necrosis and hyalinization extent in placenta observed in normal, diabetic and hypertensive pregnancies Study Design: Comparative cross-sectional study Place and Duration of Study: Institute of Basic Medical Sciences, Dow University of Health Sciences, Karachi, from 2008-2010 Methodology: One hundred and fifty placentae were divided in three groups on the basis of their histories and clinical examination Group A (control), Group B (Diabetic) and Group C (Hypertensive), each consisted of 50 samples The samples were transferred to Dow Diagnostic Reference and Research Laboratory for histopathology and gross examination The tissue samples were taken from different sites, processed and routine staining done The slides were then examined under light microscope for hyalinization and fibrinoid necrosis The data was analyzed by applying ANOVA and post-hoc Tukey at 95% confidence interval Mean ± standard deviations (SD) were computed Results: The mean number of hyalinized villi in control group was 054 ± 0908, 118 ± 19540 in the diabetic group and 214 ± 1863 in the hypertensive group The difference in their average turned out to be statistically significant (p-value < 0001) Mean number of villi having fibrinoid necrosis was statistically significant in both the diabetic and hypertensive groups as compared to the control group ie 1398 vs 402 and 1008 vs 402 respectively (p-value < 0001) Conclusion: There was significantly greater fibrinoid necrosis and hyalinization in placentae from mothers having diabetes and hypertension The fibrinoid necrosis was seen more in diabetic group as compared to hypertensive and control, while hyalinization was observed more frequently in hypertensive group as compared to the other groups Placental changes as seen in examination of delivered placentae will be helpful in preventing the adverse effects in successive pregnancies

Efficacy of single dose perioperative intravenous steroid (dexamethasone) for postoperative pain relief in tonsillectomy patients.

Abstract: Objective: To determine the efficacy of single dose perioperative intravenous steroid (dexamethasone) for postoperative pain relief in patients undergoing tonsillectomy. Study Design: Quasi-experimental study. Place and Duration of Study: Combined Military Hospital, Lahore, from November 2009 to June 2010. Methodology: Sixty patients were divided into two equal groups. A single dose of dexamethasone was given to patients of group A during induction of anaesthesia, whereas no steroid was given to the patients in group B. Postoperative pain scores were assessed at 2, 6 and 12 hours in both groups using visual analogue scale (VAS). Pain was classified as mild (0-3), moderate (4-7) and severe (8-10) on visual analogue scale. Results: There was no significant difference in pain scores after 2 hours postoperatively. Pain scores of Group A at 6 and 12 hours postoperatively were found to be significantly low than Group B. Conclusion: Single dose perioperative intravenous injection of dexamethasone in tonsillectomy patients reduces postoperative tonsillectomy pain.

Periodontal disease in type 2 diabetes mellitus.

Abstract: Objective: To determine the periodontal status in well controlled and poorly controlled type 2 diabetic patients compared with normal healthy individuals. Study Design: Cross-sectional comparative study. Place and Duration of Study: Diabetes Management Centre, Services Hospital, Lahore, from November 2009 to January 2010. Methodology: Forty well controlled and forty poorly controlled type 2 diabetic subjects having good oral hygiene (scored according to simplified oral hygiene index) were compared with a control group of forty normal healthy individuals. Probing depth (PD), gingival recession (GR), and attachment loss (AL) were recorded to obtain the periodontal status of each tooth, using a Michigan probe “0” with Williams marking. Glycemic control was evaluated by glycated Hb value. Using ANOVA and independent sample t-test, mean probing depth and attachment loss in each tooth type (incisors, canines, premolars and molars) were compared. Results: Mean age of diabetic subjects was 58.86 ± 6.21 years and that of control group was 56.92 ± 6.91 years; 60% were females. Probing depth was greater in patients with poorly controlled diabetes compared to well controlled diabetic patients and non-diabetic controls (4.21 mm vs. 3.72 mm and 2.93 mm respectively, p 0.05). Number of sites and mean percentage of sites with attachment loss of ≥ 4 and ≥ 6 mm was also significantly higher in poorly controlled diabetes compared to the control group (p < 0.05 and p < 0.001 respectively). Conclusion: Periodontal status as estimated by probing depth and degree of attachment loss deteriorates significantly with poor glycemic control in diabetes.

Nutritional status in patients with Hepatitis C

Abstract: Objective: To assess the nutritional status via the SGA (subjective global assessment) screening tool of patients at all stages of hepatitis C virus (HCV) liver disease. Study Design: Descriptive study. Place and Duration of Study: Out-patient Clinics of the Aga Khan University Hospital, Karachi, conducted from October 2009 to January 2011. Methodology: Patients with hepatitis C virus infection and their HCV-negative attendants were enrolled from the outpatient clinics, and categorized into 4 groups of 100 patients each: healthy controls (HC), those with chronic hepatitis C infection (CHC), compensated cirrhotics (CC) and decompensated cirrhotics (DC). The validated subjective global assessment (SGA) tool was used to assess nutritional status. Results: A total of 400 patients were enrolled. Most of the patients in the HC group were class 'A' (best nutritional status). In contrast, the majority (64%) in the DC group were in the class 'C' (worst status). The compensated cirrhosis (CC) group showed that 90% of patients were malnourished, while 98% of all patients were malnourished in the DC group, predominantly class 'C'. Most importantly, 14% of patients with chronic hepatitis C (CHC) also scored a 'B' on the SGA; which when compared to HC was statistically significant (p=0.005). As the groups progressed in their disease from CHC to DC, the transition in nutritional status from 'A' to 'C' between groups was statistically significant. Conclusion: Malnutrition occurs early in the course of HCV, and progresses relentlessly throughout the spectrum of HCV disease.

Role of postoperative antibiotics after appendectomy in non-perforated appendicitis.

Abstract: Objective: To determine the role of postoperative antibiotics in reducing the surgical site infections (SSIs) after open appendectomy in patients with non-perforated appendicitis (NP A). Study Design: Randomized controlled trial.

Coexistence of multiple omphalomesenteric duct anomalies.

Abstract: The omphalomesenteric duct is an embryonic structure which connects the yolk sac to the midgut. The omphalomesenteric duct attenuates between the 5th and 9th week of gestation. Failure of the omphalomesenteric duct involution, either partial or complete, results in various omphalomesenteric duct remnants including Meckel's diverticulum, patent vitelline duct, fibrous band, sinus tract, umbilical polyp and cyst. Omphalomesenteric duct remnants are present in 2% of the population but related diseases have seldom been reported in adults. The simultaneous presence of sinus tract, omphalomesenteric cyst, fibrous ligament and Meckel's diverticulum has, according to authors' knowledge, never been reported. We present a case of a 23 years old male with persisting umbilical discharge for 2 years in whom there was coexistence of the above mentioned anomalies of the omphalomesenteric duct.

Enteric fever in Karachi: current antibiotic susceptibility of Salmonellae isolates.

Abstract: Objective To determine the current sensitivity and resistance profile of Salmonellae (S.) isolates in a laboratory setting. Study design An observational study. Place and duration of study Dr. Essa`s Laboratory and Diagnostic Centre, Karachi, Pakistan, from November 2008 - October 2010. Methodology Isolates from blood culture specimens of 481 bacteraemic patients were identified using conventional biochemical tests. Salmonellae was confirmed with specific antisera and their antibiograms determined by Kirby-Bauer Disc Diffusion method using 12 relevant antibiotics. Inclusions of the study were bacteraemia documented in all blood samples positive for S. typhi, S. paratyphi-A and B. Exclusions were all samples other than blood and blood samples negative for S. typhi and S. paratyphi-A and B during the same period. Multidrug resistance (MDR) of isolates was defined as the isolates showing resistance to all conventional anti-typhoid medicines i.e., Chloramphenicol, Ampicillin and Co-trimoxazole. Results Specimens (n=217) yielded 131 Salmonellae typhi (60.36%), 71 S. paratyphi-A (32.71%), and 15 S. paratyphi-B (6.9%); these were sensitive to the Quinolones [Enoxacin: 94.96% (n=91), Ciprofloxacin, 96.47% (n=182), Ofloxacin: 95.74% (n=203)], and Cephalosporins [Cefixime: 96.62% (n=202), Cefotaxime: 99.17% (n=206), Ceftriaxone: 98.79% (n=208)]. Resistance to Amoxicillin was 96.48% (n=128) and 29.91% (n=78) to Co-trimoxazole. About 62.64% (n=136) of the isolates were MDR strains. Conclusion Ciprofloxacin is currently a suitable empirical choice in presumed enteric fever cases, but culture and sensitivity analysis should be encouraged and results incorporated in prescription strategy. Increasing frequency of S. paratyphi-A isolates possibly suggests incomplete coverage employing monovalent vaccine.

MELD Score: Utility and Comparison with King's College Criteria in Non-Acetaminophen Acute Liver Failure

Abstract: Objective: To compare Model for End-stage Liver Disease Score (MELD Score, MS) and King’s College Hospital (KCH) criteria for finding correlation of mortality in non-acetaminophen induced acute liver failure (NAI-ALF). Study Design: An analytical cross-sectional study. Place and Duration of Study: The Aga Khan University Hospital, Karachi, from 2005 to 2007. Methodology: The study included patients with NAI-ALF. KCH criteria were labelled as good and bad prognosis groups. MELD score were calculated by using the MELD calculator. ROC was plotted and sensitivity analysis was done. ETA was used to see correlation between MELD and KCH. Results: Ninety-one patients with mean age of 32.5 + 16.3 years were studied; 49 were males (54%). Out of these, 57 patients died (63%); two leading causes of non-acetaminophen induced acute liver failure (NAI-ALF) were hepatitis hepatitis B virus (HBV) (n = 30, 33%) followed by hepatitis E virus in (n = 23, 25.3%). According to King's College Hospital (KCH) criteria, 50 patients (88%) who died had bad prognosis and 24 patients (70.6%) who survived had good prognosis. The ROC determined MELD score of 32 was the best predictor of mortality with sensitivity and specificity of 79% and 71%, respectively and positive predictive value (PPV) and negative predictive values (NPV) of 82% and 67% respectively. There was significant association between mortality and bad prognosis according to KCH criteria (p < 0.001). Overall mean MELD score (MMS) was 35.35 + 8.64. MMS on admission was 38 + 7.32 in patients who died and 30.7 + 8.77 in those who survived (p = < 0.001). MMS correlated equally with KCH criteria (ETA = 0.52). Conclusion: The admission MELD score has an excellent utility and correlates equally with KCH criteria for mortality in NAI- ALF.

Blood glucose levels in neonatal sepsis and probable sepsis and its association with mortality.

Abstract: Objective: To determine the blood glucose levels among patients with neonatal sepsis and probable sepsis and evaluate their association with the mortality rate. Study Design: Analytical study. Place and Duration of Study: Fazle Omar Hospital, Rabwah, Pakistan from July 2007 to December 2008. Methodology: Neonates with culture proven and probable neonatal sepsis were included. The glucose levels at the time of admission and outcomes were recorded. The patients were divided in four groups according to their glucose levels i.e. 200 mg/dl. The patients were divided in two groups according to weight i.e. < 2.5 kg and ≥ 2.5 kg. Results: There were a total of 502 cases. The glucose levels were below 40 mg/dl in 50 patients (9.9%), between 40 mg/dl to 100 mg/dl in 322 (64.1%), between 101 mg/dl to 200 mg/dl in 95 (18.9%) and above 200 mg/dl in 35 patients (6.9%). Among these four groups, 16 (32%), 32 (9.9%), 22 (23.2%) and 17 (48.6%) neonates died respectively (p < 0.001). The difference in glucose levels among the two groups according to weight was significant (p=0.002). Conclusion: Majority of patients with neonatal sepsis and probable sepsis had glucose levels between 40 and 100 mg/dl at admission. Those with the levels below 40 mg/dl and above 200 mg/dl had higher mortality rates.

Comparison of Haemodynamic Changes in Patients Undergoing Unilateral and Bilateral Spinal Anaesthesia

Abstract: Objective: To assess the haemodynamic changes in patients receiving unilateral and bilateral spinal anaesthesia with their pre-anaesthesia recordings. Study Design: Quasi-experimental study. Place and Duration of Study: Main Operation Theater, Liaquat National Hospital, Karachi, from May 2006 to February 2007. Methodology: Sixty patients meeting the inclusion criteria were randomly allocated in two groups of 30 patients each. One and a half ml of 0.75% hyperbaric bupivacaine was injected with free flow of cerebrospinal fluid using a 23 gauge quincke needle. Lumbar puncture was performed in the sitting position at 3 ‐ 4 or 4 ‐ 5 lumbar interspace. Patients were then assigned to the supine or lateral decubitus position for 10 minutes. Heart rate, systolic, mean and diastolic blood pressures of patients were recorded with their pre-anaesthesia readings in the 1st, 5th, 15th, 30th and then at every 15th minute till the end of procedure. Recovery room readings were also taken. Results: The systolic, mean and diastolic blood pressure changes were significant in both groups. But from 1st minute to recovery room, statistically significant difference (p < 0.05) was found at each time interval, the unilateral groups (group A) being more stable with respect to pre-anaesthesia readings. The decrease in heart rate was comparable in both groups. Conclusion: Unilateral spinal anaesthesia was associated with a more stable cardiovascular profile, therefore, it is a valuable technique for high risk patients.

Diffusion weighted MR imaging of ring enhancing brain lesions.

Abstract: Objective: To evaluate the role of diffusion weighted imaging in differentiating the cause of ring enhancing brain lesions. Study Design: Analytical, descriptive study.