Journal of Fatima Jinnah Medical University <p>Journal of Fatima Jinnah Medical University is open access, peer-reviewed journal published regularly on a quarterly basis since the year 2000. The journal is recognized by the Higher Education Commission of Pakistan and the College of Physicians and Surgeons of Pakistan. The articles published in the journal are of interest to researchers in health professions, medical and biomedical sciences, and health professional education. Journal accepts original articles, review articles, and case reports in health sciences. The journal follows a double-blind peer-review system for all submissions and all the manuscripts are peer-reviewed by at least two subject experts. The Journal of Fatima Jinnah Medical University uses Open Journal System (OJS), an online open source journal management system, which allows authors to submit and track their submissions online in a real-time manner. The journal follows a strictly anti-plagiarism policy according to HEC guidelines. In this direction, all the manuscripts are screened for similarity index with Turnitin<sup>®</sup> software before forwarding them to the reviewers and before final acceptance for publication.</p> Fatima Jinnah Medical University en-US Journal of Fatima Jinnah Medical University 2616-6461 <p>The Journal of Fatima Jinnah Medical University follows the Attribution Creative Commons-Non commercial (CC BY-NC) license which allows the users to copy and redistribute the material in any medium or format, remix, transform and build upon the material. The users must give credit to the source and indicate, provide a link to the license, and indicate if changes were made. However, the CC By-NC license restricts the use of material for commercial purposes. For further details about the license please check the Creative Commons <a title="CC BY-NC" href="" target="_blank" rel="noopener">website.</a> The editorial board of JFJMU strives hard for the authenticity and accuracy of the material published in the journal. However, findings and statements are views of the authors and do not necessarily represent views of the Editorial Board. </p> <p>&nbsp;</p> Culture and sensitivity patterns of bacteriological agents in children admitted to a tertiary care hospital <p><strong>Background:</strong> Culture from various infected body fluids is one of the commonly used investigations to establish the etiology of infections and helps clinicians to select appropriate antimicrobial therapy. This study is aimed to determine the culture and sensitivity patterns of bacteriological agents grown in children admitted to a tertiary care center.</p> <p><strong>Patients and methods:</strong> This descriptive cross-sectional study was conducted at the Department of Pediatric Medicine, The Children’s Hospital and the Institute of Child Health, Lahore from April 2019 to December 2019. All admitted children of age £ 15 years who fulfilled the criteria of systemic inflammatory response syndrome and sepsis were enrolled in the study. Blood and other body fluids were cultured in appropriate medium as indicated. Profile of microorganisms grown and their sensitivity patterns were noted and recorded on a predesigned data sheet. Statistical analysis was performed by SPSS v.22.</p> <p><strong>Results:</strong> A total of 500 patients were enrolled in the study. Eighty-three of them (16.6%) had growth of different microorganisms on culture and were further analyzed. Total 58 of these 83 (69.87%) were &lt;5 years of age, Male to female ratio was 1.2:1. Blood culture was positive in 36 patients (43.37%). Cultures from throat swabs, sputum and tracheal secretions showed growth of organisms in 15 (18.10%), while cerebrospinal fluid culture was positive in 14 (16.87%) and urine culture in 11 (13.25%). Microorganism isolated were: <em>Klebsiella spp.</em> (15.66%), <em>Salmonella spp.</em> (14.45%), <em>Escherichia coli</em> (13.25%), <em>Staphylococcus aureus </em>(12.04%),&nbsp;Acinetobacter (12.04%), <em>Streptococcus pyogenes</em> (10.84%), <em>Pseudomonas aeruginosa</em> (10.84%), <em>Enterobacter spp.</em> (7.23%) and&nbsp;<em>Stenotrophomonas maltophilia</em> (3.61%). <em>Klebsiella spp.</em> and <em>E. coli</em> showed resistant to various antibiotics including penicillin, co-amoxiclav, cephalosporin, fluoroquinolones and nalidixic acid. <em>Salmonella spp.</em> was mostly sensitive to meropenem and azithromycin. <em>Staphylococcus aureus </em>was sensitive to cephalosporin, amikacin, vancomycin and linezolid.</p> <p><strong>Conclusion:</strong> Commonest micro-organism isolated were <em>Klebsiella spp.</em>, <em>Salmonella spp.</em>, <em>Escherichia coli</em>, <em>Staphylococcus aureus </em>and <em>Streptococcus pyogenes</em>. Resistance to commonly used antibiotics was observed in most cultures, which is a whistle blower against inappropriate use of these drugs.</p> Samia Naz Asma Mushtaq Sobia Qamar Nazeela Zia Aisha Iftikhar Fazaila Jabeen ##submission.copyrightStatement## 2021-12-07 2021-12-07 15 2 95 99 10.37018/GXEW6797 Diagnostic accuracy of toluidine blue in early detection of oral squamous cell carcinoma <p><strong>Background:</strong> Indian sub-continent (India, Pakistan, and Bangladesh) is one of the high-risk populations for oral cancer cases. Intraoral screening is critical to diagnosis and treating oral cancer at an early stage for a better prognosis. Among the diagnostic adjuncts, toluidine blue staining is considered a simplistic, cost-effective, and highly sensitive method. The objective of the current study was to find out the diagnostic accuracy of toluidine blue in the early detection of oral squamous cell carcinoma.</p> <p><strong>Patients and methods:</strong> This prospective observational study was undertaken at the Department of Oral and Maxillofacial Surgery, Institute of Dentistry, CMH Lahore Medical College from15-09-2019 to 15-03-2020 after getting approval from IRB. &nbsp;Based on inclusion criteria, a sample size of 100 was calculated and enrolled in the study. Non-probability convenient sampling technique was utilized. Oral staining of 100 patients was done with 1% toluidine blue on an OPD basis, and incisional biopsies were then performed. Staining pattern and histopathology reports of patients were evaluated to assess the diagnostic accuracy</p> <p><strong>Results:</strong> The study results revealed the sensitivity of Toluidine Blue as 89.87%, and specificity of toluidine blue was found as 76.19%. Positive and negative predictive values of Toluidine Blue remained 93.42% and 66.67%, respectively.</p> <p><strong>Conclusion:</strong> Toluidine blue has good diagnostic accuracy for early detection of oral squamous cell carcinoma (SCC).</p> Muhammad Salman Chishty Malik Ali Hassan Sajid Shoaib - Younus Usman Ul Haq ##submission.copyrightStatement## 2021-12-07 2021-12-07 15 2 91 94 10.37018/LXYE5273 Frequency of retinal hemorrhage after thrombolysis with streptokinase in patients presenting with ST-elevation myocardial infarction: A single-center experience at a large tertiary care center in Lahore, Pakistan <p><strong>Background:</strong> Thrombolytic therapy with streptokinase is the mainstay of pharmacological treatment in acute myocardial infarction in Pakistan. Retinal hemorrhage is a common complication of streptokinase-induced thrombolysis and is often overlooked which can lead to permanent vision loss. Therefore, this study was carried out to determine the frequency of retinal hemorrhage after thrombolysis with streptokinase in patients presenting with ST-elevation myocardial infarction (STEMI).</p> <p><strong>Patients and methods:</strong> It was an observational, cross-sectional study conducted at the Emergency Department of Mayo Hospital Lahore from 11-08-2015 to 10-02-2016. The patients underwent injection of streptokinase (1.5 million U) intravenously over 60 min and intravenous heparin 5,000 U bolus followed by 1,000 U/hour. Then patients were followed up for 24 hours followed by the ophthalmoscopy to confirm the presence of retinal hemorrhage. The data were entered and analyzed using SPSS version 20.</p> <p><strong>Results:</strong> A total of 130 patients were included in this study. The mean age of patients was 62±9.86 years. The male to female ratio was 1.6:1. The retinal hemorrhage was present in 17 (13.08%) patients. About 80 (61.5%) were diabetics and 96 (73.8%) were hypertensive. Stratified variables like age, gender, hypertension, and diabetes were not found associated with retinal hemorrhage (p-value ≥0.05). &nbsp;</p> <p><strong>Conclusion:</strong> Retinal hemorrhage was found in 13.08% after streptokinase injection in patients presenting with STEMI. Although the association was statistically insignificant but still the proportion of retinal hemorrhage was substantially high in these patients. This higher percentage demands vigilant monitoring with the drug for timely diagnosis of this ignored complication which latter can be proved hazardous to the vision. &nbsp;</p> Sarmad Zahoor Hafiz Mudabbar Mahboob Hafiz Muhammad Sajid Jehangir Bilal Mehmood Aleena Khan Usama Iqbal ##submission.copyrightStatement## 2021-12-07 2021-12-07 15 2 87 90 10.37018/BXOS4371 Spectrum of biopsied oral and maxillofacial lesions in a tertiary care hospital of Karachi, Pakistan <p><strong>Objectives:</strong> The burden of benign and malignant maxillofacial lesions in developing countries has increased rapidly over the years. Objective of this study was to provide a spectrum of oral and maxillofacial lesions biopsied in a tertiary care hospital of Karachi, Pakistan and to contribute in baseline data of target population.</p> <p><strong>Patients and methods:</strong> This descriptive cross sectional study was made of biopsies performed in patients presenting to OPD of Oral and Maxillofacial Surgery Department, Abbasi Shaheed Hospital Karachi, Pakistan, between July 2018 till June 2020. A total of 652 patients belonging to either gender, 18-75 years of age, incisional or excisional biopsy were included. Recurrent or previously diagnosed lesions and patients not willing to give informed consent were excluded. Data including age, gender, site and histopathological diagnosis was recorded on a performa. Descriptive statistical analysis was done using SPSS version 26.</p> <p><strong>Result:</strong> Out of 652 biopsies performed, (82.9%, n=541) belonged to soft tissues and (17.1%, n=111) were hard tissue lesions. The mean age of patients was 41.82 years, with a male to female ratio of 2.9:1<strong>.</strong> The most frequent sites biopsied were buccal mucosa (50.9%, n=332) and posterior mandible (10.6%, n=69). Oral squamous cell carcinoma (OSCC) (55.1%, n=359) was the most commonly reported soft tissue lesion with major involved sites buccal mucosa (74.4%, n=267), dentoalveolar mucosa (8%, n=29) and lateral border of tongue (7.2%, n=26) and for hard tissue the most common lesion was ameloblastoma of posterior mandible (3.5%, n=23).</p> <p><strong>Conclusion:</strong> This study provides useful information about distribution of oral and maxillofacial lesions and highlights OSCC as the single most frequent diagnosis involving a much younger male population.</p> Syeda Hala Raza Sufyan Ahmed Maryam Zafar ##submission.copyrightStatement## 2021-12-07 2021-12-07 15 2 81 86 10.37018/MTRK5234 Comparison of outcomes between intra-articular tranexamic acid versus intravenous tranexamic acid in unilateral knee joint replacement <p><strong>Background:</strong> The goal of this research was to assess the effectiveness and safety of intra-articular tranexamic acid (TA) with intravenous (IV) TA in reducing perioperative blood loss, the severity of early postoperative problems, and venous thromboembolism in patients who have had a primary unilateral cemented total knee replacement.</p> <p><strong>Patients and methods</strong><strong>:</strong> This comparative study was undertaken using a non-probability purposive sampling technique at the Department of Orthopedic Surgery, King Edward Medical University / Mayo Hospital, Lahore, from July 1<sup>st,</sup> 2018 to October 30<sup>th,</sup> 2019. A total of number 71 patients, aged 35 to 75 years,&nbsp;who underwent unilateral cemented total knee replacement for advanced knee osteoarthritis were included in the study. &nbsp;Patients who had known allergic reactions to tranexamic acid, risk factors of thromboembolism, severe kidney and heart diseases, and blood clotting disorders were excluded. The patients were divided into&nbsp;two groups, A and B. Pre-operatively, patients in Group A were given intraarticular tranexamic acid (3000mg). In Group B, intravenous tranexamic acid (10mg/kg) was given pre-operatively. Outcome parameters studied were drained blood (DB), level of hemoglobin (Hb), blood transfusion (BT), and hematocrit (Hct) after 48 hours of surgery and compared with the preoperative value. Data was entered and analyzed using SPSS version 21.0. Independent sample T-test was applied to compare the hematocrit and hemoglobin difference in the two groups, and the P-value was taken less than 0.05 as significant.</p> <p><strong>Results:</strong> Out of the total 36 patients in Group A, there were 20 (55.5%) males and 16 (44.4%) females, while amongst 35 patients in Group B, there were 21 (60%) males and 14 (40%) females. The mean preoperative Haemoglobin (Hb) in Group A was 13.9<u>+</u>1.2 and 13.8<u>+</u>0.9 in Group B (p = 0.44). The mean postoperative Hb in Group A was 12.11±2.47 and 11.24 ± 3.52 in Group B (p = 0.002). The mean variation of Hct in Group A was 4.49 and 6.82 in Group B (p = 0.001).</p> <p><strong>Conclusion:</strong> Intra-articular tranexamic acid during total knee joint replacement is a viable alternative to the established intravenous tranexamic acid with statistically significant high postoperative hemoglobin and hematocrit levels.</p> Mumraiz Naqshaband Muhammd Taqi Sohail Ashraf Faisal Masood Muhammad Akhtar Muhammad Jazib Nadeem Javaid Hassan Raza Rana Dilawaz Nadeem ##submission.copyrightStatement## 2021-12-07 2021-12-07 15 2 76 80 10.37018/EXBO5236 Awareness of parents of hearing-impaired children about the importance of speech-language therapeutic interventions <p><strong>Background:</strong> The importance of parental involvement of hearing-impaired children in their child's speech therapy cannot be denied.&nbsp; The current study aimed to determine parental awareness and involvement in the Speech-language therapeutic interventions of hearing-impaired children.</p> <p><strong>Subjects and methods</strong>: This was a cross-sectional study design, and a purposive sampling technique was used. Data were collected from 45 parents (male=32, female=13) of hearing-impaired children whose children received speech therapy from special education centers and schools of Gujranwala. The duration of the study was nine months, from June 2019 to February 2020. A related questionnaire was developed with the literature, and expert opinions (Cronbach's α=0.894) were used to assess parental awareness and involvement in speech therapeutic interventions. Data entered and analyzed by SPSS version 23. Descriptive statistics were used to describe demographic variables (age, gender) of the participants. Frequency and percentage were used to access the awareness and involvement of the parents of hearing-impaired children.</p> <p><strong>Results: </strong>Parental awareness survey showed that a total of 15 (33.3%) parents, both mother, and father, strongly agreed, and 24 (53.3%) agreed that speech therapy would be beneficial for their child. And results related to parents' involvement showed that 21 (46.7%) parents, both mother, and father, agreed, and 15 (33.3%) strongly agreed on their child's active involvement in speech therapy plans.</p> <p><strong>Conclusions:</strong> The study concluded that most parents understand the importance of parental awareness and involvement in the therapeutic intervention of hearing-impaired children.</p> Nazia Sheikh Bareera Saeed Atia ur Rehman Sikander Ghayas Khan Maddhia Tufail ##submission.copyrightStatement## 2021-12-07 2021-12-07 15 2 63 66 10.37018/VAUO4413 Inappropriate antibiotic use for respiratory infections in outpatient settings <p><strong>Background: </strong>Overuse of antibiotics is a significant problem in low- and middle-income countries where recommended treatment guidelines are not routinely practiced, resulting in antimicrobial resistance. Acute respiratory tract infections, mostly viral in origin, remain the clinical category for most commonly prescribed antibiotics. Due to the lack of local evidence about antibiotic prescribing trends in such infections, this study was conducted to evaluate the prescribing patterns in general and antibiotic prescribing trends specifically in prescriptions with the diagnosis of acute respiratory infections in district Mirpur of Azad Kashmir.</p> <p><strong>Patients and methods</strong>: A prospective cross-sectional study carried out in the Department of Pharmacology and Therapeutics, Army Medical College, Rawalpindi, and outpatient departments of public health facilities in district Mirpur, Kashmir, from Aug to Oct 2020. Data were collected from 10 different public health facilities in District Mirpur, Kashmir including, three rural health centers (RHC) and five basic health units (BHU). Prescribing pattern analysis by objective observations of the prescriptions after patient-physician encounter against the World Health Organization defined core prescribing indicators. The appropriateness of antibiotic use was analyzed against clinical practice guidelines. IBM SPSS Statistics for Windows, Version 26 was used for data analysis. Descriptive analysis was done to find frequencies and percentages for categorical data and means and standard deviation for continuous data.</p> <p><strong>Results:</strong> Total number of prescriptions evaluated was 144. Number of prescriptions containing antibiotics was 118 (82%) (standard, 20 - 26.8%). Inappropriate use of antibiotics was seen in 78% of cases where no antibiotics were indicated. The average number of medicines per prescription was 3.11 (standard, 2.1), whereas 79% of medicines prescribed were from the national essential medicine list (standard, 100%). Only 2.5% (standard, 100%) of the medications were prescribed with generic names.</p> <p><strong>Conclusion:</strong> This study shows an inappropriate and overuse of antibiotics for acute respiratory tract infections, indicating a lack of adherence to core prescribing indicators and clinical guidelines by the physicians in outpatient clinics of Mirpur.</p> Saman Omer Bushra Tayyaba Khan Omer Jalil Muhammad Waqar Aslam Khan Quratulain Mehdi Mahjabeen Sharif ##submission.copyrightStatement## 2021-12-07 2021-12-07 15 2 67 71 10.37018/DQUY6587 Frequency of anxiety and depression in dissociative trance (possession) disorder <p><strong>Background:</strong> The possession of a person by God or spirit is an age-old one. The ICD-10 has recorded the presence of a possession and trance disorder before formal featuring it in the 10<sup>th</sup> edition as a category of dissociative (conversion) disorders. The current study sought to determine the frequency of anxiety and depression among the patients presented in tertiary care hospitals with dissociative trance (possession) disorder, along with gender differences.</p> <p><strong>Patients and methods:</strong> This cross-sectional study was conducted at l Department of Psychiatry, Sir Ganga Ram Hospital Lahore over one year: December 2019 till December 2020. A sample of 350 patients, who met the ICD-10 criteria of dissociative trance (Possession) disorder, was recruited in the study through purposive sampling technique. Demographic information sheet and Urdu version of the Hospital Anxiety and Depression (HAD) rating scale were used as assessment measures. The data were stored and analyzed in SPSS version 20. Descriptive analysis i.e., means, standard deviations, percentages, and frequencies, and inferential statistics i.e., independent sample t-test, were performed to explore objectives.</p> <p><strong>Results:</strong> The results indicate that 13.2 % of patients with dissociative trance disorder scored in the normal range of depression, 20.7% fall in borderline depression while abnormal, and 66.1% in abnormal cases of depression was found in 66.1% of patients. For anxiety, results demonstrate that 28.2% of patients fall in the category of normal anxiety, 3 31.5% in borderline anxiety, and 40.3% fall in the case of abnormal anxiety. Differences for the gender of patients in depression and anxiety scores were evaluated by independent sample t-test and significant differences were found in depression and anxiety scores of male and female patients with dissociative trance disorder (p-value&lt;0.05). Female patients scored high on depression (19.84±6.68) and anxiety (16.02±5.54) scale than male patients’ scores for depression (27.47±5.06) and anxiety (19.35±4.95).</p> <p><strong>Conclusion:</strong> There is a definite frequency of depression and anxiety among patients with, dissociative trance disorder while females are high in the scores. This can help to decrease the comorbidity associated with dissociative trance disorder, reduce the disease burden and ensure a better outcome of treatment</p> Ammara Butt Azmat Ahad Beig Junaid ul Islam Fatima Saleem ##submission.copyrightStatement## 2021-12-07 2021-12-07 15 2 72 75 10.37018/AUMO3440 Evaluating the causative factors that lead to rejection of hearing aids among young adults having moderate to severe degree sensorineural hearing loss <p><strong>Background:</strong> Hearing loss in young adulthood causes real stigma and a state of denial. The crucial clinical management to sustain the hearing loss is hearing aid fitting, but most adult people reject it or do not use it. Many factors, including social, personal, and device problems, lessen the usage of hearing aid.&nbsp;The objective of this study was to evaluate the causative factors which can lead to the rejection of hearing aids.&nbsp;</p> <p><strong>Patients and methods: </strong>This was a cross-sectional survey carried out in 9 cities of Punjab, Pakistan, using a convenient sampling technique during summer 2018.&nbsp;A total of 171 participants were included who were young adults ranging from 19-40 years. A questionnaire with 11 factors and a further 35 sub-reasons was given to the participants. Questions were close-ended in yes or no. Data were analyzed through frequency and percentages tabulation with SPSS software.</p> <p><strong>Results</strong>: Results showed that hearing aid value/speech clarity was the most problematic reason for patients to reject hearing aid. The given factor had four sub-reasons ('noisy situation,' 'poor benefit,' 'poor sound quality, and 'not suitable for the type of hearing loss). A total number n=154 (90.05%) marked yes for facing poor sound quality followed by poor benefit n=141 (82.45%), not suitable for the type of hearing loss n=121 (70.76%) and noisy situation n=118 (69.00%), thus making hearing aid value the leading cause of rejection. The second leading cause was financial factors followed by situational factors, appearance, fit and comfort, device factors, psychosocial factors, ear infections, care and maintenance, attitude, and family pressure to use a hearing aid.&nbsp;</p> <p><strong>Conclusion: </strong>Most prevalent cause of not taking up a hearing aid is the hearing aid value followed by financial factors, situational factors, appearance, fit, and comfort.</p> Hafiz Muhammad Usama Basheer Atia Ur Rehman Humaira Waseem Wajeeha Zaib ##submission.copyrightStatement## 2021-12-06 2021-12-06 15 2 54 57 10.37018/MYWB9397 Parental compliance for speech therapy of their hearing-impaired children using cochlear implants <h5>Background: Cochlear implant is a miraculous surgery to improve hearing in profound hearing-impaired children who derive no benefit from hearing aids and consequently present with speech and language disability. This study aims to explore the parental perspective regarding compliance to speech therapy and its potential benefit in hearing-impaired children with cochlear implantation. This will help understand parental concerns and plan recommendations for providing appropriate speech therapy sessions after cochlear implantation.</h5> <p><strong>Subjects and methods:</strong> This cross-sectional study using purposive sampling recruited 217 parents of hearing impaired cochlear implanted children of both genders, aged 1 to 15 years. Sample was collected from Audiology Department of Riphah International University, Combined Military Hospital, Bahria Town Hospital and Alam Audiology Clinic, Lahore, Pakistan over a period of 6 months. Basic demographic sheet and self-structured questionnaire was used for data collection. SPSS Version 22 was used for data analysis.</p> <p><strong>Results:</strong> Results revealed that both parents of 120 (55.3%) male and 97 (44.7%) female cochlear implanted children entered the study. A poor compliance was noted with only 88(40.55%) parents got their children consulted with a speech therapist for post implant needs and of these only 75 (84.23%) received regular speech therapy. There was significant association of those who received hearing aid trial and consultation to speech therapist (p=0.01) and length of speech therapy with regular therapy sessions (p=0.03), speech language improvement with the thought that regular speech therapy was important (p=0.04)</p> <p><strong>Conclusion:</strong> By and large parents are not very compliant to speech therapy needs of their implanted children with only 40.55% consulted speech language therapists and remaining remained indifferent. Of the 40.55% who consulted speech language therapists 84.23% followed speech therapy for their children. Study also revealed a significant relationship between regular speech therapy sessions and early speech and language development.</p> Amna Asghar Tayyaba Dawood Ghulam Saulain Aqsa Irum Rabia Zaman Khan Hina Saeed Ch Noreen Anwar ##submission.copyrightStatement## 2021-12-06 2021-12-06 15 2 58 62 10.37018/HKZN3939 Traumatic brain injury of childhood <p>It is a common observation, and very unfortunate one, that only the driver wears or “bears” helmets on motorbikes. None of the other passengers, especially children, are supposed to be protected against head injury. The same callous attitude is observed in cars where children are sometimes sitting in the lap of the front seater without tightening with the seat belt. Kids are thrown in the air to recatch them for pleasure or shaken severely. At times intentionally or unintentionally abused and hit or slapped on head or face without understanding how much harm is posed to them psychologically and physically. “Children are not mini-adults.” Their unique unprotected anatomy and premature physiology make them vulnerable to catastrophic permanent damage and even death.</p> <p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Traumatic brain injury (TBI) frequently occurs in young people. It remains the most common cause of disability and death between the ages 1 and 45.<strong><sup>1</sup></strong> TBI cases are increasing rapidly in Pakistan with the increase in population and poor domestic, road, and sports safety considerations.<strong><sup>1,2</sup></strong> Falls from height remain on top while reviewing the modes of injury followed by road traffic accidents. Child abuse is increasingly observed important reason for a head injury, especially in infants and young children, as they are more vulnerable and dependent on adults.<strong><sup>2</sup></strong> Abusive head trauma (AHT) is unfortunately common in children up to two years. These children may appear with drowsiness, delayed milestones, seizures, and intracranial traumas of different stages of healing. Other associated injuries may be retinal bleeds, multiple rib fractures, and long bone fractures of different stages of recovery. Child abuse should be promptly identified and appropriately reported.</p> <p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Children are different from adults and more vulnerable to traumatic brain injuries because of their proportionately larger head, low blood circulating volume, and thin osteo-fibrous non-rigid skull. More watery and less myelinated brain, non-aerated paranasal sinuses, and less CSF cushion to protect shaking and damage. Children are also vulnerable to TBI during the birth process. During normal delivery and especially difficult instrument-assisted births neonates are left with various types of intracranial hemorrhages. Cephalic and subgaleal hematomas are not uncommonly seen. This is due to increased flexibility or decreased rigidity of the neonatal skull. This increased elasticity of premature skull caused some degree of skull deformation in small children when they are shacked. The irregular base of the skull, especially in the anterior and middle cranial fossa, and the absence of adequate CSF cushion and watery consistency of the brain make it vulnerable to “shaken baby syndrome.” When a child is severely shacked, stretching and shearing forces may tear vessels and cause contusions in brain parenchyma. It may end up in subdural hematomas and intraparenchymal contusions.</p> <p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Head size in the pediatric age group is proportionately larger than the body, making the head a bigger target for trauma. A thin neck also accompanies this with weak neck muscles, and it increases the chances of neck trauma and cervical spinal cord injury in children. It is mandatory to inspect and rule out any spinal injury with head trauma. Children have not yet developed paranasal air sinuses that could absorb force of direct impact on the skull and hence the brain. It makes the brain less protected from trauma. Children also have less circulating volume, so lacerating scalp wounds, contrary to adults, may be cause of hypovolemic shock and death in children.</p> <p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Skull fractures and the resulting severity of TBI in children are similar to in adults.<strong><sup>1-3</sup></strong> Child may come with huge linear fractures spanning over parietal, occipital, temporal, and frontal bones. These may or may not be associated with dural tears and CSF leaks. Most fractures may not need surgical treatment. There are two types of fractures specific for the early age group. A greenstick ping pong ball fracture occurs when a parietal eminence strikes over or is hit upon. It usually is associated with falls from the bed over a hard surface. Spontaneous resolution is observed in early neonates, but in toddlers, it may need surgical elevation if untreated is a potential cause of seizure activity of the brain in the future. Growing skull fracture of neonates and children younger than two years is earlier a linear fracture that grows due to pulsatile leptomeningeal or brain herniation through free edges of fracture and separating these edges apart. It should be treated surgically. Epidural hematomas in children are primarily venous sinus hemorrhages when fracture line runs over and tears the venous sinuses. Arterial causes of epidural hematoma are also possible. Indications for surgery in symptomatic patients are the same as in adults. Most non-symptomatic hematomas may resolve spontaneously by seepage through overlying skull fractures and absorption in subgaleal space.<strong><sup>3</sup></strong></p> <p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Goals and means of treatment of traumatic brain injury are similar in children as in adults.<strong><sup>3,4</sup></strong> Primary goal of treatment is to identify primary brain insults and prevent their conversion into secondary brain injure. Secondary brain injury is a result of an ongoing increase in brain oedema and reduction in cerebral perfusion. Resulting brain ischemia may cause death or irreversible mental damage. This can be achieved, stepwise, by elevation of the head by 30 degrees to facilitate CSF and venous drainage out of intracranial compartment while keeping airway patent, oxygenation, use of osmotic diuretics, external ventricular drainage of CSF, evacuation of intracranial hematomas, elective ventilation and barbiturate coma, hyperventilation with targets of CO<sub>2&nbsp;</sub>between 30 and 35, decompressive craniotomies and hypothermia as a last resort.&nbsp; The goal of all these measures is to decrease intracranial pressure and increase cerebral perfusion. Patients with a low Glasgow Coma Scale at arrival, like 3 or 4, have very few chances of surviving one year after trauma. General school-going toddlers with mild traumatic brain injury have good outcomes. These children may need prolonged psychological assistance to transition from preschool to school life.<strong><sup>1-4</sup></strong></p> <p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Particular attention should be given to children who tolerate abusive head trauma. These children are under constant torture from their caregivers. So prompt identification and reporting to the concerned government department is the health caregiver's moral and legal obligation. Transport rules should be made and implemented for safety measures in motorbikes and an unrestrained car traveling.</p> Abdul Hameed ##submission.copyrightStatement## 2021-12-06 2021-12-06 15 2 52 53 10.37018/ZNCR2683 Prevalence of insomnia and anxiety in university students during the COVID-19 lockdown: A cross-sectional study <p><strong>Background:</strong> The world is facing COVID-19 pandemic and almost 70% of the world had gone under Lockdown. People are facing stress, insomnia and anxiety. The lack of basic awareness and spread of fake news are common causes of all these issues. This study was done to determine the prevalence of insomnia and anxiety in medical and non-medical students.</p> <p><strong>Subjects and methods:</strong> Subjects were approached through friends in universities using WhatsApp. People having insomnia and anxiety before quarantine were excluded from this study. People using anti-depressants and anti-psychotics before quarantine were also excluded from this study. A descriptive cross-sectional study was conducted among 965 students of medical and non-medical universities in the cities of Lahore, Rawalpindi and Islamabad. Consent was taken for using the Hamilton Anxiety Rating Scale and Insomnia Severity Index for scoring of anxiety and insomnia respectively. An online questionnaire made in Google forms was used for data collection. Independent t-tests, Pearson Correlation and Regression analysis were performed using SPSS v25.</p> <p><strong>Results:</strong> Increased prevalence of anxiety and insomnia in non-medical students as compared to the medical students was observed. There was statistically significant strong correlation between anxiety and insomnia of the enrolled subjects (r=0.742, p&lt;0.001). A linear regression equation was formulated. Increased prevalence of anxiety and insomnia in females was also determined.</p> <p><strong>Conclusion:</strong> Non-medical students, compared to medical students, among which, females, compared to males, were more likely to suffer from anxiety and insomnia&nbsp;during lockdown.</p> Ameer Hamza Mahmood-ul-Hassan Abdul Sannan Nehala Nooz Ansa Ramay Muhammad Huzaifa Syed Muhammad Jawad Zaidi Ayesha Mahmood-ul-Hassan ##submission.copyrightStatement## 2021-08-11 2021-08-11 15 2 9 12 10.37018/raux7717 Assessment of risk factors associated with pre-term labour in Tertiary care Hospitals, Lahore <p><strong>Background:</strong> Pakistan has one of the highest rates of preterm births, nearly 16 for every 100 babies born. Around 4% of these premature babies, are at highest likelihood of death. The objective of this study was to assess association of multiple risk factors with preterm birth in Pakistani women.</p> <p><strong>Patients and methods:</strong><strong>&nbsp; </strong>An analytical cross-sectional study was carried out in Obstetrics and Gynecology Department of Akhtar Saeed Trust Hospital and Farooq Hospital, West Wood Branch, Lahore from October 2018 to December 2019. Total 116 pregnant females who gave birth to preterm babies with gestational age between 20-37 weeks were included. Data about patients’ socio-demographic profile, previous obstetric history and current gestational profile was collected using closed ended structured questionnaire. Variables were presented in the form of frequency tables. Chi-square and Fisher exact test were applied to establish association of various risk factors and preterm presentation of patients’ in hospital. A p-value ≤ 0.05 was taken as significant.</p> <p><strong>Results:</strong> Out of 116 participants, 49 (42.2%) were aged between 20-25 years, 47 (40.5%) were illiterate. Of the total sample 60 (51.7 %) participants were obese (BMI &gt;30). Eighty-two (70.7%) patients were multigravida and 65 (56.1%) gave the history of previous cesarean section. Significant association was found between preterm birth and multi-parity (p=0.001), previous history of abortion (p=0.000), intrauterine death (p=0.001), infertility (p=0.04), cesarean-section (p=0.000), and inter-pregnancy interval of less than 24 months (p=0.007). Other significant factors associated with preterm labour were urinary tract infections (p=0.001), documented fever more than 101<sup>o</sup>F (p=0.000), anemia (p=0.000), singleton pregnancy (p=0.000) and cephalic fetal presentation (p=0.002), during current pregnancy.</p> <p><strong>Conclusion:</strong> Multi-gravidity, history of abortion, intrauterine death, previous infertility, cesarean-section, inter-pregnancy interval of less than 24 months, UTI, genital tract infection, anemia, singleton pregnancy and cephalic fetal presentation during current pregnancy were observed to be significantly associated with preterm births.</p> Tanzeela Zafar Iram Manzoor Fariha Farooq ##submission.copyrightStatement## 2021-03-15 2021-03-15 15 2 13 17 10.37018/pobp2666 Maternal and fetal factors contributing to neonatal outcome in Al-Tibri Medical College and Hospital <p><strong>Background:</strong> The study was done to identify the maternal and fetal factors contributing to neonatal outcome and to evaluate the correlation between risk factors and adverse neonatal outcome.</p> <p><strong>Subjects and methods:</strong> This prospective observational study was conducted on 126 mothers and their neonates fulfilling the selection criteria at Al-Tibri Medical College and Hospital. A self-designed Performa was used to enter data of subjects. Sick neonates were referred to neonatal intensive care unit for admission and management. The results were analyzed by using SPSS version 22. A p-values <u>&lt;</u>0.05 was considered as significant.</p> <p><strong>Results:</strong> Out of 126 enrolled subjects, 81% mothers were multigravidas, 31% were unbooked, 13.5% had gestational comorbidities, 15% were drug addict, 2% were Hepatitis B positive. 22.2% underwent emergency LSCS while 31.7% delivered babies by elective LSCS. Regarding fetal factors contributing to sick babies, IUGR (20%), twin fetuses (15.4%), prematurity (47.7%) were significant. 65 were sick babies. Adverse neonatal outcomes observed were prematurity in 25.4%, IUGR in 11.1%, NICU admission in 33.3%, and neonatal death in 2%. Risk factors associated with adverse neonatal outcomes were positive maternal drug addiction (p-value = 0.028), preterm delivery (p-value&lt;0.001), NICU admission (p-value&lt;0.001) and low birth weight (p-value &lt;0.001).</p> <p><strong>Conclusion:</strong> Compromised maternal antenatal care has profound deleterious effect on fetus and neonate. Obstetricians, perinatologists and neonatologists need to work in concord to improve maternal antenatal care hence improving neonatal outcome. In our study adverse neonatal outcome was associated with unbooked cases, delivery by EmLSCS, addicted mother, preterm delivery, LBW and neonates requiring NICU admission.</p> Erum Saboohi Nighat Seema Abdulah Hadi Hassan ##submission.copyrightStatement## 2021-03-15 2021-03-15 15 2 18 22 10.37018/qbhp7754 Neonatal outcomes of birth asphyxia in tertiary care hospital of low-income country <p><strong>Background: </strong>Pakistan has highest neonatal mortality in the region and birth asphyxia is one of the main preventable contributors to this. Objective of this study is to determine the frequency of different neonatal outcomes in neonates with birth asphyxia.</p> <p><strong>Subjects &amp; Methods:</strong> It was descriptive case series study conducted in Department of Pediatrics Medicine, Services Hospital, Lahore in 6 months period during 6<sup>th</sup> Dec 2016 to 5<sup>th</sup> June 2017. 150 cases were included using non probability, consecutive sampling with 95% confidence level, 6% margin of error taking an expected percentage of neonate mortality as 15%. Data was analyzed with SPSS version 23. Categorical variables i.e., gender and neonatal outcomes in terms of neonatal mortality, discharge and neurological complications were expressed by frequency and percentage. Post stratification chi square test was applied. A p-value of <u>&lt;</u>0.05 was taken as significant.</p> <p><strong>Results:</strong> The mean age of neonates was 3.09±0.8 hours. Outcomes of these neonates was seen in terms of mortality, discharge and neurological problems. Out of total 150 patients, 51 (34%) neonates expired and 99 (66%) neonates were survived. And neonates 69 (46%) neonates were diagnosed with neurological complications.</p> <p><strong>Conclusion:</strong> We found, birth asphyxia has significant association with neonatal mortality and neurological complications. Prevention of birth asphyxia with appropriate resuscitation at birth may be helpful in reduction of morbidity and mortality due to birth asphyxia.Neonates</p> Muhammad Asif Siddiqui Sehrish Masood Tayyaba Khawar Butt Shahla Tariq ##submission.copyrightStatement## 2021-03-15 2021-03-15 15 2 23 26 10.37018/unkh2664 Screening of thyroid disorders in age and gender groups in a teaching hospital of Nowshera <p>&nbsp;<strong>Background</strong>: In Pakistan 28.7% of the population had some degree of goiter. Out of those 40% of the nodules behaved hyperthyroidism based on the lower-than-normal values of thyroid stimulating hormones (TSH). Present study was designed as to determine the screening of thyroid disorders on the basis Thyroid Stimulating Hormone (TSH) in age and gender groups in a hospital-based study.</p> <p><strong>Patients and methods:</strong> This cross-sectional study was conducted in Qazi Hussain Ahmed Medical Complex Nowshera from March 2019 to Jan 2020. Total 392 cases, 167 (42.6%) males and 225 (57.4%) females were included. All patients referred to pathology laboratory for measurement of TSH levels irrespective of age and gender were included to measure incidence of hyper, hypo or euthyroid status. Exclusion criteria were patients taking medications or iodine supplementation. Numerical variables like age and TSH values were presented with Mean with SD, Median and range. Inferential statistics and correlation statistics (chi-Square, ANOVA, Mann-Whitney U test and Spearman correlation) were used to determine the difference of TSH values in gender and age groups.</p> <p><strong>Results:</strong> Mean age of the patients was 31<u>+</u>8.1 years. Mean TSH was 5.22<u>+</u>16.5 ng/ml. The difference of TSH values in the age categories using one way ANOVA statistics was insignificant (p = 0.15). Mann Whitney U Test confirmed that the distribution of TSH is the same across the categories of gender (p=0.001). Total 55 (14%) patients were hyperthyroid, and 23 (5.9%) mild hypothyroid and 30 (7.7%) hypothyroid. Chi square test showed the relation of gender with hypo and hyperthyroidism as statistically isignificant ( p= 0.18, p=0.8) respectively. Spearman ranked correlation test showed a mild to moderate inverse correlation of hypothyroidism with increase in age categories (p=0.88, r=-0.47) and a moderate uphill correlation of hyperthyroidism with increase in age categories, again statistically insignificant (p= 0.31, r=0.51).</p> <p><strong>Conclusion:</strong> We observed a skewed distribution of TSH in our population. On the basis of the TSH values the thyroid disorders were categorized in hyper and hypothyroidism. There was a negative correlation of Hypothyroidsim (TSH&lt;0.4) with age. While a positive correlation of age was noted with hyperthyroidism. While no significant relationship of hyper or hypothyroidism was noted in gender groups.</p> Hamzullah Khan Fawad khan Zahid khan Naseer Ahmed Waseemyar khan ##submission.copyrightStatement## 2021-03-15 2021-03-15 15 2 27 30 10.37018/bhob1556 Effect of anti-tuberculosis treatment on weight of tuberculous patients following up in Gulab Devi Hospital, Lahore <p><strong>Background:</strong> Tuberculosis is the most prevalent disease in Pakistan. Multiple studies have been conducted on disease pattern and anti-tuberculosis therapy however; there is sparse literature of anti-tuberculosis therapy on weight gain of patients. The objective of this study was to measure the effect of anti-tuberculosis treatment on weight of the patient.</p> <p><strong>Subjects and methods:</strong> It was a cross sectional study conducted for a period of 1 year at Pulmonology and Surgical OPD of Gulab Devi Chest Hospital Lahore. Interview of 400 patients were recorded and there record of weight and height was collected at start of the treatment, at 02 months and at 6 months of treatment.</p> <p><strong>Results:</strong> Mean weight change in 400 patients were 3.06 ± 3.97 Kg. Out of 400 patients 310 had weight gain, 50 patients had weight loss and in 40 patients weight remain unchanged. Mean weight gain in 310 patients was 4.53 ± 2.95 kg with maximum weight gain of 16 Kg. Mean weight loss in 50 patients was 3.67 ± 2.63 Kg with maximum weight loss of 14 Kg.</p> <p><strong>Conclusion:</strong> A significant weight gain was seen in patients undergoing anti tuberculosis treatment. Younger age group, treatment completion and drug compliance had positive association with weight gain of the patient. Diabetes mellitus was the only co morbidity found to have negative association with weight gain of the patient.</p> Usman Ali Rahman Anjum Razzaq Muhammad Adil Iftikhar Shabbar Hussain Changazi Samiullah Bhatti Qamar Ashfaq Ahmad ##submission.copyrightStatement## 2021-03-15 2021-03-15 15 2 31 34 10.37018/przi9094 Association of anti dsDNA antibodies titer with non-renal manifestations of Systemic Lupus Erythematosus and Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) <p><strong>Background:</strong> Early diagnosis and effective treatment in systemic lupus erythematosus (SLE) has very crucial role. Anti dsDNA is very important diagnostic tool and activity marker in SLE. This study aimed to determine the association of anti dsDNA antibodies titer with non-renal manifestations of systemic lupus erythematosus and systemic lupus erythematosus disease activity index (SLEDAI).</p> <p><strong>Patients and methods:</strong> It was a cross-sectional study and was carried out at Department of Rheumatology and Immunology, Tertiary Care Hospital, Lahore from Feb 2021 to May 2021. The study involved 69 male and female patients satisfying the systemic lupus international collaborating clinics (SLICC) classification criteria. Questions regarding different symptoms were asked and disease activity parameters were noted excluding renal parameters. Anti-dsDNA titers were measured from standard laboratory using immunofluorescence technique and were correlated with SLEDAI score. A written informed consent was obtained from every patient.</p> <p><strong>Results:</strong> The mean age of the patients was 30.7±10.2 years while the mean duration of disease 1.94±2.65 years. We observed a female predominance among these patients with male to female ratio of 1:7.6. There were fifty-four (78.3%) patients with active disease. The mean anti-dsDNA levels were significantly higher in patients with active disease (315.73±481.68 vs. 78.46±113.64 IU/mL; p-value=0.003). There was a significantly strong positive correlation between anti-dsDNA levels and SLEDAI score (r=0.358; p-value=0.006). When compared, significant difference was observed in mean anti-dsDNA titers in patients with chronic cutaneous manifestations (p-value=0.040), lymphopenia (p-value= 0.012), pleurisy/pericarditis (p-value= 0.024) and leukopenia &lt;3000/mm<sup>3 </sup>(p-value= 0.001).</p> <p><strong>Conclusion:</strong> Anti-dsDNA antibodies titers are remarkably increased in patients with non-renal manifestations of systemic lupus erythematosus particularly with chronic cutaneous manifestations and leukopenia and positively correlate with disease activity status and SLEDAI score.</p> Sadaf Andleeb Tafazzul-E-Haque Mahmud Aflak Rasheed Muhammad Shahid Mehmood Iram Gull Maira Ahmad Mufazzal-E-Haque Mahmud ##submission.copyrightStatement## 2021-03-15 2021-03-15 15 2 35 39 10.37018/gpgq6331 Effect of Furosemide and Spironolactone on urinary zinc excretion in rats <p><strong>Background:</strong> Zinc deficiency is associated with numerous diseases including hypertension, diabetes, obesity, immune dysregulation, cancer, depression and congenital anomalies. There are many reasons of zinc deficiency including some medications. If zinc supplementation is used with these medicines than many diseases can be prevented.</p> <p><strong>Subjects and methods:</strong> This experimental study was planned to observe the effect of single diuretic dose of furosemide and spironolactone on zinc urinary excretion and blood levels in normal rats. Eighteen adult healthy male Sprague Dawley rats were&nbsp;randomly divided into three groups. After saline load rats were given distilled water, furosemide (10 mg/kg) and spironolactone (20 mg/kg) as single oral dose. Blood and urine samples were collected after five hours and analysed for zinc concentration by flame atomic absorption spectrophotometer.</p> <p><strong>Results:</strong> Single oral dose of furosemide and spironolactone highly significantly increased urinary zinc excretion&nbsp;(p-value &lt;0.001 vs normal control), and increased blood zinc level (p-value &lt;0.001 <em>vs.</em> normal control). Value of both variables were significantly higher in furosemide-treated group (p-value &lt;0.001 <em>vs</em>. furosemide-treated).</p> <p><strong>Conclusion:</strong> Results of this research conclude that furosemide and spironolactone increase urinary zinc excretion when used for short period. It is also postulated that blood zinc concentration is not reliable measure to assess the zinc status of the body because its level shows compensatory rise during deficiency states.</p> Rabab Miraj Muhammad Jahangir Akfish Zaheer Nada Azam Amer Hassan Siddiqui Sadia Chiradh ##submission.copyrightStatement## 2021-03-15 2021-03-15 15 2 40 44 10.37018/hpgq6331 Hepatotoxic effects of Diclofenac and Febuxostat combination on mice liver function tests after oral administration <p><strong>Background</strong><strong>:</strong> The liver is a major organ and involved in metabolizing various toxins, including chemicals, drugs, and natural substances.<sup>1</sup> Diclofenac is a commonly used non-steroidal anti-inflammatory drug. Febuxostat is a novel non-purine xanthine oxidase inhibitor prescribed in various hyperuricemic states. Rise in liver enzymes with diclofenac use is a well-established fact. When both drugs are used in combination, these may lead to profound hepatotoxicity. To find out these facts this study was planned.</p> <p><strong>Subjects and methods:</strong> An experimental study on mice was planned to explore these facts in University of Health sciences, Lahore. Animals were divided into 6 groups having 10 animals in each group. The animals were given drugs for 7 days. One served as control. 2<sup>nd</sup> group was given Diclofenac alone (100mg/kg), 3<sup>rd</sup> group was given Febuxostat (50mg/kg) alone while rest of three groups were administered drugs combination (Diclofenac + Febuxostat). Dose of Diclofenac (100mg/kg) kept constant while dose of Febuxostat increased in each group (5mg/kg, 10mg/kg and 50mg/kg). All drugs administered orally by gavage. After 7 days, the serum levels of liver enzymes assessed. Statistical analysis was performed using SPSS 20. One way ANOVA and Post hoc Tukey tests were applied. A p-value of ≤0.05 was considered statistically significant.</p> <p><strong>Results:</strong> The results showed that Diclofenac and Febuxostat caused liver damage when used separately but hepatotoxicity was much significant (p-value &lt;0.001) when drugs were used in combination.</p> <p><strong>Conclusion:</strong> Both drugs Diclofenac and Febuxostat when administered in combination, causes more liver profound liver damage. That is why their use in combination should be avoided in clinical settings.<a href="#_ednref1" name="_edn1"></a></p> Saima Naureen Rizwan Waseem Javaria Fatima Azher Abbas Shah Huma Manzor Bushra Shaheen ##submission.copyrightStatement## 2021-03-15 2021-03-15 15 2 45 49 10.37018/sxaw2460 Assessment of knowledge related to COVID-19 among professionals and students: A cross-sectional study from Punjab, Pakistan <p><strong>Background:</strong> COVID-19 outbreak posed a serious threat to public health and greatly impacted the life of professionals and students. Hence, this study aimed to evaluate the knowledge related to COVID-19 during a lockdown in Punjab, Pakistan.</p> <p><strong>Subjects and methods:</strong> This cross-sectional online study recruited 833 participants (males=417, females=416) from major cities (Lahore, Islamabad, Rawalpindi, Gujranwala, Bahawalpur, Faisalabad, and Sialkot) in Punjab, Pakistan, during the months of March and April 2020.&nbsp; A pre-designed questionnaire was shared, among professionals (including pharmacists, paramedical staff, lawyers, businessmen, teachers) and students (including medical undergraduate and postgraduate students, and non-medical students), containing 12 questions regarding their knowledge of COVID-19. Data were collected using convenient sampling technique. Chi-square test and logistic regression model were applied for analysis using Statistical Package for Social Sciences (SPSS) software.</p> <p><strong>Results:</strong> The mean age of the participants was 23 years ranged from 15-68 years. Of the 833 participants, 365 (43.8%) were well aware, 405 (48.6%) were aware and only 63 (7.6%) were not aware of COVID-19. Most of the participants (69.4%) did not know about coronaviruses (Severe Acute Respiratory Syndrome Coronavirus and Middle East respiratory syndrome-related coronavirus) before this pandemic. Using logistic regression analysis, age above 24 years, being a student (<em>vs.</em> being a professional) and a prior knowledge about coronavirus resulted in having higher odds of knowledge about COVID-19 with a significant p-value (&lt;0.05).</p> <p><strong>Conclusion:</strong> This study identifies that the majority of the participants had necessary knowledge about transmission, preventive measures and basic hygiene about COVID-19. However, there is a need to improve knowledge among the younger population and professionals.</p> Ali Hashim Zubair Abubakar Shah Muhammad Junaid Tahir Muna Malik Muhammad Irfan Malik Ayesha Sajjad Sardar Muhammad AL Fareed Zafar ##submission.copyrightStatement## 2021-03-15 2021-03-15 15 2 3 8 10.37018/2478 COVID-19 and Dengue: A potentially emerging healthcare challenge for Pakistan <p>Pakistan is facing the third wave of the SARS-CoV-2 pandemic and could head towards the fourth one. Although the burden of COVID-19 remained significantly low in the country as compared to its neighboring countries despite similar gene pool, health system, and climatic conditions, still Pakistan has dealt with the disease with relative effectiveness. The pandemic imposed immense pressure on the public health systems due to increased demand for specialized isolation wards and intensive care units and disease-related morbidity and mortality. Many of the tertiary care hospitals in the major pandemic-stricken districts have been transformed into specialized centers dedicated to the treatment of COVID-19. This resulted in diverting major hospital resources and manpower to deal with the pandemic at the cost of other medical and surgical conditions. A recent pulse survey conducted by World Health Organization (WHO) in 135 countries demonstrated that the SARS-CoV-2 pandemic severely affected the global health services, while services for endemic tropical diseases (like dengue) were affected in 44% of countries, especially in resource-limited countries. Moreover, large-scale community-based interventions including vector surveillance and control were disrupted in 60% of the countries.<strong><sup>1</sup></strong> Another survey by WHO on malaria control in sub-Saharan Africa demonstrated a &gt;20% increase in malaria cases and a doubling of malaria-associated deaths due to a decline in malaria control activities during the pandemic. It is expected that the future catastrophe due to malaria might be much greater than the COVID-19 in endemic regions. Therefore, WHO recommends continuous monitoring, surveillance, and treatment to control the spread of malaria.<strong><sup>2</sup></strong></p> Faiz Ahmed Raza ##submission.copyrightStatement## 2021-03-15 2021-03-15 15 2 1 2 10.37018/feog2563 Hemispheric encephalitis secondary to HAV <p>A 2-year male child, presented to National Institute of Child Health (NICH), with acute onset high grade fever and focal left sided seizures for 1 day, followed by left hemiparesis and encephalopathy. Developmental and family history was unremarkable. On physical examination, patient’s body temperature rose up to 38.7 °C. Though he had pallor along with hepatomegaly, there were no signs of jaundice or ascites. Central nervous system examination showed encephalopathy as well as positive neck stiffness. Motor system examination revealed generalized decrease in bulk of upper and lower limbs, but rest of the findings were localized to left side of the body, showing hypertonia, decreased power, brisk muscle stretch reflex, and positive ankle clonus and left Babinski sign.</p> <p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Blood investigations showed anemia (hemoglobin 9.1g/dl), leukocytosis (white blood cells 22.1 cells/μL) and raised aspartate aminotransferase (AST) levels (826 IU/L). Total bilirubin and direct bilirubin levels were normal (0.3 mg/dL and 0.1 mg/dL, respectively). Serum ammonia (64 μg/dL) and lactic acid (1.6 μg/dL) levels were also within normal ranges. The cerebrospinal fluid (CSF) was also clear, with 0 leukocytes/μL, protein levels of 25 mg/dL, and normal glucose levels (82 mg/dL), no organism was seen on gram stain. Hepatitis A Ig M antibody came out to be reactive.</p> <p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Brain computed tomography showed large hypo density along with effacement of sylvian fissure, sulci, gyri on right side involving frontal, parietal, and temporal and occipital lobe on ipsilateral side. On post contrast, there was remarkable meningeal enhancement on right side. MRI brain revealed cortical and subcortical large area of abnormal signal intensity seen in fronto-parietal and occipital cortex on the right side along with laminar necrosis.</p> <p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Seizures were controlled by given intravenous injection phenytoin and leviteracetam in bolus and then maintenance doses. Intravenous acyclovir was started</p> <p>due to clinical suspicion of herpes encephalitis but was stopped after observing clinical improvement and identification of Ig M antibody of HAV. Patient conscious level improved after 2 weeks. AST levels also decreased to 20 IU/L and he was discharged with advice to follow up after 14 days</p> Aijaz Ahmed Muhammad Ashfaq Bader -U- Nisa Hira Waseem ##submission.copyrightStatement## 2021-03-15 2021-03-15 15 2 50 51 10.37018/cmer2954 Comparison of prevalence of various ENT diseases and hearing impairment among children of government schools versus private schools of Mardan <p><strong>Background:</strong> School children are frequently afflicted with ENT diseases. The diseases and their associated complications, especially hearing impairment, can be devastating to the children and families alike. Socioeconomic status of children can have strong effect on frequency of various ENT diseases. The objective of this study is to compare the frequency of various ENT diseases among children studying in government schools versus those in private schools of district Mardan.</p> <p><strong>Subjects and methods:</strong> A cross-sectional descriptive study was carried out at Mardan from July to December 2019. The researchers visited four schools (two government and two private schools) in Mardan district. Relevant history was obtained and physical examination was done to find out the frequency of various ENT diseases. The data variables (age, gender, ENT diseases, hearing impairment) were noted in research Performa and data was entered and analysed in SPSS 21 software. Frequencies were determine for age, gender and ENT diseases. Independent t-test was used to analyze quantitative variables, while Chi-square was used to analyze qualitative variables. A p-value less than 0.05 was taken as significant.</p> <p><strong>Results:</strong> Total 2986 children were examined in 4 schools. The mean age of the children was 11 years. There were 56% boys and 44% girls. Total 2106 children were examined in two government schools and 880 children were examined in two private schools. The frequency of impacted cerumen was 18.4% (21.2% of government school children versus 11.4% of private school children; p&lt;0.05). Frequency of allergic rhinitis was 9.7% (9.5% of government school children versus 10.1% of private school children; p=0.635). The frequency of chronic suppurative otitis media (CSOM) in government school children was 4.9% versus 2.5% among those in private schools (p&lt;0.05). In this study cumulative prevalence of hearing impairment was 26.8%, where prevalence in government school children was 30.9% versus 17.2% in private schools (p-value&lt;0.001). The causes of hearing impairment were impacted ear cerumen (68.3%), CSOM (15.7%), otitis externa (6.2%), OME (4.1%), otitis media (2.8%), congenital ear deformities (1.6%) and foreign bodies in ear (1.2%). The main causes of hearing impairment in majority of children were impacted cerumen and CSOM in 84% children.</p> <p><strong>Conclusion: </strong>Various ENT diseases like impacted cerumen, rhinosinusitis, allergic rhinitis, pharyngitis, tonsillitis and CSOM are common in school going children. Impacted cerumen and CSOM are significantly more prevalent in government school children as compared to private schools which are primary cause of hearing impairment in children leading to significantly high prevalence of hearing impairment in government school children</p> Sumera Akram Muhammad Ahmed Khan Abdul Rehman Kamran Zamurrad Malik Jehangir Ahmed Afridi Sumera Akram ##submission.copyrightStatement## 2021-02-24 2021-02-24 15 2 170 175 10.37018/pjdw8445 Prevalence of vitamin D deficiency in type 2 diabetics and its association with glycemic control <p><strong>Background:</strong> Optimal glycaemic control in type 2 diabetics is of utmost importance in preventing the complications of diabetes which lead to increased morbidity and mortality related to the disease. Some studies have shown that vitamin D deficiency was prevalent in type 2 diabetic patients and was associated with poor glycaemic control. This study aimed to determine the vitamin D3 levels in type 2 diabetic patients and its association with glycaemic control.</p> <p><strong>Patients and methods:</strong> This cross sectional study was carried out in the outdoor department of Medical Unit II of Sir Ganga Ram Hospital/Fatima Jinnah Medical University Lahore from Feb 10, 2019 to May 9, 2019. A total of 45 cases of type 2 diabetes mellitus were enrolled in this study after taking informed consent from them. Demographic details (name, age, gender, including duration of diabetes) were obtained and blood sample were taken for HbA1c and 25-OH vitamin D3 levels. Vitamin D deficiency was diagnosed by taking serum level &lt;20 ng/mL as cut off. The data analysis was carried out in SPSS version 20. Quantitative variables like age and duration of diabetics were taken as mean and standard deviation. Qualitative variables, gender and vitamin D3 levels and HbA1c levels were taken as percentage. Post stratification chi-square test was applied taking p-value &lt;0.05 as significant.</p> <p><strong>Results:</strong> Out of 45 patients, 17 (37.78%) were male and 28 (62.2%) were female. Mean age was 49.56 ± 10.77 years. Mean duration of diabetes was 5.91 ± 3.74 years. Mean vitamin D levels were 36.36±17.9 ng/ml. Out of 45 patients, 7&nbsp;(15.6%) were found deficient, 10&nbsp;(22.2%) insufficient, 27&nbsp;(60%) sufficient and 1&nbsp;(2.2%) had vitamin D toxicity. Among the patients with sufficient vitamin D levels, 12 (44.4%) were male and 15 (55.5%) were female. Two (16.6%) male patients with sufficient vitamin D levels had good glycemic control as compared to none of the female patients. Two (16.6%) male and 2 (13.3%) female patients with sufficient vitamin D had fair HbA1c. Most of the patients had poor control of HbA1c despite sufficient vitamin D levels including 8 (66.6%) males and 13 (86.6%) females. Mean HbA1c concentration was 9.3±1.66%. Out of 45 patients, 2&nbsp;(4.4%) had good glycaemic control, 5 (11.11%) had fair and 38 (84.4%) had poor control. It was seen that out of 7 vitamin D deficient, 6 (85.7%) had poor glycemic control, 1 (14.3%) had fair and none had good glycaemic control. The post stratification chi-square test was applied to determine the significant association between vitamin D levels and HbA1c and showed a p-value of 0.196 which is statistically insignificant. The Pearson correlation revealed a value of -0.012 which shows a negative correlation between vitamin D and HbA1c levels.</p> <p><strong>Conclusions:</strong> No statistical significance could be established between vitamin D deficiency and poor glycemic control. There is a weak negative correlation between vitamin D and HbA1c levels showing that low Vitamin D levels are associated with higher HbA1c concentration.&nbsp;</p> Khadija Muneer Naheed Hashmat Muhammad Adnan Hasham Bushra Asif Sheikh Noma Sarwar Nouman Zafar ##submission.copyrightStatement## 2021-02-24 2021-02-24 15 2 195 199 10.37018/wego2897 Risk factors for development of dementia in Parkinson’s disease: Effect of family history <p><strong>Background:</strong> Parkinson’s disease is one of the most common neurodegenerative disease characterized by tremors at rest, rigidity and akinesia. Despite being one of the common neurodegenerative diseases etiology and progression of PD is complex and poorly understood and has proposed to be a combination of genetic and environmental factors. Nearly 80% of the patients of Parkinson’s disease go on to develop dementia. However, there are considerable variations in disease course and some patients develop dementia quite early in the disease course. The genetic factors and association of family history for early development of dementia is still something that is controversial and under study. This study is an attempt to understand the significance of family history in development of dementia in Parkinson’s disease.</p> <p><strong>Patients and methods:</strong> This cross-sectional comparative study was conducted in Sheikh Zayed Postgraduate Medical Institute Lahore in which participants were assessed for dementia through Mini mental state examination. The subjects were divided in three groups of 30 each&nbsp; - Parkinson’s disease with dementia group, Parkinson’s disease without dementia group and a healthy control group and a potential association between family history of dementia and development of dementia in Parkinson’s disease was studied.</p> <p><strong>Results:</strong> Out of total 90 patients, 23 (25.6%) had a family history of Parkinson’s disease in Group A (Parkinson’s disease with dementia), 9 (30.0%) patients in Group B (Parkinson’s disease without dementia) whereas in healthy controls only 5 (16.7%) patients had family history of Parkinson’s disease. Chi-square test revealed that the difference in the proportion of family history of Parkinson’s disease among the groups was insignificant (p-value = 0.393).</p> <p><strong>Conclusion:</strong> No associations between dementia in PD and familial occurrence of dementia could be established. A longitudinal cohort study performing cross sections at intervals would be valuable to further study the effect of family history and early signs of dementia in patients of Parkinson’s disease.</p> Tabinda Kazmi Ameena Nasir Maria Anwar Qanita Mahmud Wardah Anwar Maryam Rao ##submission.copyrightStatement## 2021-02-24 2021-02-24 15 2 191 194 Comparison of visual acuity and post-operative inflammation in phacoemulsification and removal of silicone oil with and without injection of Enoxaparin Sodium (40mg/0.04ml) <p><strong>Background</strong>: Phacoemulsification and removal of silicone oil (ROSO) is a combined, frequently done procedure in retina theatre. A common problem in this procedure is the post inflammation that affects the recovery of the patients. Thus to counter this post-operative inflammation, the study has used Enoxaparin Sodium (an anti-inflammatory enoxaparin) to counter the post-operative inflammation in phacoemulsification and ROSO.</p> <p><strong>Patients and methods</strong>: Prospective interventional study done at Ophthalmology Department, Lahore General Hospital, included 60 patients which were operated and observed for results over a period of 3 months. Total 60 patients were randomly allocated in two groups, Group A and B. Both groups underwent phacoemulsification and ROSO. Group A had Enoxaparin Sodium, admixed in infusion bottles with a dosage of 40mg/0.04ml while Group B was operated without Enoxaparin Sodium. Patients were examined on slit lamp on the 1st day after the surgery then on the 7<sup>th</sup> day and every month for 3 months for post-operative inflammation and visual recovery. The effectiveness of the procedure was defined by the comparison of post-operative inflammation as well as speedy recovery of sight.</p> <p><strong>Results</strong>: Total 60 patients were randomly allocated in two groups. Group A had 30 patients, 23 males and 7 females, with mean age of 49.43 years. Group B included 30 patients, 19 males and 11 females, with mean age of 47.73 years. Post-operative BCVA in Group A was above vision 6/60 (Snellen’s Chart) in 90% of cases while it improved to vision 6/36 and better in 93% of cases at 7<sup>th</sup> day while 93% of cases crossed recovery of Vision 6/18 by 3<sup>rd</sup> Month. While in Group B, Vision 6/60 was observed in 70% of cases while it improved to vision 6/36 and better in 67% of cases at 7<sup>th</sup> day while 53% of cases crossed recovery of vision 6/18 by 3<sup>rd</sup> Month. Post-operative results for inflammation of Group B showed grade 3 reaction on first day (94%) while it reduced to grade 2 reaction on 7<sup>th</sup> day in 97% of the cases. While Group A was observed with occasional activity in 25 out of 30 cases (84%) on the first day and grade 2 reaction in 5 (16%) cases. 100% cases of Group A showed occasional activity on 7<sup>th</sup> day with better visual recovery.</p> <p><strong>Conclusion</strong>: Intraoperative use of Enoxaparin Sodium helped in reducing post-operative inflammation as well as aided in better visual acuity after phacoemulsification and ROSO thus proving to be a viable enoxaparin agent to reduce post-operative reactions in these surgeries.</p> Hasnain Muhammad Buksh Hussain Ahmad Khaqan Usman Imtiaz Ateeq ur Rehman Mehreen Afzal Raheela Naz ##submission.copyrightStatement## 2021-02-24 2021-02-24 15 2 185 190 10.37018/xmpi6453 The outcome of postoperative paresthesia of inferior alveolar nerve after surgical removal of mandibular third molar using Orthopantomogram (OPG) versus Cone-beam CT <p><strong>Background:</strong> Periapical and Orthopantomogram (OPG) are the most commonly used radiographs for assessment of the relationship of lower 3<sup>rd</sup> molar roots with the inferior alveolar canal. Panoramic radiographs provide inadequate information of the buccolingual relationship between the roots of the 3<sup>rd</sup> molar &amp; mandibular canal being two-dimensional (2D) in nature. To verify the relationship in three (3D) dimensions and to make a predictable treatment plan, traditional investigations may be supplemented by using CBCT. Cone-beam computerized tomography (CBCT) is an office-based radiography technique used to assess the three-dimensional relationship of lower 3<sup>rd</sup> molar roots with inferior alveolar nerve.</p> <p><strong>Patients and methods:</strong> This comparative-cross sectional study was conducted at the Department of Oral and Maxillofacial Surgery, Fatima Memorial Hospital (FMH), Lahore from 1<sup>st</sup> January 2019 till 30<sup>th</sup> June 2019. A total of 124 patients requiring removal of lower wisdom tooth were enrolled and then divided into two groups (62 in each) randomly. OPG was used for diagnosis of impacted lower 3<sup>rd</sup> molars in Group A patients while CBCT for diagnosis in Group B patients. A self-designed Performa was used to collect the data and final information was collected after 3 months of follow-up. Data analysis was performed using SPSS 20. A chi-square test was used to compare the postoperative paraesthesia between the OPG group and CBCT group patients. A p-value <u>&lt;</u>0.05 was taken as significant.</p> <p><strong>Results:</strong> The occurrence of postoperative paresthesia between the two groups is significantly different; being a low percentage in the CBCT group at 2<sup>nd</sup>, 7<sup>th</sup> day and after 3 months follow-up visits with a p-value of 0.019, 0.019, and 0.005 respectively. On 3 months follow up, the distribution of paraesthesia between the two groups is significantly different; 20 patients (32.25%) in OPG group A and those of 7 (11.29%) in CBCT group B experienced paresthesia with a p-value of 0.005.</p> <p><strong>Conclusion:</strong> It is better to use CBCT to improve the postoperative paraesthesia for lower third molar surgical extraction.</p> Ali Hassan Sajid ##submission.copyrightStatement## 2021-02-24 2021-02-24 15 2 180 184 10.37018/uiae7852 Prevalence of celiac disease in irritable bowel syndrome patients: A single centre experience from a large teaching hospital of Lahore, Pakistan <p><strong>Background:</strong> Many studies have been conducted worldwide to evaluate the proportion of patients with Celiac disease (CD) in persons presenting with Irritable Bowel Syndrome (IBS), showing a positive association between the two diseases. However, reports from Pakistan remain scanty. This study aims to find out the prevalence of CD in patients presenting with IBS and to establish the correlation of both diseases.</p> <p><strong>Patients and methods</strong>: It was a descriptive cross-sectional study conducted at Combined Military Hospital, Lahore (CMHL) from January 2018 till March 2019. Consecutive, nonprobability sampling was used to include 210 patients of both genders with the age range of 15-65 years fulfilling ROME IV criteria and were not previously diagnosed as CD or CKD or CLD. Demographic data was noted. Serum Anti tTG levels and Duodenal Biopsy from the second part was assessed to diagnose CD. CD was labeled if the disease was present on both serological and Histopathological reports. Data were analyzed by using SPSS version 20. Descriptive statistics were calculated and a Chi-square test was used to compare the outcome variables with P-value <u>&lt;</u> 0.05 as significant.</p> <p><strong>Results:</strong> Of 210 enrolled patients, 113 (53, 8%) were male and 97 (46.2%) were female. The mean age of the patients was 28.40 ± 5.06 years. Eight patients (3.8%) were positive for Anti tTg and on histopathological findings suggestive of CD. Seven of 8 were less than 35 years old. Out of 8 positive patients, 6 (75%) were females. However, the p-value was found to be insignificant for age (0.549) and gender (0.096). On stratification with respect to duration of IBS, all 8 patients diagnosed with celiac disease were having symptoms of IBS for less than 12 months (100%) which was significant statistically (7.1% vs 0.0%; p=0.007).</p> <p><strong>Conclusion: </strong>The frequency of CD was 3.8% among IBS patients. Considering this percentage of CD in IBS patients s, a high index of suspicion for CD in IBS patients is required,</p> Mohammad Ahmed Saifullah Amer Ahmad Khan Sarmad Zahoor Sidra Saif Javed Sajjad Hashmi Wajeeha Amer ##submission.copyrightStatement## 2021-02-24 2021-02-24 15 2 176 179 10.37018/cndo3595 Frequency of different histopathological types of esophageal cancer patients at oncology department of a tertiary care hospital in Karachi <p><strong>Background:</strong> Around the globe, carcinoma of the esophagus is the eighth most prevalent cancer with an incidence of 456,000 cases per year and is the sixth cause of cancer mortality. There are two major histological subtypes of carcinoma of the esophagus, esophageal squamous cell carcinoma and adenocarcinoma. The aim of the current study is to evaluate the frequency of different histopathological types of esophageal cancer in patients presenting at the tertiary care hospital of Karachi.</p> <p><strong>Patients and methods:</strong> It was a cross-sectional study conducted at the Department of Clinical Oncology, Jinnah Postgraduate Medical Center, Karachi from March 2017 till March 2019. Two hundred and one histologically proven cases of esophageal cancer of in patients of either gender and between 15-80 years of age were included. Patients were interviewed and data regarding age, gender, education, marital status, employment status, addictions like cigarette or huqqa smoking, consumption of pan, betel nut, naswar, or gutka were recorded. Endoscopy and histology and <em>computed tomography</em> scan were performed. Stage, site, grade and type of tumor were noted. SPSS version 23 was used to analyze data. Mean and SD were calculated for quantitative variables. Frequency and percentage were calculated for qualitative variables. A Chi-square test was used to assess the significance between age and gender with type of EC. A p-value≤0.05 was taken as significant.</p> <p><strong>Results:</strong> Mean age of the patients was 47.84. The majority of the patients had stage 2 of cancer (42.8%) and lower tumor site (62.2%) Squamous cell carcinoma was the most common histopathological type in 137 patients out of 201 (68%). The age, gender, smoking, consumption of pan, grade, site, and stage of the tumor showed a statistically significant difference when compared with esophageal squamous cell carcinoma and esophageal adenocarcinoma.</p> <p><strong>Conclusion: </strong>The burden of esophageal squamous cell carcinoma is dramatically increasing in the Pakistani population and squamous cell carcinoma was the most common histopathological type.</p> Zoya Sheikh Ghulam Haider Khalil Ahmed Dr. Bhunisha ##submission.copyrightStatement## 2021-02-24 2021-02-24 15 2 161 165 10.37018/uqiz9862 Difference in mean weight gain and hospital stay in preterm babies receiving complete or partial kangaroo mother care compared to no kangaroo mother care: Experience from a tertiary care hospital <p><strong>Background:</strong> Pakistan is a resource limited country with one of the highest neonatal mortality rate (NMR) in the world. Kangaroo Mother Care (KMC) helps in reducing the mortality and improving the care of preterm babies. The objective of this study was to identify the benefits of KMC in hospitalized newborns in terms of better weight gain and early discharge from hospital.</p> <p><strong>Subjects and methods:</strong> A retrospective case-control study was conducted in the Neonatal Department of Services Hospital from 01.02.2019 to 31.01.2020. A total of 144 case notes, who met inclusion criteria were included. Subjects were divided in 2 Groups of 77 each. Group 1 did not receive KMC and Group 2 received KMC (partial or complete). Admission weight, gestational age at birth, duration of hospital stay and the average weight gain was noted for subjects in both groups. SPSS version 23 was used to analyze data. Independent samples t-test was applied. A p-value of <u>˂</u>0.05 is taken as significant.</p> <p><strong>Results:</strong> Mean weight gain in Group 1 was 5.521 g/kg/day (±6.664), whereas in Group 2 was 15.635 g/kg/day (±9.268). Mean hospital stay in Group 1 was 12.558 days (±10.856) and in Group 2 it was 8.208 days (±6.473). Weight gain and duration of hospital stay was significantly better in KMC Group with a p-value ˂0.05. This benefit was observed both for partial and complete KMC.</p> <p><strong>Conclusion:</strong> KMC (partial or complete) leads to better weight gain and reduces the duration of hospital stay.</p> Muhammad Asif Siddiqui Tayyaba Khawar Butt Muhammad Azhar Farooq Muhammad Tauseef Omer Farhan Zahoor Komal Khadam Hussain ##submission.copyrightStatement## 2021-02-24 2021-02-24 15 2 152 155 10.37018/qymd3680 Perception about central induction policy among postgraduate trainees of Punjab - a mixed method qualitative study <p><strong>Background:</strong> Central induction policy is recently implemented for induction of doctors for post-graduation training based on their performance in MBBS, post-graduation entrance exam, house job, studying in public institute, work in periphery and research. Despite controversies this policy was implemented in May 2016 and no feedback was taken by the stakeholders. This discrepancy aroused the need for data collection to determine effectiveness of CIP in terms of PG perceptions.</p> <p><strong>Subjects and methods:</strong> An interview based qualitative study was conducted in four Tertiary care hospitals from 05 June 2018 to 30 November 2018. Request forms were randomly sent to 75 residents inducted through and before CIP. Total 39 residents participated in the study after giving consent. Interview questions were selected by the authors after detailed discussion. Each interview was heard thrice, manuscripts were prepared in the same words used by the participant. Manuscripts were discussed among the team members to identify themes. Depending upon themes questionnaire was designed and quantitative data was collected.</p> <p><strong>Results:</strong> Qualitative evaluation identified following major themes including policy being merit based allowing every candidate to get a fair chance of induction; financial security on all the slots and provision of qualified doctors at primary health care centers for the induction policy whereas issues with choice of specialty and place of work, delay in start of training due to various factors and discrepancy in special cases like wedlock, FMGs, authenticity of research papers were identified as demerits.</p> <p><strong>Conclusion:</strong> CIP is a good initiative and is acceptable due to its merit based policy and financial security however there is need to improve the standard and evaluation method of research and option for change of specialty.</p> Maliha Nadeem Hafsa Khalid Anam Nazir Hassan Nawaz Yaqoob Ghulam Abbas Kalyar Ain ul Momina Ahmad Uzair Qureshi ##submission.copyrightStatement## 2021-02-24 2021-02-24 15 2 145 151 10.37018/bzkw5932 Diagnostic accuracy of PET/CT scan in evaluation of clinically suspected recurrent ovarian cancer <p><strong>Background:</strong> Accurate evaluation of ovarian carcinoma is utmost important for effective management. PET/CT is reported to be effective in evaluation of suspected recurrence of ovarian carcinoma. This study aims to assess the accuracy of PET/CT in evaluation of recurrent ovarian cancer among clinically suspected cases with rising tumor marker or suspicious clinic-radiological findings.</p> <p><strong>Patients and methods:</strong> This prospective cross-sectional study was conducted at Radiology department of Jinnah Postgraduate Medical Centre Karachi from 22<sup>nd</sup> April 2019 to 21<sup>st</sup> April 2020. Patients having age of 40 to 60 years and referred for PET scan with suspected recurrence of ovarian carcinoma were consecutively enrolled. Patients were suspected due to relevant history, clinical findings and initial imaging investigations with elevated CA-125 level. Results of 18FDG PET/CT scan was correlated with the raised tumor findings. The PET/CT scan showing abnormally elevated FDG take-up and higher SUV values than the background activity considered recurrence. Diagnostic accuracy of PET/CT was calculated taking raised tumor level as reference category.</p> <p><strong>Results:</strong> Of 65 patients, median age was 50 (43-56) years. The findings showed positive cases in 57 (87.7%) while negative in 8 (12.3%) patients, whereas the findings of tumor marker showed raised tumor marker in 61 (93.8%) patients. Diagnostic accuracy of PET/CT showed sensitivity, specificity, positive predicted value, negative predated value, and overall diagnostic accuracy as 93.44%, 100%, 100%, 50%, and 93.85% respectively.</p> <p><strong>Conclusion:</strong> A higher accuracy of PET/CT was observed in the diagnosis of recurrent ovarian cancer among clinically suspected cases, thus helping in devising an appropriate management plan by the treating physician.</p> Nimrah Sultana Shaista Shoukat Sadaf Nausheen Bakhtawar Memon ##submission.copyrightStatement## 2021-02-24 2021-02-24 15 2 156 160 10.37018/txti8122 Burden of febrile neutropenia in paediatric oncology: Experience from Children’s Hospital Lahore Pakistan <p><strong>Background</strong>: Infection is the major cause of morbidity and mortality in children with cancer. Chemotherapy induced febrile neutropenia-associated mortality is much higher in low-middle-income countries than in high-income countries, emphasizing the need of prevention, early identification and timely management of infection related complications in these children. Objective of this prospective study was to analyze the burden of chemotherapy induced febrile neutropenia and to assess the leading risk factors.</p> <p><strong>Patients and methods:</strong> Prospective cohort study was done in 100 patients with febrile neutropenia (fever of 38.3℃ and ANC &lt;500) admitted in the Haematology/Oncology Department of Children’s Hospital Lahore (CHL) from July to August 2016. All the children on curative chemotherapy were included in this study and children with relapse and on palliation were excluded from this study. Risk factors including knowledge of parents and caregivers about febrile neutropenia, travel time from home to hospital and duration of symptoms at home before seeking treatment and reasons for delayed response in these children’s febrile illness, were analyzed for duration of hospital stay considered as a burden on the Haematology/Oncology Department. Data regarding their age, sex, and clinical features, baseline CBC, course of therapy, hospital stay and understanding of caregivers regarding febrile neutropenia was analyzed. The first line therapy was IV Piperacillin-Tazobactam and IV Amikacin. SPSS-16 software was used to analyze the data and a p-value of <u>&lt;</u>0.05 was considered as statistically significant.</p> <p><strong>Results:</strong> Total 100 patients with age ranging from &lt;1 to 15 years were included.<strong>&nbsp;</strong>Male to female ratio was 1.7:1, 72% of the cases had Acute Lymphoblastic Leukaemia and 28% with solid tumors. About, 28% had last chemotherapy received in 72 hours, 30% in last week and rest in more than a week time 36% had&nbsp;upper respiratory tract infections, 18% gastrointestinal infections, 20% mucositis, 10% no focus found and rest 16% had other manifestations. Only 2 % presented in less than one hour of start of symptoms, 27% &lt;24 hours, 61% in &lt;5 days and 10% &gt;5 days duration of symptoms. 45% had&nbsp;Hb&nbsp;&lt;8 gm/dL, 33% had&nbsp;platelets &lt;50,000 mm<sup>3</sup>, and 54% had&nbsp;WBC&nbsp;&lt;1000 and 63% had&nbsp;ANC &lt;100. 29% presented with the first episode while 51% had 3 or more febrile neutropenia episodes. 28% cases stayed 1 hour distance from CHL while&nbsp;72% had to travel &gt;1-5 hours&nbsp;to reach the primary treatment center. 66% received paracetamol at home, 17 had oral antibiotics while 17% had no treatment before reaching hospital. Only 19% caregivers had&nbsp;adequate awareness regarding adequate management of febrile neutropenia, 72% had some understanding while 9% had no knowledge about febrile neutropenia. 46% had financial issues, 41% were unaware while, 13% showed negligence in seeking treatment. Only 2 patients stayed for a day, 46% stayed for 5 days and 48% for more than 5 days.</p> <p><strong>Conclusion:</strong> Febrile neutropenia episodes accounted for 25% of monthly admissions of the Haematology/Oncology Department of Children’s Hospital Lahore. Majority of these caregivers had inadequate basic knowledge of standard management of febrile neutropenia aggravated by increased travel time from their homes to the hospital.</p> Alia Ahmad Fauzia Shafi Khan Wasila Shamim Aman Salman Ahmad ##submission.copyrightStatement## 2021-02-24 2021-02-24 15 2 166 169 10.37018/zptb7901 Use of preoperative tranexamic acid in tonsillectomy with or without adenoidectomy to reduce primary haemorrhage <p><strong>Background:</strong> Haemorrhage during adenotonsillectomy is a common and potentially grave complication especially in children due to less physiological compensation of total blood volume. Tranexamic acid being synthetic antifibrinolytic drug has been widely used in surgical procedures to reduce bleeding. Few researches have done to see its effectiveness during adenotonsillectomy. The objective of current study is to evaluate the use of preoperative tranexamic acid to reduce primary haemorrhage in children who undergo elective tonsillectomy with or without adenoidectomy.</p> <p><strong>Subjects and methods:</strong> It was a It was a quantitative, randomized control study and conducted at Pakistan Railway hospital from June 2015 to September 2016.The current study included 80 children randomized into two groups. Children between the ages of 5 to 15 years had been operated for tonsillectomy with or without adenoidectomy. Group 1 (experimental group) was given tranexamic acid at a dose of 10mg/kg of body weight intravenously, 30 minutes before induction of anaesthesia while the other arm (control arm) did not receive injection tranexamic acid. All children underwent dissection and snare method under general anaesthesia. P-value were obtained by applying independent sample t-test and considered statistically significant at 0.05 in reduction of primary haemorrhage during the procedure.</p> <p><strong>Results:</strong> In study group mean amount of primary haemorrhage was 64.56 (<u>+</u>40.85) ml and in control group was 98.34 (<u>+</u>62.57) ml. The comparison of Boezzart blood grading scale was also significantly different between both groups.</p> <p><strong>Conclusion:</strong> Preoperative tranexamic acid when used intravenously is effective in reducing primary haemorrhage during tonsillectomy with or without adenoidectomy.</p> Nighat Arif Sadaf Raffat Mustafa Usman Aslam Aysha Nauman Sadia Chaudhary Shuman Roy ##submission.copyrightStatement## 2020-12-26 2020-12-26 15 2 125 128 10.37018/jfjmu.v13i3.643 Cesarean scar endometriosis - a case report <p>Scar site endometriosis is a rare event. It mostly occurs after obstetrics and gynaecological related surgeries. Classical presentation is cyclical pain and swelling at or near scar in relation to menstrual cycle. A case of scar site endometriosis in a 25-year-old female is presented. Patient developed characteristic clinical features 3 years after cesarean section. Clinical diagnosis was supported by ultrasonography. A wide excision with clear margins was curative. High index of clinical suspicion and wide excision remain the keys to successful management.</p> Nayyer Sultana Mariam Malik Ameelia Saddaqat ##submission.copyrightStatement## 2020-12-15 2020-12-15 15 2 140 141- 10.37018/dvsk5506 Efficacy of 4% chlorhexidine in preventing neonatal umbilical cord infection <p><strong>Background:</strong> Umbilical cord stump is a budding point for bacterial colonization subsequently leading to sepsis that contributes to high neonatal morbidity and mortality, if not properly managed. Antiseptic care can significantly reduce omphalitis and ultimately improve newborn survival. Objective of this study was to see the efficacy of 4% chlorhexidine use to prevent umbilical cord infection in neonates.<br><strong>Subjects and methods:</strong> It was a comparative analytical study conducted in Neonatal unit, Sir Ganga Ram Hospital (SGRH) Lahore from July, 2016 till January, 2017. One hundred neonates were enrolled and randomized into two equal group by simple random method (50 each). In one group, nothing was applied to cord while in chlorhexidine group, 4% chlorhexidine gel was applied on umbilicus and around it, once daily for 7 days or till cord detached whichever came early. First application was done by a nurse followed by duly trained mother/caregiver. The signs of omphalitis (redness, pus or localized oedema) were observed and recorded for each neonate in both groups. Chi square test was used to see the difference in omphalitis in these groups with p˂ 0.05 considered as statistically significant result.<br><strong>Results:</strong> Out of 100 neonates, 29 (58%) and 23 (46%) males while 21 (42%) and 27 (54%) females neonates belonged to dry care and chlorhexidine group respectively. Nineteen (38%) neonates with dry cord had omphalitis compared to only 5 (10%) in chlorhexidine group (p 0.001). Neonates with chlorhexidine application showed prolonged mean cord separation time (7.9±1.5 days) compared to dry care (6.1±1.8 days). <br><strong>Conclusion:</strong> The use of 4% Chlorhexidine was effective to lower omphalitis compared to neonates with dry cord care. </p> Fouzia Ishaq Anila Jamil Muhammad Sajjad Maria Iftikhar Muhammad Adnan Zafar Asma Anwar ##submission.copyrightStatement## 2020-12-15 2020-12-15 15 2 136 139 10.37018/ilil1903 Serum free testosterone levels in polycystic ovarian syndrome patients and its correlation with clinical hyperandrogenism in Pakistan <p><strong>Background<em>:</em></strong> Polycystic ovary syndrome (PCOS) is the most frequent pathology among women of reproductive age characterized by menstrual irregularities, hyperandrogenism and polycystic ovaries on ultrasound. Evidence suggests that high androgen levels are the fundamental factor in the pathogenesis of PCOS. The objectives of the present study was to determine serum free testosterone levels in polycystic ovarian syndrome patients, and observe its correlation with clinical hyperandrogenism.</p> <p><strong>Patients and methods</strong>: This cross-sectional study was conducted at Jinnah Allama Iqbal Institute of Diabetes and Endocrinology Lahore, Pakistan from 15<sup>th</sup> May 2019 to 15<sup>th</sup> November 2019. The study included 140 patients of PCOS diagnosed as per Rotterdam criteria. Serum testosterone levels were determined in these patients by ELISA method. Ferriman-Gallwey (FG) score was used to assess severity of clinical hyperandrogenism in the form of hirsutism. Patients were categorized into three groups, mild (FG score 8-15), moderate (FG score 15-25) and severe (FG score &gt;25). Correlation between clinical (hirsutism) and biochemical hyperandrogenism (serum free testosterone levels) was assessed using Fisher exact test. Data was analyzed using SPSS version 25.</p> <p><strong>Results:</strong> Biochemical hyperandrogenism in the form of raised free testosterone levels was present in 46 (32.9%) PCOS patients. Out of 12 patients having Ferriman Gallwey score &gt;25, 10 (83.3%) had biochemical hyperandrogenism. Out of 70 patients having Ferriman Gallwey score 15-25, 22 (31.4%) had biochemical hyperandrogenism whereas out of 58 patients having Ferriman Gallwey score 8-15, only 14 (24.1%) patients had biochemical hyperandrogenism.</p> <p><strong>Conclusion:</strong> Prevalence of biochemical hyperandrogenism in PCOS patients in our studied population was significantly low when compared to the population studied worldwide making it less reliable as diagnostic tool in this part of the world. Also there was significant positive correlation between free testosterone levels and degree of hirsutism which means that diagnostic accuracy of free testosterone in PCOS patients is considerably high in those having clinical hyperandrogenism.</p> Tahir Ullah Khan Naseer Nazeer Memon Amna Riaz Zohaib Ahmed Khan Sundus Mariyum Haroon Khurshid Ahmed Khan ##submission.copyrightStatement## 2020-12-15 2020-12-15 15 2 132 135 10.37018/fjfl1810 Screening the adequacy of hydroxychloroquine prescription and monitoring of ocular toxicity in patients with rheumatic disease <p><strong>Background</strong>: Hydroxychloroquine (HCQ) an anti-inflammatory drug used in treatment of rheumatic diseases causes retinal toxicity in a minority of patients which are both time and dose dependent. The aim of this study was to assess the compliance &nbsp;with guidelines &nbsp;of American Association of Ophthalmology for screening and dosage of this drug.</p> <p><strong>Patients and methods</strong>: In this cross-sectional analysis, the medical records of patients who were on HCQ, attending Rheumatology Outpatient Department of Fatima Memorial Hospital Shadman, Lahore from 25-05-2019 to 30-05-2019 were reviewed. The dosage and, duration of HCQ were collected, files were reviewed for physician recommendation of screening tests for retinal toxicity. HCQ dose of 5mg/kg/day was labeled as adequate dose; dose below 4.5mg/kg/day under dosed, while dose of 6mg/kg/day and above was considered overdose.</p> <p><strong>Results:</strong> Data was collected from 81 patients during the study period, 74 (91.4%) of them being female, with mean age 35.15 ± 12.6 years. Based on total body weight, 23 patients (28.4%) were receiving the correct dosage of the drug around 5mg/kg/day whereas 39 (48.1%) patients were under-dosed below 4.5mg/kg/day, and 19 patients (23.5%) were over dosed, out of which 5 (6.17%) were receiving doses above 6.5mg/kg. Baseline eye screening examination by ophthalmologist was performed within 1 year of commencing treatment in 54 (66%) patients. Of the 27 patients receiving HCQ more than 5 years, 6 patients underwent Spectral coherence Ocular CT scan (SD-OCT) evaluation at 5 years. There was minimal compliance (less than 70% of Patients) to optimum drug dosage, partial compliance (70-89% patients) to preventing over-dosage of the drug, and full compliance (more than 90% patients) was achieved in baseline screening exam recommendation. Follow-up screening documentation and 5-years screening examination had minimal compliance.</p> <p><strong>Conclusion:</strong> A significant proportion of patients are underdosed, especially the obese population where the recommended dosage is not prescribed.</p> Saira Elaine Anwer Khan Muhammad Zeeshan Aslam Asadullah Khan Zia ud Din Farhan Bashir Hajra Khan ##submission.copyrightStatement## 2020-12-15 2020-12-15 15 2 128 131 10.37018/zbsl5515 Ameliorative effects of Spinacia oleracea on sperm morphology, count, and motility by normalizing the obesity-induced oxidative stress in Sprague Dawley rats <p><strong>Background:</strong> Obesity is a prevailing metabolic disorder that affects the functioning of the male reproductive system. Excessive adipose tissue enhances reactive oxygen species generation and is linked with male infertility. Spinach has demonstrated antioxidant effects. The present study was conducted to determine the antioxidant effects of spinach on sperm parameters in obese Sprague Dawley rats.</p> <p><strong>Subjects and methods:</strong> This randomized control study was conducted at the animal house of the National Institute of Health Islamabad, Islamic International Medical College, Cosmesurge International Hospital, Rawalpindi, and Apollo lab, Islamabad, Pakistan from April 2016 to March 2017. Forty male Sprague Dawley rats having an age of 8 weeks and weight 160-200g were tagged from number 1 to 40. Every third rat was randomly allocated to control Group A (<em>n</em>=13) and remaining into the Experimental group (<em>n</em>=27). Rats of control Group A was given a standard diet while a high-fat diet was given to Experimental group rats to induce obesity for the duration of six weeks. Weight (g) was measured weekly and obesity was confirmed when rats attain more than 20% weight when compared with that of rats of control Group A. Then, after obesity induction, the experimental group was alienated into the obesity control group (Group B) and spinach treated group (Group C). For sample, rats of Group A and Group B were sacrificed, and the cauda epididymis of each rat was placed in a Petri dish containing normal saline and cut into pieces to allow the release of sperm and then sperm parameters (sperms concentration, motility, and morphology) were recorded under the microscope. Then, spinach (5% hot water extract) along with the persistence of fat diet was administered to Group C for 4 weeks and finally, sperm parameters were measured in this group.</p> <p><strong>Results:</strong> Sperm concentration/ml, motility (%), and normal morphology (%) of Group B rats were significantly decreased as compared to Group A rats. However, sperm concentration/ml, motility (%), and normal morphology (%) of Group C (spinach treated group) rats was significantly increased (p&lt;0.001) as compared to Group B (obesity control group) rats after administering spinach.</p> <p><strong>Conclusion:</strong> The addition of Spinach in a normal diet regimen restores normal sperm morphology, improves sperm motility and concentration.</p> Somia Iqbal Noman Sadiq Saad Siddiqui Hira Iqbal ##submission.copyrightStatement## 2020-12-15 2020-12-15 15 2 124 127 10.37018/jspf4712 The Role of MDCT and 3D computed tomography in the assessment of maxillofacial fractures and their types: a tertiary care hospital experience <p><strong>Background:</strong> Maxillofacial region is a complex anatomical region that is commonly injured due to trauma and Multidetector Computed Tomography and Three-Dimensional Computed Tomography are used for accurate assessment of fractures and associated soft tissue injuries for correct clinical management. The objective of this study was to determine the frequency, various types of maxillofacial fractures and associated injuries using MDCT and 3D computed tomography (3D CT) at Sharif Medical City Hospital, Lahore.</p> <p><strong>Patients and methods:</strong> This was a cross-sectional study, carried out in the Department of Diagnostic Radiology, Sharif Medical City hospital, Lahore from December 2018 to November 2019. 3D reconstructed CT images were obtained in 70 patients with maxillofacial injuries referred to the Radiology Department of Sharif Medical City Hospital, using 16 slices Toshiba<sup>®</sup> Aquillion Multidetector Computed Tomography scanner. CT images were evaluated by consultant radiologists and data was collected.</p> <p><strong>Results:</strong> The maxillofacial fractures were significantly higher in the male population 61 (87%) than the female population 9 (13%). Road traffic accidents were the most common cause of injury and the mean age was 30±12 years with the most common age group were 21-30 years (32.8%). Maxilla and maxillary sinus wall fracture were commonest fracture 23 (33%) followed by orbital 20 (28%) bone fractures. Hemosinus 22 (31.4%) was the commonest associated injury.</p> <p><strong>Conclusion</strong>: The complex anatomy of the facial bones requires MDCT and 3D CT which offers excellent spatial resolution, and helpful in the accurate diagnosis of the maxillofacial fractures their exact site, number, and associated injuries, and surgical planning.</p> Asma Iqbal Abeer Yasin Mahwish Javeed Tashhir Rana Basma Khan Ariba Yasin ##submission.copyrightStatement## 2020-12-15 2020-12-15 15 2 119 123 10.37018/dvdu4414 Pathological response rate in patients who achieve clinical response after neoadjuvant concurrent chemoradiotherapy in localized esophageal cancer <p><strong>Background:</strong> The incidence of esophagus carcinoma is raising and it is the 6<sup>th</sup> leading cause of mortality. The objective of this study is to determine pathological response rate in patients who achieve clinical response after neo-adjuvant concurrent chemoradiotherapy in locally advanced esophageal cancer presented at a single tertiary care centre in Karachi.</p> <p><strong>Patients and methods:</strong> It was a longitudinal study conducted at the Department of Oncology of Jinnah Postgraduate Medical College from May 2017 to July 2018. Thirty five patients with locally advanced carcinoma involving lower and middle esophagus had concurrent chemoradiotherapy. Induction of concurrent chemoradiotherapy with radiations in which carboplatin and paclitaxel was given weekly. After 6 weeks at the end of irradiation, the clinical response was assessed on CT scan. All patients who had achieved stable, partial and complete clinical response after completion of concurrent chemoradiotherapy (CCRT) underwent surgery within 6-8 weeks. After surgery, pathologist evaluated resected specimen and staging was done on the basis of residual tumor. To grade the response to therapy, the degree of histomorphologic regression classified into four categories as Pathological complete response (pCR), pathological partial response, stable disease as no pathological response and progression of disease. Statistical analysis was performed using SPSS version 23. Chi-square test was applied to assess association between effect modifiers and complete pathological response.&nbsp;</p> <p><strong>Results:</strong> Total of 35 patients were included in the study. Mean age of the patients was 42.42±14.16 years. There was female preponderance (57.4%) with male to female ratio of 17:18. Eleven patients (31%) achieved complete clinical response and 2 patients (6%) had stable disease. After surgery, complete pathological response was observed in 21 (60%) patients. However, 10 (28.6%) patients achieved partial pathological response, 1 (2.9%) patient had stable disease and 3 (8.6%) patients showed progression of disease.</p> <p><strong>Conclusion:</strong> The achievement of complete pathological response was comparatively higher than partial response among locally advanced EC patients who had neoadjuvant CCRT followed by surgery.</p> Ravisha Bai Ghulam Haider Kanwal Satyawan Ammara Manzoor Shahid Hussain Muhammad Hayat Sasoli ##submission.copyrightStatement## 2020-12-15 2020-12-15 15 2 114 118 10.37018/qsqy1921 The outcome of the Trendelenburg procedure with stripping vs. no stripping in the management of varicose veins <p><strong>Background:</strong> Varicose veins is a common problem in Pakistan with multiple treatment options. One of its recommended and commonly performed surgical treatment includes the flush ligation of Saphenofemoral junction (Trendelenburg procedure) with stripping of great saphenous vein and avulsion of varicosities which is a cumbersome process. This study aims to evaluate the effect of stripping of great saphenous vein on the recurrence rate.</p> <p><strong>Patients and methods:</strong> A randomized controlled trial was conducted in the Surgical Unit I, Services Hospital, Lahore over a period of 22 months from 20-09-2016 to 20-07-2018. Seventy patients were divided equally into two groups of 35 patients each i.e. Trendelenbrug procedure and avulsion of varicosities with stripping down to the knee, (Group A) versus Trendelenbrug procedure and avulsion of varicosities without stripping (Group B). Recurrence at 12 weeks was noted. SPSS version 17.0 was used to analyze data. Comparison of recurrence and stratified confounding factors such as age, gender, and BMI were assessed by the chi-square test (significant p-valve ≤0.05).</p> <p><strong>Results:</strong> In group A, 32 out of 35 patients were male (91.43%) and 3 (8.57%) were female. While in group B, 31 out of 35 patients were male (88.87%) and 4 (11.43%) were female. Four out of 35 (11.43%) patients in group A whereas 6 (17.14%) group B patients (p-value=0.494) had a recurrence in the perforators below the knee at 12 weeks. Stratification (p-values) of recurrence rate with respect to age (&lt;40 years: 0.41 versus ≥ 40 years:0.905), gender (female: p-value not applicable versus male: 0.96) and BMI was done (&lt;25 kg/m<sup>2</sup>: 0.36 versus ≥ 25 kg/m<sup>2</sup>: 0.901)</p> <p><strong>Conclusions:</strong> Stripping does not significantly affect the outcome of varicose vein surgery in relation to the recurrence rate at 12 weeks and recurrence was independent of age, gender, and BMI of patients.</p> Jibran Mohsin Muhammad Haris Janjua Jumana Fatima Muhammad Usman siddique Muhammad Yasir Naseem Imdad Ahmad Zahid ##submission.copyrightStatement## 2020-12-15 2020-12-15 15 2 110 113 10.37018/wdid8444 Barriers to the access of oral health care facilities among adults: an exploratory study from Lahore <p><strong>Background:</strong> Oral health is one of the key indicators of the quality of life, overall health and well‑being of the general population. Globally, the high prevalence of the periodontal disease, excessive tooth loss, dental caries experiences, oral cancers and xerostomia are the major issues reported among adult populations. Timely access to oral healthcare facilities preserves the function, morbidity and mortality. The best possible health outcomes are only possible if the personal health care services are accessible timely. So, the primary objective of this study was to explore the barriers to the access of oral health care facilities among adults. In addition, the study also determined the association between adult’s demographic factors and their visits to dental clinics.&nbsp;</p> <p><strong>Subjects and methods:</strong> This exploratory study was conducted for two months between November 2019 and January 2020. The study recruited 400 adults including 200 males and 200 females visiting outpatient department (OPD) of public hospital i.e. Jinnah Hospital, Lahore. Participants were included in this study if they were 18 years of age or older and had provided written informed consent before data collection. Data were collected using a structured questionnaire whereas barriers to access the oral healthcare facilities was confirmed by asking an open-ended question. Statistical Package for Social Sciences (SPSS) software was used to calculate descriptive statistics (i.e., mean, standard deviation, percentages). The study also determined the association between sociodemographic factors of adults and their tendency to visit dental clinics just for routine checkups using the chi-square test.</p> <p><strong>Results:</strong> The average age of the participants was 36.81±9.29 years ranged from 18 – 63 years. Of the 400 participants, 259 (64.75%) reported costly treatment as a barrier affecting access to oral healthcare facilities followed by difficulty in access to dental clinics (27.75%) and fear of the pain of dental procedures (20.25%). Only 52 (13%) adults were regularly visiting dental clinics for routine check-ups whereas 21 (5.25%) respondents never had been to the dentist throughout their life. Nearly, half of the respondents i.e. 189 (47.25%) stated that dental care expenditures were borne by them and none of them was health insured. Statistically, a significant association was found between demographics (i.e. education, rural background and income) and the tendency to visit the dental clinics (p&lt;0.05).</p> <p><strong>Conclusion: </strong>Expensive treatment, difficulty in accessing dental facilities and fear from dental procedures are the major barriers to the utilization of dental services. Access to dental clinics for routine check-ups is significantly influenced by sociodemographic factors.</p> Shehla J. Akram Raheela Yasmin Saira Atif Asadullah Rathore Omair Anjum Muhammad Bilal Arshad Imran Hameed Khaliq ##submission.copyrightStatement## 2020-12-15 2020-12-15 15 2 105 109 10.37018/iyvh7026 Role of sleep deprived EEG in undiagnosed epileptic patients with negative standard EEG <p><strong>Background:</strong> Epilepsy is a common illness and most of the times it is diagnosed with standard electroencephalography (EEG). However, this is not positive in all the patients. Among these patients sleep deprived EEG is recommended by many authors but this is not routinely used. This study was conducted to evaluate that how commonly sleep deprived EEG will show positive results among patients with unspecified seizures having negative standard EEG.</p> <p><strong>Patients and methods:</strong> This was a cross sectional survey that included 100 patients with unspecified seizure having negative standard EEG. All the patients had sleep deprived EEG. The frequency of patients positive for epilepsy on sleep deprived EEG was calculated.</p> <p><strong>Results:</strong> Forty one (41%) patients were found positive for epilepsy on sleep derived EEG, while rest of 59 (59%) patients were negative.</p> <p><strong>Conclusions:</strong> it is recommended that all the patients with unspecified seizures having negative standard EEG should have sleep deprived EEG in our clinical setup.</p> Zia ul Haq Tahira Liaquat Tahir Bashir Muhammad Anas Bashir Anam Khan Shazia Siddique Seemeen Hussain ##submission.copyrightStatement## 2020-07-27 2020-07-27 15 2 107 109 Hypomagnesemia in hemodialysis patients taking proton pump inhibitors <p><strong>Background:</strong> Proton pump inhibitors (PPIs) are in routine widely prescribed to hemodialysis patients. Recent studies have reported the association of PPIs use with hypomagnesemia in patients with long term hemodialysis. This study aims to determine the frequency of hypomagnesemia in patients of hemodialysis taking proton pump inhibitors.</p> <p><strong>Patients and methods:</strong> This cross-sectional study was conducted in the Department of Nephrology of Sandman Provincial Hospital Quetta from 01-6-2019 till 01-9-2019. A total of 120 patients (52 PPI users and 68 non-PPI users) who were on HD for more than 06 months were included. Data regarding age, gender, duration of hemodialysis and taking PPIs were collected. Determination of serum magnesium was made by taking 3 different samples at 2 weeks’ interval and the mean value of serum magnesium was calculated. Serum Mg<sup>2+ </sup>levels &lt;2.0 mg/dL was taken as hypomagnesemia. A Chi-square test was applied to determine the association of PPI use with hypomagnesemia.</p> <p><strong>Results:</strong> Demographic variables such as age and gender were not significantly different between the groups. There was female dominance in both groups (73% in PPI groups and 66.1% in the non-PPI group (p-value 0.65). The mean duration of dialysis was 45.3±13.8 months in PPI users versus 48.9±12.9 months in non-PPI users (p-value 0.14). There was a significantly higher frequency of hypomagnesemia in PPI users; 36 (69.3%) versus 27 (39.7%) in non-PPI users (p-value 0.001).</p> <p><strong>Conclusion:</strong> The use of PPI is associated with a significant reduction in serum magnesium levels. So serum magnesium levels should be advised as routine monitoring in patients of hemodialysis taking PPIs.</p> Abdul Malik Syed Mohkumuddin Humaira Rahim Shamima hanif ##submission.copyrightStatement## 2020-07-15 2020-07-15 15 2 55 58 10.37018/dezk2659 Use of non-contrast computed tomography determined urinary stone fragility in predicting the outcome of extracorporeal shockwave lithotripsy treatment: a single-center study <p><strong>Background:</strong> Renal stones represent a common urological pathology where standard treatment advised is ESWL in current practice. However, NCCT based determination of stone fragility may help to predict the outcome of ESWL treatment, hence optimizing its clinical use. Therefore, this study evaluated the role of NCCT determined urinary stone fragility in predicting the outcome of ESWL treatment in local clinical settings.</p> <p><strong>Patients and methods:</strong> One hundred patients with single renal calculus of 0.6-2 cm in size were included. NCCT based determination of stone fragility in HU units was done for all patients. Patients were then subjected to ESWL, with a maximum of 3000 shock waves given per ESWL session. Plain film and/or ultrasonography was used to monitor ESWL treatment progress with a final NCCT evaluation at 12 weeks to determine the clearance of the calculi for each patient. Association of NCCT based stone fragility and outcome of ESWL was statistically analyzed using Fisher exact test.</p> <p><strong>Results:</strong> The mean age of the patients was 37.7 ± 10.9 years with 54% being male. Decreasing stone fragility on NCCT (high = &lt;500HU, moderate = 500-1000HU, and high = 1000HU) required more number and intensity of ESWL sessions (1-2 visits and 3000-6000 shock waves for high stone fragility group, 3-5 visits and 7000-18000 shock waves for the moderate group, and 6 visits and &gt;18000 shock waves for low fragility group, respectively) necessary for clearance of urinary stones (p&lt;0.001). In 98% of patients, the clearance of urinary stones was excellent.</p> <p><strong>Conclusion:</strong> Renal stone patients with NCCT determined high and moderate stone fragility show an optimal response after ESWL treatment, whereas, for low fragility renal stones attenuative treatment like percutaneous nephrolithotomy and/or ureteroscopy should be considered instead of ESWL. This approach can enable patient stratification before ESWL therapy ensuring better clinical management of the renal stone disease.</p> Athar Hameed Khazir Hayyat Gondal, ` ##submission.copyrightStatement## 2020-07-15 2020-07-15 15 2 59 63 10.37018/xivf1000 Patterns of serum CEA levels in different clinico-pathological variables of colorectal cancer <p><strong>Background:</strong> Globally, colorectal malignancy is the 3<sup>rd</sup> most frequent cancer and the 2<sup>nd</sup> major cause of mortality. Serum carcinoembryonic antigen (CEA) is a simple tumor marker for the diagnosis, predicting response to therapy and survival and identifying the recurrence of colorectal cancer. Therefore, the aim was to evaluate the pattern of serum CEA levels in patients with colorectal cancer presenting at a tertiary care hospital in Karachi</p> <p><strong>Patients and methods:</strong> It was a cross-sectional study conducted at the Department of Medical Oncology of Jinnah Postgraduate Medical Center, Karachi from January till August 2019. One ninety-nine patients of 12-80 years age and either gender diagnosed with colorectal cancer (biopsy-proven) were included. Data on demographics, clinical and pathological findings were recorded in the pre-designed proforma. The serum CEA levels in colorectal cancer patients were assessed using an ELISA kit. CEA levels higher than 5.0 ng/mL were deemed as elevated CEA levels in colorectal patients. Data were analyzed using SPSS version 23.</p> <p><strong>Results:</strong> A total of 191 colorectal cancer patients were included. The mean age of the patients was 42.81±15.22 years. Most of the patients (61.3%) were male. Out of 191 colorectal cancer patients, 60 (31.4%) had CEA level 0-0.3 ng/ml, whereas 79 (41.4%) had elevated serum CEA level (&gt;10 ng/ml). The CEA levels were stratified with respect to effect modifiers. The size of the tumor, TNM staging and localization and metastasis of cancer showed a statistically significant difference between levels of CEA (p&lt;0.05).</p> <p><strong>Conclusion:</strong> The raised CEA levels are associated with clinically progressive or presence of residual and recurrent disease. For patients with progressive tumors, particularly colorectal carcinoma, CEA assays are an important guide to assess the burden of the tumor, hence clinicians and surgeons ought to monitor antigen levels. It is recommended to enhance the clinical efficacy of the CEA levels.</p> Muhammad Hayat Ghulam Haider Shahid Hussain Perwasha Kerio Ravisha Bai Shakeel Akbar Saima Zahoor ##submission.copyrightStatement## 2020-07-15 2020-07-15 15 2 68 71 10.37018/mmtu5850 Gender difference in risk factors associated with ischemic heart disease in Lahore <p><strong>Background:</strong> Ischemic heart disease (IHD) is one of the leading causes of mortality in Pakistan. With advancement in research, multiple causes have contributed in development of web of causation of this public health issue. The objective of this study was to assess gender differences in risk factors associated with ischemic heart disease in patients presenting at the biggest cardiology hospital of Lahore.</p> <p><strong>Patients and methods:</strong> A comparative cross-sectional study was carried out in Punjab Institute of Cardiology, Lahore from January to August, 2018 on a sample of 296 diagnosed patients of IHD, through non-probability consecutive sampling technique. Data was collected on pretested questionnaire. The data was analyzed using SPSS version 22. Chi-Square test of significance was applied and a p-value ≤0.05 was considered statistically significant.</p> <p><strong>Results:</strong> The mean age of participants was 45±12 years with predominance of male patients (71.3%). Frequency of risk factors for IHD included increase body mass index (83.8%), hypertension (61%), insufficient physical activity (43%), diabetes (38.5%) and smoking (23%). Increase serum cholesterol was reported in 95% and triglycerides in 99% of the participants. Gender difference was significant with females residing in urban population (p=0.054) and exercise routine (p=0.034). Males showed high tendency of IHD with smoking pattern (p&lt;0.001) contrary to presence of diabetes in females (p=0.05), hypertension (p=0.054), BMI (p=0.0379) and stressful event in life (p=0.002). Males showed regular intake of medicines (p =0.045) after diagnosis as compared to female population.</p> <p><strong>Conclusion:</strong> There is more frequency of ischemic heart disease in males as compared to females. Significant association was observed with residence in urban area, presence of diabetes, hypertension, high BMI and stressful event in life in occurrence of ischemic heart disease in female population.</p> Muhammad Salman Tariq Iram Manzoor Qurat ul Ain Zulfi Naeem Hussain Nimra Saleem Murtaza Shabbir ##submission.copyrightStatement## 2020-07-15 2020-07-15 15 2 72 77 10.37018/hjie6482 Role of intravitreal ranibizumab for rapid recovery of central serous chorioretinopathy <p><strong>Background:</strong> Central serous chorioretinopathy (CSCR) is an idiopathic disorder in which there is leakage of fluid from hyper permeable choriocapillaris and the collection of fluid between neurosensory and neuropigmentry retina in the macular area that is responsible for decrease visual acuity. CSCR may be acute or chronic. Various treatment options include simple observation, argon laser photocoagulation of the leaking spot, photodynamic therapy (PDT), oral ketoconazole and oral rifampicin are available. Ranibizumab is a monoclonal antibody fragment that act as vascular endothelial growth factor inhibitor, stabilize blood retinal barrier and decrease leakage from choriocapillaris. This study aims to evaluate the role of intravitreal ranibizumab for rapid recovery in central serous chorioretinopathy.</p> <p><strong>Patients and methods:</strong> This descriptive case series was carried out at Department of Ophthalmology, Nishtar Medical University Multan, Pakistan from 01-10-2019 till 30-04-2020. The study included twelve eyes of twelve patients suffering from acute CSCR. All patients were given a single injection of intravitreal ranibizumab (0.5mg/0.05ml) as a primary treatment and followed for two months after injection at one week, one month and two months interval to document efficacy of intravitreal ranibizumab. At each baseline and follow up visits, dilated fundus examination was carried out, ending up with patients’ best corrected visual acuity. Central retinal thickness (CRT) was also recorded and results were compared with prior visit results of patients. Major outcomes were the improvement in visual acuity and decrease in CRT. Baseline CRT values were also compared with post injection CRT values at one week, one month and two months intervals using paired sample t-test and best corrected visual acuity (BCVA) was compared using chi–square test.</p> <p><strong>Results:</strong> Mean age of the patients was 39.6 years with a male to female ratio of 9:1. Best corrected visual acuity was 6/60 on Snellen chart at baseline. All patients exhibited mean improvement of best corrected visual acuity of three Snellen lines after one week. Eleven patients were back to best corrected visual acuity of 6/6 after one month. Remaining one patient gained best corrected visual acuity of 6/6 after two months of post injection. The mean CRT at presentation was 500 ± 80U (range; 386–580) which reduced significantly to 272 ± 52 U (range 220–338) from baseline after one month showing significant reduction (p&lt;0.001). At the last follow-up visit, the CRT was measured 230 ± 20 U (range 220—250) which shows complete resolution of sub-retinal fluid.</p> <p><strong>Conclusion:</strong> Intravitreal ranibizumab can be used for rapid absorption of sub-retinal fluid in acute CSCR and significant reduction in CRT along with improvement in BCVA indicate that it may be safely employed in CSCR to achieve better clinical outcomes.</p> Kamran Shahzad Syed Ahmer Hussain Muhammad Zafarullah Nausherwan Adil ##submission.copyrightStatement## 2020-07-15 2020-07-15 15 2 78 82 10.37018/ykjf3651 Evaluation of Chicago sky blue stain against Potassium Hydroxide-Dimethyl Sulfoxide wet mount in the identification of dermatophytes <p><strong>Background:</strong> Dermatophytoses infections are widespread in the developing world. The laboratory diagnosis of dermatophytes has been a challenge as it involves microscopy and trained personnel. Potassium hydroxide wet mount with dimethyl sulfoxide added is routinely used in direct microscopy. But it lacks color contrast and the hyphae may be missed on routine microscopy. The study aimed to evaluate the effectiveness of the Chicago sky blue stain against routine potassium hydroxide-dimethyl sulfoxide (KOH/DMSO) wet mount in direct microscopy.</p> <p><strong>Patients and methods</strong>: The study was carried out at the Department of Microbiology, Postgraduate Medical Institute, Lahore over a period of nine months from July 2013 till March 2014. Patients of either gender regardless of age, clinically diagnosed as having dermatophytoses by dermatologists were selected for this study. Specimens from 100 patients were collected from the dermatology outdoor of a tertiary care hospital for this study. They were evaluated microscopically with routine potassium hydroxide-dimethyl sulfoxide (KOH-DMSO) wet mount and Chicago sky blue (CSB) stain. Data were collected and entered in Statistical Package for the Social Sciences (SPSS) version 20.0.</p> <p><strong>Results</strong>: Out of a total of 100 samples collected from skin, hair and nails, 59% were positive on direct microscopy with KOH/DMSO wet mount. Whereas direct microscopy using CSB stain revealed dermatophytes in 62% of cases.</p> <p><strong>Conclusion</strong>: Chicago sky blue staining is a better technique for the detection of dermatophytes as compared to potassium hydroxide wet mount examination. It is simple, rapid, and easy to interpret. We recommend the use of this technique to improve the detection of dermatophytes without awaiting the results of the culture.</p> Majid Rauf Ahmad Iffat Javed Suhaila Mushtaq ##submission.copyrightStatement## 2020-07-15 2020-07-15 15 2 83 86 10.37018/ybro2935 Efficacy and safety of oral dapsone in acne vulgaris – experience of a tertiary care teaching hospital in central Lahore <p><strong>Background:</strong> Acne is the eighth most prevalent disease affecting 9.4% of the population worldwide and its prevalence in our country is estimated to be around 5%. Severe inflammatory acne is most likely to leave scars and in order to prevent facial disfigurement due to acne scarring, early treatment is desirable. Various treatment options have been formulated for acne, and are tailored according to the severity of the disease. Numerous clinical trials have been conducted till now, to determine the usefulness and side effect profile of such therapies, making acne treatment a highly studied area in dermatology. Objective of this study is to highlight the fact that oral Dapsone could be used as a cheaper alternate to isotretinoin in recalcitrant severe acne, especially in females where retinoids are sometimes contraindicated.</p> <p><strong>Patients and methods:</strong> 51 patients, suffering from severe nodulocystic acne, fulfilling the criteria, were enrolled from the Department of Dermatology, Sir Ganga Ram Hospital, Lahore. All the study patients were given oral Dapsone 50mg for initial two weeks and then 100mg daily for the next 10 weeks along with oral cimetidine and topical clindamycin application twice daily. Investigator Global Assessment Scale (IGAS) was employed to measure effectiveness. The treatment was considered ʽeffectiveʹ if the patient achieves 2 or more than 2-grade improvement or almost clear or clear skin at the end of 12 weeks according to IGAS scale. The lesion counts were also done before the start of therapy (day 1) and at every two weeks follow up for 12 weeks. The change in lesion count observed between the baseline number and that seen at follow up visits was also used to evaluate the effectiveness of oral Dapsone. Safety was analyzed by fortnightly visits of the patients to look for any undesirable side effects and monitoring of the hematologic profile of the patients. Final follow up was done at the end of 16 weeks.</p> <p><strong>Results:</strong> The study was conducted on 51 patients, with a ratio of 1:3 for males and females and a mean age of 25.2 years (SD ±5.81). At 12<sup>th</sup> week, patients had significant reduction in their acne lesions; with 7 patients (13.7%) showing completely clear skin, 17 patients (33.3%) had almost clear skin, 5 patients (9.8%) had 3-grade improvement. Twelve patients (23.5%) had 2-grade improvement from baseline score and only 2 patients (3.9%) had 1-grade improvement from baseline. Based on percentage reduction of lesions, excellent response was seen in 32 patients (62.7%), good response in 9 patients (17.6%), moderate response in 2 patients (3.9%), while no patient showed poor response. Dapsone was discontinued in 8 patients due to derangement of hematologic profile.</p> <p><strong>Conclusion:</strong> Oral Dapsone, when given carefully, is a very effective therapeutic option in severe recalcitrant acne, with limited side effects.</p> Sadaf Amin Chaudhry Nadia Ali Zafar Rabia Hayat Ayesha Noreen Gulnaz Ali Zain Ali Raza Muhammad Nadeem ##submission.copyrightStatement## 2020-07-15 2020-07-15 15 2 87 90 10.37018/xqbw1463 Usefulness of Grey Scale and Doppler transvaginal sonography in diagnosis of ovarian torsion <p><strong>Background:</strong> Ovarian torsion diagnosis is a great challenge as delay in diagnosis can cause severe morbidity. Early accurate diagnosis is crucial to preserve ovarian function. Ultrasonography being the primary imaging modality plays a vital role in the evaluation of suspected ovarian torsion by helping surgeons reach the correct diagnosis, thus avoiding unnecessary intervention. This study aims to determine the diagnostic accuracy of isolated and combined sonographic features of ovarian torsion on grey scale and Doppler transvaginal ultrasonography.</p> <p><strong>Patients and methods:</strong> From radiology database, from January 2016 till December 2019, sonographic signs of ovarian torsion in 113 women with suspected ovarian torsion on ultrasonography and subsequent surgical diagnosis were evaluated. Ultrasound findings were compared with surgical findings to determine the accuracy, sensitivity, specificity, and positive and negative predictive values of individual and combined ultrasound signs.</p> <p><strong>Results:</strong> Diagnostic accuracy of ultrasound for ovarian torsion was 85.8%. Abnormal ovarian Doppler flow was the most accurate individual sonographic sign with accuracy, sensitivity, specificity and positive predictive value of 85.8%, 83.5%, 100% and 100% respectively followed by ovarian enlargement and ovarian edema. Combined ultrasound signs resulted in higher sensitivity and positive predictive values, and lower specificity and negative predictive values for ovarian torsion. Increasing the number of sonographic parameters increased the specificity but decreased sensitivity. High accuracy, sensitivity, positive predictive value, specificity and negative predictive value was seen when combination of three or two sonographic parameters was used as diagnostic criteria.</p> <p><strong>Conclusion:</strong> Transvaginal sonography is a convenient, reliable and extremely useful imaging modality for preoperative diagnosis of ovarian torsion with high specificity, sensitivity, positive predictive value and diagnostic accuracy helping treating physicians to take prompt decisions regarding timely surgical intervention. However, due to low negative predictive values, absence of sonographic signs does not rule out ovarian torsion and high index of clinical suspicion remains of utmost importance.</p> Khalid Rehman `Yousaf Shahzad Saeed Saman Chaudhry Rabia Bashrat Abadullah Khalid Usman Baig Maria Haq Talal Azhar Moeez Zafar ##submission.copyrightStatement## 2020-07-15 2020-07-15 15 2 97 102 10.37018/kori7947 Posterior and lateral ponticles of atlas: An osteological study at Fatima Jinnah Medical University, Lahore <p><strong>Background:</strong> Among the cervical vertebrae, atlas is known to have many variations, posterior ponticle being the commonest. It may completely or incompletely covers the groove of vertebral artery leading to ischemia of posterior circulation. Therefore, vertebral artery is at greater risk of injury during neurological and spinal surgeries. Prevalence of posterior ponticles varies widely among different populations, for instance in Turkish population it was 10.8%, in American 22.1%, Kenyan 14.7%, Brazilian and Indian 16.7%. The prevalence of lateral ponticle in Kenyan population was reported to be 3.9% and in Indians it was 2%. However, the data regarding the prevalence of these ponticles is largely lacking in Pakistan. Therefore, this research was designed to determine the prevalence of posterior and lateral ponticle in atlas vertebrae of Pakistani population.</p> <p><strong>Materials and methods:</strong> A total of 47 human atlas vertebrae of unknown age and gender from bone bank of Department of Anatomy Fatima Jinnah Medical University, Lahore were studied for the presence of complete and incomplete posterior and lateral ponticles. The bones studied were completely intact and did not have any pathology.</p> <p><strong>Results:</strong> Total incidence of ponticles was 38 % in this study, of which 36% were posterior ponticles and 2% were lateral ponticles. Bilateral incomplete posterior ponticles/were found in 8 (17%) atlas vertebrae whereas bilateral complete posterior ponticles/foramen arcuale were found in only 1 (2%) atlas vertebrae. Unilateral incomplete posterior ponticle was identified on right side in 5 (11%) and left side in 2 (4%) atlas vertebrae. Unilateral complete posterior ponticle was found in only 1 (2%) atlas on the left side whereas no such finding was identified on right side in any vertebra. Unilateral complete lateral ponticle was found in only 1 (2%) atlas on the right side but not on left side. No bilateral complete lateral ponticle and incomplete unilateral or bilateral lateral ponticles were identified in this study.</p> <p><strong>Conclusion: </strong>Presence of posterior and lateral ponticles pose a risk of vertebrobasilar vascular insufficiency and may cause variety of symptoms. Vertebral artery may be at risk during neurosurgical procedures when having a foramen arculae and may give a false impression of much wider posterior arch of atlas. Knowing the prevalence of this can help neurosurgeons, general surgeons, radiologists, and chiropractors in management of the patients.</p> Saira Munawar Farhana Jafri Ahmad Farzad Qureshi Darab Fatima Aliya Zahid ##submission.copyrightStatement## 2020-07-15 2020-07-15 15 2 91 96 10.37018/NQOV7890 Internal limiting membrane peel with or without finesse flex loop assistance <p><strong>Background:</strong> Internal Limiting Membrane (ILM) peeling, currently, due to more successful hole closure rate and prevention of postoperative reopening, has been accepted globally but it may leads to other trivial complications like subretinal and retinal hemorrhage, vitreous hemorrhage and retinal edema etc., which may be avoided by using adjuvant instruments, like Finesse flex Loop. The aim of this study was to compare complications after ILM peel, with and without finesse loop.</p> <p><strong>Patients and methods:</strong> In this comparative cross-sectional study conducted in Ophthalmology Department of Lahore General Hospital, Lahore from February 2018 to January 2019, the data of thirty (30) patients was compared after taking informed consent through self-made pro-forma. Data analysis was done on SPSS-21. Frequency / percentage table of qualitative variables like retinal hemorrhage, retinal tear, retinal detachment and surface irregularities were designed by using excel-16. Fischer’s exact test was applied to compare complications after ILM peeling with and without using Finesse loop. Confidence interval of 0.95 with α of 0.05 was taken as significant.</p> <p><strong>Results:</strong> This study included thirty (30) patients (female: 13; male: 17) with mean age of 56 years and 8 months. Comparison between outcomes of ILM peeling with and without using Finesse™ Flex Loop showed that there is statistically non-significant difference in occurrence of retinal hemorrhage (p=0.245), retinal tear (p=0.224), retinal detachment (p=1.00) and surface irregularities (p=0.39). However, the prevalence of complications like surface irregularities, retinal tear, retinal hemorrhage and retinal detachment with finesse loop were less as compared to without finesse loop.</p> <p><strong>Conclusion:</strong> The prevalence of complications during ILM peel with finesse loop in a macular hole surgery, were less than that in ILM peel with ILM forceps alone.</p> Faisal Mehmood Abdullah Irfan, PGR Ophthalmology Awais Afzal, PGR Ophthalmology Muhammad Moin Muhammad Muneeb, PGR Ophthalmology ##submission.copyrightStatement## 2020-07-15 2020-07-15 15 2 64 67 10.37018/tqqv9443 Microbial contamination in a pediatric surgery operation theatre <p><strong>Background:</strong> In surgical patients, 38% of nosocomial/ health care associated infections are surgical site infections (SSI). The exogenous causes of SSI include microbial contamination of operation theatre environment, equipment, and personnel. The objective of this study was to generate local data involving microbial contamination of operation theatre environment, equipment, and personnel.</p> <p><strong>Methods:</strong> This cross sectional survey was conducted in Pediatric Surgery Operation Theatre, Mayo Hospital, Lahore from August 2018 to September 2018. Samples for bacterial culture were taken by theatre sister and list in charge using cotton swabs moistened in normal saline. After informed consent, 53 samples were taken from the dominant hand and anterior nares of theatre staff (surgeons, nurses, theatre assistants and anesthetists), and 33 samples from operation theatre equipment and environment (laryngoscope, anesthesia machine, operation table, wall and floor of the theatre, dirty area, and store.). Air samples were collected by night staff using settle plate method on blood agar. After collection, all samples were transported to laboratory within 15 minutes, where pathologist performed antimicrobial susceptibility testing for all bacterial isolates using the Kirby-Bauer disc diffusion method.</p> <p><strong>Results:</strong> This study had 24 (45%) of the samples from anterior nares, and 29 (55%) samples from dominant hand, while 33 samples were taken from theatre environment and equipment. Positive bacterial growth from theatre staff was seen in 9 (17%) out of 53 collected samples. <em>Staphylococcus aureus</em> was present in 5 (55.6%) of these 9 samples, while <em>Staphylococcus epidermidis</em> was present in 3 (33.3%), and 1 (11.1%) sample revealed <em>Escherichia coli</em>. In samples from operation theatre environment and equipment, 11 samples (33.3%) out of 33 samples had bacterial growth. Most common growth obtained was bacillus species (90.9%) either alone or as mixed growth, while 1 (9.1%) was <em>Staphylococcus aureus</em>.</p> <p><strong>Conclusion</strong><strong>: </strong>Despite observing standard protocols of theatre sterilization, microbial contamination was noted in 33.3% of samples collected from theatre and 17% from personnel. The main microorganism isolated from theatre environment and equipment’ samples was Bacillus (90.9%), and <em>Staphylococcus aureus</em> (55.6%) from theatre personnel.</p> Fatima Naumeri Bilal Qayyum Sushil Rijal Sohail Jamil ##submission.copyrightStatement## 2020-07-13 2020-07-13 15 2 49 52 10.37018/ZDZE280 Predictive value of CA 19-9 in patients with pancreatic tumours <p><strong>Background:</strong> Pancreatic carcinoma is a disease with high modality and has a high incidence of recurrence after surgical resection. The prognosis depends on early diagnosis and treatment. Numerous international studies have reported use of CA 19-9 in diagnosis of pancreatic cancer. We planned this study to validate role of CA 19-9 in our local population. The objective of this study is to correlate raised serum CA 19-9 levels in patients with pancreatic tumours to distinguish between benign and malignant pancreatic disease.</p> <p><strong>Subjects and methods: </strong>The present study is a validation study. Thirty-five patients with diagnosis of pancreatic tumor on radiological imaging were included after their informed consent. Data collection forms were filled, blood samples were taken and serum CA 19-9 was estimated by ELISA in Biochemistry department, SIMS. Histopathology samples were collected at time of surgical resection, sent to pathology departments of respective hospitals and histopathological reports collected. All data was collected and analysed by using descriptive method. The study was conducted in Biochemistry department of PGMI and SIMS, Lahore from May 2015 till June 2016.</p> <p><strong>Results:</strong> Out of 35 patients, nineteen (54.3%) were female and sixteen (45.7%) were male. Thirty [85.7%] patients were between third to seventh decades of their life. The mean age range around 47.28. Thirty-four patients had malignant tumor and 1 benign on histopathology. CA 19-9 was raised (&gt;37 U/ml) in 33 out of 34 patients with malignant pathology. The patient with benign pathology had CA 19-9 level &lt;37U/ml (the cut off value). Head of pancreas was the commonest site in 32 patients (65%) for tumour occurrence. Total 28 (82%) patients had adenocarcinoma as the histological type of pancreatic tumour. Cholangiocarcinoma in Periampullary region of pancreas was second in frequency, 4 patients (12%). CA 19-9 shows sensitivity of 97% and specificity of 100% to diagnose carcinoma of pancreas in patients with pancreatic tumour. CA 19-9 has 100% positive predictive value to diagnose benign tumour and 50% negative predictive value to diagnose malignant tumours.</p> <p><strong>Conclusion: </strong>Raised levels of CA 19-9 has an important role in diagnosis of patients with pancreatic tumour to differentiate between benign and malignant pathology.</p> Faiza Abrar Adnan Riaz Kaukab Sultana Tariq Feroz Khawaja ##submission.copyrightStatement## 2020-07-13 2020-07-13 15 2 45 48 10.37018/UBUG4188 Sofosbuvir plus Daclatasvir without Ribavirin for the Treatment of Chronic Hepatitis C in Patients with Decompensated Liver Disease <p><strong>ABSTRACT</strong></p> <p><strong>Background: </strong>In chronic hepatitis C infection, hepatic decompensation remained a contraindication to treatment for many years. The direct acting antiviral drugs have shown high treatment success even in decompensated liver disease. This study aims to assess the response and safety profile of Sofosbuvir and Daclatasvir in patients of decompensated cirrhosis with chronic hepatitis C.</p> <p><strong>Patients and </strong><strong>Methods:</strong> It was a prospective observational study conducted at Gastroenterology Department of Gujranwala Medical College/ DHQ teaching Hospital, Gujranwala from February 2016 to December 2017.Consecutive patients of hepatitis C with decompensated cirrhosis were enrolled in the study. Sofosbuvir 400mg and Daclatasvir 60mg was given to all patients without ribavirin for a period of 24 weeks. Sustained virologic was taken as primary end point.</p> <p><strong>Results:</strong> A total of 140 patients were included in our study, 122 patients (87%) completed the study, 08 patients (5.7%) were lost to follow up, treatment discontinuation was seen in 06 patients (4.2%) &amp; 04 patients (2.8%) died during the study. 110 patients (90.2%) achieved end treatment response (ETR), 12 patients (9.8%) remained treatment non-responder, 100 patients (82%) achieved sustained virological response (SVR<sup>12</sup>) and 10 patients (8%) had a relapse of HCV infection.</p> <p><strong>Conclusion:</strong> Once daily oral Sofosbuvir plus Daclatasvir without Ribavirin achieved overall high rates of sustained virologic response in patients with chronic HCV having decompensated liver disease.</p> Mahmood Ahmad Muhammad Ayub Fawad Iqbal Janjua Abdul Moiz Bhatti Nooman Gilani ##submission.copyrightStatement## 2020-07-13 2020-07-13 15 2 41 44 10.37018/WOXS1774 Comparison of health-related quality of life in children with normal hearing and those with cochlear implant at age of 4-6 years <p><strong>ABSTRACT</strong></p> <p><strong>Background:</strong> Hearing impairment during early life years have profound negative consequences on linguistic output, educational, psychosocial and physical functioning. Auditory perception plays a key role in the development of child. Severely hearing-impaired children receiving cochlear implant (CI) before the age of speech and language acquisition may enjoy their quality of life similar to their normally hearing peers. Considering the beneficial effects of CI on quality of life of hearing-impaired child, it is evident to properly investigate the similarity in life quality of children with CI and their normal hearing mates of same age group.</p> <p><strong>Patients and Method:</strong> This comparative cross-sectional study was conducted on parents of 50 children, who were allocated in two equal groups by purposive sampling. The questionnaire was administered by interviewing the parent participants using a validated quality of life questionnaire of Children for Parents and findings were compared with the responses from parents of normal hearing children. Responses from both the groups were analyzed by independent sample t-test.</p> <p><strong>Results:</strong> Parents of Cochlear Implanted children rated their children’s Health Related Quality of Life positively. All the sub domains showed the similar results except self-esteem. Findings suggest that normally hearing children had better self-esteem than CI children. No significant difference was found between overall Health Related Quality of Life of Cochlear Implanted children and their normally hearing peers.</p> <p><strong>Conclusion:</strong> Overall health related quality of life of children with cochlear implant is similar to that of normal hearing peers of same chronological age.</p> Noreen Anwar Tayyaba Dawood Munaza Hayyat Atia ur Rehman Muhammad Adnan Waris Ali ##submission.copyrightStatement## 2020-04-16 2020-04-16 15 2 175 179 10.37018/jfjmu.673 Effectiveness of crystal violet stain for localization of mitotic activity in oral squamous cell carcinoma <p><strong>Background:</strong> Mitotic figure counting is simplest and oldest method for determining proliferative activity of cell. It is considered as one of the important diagnostic aid in cancer pathology. Though advanced methods to evaluate dysplastic features are more precise and definite but expense and time makes them less practicable for routine use. Therefore an effort was made to use economical as well as simple approach involving crystal violet stain (1%) to study the mitotic figures in oral squamous cell carcinoma.</p> <p><strong>Materials and Methods:</strong> This descriptive research included samples, consisting of thirty three cases of the oral squamous cell carcinoma (OSCC). Representative sections were stained with H&amp;E stain and 1% crystal violet stain respectively. The stained sections were viewed under optical microscope to count mitotic figures for evaluating the effectiveness of 1% crystal violet stain. Data obtained was statistically analyzed by using sample t-test.</p> <p><strong>Results:</strong> There was noteworthy increase in the mean mitotic count among the crystal violet stained sections of OSCC in contrast to the OSCC sections stained with H&amp;E (P = 0.00).</p> <p><strong>Conclusion:</strong>1% Crystal violet stain can be considered as one of the optimum stains to observe the mitotic figure. Practice of staining with 1% crystal violet during routine histopathological procedures will be cost effective and may be used as a selective stain.</p> Aneequa Sajjad Muhammad Qasim Raza Syeda Zaira Sajjad Ihtesham-ud-Din Qureshi Syed Sajjad Sarwar Sadia Minhas ##submission.copyrightStatement## 2020-04-16 2020-04-16 15 2 166 169 10.37018/jfjmu.671 Functional outcome of manipulation under anaesthesia for the treatment of frozen shoulder <p><strong>Background:</strong> Frozen shoulder is defined as painful progressive loss of shoulder movements with unknown etiology. It is a self-limiting disease with the natural history of 18-30 months but with residual pain and restriction of shoulder movement. Its incidence is 2-5%. Various treatment modalities include benign neglect, physical therapy, non-steroidal anti-inflammatory medications, oral glucocorticoids, distention arthrography, intra articular steroid injections, closed manipulation under anaesthesia (MUA) and arthroscopic release of joint capsule. MUA regarding pain control and range of motion is safe, yields immediate results and is very cost effective. The purpose of this study was to ascertain the functional outcome of manipulation under anaesthesia and physiotherapy for the treatment of frozen shoulder in term of safety, cost effectiveness and immediate results.</p> <p><strong>Patients and Methods:</strong> In the 6 months study period, 50 patients with adhesive capsulitis were included by non-probability purposive sampling. Manipulation of shoulders was done under general anaesthesia and after the MUA intra articular injection of a mixture of corticosteroid and local anaesthetic was injected. Postoperatively, all patients underwent physiotherapy. Functional outcome was measured using Shoulder Pain and Disability Index (SPADI) preoperatively and postoperatively at 1<sup>st</sup>, 2<sup>nd</sup> and 3<sup>rd</sup> week follow up.</p> <p><strong>Results:</strong> Out of 50 patients, 32 (64%) were females and 18 (36%) were males having female to male ratio of 1.8:1. Average age was 51 years and average duration of symptoms preceding to MUA was 4 months and 27 days. The average pain score decreased from 92.52% to 18.08% and the average disability score reduced from 95% to 17.10%, both at 3<sup>rd</sup> week postoperative follow up. There were no procedure-related complications.</p> <p><strong>Conclusion:</strong> Manipulation under anaesthesia along with physiotherapy diminishes pain and disability, improves range of motion and expedites early recovery of function in patients having frozen shoulder.</p> Yasir Arfat Muhammad Umer Anwer Maria Imdad Faheem Ahmad Usmani Sana Imdad Shazia Rizwan Zahid Shafiq ##submission.copyrightStatement## 2020-03-14 2020-03-14 15 2 34 40 10.37018/KRCW7511 Evaluation of anti-arthritic effect of Torilis leptophylla and its comparison with indomethacin <p><strong>Background:</strong> Rheumatoid arthritis is an autoimmune debilitating disease involving multiple joints and organs. Many treatment options are available but all are associated with frequent side effects. Phytochemical screening of <em>Torilis leptophylla</em> has shown the presence of anti-inflammatory compounds like flavonoids, phenols and anthraquinones. This study was designed to evaluate its effect on joints inflammation (rheumatoid arthritis). Indomethacin is one of the oldest and most commonly used drugs for arthritis. It was used as a standard drug to compare with indomethacin.</p> <p><strong>Methods:</strong> This experimental study was carried out in Pharmacology Department, University of Health Sciences, Lahore. Thirty six male albino Wistar rats were randomly divided into six groups (group I-control, group II-positive control, group III-10 mg indomethacin, group IV,V,VI--100mg, 200mg, 300mg <em>Torilis leptophylla</em> extract (TLE) administered (orally) respectively). Arthritis was induced by sub plantar injection of 0.1 ml Freund’s complete adjuvant (FCA) to all groups except the control group. Body weight (weekly) and ankle joint diameter (every 4<sup>th</sup> day) were measured. At day 29 blood was collected and all animals were killed by overdose of ether. Acid phosphatase and alkaline phosphatase levels were determined by chemistry analyzer (RX MONZA, RANDOX, Republic of Ireland). Statistical analysis was performed using SPSS 20. One way ANOVA and Post hoc -Tukey tests were applied. A p-value of ≤0.05 was considered statistically significant.</p> <p><strong>Results:</strong> Treatment with indomethacin caused significant (p≤0.001) reduction in all the inflammatory parameters. <em>Torilis leptophylla</em> extract also significantly (p≤0.05) reduced all the inflammatory parameters. Anti-inflammatory effect was comparable to indomethacin.</p> <p><strong>Conclusion: </strong><em>Torilis leptophylla</em> has significant anti-arthritic activity as it modified the parameters of joint inflammation and destruction.</p> Javaria Fatima Bushra Shaheen Saba Batool Tooba Malik Sheikh Maria Qammar Saima Naureen ##submission.copyrightStatement## 2020-03-14 2020-03-14 15 2 25 29 10.37018/XELK8039 Assessment of health status of traffic constables: An occupationally exposed group in Pakistan <p><strong>Background:</strong> Traffic constables are exposed to various occupational health hazards worldwide. This study is planned to assess occupational health hazards in traffic constables in Punjab, Pakistan.</p> <p><strong>Subjects and Methods:</strong> A descriptive cross-sectional study was conducted in different cities of Punjab including Lahore, Gujranwala, Bahawalpur, Bahawalnagar, Sialkot and Islamabad from March till August 2018. A sample of 384 traffic personals were selected by using non-probability convenient sampling technique. Retired traffic constables and those with work experience less than a year were excluded. A pretested questionnaire was used to conduct the interviews after taking informed consent. Data was collected and analyzed using SPSS version 22 and presented in frequency tables and charts.</p> <p><strong>Results</strong>: Maximum number of constables belonged to 31-40 years of age group. Among them 98.7% were male, 25% were having education level above graduation. Results of physical health hazards showed that 53% of warden were smoker, 16.14% were known diabetics and 19.53% were found to be hypertensive. Other physical ailments included respiratory problems (23.4%), hearing impairment or loss (15.88%) and various eye ailments (13.28%). Additionally, 9.1% of participants had evidence of lead poisoning, 33.84% complaints of tightness in muscles and 13.72% of headache, whereas 35.7% had met an accident in the last year. Prevalence of stress and anxiety were 30% and 33.33%. Regarding social health issues 36.7% reported that they were unable to give family time and 42.48% felt lack of independence due to their occupation. Job satisfaction was reported by 50%.</p> <p><strong>Conclusion:</strong> The traffic constables in Punjab suffer from a large number of physical, mental and social health issues. Their perception about their occupational health hazards is low and needs improvement through imparting health education.</p> Mahnoor Taheer Butt Iram Manzoor Muhammad Ahmad Muhammad Abbas Shah ##submission.copyrightStatement## 2020-03-14 2020-03-14 15 2 19 24 10.37018/VEIG5252 Role of behavioral sciences in development of professionalism among MBBS students <p><strong>Background:</strong> Professionalism is a global quality expected in medical students’ along with clinical skills. Behavioral sciences have been included in 3rd year MBBS curriculum since 2014 at FJMU. The purpose of this change is to enhance Professionalism formally in addition to other areas of the subject. This study aims to determine effectiveness of studying behavioral sciences as a subject in enhancing elements of Professionalism.</p> <p><strong>Subjects and Methods:</strong> The mixed-methods study was used and a sample of 240 3<sup>rd</sup> year medical students was taken by convenient sampling. In the first (quantitative) phase of the study, Penn State College of Medicine Professionalism Questionnaire (PSCOM-PQ) was administered before and after studying behavioral sciences as a subject, to collect pre and post statistical results about students’ attitudes towards professionalism. The results were analyzed by paired sample t-test. In the second (qualitative) phase, Focus Group Discussion (FGD) was conducted to reveal the reasons for professionalism development and role of Behavioral Sciences in its development. 8 students were selected by purposeful homogeneous sampling technique. FGD session was audio-taped and transcribed, finally thematic analysis was done.</p> <p><strong>Results:</strong> The results showed highly significant increase (p-value= 0.00,<strong> t= -74.39,</strong> mean= -72, SD= 14.99)<em> in</em> the scores of Professionalism after studying behavioral sciences as a subject. The broad themes identified by FGD were “Professionalism Related Skills Learned through Behavioral Sciences” and “Modes of Information Transfers’ Role in Professionalism Understanding”. The professional skills conceptualized by the students included emotional stability, empathy, psychoeducation, confidentiality, competency and sense of responsibility. The participants felt that professionalism develops by the means of lectures, workshops, role plays, modeling and formal assessment sessions.</p> <p><strong>Conclusion:</strong> Study of behavioral science has significant effect in the development of professionalism among MBBS students and is well received by third year MBBS students.</p> Ammara butt Abid Ashar ##submission.copyrightStatement## 2020-03-14 2020-03-14 15 2 3 9 10.37018/TWMG3311 Insight into strategies adopted by the residents who passed exit fellowship examination in first few attempts <p><strong>Background:</strong> The residents who pass exit fellowship examination in few attempts adopt certain strategies for early success. The lived experiences of residents passing FCPS final examination in few attempts, barriers to success and strategies to overcome those barriers were studied.</p> <p><strong>Participants and methodology:</strong> This phenomenological research study was conducted at Services Hospital, Lahore, Pakistan from June 2015 to May 2017. Purposeful snowball sampling was done. Eleven residents who passed their Final FCPS examination in few attempts, in the last 15 years were included in the study. Semi-structured open-ended interview of the residents was audio-recorded and transcribed. Three themes of helpful factors, barriers encountered and suggestions to overcome those barriers to get through the final FCPS examination and the emerging sub-themes were analyzed and textural and structural description were assigned.</p> <p><strong>Results:</strong> Three themes were based on the aim of study and their related emerging sub-themes were found. The helpful factors included self-directed learning, peer assisted learning, interactive educational environment, rehearsal and self-determination. Barriers encountered were related to learning difficulties, competing responsibilities and physical and emotional burnout. Lastly, suggestions to overcome the barriers were use of multiple technology based learning strategies, developing self-confidence and self-efficacy together with prioritization of emotional and physical wellbeing.</p> <p><strong>Conclusions:</strong> This study found that self-regulation and internal motivation were important strategies for success in the FCPS exit examination. Barriers can be overcome through technology based learning and increased self-efficacy and prioritizing physical and emotional wellbeing.</p> Humera Zafar Ali Khan Amina Ahmad Abid Ashar Hamid Mahmood ##submission.copyrightStatement## 2020-03-14 2020-03-14 15 2 10 15 10.37018/QASN5232 Effectiveness of the social communication emotional regulation and transactional support (SCERTS) model based intervention in language development and fostering social communication in children with autism spectrum disorder <p><strong>Background:</strong> Social Communication Emotional Regulation Transactional Support (SCERTS) model is based on studies and has manuals for assessing children and designing individual treatment plans. However, limited research has been done to evaluate the efficacy of this model. This study attempts to evaluate the impact of SCERTS model-based intervention on children with Autism Spectrum Disorder (ASD) in Lahore with the objective to determine the usefulness of SCERTS in promoting language development and improvement in social skills in children with ASD.</p> <p><strong>Patients and methods</strong><strong>:</strong> This quasi experimental study was conducted at Roots and Wings autism center, located in Bahria Town Lahore, for the duration of nine months. Children with formal diagnosis of Autism Spectrum Disorder, with age range of 3 years to 6 years old. Prior to intervention and subsequently after that, the children were evaluated with the portage checklist in the domain of language and socialization skills.</p> <p><strong>Results:</strong> Participating children demonstrated improvement in their language and social skills after the intervention, as assessed by portage.</p> <p><strong>Conclusion:</strong> SCERTS based intervention can facilitate children with autism spectrum disorder to improve their language and social communication skills.</p> Hafsa Fiaz Atia Ur Rehman ##submission.copyrightStatement## 2020-03-14 2020-03-14 15 2 16 18 10.37018/IENH3595 Risk factors associated with early variceal rebleed after endoscopic variceal band ligation in cirrhotic Hepatitis B and C patients with variceal bleed <p><strong>Background:</strong> Chronic liver disease is endemic in Pakistan with esophageal variceal bleeding as one of the important complications and is treated with EVBL. The early esophageal variceal rebleeding is one of the ignored factors which carries the high mortality and morbidity.</p> <p><strong>Patients and methods:</strong> This case-control study was conducted in the Gastroenterology Department at Jinnah Hospital, Lahore, from February 2016 to February 2017. The Study included total 100 patients and out of these 50 were rebleeding cases while 50 were controls (without esophageal rebleed). Cases and control were matched for age, sex, Presence of hepatitis B and C and cirrhosis. The endoscopic findings of any active bleed and white nipple sign was recorded.</p> <p><strong>Results:</strong> In this study, association of risk factors for prediction of early variceal rebleed after banding in cirrhotic hepatitis b and c patients with variceal bleed was recorded as 58%(n=29) in cases and 12%(n=6) for active bleeding, O.R was 10.12, 68%(n=34) in cases and 14%(n=7) in controls had nipple sign, O.R was 13.05, Hb level &lt;9 g/dl was recorded in 88%(n=44) in cases and 40%(n=20) in controls, O.R 11.00, PT&gt;18 sec was recorded in 96%(n=48) in cases and 4%(n=2) in controls, O.R was 576.00.</p> <p><strong>Conclusion:</strong> Active bleeding and nipple sign, Hb level &lt; 9 g/dl and PT &gt; 18 sec are found to have strong association for prediction of early variceal rebleed after EVBL in cirrhotic hepatitis B and C patients.</p> Atif Nasrullah Muhammad Kashif Haris Nasrullah Arif Mahmood Saddiqiui ##submission.copyrightStatement## 2020-03-14 2020-03-14 15 2 30 33 10.37018/PENC3048 Pakistan and the COVID-19 challenges <p>not applicable</p> Iram Manzoor ##submission.copyrightStatement## 2020-03-14 2020-03-14 15 2 1 2 10.37018/DSMY7203 Medial transport of the fibula using the Ilizarov device for reconstruction of a large defect of the tibia <p>Background: Large tibial defects are always a challenging to treat, especially those associated with soft tissue compromise and infection. There are different treatment options available for bridging such gaps. Therefore, current study undertakes to test Ilizarov technique for transport of fibula to establish its usefulness in bridging large tibial defects.<br>Patients and Methods: This prospective case series was carried out from April 2013 to December 2016 at Orthopedic ward Lahore General Hospital in which 11 patients with large tibial defects having associated compromised soft tissue were treated by medial transport of fibula using Ilizarov external fixator.<br>Results: Among total 11 patients, 63.6% were male while 36.4% were female. The mean age of the patients was 31.6 years. There were 45.5% patients reported with right side while 6 (54.5%) were reported with left side tibia with bone defect. Most of the patients (54.5%) had open fracture with bone loss while 45.5% patients had chronic osteomyelitis. Average time to union was 5.2 months. Average tibial defect size was 10.7 cm. Among them 72.7% patients regained normal walk. All patients had multiple previous surgeries on their limbs.<br>Conclusion: Use of Ilizarov for medial transport of fibula is an effective procedure for reconstruction of large tibial defects especially in those patients who underwent multiple previous surgeries and with compromised soft tissue.</p> Adnan Latif Malik Muhammad Hanif ##submission.copyrightStatement## 2020-03-02 2020-03-02 15 2 2 5 Effectiveness of 3% arbutin cream in the treatment of epidermal melasma <p>Background: Melasma is a common acquired, circumscribed hypermelanosis of sun-exposed areas. Multiple treatment options are available for melasma but they require a long time to yield effective results. Arbutin has shown promising results in the treatment of melasma. The objective of this study was to determine the effectiveness of 3% arbutin cream in the treatment of epidermal melasma.<br>Patients and Methods: It was an interventional study conducted at the Department of Dermatology, Sir Ganga Ram Hospital, Lahore from 1st September, 2011 to 29th February, 2012. After approval from the Hospital Ethical Committee a total of 120 patients with epidermal melasma (diagnosed on Wood’s Lamp Examination), were enrolled in the study. All the patients were advised to apply 3% arbutin cream twice daily for 12 weeks. They were advised to do follow up visits every 2 weeks with a final visit 2 week after completion of treatment. Melasma Area Severity Index (MASI)1 score was calculated at the baseline and 2 weeks after completion of treatment period. Efficacy was measured by the decrease in MASI score (&gt;50%). All the information was collected on a specially designed proforma. Photographs were taken at the start and end of study period.<br>Results: There were 7 (5.8%) male patients and 113 (94.2%) female patients in the study. The male to female ratio was 1:16.4. The mean age of patients was 33.93±6.1. In this study, 65 patients (54.16%) showed improvement in terms of &gt;50% reduction in MASI score at 2 weeks follow up visit after the completion of treatment.<br>Conclusion: Use of arbutin 3% cream is an effective treatment modality in patients of epidermal melasma.</p> Rabia Hayat Tariq Rashid Atif Shehzad Muhammad Nadeem ##submission.copyrightStatement## 2020-03-02 2020-03-02 15 2 6 8 Cytogenetic analysis of children with congenital dysmorphism reported to tertiary care hospital in Lahore, Pakistan <p>The chromosomal imbalances are often seen in association with congenital dysmorphism. The identification of such chromosomal abnormalities is important, both as regards clinical management and for accurate genetic counselling. The current study sought to determine the association of chromosomal abnormalities to different groups of dysmorphisms. Patients and Methods: This one-year descriptive cross-sectional study was conducted at The Children’s Hospital and the Institute of Child Health, Lahore. Total 100 children between the age of 1 day to 12 years, reported with congenital dysmorphism were included in this study. Physical examination of the patients was carried out to note down their dysmorphic features. The blood samples of these children were taken to culture cells for chromosomal analysis by the G-banding method. Results: Physical examination of the 92 patients revealed isolated dysmorphism in 14% and multiple dysmorphisms in 86% of the cases. Chromosomal abnormalities were found in 23.9% of the total patients. Among them, 7.7% with isolated and 26.5% cases with multiple malformations had chromosomal abnormalities. Conclusion: This study concluded that both isolated and multiple congenital dysmorphisms are significantly associated with chromosomal abnormalities, therefore, chromosome analysis should be part of initial investigations of all the dysmorphic children.</p> Ruqyya Khalid Saqib Mahmood Faiz Ahmed Raza Khawaja A Irfan Waheed ##submission.copyrightStatement## 2020-03-02 2020-03-02 15 2 9 12 Coblation tonsillectomy versus cold dissection tonsillectomy <p>Post tonsillectomy pain and haemorrhage are important factors for the safety and efficacy of any surgical procedure. This study aimed to compare the efficacy of two surgical techniques i.e. coblator assisted tonsillectomy and time-tested gold standard operation of cold steel dissection tonsillectomy. Assessment of efficacy of coblator assisted tonsillectomy with cold steel dissection tonsillectomy. Patients and Methods: A prospective comparative interventional study was conducted on 100 patients. Coblation group included 50 patients while 50 patients were in cold dissection group. Following parameters like operative time, intraoperative bleeding amount, postoperative bleeding (secondary haemorrhage), postoperative pain, tonsillar fossa healing and time required to resume normal diet were compared. Results: In this study operation with coblator took shorter time with less per operative bleeding (p-value&lt;0.001). For initial five days after surgery, patients who underwent coblation tonsillectomy experienced less pain as compared to dissection method (p-value&lt;0.001). Coblation group also took less time to resume normal activity and diet. Conclusion: Coblation tonsillectomy appears to be a safe method. It is an effective procedure to reduce operative time and bleeding. It provides early healing of fossa with less postoperative pain. Being a new procedure, long term follow up studies will be required to analyze the long term outcomes.</p> Tahir Rashid Imran Saeed Muhammad Riaz ##submission.copyrightStatement## 2020-03-02 2020-03-02 15 2 13 15 Audit of common errors in death certificates issued by tertiary care hospitals in Lahore <p>Death certificate is the last legal document of one’s life. It provides not only valuable information about the deceased but also is a source of data required for devising national health related policies. So, this necessitates its completion according to the guidelines issued by World Health Organization (WHO).1 This study was aimed to determine the types and frequencies of errors during the completion of death certificates by the doctors at tertiary care hospitals of Lahore. Subjects and Methods: It was a retrospective study carried out at 3 tertiary care hospitals of Lahore during a period from Jan 2015 to June 2015. A total of 10359 death certificates of the patients who died during the said period and did not undergo autopsy were included in the study. Errors were abstracted and divided into 7 categories starting from category I to VII. Results: No death certificate was found error free. The highest number (97.4%) of the error was confusion between cause of death and mechanism/mode of death. It was followed by error in underlying cause of death accounting for 81.6% and then immediate cause of death 57.8%. Frequency of errors in the standard WHO recommended format was 49.95%. Conclusion: Most common error observed in this study was confusion of cause of death with mechanism/mode of death sufficient to misinterpret the cause. These errors may be attributed to lack of knowledge, training, and experience of the certifying doctors.</p> Muhammad Maqsood Muhammad Zahid Bashir Muhammad Abaidullah ##submission.copyrightStatement## 2020-03-02 2020-03-02 15 2 16 20 Incidental extra-cardiac pathologies on cardiac computed tomography <p>Extracardiac pathologies are frequently present in cardiac CT but are not routinely commented upon, and sometimes may have serious medical concern. This study aims to identify extracardiac pathologies present in patients undergoing cardiac computed tomography (CT) for some cardiac reasons. Patients and Methods: This six months cross sectional study was conducted in the Department of Diagnostic Radiology in collaboration with Department of Cardiology, Punjab Institute of Cardiology Lahore. Total 200 patients from Jan to June 2017 referred to Radiology department for Cardiac CT were evaluated for extracardiac manifestations, including insignificant incidental findings and normal variants. The data was entered into SPSS version 20 and simple percentages were calculated. Results: In this study, out of total 200 patients, 61% of the patients had extra cardiac pathologies. Most common extra cardiac findings included lung pathologies (63%), hepatic diseases (11%), mediastianal pathologies (9%), pulmonary embolism (4%), aortic dissection (4%), bone abnormalities (3%), breast diseases (2%), adrenal diseases (2%) and normal anatomical variants (2%). Conclusion: On the basis of findings of this study, it is concluded that there is a high percentage of non-cardiac pathologies in patients undergoing CT for cardiac assessment. It is therefore suggested that the radiologists should routinely report and emphasize any significant incidental extracardiac pathology and cardiologists should consider these findings for an optimal patient outcome</p> Amna Malik Basma Khan ##submission.copyrightStatement## 2020-03-02 2020-03-02 15 2 21 24 Frequency of depression in patients with non-alcoholic fatty liver disease <p>Non-alcoholic fatty liver disease (NAFLD) includes simple fatty change, hepatitis and cirrhosis. Patients with non-alcoholic fatty liver disease are at increased risk of arteriosclerosis, metabolic syndrome, cardiovascular and psychiatric disorders. Depressive disorders are among the prevalent psychiatric illnesses and pose public health problem. Depression is associated with poor outcome in the treatment of non-alcoholic fatty liver disease especially with lifestyle modifications. The aim of this study is to determine the frequency of depression in patients with NAFLD. Patients and Methods: Total of 170 newly diagnosed patients with non-alcoholic fatty liver disease based on ultrasound were included in the study. The frequency of depression was calculated using the Patient Health Questionnaire (PHQ-9) scale and other causes of depression particularly chronic diseases other than nonalcoholic steatohepatitis (NASH) and family history of psychiatric illness were excluded. A score of &gt; 20 was suggestive of severe depression. Results: Average age was 39.8 ± 8.8 years. 109 patients (64.1%) were male. Of this population, 41 patients (24.1%) suffered from depression according to depression scale PHQ-9 score. There were no effects of age, gender, socioeconomic status on depression in patients with fatty liver disease. Conclusion: It is concluded that depression is more frequent in patients with non-alcoholic fatty liver disease. </p> Tahir Bashir Anam Shafi Fozia Khalil ##submission.copyrightStatement## 2020-03-02 2020-03-02 15 2 25 27 Histopathological analysis of salivary gland tumors at Pathology Department of King Edward Medical University Lahore <p>Salivary gland tumors are distributed in the head and neck area. The purpose of the study was to see the distribution of these tumors. The tumors were studied against the demographic variables like age and sex. Patients and Methods: This was a descriptive cross-sectional study conducted at department of pathology of King Edward Medical University from 01 January 2010 to 31 December 2017. Three hundred and nineteen cases were included. Their diagnosis and demographic details like site, age and sex were recorded in a proforma. Statistical package for social sciences (SPSS) version 20 was used for descriptive analysis and the results were tabulated. Results: Total 319 cases of salivary gland tumors (SGT) were enrolled in the study. Female to male ratio was 1.3:1. Minimum and maximum age of the patients were 5 and 80 years. Mean age was 37.45±15.7 years. Malignant tumors were seen in relatively older age group as compared to benign tumors. Majority cases were benign 214 (67.1%) while malignant cases were 105 (32.9%). The commonest benign tumor was pleomorphic adenoma 203 (63.6%) and the commonest malignant tumor was mucoepidermoid carcinoma (MEC) 43 (13.5%) followed by adenoid cystic carcinoma (AdCC) 42 (13.2%). Most of the tumours 146 (45.8%) were located in parotid area followed by submandibular gland 45 (13.8%) and hard palate area 37cases (11.6%). Overall, 194 (60.8%) cases were found in major salivary glands and 125 (39.2%) were distributed in minor salivary glands. Benign versus malignant tumors in major SG were 150 and 44 (3.4:1) as compared to 64 versus 61 (1.04:1) in minor salivary glands. Conclusion: Pleomorphic adenoma was the commonest benign salivary gland tumor whereas mucoepidermoid carcinoma remained the commonest malignant tumor followed by adenoid cystic carcinoma. Parotid and minor salivary glands were predominant locations for benign and malignant tumors respectively.</p> Zahid Mahmood Akhtar Muhammad Wajid Khurshid Sipra Saeed Ahmad Hassan Saeed Filza Saeed ##submission.copyrightStatement## 2020-03-02 2020-03-02 15 2 28 32 Incidence of placenta previa in Southern Punjab and maternal outcome <p>Placenta previa is a worldwide problem associated with many pregnancy related complications. However, the information regarding placenta previa and its effect on pregnancy outcome are lacking in this area of Pakistan. This study aims to find out incidence of placenta previa in pregnant females, its consequences and outcome of pregnancy in the local population of Southern Punjab admitted to tertiary care public sector hospital at Rahim Yar Khan region. Patients and Methods: This observational cross sectional study was conducted in the department of Obstetrics and Gynaecology, Sheikh Zayed Hospital, Rahim Yar Khan from March to November 2017 on 4658 pregnant females. Gravid females with vaginal bleeding after 28 weeks gestation underwent ultrasonography to assess placenta previa. Findings of placenta previa were noted and females were followed-up till they were discharged and complications, including obstetrical hysterectomy, anemia, disseminated intravascular coagulation (DIC), multi-organ dysfunction or failure, blood transfusion requirement and maternal death, were recorded. Results: Mean age of the patients was 33.2±5 years and mean gestational age at presentation was 35.38±3 weeks. Out of the 4658 females, 2402 (51.6%) underwent spontaneous vaginal delivery and 2256 (48.4%) underwent cesarean section. Among 2256 females who underwent cesarean section, 210 (9.3%) had placenta previa. Among them, 38 (18%) had obstetrical hysterectomy, 4 developed DIC, 2 had multi-organ failure and 2 (0.95%) died, whereas 198 patients received multiple blood transfusion. Conclusion: The frequency of placenta previa was lower in local female population presenting at a tertiary care hospital for delivery. However, the complications were high in females with placenta previa and hysterectomy was one of the major complications of pregnancy with placenta previa.</p> Mahwish Najam Sana Javed Nuzhat Rasheed ##submission.copyrightStatement## 2020-03-02 2020-03-02 15 2 33 36 A review of gynaecological oncology patients seen in Sir Ganga Ram Hospital Lahore <p>Gynaecological cancers represent significant source of morbidity and mortality in women. Female genital malignancies have different geographic distribution which varies from one region to another. Cervical cancer was reported to be the most common malignancy worldwide in 2008.1 However, other literature reviews showed ovarian cancer being more common in different regions of Pakistan.2,3 The objective of this study is to see demographic factors, signs and symptoms, prevalence, and type of tumor in the local patient population presented to a tertiary care hospital in Central Lahore. Patients and Methods: A prospective descriptive study was carried out in Gynaecology Unit 1, Sir Ganga Ram Hospital/Fatima Jinnah Medical University Lahore. All the patients who managed with suspicion or diagnosis of Gynaecological malignancy from August 2012 till August 2017 were included in study. Case notes of all these patients were studied to determine the, age, parity, signs and symptoms and type of tumor. All data was recoded on a predesigned proforma after taking informed consent of the patients and getting approval from hospital ethical committee and was analyzed using SPSS version 20. Results: Total of 100 patients managed for suspected or confirmed gynaecological malignancy during the study period. The most common type of malignancy was ovarian cancer present in 58 (58%) patients. Most common age group for this malignancy was 40-59 years in 24 patients (41%) and 28 (48.27) were having parity of 1 to 5. Common presentation in ovarian cancer was abdominal distension, anorexia and weight loss observed in 21 patients (36.2%). Mucinous cyst adenocarcinoma was the most common histopathology reported in 25 (43%) cases. Next most common type of malignancy was cervical cancer with prevalence of 25%; 13 (52%) were 60 years of age or above. Presenting complaint of per vaginal discharge was present in 9 (36%) out of 25 cases. Histopathology was squamous cell carcinoma in all 25 cases (25%). Uterine carcinoma being third most common malignancy was observed in 17 patients (17%). Most common age group for this cancer was above 60 years in 8 patients (47.08%) with parity of more than 4 in 13 (76.47%). Most common presenting complaint in these patients was postmenopausal bleeding found in 10 cases (58.82%). Uterine adenocarcinoma was the commonest reported histology in 15 (88.73%) of these patients. Conclusion: This study highlights the demographic features, prevalence, signs and symptoms, type of tumor of different types of gynaecological malignancies in the local population. The identification of common modes of presentation may be helpful in early detection and diagnosis resulting in timely intervention which may improve patient outcome</p> Sadia Afzal Randhawa Shamsa Humayun ##submission.copyrightStatement## 2020-03-02 2020-03-02 15 2 37 40 Changing needs of medical education in Pakistan <p>Medical education, encompasses a large variety of learning experiences. Broadly it includes premedical years, undergraduate education, house job clinical rotation, residency, subspecialty training, and continuous professional development. These phases of learning and training entails a medical student to become self-directed lifelong learner. The educationists acknowledge that traditional teacher centered medical education does not allow students to become self-directed learners. The changing expectations of society and newly defined roles of doctors’ envisage them to become lifelong learners, through continuous professional development.</p> Shamsa Humayun ##submission.copyrightStatement## 2020-03-02 2020-03-02 15 2 1 1 Pattern of clinical response after concurrent chemoradiotherapy in patients with esophagus carcinoma <p><strong>Background:</strong> Around the globe esophagus carcinoma is the 8<sup>th</sup> most common cancer with the incidence of 456,000 cases yearly &amp; it is the 6<sup>th</sup> cause of mortality due to cancer. It is the 7th most common malignancy in men and 6th most common malignancy in females of Karachi. Chemoradiation therapy followed by surgery is the standard strategy for the treatment of locally advanced esophageal cancer. However, optimization of radiation dose, technique, chemotherapy, and patient selection is necessary to maximize its benefits. The objective of this study is to investigate the pattern of clinical response after concurrent chemoradiotherapy in patients with esophagus carcinoma.<br><strong>Patients and methods:</strong> It was a longitudinal study conducted at the Department of Oncology of Jinnah Postgraduate Medical College from May 2017 to July 2018. The patients of age 19-70 years of either gender with histological proven esophagus carcinoma of stage IA-IIIB<strong><sup>1</sup></strong> were included in the study. Patients with metastasis disease&nbsp;were excluded from the study. Every patient underwent full disease staging at baseline that included PET-computed tomographic (CT) scans, endoscopic ultrasonography, blood tests, and endoscopic biopsies. The cross trial<strong><sup>2</sup></strong> was inducted in patients with lower and middle esophagus in which concurrent chemoradiotherapy was performed with radiations in which carboplatin and paclitaxel was given weekly. For the upper esophagus the RTOG 85-01 trial<strong><sup>3</sup></strong> was inducted, in which concurrent chemoradiotherapy with cisplatin at day 1 and 5FU was administered on day 1 to 5. After 6 weeks at the end of chemoradiation, the clinical response was assessed on CT scan. The absence of visible tumor on CT scan and dysphagia was labelled as clinical complete response, a reduction of more than 30% of the tumor length on CT scan was labelled as partial response and appearance of new tumors or 30% increase in size of existence lesion was labelled as progression of disease and non-response, while patients with no change in index lesion was labelled as stable disease. Statistical analysis was performed using SPSS version 23.<br><strong>Results:</strong> Total of 70 patients were included in the study. The median age of the patients was 43.32±14.24 years. The partial clinical response was achieved in majority of the patients after concurrent chemoradiation therapy (CCRT) (55.7%). However, 14 patients achieved complete response, 10 patients showed stable disease, 6 patients expired and only one patient showed disease progression with metastases.<br><strong>Conclusion:</strong> The results showed that the achievement of complete clinical response was comparatively low after CCRT than partial response.</p> Ravisha Bai Ghulam Haider Ammara Manzoor Kanwal Satyawan Shahid Hussain Muhammad Hayat ##submission.copyrightStatement## 2020-02-24 2020-02-24 15 2 129 134 10.37018/jfjmu.v13i3.626 Frequency of histopathological patterns of Lupus Nephritis according to WHO classification – Report from a tertiary referral centre from Central Lahore <p><strong>Background:</strong> Renal involvement in Systemic Lupus Erythematosus (Lupus Nephritis) carries high morbidity and mortality. It is important to classify Lupus Nephritis to ensure appropriate management for improved long-term prognosis. This study was conducted to determine the frequency of histopathological patterns of lupus nephritis according to World Health Organization (WHO) classification on renal biopsy in patients presenting at a Tertiary referral centre in Central Lahore.<br><strong>Patients and methods:</strong> This cross-sectional study was done at Division of Rheumatology, Fatima Memorial Hospital, Lahore from January 2017 till July 2017. Eighty-three consecutive patients, fulfilling 2012 Systemic Lupus International Collaborating Clinics (SLICC) classification criteria for Systemic Lupus Erythematosus (SLE), and having evidence of nephritis were enrolled. An informed consent was obtained from the subjects to include their data in the study. Renal biopsy was done by the same Consultant Nephrologist and biopsy specimens sent to the Pathology Department were reported by the same Consultant Pathologist. Patterns of Lupus Nephritis according to WHO classification criteria were recorded on a pre-designed proforma. Data was analysed using SPSS version 22.0 for Windows. Frequency of each class of nephritis was calculated.<br><strong>Results:</strong> Total of 83 diagnosed patients were evaluated. Majority of patients (69%) were between 31-50 years (n=57). Mean age was 43.76±4.74 years. There were 49 females (59.03%). Patterns of Lupus Nephritis according to WHO classification showed that 9.63% (n=8) had Class I, 21.68% (n=18) Class II, 26.50% (n=22) Class III, 32.53% (n=27) Class IV, 6.02% (n=5) Class V and 3.61% (n=3) had Class VI.<br><strong>Conclusion:</strong> The frequency of WHO Class III and Class IV is high among patients with Lupus Nephritis. So, every patient who presents with nephritis should be sorted out for class of the disease in order to start early treatment to limit renal failure.</p> Muhammad Rafaqat Hameed Bilal Azeem Butt ##submission.copyrightStatement## 2020-02-24 2020-02-24 15 2 140 142 10.37018/jfjmu.v13i3.635 Pattern of admission and outcome of neonates admitted to tertiary care neonatal ICU <p><strong>Background: </strong>In the last two decades, the neonatal mortality and morbidity profile has reportedly improved due to better critical care facilities worldwide and neonatal mortality fell by 49%. However, in Pakistan, neonatal morbidity and mortality is still a major health problem and recent estimates has reported -0.33% per annum in Pakistan. It is important that the changed picture of neonatal morbidity and mortality should be determined. This study aims to assess the pattern of admission and outcome of neonates admitted to tertiary care neonatal intensive care unit of a tertiary care hospital in Rawalpindi.<br><strong>Subjects and methods:</strong> A cross-sectional study was conducted at the Neonatal Unit of the Military Hospital, Rawalpindi from January till June 2018. All consecutive neonates admitted in neonatal unit irrespective of gender were enrolled. The outcome of the admission in terms of discharge, expired or Left against medical advice (LAMA) were noted along with the baseline characteristics like age, gender, weight, gestational age, mode and place of delivery of the neonates.<br><strong>Results:</strong> Of 1922 neonates admitted in the study period, male preponderance was observed (63.2%). Most common reason for admission in neonates was preterm (n=445, 23.2%), followed by neonatal sepsis (n=405, 21.1%), and transient tachypnea of newborn in 248 (12.9%). Preterm was the most common diagnosis in both males and females, i.e. 265 (22%) and 180 (25%) respectively. Mortality was observed in 266 (13.8%) neonates while LAMA in 10 (0.5%) neonates. A significant difference in outcome was found with the diagnosis of the neonates (p-value &lt;0.001).<br><strong>Conclusion:</strong> The finding of this study has reported preterm, neonatal sepsis, and transient tachypnea of newborn as the most common reason for neonatal admission. Further studies are recommended to validate these findings and find out predictors of improved survival.</p> Sidra Tanveer Faisal Basheer Fady M.A. Motlaq Arshad Khushdil Raazia Nawaz Fawad Ahmad Khan ##submission.copyrightStatement## 2020-02-23 2020-02-23 15 2 116 120 10.37018/jfjmu.v13i3.638 Frequency and risk factors of retinopathy of prematurity in preterm babies at a tertiary care hospital in Lahore <p><strong>Background:</strong> Retinopathy of prematurity (ROP) is a serious but preventable morbidity, leading to childhood blindness. The aim of this study was to analyze the incidence and risk factors of ROP in preterm babies.<br><strong>Subjects and methods:</strong> A prospective cohort study was conducted at Neonatology Unit, Hameed Latif Hospital, Lahore, from July 2017 to February 2019. All preterm babies born at Hameed Latif Hospital at ≤ 34 weeks of gestation, birth weight of &lt;1.5 kg, born at 34-37 weeks of gestation with birth weight of 1.5- 2.5 kg having a significant course of illness, were included in the study. Their maternal history was obtained for gestational age, and maternal risk factors. Neonates were monitored and evaluated for clinical course, morbidity and mortality, during their stay at the hospital. These preterm neonates were screened for ROP by ophthalmological examination at 4-5 weeks of age. Data was analyzed to see the incidence of ROP and univariate and logistic regression analyses were applied to determine association of risk factors with ROP.<br><strong>Results:</strong> Twenty eight percent (n=21) of the total screened (<em>n</em>=75) preterm neonates, had developed ROP. Logistic regression analysis showed that anemia (with Hb&lt;10g/dl or HCT &lt;30%) (p=0.011), fraction of inspired oxygen (FiO<sub>2</sub>&gt;40% (p=0.018) and birth weight&lt;1.5 kg (p=0.048) were the risk factors associated with development of ROP.<br><strong>Conclusion:</strong> Development of protocols and their implementation in neonatal units to save newborns from the identified associated risk factors can help prevent development of ROP leading to childhood blindness.</p> Mayda Riaz Sajjad Rafique Ammara Hina Munibah Bashir Muhammad Tahir Majeed Sajid Maqbool ##submission.copyrightStatement## 2020-02-23 2020-02-23 15 2 110 115 10.37018/jfjmu.v13i3.607 Job satisfaction among anaesthesiologists working at teaching and tertiary care hospitals of Lahore <p>Background: Anaesthesiology is perioperative medicine that also &nbsp;encompasses &nbsp;intensive and critical care and pain management. The breadth of the profession has dramatically expanded in the last decade. Anesthesiology not only requires a considerable depth of knowledge but also demands experience, fine skills, vigilance ,dedication and commitment to the job, which makes it stressful and increases the risk of burnouts &nbsp;and job dissatisfaction among anesthesiologists. The purpose of this study was to assess job satisfaction among anesthesiologists working at teaching and tertiary care hospitals of Lahore and to identify factors responsible for job related stress and dissatisfaction.</p> <p><strong>Patients and Methods:</strong> A cross-sectional study, questionnaire based. The study was conducted after approval from the Local Ethical Committee. Total &nbsp;171 anesthethesia &nbsp;consultants, senior registrars, registrars and medical officers &nbsp;working at teaching and tertiary &nbsp;care hospitals of Lahore participated in this study.&nbsp; A questionnaire was designed to collect informations regarding &nbsp;&nbsp;job satisfaction, private practice , professional income, public awareness of the &nbsp;specialty, identification of stressors, working relationship with surgeons , working environment and other elements associated with job &nbsp;dissatisfaction. There were 23 questions that had to be answered in either &nbsp;yes &nbsp;or no &nbsp;and data was presented as frequencies and percentages.</p> Khalid Javed Zahra Ishrat Tahir Mahmood Chaudhary ##submission.copyrightStatement## 2020-02-08 2020-02-08 15 2 135 139 10.37018/jfjmu.v13i3.686 Comparison of tissue doppler derived systolic strain between different severities of left ventricular dysfunction in patients having rheumatic severe mitral regurgitation <p><strong>Background:</strong> Tissue doppler derived systolic strain detects the subtle changes in left ventricular (LV) function. This new modality can detect LV dysfunction in severe rheumatic mitral regurgitation (MR) at earlier stages. The present study was conducted to compare tissue doppler derived peak systolic strain between patients with different severities of LV dysfunction in rheumatic severe MR and to look for the negative correlation between LV dysfunction and peak systolic strain.</p> <p><strong>Subjects and methods:</strong> A descriptive correlational study was conducted from January 2017 to March 2018 at Punjab Institute of Cardiology, Lahore. Fifty healthy controls taken as group-I and 150 asymptomatic patients of rheumatic severe MR were divided into Group-II (with ejection fraction (EF) ≥60% and left ventricular end systolic dimension (LVESD) ≤40mm), Group-III (with EF≥ 60% and LVESD 41-50mm) and Group-IV (with EF &lt;60%).Longitudinal peak systolic strain (PSS) of the groups were measured by tissue doppler imaging and compared. The correlation between systolic dysfunction and PSS was further studied.</p> <p><strong>Results:</strong> Out of 200 subjects, 91(45.5%) were male and 109 (54.5%) female. Mean age of study subjects was 31± 9.5 years. Moving from group-I to group-IV, mean LVESD increased from 23.3±2.4 to 49.3±3.0, mean LVEDD (left ventricle end diastolic dimension) increased from 46.4±3.4to 64.0±3.6, ejection fraction decreased from 63.6±2.1to45.7±6.7 and average PSS decreased from 17.8±0.53 to 8.31±0.52.Significant difference was found in average PSS between these groups (p&lt;0.001).There was a significant (p&lt;0.001)negative correlation (correlation coefficient = -0.968) between average PSS and LV dysfunction (i.e. group number).</p> <p><strong>Conclusion:</strong> Inrheumatic severe mitral regurgitation, tissue doppler derived peak systolic strain decreases with increase of LV dysfunction showing a significant negative correlation between the two.</p> Muhammad Khaleel Iqbal Muhammad Furrakh Maqbool Shahzad Tawwab Usman Mahmood Butt Imran Saleem Tahir Naveed ##submission.copyrightStatement## 2020-01-15 2020-01-15 15 2 145 149 10.37018/jfjmu.631 Awareness regarding hepatitis B and it’s vaccination status among medical students, doctors and paramedics studying & working at DHQ Teaching Hospital, Sahiwal <p><strong>ABSTRACT</strong></p> <p><strong>Introduction:</strong> Hepatitis B is a risk factor for Health Care Workers (HCW) and medical students attending wards at hospital. Hepatitis B vaccine has been recommended since 1982 for use by HCWs to prevent HBV infection. The aim of this study was to evaluate the vaccination coverage among HCWs and medical students, their level of knowledge regarding vaccination as well as and their beliefs regarding Hepatitis B vaccine at a Teaching District Headquarter (DHQ) Hospital of Punjab, Pakistan.</p> <p><strong>Subjects and Methods: </strong><strong>&nbsp;</strong>This cross sectional descriptive study based on a questionnaire-based survey was carried out at DHQ Teaching Hospital, Sahiwal, Pakistan from 01-04-2019 to 31-07-2019. Doctors, medical students and paramedical staff involved in active physical care of the patients were included in the study.</p> <p><strong>Results: </strong>A total of 300 participants were provided questionnaire including consent, out of which 285 participants responded. There were 127 doctors (44.56%), 86 medical students (30.18%) and 72 paramedics (25.26%). 132 (46.31%) participants were fully vaccinated, 9.12% had received 2 doses of vaccine, 8.77% received only one dose whereas 35.43% were unvaccinated. Out of unvaccinated individuals, 32.35% reasoned lack of time being the main cause followed by other reasons including lack of need, lack of awareness and accessibility.</p> <p><strong>Conclusion:</strong> This study showed that vaccination coverage among HCWs was alarmingly low along with lesser knowledge of vaccination and infection. Therefore, HCWs and medical students are at an increased risk of acquiring Hepatitis B infection.</p> Rana Aamir Diwan Khalil Ahmad Fahad Mukhtar Hashmi Muhammad Arslan Muhammad Nabeel Bhatti ##submission.copyrightStatement## 2020-01-15 2020-01-15 15 2 150 154 10.37018/jfjmu.637 Picture quality comparison between panoptic ophthalmoscope and non-mydriatic fundus camera <p><strong>ABSTRACT</strong></p> <p><strong>Background:</strong> Non-mydriatic fundus photography has been shown to be a potential alternative to direct ophthalmoscopy in the emergency department. Panoptic ophthalmoscope is a newer handheld alternative to non-mydriatic fundus camera. Its advantages include greater portability and lower price. Panoptic Ophthalmoscope compatibly utilizes mobile phone’s camera to capture high definition fundus photographs, however lower in quality in comparison with a fundus camera. This study compares the picture quality between panoptic ophthalmoscope (POO) and non-mydriatic fundus camera (NMFC).</p> <p><strong>Patients and Methods:</strong> This comparative cross-sectional study was conducted in Lahore General Hospital, Lahore. Three twenty three (323) fundus pictures were taken from two different cameras. One hundred sixty pictures (160) were taken with NMFC and one hundred sixty three (163) with POO. Quality of each picture was assessed by two consultant ophthalmologists independently. The data was computed and analyzed by SPSS version 21. Chi square test was applied to the data. Confidence interval of 0.95 with α of 0.05 was taken.</p> <p><strong>Results:</strong> There was statistically significant difference in picture quality of disc, macula, superior and inferior vascular arcades (p&lt;0.001). &nbsp;Total 122 out of 160 pictures taken by NMFC and 48 out of 163 pictures taken by POO were considered ideal by first ophthalmologist whereas 96 of 160 pictures taken by NMFC and none taken by POO were considered ideal by second ophthalmologist.</p> <p><strong>Conclusion:</strong> Quality of images taken with NMFC is significantly better as compared to POO.</p> Faisal Mehmood Ahsan Mehmood Awais Afzal Abdullah Irfan Muhammad Moin Muhammad Muneeb ##submission.copyrightStatement## 2020-01-15 2020-01-15 15 2 159 162 10.37018/jfjmu.657 Frequency and types of congenital heart disease in neonates: A cross-sectional study from large public sector hospital of Karachi, Pakistan <p><strong>Background:</strong> Congenital heart disease (CHD) is one of the frequent congenital health issues in neonates. Early diagnosis is a key factor to combat this problem. This study aims to assess the frequency and common types of CHD among neonates presenting to a tertiary care hospital, Karachi.</p> <p><strong>Patients and methods:</strong> This descriptive cross-sectional study was conducted in a Neonatal Intensive Care Unit (NICU) of National Institute of Child Health (NICH), Karachi from March to September 2017. All neonates of gestational age ≥37 weeks with suspected CHD (presence of blue-tinged skin, i.e. cyanosis on routine clinical examination) were included. Information regarding presence of CHD and its types were collected along with the demographic characteristics and history of the patients.</p> <p><strong>Results:</strong> Of 134, frequency of CHD was observed in 126 (94%) patients. Out of these 126 CHD patients, Ventricular septal defect (VSD) was observed in 49 (38.9%), patent ductal arteriosus (PDA) in 29 (23%), atrial septal defect (ASD) was observed in 19 (15.1%), Transposition of great arteries (TGA) in 18 (14.3%), and tetralogy of Fallot (TOF) in 14 (11.1%) patients. A significant association of VSD was observed with neonatal age (p = &lt;0.001), ASD with neonatal age (p = 0.037) and maternal age (p = 0.025), while TGA was found significantly associated with neonatal age (p&lt;0.001).</p> <p><strong>Conclusion:</strong> CHD was observed in majority of the suspected patients with VSD as commonest type of congenital heart diseases among neonates.</p> Misbah Majeed Muhammad Ashfaq Bader u Nisa Aijaz Ahmed Jai Parkash ##submission.copyrightStatement## 2020-01-15 2020-01-15 15 2 163 165 10.37018/jfjmu.661 Comparison of urinary vitamin D binding protein with albumin-creatinine ratio in type 2 Diabetes Mellitus as an early screening tool for diabetic nephropathy <p><strong>ABSTRACT</strong></p> <p><strong>&nbsp;</strong></p> <p><strong>Introduction:</strong>-</p> <p>Diabetes mellitus (DM) is a group of metabolic disorders. Diabetic nephropathy is one of the chronic complications of DM, leading to End stage renal disease (ESRD). A current diagnostic criterion for diabetic nephropathy is measurement of microalbuminuria, which is 30 to 300 mg of albumin/24 hour’s urine or ratio of albumin to creatinine &nbsp;(ACR) in the range of 30 to 300 mg/g in random urine sample but it shows inadequate sensitivity for the early detection of diabetic nephropathy.</p> <p><strong>Methodology</strong>:- This was a comparative cross sectional study, which comprised of seventy five study subjects and were distributed into three study groups with 25 subjects in each group, having age&nbsp; in the range of 40-50 years.Group-1 comprising controls (without diabetes mellitus),Group-2 contained diabetes mellitus patients with normoalbuminuria. Group-3 composed of diabetes mellitus patients with microalbuminuria. Vitamin D binding protein, urine creatinine and albumin was measured from the urine sample of each study subjects. Determination of creatinine in urine was performed by jaffe method and albumin in urine was determined by immunoturbidimetric method. Vitamin D binding protein was measured by ELISA method. Levels of VDBP and albumin were normalized with urine creatinine and expressed as VDBP creatinine ratio as (ng/mg) and albumin creatinine ratio as (mg/g) in the spot urine sample.</p> <p><strong>Results</strong>:-Results of this study showed that level of Vitamin D binding protein was significantly increased in diabetes mellitus in comparison to control subjects.</p> <p><strong>Conclusion</strong>:- Our results proposes that urinary vitamin D binding protein levels is likely to become a useful biomarker for the early detection of diabetic nephropathy in diabetic patients which can be helpful in early treatment and will help to manage diabetic nephropathy.</p> <p><strong>ABSTRACT</strong></p> <p><strong>Introduction:</strong> Diabetes mellitus (DM) is a group of metabolic disorders. Diabetic nephropathy is one of the chronic complications of DM, leading to end stage renal disease (ESRD). A current diagnostic criterion for diabetic nephropathy is measurement of microalbuminuria, which is 30 to 300 mg of albumin/24 hour’s urine or ratio of albumin to creatinine (ACR) in the range of 30 to 300 mg/g in random urine sample but it shows inadequate sensitivity for the early detection of diabetic nephropathy .Current diagnostic criterion for diabetic nephropathy (DN) is detection of microalbuminuria, which is 30 – 300 mg/24 hours of albumin excretion in urine or albumin to creatinine ratio (ACR) in the range of 30 – 300 mg/g in the random urine sample but, it shows inadequate sensitivity for the early detection of DN. It has been observed that increased excretion of UVDBP is related to tubular dysfunction. This protein is excreted in urine earlier than albumin. Hence it can be used as a tool to early detection of DN in type 2 diabetic patients.</p> <p><strong>Methodology</strong>: This was a comparative cross sectional study, which comprised of seventy five study subjects and were distributed into three study groups with 25 subjects in each group, having age in the range of 40-50 years. Group-1 comprising controls (without diabetes mellitus), Group-2 had diabetes mellitus with normoalbuminuria while Group-3 comprised of diabetes mellitus patients with microalbuminuria. Vitamin D binding protein, urine creatinine and albumin were measured from the random urine sample preferably early in the morning urine sample of each study subjects using ELISA, Jaffe and immunoturbidimetric methods respectively. Levels of VDBP and albumin were normalized with urine creatinine and expressed as VDBP creatinine ratio as (ng/mg) and albumin creatinine ratio as (mg/g) in the spot urine sample.</p> <p><strong>Results</strong>: Urinary VDBP levels among the three groups were as the highest Median, IQR (Q1- Q3) values were observed in group 3 as 1056 ng/mg,(905 ng/mg – 1215 ng/mg) followed by group 2 as 442 ng/mg,(381.50 ng/mg – 523 ng/mg) and group 1 as 98 ng/mg,(73.50 ng/mg – 149 ng/mg) respectively, and a statistical significant difference was observed among the three groups with a <em>p</em>- value of 0.000. Results of this study showed that level of Vitamin D binding protein was significantly increased in diabetes mellitus in comparison to control subjects.</p> <p><strong>Conclusion</strong>: Results suggest that urinary vitamin D binding protein level is likely to become a useful biomarker for the early detection and management of diabetic nephropathy in Type 2 diabetic patients.</p> <p>&nbsp;</p> Hafiz Muhammad Khalid Mehmood Munazza Yasmeen Sumbla Ghaznavi Mr. Abdul Waheed Miss Nadia Rasheed ##submission.copyrightStatement## 2020-01-15 2020-01-15 15 2 170 174 10.37018/jfjmu.672 Bacterial urinary tract infection and antibiotic sensitivity pattern among type II diabetic patients – A cross-sectional study from tertiary care teaching hospital in Central Lahore <p><strong>ABSTRACT</strong></p> <p><strong>Background:</strong> Diabetes mellitus is the fifth leading cause of death in developed countries.Risk of infections is increased in diabetic patients with urinary tract being the most common site of infection. Worldwide, the prevalence of urinary tract infections (UTI) is estimated to be around 150 million persons per year&nbsp;. UTI exhibit a poorer prognosis in patients of type 2 diabetes mellitus (T2DM) due to a compromise in their immune status in addition to emerging antimicrobial resistance due to widespread use of antimicrobial agents. This study aims to determine frequency of common bacterial pathogens causing UTI and antibiotic sensitivity pattern among type 2 diabetic patients. This may help to guide physicians regarding appropriate management of UTI in the local population to avoid multidrug resistance.</p> <p><strong>Patients and Methods:</strong> This cross sectional study involved 215 type 2 diabetic patients admitted to Medical Unit-III of Sir Ganga Ram hospital, Lahore from 01-12-2016 to 31-05-2017. Type 2 adult diabetic patients (diagnosed for at least 1 year) of age 40-80 years, either male or female , with urine pus cells ≥5/HPF performed as baseline investigation at admission were included in the study. Further urine samples were obtained (clean catch midstream urine 10cc in two wide mouth sterile screw capped plastic jars) before starting treatment. Samples were sent for microscopy and culture. Culture results and antibiotic sensitivities were recorded. Data was analyzed using SPSS for windows version 23.0. Categorical variables like gender, organisms and antibiotic sensitivitywas presented in Frequency or Percentage form. Numerical variables like age and duration of diabetes were presented as Mean± SD. Data was stratified for age, gender and duration of DM to deal with effect modifiers. Post stratification chi-square test was applied. P-value of ≤0.05 was considered significant.</p> <p><strong>Results:</strong> Total of 215 patients were included. Mean age was 63.76±10.342 years of which 164 (76.3%) were females, while 51 (23.7%) were males reflecting female predominance.Most common isolated organism in urine culture was E.coli (58.6%), followed by Klebsiella (20.5%), Proteus(9.3%), Pseudomonas(8.4%) and Enterococcus (3.3%)species.Most of the patients (76.7%) were sensitive to piperacillin-tazobactam followed bycarbapenems (67%) and Gentamycin(56.7%), whereas 24.2% showed sensitivity to all antibiotics.</p> <p><strong>Conclusion:</strong> Females are most commonly affected among diabetic patients. The commonest isolate was E.coli among culture positive UTIs. E.coli was most sensitive to piperacillin-tazobactam and carbapenems followed by Gentamycin while least sensitive to Ceftriaxone.The results emphasize the importance of practcse of urine culture and sensitivity testing in diabetic patients and cautious approach to use of commonly used antibiotic ceftriaxone and ciprofloxacin as empirical treatment for UTI despite the low sensitivityof the drug to the most prevailing organism.</p> Khadija Muneer Kaneez Fatima Naheed Hashmat Sana Humayun Qaiser Pervaiz Saim Maqsood ##submission.copyrightStatement## 2020-01-15 2020-01-15 15 2 180 183 10.37018/jfjmu.684