Journal of Rawalpindi Medical College

Neurocognitive Functioning And Interpersonal Difficulties In Diabetic Mellitus Type II Patients

Nazish Rashid — 2023-09-01

Objectives: To determine the level of Neurocognitive Functioning, and Interpersonal difficulties in People with Diabetes Mellitus type II.

Material and Method: A purposive sampling strategy was used. A sample (N=100) with age range (40-60) years was taken in the study, in which 46% Men or 54% Women Diabetes Mellitus type II patients were included. The research design was cross-sectional. Neuro-Cognitive Assessment Battery and Interpersonal Relationship Scale for Diabetic Patients were used.

Results: Pearson Correlation analysis results showed that there was a positive significant relationship between neurocognitive functioning and interpersonal difficulties. Hierarchal Regression analysis showed education level was a predictor of interpersonal difficulties in diabetic mellitus type II patients with poor neurocognitive functioning. Limitations and suggestions are discussed.

Keywords: Neurocognitive functioning, Interpersonal Difficulties, Diabetic Mellitus Type II

Anxiety And Depression Among Medical Students During Covid-19 Pandemic In Faisalabad

Mohi ud Din — 2023-09-01

Objectives: To find out the frequency of anxiety and depression among medical students during the Covid-19 pandemic and to study their relationship with socio-demographic factors.

Methodology: Analytical cross-sectional study was conducted on medical students of various medical institutions in Faisalabad and their consent was taken beforehand. The study duration was 2 months (August to September 2021). Ethical approval was taken. The questionnaire was distributed online through google forms on social media platforms to all MBBS students of a medical college and the total number of responses received was 452. Non-probability purposive sampling was done. The inclusion criteria were those students who gave consent and filled out the questionnaire and the exclusion criteria were those who didn't concede. A validated and structured questionnaire was used. The questionnaire consisted of four sections: demographic data; COVID-19-related attitudes and practising preventive behaviours, generalized anxiety disorder scale – 7 (GAD-7) to determine anxiety among medical students and patient health questionnaire – 9 (PHQ-9) to determine depression.

Results: Most of the students i.e. 132 (29.2) were having mild anxiety, followed by minimal, moderate and severe anxiety. Similar scores were observed in PHQ-9 results which showed mostly students were having mild depression i.e. 127 (28.1) followed by minimal, moderate, moderately severe and severe depression respectively. Average GAD-7 score was 8.73 (M = 8.73; SD = 5.78); average PHQ-9 score was 10.78 (M = 10; SD = 7.1). Significant relationship was found between gender (p = 0.00), year of study (p = 0.039), suffered Covid-19 in present or past (p = 0.00), afraid of getting Covid-19 (p=0.001) with anxiety and gender (p = 0.00), suffered Covid-19 in present or past (p=0.001) and afraid of getting Covid-19 infection (p=0.001) with depression.

Conclusion: There was a high prevalence of medical students suffering from anxiety and depression during Covid-19. The students in the age group above 21 years, females, year of study (4^th year) and afraid of getting Covid-19 infection were at higher risk of psychological distress in a pandemic. It is important to find ways to alleviate the pressure and fear of college students, provide them with more social support, and help them adapt to the changes in their learning styles and lifestyle.

Effectiveness Of Kaltenborn Mobilization Versus Muscle Energy Technique On Shoulder Range Of Motion In Adhesive Capsulitis

Muhammad Umar — 2023-09-01

Objective: To compare the effectiveness of muscle energy techniques (post isometrics relaxation) and Kaltenborn mobilizations on shoulder range of motion (ROM) in adhesive capsulitis.

Methodology: A randomized Control Trial (CRT) was conducted on patients with adhesive capsulitis for 6 months September 2021 to February 2022. Data was collected through a convenient sampling technique. 30 patients were taken from the physiotherapy department of the holy family hospital, Rawalpindi. The sample size was calculated using the Open Epi Tool. Data was collected by using Universal Goniometer at baseline, after 2 weeks and after 4 weeks of treatment. Patients who met the inclusion criteria and gave consent were included in the study. Patients were randomly allocated into two groups: Group A & Group B. Group A received muscle energy technique and Group B received grade II & III Kaltenborn mobilizations.

Results: Data was analysed using SPSS software version 22. Both groups showed improvements in shoulder range of motion but Group A showed a statistically significant difference (p<0.05) in flexion and abduction ROM from Group B.

Conclusion: The muscle energy technique is much more effective in improving flexion and abduction ROM except rotation than Kaltenborn mobilizations in adhesive capsulitis.

Development Of Curriculum Of Anatomy For BDS Students In UZ, Harare: A Survey-Based Study

Maimoona Khan — 2023-09-26

Objective: To evaluate and optimize the anatomy curriculum for BDS students in UZ.

Study design: It is a survey-based study.

Place and duration of study: A six-month study was carried out in the Anatomy Department, College of Health Sciences, University of Zimbabwe, Harare (March to August 2020).

Material and Methods: A survey-based study was conducted in UZ, College of Health Sciences. To collect the data, two separate structured questionnaires were prepared. The structured questionnaires were then administered to medical faculty, BDS students of 3^rd, 4^th & 5^th yr and practising dentists & internees, respectively. The sample size of the study was 70.

Results: The data collected via the two structured questionnaires was analyzed. Analysis showed that all the stakeholders thought that the core dentistry subjects should be introduced earlier to the BDS students. Moreover, it was recommended that CBL/PBL be added to the curriculum to make the overall BDS curriculum more effective.

Conclusion: The majority of the faculty members, BDS students, dentists and internees thought that the content of Anatomy for BDS students should be concise, specific and pertinent. The respondents supported the incorporation of CBL/PBL in the existing curriculum to make it more worthwhile.

Heterotaxy Syndrome In A Middle-Aged Pakistani Male

Seema Kanwal — 2023-09-26

Background: Heterotaxy syndrome (or situs ambiguous) is an extremely rare disorder in which the viscera are arranged in an abnormally asymmetrical pattern around the midline along with cardiac and spleen abnormalities. The management of this disorder depends upon the extent and variability of the organ involvement and a multi-disciplinary approach is often required.

Case presentation: A middle-aged male presented in pulmonology OPD with with complaint of hemoptysis and shortness of breath for 3 weeks. He had a history of cyanotic spells since childhood. His HRCT chest revealed dextrocardia, generalized mild centrilobular emphysema of the lungs with fibrotic bands and mild cylindrical bronchiectasis and his echocardiography showed dextrocardia along with ventricular septal defect and pulmonary hypertension. He was found to have abnormally positioned abdominal viscera along with multiple spleens and he was diagnosed as a case of heterotaxy syndrome with left isomerism. His respiratory symptoms were treated conservatively and the patient was referred to the cardiology unit for management of cardiac defects.

Conclusion: This manuscript describes a case of heterotaxy syndrome which is a rare disorder with significant mortality and morbidity. The patient may present with vague symptoms. Early involvement of all the relevant specialities might help in a prompt diagnosis and timely management, which may improve the disease outcome.

Comparison Of Naproxen And Diacerein In The Treatment Of Knee Joint Osteoarthritis

Mehtab Munir — 2023-09-26

Background: Knee osteoarthritis is a common disease in older age. Pain and limitation of movement are the main symptoms of knee osteoarthritis. Many pharmacological options are available for symptomatic relief but NSAIDs are mostly prescribed. Diacerein is also prescribed for osteoarthritis but data regarding its efficacy is still controversial. Moreover, studies regarding the comparison of diacerein with NSAIDs are deficient in Pakistan.

Objective: The objective of the study was to compare the clinical efficacy of naproxen (NSAID) with diacerein in treating knee osteoarthritis.

Methodology: Patients fulfilling inclusion criteria were included in the study. After written informed consent 60 patients of knee osteoarthritis were included in the study. They were divided randomly into two groups. Group A (n=30) was prescribed with tablet naproxen 500mg twice daily and group B (n=30) was given capsule diacerein 50mg twice daily for 12 weeks. Baseline VAS and WOMAC scores of the patients were noted. These scores were compared with scores achieved 12 weeks after intervention. Intra-group comparison of the scores was also carried out. SPSS version 23.0 was used for statistical analysis.

Results: WOMAC and VAS scores comparison of the two groups (A & B) before intervention showed an insignificant p-value that is 0.815 for the WOMAC score and 0.509 for the VAS score. After intervention means WOMAC score i.e.10.50 ± 2.46 of group A (treated with naproxen) was better than the mean 29.62 ± 7.03 of group B (treated with diacerein) showing significant p-value (< 0.001). Similarly mean VAS of group A 1.92 ± 0.58 improved more than the mean VAS of group B i.e 3.38 ± 0.75 with significant p-value (< 0.001). Intra-group comparison of the groups also showed a significant p-value.

Conclusion: Clinical efficacy of naproxen is better than diacerein in treating knee osteoarthritis.

Association Of Electroencephalogram Patterns With Ammonia Levels In Hepatic Encephalopathy Patients

Anam Fatima — 2023-09-26

Objective: To find out the association between electroencephalogram (EEG) and hepatic encephalopathy.

Methodology: This cross-sectional study included 100 patients (with the age of52.5±6.09years for males and 51.7 ± 6.10 years for females) of reported hepatic encephalopathy, visiting the medical department (indoor and OPD) at Federal Government Polyclinic Hospital, Islamabad. The study was conducted from January 2020 to May 2021. Patients who had known epileptic and structural brain lesions or strokes were excluded from the study. Statistical analysis was done using GraphPad Prism software. The significance of data (p-value or R² value) was calculated through a two-tailed test or correlation coefficient.

Results: All the patients in hepatic encephalopathy grade IV reported abnormal EEG representing triphasic waves and flattening of EEG pattern. There was no correlation observed between age, gender and hepatic encephalopathy grades. However, a significant correlation (R²= 0.9032) was observed between serum ammonia levels and hepatic encephalopathy grades. Elevated serum ammonia levels depicted the severity of hepatic encephalopathy. Overall, the percentage of patients with abnormal EEG increased with increasing grade of hepatic encephalopathy. It was quite intriguing to note that EEG, being the common method to diagnose hepatic encephalopathy grades, is not dependent on patients’ socio-economic status.

Conclusion: Data concluded that serum ammonia levels are well associated with the progression of hepatic encephalopathy. Moreover, the EEG patter provides the appropriate information about the neurological abnormalities associated with the severity of hepatic encephalopathy. Hence, serum ammonia levels and EEG both should accurately be used as indicators for diagnosis and monitoring the response to the treatment of various grades of hepatic encephalopathy. Data warrant further investigations to get a better insight into hepatic encephalopathy's relationship with EEG patterns through the inclusion of molecular parameters.

Impact Of COVID-19 Pandemic On Ophthalmology Residency Training- A Cross-Sectional Survey Among Pakistani Residents

Muhammad Shaheer — 2023-09-26

Background: The purpose of this study was to get an idea of the impact of COVID-19 on Ophthalmology post-graduate training.

Materials & methods: This cross-sectional questionnaire-based study was conducted at the College of Ophthalmology and Allied Vision Sciences/Eye Unit III (King Edward Medical University), Lahore from 01-03-2021 to 31-08-2021. A web-based close-ended questionnaire (Google form) was developed consisting of questions related to residency training in the wake of the COVID-19 pandemic. Eighty-one Ophthalmology residents from across the country participated in this survey. Based on the responses to 21 questions, percentages of various variables in questions were calculated. Data analysis was done on SPSS version 22. Responses to questions are mainly presented as percentages. A chi-square test was applied to see the significant difference in survey questions. For categorical variables, Fisher’s Exact test was applied. P-value ≤0.05 is considered significant.

Results: Twenty-seven ophthalmology residents were 1^st year residents 23 were 2^nd year residents while 3^rd and 4^th year residents were 14 and 17 respectively. 33% of residents thought their surgical training was affected badly due to covid-19 pandemic while 55% of them were concerned about their basic cataract surgery skills. 67% of residents were in favour of their training extension for 6-12 months. The majority of residents stated that COVID-19 affected their training adversely (p=0.000) and cataract surgery training was the most affected one (p=0.000)

Conclusion: The COVID-19 pandemic has severely affected the clinical and surgical training of post-graduate ophthalmology residents. Formulation of institution-based & nationwide short and long-term strategies regarding web-based teaching, surgical simulation courses and necessary adjustments in curriculum are the need of the hour.

Perception And Attitude Towards COVID-19 Vaccine: A Cross-Sectional Study From Pakistan

Kausar Malik — 2023-09-26

ABSTRACT

Objective: The aim of this study was to investigate the awareness regarding COVID-19 vaccines and identify the factors underlying refusal.
Methodology: A cross-sectional study was carried out amongst the general population from different walk of life regarding awareness and myths about COVID-19 vaccine selected by convenient sampling method. To collect data, we developed an online survey using questionnaires regarding beliefs and myths about vaccination. The study was started in March 2021 after approval from the ethical committee. Survey consisting of several questions was created using google form. The link was shared on different social media applications and participants were requested to fill the questionnaires. Some patients and their attendants who were visiting HIT hospital Taxila for any reason were also included in the study and they were requested to fill the form at the spot. Participants were given a brief summary of the survey and its purpose, as well as the study protocol and a declaration of confidentiality and privacy, before beginning the questionnaire.

Data was collected on online server form. Demographic information was noted. They were asked about their registration, vaccination status and their fear regarding vaccine and its complications. They were questioned about myths and misbeliefs about covid 19 vaccine. Post vaccination symptoms, their preference for different types of available vaccine, and need of booster dose were also inquired. Their beliefs regarding effectiveness of vaccine in prevention of covid-19 symptoms and severity and following the SOPs released by health authorities were noted.

Results: Total 287 individuals were included in this study. 62% were females and 31% were males. 50% were doctors and 30% were not registered for vaccination. 70% of individuals were vaccinated and 83% were not afraid to get vaccination while 50% of people thought that they will get COVID-19 after vaccination. 35% participants were afraid that they will get allergic reaction post vaccination and 9% thought that COVID-19 is fake i.e., there is no such disease as COVID-19. 82% were aware that they will need vaccine even if they had COVID-19. Only 7% of population thought that COVID-19 will change their DNA.

Chi square test was applied to find out statistically significant difference in opinion between three groups i.e., age, gender and academic qualification. Majority of the statistical correlation was found in these questions on the basis of qualification. There was statistically significant difference in opinion depending on academic qualification, health care and non-health care workers shown by p value less than 0.05. Health care professionals think there is need for new vaccinations for every new variant, there were mild covid symptoms post vaccination and there was need of booster dose every year while others have contrary opinion. Medical students didn’t believe in DNA alteration.

Their was also statistically significant difference in opinion between male and female gender. Most female participants believe that there was requirement of new vaccine for every new variant, there were more chances of covid after vaccination and they need booster dose every year to prevent covid while males have opposite opinion. Majority of the post vaccination symptoms were observed in femaleswhile male observed pain on the injection site only

Conclusion: Awareness and education of general population regarding safety, efficacy and benefits of covid-19 vaccination is the cornerstone of the path to eradicate this pandemic. Different platform of social, print and electronic media plays a pivotal role in this regard. However, the importance of health authorities, religious scholars, social activists and politicians in creating awareness cannot be denied either. Collectively all these factors attribute towards the COVID free Pakistan.
Key Words: COVID-19, vaccine hesitancy, Pakistan, public awareness, myths

Accuracy Of Serum Ferritin, C-Reactive Protein, Lactate Dehydrogenase And D. Dimers In Assessing Severity And Outcome Of COVID-19 Infection

Aziz-Un-Nisa — 2023-09-26

ABSTRACT:

Introduction:

Covid-19 emerged as pandemic. In the beginning, due to the rapid spread of virus it was difficult to understand fully its pathogenesis but various inflammatory markers were found to be raised. Along with the detection of virus by polymerase reaction (PCR), studies of these markers not only help in diagnosis but also in assessing the prognosis of covid-19 infection.

Material and methods:

This cross sectional study was conducted in the Capital Hospital, CDA Islamabad from December to June 2022. After taking consent various inflammatory markers were recorded on a proforma. Patients were followed and outcome was also recorded. The data collected was analyzed by percentage/ frequency distribution. T-test was applied and p-values were calculated (significant p-value=<0.05). Sensitivity, specificity, positive and negative predictive values, area under curve (AUC) and accuracy were calculated by using SPSS, version 23.

Results:

A total of 185 covid-19 PCR positive patients were included in the study. 112(60.5%) were men and 73 (39.5%) were women. 165(89.2%) patients were > 40 years of age. 117 (63.2%) patients had mild /moderate disease and 68(36.8%) had severe disease. 162 (87.5%) patients were discharged and 23 (23.4%) expired. AUC in relation to severity of disease was 0.603 for C- reactive protein (CRP), 0.543 for lactate dehydrogenase (LDH), 0.525 for D. dimers and 0.619 for ferritin. Accuracy in relation to disease severity was as following: CRP 57.4%, D. dimers 52.4 %, ferritin 57.9% and LDH 55.7%. AUC in relation to outcome of covid-19 was 0.699 for CRP, 0.668 for LDH, 0.742 for D. dimers and 0.677 for ferritin. Accuracy of inflammatory markers in relation to outcome was as following: CRP 45.9%, D. dimers 61.2%, LDH 48.1% and ferritin 46.9%.

Conclusion:

Serum ferritin showed the highest accuracy (57.9%) in assessing the covid-19 severity and D. dimer came up with highest accuracy (61.2%) in assessing disease outcome.

A Comparative Evaluation Of Premedication With Flurbiprofen And Prednisolone On Post Endodontic Pain In Teeth With Symptomatic Irreversible Pulpitis: A Randomized Clinical Trial

Umair ul Haq — 2023-09-26

Background: Root canal treatment is an endodontic procedure that encompasses cleaning & shaping i.e. preparation of root canals followed by obturation of the prepared canals. Pain is a very common sensation that occurs few hours after root canal treatment (RCT).

Objective: To evaluate and compare the efficacy of premedication with flurbiprofen and prednisolone on post-endodontic pain in teeth with symptomatic irreversible pulpitis.

Materials and Methods: It is a randomized control trial study conducted in the department of Operative Dentistry & Endodontics, Sardar Begum Dental College, & Hospital Peshawar. Patients were randomly allocated into two groups i.e. A and B using coin flip technique. Thirty minutes before starting the endodontic therapy, single pretreatment dose of Flurbiprofen (100mg) was given to patients in Group A and Prednisolone (30mg) to patients in Group B. Patients’ pain intensity experience was measured using the visual analog scale (VAS) after root canal treatment. They were instructed to complete a pain diary at specific intervals (i.e. at 6, 12 and 24 hours after the commencement of treatment) in order to determine efficacy in both groups.

Results: As per efficacy in both groups, in Group A, 44 (55%) showed effective results whereas in Group B, only 20 (25%) patients showed effective results.

Conclusion: Single pretreatment dose of flurbiprofen has a more sustained effect in reducing post-endodontic pain as compared to prednisolone.

The Diagnostic Accuracy Of Hyperbilirubinemia In Acute Appendicitis

Saeed Baseer — 2023-09-26

Objective: To determine the diagnostic accuracy of serum Bilirubin in cases of acute appendicitis keeping the histopathological findings as Gold standard.

Study Design: Cross sectional validation study.

Place and Duration of the Study: Surgical Unit, Sheikh Khalifa Bin Zayed Al-Nayhan Hospital (Combined Military Hospital), Rawalakot, Azad Kashmir, from Jan 2022 to June 2022.

Methodology: A total of 380 patients aged between 18 to 65 years, who matched the inclusion and exclusion criteria suspected of acute appendicitis were included. Serum Bilirubin level was noted. Appendectomy was done. Specimen of appendix was sent for histopathology for confirmation of the diagnosis.

Results: In our study, mean age of the patients was 34.015 with a standard deviation of 13.32. 65% (n=247) of the patients were males and 35% (n=133) were females. Frequency of acute appendicitis on histopathology was 82.89% (n=315) while 17.1% (n=65) had no findings of the disease. Validity of serum Bilirubin in diagnosing appendicitis using histopathology showed 57.36% (n=218) were true positive, 2.1% (n=8) were false positive, 15% (n=57) were true negative and 25.52 %( n=97) were false negative. Specificity, sensitivity, negative predictive value, positive predictive value, accuracy rate, positive likelihood ratio and negative likelihood ratio were 87.69%, 69.20%, 37.01%, 96.46%, 72.36%, 5.62 and 0.35 respectively.

Conclusion: Serum Bilirubin is a useful marker for diagnosing the acute appendicitis and can be used as a good alternative diagnostic modality in suspected cases of acute appendicitis.

Comparison Of Quality Of Sleep Between Diabetic And Non-Diabetic Population Using Pittsburgh Sleep Quality Index

Bilal Saeed — 2023-09-26

Background: Sleep is an essential event that effects quality of life and hormonal balance in human body. The association between sleep and diabetes is bi-directional.

Methods: This study was conducted with a case control design in the Department of Medicine of Combined Military Hospital Peshawar between June 2022 to November 2022.

Results: . Mean age of study population was 51.1±12.94 years with 46% females and 54% males. Majority population was educated up to matriculation with BMI in normal (18.5-24.9 kg/m²) range. There was no statistical difference in demographic data amongst diabetic and control group . Avg HbA1c was 8.546% ± 1.57% in the diabetic group and 5.712% ± 0.49% in control group. As per PSQI questionnaire 47 (47%) participants were good sleeper across the study population, which included 17 out 50 (34%) individuals in the diabetic and 30 out of 50 (60%) in control group. This equated to statistically significant difference amongst two group with a p value 0.007. A statistically significant difference (p = 0.001) was also seen in PSQI score between diabetic and control groups (9.40 ± 5.82 vs 5.98 ± 4.85 respectively). Diabetics had 2.9 times odds (95% confidence interval 1.29-6.57, p = 0.01) of having bad quality sleep as compared to controls. In the diabetic group majority were males educated up to matriculate having medium adherence treated with both oral hypoglycemic drugs and insulin having 3 or more comorbid condition with hypertension being most prevalent single comorbid disease.

Conclusion: By strict glycemic control in diabetics we can imove their quality of sleep Interventions to improve sleep hygiene can be suggested to patients by diabetes educators as part of diabetes self-management education programs.

Assessment Of Predictive Value Of Serum Uric Acid Levels For Low Birth Weight In Pre-Eclampsia

Sadaf Asma — 2023-09-26

OBJECTIVE: To assess the diagnostic accuracy of raised serum uric acid level in females with pre-eclampsia, in predicting low birth weight.

SUBJESTS & METHODS: Cross sectional study carried out at Gynecology Department, FGSH Poly Clinic, Islamabad & duration of study was 6 months from July 21, 2021 to Jan 20, 2022. A total of 225 Preeclampsia pregnant female were clinically examined and included in the study. Blood sample were collected for serum uric acid and followed till the birth of the baby.

RESULTS: The study included age ranged from 18 up to 40 years. Average age was 28.69years +5.01SD. Sensitivity & specificity of uric acid level in Serum in diagnosis of low birth weight are 85.71% and 81.42% respectively while it has positive predictive & negative predictive value of 51.43% & 96.13% respectively. Diagnostic accuracy of uric acid level in serum was 82.22%.

CONCLUSION: Uric acid level in serum is of great diagnostic and prognostic importance in women with pre-eclampsia & helps in predicting low birth weight.

Exploring Empathy In A Dentist-Patient Relationship. Conclusions From Qualitative Exploratory Research Of Practicing Dentists

Gulmina Saeed Orakzai — 2023-09-26

Objective: This study explored the factors influencing the development of empathy in a dentist-patient relationship.

Design: An exploratory qualitative study.

Place and duration of the study: Khyber Medical University KPK, Pakistan October 2019 to April 2020.was conducted during 2019-2020

Methodology: This exploratory qualitative study was conducted during 2019-2020. It was conducted on 12 dental surgeons, recruited from four major dental clinical specialties. A purposive sampling technique was used. In-depth interviews were conducted through a semi-structured format. The interviews were audio recorded, transcribed verbatim and analyzed, using the thematic analysis framework.

Results: Three themes were extracted from data. 1) Institutionalization of empathy, indicating a need for incorporating empathy in undergraduate and postgraduate dental curriculum, 2) Barriers in the path of empathetic attitude, including a variety of factors hampering the development of empathy in a dentist-patient relationship and 3) Cultivating a Culture of empathy for better health care provision, indicating a need for changing the collective attitude of all health care professionals, administrative staff, and students. The participants of the study observed that development of empathy in a dentist-patient relationship includes a wide range of factors, ranging from curricular, personal, social, organizational, and cultural. These factors elaborate that empathy is a multidimensional phenomenon with roots deeply entrenched in professional and personal domains.

Clinico-Laboratory Profile And Drug Sensitivity Pattern In Urinary Tract Infection Of Children In A Tertiary Care Hospital

Muhammad Bilal — 2023-09-26

Background: Any component of the urinary system can get infected with bacteria, which is known as a urinary tract infection (UTI). It is one of the most common bacterial diseases in children. The study's objectives included identifying the clinical symptoms of UTI in children between the ages of one month and fifteen, as well as the bacteria responsible for the illness and their sensitivity to various medicines.
Methods: This cross-sectional study was conducted at the CMH Rawalpindi, Pakistan, from January to June of 2022. Our analysis comprised 137 strongly suspected instances of UTI in children (1 month to 15 years old).
Results: A total of 137 urine samples from paediatric patients suspected of having UTI were obtained in which the 93 samples (67.88%) generated significant bacteria. The two most common clinical symptoms of UTI patients in our research were fever and dysuria. E. coli was the most prevalent isolate in cases with paediatric UTI. Ampicillin, cephalosporins, and co-trimoxazole were the medications that were most effective against E. coli and Klebsiella, respectively.
Conclusions: The age range between 1 and 5 years old was the one most usually affected by UTI. We must be aware of the need of doing a urine culture sensitivity test before to starting antimicrobial medicine in order to detect UTI early, avoid recurrent UTI, and reduce paediatric morbidity and mortality.

Diagnostic Accuracy Of Acromioaxillosuprasternal Notch Index For Prediction Of Difficult Airway Taking Cormack And Lehane Grading System As Gold Standard

Muhammad Mohsin Sajjad — 2023-09-26

Background:

General anesthesia is still needed for several surgical interventions and requires endotracheal intubation. The difficult airway is a well-known entity, and a long list of predicting scores is present, yet a high degree of diagnostic accuracy still needs to be improved. Acromioaxillosuprasternal notch index (AASI) has shown some excellent results in recent times.

Objective:

Its objective is to determine the diagnostic accuracy of acromioaxillosuprasternal notch index for predicting difficult airways and to take the Cormack and Lehane grading system as the gold standard.

Methodology:

In this study, adults of both genders aged 20 to 70 years undergoing any surgery under general anesthesia having ASA class I to IV were included. AASI score of equal or less than 0.49 was taken as difficult airway while on Cormack and Lehane grade; it was labeled as yes where grade III or IV was seen.

Results:

The total number of cases were 350 cases, out of which 218 (62.29%) were males, and 132 (37.71%) were females. The mean age was 40.20±12.86 years, and the mean BMI was 24.71±3.13 (table 17). There were 294 (84%) cases in ASA Class I and II and 56 (14%) in class III and IV. Difficult intubation on AASI was seen in 54 (15.43%) and 57 (16.29%) cases on Cormack and Lehane grading.

The diagnostic accuracy of AASI for prediction of difficult intubating a difficult was 96.29% with sensitivity of 90.74%, specificity of 97.30%, PPV of 85.96%, NPV of 98.29% with p= 0.001. This difference was also statistically significant with all the confounding variables like age, gender, ASA class, and BMI.

Conclusion:

The acromioaxillosuprasternal notch index is a

significant predictor for tubing a difficult airway and taking Cormack and Lehane's grading as the gold standard. This difference is considerably better regarding age, gender, BMI, and ASA class.

Diagnostic Validity Of Low Dose CT KUB In Demonstration Of Genitourinary Tract Calculi Compared To Normal Dose Ct Kub: A Provisional Study

Fizza Batool — 2023-09-26

Objective: Renal colic is a common clinical condition. Our objective is to evaluate the diagnostic accuracy of low dose CT KUB for detection of urinary stones, to minimize radiation dose to the patients, and to analyze diagnostic accuracy of LDCT KUB in comparison to standard dose CT KUB. We speculate the LDCT KUB may reduce patient radiation dose while maintaining diagnostic value.

Materials and Methods: This comparative cross sectional validation study was conducted at Department of Radiology in Benazir Bhutto Hospital, Rawalpindi June 2021 to Feb 2022. After approval of hospital ethical committee, a sample of 49 kidneys of 31 patients was collected by non-probability consecutive sampling technique. Included were the patients diagnosed with renal calculi referred from other departments. All the included patients were scanned by Toshiba Aquilion 16 slices, using automated tube current modulation, without any oral or IV contrast. CT scan started from diaphragm down to pubic symphysis with standard dose CT (SDCT) followed by low dose CT (LDCT). After the data was recorded, statistical package for social sciences, version 20.0 (SPSS Inc., Chicago, Illinois, USA) was used to analyse the data and generate results. Mean + standard deviation was calculated for qualitative data while frequency and percentage for qualitative variables. The means were compared by independent sample t test while the agreement between standard and low dose was depicted by kappa value.

Results: A total of 49 kidneys of 31 patients with renal stones was included in this study. The mean age of the patients ranged from 27 years to 48 years with a mean of 36.42 + 9.97 year. In gender distribution, 75.5 % (37) were male while 24.5 % (12) were females. More than half 59 % (29) were right while 41 % (20) were left kidneys.

Conclusion: This study demonstrated that LDCT was a productive and effective technique in the detection of urothelial stones despite considerable reduction in radiation dose and exposure as seen in SDCT.

The Apolipoprotein E Polymorphism And Dyslipidemia In Elderly Patients Of Calcific Aortic Stenosis

Erum Afaq — 2023-09-26

Objective: This study aimed to investigate the impact of the Apo E polymorphisms on plasma lipid profile and to identify the polymorphism of the apo-E gene as genetic predictor of calcific AS in Pakistani population.

Methodology: This was a case control study conducted in Dow University of Health Sciences and National Institute of Cardiovascular Disease, Karachi. It included total of 100 individuals, 50 echocardiographically identified calcific AS cases and 50 age and gender matched controls. Apo E allele frequencies were computed, lipid profiles were estimated and Apo E gene polymorphism was identified by the techniques of polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP).

Result: Apo E 2, 3, and 4 allele frequencies were 16%, 52%, and 32% in calcific AS cases, and

10%, 52%, 28% in controls respectively (p=0.622). Out of 50 cases, 18% presented with mild AS, 22% moderate AS and 60% lied in severe calcific AS. It was observed that levels of total cholesterol (TC), triglyceride (TG) and low-density lipoprotein (LDL) were higher in Apo E4 allele as compared to other genes in both cases and control.

Conclusion: The findings of this study suggested that Apo E4 allele of Apo E gene is an impotent risk factors for dyslipidemia while Apo E4 allele is not associated with calcific AS contemplates distinctive genetic backgrounds of CAD and AS.

Efficacy Of Cyproterone Acetate And Drosperinone Containing Cocps In Treatment Of Hirsutism In Patients With PCOS

Nazish Sarfraz — 2023-09-26

Introduction: Hirsutism is a condition characterized by excess hair growth on the face, chest, and/or back in women and it is often caused by an imbalance of hormones, such as androgens. OCPs prove to be effective in reducing hirsutism in patients with PCOS by inhibiting the production of androgens and decreasing the activity of androgen receptors. OCPs may have additional benefits for patients with PCOS, such as regulating menstrual cycles, improving fertility, and reducing the risk of endometrial cancer. However, OCPs may not be suitable for all women with PCOS.

Methods: The study was conducted to investigate the effectiveness of these OCPs in reducing hirsutism in PCOS patients. In the study, 80 participants were included, 40 in the intervention group and 40 in the control group. The intervention group received a combination oral contraceptive pill containing cyproterone acetate and drosperinone (COCP) for a period of 6 months, while the control group received a placebo. Hirsutism was assessed at baseline and at the end of the 6-month treatment period using the Ferriman-Gallwey score. The primary outcome measure was the change in Ferriman-Gallwey score from baseline to the end of the treatment period.

Results: The study found that OCPs containing cyproterone acetate and drosperinone were more effective in reducing hirsutism in patients with PCOS compared to OCPs containing levonorgestrel.

Conclusion: It is important to note that OCPs may not be appropriate for all women with PCOS, therefore it's crucial to explore the risks and advantages with a healthcare professional before beginning therapy.

Comparison Of Prophylactic Injection Of Corticosteroid With Placebo, In Management Of Wrist Pain On Ulnar Aspect In Patients Of Fractures Of Distal Radius

Rahman Rasool Akhtar — 2023-09-26

INTRODUCTION:

Distal radius fractures are one of the commonest fractures experienced by the Orthopaedic surgeons. Pain on the ulnar aspect of the wrist is the most usual complication of such fractures. Corticosteroid injection is a simple and effective method for elevating pain of such nature.

OBJECTIVE: To compare the mean pain score with prophylactic corticosteroid injection versus placebo in management of wrist pain on ulnar aspect in patients presenting with fracture of distal radius.

MATERIAL AND METHODS:

Study Design: Randomized controlled trial

Setting: Orthopedic Surgery Department, Benazir Bhutto Hospital, Rawalpindi

Duration: Six months (March 5, 2018 to Sept 5, 2018)

Data Collection Procedure:

80 patients were included by using non-probability consecutive sampling after fulfilling the selection criteria. Demographic profile (patient name, age, gender, anatomical side and contact details) was obtained. Patients were splitted in two random groups by simple lottery method. Patients of group A were given one shot of 80mg corticosteroid in the area of ulnar styloid process near TFCC and group B patients were given a shot of distilled water (2 cc). Both group of patients were followed in OPD for 3 months in their postoperative visits. Visual analogue scale (VAS) score was recorded. Data was analyzed using SPSS version 21.

Results:

The mean age of the patients was 41.05 ± 11.05 years and age range of 40 years. The mean age in the corticosteroid and placebo groups was 39.68±10.67 years and 42.42 ± 11.39 years respectively. There were 42 (52.50%) male and 38 (47.50%) female patients with a higher male ratio i.e., 1.10:1. In corticosteroid and placebo groups there were 21 (52.50%) male and 19 (47.50%) female cases. The mean pain at baseline was 7.72 ± 1.66 while in the corticosteroid and placebo group, the mean pain was 7.60 ± 1.67 and 7.85 ± 1.65 respectively with statistically equal mean pain p-value = 0.504. After 3 months of treatment, mean pain in the corticosteroid group was 1.30 ± 0.66 and was 2.60 ± 1.58 in the placebo group, p-value < 0.001.

Conclusion:

Our findings suggested that prophylactic corticosteroid injection is more effective in reducing pain in patients with distal radial fracture than placebo. By using prophylactic corticosteroid injections in the future, we can reduce pain to achieve more satisfaction of patients.

Association Of Raised Serum Triglycerides With Incidence Of Pre-Eclampsia

Saima Shafiq — 2023-09-26

Background: Pre-eclampsia, a serious multi-systemic pregnancy complication is estimated to occur in 5-10% of pregnancies worldwide.

Objective: To determine the frequency of pre-eclampsia in pregnant females with hyper-triglyceridemia and to study its associations.

Methodology: This Cross-sectional study was conducted at Gynecology Dept. Poly Clinic Hospital, Islamabad (March - Sept. 2022). Pregnant females of age 15-40 years, gestational age 13-20^th weeks and singleton pregnancy were included. Known hypertensives, receiving lipid-lowering or anti-hypertensives, chronic kidney or liver disease, teenage pregnancies, primigravida, history of CVA, IHD, epilepsy or endocrine disorders were excluded. After the detailed clinical evaluation, fasting serum triglyceride levels were checked. A total of 225 cases with elevated serum triglycerides were finally selected and evaluated for the presence of pre-eclampsia by monitoring the blood pressure, cardiovascular, gynaecological examination and urine for the presence of proteinuria. Patients were followed till the development of pre-eclampsia or completion of pregnancy. Results: Among 225 pregnant females with raised serum triglycerides, the mean age was 24.28+5.5 years. Pre-eclampsia was observed in 47(20.89%) of patients. The Chi-square tests of association between pre-eclampsia and each of parity, residential status, and socio-economic status were insignificant while BMI and Gestational age were significant. Conclusion: There is a high prevalence of pre-eclampsia in pregnant women with hypertriglyceridemia. Serum triglyceride levels may predict the women at risk for pre-eclampsia. The risk of preeclampsia in women with hyper-triglyceridemia is independent of parity, and socioeconomic or residential status. Hypertriglyceridemia may predispose to pre-eclampsia even at lower BMI levels. The development of hypertriglyceridemia in early gestation may be an additional risk factor. Early screening of women at risk may lead to better outcomes.

Association Of Maternal Age And Hemoglobin Level With Apgar Score Of Newborns In A Tertiary Care Hospital Of Suburbs Of Islamabad

Muhammad Hassaan Farooq — 2023-09-26

Objectives: To determine the association of Apgar score with maternal age and hemoglobin.

Methods

A cross-sectional study was conducted on mothers (n=306) delivering live, full-term, singleton babies by spontaneous vertex delivery. Women who suffered stillbirths had babies of unknown gestational age or showed co-morbidities were excluded.

SPSS version 26 was used for data analysis. Mean + standard deviation, and percentages were calculated. Cross-tabulation and logistic regression were done to see the association between dependent and independent variables. A p-value of <0.05 was statistically significant.

Results

The ages of women ranged from 20 to 40 years (mean= 25+1.9). The number of patients aged 24 years with Hb <7g/dl was 6 (37.5%). Out of all, 90 (29.4%) patients had Hb >11g/dl, and their ages were 30 years which was significant (p = 0.000). Apgar score for the neonates showed that 258 (84.3%) had an Apgar score >7 while 48 (15.7%) had a score < 7. Babies of mothers whose age was 26 years had Apgar score < 7(25%) (p = 0.001). Neonatal birth weight, of <2kg was observed in infants born to young mothers of 26 years of age (20%) (p = 0.001), and a weight >3.5kg was recorded in 20 infants (6.5%). The younger mothers had lower Hb, and their babies had low Apgar scores <7 at the time of birth (p = 0.001).

Conclusion

Women of younger age and lower hemoglobin levels give birth to infants with low Apgar scores and birth weight. Low birth weight in neonates is significantly associated with a low five-minute Apgar score.

The Validity Of 75gms OGTT For Detection Of GDM Keeping 100gms OGTT As Gold Standard

Shazia Mehreen — 2023-09-26

Objective: To determine the validity of 75gms (Oral Glucose Tolerance Test) OGTT for the detection of GDM keeping 100gms OGTT as the gold standard.

Methodology: This was a Cross-sectional validation study done at the Mother and Child Health Centre, Pakistan Institute of Medical Sciences, Islamabad. The duration of the study was Six months from the approval of the synopsis. Data was collected from March 2019 to September 2019. Informed consent for participating in the study was taken from all 205 patients. The patients' bio data along with the hospital registration number was entered pro forma. The patients were assessed initially by History taking and examination. All pregnant women underwent a 75g oral glucose test in the 2nd trimester at 24-28 weeks of gestation. For this, the patients were sent to the MCH laboratory with overnight fasting where FBS was taken and they were given a 75 g glucose drink. Their blood sample was taken at 1-hour and 2-hour interval. Two or more elevated values out of the 3 blood samples were sufficient to diagnose GDM. Laboratory reports were reviewed and data was entered in the performa (attached) by the researcher. All the diagnosed patients were further evaluated for a 100g OGTT dose at the MCH laboratory with overnight fasting. Their FBS was studied and women were given a 100 g glucose drink and blood samples were drawn at an interval of 1, 2 and 3 hours respectively. Out of the 4 blood samples, two or more elevated values were sufficient to diagnose GDM. Lab reports were entered in the Performa.

Results: From a total of 205 patients, the sensitivity and specificity of OGTT-75 g for diagnosing GDM were 83.02% and 82.83%. However, positive predictive and negative predictive value for OGTT-75 g was 83.81% and 82% respectively. However, the overall diagnostic accuracy of OGTT-75 g was 82.93%.

Conclusion: Results of this study showed that 75 gms OGTT is highly sensitive (83.02%) and specific (82.83%) for the detection/diagnosis of gestational DM. Advanced screening and diagnosis of gestational DM, and its effective treatment not only inhibit adverse perinatal and maternal outcomes but also save the lives of both child and mother from diabetes in future.

Role Of Dose Aspirin In Preventing Preterm Birth In Patients With Previous History Of Preterm Delivery

Maliha Sadaf — 2023-09-26

Objective: Preterm birth (PTB) occurs between 24-37 weeks of gestation. The important risk factor for PTB is a previous PTB and currently progesterone is used for the management of recurrent spontaneous PTB. Some studies have shown good outcomes but recent studies revealed that the use of vaginal progesterone was not related to a decreased likelihood of PTB or neonatal adverse effects. Thus, the controversy in the literature suggests multiple underlying pathological mechanisms involved in the progression of PTB. This study aims to determine the role of low-dose aspirin in the prevention of preterm birth in patients with a previous history of preterm delivery.

Methodology: In this randomized controlled trial, a total of 172 patients fulfilling the inclusion criteria were selected from the inpatient and outpatient departments. Patients were divided randomly into two groups (group A and group B), using random number tables. In Group A, low-dose aspirin (75mg) was given while group B was taken as a control group. Patients were called every 8 weeks in the outpatient department for the assessment of compliance and side effects of the drug. The data were entered and analyzed by using SPSS v25.0. Chi-square was used to compare the two groups for incidence of preterm birth. Relative risk (along with a 95% confidence interval) for the decrease in the incidence of preterm birth with the use of aspirin was calculated.

Results: The age of participants included in the study was 18 to 40 years. The mean age of patients in group A was 33.85±5.210 years and in group B was 32.86±4.139 years. The mean fetal birth weight in group A was 2281.1962±363.125 grams and in group B was 2271.4344±374.797 grams. In the low-dose aspirin group, 10(11.6%) had preterm birth and 31(36.0%) in the control group with a p-value of 0.001, which is statistically significant. The risk of having preterm birth with low-dose aspirin was 1.801 times less than controls.

Conclusion: aspirin in low dose given before 14 weeks of gestation decrease spontaneous preterm birth as compared to the control group in a woman with a history of previous preterm birth which was spontaneous

Diagnostic Accuracy Of Barium Swallow For Dysphagia, Keeping Rigid Esophagoscopy As The Gold Standard

Ansa Umara Akram — 2023-09-26

Objective: To determine the diagnostic accuracy of Barium Swallow in detection of patients presenting with dysphagia.

Study Design: Cross-sectional validation study.

Study Setting & Duration: Department of Otorhinolaryngology, Head & Neck Surgery, District Headquarter Hospital Rawalpindi from 01-09- 2022 to 01-03-2023.

Materials and Methods: Approval of the study was obtained from the Hospital Ethical Committee. A total of 111 patients both male and female patients were selected. The patients suffering from dysphagia as per operational definitions and who have reported for work-up to the Department of ENT, District Headquarters Hospital, Rawalpindi, and fulfill the complete inclusion and exclusion criteria, were selected. Informed consent was obtained from all the patients. Patients were selected by consecutive non-probability sampling technique. The data was analyzed using SPSS 24.

Results: A total of 111 patients were included in this study. The mean age of these patients was 50.79 ± 13.01 years, ranging from 28 to 70 years. The frequency distribution of females 70.27 % was found to be more than that of males 29.73 %. Majority of patients' barium swallow (74.77%) revealed pathologies, while only a small percentage of patients (25.23%) had normal barium swallow. Most of patients (87.39%) had pathologies found during rigid esophagoscopy, while just a small number (12.61%) had normal rigid esophagoscopy. Comparing both investigating tools, esophagoscopy discovered 87.39% of pathologies while Barium swallow detected 74.77%, indicating that esophagoscopy was a more accurate procedure. Patients had esophageal web 55 (25.2%) on barium swallow and 69 (62.2%) on the Rigid esophagoscopy. Barium Swallow had esophageal stricture 28 (52.2) and no Pathology was detected in 28 (25.2 %) patients. As well as Rigid esophagoscopy had esophageal growth13 (11.7), esophageal stricture 15 (13.5), and no Pathology was detected in 14 (12.6 %). Rigid esophagoscopy is more efficient in detecting esophageal pathology than Barium Swallow. In Barium swallows most patients had esophageal web 55 (25.2%) than the esophageal stricture 28 (52.2) and no pathology was detected 28 (25.2). In rigid esophagoscopy most patients had esophageal web 69 (62.2%) than the esophageal growth13 (11.7), esophageal stricture 15 (13.5) and no pathology detected 14 (12.6).

Conclusion: A range of diseases are associated with dysphagia can be found in patients. Two often used diagnostic methods are barium swallow and rigid esophagoscopy. Both Barium swallow and Rigid esophagoscopy are successful in the diagnosis of esophageal cancer. The use of a Rigid esophagoscopy is still a gold standard diagnostic and therapeutic tool for upper aerodigestive tract pathologies.

Comparison Of Isoconazole Nitrate Versus Nystatin For The Treatment Of Otomycosis

Amna Kausar — 2023-09-26

Objective: To compare the efficacy and local adverse effects of Isoconazole Nitrate versus Nystatin for the treatment of patients having Otomycosis

Sudy Design: Group experimental study.

Study Setting & Duration: Department of Otolaryngology, Head & Neck Surgery at Rawalpindi Teaching Hospital, Rawalpindi. Duration of study was 6 months after approval by Ethical Committee from Feb 2023 to july 2023

Materials and Methods: Total of 64 patients were selected. The study participants were individuals who, according to operational definitions had Otomycosis and who had presented for evaluation at the Department of Otolaryngology Rawalpindi teaching Hospital, Rawalpindi. They also met all inclusion and exclusion criteria requirements and these requirements were strictly adhered to in order to control confounders and bias. Isoconazole nitrate ointment was used to treat patients in Group A and Nystatin ointment was used to treat instances in Group B. Patients were chosen by randomization using lottery method. SPSS 28 was used to determine the frequencies in the data.

Results: 64 individuals (32 cases in each group) were chosen for the study by the ENT outpatient clinic. Out of which 33 (51.6%) being female and 31 (48.1) being male. The age ranged from 12 to 80 years, with a mean age of 44.29 ±19.13. After two weeks, there was a substantial improvement in 25 (39.06%) of the group A patients (p=0.08), a moderate improvement in 7 (10.9%), and a minor improvement in 5 (7.81%) patients (p=0.37) while in group B exhibited a substantial improvement in just 19 (10.9%) (p=0.08), a moderate improvement in 9 (39.0%) (p=0.38), and a small improvement in 7 (42.19%) (p=0.37). After four weeks 21 (32.81%) in Group B showed insignificant improvement, while 26 (40.63%) in Group A exhibited better improvement than Group B. The treatment for group A, which included isoconazole nitrate, was substantially more successful than the Nystatin treatment for group B. Isoconazole was found insignificantly more effective than (p=0.08). The majority of patients in both groups didn't notice any adverse .

Conclusion: Nystatin was shown to be significantly less efficacious than isoconazole nitrate ointment in treating otomycosis.

Nocardia Brain Abscess In A Patient With Advanced HIV-AIDS: Case Report

Muhammad Usman — 2023-09-26

Nocardia is a gram-positive bacterium that causes localised and disseminated infections. A rare case of Nocardia infection in an immunocompromised individual is presented. Nocardiosis should be kept in mind as a diagnosis in immunocompromised patients with a solitary space occupying lesion in the brain.

Huge Malignant Peripheral Nerve Sheath Tumors Originating In Neurofibromatosis Type 1

Nabeela Riaz — 2023-09-26

Malignant peripheral nerve sheath tumors (MPNST) are malignant soft tissue neoplasms which account for 2% of all soft tissue sarcomas. These tumors are associated with poor prognosis, propensity to metastasize and high recurrence rates. About half of the MPNST arise from pre-existing neurofibroma and are associated with Neurofibromatosis type I (NF1), 10% are radiotherapy induced others are sporadic. Pathogenesis of MPNST is not fully understood yet. MPNST are common in extremities followed by trunk but are less common in head and neck area. MPNST show limited sensitivity to radiotherapy and chemotherapy and wide surgical resection is mainstay of treatment. We present a series of 3 cases of MPNST of head and neck region originating in patients having NF1.

A Case Report Of A Giant Plunging Ranula In A 25-Year-Old Patient

Tafiya Erum Kamran — 2023-09-26

Abstract

This case report aims to present an unusual case of a plunging ranula that extended to the superior vertebral body of the T4 vertebrae, we will be elaborating on the patient presentation, investigations, diagnosis, and treatment of the lesion, while also talking about the adversities faced while diagnosing and treating the patient. The rarity of this condition and an atypical presentation makes this a difficult case to diagnose and vigilant treatment is needed to prevent any complications associated with the condition and ensure a successful treatment and recovery.

Antenatal Care - How to ensure quality!

Lubna Ejaz — 2023-09-26

Antenatal care (ANC) improves maternal and newborn health by providing a platform for important healthcare services, including health promotion, primary and secondary prevention by vaccination and screening, timely diagnosis & prompt treatment of various obstetrical and medical complications, which may arise or aggravate during pregnancy. Antenatal care substantially contributes to preparedness for labor and postnatal period¹. Healthcare workers should effectively communicate with pregnant women about their physiological, psychological, and sociocultural issues and provide medical, emotional, psychological, financial, and social support during this vulnerable time period ^{2, 3}. Previously, the quality of ANC was assessed by the number of antenatal visits (ANVs) of a pregnant woman with healthcare providers (contact coverage), but now this indicator of the quality of ANC is no longer accepted because it measures contact frequency without looking into the content of the care actually received during ANVs. Discerning the true picture of ANC quality demands the details of each ANV about the four essential parameters including: WHO recommended indicators, effective utilization of health services, doctors’ performance, and patients’ compliance⁴. WHO has published widely accepted recommendations for ANC, including suggestions for appropriate contact (frequency and timing between clients and the health system) and content (screening and management) based on evidence of effectiveness⁵. Measuring effective coverage of essential ANC interventions is more comprehensive than just counting the number of ANVs for assessing the ANC quality.

Conceptually, effective coverage is “the proportion of the population who needs a service and receives it with sufficient quality for it to be effective” ⁶. Therefore, it is important to comprehend that effective coverage, in perspective of ANC, has two components: ANC attendance (contact coverage) refers to total number of ANVs, and standard ANC content (effective coverage) refers to a set of interventions, which include WHO recommended indicators of history, examination, screening tests and managements at specified times during pregnancy^7,8. It is pertinent to add that effective ANC should ensure optimum feto-maternal health outcomes according to the available healthcare facilities.

In recent years, there has been growing interest in measuring the quality of ANC but there is no standard measurement system to categorize ANC into poor, average or good. Although several studies have incorporated various groups of indicators for evaluation of quality of ANC, only few studies have proposed categorization systems to objectively assess this important area of healthcare⁹. Even the proposed systems are insufficient for global assessment of ANC quality. Therefore, a more comprehensive categorization system should be devised by using maximum indicators of WHO guidelines to assess the ANC quality and correlate it with fetomaternal outcomes, being the main goal of ANC.

Pakistan Demographic Health Surveys (PDHS) have shown a significant increase in the number of women having at least one ANC contact with a skilled healthcare provider. The contact coverage has improved with an almost 3-fold increase in ANVs i.e. from 26% to 86% as described in surveys of 1990-91 and 2017-18 respectively. On the other hand, there is only 1.5-fold reciprocal decline in maternal mortality ratio during this time period i.e. from 431/100,000 live births in 1990-91 to 186/100,000 live births in 2017-2018 ^{10, 11}. A possible explanation for these disproportionate figures might be the lack of desired quality of ANC. Some of the major factors adversely affecting the ANC quality are poor infrastructure of the healthcare system¹², lack of well-trained human resources¹³, insufficient preventive services¹⁴, and inefficient utilization of available resources at all levels. Lack of health awareness and poor compliance by patients and their families are other major social contributors towards this grim situation¹⁵. Pakistan is still contributing 14.47% of the total maternal deaths in South Asia¹⁶. In this scenario, it becomes the professional responsibility of the public tertiary care hospitals to develop evidence-based strategies for improvement in ANC quality.

In Rawalpindi Medical University, the Department of OB/GYN is not only involved in teaching and training of undergraduates and postgraduate doctors but also provides obstetric care to a large number of complicated cases¹⁷. A study aimed at checking the quality of ANC in the department has recently been conducted and presented as an e-poster in RCOG Conference 2023. The quality of antenatal care was assessed in different dimensions by comparing the proportion of patients having an optimum number of antenatal visits, booking trimesters, effective screening for anemia, diabetes, hypertension, Hepatitis B & C, prophylaxis for tetanus, anemia and malnourishment, early diagnosis and prompt treatment of various obstetrical problems and the impact of these interventions on the fetomaternal outcomes. The study concluded that 15.8% of patients received good ANC, 71.4% received average and 12.8% received poor ANC.The women were broadly divided into 2 groups: Group A (≤ 3 visits) and Group B (> 3 visits) because the number of antenatal visits had a definite impact on the rate of early diagnosis and prompt treatment of medical disorders. Hypertension was picked up in 8% & 16%, while diabetes was diagnosed in 4% & 7% in Group A and B, respectively. Due to delayed diagnosis of high-risk patients in Group A, the LSCS rate was lower (33%) compared to Group B (40%), but it resulted in a higher rate of stillbirth (5% vs 2%), IUGR (2% vs 1%), PPH (3% vs 2%) and near miss patients (4% vs 2%) in Group A compared to Group B. In Group A, 14% were still anemic at the time of admission in labor while only 8% were anemic in Group B.

To conclude, improvement in quality of antenatal care has a positive impact on pregnancy outcomes. Each healthcare facility must assess its quality of ANC, not only in terms of ANC attendance (contact coverage) but also in terms of standard ANC content (effective coverage),in order to find out the deficiencies in services. This self-assessment will guide us for future improvement in standards of maternal and child health status in our country.