Showing papers in "Jcpsp-journal of The College of Physicians and Surgeons Pakistan in 2014"

Ammonia levels and the severity of hepatic encephalopathy.

Abstract: Objective: To evaluate the correlation between ammonia levels with the severity of HE in patients coming to the tertiary care hospital with liver cirrhosis and hepatic encephalopathy (HE). Study Design: Descriptive, analytical study.

RIPASA score: a new diagnostic score for diagnosis of acute appendicitis.

Abstract: Objective To determine the usefulness of RIPASA score for the diagnosis of acute appendicitis using histopathology as a gold standard. Study design Cross-sectional study. Place and duration of study Department of General Surgery, Combined Military Hospital, Kohat, from September 2011 to March 2012. Methodology A total of 267 patients were included in this study. RIPASA score was assessed. The diagnosis of appendicitis was made clinically aided by routine sonography of abdomen. After appendicectomies, resected appendices were sent for histopathological examination. The 15 parameters and the scores generated were age (less than 40 years = 1 point; greater than 40 years = 0.5 point), gender (male = 1 point; female = 0.5 point), Right Iliac Fossa (RIF) pain (0.5 point), migration of pain to RIF (0.5 point), nausea and vomiting (1 point), anorexia (1 point), duration of symptoms (less than 48 hours = 1 point; more than 48 hours = 0.5 point), RIF tenderness (1 point), guarding (2 points), rebound tenderness (1 point), Rovsing's sign (2 points), fever (1 point), raised white cell count (1 point), negative urinalysis (1 point) and foreign national registration identity card (1 point). The optimal cut-off threshold score from the ROC was 7.5. Sensitivity analysis was done. Results Out of 267 patients, 156 (58.4%) were male while remaining 111 patients (41.6%) were female with mean age of 23.5 ± 9.1 years. Sensitivity of RIPASA score was 96.7%, specificity 93.0%, diagnostic accuracy was 95.1%, positive predictive value was 94.8% and negative predictive value was 95.54%. Conclusion RIPASA score at a cut-off total score of 7.5 was a useful tool to diagnose appendicitis, in equivocal cases of pain.

Intraoperative Low-Dose Ketamine Infusion Reduces Acute Postoperative Pain Following Total Knee Replacement Surgery: A Prospective, Randomized Double-Blind Placebo-Controlled Trial

Abstract: Objective: To evaluate the effect of intraoperative low-dose ketamine with general anesthesia on postoperative pain after total knee replacement surgery. Study Design: A randomized, double-blind comparative study. Place and Duration of Study: Ankara Numune Training and Research Hospital, Turkey, from January and June 2011. Methodology: Sixty adults undergoing total knee arthroplasty were enrolled in this study. The patients were randomly allocated into two groups of equal size to receive either racemic ketamine infusion (6 µg/kg/minute) or the same volume of saline. A visual analogue scale (VAS) was used to measure each patient's level of pain at 1, 3, 6, 12, and 24 hours after surgery. Time to first analgesic request, postoperative morphine consumption and the incidence of side effects were also recorded. Results: Low-dose ketamine infusion prolonged the time to first analgesic request. It also reduced postoperative cumulative morphine consumption at 1, 3, 6, 12, and 24 hours postsurgery (p < 0.001). Postoperative VAS scores were also significantly lower in the ketamine group than placebo, at all observation times. Incidences of side effects were similar in both study groups. Conclusion: Intraoperative continuous low-dose ketamine infusion reduced pain and postoperative analgesic consumption without affecting the incidence of side effects.

The Pittsburgh Sleep Quality Index: Validation of the Urdu Translation

Abstract: Objective: To translate and validate the Pittsburgh Sleep Quality Index (PSQI), a standardized self-administered questionnaire for the assessment of subjective sleep quality into the Urdu language. Study Design: Validation study. Place and Duration of Study: Mayo Hospital, Lahore, from March to April 2012. Methodology: The PSQI was translated into Urdu following standard guidelines. The final Urdu version (PSQI-U) was administered to 200 healthy volunteers comprising medical students, nursing staff and doctors. Inter-item correlation was assessed by calculating Cronbach alpha. Correlation of component scores with global score was assessed by calculating Spearman correlation coefficient. Correlation between global PSQI-U scores at baseline with global scores for each PSQI-U and PSQI-E at 4-week interval was evaluated by calculating Spearman correlation coefficient. Moreover, scores on individual items of the scale at baseline were compared with respective scores after 4-week by t-test. Results: One hundred and eighty five (185) participants completed the PSQI-U at baseline. The Cronbach alpha for PSQI-U was 0.56. Scores on individual components of the PSQI-U and composite scores were all highly correlated with each other (all p-values < 0.01). Composite scores for PSQI-U at baseline and PSQI-E at 4-week interval were also highly correlated with each other (Spearman correlation coefficient 0.74, p-value < 0.01) indicating good linguistic interchangeability. Composite scores for PSQI-U at baseline and at 4-week interval were positively correlated with each other (Spearman correlation coefficient 0.70, p < 0.01) indicating good test-retest reliability. Conclusion: The PSQI-U is a valid and reliable instrument for the assessment of sleep quality. It shows good linguistic interchangeability and test-retest reliability in comparison to the original English version when applied to individuals who speak the Urdu language. The PSQI-U can be a tool either for clinical management or research.

Adams-Oliver syndrome.

Abstract: A new-born male baby with typical features of Adams-Oliver syndrome (AOS) is described. Adams-Oliver syndrome is the association of aplasia cutis congenita with terminal transverse limb reduction defects with or without cutis marmorata telangiectatica congenita. The patient presented with brachydactyly involving all the digits of his hands and shortening of both big toes along with aplasia cutis on the scalp. There was no systemic involvement. The patient was placed on regular follow-up.

Possible role of brain-derived neurotrophic factor (BDNF) in autism spectrum disorder: current status.

Abstract: Brain-derived neurotrophic factor (BDNF), a member of the neurotrophin family of survival-promoting molecules, plays a vital role in the growth, development, maintenance, and function of several neuronal systems. The purpose of this review is to document the support for the involvement of this molecule in the maintenance of normal cognitive, emotional functioning, and to outline recent developments in the content of Autism spectrum disorder (ASD). Current and future treatment development can be guided by developing understanding of this molecule's actions in the brain and the ways the expression of BDNF can be planned. Over the years, research findings suggested a critical role played by BDNF in the development of autism including increased serum concentrations of BDNF in children with autism and identification of different forms of BDNF in families of autistic individuals.

Relationship between resilience and quality of life in diabetics.

Abstract: OBJECTIVE To determine the relationship between resilience and quality of life of diabetes patients controlling the effect of personal level (i.e., gender, age, and income) and disease-specific (i.e., duration of disease, and current glucose level) demographics. STUDY DESIGN Analytical study. PLACE AND DURATION OF STUDY Outpatient Departments of various hospitals in Islamabad and Rawalpindi, from October to November 2012. METHODOLOGY Patients diagnosed with diabetes taking treatment in an outdoor patients' facility were included. Patients with a major diabetes complications causing or coexistent with a physical disability, medical condition or psychiatric comorbidity were excluded. Informed consent was taken from patients before administration of questionnaires. The patients were asked to respond to a demographic sheet, State-Trait resilience inventory, and WHO-Quality of Life BREF. Statistical testing was conducting using bivariate correlation, Mann-Whitney U-test, and multiple linear regression analysis for moderation testing. RESULTS There were 242 patients including (n=108, 44% females; and n=134, 56% males) aged 17 - 85 years with mean of 44.56 ± 16.56 years. Trait resilience predicted all aspects of quality of life of diabetic patients (b range = 0.30 to 0.42, p < .01) and explained 17% variance in physical functioning, 29% in psychological functioning, 17% in environmental functioning, 30% in social dimension, and 29% in overall quality of life. Duration of diabetes moderated effect of state resilience on all aspects of quality of life (b interaction range = 0.20 to 0.26, p < .05) and explained an additional 4% variance in physical functioning, 5% in psychological functioning, 3% in environmental functioning, 5% in social dimension, and 4% in overall quality of life of diabetics. CONCLUSION Trait resilience has unconditional positive effect on all aspect of quality of life. Long standing diabetics may benefit from intervention addressing state resilience.

Bacteriologic profile and antibiogram of blood culture isolates from a children's hospital in Kabul

Abstract: Objective To identify the bacterial pathogens causing paediatric septicaemia in Kabul and to determine their antibiogram to improve empirical antibiotic therapy. Study design Cross-sectional study. Place and duration of study Microbiology Laboratory of FMIC, Kabul, Afghanistan, from January 2010 to June 2012. Methodology Blood cultures from suspected cases of sepsis were processed in BD (Becton Dickinson, USA) for culture BACTEC™ 9240 Blood Culture System. Positive growths were examined and isolates were identified by conventional biochemical tests. Bacteria were identified to the species level using various Analytical Profile Index (API) identification strips. Antibiotic susceptibility testing was performed by modified Kirby-Bauer disk diffusion method. Drug resistant strains were studied for extended spectrum beta lactamase (ESBL) production by combination disk method and for methicillin resistant Staphylococcus aureus (MRSA) by Cefoxitin disk diffusion method. Results Out of a total 3360 blood cultures received from in-patients, 410 yielded monomicrobial growth; hence the frequency of positive blood culture was 12.2%. Out of a total 410 isolates, 212 (51.71%) were gram-negative bacilli and 184 (44.88%) were gram-positive cocci. In addition, 14 (3.41%) Candida species were also isolated. The frequently isolated species of gram-negative bacteria belonged to Enterobacteriaceae and included 66 Klebsiella (16.1%), 42 Enterobacter (10.2%), 35 Escherichia (E.) coli (8.5%) and 16 Serratia (3.9%) species. In addition, 21 (5.12%) Pseudomonas species were also isolated. Correspondingly, amongst gram-positive cocci, the most frequently isolated species were 108 coagulase-negative Staphylococci (26.34%) followed by 49 Staphylococcus aureus (11.95%) and 21 Streptococcus species (5.12%). Among gram-negative isolates, those that produced ESBL i.e., 110 out of 212 (51.9%) were found to be multidrug-resistant and showed high resistance to commonly used antibiotics namely Ampicillin, Gentamicin, 3rd generation Cephalosporins, Fluoroquinolones and Co-trimoxazole. Most of the isolates were susceptible to Imipenem (200/212, 94.3%), Amikacin (172/212, 81.1%) and Fosfomycin (166/212, 78.3%). Amongst gram-positive cocci, majority were resistant to Penicillin, Gentamicin, 3rd generation Cephalosporins, Fluoroquinolones and Cotrimoxazole. However, most were sensitive to Vancomycin (183/184) Pristinamycin (161/184, 87.5%) and Fosfomycin (134/184, 72.8%). All Staphylococci were resistant to Penicillin and 80/157 (51%) were MRSA. Conclusion Klebsiella, E. coli, Enterobacter and Staphylococci remain the principal organisms responsible for blood stream infection in a paediatrics tertiary care setting in Kabul. The most sensitive among the tested antibiotics for gram-negative organisms were Imipenem, Amikacin, and Fosfomycin and for gram-positive organisms were Vancomycin, Pristinamycin and Fosfomycin.

Hypolipidemic effect of fenugreek seeds and its comparison with atorvastatin on experimentally induced hyperlipidemia.

Abstract: OBJECTIVE To determine the hypolipidemic effect of fenugreek (Methi) seeds and its comparison with atorvastatin on experimentally induced hyperlipidemia in rabbits. STUDY DESIGN Experimental interventional study. PLACE AND DURATION OF STUDY Department of Physiology, Dr. S. N. Medical College, Jodhpur, Rajasthan, India, from April 2012 to March 2013. METHODOLOGY Twenty, 1 - 2 years old albino rabbits of European Strains were randomly divided into two groups of 10 rabbits each. All were fed pure cholesterol (0.5 g/kg body weight/day) for 4 weeks to induce hyperlipidemia. Group-I comprised of 10 hyperlipidemic rabbits which were fed normal (regular) diet supplemented with 2 ml aqueous emulsified fenugreek seeds powder (500 mg/kg body weight/day) for 4 weeks. Group-II comprised of 10 hyperlipidemic rabbits, which were fed normal (regular) diet supplemented with 2 ml aqueous emulsion of atorvastatin (0.5 mg/kg body weight/day) for 4 weeks. Fasting blood samples were collected two times during experimental period at weeks (4 and 8) and analyzed for serum total cholesterol and triglycerides, using semi-automated chemistry analyzer. HDL-C was determined by precipitation method and LDL-C and VLDL-C were estimated by Friedewalds formula. LDL/HDL ratio and TG/HDL ratios were also calculated. The significance of difference in mean values of both groups (lipid profile) was assessed by independent student's t-test. RESULTS Atorvastatin showed a more potent hypolipidemic activity. It reduced serum total cholesterol, TG, LDL and VLDLcholesterol, and the atherogenic index (LDL-C/HDL-C; p < 0.001) highly significantly as compared to fenugreek. There was a significant increase of HDL-C (p < 0.01) in group-I as compared to group-II. CONCLUSION Fenugreek and atorvastatin both have hypolipidemic activity in rabbits but atorvastatin is more potent than fenugreek seeds powder.

Effects of pre-operative submucosal dexamethasone injection on the postoperative swelling and trismus following surgical extraction of mandibular third molar.

Abstract: OBJECTIVE To determine the effects of pre-operative submucosal dexamethasone injection on postoperative swelling and trismus following surgical extraction of mandibular third molar. STUDY DESIGN Randomized controlled trial. PLACE AND DURATION OF STUDY Department of Oral and Maxillofacial Surgery, Armed Forces Institute of Dentistry (AFID), Rawalpindi, from October 2009 to March 2010. METHODOLOGY A total of 100 patients aged 18 - 40 years with good periodontal health and mesioangular impaction were divided in two treatment groups (50 in each group). Group-A received prophylactic 4 mg submucosal dexamethasone intraoral injection and Group-B acted as control group. Facial swelling and trismus were assessed at baseline, 2nd and 7th postoperative days. Data was analyzed using SPSS-10. RESULTS There were 35 (70%) males and 15 (30%) females in group-A and 34 (68%) males and 16 (32%) females in group-B. Surgical time ranged from 30 - 50 minutes (mean = 40.62 ± 4.886 minutes) for group-A and 33 - 50 minutes (mean = 42.12 ± 4.543 minutes) for group-B. Administration of dexamethasone had statistically significant effect in reduction of swelling and trismus on second postoperative day (p < 0.05) in group-A. CONCLUSION Pre-operative 4 mg submucosal dexamethasone injection was significantly effective in reduction of postoperative swelling and trismus.

Platelet counts, MPV and PDW in culture proven and probable neonatal sepsis and association of platelet counts with mortality rate.

Abstract: OBJECTIVE To determine frequency of thrombocytopenia and thrombocytosis, the MPV (mean platelet volume) and PDW (platelet distribution width) in patients with probable and culture proven neonatal sepsis and determine any association between platelet counts and mortality rate. STUDY DESIGN Descriptive analytical study. PLACE AND DURATION OF STUDY NICU, Fazle Omar Hospital, from January 2011 to December 2012. METHODOLOGY Cases of culture proven and probable neonatal sepsis, admitted in Fazle Omar Hospital, Rabwah, were included in the study. Platelet counts, MPV and PDW of the cases were recorded. Mortality was documented. Frequencies of thrombocytopenia ( 450000/mm3) were ascertained. Mortality rates in different groups according to platelet counts were calculated and compared by chi-square test to check association. RESULTS Four hundred and sixty nine patients were included; 68 (14.5%) of them died. One hundred and thirty six (29%) had culture proven sepsis, and 333 (71%) were categorized as probable sepsis. Thrombocytopenia was present in 116 (24.7%), and thrombocytosis was present in 36 (7.7%) cases. Median platelet count was 213.0/mm3. Twenty eight (27.7%) patients with thrombocytopenia, and 40 (12.1%) cases with normal or raised platelet counts died (p < 0.001). Median MPV was 9.30, and median PDW was 12.30. MPV and PDW of the patients who died and who were discharged were not significantly different from each other. CONCLUSION Thrombocytopenia is a common complication of neonatal sepsis. Those with thrombocytopenia have higher mortality rate. No significant difference was present between PDW and MPV of the cases who survived and died.

Peer assisted versus expert assisted learning: a comparison of effectiveness in terms of academic scores.

Abstract: OBJECTIVE To compare the effectiveness of peer assisted learning versus expert assisted learning in terms of academic scores. STUDY DESIGN Cross over-randomized control trial followed by a cross-sectional survey. PLACE AND DURATION OF STUDY Fatima Memorial Hospital, College of Medicine and Dentistry, Lahore, during January to October 2012. METHODOLOGY This study was conducted on 4th year MBBS students. The students were randomly divided in two groups by lottery method following their roll numbers. The groups A and B were dealt with Peer Assisted Learning (PAL) and Expert Assisted Learning (EAL) respectively. Effectiveness of both methods of learning was calculated on the basis of academic scores obtained in MCQ tests. One best answer type of MCQs were used and their construct validity was checked by other senior faculty members. After crossover of groups and altered teaching strategy, academic scores were compared again within the group and the comparable group. Student's views about this technique were measured by Likert's scale. P-values were obtained by applying independent and paired t-tests and considered statistically significant at ≥ 0.05. RESULTS There were 70 students of 4th year MBBS which included 24 (34.3%) males and 46 (65.7%) females. TheCrohnbach's alpha value of these MCQs was 0.64. Scores of MCQ test were compared by applying independent t-test and p-value obtained was 0.971; after cross over p-value was 0.468 which was not significant between the results obtained by two learning strategies. Twenty five students (46.3%) said that PAL is an effective technique. Thirty eight (70.4%) students found it easy to communicate with a peer. For incorporation of PAL in curriculum of community medicine, 24 (44.4%) students voted in its favour. CONCLUSION Peer assisted learning has proved of equivalent efficacy in terms of students score in MCQs test as expert assisted learning.

Antimicrobial susceptibility pattern of bacteria isolated from patients with urinary tract infection.

Abstract: Objective: To determine the antimicrobial susceptibility pattern of bacterial pathogens in the patients of urinary tract infection reporting at a tertiary care hospital. Study Design: Laboratory based study. Place and Duration of Study: Department of Microbiology, Armed Forces Institute of Pathology, Rawalpindi, from January to December 2012. Methodology: A total of 440 culture positive bacterial isolates from 1110 urine samples; submitted over a period of one year were included in this study. Identification of bacterial isolates was done by standard biochemical profile of the organisms. The antimicrobial susceptibility of culture positive bacterial isolates was performed by disk diffusion method as recommended by Clinical Laboratory Standard Institute guidelines (CLSI). Results: Out of the 440 culture positive urine samples, 152 (34.6%) were from indoor patients whereas 288 (65.4%) from outdoor patients. Gram negative bacteria accounted for 414 (94%) of the total isolates while rest of the 26 (6%) were Gram positive bacteria. The most prevalent bacterial isolate was Escherichia (E.) coli 270 (61.3%) followed by Pseudomonas (P.) aeruginosa 52 (12%) and Klebsiella (K.) pneumoniae 42 (9.5%). The susceptibility pattern of E. coli showed that 96.2% of the bacterial isolates were sensitive to imipenem, 85.1% to amikacin, 80.7% to piperacillin/tazobactam and 72.6% to nitrofurantoin. In case of P. aeruginsosa, 73% bacterial isolates were sensitive to tazobactam/piperacillin, 69.2% to sulbactam/cefoperazone and 65.38% to imipenem. The antibiogram of K. pneumoniae has revealed that 76.1% of the bacterial isolates were sensitive to imipenem and 52.3% to piperacillin/tazobactam. Nitrofurantoin and imipenem were the most effective antimicrobials amongst the Enterococcus spp. as 92.3% showed susceptibility to this bacterial isolate. Conclusion: Majority of the bacterial isolates were sensitive to imipenem and piperacillin/tazobactam while susceptibility to most of the commonly used oral antibiotics was very low. Among the oral antimicrobials, nitrofurantoin showed good susceptibility against Enterobacteriaceae family and Gram positive organisms.

Team Based Learning (TBL) in undergraduate medical education.

Abstract: OBJECTIVE To determine if modified Team Based Learning (TBL) was more effective than Traditional Didactic Lecture (TDL) in improving knowledge outcomes about Diabetes management in fourth year medical students and to check the students' view about the TBL method in comparison with their earlier experience with TDL. STUDY DESIGN A comparative study. PLACE AND DURATION OF STUDY Lahore Medical and Dental College, Lahore, from January to February 2011 in 4 weeks. METHODOLOGY Modification of the original TBL method as described by Michaelsen was done to accommodate the educational system. A total of 7 sessions were allotted to teach non-communicable diseases to fourth year MBBS students. Session which was scheduled for teaching Diabetes mellitus was conducted first by TDL and three weeks later with the TBL session. MCQ based tests were administered to self paired groups of students first after the TDL session and then after the TBL session. Wilcoxon signed-rank test was used to compare post-TDL and post-TBL test scores of the students. Students' views about the TBL session compared to the TDL session were checked by using pre-tested questionnaire. RESULTS Seventy two, fourth year MBBS students participated in this TBL session. Majority were females 49 (68.1%). There was improvement of test scores of students after the TBL session when compared to the test scores after TDL session (p < 0.001). Majority of the respondents noted that TBL session was a better learning strategy compared to TDL. CONCLUSION The 72 students included in the study achieved higher mean test scores on test questions that assessed their knowledge of Diabetes mellitus content learned using the TBL strategy compared with TDL method (p < 0.001). TBL learning method was favoured by a majority of medical students compared to the TDL session.

Correlation of CRP, fasting serum triglycerides and obesity as cardiovascular risk factors.

Abstract: Objective To determine the correlation of C-reactive protein (CRP) with fasting triglycerides (TG) among pre-obese and obese patients without established diagnosis of coronary artery disease (CAD). Study design A comparative cross-sectional study. Place and duration of study Mayo Hospital, Lahore, from January to June 2010. Methodology Patients with BMI > 23 kg/m2 aged between 18 - 65 years were inducted and above variables were studied. Patients with signs of fluid retention, collagen vascular disease, CAD, patients on corticosteroids, immunomodulators or lipid lowering medications and febrile patients were not recruited. Body mass index was also determined. Independent sample t-test was applied to see the mean difference of age, CRP level and triglycerides level in relation to gender. Chi-square test was used to see the association between qualitative variables. ANOVA was applied to see CRP and fasting serum TG level in relation to BMI categories. Pearson correlation and simple linear regression was applied to see the dependency of CRP and triglycerides with BMI. P-value ² 0.05 was taken as significant. Results Raised CRP was major finding among all groups of BMI. Most of obese and pre-obese patients were young and middle aged and belonged to pre-obese group followed by class-1 and class-2 obesity. CRP level increased with body mass index. No such trend was observed for triglycerides. There was an intermediate positive correlation between CRP and BMI and triglycerides and BMI showed a weak negative correlation. If BMI increases by 1 unit on the average, CRP rises by 0.239 times and this unit rise was significant. Whereas 1 unit rise increase in triglycerides on the average cause CRP to decrease -0.006 times but this value was insignificant. Conclusion Raised CRP and high fasting TG were major findings in all age groups especially among young and middle aged people. Obesity, hypertriglyceridemia and raised CRP are interrelated suggesting that obesity is not only linked to hypertriglyceridemia but vascular inflammation among pre-obese and obese without overt diabetes mellitus causes high CRP as well and this can be used as a marker to predict the future risk of CAD. However, in the absence of dyslipidaemia, raised CRP can still be considered as a strong predictor of CAD and stroke.

Comparison of friedewald formula and modified friedewald formula with direct homogeneous assay for low density lipoprotein cholesterol estimation.

Abstract: Objective: To compare the Friedewald and modified Friedewald formulae with direct homogeneous assay for serum lowdensity lipoprotein cholesterol (LDL-C) levels estimation. Study Design: Cross-sectional study. Place and Duration of Study: Armed Forces Institute of Pathology, Rawalpindi, from June to December 2011. Methodology: Healthy subjects of either gender, from Rawalpindi, aged 18-75 years were included by consecutive sampling. Patients with diabetes mellitus, chronic liver disease, chronic kidney disease, those taking lipid lowering drugs and samples with triglyceride (TG) > 4.52 mmol/l were excluded from the study. Total cholesterol, high-density lipoprotein cholesterol, TG and LDL-C were measured on Hitachi 912 chemistry analyzer (Roche). LDL-C levels were also calculated by Friedewald formula (FF) and Vujovic modified formula (VMF). Paired sample t-test and scatter plots were used for statistical analysis. Results: Although both calculated methods showed good correlation with direct assay (r > 0.93) in 300 subjects, but the difference was statistically significant. The ffLDL-C were 0.12 ± 31 mmol/l (p < 0.001) lower and vmfLDL-C were 0.11 ± 26 mmol/l (p < 0.001) higher than dLDL-C. The difference was not significant between ffLDL-C and dLDL-C at TG levels < 1.70 mmol/l (p = 0.58) and between vmfLDL-C and dLDL-C at TG levels 2.26 – 4.52 mmol/l (p = 0.38). At all other TG levels, the difference between LDL-C calculated by both formulas and dLDL-C was statistically significant (p < 0.001). As compared to direct assay, 11% and 14% subjects were classified in wrong National Cholesterol Education Programm's cardiac risk categories by FF and VMF respectively. Conclusion: LDL-C should be measured by direct homogeneous assay in routine clinical laboratories, as the calculated methods did not have a uniform performance for LDL-C estimation at different TG levels.

Peer assisted learning as a formal instructional tool.

Abstract: OBJECTIVE: To explore the utility of peer assisted learning (PAL) in medical schools as a formal instructional tool. STUDY DESIGN: Grounded theory approach. PLACE AND DURATION OF STUDY: King Edward Medical University, Lahore, from July 2011 to December 2011. METHODOLOGY: A study was designed using semi-structured in-depth interviews to collect data from final year medical students (n=6), residents (n=4) and faculty members (n=3), selected on the basis of non-probability purposive sampling. The qualitative data thus generated was first translated in English and transcribed and organized into major categories by using a coding framework. Participants were interviewed two more times to further explore their perceptions and experiences related to emergent categories. An iterative process was employed using grounded theory analysis technique to eventually generate theory. RESULTS: PAL was perceived as rewarding in terms of fostering higher order thinking, effective teaching skills and in improving self efficacy among learners. CONCLUSION: PAL can offer learning opportunity to medical students, residents and faculty members. It can improve depth of their knowledge and skills.

Efficacy of Rifaximin in prevention of recurrence of hepatic encephalopathy in patients with cirrhosis of liver.

Abstract: Objective To determine the efficacy of Rifaximin in prevention of repeated episodes of hepatic encephalopathy in patients with liver cirrhosis as compared to placebo. Study design Triple-blind, randomized placebo-controlled trial. Place and duration of study Department of Gastroenterology-Hepatology, Shaikh Zayed Hospital, Lahore, from October 2012 to April 2013. Methodology Patients in remission from recurrent hepatic encephalopathy resulting from cirrhosis were randomly assigned to receive either Rifaximin, at a dose of 550 mg twice daily (63 patients), or placebo (63 patients.) Patients were requested to take the drug orally twice daily for 6 months or until they developed a breakthrough episode of hepatic encephalopathy. Results Mean age of patients in treatment and control group was 40.21 ± 2.33 years and 42.87 ± 4.54 years respectively. The most common etiology of cirrhosis was hepatitis C followed by hepatitis B. Patients who remained free of hepatic encephalopathy during study period were 40 out of 63 patients in control group and 35 patients out of 63 patients (p = 0.56). Most of the patients who developed breakthrough hepatic encephalopathy had a MELD score range of 21-25 in both groups. The number of deaths and adverse events was similar in both groups. Conclusion Over a 6-month period, treatment with Rifaximin failed to maintain remission from hepatic encephalopathy more effectively than placebo in the studied group.

Missed vascular injuries: presentation and outcome.

Abstract: Objective To describe the different presentation, diagnostic evaluation, management and outcome of complications of missed vascular injuries. Study design A case series. Place and duration of study Combined Military Hospital, Rawalpindi and Combined Military Hospital, Kharian Cantt, from June 2009 to June 2012. Methodology All the patients with vascular injuries missed at the time of causative trauma who reported during this study period were included. Patients presented with acute vascular injuries and iatrogenic aneurysm at the vascular anastomosis site were excluded. All cases were evaluated with either CT or conventional angiography and managed with various open vascular surgical techniques and their results were assessed. Results Twenty eight patients with missed vascular injury underwent various vascular repairs. Age of patients ranged from 16 to 78 years (mean = 33.7 ± 15.4 years). Male to female ratio was 6:1. Twelve (42.8%) patients presented with pseudoaneurysm alone, 10 (35.7%) with traumatic arteriovenous fistulae, 4 (14.3%) with post-traumatic thrombosis and occlusion and 2 (7.1%) with pseudoaneurysm and hemorrhage. Penetrating injuries were the commonest cause in 19 (67.8%). The time interval between injury and presentation in hospital ranged from 2 to 1300 weeks (mean 228 weeks). Lower limb vessels were affected in 20 (71.4%), the upper limb in 5 (17.8%) and neck vessels in 3 (10.7%). Superficial femoral artery was the most frequently involved artery in 9 (32.1%) cases. Interposition reverse autogenous saphenous vein graft was most common type of repair in all types of missed vascular injuries. One (3.5%) patient had amputation after secondary hemorrhage. Conclusion Low velocity penetrating trauma was the common cause of missed vascular injury. Pseudoaneurysm was the most common presentation.

Clinical presentations of acute leukemia.

Abstract: Objective To document the clinical presentation and epidemiology of various types of acute leukemia with their respective referral source at a tertiary level centre in Peshawar. Study design An observational study. Place and duration of study Department of Pathology, Hayatabad Medical Complex (HMC), Peshawar, from January 2011 to May 2012. Methodology A total of 618 bone marrow biopsy reports were reviewed. All biopsy reports labeled as acute leukemia were reviewed for age, gender, address, referring unit, diagnosis on bone marrow examination, presenting complaints, duration of illness and findings of clinical examination. Results Ninety-two patients were diagnosed as suffering from acute leukemias (15%). ALL was most prevalent (46%), followed by AML (38%) and undifferentiated acute leukemia (16%). Males were affected more compared to females (60% vs. 40%). ALL and AML were predominant in pediatric (64%) and adults (77%) patients respectively. Patients from Afghanistan accounted for 33% of all cases followed by Peshawar (14%). Fever (77%), pallor (33%) and bleeding disorders (23%) were the main presenting complaints. Enlargement of liver, spleen and lymph nodes together was associated with ALL compared with AML (p = 0.004). Conclusion ALL-L1 and AML-M4 were the most common sub-types. Fever, pallor and bleeding disorders were the main presenting complaints. Enlargement of liver, spleen and lymph nodes was more frequently associated with ALL compared to AML.

Generation of hepatocyte-like cells from human induced pluripotent stem (iPS) cells by co-culturing embryoid body cells with liver non-parenchymal cell line TWNT-1.

Abstract: Objective To generate a homogeneous population of patient-specific hepatocyte-like cells (HLCs) from human iPS cells those show the morphologic and phenotypic properties of primary human hepatocytes. Study design An experimental study. Place and duration of study Department of Surgery, Okayama University, Graduate School of Medicine, Japan, from April to December 2011. Methodology Human iPS cells were generated and maintained on ES qualified matrigel coated plates supplemented with mTeSR medium or alternatively on mitotically inactivated MEF feeder layer in DMEM/F12 medium containing 20% KOSR, 4ng/ml bFGF-2, 1 x 10-4 M 2-mercaptoethanol, 1 mmol/L NEAA, 2mM L-glutamine and 1% penicillin-streptomycin. iPS cells were differentiated to HLCs by sequential culture using a four step differentiation protocol: (I) Generation of embryoid bodies (EBs) in suspension culture; (II) Induction of definitive endoderm (DE) from 2 days old EBs by growth in human activin-A (100 ng/ml) and basic fibroblasts growth factor (bFGF2) (100 ng/ml) on matrigel coated plates; (III) Induction of hepatic progenitors by co-culture with non-parenchymal human hepatic stellate cell line (TWNT-1); and (IV) Maturation by culture in dexamethasone. Characterization was performed by RT-PCR and functional assays. Results The generated HLCs showed microscopically morphological phenotype of human hepatocytes, expressed liver-specific genes (ASGPR, Albumin, AFP, Sox17, Fox A2), secreted human liver-specific proteins such as albumin, synthesized urea and metabolized ammonia. Conclusion Functional HLCs were generated from human iPS cells, which could be used for autologus hepatocyte transplantation for liver failure and as in vitro model for determining the metabolic and toxicological properties of drug compounds.

Fetomaternal outcome in acute hepatitis e.

Abstract: Objective: To determine fetomaternal outcome in pregnant women with acute hepatitis E in terms of pregnancy outcome and perinatal mortality. Study Design: Case series. Place and Duration of Study: Department of Obstetrics and Gynecology, Sir Ganga Ram Hospital, Lahore, from July 2012 to March 2013. Methodology: Serum samples of 38 patients who presented with jaundice in pregnancy were collected to detect hepatitis E IgM antibodies. Demographics, pregnancy outcome and perinatal mortality was noted in hepatitis E positive cases with cause of complications. Cases with jaundice due solely to any other cause were excluded. Results: Twenty five patients had acute hepatitis E with coexistent acute hepatitis A in 1(4%) patient. Their mean age was 25 years and mean gravidity was 2. Among them, 10 (40%) patients were primigravida followed by gravida two in 7 (28%) cases. Twenty four (96%) patients presented in third trimester of pregnancy and in 1 (4%) pregnancy ended in second trimester missed miscarriage. The mean gestational age was 32 weeks. Twenty one (84%) babies were born alive, among them 18 (86%) were preterm. Perinatal mortality was 26%; contributed by intrauterine deaths and early neonatal deaths in 3 (14%) cases each. Total maternal deaths were 5 (20%), 4 (80%) in postpartum period and 1 (20%) in antepartum period due to fulminant hepatic failure in all cases. Conclusion: Prematurity in newborns and fulminant hepatic failure in mothers are major cause of poor fetomaternal outcome in acute hepatitis E in pregnancy.

Facial nerve morbidity following surgery for benign parotid tumours.

Abstract: OBJECTIVE: To determine the frequency and severity of facial nerve dysfunction following surgery for benign parotid gland tumours. STUDY DESIGN: A case series. PLACE AND DURATION OF STUDY: ENT Department, Karachi Medical and Dental College and Abbasi Shaheed Hospital and Ziauddin University Hospital, from 1990 to 2010. METHODOLOGY: Data was collected of all patients who were surgically managed for benign parotid tumours from 1990 to 2010. Data was reviewed for presentation of tumour, age and gender of the patient, site of tumour, nature and morphology of the tumour, primary or recurrent, surgical procedure adopted and the complications of the surgery especially the facial nerve dysfunction, its severity, complete or partial paresis and transient or permanent and time of recovery. RESULTS were described as frequency percentages. RESULTS: Out of 235 patients, 159 (67.65%) were female and 76 (32.35%) were male. Age ranged from 18 to 70 years. Pleomorphic adenoma was the most common tumour (n=194, 82.6%), followed by Warthin's tumour. Superficial parotidectomy was done in 188 cases and extended parotidectomy in 47 cases. In the immediate postoperative period facial nerve function was normal in 169 (72%) patients and nerve dysfunction was observed in 66 (28%) patients. Complete paresis involving all the branches of facial nerve was seen in 25 (10.6%) patients and 41 (17.4%) patients were having incomplete dysfunction. Of these, 62 (26.3%) recovered and 04 (1.7%) had permanent facial nerve dysfunction. Marginal mandibular branch of facial nerve was involved in 57 (86.3%) cases. CONCLUSION: The frequency of temporary and permanent facial nerve dysfunction was 26.3% and 1.7% respectively in 235 consecutive parotidectomies for benign parotid gland tumours. Higher frequency of facial nerve dysfunction was found in recurrent and deep lobe tumours.

Chromosomal Abnormalities in Primary Myelodysplastic Syndrome

Abstract: OBJECTIVE To determine the frequency of cytogenetic abnormalities in patients diagnosed as primary myelodysplastic syndrome (MDS) using conventional karyotyping. STUDY DESIGN Case series. PLACE AND DURATION OF STUDY The Clinical Laboratory, The Aga Khan University Hospital, Karachi, between January 2006 - June 2012. METHODOLOGY Patients of all ages and either gender who fulfilled WHO criteria for MDS were included. Cytogenetic analysis was conducted at the time of diagnosis. Patients who had secondary MDS were excluded from analysis. Chromosome identification and karyotype description was done according to the International System for Chromosome Nomenclature (ISCN, 1995) and described as frequency percentage. RESULTS Out of the 122 cases of MDS, 71 patients had their karyotype done at the time of diagnosis, including 42 males (59.2%) and 29 females (40.8%) with median age of 60 years. Forty one (57.7%) showed normal karyotype and 30 (42.3%) showed clonal karyotypic abnormalities at diagnosis. Out of which 14 (19.7%) had single, 11 (15.5%) had complex and 6 (8.5%) had double cytogenetic abnormalities. The common abnormalities found were: trisomy 8 in 7 cases (9.9%), -7/del (7q) in 3 cases (4.2%), -Y and complex 5q in 2 cases (2.8%) each, complex trisomy 8, del 11q , inversion 9, trisomy 19 and del 20q were found in 1 case (1.4%) each. Other abnormalities were found in 11 cases (15.5%). CONCLUSION Trisomy 8 was the most common disorder/abnormality found in this study population followed by the complex cytogenetics.

Effect of intracameral use of dexamethasone on corneal endothelial cells.

Abstract: Objective To evaluate the effect of intracameral dexamethasone on corneal endothelium. Study design Quasi experimental study. Place and duration of study Layton Rehmatulla Benevolent Trust Eye Hospital, Lahore, from May 2011 to January 2012. Methodology Study subjects were adults of either gender with senile cataract who underwent phacoemulsification. They were divided in two groups, each had 110 patients. Group-A received subconjunctival injection of dexamethasone (2 mg/0.5 ml) at the end of surgery while group-B received intracameral injection of dexamethasone (0.4 mg/0.1 ml) at the end of surgery. Endothelial cell count was performed by specular microscopy pre-operatively and postoperatively at first week, first month and three months. Outcome measures included changes in endothelial cell count. Results were compared using t-test for means. Results There were 55 (50%) males and 55 (50%) females in group-A and 44 (40%) males and 66 (60%) females in group-B. In group-A, there were 66 (60%) right and 44 (40%) left eyes while group-B had 62 (56.36%) right and 48 (43.63%) left eyes. Mean age in group-A was 55.17 ± 5.93 years and 54.87 ± 5.55 years in group-B. Mean phacoemulsification time in group-A was 1.92 ± 0.63 minutes and 1.82 ± 0.54 minutes in group-B. After 3 months, in group-A, there was 7.55 ± 1.19% endothelial cell loss while in group-B, there was 7.63 ± 1.10% endothelial cell loss. The difference between the two groups was not statistically significant (p=0.614). Conclusion Use of intracameral dexamethasone at the end of cataract surgery is safe for corneal endothelium.

Management of sigmoid volvulus: options and prognosis.

Abstract: Objective To describe the management of sigmoid volvulus with reference to the type of surgical procedures performed and to determine the prognosis of sigmoid volvulus. Study design A case series. Place and duration of study Ghaem Hospital of Mashhad, University of Medical Sciences, Mashhad, Iran, from 1996 to 2008. Methodology A total of 944 cases of colon obstruction were reviewed. Demographic, laboratory and treatment results, mortality and complications were recorded. The data was analyzed using descriptive statistics as frequency and percentage for the qualitative variables and mean and standard deviation values for the quantitative variables. Also chisquare and Fisher's exact test were used for the association between the qualitative variables. SPSS statistical software (version 18) was used for the data analysis. Results In all patients except those with symptoms or signs of gangrenous bowel, a long rectal tube was inserted via the rectosigmoidoscope which was successful in 80 (36.87%) cases. Rectosigmoidoscopic detorsion was unsuccessful in 137 (63.13%) patients, who underwent an emergent laparotomy. The surgical procedures performed in these cases were resection and primary anastomosis in 40 (29.1%), Mikulicz procedure in 9 (6.6%), laparotomy detorsion in 37 (27.01%), Hartmann procedure in 47 (34.3%), mesosigmoidoplasty in 3 (2.19%) patients and total colectomy in one (0.73%) case. The overall mortality was 9.8% (22) patients. Conclusion In sigmoid volvulus, the most important determinant of patient outcome is bowel viability. The initial treatment of sigmoid colon volvulus is sigmoidoscopy with rectal tube placement.

Postoperative sensitivity of self etch versus total etch adhesive.

Abstract: Objective To compare postoperative sensitivity following composite restoration placed in supra gingival class-V cavities using self etch adhesive and total etch adhesive. Study design A randomized clinical trial. Place and duration of study Operative Dentistry Department of Armed Forces Institute of Dentistry, Rawalpindi, from July to December 2009. Methodology A total of 70 patients having class-V supra gingival carious lesions were divided into two groups. Classes-V cavities not exceeding 3 mm were prepared. One treatment group was treated with self etch adhesive (adhe SE one Ivoclar) and the control group was treated with total-etch adhesive (Eco-Etch Ivoclar) after acid etching with 37% phosphoric acid. Light cured composite (Te-Econom Ivoclar) restoration was placed for both groups and evaluated for postoperative sensitivity immediately after restoration, after 24 hours and after one week. Data was recorded on visual analogue scale. Results Comparison of sensitivity between the two treatment groups on application cold stimulus after 24 hours of restoration showed significant difference; however, no statistically significant difference was observed at baseline, immediately after restoration and at 1 week follow-up with cold stimulus or compressed air application. Conclusion Less postoperative sensitivity was observed at postoperative 24 hours assessment in restoration placed using SE adhesives compared to TE adhesives. Thus, the use of SE adhesives may be helpful in reducing postoperative sensitivity during 24 hours after restoration placement.

Age-related frequency of triple negative breast cancer in women.

Abstract: OBJECTIVE To determine frequency of triple negative breast cancer (TNBC) in Pakistani women with respect to age. STUDY DESIGN Observational study. PLACE AND DURATION OF STUDY Armed Forces Institute of Pathology (AFIP), Rawalpindi, from July 2005 to July 2010. METHODOLOGY Pathological records of all specimens of breast cancer were reviewed and data was obtained for estrogen receptor (ER), progesterone receptor (PR) and HER-2 neu receptor proteins. Specimens having complete record of all three proteins were included for analysis. TNBC was defined as those who were ER, PR and HER-2 neu negative. Overall frequency as well as frequency with respect to age was calculated. Descriptive and categorical variables were analyzed using SPSS version 17. RESULTS Eight hundred and fifteen patients out of 4715 (17.28%) were found to be TNBC. Mean age of diagnosis of TNBC was found to be 46.26 ± 12.22 years of age while other breast cancers had a mean age 52.90 ± 9.78 years (p 50 years while majority of patients with other breast cancers were elderly females (p < 0.001). CONCLUSION TNBC comprised 17.28% of the breast cancers in Pakistani women diagnosed at the studied centre. A higher frequency of TNBC was noted in significantly younger patients.

Spinal cystic schwannoma: an MRI evaluation

Abstract: Spinal cystic schwannomas are a very rare entity and have been reported in only a few case reports in literature; its diagnosis and management has remained a challenge. This study reviewed the results of magnetic resonance imaging (MRI) of 12 patients (7 men and 5 women; aged 37 - 67 years; mean age: 52.75 years) with pathologically proven cystic schwannoma of the spine and discussed their differential diagnosis. All patients underwent surgery at our institutions between June 2000 and April 2012. MRI showed well-delineated intradural and extramedullary lesion of iso- to low signal intensity on T1 weighted images, high signal intensity on T2 weighted images, and rim enhancement on contrast-enhanced images. A precise understanding of the MRI features of spinal schwannomas, especially the typical characteristic of enhancement, may help clinicians in their pre-operative diagnoses and surgical planning.

Ophthalmic injuries in orbito-zygomatic fractures.

Abstract: Objective To assess the frequency and severity of ophthalmic injuries in patients with orbito-zygomatic fractures. Study design A case series. Place and duration of study Oral and Maxillofacial Department, KEMU/Mayo Hospital Lahore, from January 2009 to December 2011. Methodology Patients with orbito-zygomatic fractures were divided into three groups. Group-1 patients had fracture of floor/medial wall of the orbit (orbital-blow out fracture). Group-2 had comminuted orbito-zygomatic fractures. Group-3 had simple zygomatic bone fractures. Frequency and types of ocular injuries were determined on each group. Results There were 296 (260 male, 36 female) patients with mean age of 31.7 years. Group-1 (n = 20) had 28 ocular findings in 12 (60%) patients including diplopia (n = 10, 36%), enophthalmos (n = 6, 14%), and hyphema, vitreous hemorrhage, retinal hemorrhage, choroidal rupture, traumatic mydriasis, and commotio retinae in 2 cases, 7% each. In Group-2 (n = 106), 44 ocular findings were identified in 30 (28%) patients including diplopia (n = 10, 23%), enophthalmos (n = 4, 9%), commotio retinae (n = 10, 23%), reduced visual acuity (n = 6, 14%), retinal hemorrhage (n = 4, 9%) and corneal laceration, corneal abrasion, retinal detachment, traumatic mydriasis, and canthal laceration in 2 cases, 4.5%. In Group-3 (n = 170), 22 ocular findings were seen in 16 (9%) patients included diplopia (n = 10, 45%), enophthalmos (n = 4, 18%), and retinal tear, hyphema, angle recession, and traumatic mydriasis in 2 cases, (9%) each. Conclusion Ophthalmic injuries are a common complication of orbitozygomatic fractures occurring in about 20% of patients in this study, most frequent in the orbital blow fractures subgroup. Ophthalmology consultation is recommended for patients presenting with midface fractures.