Journal of Rawalpindi Medical College

Comparison of Polyetheretherketone (PEEK) Cage versus Iliac Bone Graft undergoing Anterior Cervical Discectomy and Fusion (ACDF): A multicenter experience

Saad Javed — 2023-04-01

Background:
In anterior cervical discectomy and fusion (ACDF), the two most frequently used materials are allografts and polyetheretherketone (PEEK) cages. The aim of the study was to compare the functional and radiological outcomes of polyetheretherketone (PEEK) cages with iliac crest allografts in anterior cervical decompression and fusion (ACDF) in patients of symptomatic Cervical spondylotic myelopathy (CSM).
Methods:
In this cohort study, we included 70 (35 in each group) patients of symptomatic CSM having degenerative cervical disc disease who were planned for ACDF from Jan-2017 to Jan-2021 in Rawalpindi Medical University. All procedures were performed under general anesthesia in supine position, standard ACDF technique was used in all patients. Anterior cervical locked plates were used for fixation of PEEK cages or the iliac allografts in the inter-vertebral space. Radiologic and functional outcomes were determined till 6 months after surgery.
Results:
The baseline study characteristics were similar between the groups. Mean Modified Japanese Orthopaedic Association (MJOA) score at 06 months’ follow-up was same between the groups; 14.16±4.30 in group A and 13.54±3.24 in group B (p-value 0.49). Disc space height at 06 months’ follow-up was also similar between the groups; 10.01±0.67 mm in group A versus 10.11±0.70 mm in group B (p-value 0.54). Fusion rate at final follow-up was 31 (88.6%) in group A versus 30 (85.7%) in group B (p-value 0.72).
Conclusion:
PEEK cages have similar functional and radiologic outcomes in comparison to ileal crest allografts. So, PEEK cages can be used as a successful alternative to ileal crest allografts this will help to reduce donor site morbidity and will reduce longer surgical times associated with graft harvesting.

Frequency of Hepatitis B in Thalassemia Major Patients

2023-04-01

Background: Thalassemia is a set of inherited hematological illnesses caused by mutations in the genes that code for globin. Regular blood transfusions extend the lives of thalassemia patients, but they also increase the danger of blood-borne illness infections.

Objective: The current study was conducted to check the frequency and risk factors of hepatitis B virus (HBV) infections among β thalassemia major patients.

Methods: The study was conducted over a period of 3 months that is from November 2021 to February 2022 in the department of Thalassemia center CMH Rawalpindi. The study consists of thalassemia patients aged 6 months to 15 years including both male and female patients. Their venous blood was taken and transmitted to the laboratory, Armed force institute of pathology CMH Rawalpindi, for hepatitis B surface antigen test (HbsAg). Their demographic information was gathered, including their age, gender, number of blood transfusions received each year and Hepatitis B virus (HBV) vaccination status.

Results: Out of 100 patients there were 45 patients who were male and 55 patients who were female. The patients' ages span from 6 months to 15 years, with a mean age difference of 11.20 years and a standard deviation of 5.56. In three months, the mean difference in the number of blood transfusions received by patients was 22.7 6.6 SD. Patients under the age of ten were 50 percent of the time, and patients beyond ten were also 50 percent of the time (50 percent). Five (5%) of the total 100 patients tested positive for hepatitis B. In three months, the mean difference in the number of blood transfusions received by patients was 18.2 5.6 SD. Thirty (30%) patients out of a total of 100 were not immunized.

Conclusion: Frequency of hepatitis B in beta thalassemia major patients is minimal (less than 5 per 100) is seen in our study. To reduce the future risk of TTI, development of strong national and regional policies on safe blood transfusion procedures, VNRD-based transfusions, and universal quality-assured donor screening are recommended.

Key Words: Thalassemia, Hepatitis B, Blood transfusion, viral infection

Evaluating the learning environment in Dental colleges from students’ perspective; a qualitative exploratory research

2023-04-01

Objective: Learning environment has a great role in students learning, achievement and success. It is also essential for the development of curriculum. The aim of this study is to document the perception of dental students regarding their learning environment.

Material and methods: This qualitative research were conducted from Dec 2021 to May 2022, at four dental colleges of Rawalpindi. A total of 16 students from all these college who were regularly enrolled and voluntary participating in the study were included. Focus group interview (n=4 in each group) comprised of students from both basic sciences year (1st and 2nd year BDS) and clinical years (3rd and final year BDS). Data was transcribed verbatim and thematic analysis was done.

Result: Students overall expressed a good level of satisfaction with the learning environment but pointed out some issue which were summed up under major themes identified such as issues in lectures, issues in clinical teaching, issue in the dental curriculum and lack of academic motivation.

Conclusion: This study suggests that the dental students generally hold a positive perception towards their learning environment, but they pointed out the short comings in their lectures, clinical teaching, dental curriculum and dearth of motivation. Taking students view point regarding their learning environment will help the stake holders and policy makers to provide better learning environment with more facilities and support system for the students to enhance their learning.

Keywords: Dental curriculum, dental students, learning environment

A rural community-based investigation to assess mHealth for family planning advice in district Multan

2023-04-01

Background: Globally, Pakistan is the 5th populous country. To increase the use of family planning services by public private business model, Punjab Population Innovation Fund selected “Connect4fp” project implemented by International Rescue Committee organization. The purpose of this research was to determine the impact of mobile health(mHealth) advice on family planning in project area. This project was implemented in 9 Union councils of district Multan, Pakistan. The innovative idea of this project was the use of mobile phones to spread family planning knowledge among community in the form of Interactive Voice Response (IVR) as well as Short Message Service (SMS) (i.e., text messages).

Methods: A cross-sectional study targeted 197 men as well as women (mostly married women of reproductive age) receiving mobile messages or recorded robocalls from the project area. The purpose was to assess their family planning knowledge and awareness by using structured Likert scale questionnaire. Secondly the viewpoint about mHealth and its effect on family planning was determined from 40 private providers and 27 Family planning Champions (who were part of the project) by telephonic interviews. Their response was quantified by using Likert scale. Descriptive statistics were calculated of the study’s main variables. The association of family planning knowledge of community members was determined to their contraceptive use by using Chi square.

Results: The results specified that 60% community members included in this study told that their family planning knowledge is increased due to this mHealth program. 36% Private providers while 75% FP Champions were agreed that family planning patients are increased due to this mHealth program.

Conclusion: Mobile messages and robocalls about family planning sent in local language positively contributed to increase FP knowledge and awareness in community. This may trigger communication about family planning within couples, as a result increase use of family planning services.

Keywords: Family planning, mHealth, Private providers, Family planning champions

Establishing normal range of fetal renal artery RI and PI values in singleton pregnancies during 18-38 weeks of gestation

2023-04-01

INTRODUCTION: Human kidney constitutes an integral organ during the period of embryogenesis. The use of regular ultrasound during antenatal follow ups not only assesses structural aspects of fetal body but can also evaluate functional integrity of developing organs to some extent. Unfortunately, fetal renal hemodynamics has been studied more in western population which have better socio-economic status as well as good antenatal care. Our study aims at establishing a normal reference range for fetal renal artery indices in healthy Pakistani pregnant population which has not been done before.

METHODOLOGY: This is a nonprobability convenient study investigating 130 healthy pregnant women during 18-38weeks of gestation. Resistivity and pulsatility indices (RI and PI) of the fetal renal arteries were evaluated dividing the patients in four groups as per their gestational age. Normal reference ranges of RI and PI values were established. P values for RI and PI were also being calculated.

RESULTS: Mean values of the RI and PI of the fetal renal arteries were calculated. P value for RI is 0.05 and PI is 0.69. Hence the values remain unaltered with advancing gestational age.

CONCLUSIONS: These reference ranges demonstrate the minimal change of the fetal renal hemodynamics during healthy pregnancies pertinent to our reference population. These may be applicable in antenatal practice to identify deviations from these reference ranges and will be beneficial in further studies related to prediction of fetal renal function.

KEYWORDS: Fetal renal artery; antenatal pulse wave doppler; pulsatility; resistivity; normal range.

PLASMA DONATION AND PERCEPTION, ATTITUDE, BEHAVIOR OF COVID-19 PATIENTS: A CROSS SECTIONAL STUDY

2023-04-01

BACKGROUND: Current study aims to identify the perception, attitude and behavior about Covid and plasma donation in the Covid cases.

METHODOLOGY: This descriptive cross-sectional study was conducted ---removed for blind review---Adult COVID-19/post-Covid patients were included by consecutive sampling. The critically ill, mechanically ventilated cases were excluded. Special questionnaire was developed including the demographic variables, mode of transmission, personal hygiene, prevention, post covid immunity, re-infection, psychosocial factors, financial reservations and post covid life. Willingness for plasma donation, laboratory diagnostics and blood groups inquired. Data was collected by direct interview by researcher and analyzed by SPSS V.20.

RESULTS: Mean age was 39.8+15 years; 122(54%) females and 104(46%) males. Total 163(73%) participants said Covid has impact on health, economy, social, mental and psychological state. 188(83%) considered Covid a threat to human life. 142(63%) had a close Covid contact and 15(6.6%) had recently travelled. 131(58%) said they could have prevented getting infected. 171(75.7%) considered handwashing and 208(92%) cleanliness and158(77%) considered natural, herbal remedies as preventive. 191(84.5%) wore mask for most/all of the time. 130(57.5%) said they will be immune to Covid post-recovery. 179(79.2%) were aware of re-infection. 169(74.8%) considered smoking as a risk for Covid and137(60.6%) aimed to quit smoking. 204(93%) committed to hand washing and 210(92.9%) to wearing masks post-Covid. 127(56%) were concerned about their food, 78(34.5%) about finances, 103(45.6%) about their family getting infected. 213(94%) expected life to normalize post-Covid. Most frequent blood group was B+ 67(29.6%) followed by A+ 42(18.6%) and O+ 41(18.1%). 128(66.6%) participants showed willingness to donate their plasma after recovery. 24(10.6%) refused the donation. 134(59.3%) agreed that plasma donation won’t reduce their immunity. 186(82.3%) were clinically recovered at the time of interview. CONCLUSION: Our Covid patients had a positive approach towards plasma donation. They expected normalization of life post Covid and showed commitment toward continuation of preventive habits and smoking cessation. However, there were significant concerns about finances, safety of loved ones and mental health.

KEY WORDS: Plasma Donation. Covid-19

Prevention of Ovarian Hyper stimulation Syndrome by using gonadotrophic releasing hormone analogue to induce final ovulation trigger in invitro fertilization cycles

2023-04-01

Objectives: To find out occurrence of ovarian hyperstimulation in patients who were hyper responders in in vitro fertilization cycles. Secondary outcome was to assess number of metaphase II oocyte and fertilization rate, cleavage rate and pregnancy outcome when GnRHa is used for final maturation and triggering ovulation.

STUDY DESIGN, SIZE, and DURATION: This is retrospective descriptive analysis of cases managed at single center from June 2017 till May 2018.

PATIENTS & METHODS: Twenty patients were identified as hyper responders based on baseline, ovarian reserve characteristics, that is antral follicle count, (AFC) > 25, AMH > 4ng/ml and on day of trigger, follicles >-25 in number of ≥ 11mm were administered GnRHa trigger and 1500IU hCG on oocyte retrieval day while luteal phase was supported with daily vaginal progesterone and twice daily estradiol valerate. Sixteen patients underwent fresh transfer while four patients had their embryos frozen.

MAIN RESULTS: Twenty patients were identified as high risk and their baseline characteristics were, mean age 31.7 ± 4.50, mean antral follicle count 25.7 ± 5.01, Anti Mullerian hormone level mean 4.64 ± 2.52 and PCOS was present in 35% cases. Peak estradiol level mean 13455-± 6632pmol/l and mean follicles count of 25.45 ± 8.78 confirmed a high response. Oocyte yield was 11.45+ Metaphase oocyte retrieved were 85.5% and cleavage rate of 93%. No case of early onset OHSS was identified. Only one patient developed moderate OHSS. Pregnancy rate was 31.25%. Miscarriage rate was 6.3% and ongoing pregnancy was 25%.

CONCLUSION: This small retrospective descriptive analysis supports the view of current literature that GnRH trigger not only prevents early onset OHSS also achieves increase of M11 oocytes. In addition, pregnancy outcome is not statistically different to those cycles where hCG is used as trigger.

Keywords: GnRH trigger, PCOS, IVF outcome, OHSS

Survival outcomes of different Histopathological Subtypes and stages of Wilms Tumor treated following SIOP 2001 Protocol, Children Hospital Lahore, Pakistan experience

2023-04-01

Introduction: Wilms tumor is the most common pediatric renal neoplasm. Following preoperative therapy, various histological subtypes, risks and clinical stages are determined as per following SIOP 2001 protocol. To determine the clinicopathological features of different histopathological subtypes and stages of Wilms tumor after completing course of preoperative as well as postoperative chemotherapy following SIOP 2001 protocol.

Methodology: This is a retrospective cross-sectional study and sample size calculated by non-probability technique. Ninety-three patients with abdominal masses in the Hematology/Oncology Department were included. After radiological and histopathological diagnosis, four weeks of preoperative chemotherapy, given to patients, followed by partial and radical nephrectomies by surgical team. Specimens received in Histopathology Department grossed and microscopically examined for different post chemotherapy histological subtypes. Further risk categorization and clinicopathological staging in accordance with SIOP 2001, done after completion of treatment. Patients called for yearly follow up for the next five years. Categorical variables presented as frequencies and percentages.

Results: Mean age of ninety-three children was 44.4 months + 30.92with predominance of males (55.9%) and more common in right sided kidney (55.9%). Majority patients completed the entire course of treatment (77.4%). Majority were intermediate risk tumors (76.3%) and most common histological subtype was Mixed Tumor subtype (23.4%). In our study majority, tumors were stage III (48.3%) and patients died due to febrile neutropenia (9.6%)

Conclusion: In our study majority, patients completed the entire course of treatment and relapse was fairly less. Patients lost to follow up after nephrectomy and deaths at home caused by febrile neutropenia were our major challenges.

Key words: Wilms tumor (WT), Internal Society of Pediatric Oncology (SIOP 2001), Post chemotherapy.

Effectiveness of Tocilizumab in reducing inflammatory response associated with COVID-19 pneumonia at Islamabad Medical Complex, Islamabad

2023-04-01

Objective: To determine the effectiveness of Tocilizumab in covid-19 related severe pneumonia.

Introduction: COVID-19 is a global health problem causing respiratory infection. This is triggered by IL-6 characterized by raised inflammatory markers that is called cytokine release storm. Severe disease leads to hospitalization, oxygen requirement and poor outcome.

Methods: This interventional study (descriptive analytic) was conducted from July-December 2021 at Intensive Care Unit, after ethical approval. Seventy cases of COVID-19 pneumonia with cytokine storm were included. Twenty cases were dropped either refusal to tocilizumab, pregnancy or having contraindication to tocilizumab, leaving 50 study participants. The patient’s demography, clinical, laboratory and radiological findings, timing and response variables of tocilizumab were recorded. The temporal readings of inflammatory markers, oxygen requirement and clinical status were compared at admission and after tocilizumab. SPSS version 25 was used for data analysis. Chi-square test was applied with significant p-value < 0.05.

Results: There was male predominance of 66% with mean age of 58.6±14.8 years. Mean day of illness and hospital stay was 8^th day and 17.56 days respectively. C-reactive protein levels improved in all cases 50(100%) (p <0.0001), ferritin in 31(62%) (0.019), D dimers in 28 (56%) (p0.014), LDH in 30(60%) (p 0.02) and interleukin-6 in 32(64%) (0.017. Survival benefit with tocilizumab was significant in patients that received within 10^th day of illness (p 0.021). At discharge, 66.6% were off oxygen and 33.3% required domiciliary oxygen.

Conclusion: COVID-19 Pneumonia with cytokine release storm bears high mortality. Significant improvement in inflammatory markers like CRP, ferritin, D-dimers and LDH shows effectiveness of tocilizumab. Early administration within 10 days of illness has survival benefits.

Keywords: COVID-19 infection, Cytokine storm, Tocilizumab

360-degree Evaluation of Postgraduate residents at Rawalpindi Medical University: Appraising the achievement of core competencies by comparing the scores of 1st &

2023-04-01

Objectives: To compare 360-degree evaluation scores of postgraduate residents during 1^st and 2^nd cycles of evaluation to analyze the acquisition of core competencies.

Materials & Methods: A cross-sectional analytical study was done to compare the acquisition of core competencies as per ACGME by MS/MD residents in 3 public sector teaching hospitals of Rawalpindi. The enrolled residents undergone 1^st and 2^nd cycle of 360-degree evaluation from Jan-June 2018 and July 2018 -Jan 2019 respectively. The data was gathered from supervisors, faculty, nursing staff, patients and their attendants by structured proforma. Data was analyzed by SPSS version 25.0. Specialty-wise scores were statistically presented with 95% CI. Differences in scores of core competencies during both cycles were determined by independent sample t-test. P < 0.05 was considered significant.

Results: About 93 and 113 trainees were evaluated during 1^st and 2^nd cycle of evaluation respectively. Most (41.70%) of them were 1^st year residents. 2^nd cycle of evaluation revealed statistically significant improvement (P<0.00001) in all 6 core competencies. Feedback from the patients also illustrated significant difference in scores of both cycles (P = 0.01). Trainees of MS Surgery & Allied programs were determined as highly competent with 250.06 ± 38.57 score followed by those of MD Medicine & Allied (247.59 ± 42.15) and Gynecology & Obstetrics (246.71 ± 46.26) out of total score of 331. Residents of HFH and DHQ Hospital had statistically significant enhancement of competencies (P<0.0001) than those of BBH (P=0.003).

Conclusion: There was substantial enhancement of core competencies among postgraduate trainees.

Keywords: 360-degree evaluation, ACGME, university residents, core competencies.

IMPACT OF COVID-19 HEALTH CARE EMERGENCY ON TRAUMA RELATED OUTCOMES

2023-04-01

Objective: To determine the impact of Covid-19 healthcare emergency on trauma-related outcomes.

Study Design: Cross-sectional observational study

Duration and Place of Study: Emergency department of surgery and allied of –removed for blind review----and from 1st March 2021 to 30th May 2021 for three months.

Patients and Methods: A comparison was made between the number of trauma patients admitted to the emergency department during the pandemic and the patients admitted during the same period of the previous year in the same center (data extracted from hospital records). Furthermore, we compared trauma-related disorders, patterns of injuries, and clinical characteristics of trauma patients in our hospital during a pandemic with those in a non-pandemic.

Results: The number of trauma patients in the pandemic was significantly lower than it was before Covid. Before Covid, 1520 (64.5%) were admitted to the emergency room (non-Covid group), whereas only 835 (35.5%) were admitted to the emergency room during the pandemic (Covid group). There was a 48 % reduction in total. Gender and age ratios did not differ much between the two groups. Between cohorts, there was a significant association between mechanism of injury and type of trauma (p<0.03). Mortality rates decreased during the Covid-19 era (1.3% vs. 3.4%).

Conclusion: As a result of the Covid-19 outbreak, there was a 48% decrease in trauma patients admitted to hospitals and a decrease in their mortality as well. The findings of this study may open the new door to new ways of managing surgical emergencies without engulfing the already busy hospitals.

Keywords: Trauma, Emergency, Covid-19, Trauma care

Thyroidectomy with Drain and Without drain; A Clinical Comparative Study

2023-04-01

Background: Thyroidectomy is one of the most difficult surgical procedures. The study aims to compare the thyroidectomy procedure with drain placement and without drain concerning the hospital stay, Postoperative complications, and pain assessment using a visual analog scale.

Methods: A prospective comparative study was designed in the Department of otorhinolaryngology & Head Neck Surgery---removed for blind review----. A total of 117 patients were enrolled in the study from which 9 were excluded due to loss of follow-up. The patients were divided into two groups by using computer-generated randomized numbers containing sealed envelopes. Both groups contained 54 patients. Group A patients with a drain placed while group B contained patients without a drain. The patients with drain have a longer hospital stay and reported increased pain as compared to the patients with drainless thyroidectomy.

Results: The mean age and standard deviation calculated for the patients enrolled in both groups after randomization was 13.28 42.5 and 12.18 43.9 in groups A and B respectively. The mean ages were statistically insignificant. However, Postoperative variables such as length of hospital stay and post-operative pain by visual analog scale were assessed. The hospital stays of the patients with a drain placed was found statistically significant with a P-value < 0.05 Postoperative pain assessed by visual analog scale was also significant having a P-value <0.05 for patients having stayed for 2 to 4 days.

Conclusion: Placement of drain after thyroidectomy saves the patient from life-threatening complications but at the same time increases the post-operative pain on day one and increases the length of hospital stay of the patient. The routine practice of drain placement should be avoided unless there must be a risk of the development of hematoma or seroma.

Keywords: Thyroidectomy, thyroidectomy with drain, thyroidectomy without drain

Frequency of Meningitis in Neonatal Sepsis

2023-04-01

Objective: The aim of current study was to examine the frequency of meningitis in infants having late onset sepsis (LOS). Bacterial sepsis and meningitis endure to be leading causes of illness and mortality in neonates around the world, predominantly in preterm neonates. They must be discovered and cured as soon as possible to avoid death or disability.

Study Design: The Cross-Sectional method was used to conduct a study.

Duration and Place of Study: The study period was July to December 2021. Data was collected from Pak Emirates Military Hospital (PEMH) NICU Rawalpindi.

Material and Method: The study comprised a total of 110 individuals, both male and female. All of them were older than 3 days and had been hospitalized and diagnosed with late onset sepsis. A neonate was diagnosed with meningitis if his or her cerebrospinal fluid (CSF) had > 30 leukocytes/mm3 and any of these two: >200 mg/dl protein or 40 mg/dl glucose.

Results: Out of 110 infants having LOS 38 were diagnosed with meningitis in which 21(55.2%) were male and 17(44.8%) were female. Overall mean weight of neonates was 2.38±1.72. A total of 24(63.1%) having low body weight and 22(57.8%) were premature. Meningitis was found to have a significant association with low bod weight and pre-term birth (p value<0.05).

Conclusion: Meningitis was considerably high in neonates with (LOS). Low body weight and pre-term birth had significant association with meningitis having (LOS).

Key Words: Frequency, Meningitis, Late onset sepsis, Pre-term, Low body weight, Neonates.

Anti-Hyperlipidemic Effect of Zinc complex of Betulinic acid in High Fat Diet- Induced Hyperlipidemia

2023-04-01

Background: Hyperlipidemia is considered a modifiable risk factor for cardiovascular disease and atherosclerosis. Drugs of first choice, Statins, despite being well tolerable, are accompanied by many adverse effects. To tackle the shortcomings of standard drugs, there is dire demand to make an agent which equates to a better response. This study evaluated the anti-hyperlipidemic and comparative effects of Zinc complex of Betulinic acid (Zn+BA) with simvastatin (SIM), on high-fat diet-induced hyperlipidemia in rats, and the safety profile of the two treatments was also assessed.

Methodology: Hyperlipidemia was induced by giving a high-fat diet. BA +Zn 10 mg/kg and SIM 20 mg/kg were given orally for four weeks. On the final day terminal sampling was done and serum lipid profile (TG, TC, LDL, HDL) and hepatic enzymes (ALT) for assessing hepatotoxicity were estimated. Results: Our results showed that BA+Zn significantly increased HDL levels and significantly reduced serum TC, TG, and LDL (p<0.001) as compared to Simvastatin. Correspondingly serum ALT levels also showed significant reduction (p<0.001) in comparison with Simvastatin.

Conclusion: Our study suggests that BA+Zn effectively attenuates high-fat diet-induced hyperlipidemia while preserving hepatic function and could serve as a better alternative to simvastatin in treating hyperlipidemia.

Keywords: Zinc, Betulinic acid, High Fat Diet, Hyperlipidemia, Simvastatin

Comparison of Intra-articular Platelet Rich Plasma versus Corticosteroid Injections for the Treatment of Moderate Knee Osteoarthritis

2023-04-01

Objective: To compare the efficacy of intra-articular injections of prednisolone acetate and platelet rich plasma in cases of moderate knee osteoarthritis.

Study design: Prospective comparative study.

Place and Duration of study: Department of Orthopedic Surgery, Khairpur Medical College, Khairpur Mirs, from January 2021 till December 2021

Methodology: A total of 100 patients were selected for the study and were randomly divided into two equal groups. Group C patients received intra-articular corticosteroid injection along with local anesthetic (Prednisolone acetate 40 mg + 3 ml of 0.5% bupivacaine) under ultrasound guidance. Group P patients received 3 injections of PRP, each of 8 ml volume given at one week’s interval. Patients with signs of hemodynamic compromise, sepsis, past history of any intra-articular injection in the same joint were also excluded from the study. Follow up of patients was carried out at 1, 3 and 6 months. The Western Ontario and McMaster Universities Osteoarthritis (WOMAC) scale was used to assess the patients prior to injection and then at each follow up. WOMAC scale consists of three subsets i-e pain, stiffness and physical function.

Results: Demographic data was comparable between both groups. Pre-injection WOMAC score in group C and P was 71.54±12.18 and 75.20±8.58 respectively (p-value=0.086); after one month of injections, it was 34.20±10.48 and 35.38±6.31 respectively (p-value=0.580). After 3 months of injection, it was 33.20±8.13 and 31.10±5.50 respectively (p-value=0.195). After 6 months of injection, it was 35.32±10.41 and 32.10±6.63 respectively (p-value=0.68).

Conclusion: It is concluded in our study that intra-articular injections of prednisolone acetate and PRP are equally effective in patients of moderate knee osteoarthritis.

Keywords: Corticosteroids, intra-articular injections, knee osteoarthritis, knee pain, osteoarthritis, platelet rich plasma, prednisolone acetate.

CAN SHOE SIZE CORRECTLY PREDICT THE SIZE OF COMPONENTS OF TOTAL KNEE REPLACEMENT PRE-OPERATIVELY

2023-04-01

Objective: To ascertain the correlation between shoe size and sizes of femoral and tibial components of total knee replacement preoperatively in patients undergoing total knee arthroplasty.

Study design: Prospective cohort study

Study settings and duration: This study was conducted at department of orthopedic surgery, Shifa International Hospital, Islamabad from July 2020 – December 2020.

Material and methods: Sample size was calculated using WHO calculator and it was 43 patients in total. Patients were approached through non-probability consecutive sampling. Shoe size of patients was measured using a Brannock device. During surgery, Implant model and sizes of the femoral and tibial components implanted during knee replacement were noted. Data was analyzed with the help of SPSS version 24. We applied Pearson’s correlation cofficeint. P value ≤ 0.05 was considered significant.

Results: Out of 43, there were 9(20.9%) male and female 34(79.1%). Mean age of patients was 51.7±6.8 (SD). We found good positive correlation between shoe size and tibial component (p=<0.001). Positive co relation was found between femoral component and shoe size (p=0.001). Shoe size predict 72% of Tibial component and 65% femoral component.

Conclusion: Shoe size is effective and safe predictors of total knee replacement components pre-operatively. This procedure is more accurate and less labor intensive. Accurate templating result in less surgical duration and provide several benefits to patients and health care providers.

Key words: Femoral Component, Shoe Size, Tibial Component, Total Knee Replacement

Adult Hemophiliacs in Pakistan: Health-Related Quality of Life and Psychological Aspects

2023-04-01

Introduction: Coagulation factor VIII (FVIII) (in hemophilia A) or IX (FIX) (in hemophilia B) deficiency associated with the X chromosome is the primary cause of hemophilia. Bleeding carried on by hemophilia can have an impact on a patient's mental health and quality of life. Recurrent bleeds in their muscles and joints cause hemophilia patients to experience constant pain. Certain variables, such as depression brought on by low self-esteem in comparison to "normal" siblings and peers, may have an impact on hemophilia patients.

Objective: The goal of this investigation is to assess how psychological factors and pain affect adult hemophiliac patients' well-being.

Materials and Methods: On 102 hemophiliacs, a cross-sectional study was done. Data were gathered using visual analogue scales for pain, depression anxiety stress assessments, and quality of life questionnaires specific to hemophilia. Regression analysis, analysis of covariance, and correlation coefficients were used to analyze the data. Results: According to the findings, 70.8% of hemophiliac patients felt pain on the research day. Patients with hemophilia had an average HRQoL score of 50.08 (standard deviation: 18.49). Additionally, stress, worry, and mild to serious depression were present in 45.7 %, 63.5% and 58.3% of the patients, respectively. Additionally, a substantial correlation between HRQoL and sadness, anxiety, and pain intensity were found. The study variables were able to explain 47% of changes in HRQOL in the regression model, with depression and pain intensity serving as important predictors. Conclusion: To enhance the psychosocial health and quality of life of patients, emphasis should be given to these factors.

Key Words: Hemophilia, psychological factors, Pain

The Prevalence & Severity of Depression in patients with chronic obstructive airway disease

2023-04-01

Objective: To determine the Prevalence & Severity of depression in Chronic Obstructive Airway Diseases (COPD) patients.

Background: Chronic Obstructive Airway Disease is a chronic heterogeneous disease that is also progressive. Depression is a common entity in chronic diseases. COPD causes long-term respiratory symptoms and depression is commonly found in these patients. The symptoms of these two diseases are overlapping and depression in COPD patients’ needs to be diagnosed and adequately treated. Untreated patients lead to poor control of respiratory symptoms and further deterioration of the illness. Our study aimed to determine prevalence and severity of depression in COPD patients using HAM-D score.

Material and Methods: This study was conducted in Medicine & Pulmonology OPD, Fuji Foundation Hospital, Rawalpindi from August 2019 to February 2021. Using a cross sectional study design, a total of 169 cases of COPD were recruited and tested for the presence of absence of depression using the HAM-D rating scale and observations were recorded.

Results: Total 169 patients recruited in this study with female & male percentage of 59% and 47% respectively. The Mean duration of illness was 11.5 years ± 6.48. The incidence of Anxiety & Depression was high (45% and 36%) in moderate to severe disease with total prevalence of 54 % among participants in the study.

Conclusion: Anxiety & depression is commonly prevalent in COPD patients. Female patients are found to have more psychological disturbance irrespective to their COPD severity. Psychological impairment must be carefully evaluated in patients having COPD.

Keywords: Chronic obstructive pulmonary disease (COPD), Hamilton depression grades (HAM-D), Forced Expiratory Volume in one second (FEV1).

Emotional Distress Among Pediatric Cancer Patients and their Siblings

2023-04-01

Objectives: Cancer being a serious chronic illness, causes profound effects on physical and mental health of the individual as well as affects their caregivers and family members' mental health. This study aims to find out the burden of emotional distress in patients of childhood cancer as well as their healthy siblings.

Methods: It was a descriptive cross-sectional study. Parents of the children undergoing cancer treatment or having completed treatment within past one year were asked to complete an interview proforma (Pediatric Emotional Distress Scale) about their child’s behaviour over past one month, scoring each behaviour on a scale of 1 to 5 according to the frequency of symptoms. The data was then analysed using SPSS 20. The frequency distribution, central tendencies and standard deviations were calculated accordingly.

Results: Almost eighty-five% of the patients showed scores above the clinical threshold for emotional distress. Eighteen% of the healthy siblings also had scores above the clinical threshold. Patients as well as their healthy siblings showed high levels of anxiousness in their behaviours.

Conclusions

Childhood cancer is a cause of major emotional trauma in patients.
Age-matched siblings usually cope well with the illness.

Key words: Psychological distress, survivor, childhood cancer

In vitro efficacy of fosfomycin against E. coli and prevalence of MDR and XDR E. coli isolates from UTI Patients

2023-04-01

Objective: The efficacy of fosfomycin against ESBL and/or carbapenem-resistant E. coli isolated from urine samples was determined.

Methodology: Three hundred fifty (350) urine samples were collected from the patients having UTI visited to the department of Urology, JPMC, Karachi. The CLED agar was used for the primary isolation of uropathogens. Regular antimicrobial sensitivity testing was conducted in accordance with CLSI standards, and the minimum inhibitory concentration (MIC) of fosfomycin was assessed using E-strips.

Results: Out of 350 urine samples 213 (60.85%) were E. coli. Patients with E. coli had an average age of 38.75 15.01 years. Females are more prone to have UTI 146(68.54%). E. coli was highest among uropathogens having frequency of 213(60.85%). E. coli manifest highest resistance to ampicillin 187(87.79%) and low resistance to meropenem 12(5.63%), imipenem 15(7.51%) and fosfomycin 21(9.85%). The overall carbapenem resistant E. coli was 9(6.4%) and majority of (61.5%) fosfomycin resistant E. coli, MIC value was >1024µg/ml. Isolates were categories in the non-MDR, MDR and XDR. Most of the isolates were MDR (53%), followed by the non-MDR (35%) and XDR (11%).

Conclusion: In conclusion present study suggests that fosfomycin is still effective against E. coli. More than 50% E. coli isolates were MDR and it’s an alarming situation for urologist.

Keywords: Carbapenem resistant, Extensively Drug Resistant, Fosfomycin, Multidrug resistant E. coli, Urinary tract infection

Diagnostic Accuracy of Serum Prostate Specific Antigen and Gleason Score in Determining the Presence of Skeletal Metastasis in Prostate Cancer Patients: a Pakistani Perspective

2023-04-01

Objective:

To determine the cut-off values for serum Prostate Specific Antigen and Gleason score for predicting bone metastasis of Prostate cancer.

Methodology:

This diagnostic accuracy study was conducted in Pakistan Institute of Medical Sciences (PIMS), Islamabad from 2015 to 2018. 330 patients of Prostate cancer were enrolled in the study. Prostate Specific Antigen (PSA) and Gleason Scores (GS) were determined using commercially available ELECSYS® assays in the Modular Analytics E170 (Roche Diagnostics) and histopathology respectively. Tc99m methylene diphosphonate (MDP) was used to perform the Bone scan. Any correlation between these variables was nvestigated to determine a cut-off value for PSA and GS.

Results:

Out of the total 330 patients included in the sample, BS was positive for metastasis in 186 (56.4%) patients and negative in 144 (43.6%) patients. Amongst these 186 positive patients, 5 (2.7%) had PSA < 20 ng/ml, 174 (93.5%) had PSA between 20 and 90 ng/ml, and 9 (4.8%) had PSA > 90 ng/ml. Out of the 144 patients with negative BS, 142 (98.6%) had PSA < 20ng/ml. Only 2 (1.4%) had PSA in the range of 20 and 90 ng/ml, while none had PSA > 90 ng/ml. In the 147 patients with PSA < 20 ng/ml, 142 (96.6%) did not have any skeletal metastases. Of the 183 patients with PSA > 20 ng/ml, 181 (98.9%) had positive bone scans. Using a cut-off value of 20 ng/ml for serum PSA, 142 unnecessary scans would have been unnecessary.

Out of the 186 patients with positive bone scan (BS), 3 (1.6%) patients had GS < 7, 160 (86.0%) patients had GS between 7 and 9, and 23 (12.4%) patients had GS > 9. Out of the 144 patients with negative BS, 84 (58.3%) had GS < 7, 60 (41.7%) had GS between 7 and 9, and none of the patients had a GS more than 9. Of the 87 patients with GS < 7, 3 (3.4%) patients had a positive BS while 84 (96.6%) patients had a negative BS. Of the 243 patients with GS > 7, 183 (75.3%) had a positive BS while 60 (24.7%) patients had a negative GS. These results indicate that a GS > 7 cannot be reliably used to rule in the need for a BS in patients with Prostate cancer.

Conclusion:

Our study reports that serum PSA < 20 ng/ml can be safely used to omit a bone scan. It also suggests that Gleason Score < 7 nullifies the need to conduct a bone scan. However, serum PSA is a better and more reliable indicator of bone metastases as it has better sensitivity and specificity values as compared to GS. If these results are applied in hospitals all over the country, we can significantly reduce the burden on our resources and prevent unnecessary, low-yield diagnostic tests from being carried out.

Association of Central Corneal Thickness among Myopic and Emmetropic Patients Visiting Ophthalmology Department of a Tertiary Care Hospital in Islamabad.

2023-04-01

Aim The aim of the study was to determine difference between central corneal thickness (CCT) among myopic and emmetropic eyes.

Material and Methods A total of 186 participants participated in this comparative cross-sectional study. Sample size was calculated using the WHO calculator and enrolled by consecutive sampling technique. Detail eye examinations were performed of anterior and posterior segments with slit-lamp and refractive status were determined with Auto-refractometer (Nidek ARK 1a) and Pachymetry with Specular Microscope (Topcon SP2000P). The analysis of data was performed in SPSS 22.

Results To carry out the study, 186 candidates volunteered their time and effort. Male and female participants were included in the study. About 56% of the candidates were men, and 44% were women. Individuals' ages varied from 16 to 49, on average (16-49). As for the control group, the average central corneal thickness was 522.30 microns and standard deviation of ± 29.563. Their sizes varied from 439 microns to 619 microns. The average CCT of myopic people was 515.18 microns, and the standard deviation was ±28.972 microns. The relationship between CCT in myopic eyes and CCT in emmetropic eyes was analysed using a paired t test. The P value was only 0.09, the relevance of the test was not significant.

Conclusion: CCT difference between myopic and emmetropic eyes was no statistically significant (P 0.09).

Keywords: Myopes, Emmetropes, CCT

Effect of Reperfusion on Time Domain Parameters of Heart Rate Variability

SIDRA HAMID SIDRA HAMID — 2023-04-01

Objective: To compare effect of reperfusion by measuring time domain parameters of heart rate variability before and after percutaneous transluminal coronary angioplasty. Study design: Quasi experimental study design Place and Duration: Department of Clinical Cardiac Electrophysiology, Armed Forces Institute of Cardiology/National Institute of Heart Diseases (AFIC/NIHD), Rawalpindi from January 2014 till January 2015. Patients and Methods: 40 patients with coronary artery disease having mean age of 55.20 ± 8.03 years were recruited by non-probability convenience sampling. DMS 300-4A Holter monitors were used to obtain 24 hours ambulatory ECG recording before and within 24 hours after percutaneous transluminal coronary angioplasty. Digital ECG data were transferred to the computer and edited with the help of DMS Cardioscan software. Heart rate variability was analysed in time domains measures. For time domain analysis normal heart rate, SDNN, SDNNi, SDANN, RMSSD and pNN50 were recorded from 12 lead digital ECG data.

Results: The results of our study demonstrated significantly decreased heart rate variability in coronary artery disease patients on comparison of pre and post-angioplasty values only SDNNi was significantly reduced (p-value = 0.035) whereas the reduction in SDNN and pNN50 was statistically insignificant (p-value > 0.05). On the contrary, SDANN and RMSSD displayed slight rise after angioplasty but it was not significant (p-value > 0.05).

Conclusion: Reperfusion after percutaneous transluminal coronary angioplasty decreases heart rate variability within 24 hours after the procedure. Whereas, heart rate during the same period after angioplasty increases. This reflects autonomic balance shifts towards sympathetic predominance as indicated by reduced heart rate variability and rise in heart rate. This makes the susceptible patients vulnerable for development of ventricular arrhythmias especially during 24 hours after angioplasty. Therefore, patients with decreased heart rate variability are at risk of ventricular arrhythmogenesis so they may be kept under medical surveillance for at least 24 hours after percutaneous transluminal coronary angioplasty.

The frequency of stroke-acquired pneumonia in patients admitted to ICU with Cerebrovascular accident (CVA)

Fatimah Rasool — 2022-09-30

Introduction: Stroke is themost prevalent disorder. In our country, it can cause significant mortality and morbidity due to its associated complications such asstroke-associated pneumonia (SAP). Stroke can be fatal directly due to affecting the respiratory system andneurological damage. Stroke-acquired pneumonia is defined as any respiratory tract infection acquired within 7 days of stroke.

Objective:To find out the actual frequency of stroke-acquired pneumonia in ICU patients.

Study Design:Descriptive case series.

Setting:Department of Medicine, DHQ Teaching Hospital, Sargodha.Duration:Six months from 15thOctober 2018 to 15thApril 2019.Materials and

Methods:In this study, the cases of either gender or aged30 to 70 years suffering from stroke within 12 hours were included. SAP was labelled based onfever, cough,and non-homogenous opacities on chest X-ray.

Results:Current study comprises about 160 cases of stroke and out of these 78 were (48.75%) females and 82 (51.25%) were males. The mean duration of stroke was 7.05±2.54 hours and the average age of the subjects was 54.24±7.15 years. They were 30 (18.75%) cases that had a history of smoking, 28 (17.50%) had HTN,and 35 (21.88%) cases that had DM. Stroke-acquired pneumonia (SAP) was seen in 20 (12.50%) of the cases. SAP was seen in 12 (15.38%) female cases as compared to 8 (9.75%) males with p= 0.34. SAP was more seen in cases with DM where this was observed in 7 (20%) of the cases as compared to 13 (10.4%) with no DM with p= 0.15. SAP was seen in 5 (17.85%) cases with HTN and 4 (13.33%) cases with a history of smoking with p valuesof 0.35 and 1.0 respectively. SAP was seen in 15 (14.42%) cases with a duration of stroke of 6-12 hours in contrast to 5 (8.92%) cases with a duration less than this with p= 0.45.

Conclusion:SAP is not infrequent and is found in more than 1 out of every 10 cases and the cases of SAP were found more in females and those who have a history of DM, HTN,and a duration of stroke of 6 to 12 hours; though none of this variable was found statistically significant.

Keywords:SAP, HTN, DM, Smoking.

ANATOMY IN THE UNDERGRADUATE MEDICAL CURRICULUM; BLENDING THE OLD AND NEW

Ayesha Yousaf Ayesha Yousaf — 2023-04-01

“The nature of the body is the beginning of medical science”-Hippocrates.

From the chosen Dhanvantri of ancient India to Imhotep of Egypt, to Huangdi of China^[i], disease was seen as a combination of the supernatural and the natural and medicine focused on healing the soul and the body. While practices have changed drastically since the establishment of the first organized medieval medical school Schola Medica Salernitana in Italy^[ii], what remains unchanged is the importance of the basics. If anything, modern knowledge and analysis has increased the emphasis laid on basic sciences and anatomy can be regarded as the backbone, the core of basic medical sciences.

Just as a mechanic cannot repair a car without a thorough knowledge of its form, external and internal, a doctor cannot heal the human body without a deep understanding of its structure. A fact that has been understood and utilized by the likes of Herophilus and Vesalius, fathers of anatomy^[iii]. The subject deals with the learning of the structure of the human body from the gross external features down to the microscopic level, at all stages of development, from the embryo to the elderly. This knowledge is essential for a physician in order to understand the functioning of the body, disease pathophysiology and treatment modalities.^[iv] The specialty that benefits the most from this subject in clinical practice is surgery while the rest of the specialties rely on anatomy while during physical exams, symptom interpretation, patient education and interpretation of radiological images.^[v]

If we talk specifically about the undergraduate medical curriculum, anatomy is a vital component of the basic sciences taught during the first one or two years of medical or dental school. The role this subject plays in the curriculum can be discussed int two categories: the ideal, theoretical role and the less-than-perfect, practical reality.

Most medical schools in Pakistan, UK and USA, despite having adopted an integrated modular system, still teach anatomy in the first two years at the most.^[vi] During these two years, a specific number of hours (from around 150 hours of total teaching time for anatomy) is allocated to gross anatomy, neuroanatomy, histology etc. For deeper understanding and integration, anatomy should be taught all 4-5 years of medical school, assimilated with clinical subjects. While the systems approach of teaching medial curriculum sounds fine on paper, the lack of a standardized practical application of this approach has its pitfalls like the especially for complex subjects like anatomy. Study shows that students who learnt anatomy via the old curriculum scored higher in the subject as compared to students taught through the modular approach. ^[vii] Instead of taking anatomy to a higher pedestal, newer recommendations have actually decreased the time and resources spent teaching anatomy, raising concerns among students, faculty and clinicians. ^[viii] A sound, comprehensive anatomy curriculum needs to be created, one aligned with clinical practice, with input from anatomists, clinicians and educationists. ^[ix]

Added to this is the issue of the anatomy faculty. In Utopia, medical schools would have a highly trained team of anatomists, proficient in the traditional and modern methods of teaching the subject. The reality, however, is bleak: anatomists have been rapidly dwindling in number with the passing years and the funds allocated to anatomists and their relevant research have been declining leading to lesser people choosing the subject as a profession. The medical world has become enchanted with fields like molecular genetics and cellular biology, diverting staff, resources and graduate requirements to newer fields. Medical students rarely choose to teach the subject after their medical school years. Anatomists now form a very small community, and their training level has deteriorated.^[x] Pakistan has not been spared by this pedagogical plague and PHd trained anatomists are now an almost extinct species in the country adding to the multitude of challenges already faced in anatomy teaching. ^[xi] The problem of the ‘disappearing anatomists’ and its impact on medical education has been widely studied but no concrete steps have been taken to address this issue that threatens to disrupt the fabric of medical education.

If anatomy is to be seen as the backbone of the basic sciences, the subject that sets the stage and scenery for all other basic sciences subjects, then dissection can be called the building block of that backbone. A lot has changed since the seventh century when the first dissections were practiced and consequently outlawed for the next few centuries. Dissections can now be performed legally, within ethical parameters, and yield a treasure trove of knowledge regarding the human body. ^[xii] Not only does dissection provide solid, tangible scientific knowledge, it also teaches important skills like teamwork, professional development, empathy and coming to terms with the prosaic reality of death. ^[xiii] However, due to the question of ethics and resources, dissection has been removed from many medical curricula. But has this been a wise decision? Surveys show that most medical students feel that more hours and detail should be invested in dissections and prosections. ^[xiv] Medical schools that previously removed cadaveric dissection from the curricula realized their folly and started reintroducing this age-old practice, most of them taking steps to inculcate it along the lines of vertical integration. ^[xv]

‘Obsolete’ is a slur frequently directed at the didactics of anatomy. While paying homage to tradition and all that can learn from it, it is imperative that the subject gains maximum benefit from the fruits of technology and development.^[xvi] Computer assisted learning utilizing 2-D and 3-D imaging, virtual dissection, radiological aids, live surgical streaming^[xvii] and modern educational tools like Problem-Based learning need to be integrated especially in a country like Pakistan where most students still learn anatomy swotting over bland textbooks with the occasional once-in-a-lifetime trip to a poorly equipped dissection hall. Modern educational tools can be manna in our country where medical education is already suffering due to lack of allocated resources and trained staff. The most avant-garde medical colleges in Pakistan are still using hopelessly outdated multimedia options, resulting in increasing student dissatisfaction. ^[xviii]

In conclusion, an exhaustive amount of research has been carried out to define and appreciate the role of anatomy in the undergraduate curriculum, with most clinicians agreeing to anatomy being the cornerstone of medical education.^[xix] Is this subject being taught in a manner fitting it vast implications in the life of a doctors and patients? The answer is no. Do most students possess an adequate knowledge of anatomy? No^[xx]. If anything, the conditions of anatomy learning, despite incorporation of novel technologies, are worsening in medical institutions, leading to potentially grave consequences for the future of healthcare. The stakeholders need to take urgent and applicable steps in the right direction.

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